809 Evaluation of the Two Week Wait Colorectal Cancer Pathway in a District General Hospital

Introduction

Updated guidelines published by the National Institute for Health and Care Excellence in 2015 widened the referral criteria for the two week wait (2WW) pathway for suspected lower gastrointestinal cancer, in an attempt to increase early diagnosis. The aim of this study was to evaluate the compliance of referrals received via the (2WW) pathway for suspected lower gastrointestinal cancer.

Method

We conducted a retrospective study which utilised a local cancer registry to identify all patients who had been referred to United Lincolnshire Hospitals Trust over a two-month period. Electronic patient records were checked to establish whether patients fulfilled the 2015 referral criteria.

Results

Out of 615 patients referred, 51 (8%) had colorectal cancer. 92 (15%) referrals did not meet the criteria for the 2WW pathway. Whether or not the referral was ‘appropriate’ had no significant effect on the diagnoses of bowel cancer (X2 = .003, p>.05).

Conclusions

16% of all referrals did not meet criteria. This may appear as an inefficient use of resources, however there was no difference in rates of cancer between appropriate and inappropriate referrals. The referral criteria are likely to evolve over the course of time, and perhaps clinicians’ judgement should be taken into account.

Comparison of conventional straight and swan-neck straight catheters inserted by percutaneous method for continuous ambulatory peritoneal dialysis: a single-center study

OBJECTIVE

To evaluate the incidence of mechanical and infectious complications of conventional straight catheter (SC) versus swan-neck straight catheter (SNSC) implanted by percutaneous method.

PATIENT AND METHODS

We retrospectively analyzed 45 catheter insertions being done by percutaneous method from January 1, 2011, to May 31, 2014. SC was inserted in 24 patients, and SNSC was inserted in 21 patients. Baseline characteristics for the two groups were similar with respect to age, sex and diabetic nephropathy as the cause for end-stage renal disease.

RESULTS

Incidence of mechanical and infectious complications in SNSC group was found to be low as compared to the SC group and was statistically significant (1 in 11.6 patient months vs. 1 in 14.4 patient months, p = 0.02). Catheter migration was found to be the most common mechanical complication (20 %), and peritonitis was found to be the most common infectious complication in conventional SC group (27 episodes in 420 patient months vs. 11 episodes in 333 patient months, p = 0.03). The incidence of exit site and tunnel infection rates revealed no difference between the groups.

CONCLUSION

SNSC insertion by percutaneous method is associated with low mechanical and infectious complications.

Comparative evaluation of fosinopril and herbal drug Dioscorea bulbifera in patients of diabetic nephropathy

Worldwide, diabetic nephropathy is one of the leading causes of end-stage renal failure. This hospital-based single-center prospective open-label randomized case-control interventional study was performed to evaluate and compare the native drug Dioscorea bulbifera with fosinopril in the management of diabetic nephropathy. Patients with diabetic nephropathy with proteinuria >500 mg/day or albuminuria >300 mg/ day, S Cr ≤2.5 mg/dL and hypertension controlled with a single drug were included into the study and were divided into three groups according to the interventional drugs that they were given; group A (n = 46) on fosinopril (5-40 mg/day), group B (n = 45) on Dioscorea bulbifera (500 mg BD) and group C (n = 46) on neither of these drugs. All necessary laboratory investigations needed to assess the effect of both the drugs were carried out. Patients were followed-up for six months. The study included 137 patients (M:F 2.61:1) with an age range of 19-76 years. At the sixth-month follow-up, a significant decrease in the systolic blood pressure was noted in all three groups whereas the diastolic blood pressure decreased significantly only in group B. There was significantly better control of both systolic and diastolic blood pressures in group B than in the other groups. Although fasting blood sugar was poorly controlled in the initial visit in all three groups, there was a significant decrease at the sixth-month follow-up in all three groups. Moreover, the decrease was significantly more pronounced in group B than in the other two groups. Low-density lipoprotein decreased significantly only in group B. Proteinuria, serum transforming growth factor-β, interleukin-6 (IL-6) and C-reactive protein decreased in both group A and group B, more so in the latter, but the differences between the groups were not statistically significant. Importantly, proteinuria and serum IL-6 showed an increasing trend in group C. It can be concluded that Dioscorea bulbifera was more effective than fosinopril in controlling blood pressure, glycemia, cholesterolemia and inflammatory state in diabetic nephropathy. Both agents decreased proteinuria. However, creatinine clearance significantly decreased with both the drugs, more so with Dioscera, and thus further evaluation with a larger trial is needed.

Prevalence and pattern of antiphospholipid antibody syndrome in a hospital based longitudinal study of 193 patients of systemic lupus erythematosus

BACKGROUND

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disease characterised by thrombophilic state and obstetrical complications. Prevalence of APS varies in different parts of the world. So this study was conducted to find out the prevalence and pattern of APS in systemic lupus erythematosus (SLE) in this region.

MATERIAL AND METHODS

In this hospital based longitudinal study from 2004 to 2011, we studied 193 patients of systemic lupus erythematosus (SLE) for prevalence of APS and its different characteristics. The diagnosis of SLE was made according to American College of Rheumatology (ACR) criteria and diagnosis of APS was made according to Sapporo criteria.

RESULTS

Prevalence of APS in SLE was 25.38%. Mean age at study entry was 25.5 +/- 6.9 years and majority of APS patients were in the age group 21-30 yrs (44.89%). The most common clinical manifestation in both SLE with APS and SLE without APS was musuloskeletal involvement (79.59% and 84.72% respectively). Among 49 patients of SLE having APS, multisystem involvement was present in 16 patients and life threatening complications were present in 12 patients. Late foetal loss was the most common obstetrical manifestation of APS (26.53%) and deep vein thrombosis was most common thrombotic manifestation (16.32%). Anticardiolipin antibodies(IgG aCL) were the most common antibody (85.71%) detected. Lupus anticoagulant was present in 71.42% cases of SLE having APS. ANA and anti-dsDNA antibodies were present in 97.95% and 77.55% cases of SLE having APS.

CONCLUSION

APS is a major cause of morbidity and mortality in patients of SLE. The incidence of secondary APS in SLE varies in different geographical regions and it was 25.38% in our study. Pregnancy morbidity and deep vein thrombosis were the most common complications of APS. IgG aCL was the most common antibody in APS patients. Screening for the presence of aPL antibodies in SLE patients and timely initiation of prophylactic treatment can prevent many of the complications.

Urinary MCP-1 as diagnostic and prognostic marker in patients with lupus nephritis flare

AIM OF THE STUDY

This study aimed to assess correlation of urinary monocytic chemoattractant protein-1 (UMCP-1) with severity of lupus nephritis and its role as predictor of outcome.

METHOD

Twenty patients with lupus nephritis flare were included in the study. Ten patients in each group of stable systemic lupus erythematosus and non-renal flare were taken as controls. Biopsy was done to define lupus nephritis stage. UMCP-1 levels were measured in all patients at the time of entry and at four and eight weeks of follow-up.

RESULTS

Mild, moderate and severe lupus nephritis flare was noted in one, five and 15 patients, respectively. UMCP-1 levels were high in patients with severe lupus nephritis flare (2.74 ± 0.95 ng/mg creatinine) as compared to patients with moderate (1.43 ± 0.46 ng/mg creatinine) and mild lupus nephritis flare (0.76 ± 0.57 ng/mg creatinine) (P = 0.0093). Baseline mean UMCP-1 levels in lupus nephritis flare, non-renal flare and stable SLE patients were 2.32 ± 1.06, 0.171 ± 0.03 and 0.213 ± 0.026 ng/mg creatinine, respectively. The difference among the three groups was very significant (P < 0.001). Also, mean UMCP-1 levels correlated significantly with severity of lupus nephritis class (P = 0.0358). During follow-up, 15 patients achieved complete or partial remission, and in these patients mean UMCP-1 levels had significant decline at eight weeks (P < 0.0001). However, mean UMCP-1 levels in the remaining five non-responders did not show significant changes at four and eight weeks (P = 0.4858).

CONCLUSION

Mean UMCP-1 levels were significantly higher in the lupus nephritis flare group as compared to non-renal flare and stable patients. Baseline mean UMCP-1 levels significantly correlated with both lupus nephritis class and severity of lupus nephritis flare, hence UMCP-1 could be used as a non-invasive marker for the judgement of lupus flare and lupus nephritis class.

Study on the role of humoral immunity in renal transplant rejections and its correlation with histopathological findings

Immunoglobulins (Ig) and complement, which are components of humoral immunity, are supposed to play a role in renal transplant rejection. The present study was undertaken to study the level of complement C3, C4 and IgG, A and M in patients with chronic renal failure (CRF) and in those with renal transplant rejection (Tx Rej) as well as stable transplant recipients (Tx Stb) and normal healthy controls (NHC) in order to assess their role in transplant rejection and to correlate them with histopathological findings. The mean level of C3 and C4 in the CRF, Tx Rej and Tx Stb groups was not significantly different from the NHC group (P > 0.05). The mean level of C3 in the Tx Rej group was not different from that in the Tx Stb group. However, the C4 level was significantly reduced in the Tx Rej group when compared with the Tx Stb group (P < 0.05). There was no histopathological correlation between C3 levels and acute cellular rejection (ACR) or chronic allograft nephropathy (CAN); however, C4 levels were reduced in about 50% of the cases with CAN. The mean serum IgG level was significantly reduced in patients with CRF and transplant recipients as compared with NHC. The serum IgA level was also significantly reduced in Tx Rej cases. Correlation of serum IgA with histopathology in cases with rejection showed that in ACR, a lower mean level of IgA was seen as compared with that seen in cases with CAN. The serum IgM level was significantly higher in the Tx Rej group as compared with the Tx Stb group. There was no significant correlation between serum IgM levels and renal histopathology in patients with ACR and CAN. The C3 level showed a significant positive correlation with IgG (r = +0.50, P < 0.05) in the Tx Stb group. This study shows that cell-mediated immunity is the main cause of rejection in both ACR and CAN while humoral immunity is also involved along with cellular immunity in some cases with CAN.

Evaluation of serum tumor necrosis factor alpha and its correlation with histology in chronic kidney disease, stable renal transplant and rejection cases

Tumor necrosis factor alpha (TNF alpha) is a cytokine secreted by macrophages, helper T cells, natural killer cells, B lymphocytes and non lymphoid cells e.g. endothelial cells, fibroblast and tumor cell lines. Aim of the study was to find the utility of TNF alpha in diagnosing renal transplant rejection among the renal transplant cases (n=29), and comparison with the levels in patients on maintenance hemodialysis (n=21) and healthy controls (n=20). TNF alpha in healthy controls varied from 2 to 15 pg/mL. In chronic renal failure and renal transplant rejection cases TNF alpha was above 45 pg/mL. In stable renal transplant patients it was higher than normal (16 to 30 pg/mL). In both acute and chronic transplant rejection TNF alpha increase correlated well with histology. Thus our study suggests that TNF alpha level more than 45 pg/mL can be taken as an immunological marker of renal transplant rejection.

A preliminary study on the significant value of beta-2-microglobulin over serum creatinine in renal transplant rejection and renal failure

INTRODUCTION

Beta-2-microglobulin (beta2M) is a light chain of HLA class I molecule, which is filtered by glomerulus, reabsorbed and catabolised by proximal tubule. It is one of the markers of transplant rejection. The aim of the present study was to find out the level of beta2M in acute renal failure (ARF), chronic renal failure (CRF), renal transplant rejection (TR) and renal transplantation stable (TS) cases, and correlation of beta2M with serum creatinine (SCr) in assessing renal failure.

METHODS

23 patients with ARF, 22 patients with CRF, six cases of TR, seven patients with TS, and 28 normal healthy controls were studied within a one-year period.

RESULTS

Highest mean value of beta2M was noted (12.97 +/- 3.83 microg/ml) in CRF, and all cases had elevated beta2M of which 81.8 percent of cases had beta2M above 10 microg/ml. In ARF, all cases had elevated beta2M and 78.3 percent patients had a value more than 10 microg/ml with a mean value of 11.75 +/- 2.09 microg/ml. TR cases also had elevated beta2M but 50 percent had mild elevation (less than 10 microg/ml) and 50 percent had marked elevation (more than 10 microg/ml). 42.8 percent of TS patients also had mild elevation of beta2M in the range 2.10-3.70 microg/ml. Interestingly, in normal healthy controls, 21.4 percent of patients had mild elevation of beta2M of 2.1-2.75 microg/ml, while 78.6 percent of cases had a normal range of beta2M (less than 2 microg/ml). All normal healthy controls and 71.4 percent of TS cases had normal SCr (less than 1.4 mg/dL). All cases of CRF and TR cases, and 28.6 percent of TS cases had elevated SCr. 81.8 percent of cases with CRF and 60.9 percent of cases with ARF had a marked rise of serum creatinine above 5 mg/dL.

CONCLUSION

Our study showed that beta2M is not superior over SCr for renal failure and TR cases, because it is also elevated in 21.4 percent of normal controls and 42.8 percent of TS cases. SCr is a cheaper, simpler and comparatively good test to assess renal failure and TR.

Mesangioproliferative glomerulonephritis: an important glomerulonephritis in nephrotic syndrome of young adult

Mesangioproliferative glomerulonephritis (MesPGN) consists 10% of the total renal biopsy of glomerulonephritis. Aim of the present study was to find out clinicopathological changes in MesPGN and differences between diffuse and focal variety. MesPGN was seen mostly in young adults with mean age of 28.63 years for males and 26.3 years for females. Male predominance was noted (M:F ratio - 1.4:1). About 70.83% patient presented with edema feet, followed by hypertension (29.19%), fever (16.66%), oliguria, nausea and vomiting (10.41%). Urine analysis in 50 patients revealed that 70% patients presented with nephrotic-range proteinuria, 36% patients with microscopic hematuria and 56% patients with leukocyturia. Statistically, no significant difference was found in clinical features of diffuse and focal MesPGN. Microscopic comparison between diffuse and focal variety showed that significant increase of focal glomerular basement membrane thickening, focal endothelial cell proliferation, focal smooth muscle hyperplasia, hyaline sclerosis and vasculitis was more common in diffuse variety. In focal variety, Capillary loop congestion, periglomerulitis, cloudy swelling and vacuolar degeneration in tubules were significantly more as compared to diffuse variety. Details of the clinical features, special laboratory tests and histological details revealed that diffuse variety had systemic diseases, which included Wegner's granulomatosis, microscopic polyangitis, Henoch's schonlein purpura, systemic lupus erythematosus (two cases) and one case each of Kimura's disease, pyelonephritis and tuberculosis. Only one case of focal MesPGN showed tuberculosis. Thus, our study concludes that MesPGN is an important cause of nephrotic syndrome among young adults. Secondly, search for some other diseases should be made and thirdly, if biopsy shows focal mesangial cell proliferations in minimal change glomerulonephritis (MCGN), it should be diagnosed as focal MesPGN rather than MCGN because these cases show recurrences.

An unusual case of Acanthamoeba peritonitis in a malnourished patient on continuous ambulatory peritoneal dialysis (CAPD)

An unusual case of peritonitis in a 61-year-old patient is reported where culture for bacteria and fungi were negative. Acanthamoeba was isolated and the patient was treated with Ceftazidine, Cefazolin, Levofloxacin, Fluconazole and Rifampicin with regular haemodialytic support. The patient was completely cured of the infection and continuous ambulatory peritoneal dialysis (CAPD) fluid became clear after 2 weeks of treatment. Diagnosis and treatment of Acanthamoeba infections are difficult due to the rarity of the infections, lack of familiarity of most clinicians with disease syndromes, and limitations of therapeutics options. Even an experienced microbiologist can easily mistake the amoebae in ascitic fluid for peritoneal macrophages or lymphocytes.

Myeloma in young age

Total 14 cases of myeloma in young age group (<40 years) have been reported out of 178 cases of myeloma in a time period of 7 years (1993-1999). Males predominated overfe males. Like adult myeloma, patients presented mostly with the backache, pain in pelvis, lower spine and weakness in about 60% of cases followed by swelling of bone in 40% of cases. One case presented with bleeding gum, malena and hepatosplenomegaly and was diagnosed as plasma cell leukemia. Radiological examination revealed lytic lesion in almost all the cases with fracture femur and rib in 28.57% of cases. Anaemia and raised ESR was noted in all the cases. Myeloma typing revealed IgG myeloma in 10 cases, light chain myeloma in 3 cases and IgA myeloma in one case. None of the patient was traceable after 2 years. Thus our study concludes that myeloma in the young age in India occurs in increased frequency and clinically presents just like adult and elderly myeloma, but serologically are predominantly of IgG type. There is also an increased frequency of solitary plasmacytoma as compared to adult myeloma.

Aliphatics from Peristrophe bicalyculata

The isolation and spectral data of the new 14-methyl-tritriacont-14-en-15-ol (1) and 35-hydroxynonatriacontanal (2) from the aerial parts of Peristrophe bicalyculata are reported.

Severe mitral regurgitation due to mitral valve prolapse: risk factors for development, progression, and need for mitral valve surgery

Patients with mitral valve prolapse (MVP) may develop severe mitral regurgitation (MR) and require valve surgery. Preliminary data suggest that high body weight and blood pressure might add to the irreversible factors of older age and male gender in increasing risk of these complications. Fifty-four patients with severe MR due to MVP were compared with 117 control subjects with uncomplicated MVP to elucidate factors independently associated with severe MR: the need for valve surgery and the cumulative risk of requiring mitral valve surgery. Patients with severe MR were older (p<0.00005), more overweight (p = 0.002), had higher systolic (p = 0.0003) and diastolic (p = 0.007) blood pressures, and were more likely to have hypertension (p = 0.0001) and to be men (p<0.001). In both groups, men had higher blood pressure and relative body weight than women. In multivariate analysis, older age was most strongly associated with MR; higher body mass index, hypertension, and gender were independent predictors of severe MR in analyses that excluded age. Among the 54 patients with severe MR, the 32 (59%) who underwent mitral valve surgery during 11 years of follow-up were older, more overweight, and more likely to be hypertensive than those not requiring surgery. Among patients undergoing mitral valve surgery in 3 centers, mitral prolapse was the etiology in 25%, 67% of whom were men. Using these data and national statistics, we estimate that the gender-specific cumulative risk for requiring valvular surgery for severe MR in subjects with MVP is 0.8% in women and 2.6% in men before age 65, and 1.4% and 5.5% by age 75. Thus, subjects with MVP who are older, more overweight, and hypertensive are at greater risk for severe MR and valve surgery. Higher blood pressure and relative weight in men with MVP appear to contribute to the gender difference in risk for severe MR.

Evaluation of muscle changes in patients with chronic renal failure

Forty patients of chronic renal failure (CRF) and five patients of acute on chronic renal failure (ACRF) were evaluated clinically and electrophysiologically for involvement of muscles. EMG studies showed features suggestive of denervation myopathy in 10 of patients of CRF only. Histopathological study of muscle biopsies, done in 25 patients with CRF, showed constellation of histopathological features suggestive of denervation myopathy in 48 and toxic myopathy in 24. In five patients with ACRF,denervation myopathy was observed in 60 and toxic myopathy in 20 cases on histopathological examination.

Body mass index (BMI) in the Saudi population of Gassim

In a total cross-sectional population survey of the Faizia East Primary Health District of Buraidah, Gassim region of Saudi Arabia, 6,044 (2727 male and 3317 females) subjects out of a de facto population of 7695 got their BMI computed because infants and restless or bedridden subjects could not be examined. Mean (+/- SD) and percentiles (25th & 75th) were calculated in the conventional 5-year age cohorts as well as in functional age groups, namely, 0-5, 6-12, 13-49, 50-69 and 70+ years. 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles were computed only for the functional age groups. In general, the trend was for BMI to increase with age in both genders but the curve pattern showed some plateauing from about the age of 50 with slight decline in later life. Females had significantly higher indices than males, this becoming quite prominent from the 10-14 year age cohort. This difference persisted irrespective of the types of age grouping or residential location. Overall means (+/- SD) were 20.14 +/- 5.98 vs 22.22 +/- 7.21 for males and females respectively; df: 5771; p = 0.0000; 95% CI: -2.43, -1.735. Subjects in the urban living environment had significant higher indices than their rural counterpart: (21.666.92 vs 20.446.33: df: 5771; P = 0.0000; 95% CI: 1.595, -0.840). From the age of 15 about one quarter of females are overweight (BMI at the 75th percentile > 25) and from 30 years the same proportion are frankly obese (BMI > 30). Both systolic and diastolic blood pressure were significantly positively correlated with BMI in both genders: male SBP: r = 0.22, P < 0.0001; male DBP: r = 0.21, P < 0.00001; female DBP: r = 0.18, P < 0.00001.

Studies of preventive nephrology: self-urinalysis as a feasible method for early detection of renal damage

The ever expanding pool of ESRF patients is exerting considerable strain on the health care resources of all nations of the world. Rationing, in one form or the other has therefore become the norm for most countries. Because dialysis prolongs life and is more readily available, and because ethically acceptable donor kidneys remain in short supply, thus limiting the potential of renal transplantation, this rather exasperating situation is bound to continue unless the entry point into the pool can be actively tacked. As part of our initial effort in this direction, we have examined the feasibility of self urinalysis by the general population as an epidemiological tool for detecting evidence of early renal damage by a total population cross-sectional survey of Faizia East Primary Health District (FEPHD) of Buraidah, capital city of the Gassim region of Saudi Arabia. Out of a de facto population of 7,695, 75.37% (5,800) cooperated fully. Majority of those who could not cooperate (881 [11.44%]) were infants and children. A total of 969 subjects (12.59%), mostly males at work, were not available. Only 45 (0.58%) subjects refused to participate. Housewives were significantly more amenable to the organisation of family self-urinalysis than head of the family (92.2% vs 61.4%; chi square = 321.78; df: 3; P < 0.0001). The mean family size was 7.82 (+/- SD: 3.82). Above the age of 4 years, 66.5% of males (2108/3170) as against 81.7% of females (2,641/3232) were able to carry our self-urinalysis. 11.76% of boys and 8.5% of girls below the age of 5 years were able to carry out self-urinalysis. Only 0.05% of male subjects and 0.03% of females failed to interpret colour change for proteinuria correctly. Similar remarkable competence was demonstrated for glycosuria by the population. We conclude that self-urinalysis is quite feasible in the general population, even if illiterates, if young. It can form a sound foundation, if properly harnessed, for a renal registry.

Some aspects of the pattern of systemic hypertension in the adult population of Gassim, Saudi Arabia: age distribution of the subsets of hypertensives

As part of our studies in prevent nephrology, we have recorded causal blood pressure during a total population cross-sectional survey of the Faizia East Primary Health District of Buraidah (FEPHD), capital of Gassim region of Saudi Arabia. Out of 5671 subjects whose blood pressure could be recorded, 2222 were above 19 years of age and constituted our adult population. For this report, hypertension have been defined as equal to and greater than 140/90 mm Hg. Total hypertensive population had been divided into three subsets, based on this basic definition, namely combined systolic and diastlic hypertension (S/DHPN), isolated systolic hypertension (ISHPN) and isolated diastolic hypertension (IDHPN), a format which is not generally clear in previous studies on the subject. The overall prevalence of systemic hypertension was found to be 23.58%, which is lower than the figure of 36% for USA (pre-primary prevention intensive campaign). It is assumed that all the three subsets mentioned above have been used in calculating the latter. Although males tended to be more hypertensive than females (OR = 1.22; Chi Square = 3.89; P = 0.05; C.I.: 1.00 < OR < 1.49), the marginal difference (25.7% vs 22.10%) was largely due to the IDHPN subset (OR = 1.73; Chi Square = 4.48; P = 0.034; C.I.: 1.01 < OR < 2.96). In both the S/DHPN and ISHPN: statistical significance was not achieved. Significantly, ISHPN subset constituted the bulk--56.68%--of the hypertensive population while IDHPN constituted the least--11.64%. When analysed into 10-year-age cohorts, ISHPN showed the steepest rise in prevalence with age. Rather suprisingly, the IDHPN did not rise with advancing age while the S/DHPN slope was in between the two. We are unable to identify this pattern in our literature search on the subject. We cannot assess its significance by this study, but we wonder whether or not it carries any prognostic significance in terms of target organ damage. It is possible that this pattern may be peculiar to the sub-region but it certainly is not spurious and in our view deserves further scrutiny. We wish to suggest that clear definition of the three subsets of hypertensive population should be mandatory when defining prevalence. This may provide some further clues in the prognosis and pathogenesis of target organ damage.

Blood pressure pattern in Saudi population of Gassim

Blood pressure pattern for the Kingdom of Saudi Arabia has not been defined. In a total cross-sectional population survey of the Faizia East Primary Health District of Buraidah, capital of Gassim region, Saudi Arabia, 5671 subjects out of a de facto population of 7695 got their blood pressure recorded. The study district consisted of an urban section and a rural sector. Mean systolic and diastolic blood pressure were computed for the total population in conventional 5-year age cohorts as well as in an arbitrary functional age groups. The curve pattern and trends of the percentiles, were defined. Mean blood pressure (systolic and diastolic) was found to rise with age in both genders (male SBP: r = 0.66, P < 0.000001: female SBP: r = 0.58, P < 0.00001; male DBP: r = 0.53, P < 0.00001; female DBP: r = 0.45, P < 0.00001) and to correlate significantly with BMI. Both systolic and diastolic values were consistently higher in females than males. Overall means (+/- SD) were: for SBP, male 109.9 (+/- 21.57) vs female 114.33 (+/- 21.22) mm Hg; df: 5669: P < 0.00000; CI: -5.5, -2.0; for DBP, male 62.85 (+/- 16.89) vs female 64.67 (+/- 14.99) mm Hg; df: 5669; P < 0.0000; CI: -2.65, -0.989. Proteinuria (macroalbuminuria) was found to correlate positively and very significantly with both systolic and diastolic blood pressure: for SBP: r = 0.074, P < 0.0001; DBP: r = 0.055, P < 0.0001. Perhaps more significantly, in the context of preventive nephrology, is the observation that the intercept of the regression line with blood pressure was below the level conventionally regarded as hypertensive, suggesting that nephron damage may have occurred at this lower level. Overall mean diastolic blood pressure but not systolic was found to be significantly higher in the rural environment than the urban setting: mean rural DBP: 66.43 (+/- 15.699) vs urban: 62.78 (+/- 78); P < 0.00001; rural SBP: 113.71 (+/- 23.95) vs urban: 112.69 (+/- 19.87), P = NS. No discernible effect of consanguinity in marriage on blood pressure could be detected in this study but we believe that further details are required before a definite statement can be made on this important subject. The percentiles presented can only be regarded as foundation figures requiring further validation before they can be useful in determining cut-off levels for hypertension for the Saudi population.

Contrasting influence of the living environment and gender on systemic hypertension in Saudi population of Gassim, Saudi Arabia

In a cross-sectional total population survey of Faizia East Primary Health District of Buraidah, which is divided into an "urban" and "rural" sections, casual blood pressure was recorded in 5671 subjects. 2222 (910 males) were adults (> 19 years). 3299 (1561 males) were between 3-18 years, making the paediatric/adolescent cohort of the population. The rest were below 3 years and were not included for calculations in this report. For adults, HPN was defined as > or = 140/90 mm Hg and P/A it was > or = 95th percentile for the age cohorts 3-5, 6-9, 10-12, 13-15 and 16-18 years as recommended by The Task Force for Blood Pressure Control in Children (1987). Each of the three subsets of HPN were derived from these basic definitions without modification. In the adults population, overall prevalence (S/DHPN + ISHPN + IDHPN) was 23.58% (524/2222) and gender prevalence was marginal in favour of males (25.71 vs 22.1% for males and females respectively; OR: 1.22, chi square = 3.89; p = 0.05; CI: 1.00 < OR < 1.49). By contrast, overall HPN prevalence in P/A was 10.64% (351/3299) and in all the age cohorts, girls were very significantly more hypertensive than boys. Overall figures were 13.06 vs 7.94% respectively for girls and boys; OR: 0.57; chi square = 22.65; p < 0000019; CI: 0.45 < OR < 0.73. Only in severe HPN (> or = 99th percentile) in 16-18 year age cohort did male preponderance become obvious. When the influence of the living environment was examined, in adult population (urban: 40,001; rural: 1670 subjects), for all age cohorts the rural environment which is largely inhabited by the unsophisticated Bedouins living close to their livestock, significantly predisposed to HPN as compared to the urban setting. Overall figures are 19.95 vs 32.60%, urban vs rural respectively: OR: 0.52; chi square = 40.4; p < 0.000000; CI: 0.42 < OR < 0.64. On the other hand, in the P/A population (2301 urban, 998 rural) for the age cohorts 3-5 and 6-9 years the urban environment significantly predisposed to HPN. At 10-12 years the prevalence was virtually even (12.65 vs 12.71%; OR: 0.99; p: NS). Thereafter, i.e. 13-15, 16-18 year cohorts, the rural environment became more dominant, just like the adult pattern. In other words whatever the factors in the unsophisticated Bedouin "rural" setting which predisposes to HPN does not become operative until after childhood--after 12 years. This contrasting gender and environmental influence in our study population seems unique, being reported for the first time. It may be pointing us in new direction in the elucidation of the pathogenesis of HPN and should deserve further studies.

Studies on preventive nephrology: Systemic hypertension in the pediatric and adolescent population of Gassim, Saudi Arabia

Casual blood pressure was recorded for subjects of Faizia East Primary Health District during a cross-sectional population survey. Valid information was obtained from 5671 subjects, out of which 3299 (1561 males and 1738 females) were between the ages of three and 18, constituting therefore the pediatric/adolescent (P/A) sector of our study population. The prevalence of hypertension (HPN), defined as A(3) 95th percentile for total HPN population (mild and severe) and A(3) 99th percentile for severe, was calculated for the three-year age cohorts suggested by the Task Force on Blood Pressure Control in Children (1987). The three subsets of HPN were derived from the suggested cut-off levels without any modifications. Overall prevalence of HPN was, for the P/A, found to be 10.65% (351/3299). Females in all the age cohorts were significantly more hypertensive than males, overall gender prevalence being 7.94% (124/1561) for males against 13.06% (227/1738) for females: P=0.0000019; CI: 0.45<OR7lt;0.73. One hundred and twenty-eight subjects (3.88%) had severe HPN, again with gender difference in favor of females (2.57 versus 5.06%), P=0.00022; CI: 0.33<OR<0.74). Sixty-seven and a half percent (237/351) of the HPN population were in the six to 12 year age group, with the significant gender difference persisting (P=0.000407; CI: 0.41<OR<0.74). Ninety-four of these (73.44%) had the severe HPN, with similarly significant gender difference (P=0.0018; CI: 0.31<OR<0.79). Significantly, 67% of gross proteinuria for the entire population has been found in the same age cohort with the same significant gender difference. ISHPN was found to constitute 51.57% (181/351) of the HPN population, followed by IDHPN with 32.48% (114/351) and S/DHPN the least with 15.95% (56/351). The significant gender difference in favor of females noted seems to be unique to the Saudi population. Similarly, the preponderance of ISHPN subsets is, to our knowledge, being recorded from the first time in literature. When coupled with the pattern of proteinuria, we believe that, in the context of preventive nephrology, greater attention will need to be devoted to the pediatric population, especially females.

Studies on preventive nephrology: pattern of the subsets of hypertension in the paediatric, adolescent and adult population of Gassim, Saudi Arabia

As part of our studies in preventive nephrology, we have recorded the casual blood pressure during a total population cross-sectional survey of the Faizia East Primary Health District (FEPHD). A total of 5671 subjects had adequate records. Of these 2222 were adults (> 19 years). The prevalence of systemic hypertension (HPN) was calculated, using as cut-off levels, > or = 140/90 for the adult population and > or = 95th percentile as recommended by the Task Force for Blood Pressure Control in Children (1987) for the paediatric and adolescents (3-18 years). Using these definitions without modification, the three subsets of HPN viz. combined systolic/diastolic (S/DHPN), isolated systolic (ISHPN) and isolated diastolic (IDHPN) were derived for each of the age cohorts studied-10-year age cohorts for the adults and the Task Force 3-year age cohorts for the paediatric/adolescent (P/A) population. In both adult and P/A population ISHPN constituted the bulk of the hypertensive population (56.68% for the adults and 51.57% for P/A). the IDHPN subset was the least for adults making up 11.64% while the S/DHPN was in between constituting 31.68%: For the P/A population S/DHPN was the least, 15.95% and IDHPN (32.48%) was in between. When distributed into 10-year age cohorts for the adults, ISHPN showed the steepest gradient depicting increasing prevalence with advancing age. On the other hand, IDHPN did not rise with age; if at all, it tended to fall. The slope for S/DHPN was sandwiched in between. For the P/A population, for all the 3-year age cohorts, and for all the three subsets, there was an initial peak in childhood followed by a decline in adolescence. However, some variations were discernible in each subset. ISHPN in girls peaked at 10-12 before declining but in boys it virtually followed an even keel. IDHPN, in both boys and girls peaked sharply at 6-9 before a rapid decline in prevalence into adolescence. S/DHPN also peaked at 6-9 but both the upward slope and the subsequent decline were more gentle than the other subsets. When viewed together for our study population, assuming equivalence in cut-off levels for HPN, both ISHPN and S/DHPN seem to exhibit a bimodal curve, with one peak in childhood and a second rise in adulthood continuing into old age. IDHPN showed a unimodal curve, with the one peak in childhood followed by a continuing decline through adolescence into adulthood to virtual disappearance in old age. We believe these slopes may have prognostic significance which are not entirely clear at the moment but our findings reinforce the importance of the systolic blood pressure and that diastolic blood pressure alone should no longer be used as the index treatment or complication of high blood pressure.

Ten years follow-up of idiopathic focal and segmental glomerulosclerosis

Sixty-four biopsy proven cases of idiopathic focal and segmental glomerulosclerosis (FSGS) were studied retrospectively for 10 years. The mean age of the study patients was 29.5 years and 81.2% of the patients were males. Edema, hematuria, hypertension and azotemia were the main presenting features. All cases were initially treated with steroids alone. Nineteen cases (29.7%) had complete and 14 patients (21.9%) had partial remission while 31 cases (48.4%) had no response. Twenty non-responsive cases were given cyclophosphamide in addition to steroids and seven (35%) patients had complete remission and a similar number had partial remission. Patients who had azotemia, hypertension, nephrotic range proteinuria and diffuse mesangial hypercellularity in addition to segmental sclerosis on renal histology at presentation were classified as malignant FSGS. There were eight such cases of which two showed partial response to steroids. One patient went into complete remission with steroids and cyclophosphamide while two others showed partial remission. Mean duration before the occurrence of renal death in benign FSGS patients was six years while all malignant FSGS cases had renal death within two years. Differentiating benign and malignant FSGS will help in prognostication of patients with this pathology.

What decides: high mortality in paediatric acute renal failure?

Forty paediatric cases of A.R.F. (Acute Renal Failure) of various aetiology were included in the study. 60% of patients were less than 4 years of age with male predominance. 80% cases reported to us very late with oligoanuria of more than 24 hours (2-7 days). Diarrhoea, vomiting and fever were other dominant symptoms. Maximum cases were severely anaemic (87.5%) with mean Hb 7.73 +/- 1.9 gm%. 40% cases were of underweight while only one case (2.5%) was of over weight, inspite of volume excess in 40% cases. All 24 cases, who were estimated for serum albumin, found to have marked hypoalbuminemia. Mortality was found to be as high as 65% inspite of effective peritoneal dialysis in all cases. High mortality seems to be due to profound anuria of many days (because of marked delay in reaching the hospital), fever and malnutrition besides other factors as aetiology.

Evaluation of cellular immunity in diabetic uraemics by cutaneous response to recall antigens and 2:4 dinitrochlorobenzene and T-cell rosette formation

Twenty diabetic uraemics and twenty two healthy matched controls comprised the material for this study. Cell mediated immunity was assessed by estimation of T-cell rosette percentage and cutaneous response to recall antigens--purified protein derivative, candida antigen and 2:4 dinitrochlorobenzene. Results analysis revealed depressed cell mediated immunity in diabetic uraemics in the form of impaired cutaneous response to recall antigens and reduction in T cell rosette percentage, in comparison to controls.

Ascorbic acid status in uremics

Plasma levels of ascorbic acid (AA) and dehydroascorbic acid (DHA) were estimated in 27 patients of end stage renal failure (ESRF) on standard conservative therapy (group A) and 9 patients of ESRF on maintenance haemodialysis (MHD; group B). Fourteen healthy subjects matched for age and sex served as control (group C). The dietary intake of vitamin C was significantly decreased in group A than in group B compared to control. Similarly, plasma AA was significantly lowered to 0.801 +/- 0.283 mg per cent in group A compared to 1.421 +/- 0.47 mg per cent in control. While it was just lowered to 1.058 +/- 0.272 mg per cent in group B. Although plasma level of DHA was raised to 0.243 +/- 0.486 mg per cent and 0.166 +/- 0.54 mg per cent in groups A and B respectively, the increase was not statistically significant. In our present study, the DHA/AA ratio was found to be inversely proportional to the plasma AA. Further, this ratio has been claimed to be a better indicator of overall reducing atmosphere (i.e., profile of vitamin C) of the body.

Hepatic changes during short-term haemodialysis

Twenty five patients with end stage renal disease were studied to find out the biochemical and hepatic morphological changes during short term haemodialysis. Asymptomatic hepatomegaly was seen in 32% of cases, transaminase elevation in 28% and positive Australia antigen in 12% of cases. Histopathological changes were observed in all the 12 patients in whom liver biopsy was done. Ten patients (82%) exhibited multiple abnormalities. The commonest findings were fatty change (8 patients); hepatic congestion, focal necrosis, Kupffer cell hyperplasia (6 patients each); and portal triaditis (5 patients).

Hypermagnesemia following aluminum phosphide poisoning

Aluminum phosphide (ALP) is highly toxic to the lungs, heart and blood vessels causing pulmonary edema, shock and arrhythmias. There is massive focal myocardial damage resulting in raised cardiac enzymes. This study included 92 patients of proven ALP poisoning. The age varied between 20-50 years and the majority (74) were females. Clinical manifestations were nausea and vomiting (92), dyspnea and palpitation (72 each), cyanosis (54), hypotension (32) and shock (46) etc. Cardiac arrhythmias were present in 80 cases and hypermagnesemia in 78 patients. Mean serum magnesium level (1.95 +/- 0.18 mE/l) was significantly (p less than 0.01) raised compared to mean magnesium level in control subjects (1.62 +/- 0.26 mEq/l). Hypermagnesemia results from myocardial and liver damage and to our knowledge has not been described in the literature. Of 92 cases studied, 66 died, 60 of whom died within 24 hours of ALP ingestion. Treatment is supportive.

Effect of calcium and calcium blockers in hypertension

Calcium is important in the maintenance of arterial smooth muscle function and its alteration from normal may predispose to atherogenesis and hypertension. Slow channel inhibitors such as nifedipine and calcium salts have been used separately to modulate arterial calcium in patients with hypertension. This study included 41 patients with essential hypertension, of whom 29 responded to calcium gluconate therapy (9.8/6.3 mmHg) and the remaining 12 (group B) showed either no response or a rise in blood pressure. Combined administration of calcium and nifedipine in responders (29 cases, group A) in a single-blind, placebo-controlled manner showed a further substantial decrease (9.6/3.2 mmHg) in pressure compared with pressures during placebo administration in both short- as well as long-term administration in group B patients. Although it is difficult to predict the positive role of calcium in hypertension, non-obese females with increased salt intake show a greater response to calcium therapy. It is possible that calcium salts plus calcium blocker therapy can further reduce the blood pressure in a particular subset of hypertensives. However, this needs further confirmation in a larger study.

Relationship between occupational stress and social support in flight nurses

Social support has been consistently implicated as a means of dealing with stress. The purpose of this study was to examine the relationship between the levels of occupational stress and social support in flight nurses. Chosen by systematic random sampling, 160 flight nurses were asked to complete demographic, social support, and occupational stress questionnaires. Hans Selye's stress response model was used as the conceptual framework. The 113 respondents were predominately white females with university preparation. They reported low levels of occupational stress and high levels of social support (r = -0.42, p less than 0.01). Statistically significant (p less than 0.01) negative correlations were also found between social support and three of the four occupational stress subscales: job dissatisfaction, organizational stress, and somatic distress. The results of this study support the hypothesis that high levels of perceived social support are associated with low levels of perceived occupational stress.

Clinicopathological studies of carcinoma oesophagus with special reference to changes in surrounding epithelium

A total 17 cases of carcinoma oesophagus were studied in a period of 2 years. Ten patients (58.82%) were males and rest were females. Maximum cases (64.70%) were seen in 5th and 6th decades. Majority of the patients belonged to low socio-economic group (47.05%) followed by middle socio-economic group (41.17%). Dysphagia was present in all cases, followed by weight loss 52.94% and other symptoms. Cancer was equally distributed in middle third and lower third of the oesophagus (41.18% in each group) only in 3 cases it was in upper third of the oesophagus. Histologically 70.5% tumours were squamous cell carcinoma, 17.64% were adenocarcinoma and 11.76% were undifferentiated carcinoma. Surrounding epithelium in 17.64 per cent cases showed chronic oesophagitis, 4 cases (23.52%) showed acanthosis and dysplasia, and two cases revealed carcinoma in situ. Hence findings of oesophagitis, acanthosis, dysplasia, carcinoma in situ suggest that oesophagitis and acanthosis may be considered as precancerous lesions.

Pre-cancerous lesions of stomach

Total 39 cases of carcinoma stomach were noticed out of 142 malignant tumours of GIT (27.46 percent). Histologically maximum cases were of diffuse type (56.41 percent) followed by intestinal type (35.89 percent) and indolent mucoid carcinoma (7.69 percent) of the stomach. The surrounding epithelium showed lot of changes in the intestinal type of carcinoma stomach. About 78.57 percent showed intestinal metaplasia, 14.28 percent of these cases showed chronic gastric ulcer and severe dysplasia (carcinoma in situ) and another 14.28 percent revealed villous adenoma with carcinoma in situ. In contrast to this, in diffuse variety, only 13.63 percent cases revealed intestinal metaplasia, 27.27 percent showed basal cell hyperplasia, stratification of the epithelium of crypts and diffuse infiltration of mucosa by malignant cells and 4.54 percent showed atrophic gastritis also. In mucoid carcinoma all cases had basal cell hyperplasia and stratification of crypts. Hence these conditions should be taken as premalignant lesions of stomach and should be cured in proper time.