Evaluating tools to support a new practical classification of diabetes: excellent control may represent misdiagnosis and omission from disease registers is associated with worse control

AIMS

To conduct a service evaluation of usability and utility on-line clinical audit tools developed as part of a UK Classification of Diabetes project to improve the categorisation and ultimately management of diabetes.

METHOD

We conducted the evaluation in eight volunteer computerised practices all achieving maximum pay-for-performance (P4P) indicators for diabetes; two allowed direct observation and videotaping of the process of running the on-line audit. We also reported the utility of the searches and the national levels of uptake.

RESULTS

Once launched 4235 unique visitors accessed the download pages in the first 3 months. We had feedback about problems from 10 practices, 7 were human error. Clinical audit naive staff ran the audits satisfactorily. However, they would prefer more explanation and more user-familiar tools built into their practice computerised medical record system. They wanted the people misdiagnosed and misclassified flagged and to be convinced miscoding mattered. People with T2DM misclassified as T1DM tended to be older (mean 62 vs. 47 years old). People misdiagnosed as having T2DM have apparently 'excellent' glycaemic control mean HbA1c 5.3% (34 mmol/mol) vs. 7.2% (55 mmol/mol) (p<0.001). People with vague codes not included in the P4P register (miscoded) have worse glycaemic control [HbA1c 8.1% (65 mmol/mol) SEM=0.42 vs.7.0% (53mmol/mol) SEM=0.11, p=0.006].

CONCLUSIONS

There was scope to improve diabetes management in practice achieving quality targets. Apparently 'excellent' glycaemic control may imply misdiagnosis, while miscoding is associated with worse control. On-line clinical audit toolkits provide a rapid method of dissemination and should be added to the armamentarium of quality improvement interventions.

Meal patterns of malaysian adults: findings from the Malaysian adults nutrition survey (MANS)

INTRODUCTION

Meal patterns have received little attention in nutrition studies. The aim of this study is to present the findings on general meal patterns of Malaysian adults.

METHODS

The Malaysian Adults Nutrition Survey (MANS), carried out in 2002 and 2003, involved 6,928 adults selected by stratified random sampling from all households by zone in Peninsular Malaysia, Sabah and Sarawak.

RESULTS

In general, the results showed that most respondents (74.16%) ate three meals per day; 89.20% of the respondents consumed breakfast, while 88.57% consumed lunch and 91.97% consumed dinner with no significant difference in terms of sex. In Peninsular Malaysia, the Northern Zone had the highest number of people consuming breakfast compared to other zones. Meanwhile, the population in Sarawak had the largest proportion of people consuming lunch and dinner, but the smallest proportion of people consuming breakfast. A significantly higher number of the rural population consumed breakfast and lunch than urbanites; however there was no significant difference in dinner consumption. Generally, breakfast consumption increased with age whereby significant difference existed between the 18 to 19 years age group and the age group of 30 years and older. Lunch intake among the age groups showed no significant difference. In contrast, dinner consumption was significantly lower among the 18 to 19 years age group compared to all other age groups. Comparison among the ethnic groups showed that the Indian population had the lowest percentage of having breakfast and lunch while the Orang Asli had the lowest percentage of consuming dinner. However, the Orang Asli recorded the highest percentage for taking breakfast and lunch while the Chinese had the highest percentage of taking dinner.

CONCLUSION

Considering that Malaysian adults consumed their conventional breakfast, lunch and dinner, these findings indicatethat Malaysians are maintaining their traditional meal patterns.

Miscoding, misclassification and misdiagnosis of diabetes in primary care

AIMS

To determine the effectiveness of self-audit tools designed to detect miscoding, misclassification and misdiagnosis of diabetes in primary care.

METHODS

We developed six searches to identify people with diabetes with potential classification errors. The search results were automatically ranked from most to least likely to have an underlying problem. Eight practices with a combined population of 72,000 and diabetes prevalence 2.9% (n = 2340) completed audit forms to verify whether additional information within the patients' medical record confirmed or refuted the problems identified.

RESULTS

The searches identified 347 records, mean 42 per practice. Pre-audit 20% (n = 69) had Type 1 diabetes, 70% (n = 241) had Type 2 diabetes, 9% (n = 30) had vague codes that were hard to classify, 2% (n = 6) were not coded and one person was labelled as having gestational diabetes. Of records, 39.2% (n = 136) had important errors: 10% (n = 35) had coding errors; 12.1% (42) were misclassified; and 17.0% (59) misdiagnosed as having diabetes. Thirty-two per cent (n = 22) of people with Type 2 diabetes (n = 69) were misclassified as having Type 1 diabetes; 20% (n = 48) of people with Type 2 diabetes (n = 241) did not have diabetes; of the 30 patients with vague diagnostic terms, 50% had Type 2 diabetes, 20% had Type 1 diabetes and 20% did not have diabetes. Examples of misdiagnosis were found in all practices, misclassification in seven and miscoding in six.

CONCLUSIONS

Volunteer practices successfully used these self-audit tools. Approximately 40% of patients identified by computer searches (5.8% of people with diabetes) had errors; misdiagnosis is commonest, misclassification may affect treatment options and miscoding in omission from disease registers and the potential for reduced quality of care.

Primary lung cancer presenting as metastasis to the big toe

A 62-year-old man presented with a 6-week history of shortness of breath, weight loss and painful swelling of the great toe. Examination elicited an ulcerated swelling of the right great toe, thought to be an ingrowing toenail. Chest ‘crackles’ and an enlarged supraclavicular lymph node were detected. Biopsies of the toe swelling and bronchi both showed squamous cell carcinoma, confirmed radiologically as stage IV lung cancer. The patient was referred for palliative amputation of the toe. Cancer metastases to the digits may arise in bone, before enlarging to invade skin, or arise in skin first. 20-60% of cutaneous metastases present before or at the same time as the primary lung tumour. Cutaneous metastases and those in the digits indicate very poor prognosis. Their prompt diagnosis and management can dramatically improve a patient’s quality of life and should be strived for.

Hysterosalpingographic findings in infertile women: a seven year review

OBJECTIVES

To review the hysterosalpingographic (HSG) findings in women investigated for infertility in a tertiary center in north eastern Nigeria.

MATERIALS AND METHODS

A retrospective review of HSG films of 272 women investigated for infertility between January 2000 and December 2006 were reviewed.

RESULTS

One hundred and thirty (47.8%) were investigated for primary infertility, while 142 (52.2%) were investigated for secondary infertility. Most of the women investigated for infertility by HSG had abnormal findings 192(70.6%). The most common pathology revealed among the infertile women was tuboperitoneal factor in 196 (72.1%) followed by uterine synechia in 35(12.9%). Seventeen (6.3%) had bilateral tubal block and 5 (1.8%) had bicornuate uterus.

CONCLUSION

HSG is helpful in the investigation of infertile women.

Sonographic gallbladder wall thickness in normal adult population in Nigeria

Aim. The aim of the study was to determine the ultrasonic gallbladder wall thickness in normal adult Nigerians so as to create standards for defining gallbladder abnormalities in Nigerians. Method. Four hundred adults comprising 228 (57%) women and 172 (43%) men aged 16 - 78 years, who had normal clinical history and physical findings, were recruited. The gallbladder wall thickness was obtained in the supine, prone and right anterior oblique positions. Differences in gallbladder wall thickness were determined using the chi-square test, while the relationship between the ultrasound-measured gallbladder wall thickness and the subjects’ age, sex, height and weight were analysed using the Pearson product moment correlation. Normal ranges and related statistics were estimated and tabulated according to age group and sex. Results. The mean age of the subjects was 32±13.2 years. The mean gallbladder wall thickness range was 1.8 - 2.8 mm±0.5mm. The thickness range for females was 1.7 - 2.7 mm±0.5 mm, and that for males was 1.9 - 2.9 mm±0.5 mm. There was a statistically significant difference (p

Breastfeeding in Malaysia: Results of the Third National Health and Morbidity Survey (NHMS III) 2006

In Malaysia, the National Breastfeeding Policy recommends exclusive breastfeeding for the first six months of life and continued up to two years. Since the 1990s, several breastfeeding promotion programmes had been implemented in the country. This article reports the findings on the prevalence of breastfeeding practice from The Third National Health and Morbidity Survey (NHMS III) which was conducted in 2006. A total of 2167 mothers or carers of children below two years old were interviewed representing 804,480 of the estimated population of children aged below 2 years in Malaysia. Respondents were asked whether various types of liquid or solid food were given to the child at any time during the preceding 24-hour period. The overall prevalence of ever breastfed among children aged less than 12 months was 94.7% (CI: 93.0 - 95.9). The overall prevalence of exclusive breastfeeding below 6 months was 14.5% (CI: 11.7 - 17.9). Prevalence of timely initiation was 63.7% (CI: 61.4 - 65.9) and the continued prevalence of breastfeeding up to two years was 37.4% (CI: 32.9 - 42.2). The findings suggest that the programmes implemented in the last ten years were effective in improving the prevalence of ever breastfeeding, timely initiation of breastfeeding and continued breastfeeding up to two years. However, the challenge is to improve exclusive breastfeeding practice. Longterm community-based interventions need to be carried out in partnership with the existing health care system, focusing on discouraging the use of water and infant formula, especially in the first few months of life.

Physical Activity Pattern and Energy Expenditure of Malaysian Adults: Findings from the Malaysian Adult Nutrition Survey (MANS)

This paper aims to report the physical activity pattern and energy expenditure of adults aged 18 - 59 years in the Malaysian Adults Nutrition Survey (MANS) carried out between October 2002 and December 2003. The survey included 7349 adults representative of Peninsular Malaysia (Northern, Southern, Central and East Coast), as well as Sabah and Sarawak. A total of 6926 adults, comprising 3343 men and 3583 women, completed the physical activity section of the survey. Physical activity data was obtained using a physical activity questionnaire and 24-hour physical activity recall. Basal metabolic rate (BMR) was calculated from Ismail et al. (1998) predictive equations; total energy expenditure (TEE) was then estimated through factorial calculations based on time allocated and energy cost of various activities. Physical activity level (PAL) was calculated as the ratio of TEE to BMR. It was found that almost three-quarters of Malaysian adults traveled by passive modes of transportation. Only a third reported having ever-exercised, and an even smaller proportion of the population (14%) had adequate exercise. The population also spent the majority of their time (74% of the day) in sedentary activities, such as sleeping or lying down; doing light intensity activities (15% of the day), and doing moderate to vigorous intensity activities (10% of the day). Mean BMR and TEE was significantly higher amongst men than women, while mean PAL values were similar for men [1.6 (1.6 - 1.7)] and women [1.6 (1.6 - 1.6)]. More men (16%) were categorised as having active PAL compared to women (10%), while more women (43%) were categorised as having sedentary PAL compared to their male counterparts (37%). The present study provides the first in-depth report of the physical activity pattern, and national estimates of energy expenditure and physical activity levels of Malaysian adults, and concluded that Malaysian adults are generally sedentary. It is thus important that physical activity be further promoted and integrated into the lives of the population, preferably through various health promotion efforts as well as through the commitment of the authorities in providing a suitable environment for an active lifestyle.

PET-CT as an effective imaging modality in the staging and follow-up of post-transplant lymphoproliferative disorder following solid organ transplantation

INTRODUCTION

To establish the role of positron-emission tomography (PET)-computed tomography (CT) in post-transplant lymphoproliferative disorder (PTLD) patients, compared to conventional imaging (ultrasonography/CT/magnetic resonance imaging) in relation to its accuracy, sensitivity and specificity.

METHODS

30 patients (26 males and 4 females), with a median age of 49.5 (range 18-74) years, were retrospectively evaluated. In 29 cases, the diagnosis was confirmed by histopathology. Malignant lymphoma was detected in 20 cases, polymorphic lymphoproliferative disorder in six cases, multiple myeloma in two cases and Hodgkin's disease in one case. A total of 49 PET-CTs (13 studies for staging at diagnosis and 36 studies at follow-up as assessment post-therapy) were compared to conventional imaging. Imaging results in accordance with disease status were assessed at a median follow-up of 17.8 (range 1.5-42.2) months post-PET-CT.

RESULTS

In 41 of 49 examinations performed for staging and on follow-up, PET-CT and conventional imaging findings were concordant. Compared to conventional imaging, PET-CT showed comparable sensitivity (75 percent vs. 83 percent), similar specificity (100 percent in both modalities) and comparable accuracy (77 percent vs. 85 percent) during staging at diagnosis. PET-CT was found to be superior to conventional imaging modalities at follow-up, with greater sensitivity (100 percent vs. 81 percent), specificity (80 percent vs. 100 percent) and accuracy (97 percent vs. 83 percent).

CONCLUSION

PET-CT is an accurate diagnostic tool for staging and for the follow-up of PTLD patients. It represents a good alternative imaging method to avoid contrast-related nephrotoxicity in patients who often develop impaired renal function secondary to chronic immunosuppressive therapy. However, further studies are recommended before considering PET-CT as a routine diagnostic tool in PTLD.

Use of traditional and complementary medicine in Malaysia: a baseline study

BACKGROUND

The increasing popularity and use of traditional and complementary medicine (TCAM) in both developed and developing countries, including Malaysia, have raised significant public health policy issues. However, currently, there is a paucity of baseline data on such usage by the Malaysian community.

OBJECTIVE

This study was conducted to identify and describe the prevalence and frequency of various TCAM modalities that are being used by the Malaysian population by age, gender, marital and working status, educational level and ethnic group for health issues and maintenance.

DESIGN

A nationwide interviewer-administered questionnaire survey was conducted in August 2004. An open-ended questionnaire pertaining to TCAM modalities was used to increase the probability of capturing maximum data. This survey implemented a multistage design, stratified by state and urban/rural random sampling, proportionate to the size of the state population and was representative of the Malaysian population. Post-survey classification of modalities was done accordingly. Complex data analysis was carried out using SPSS 13.0.

RESULTS

Various TCAM modalities that were used by the Malaysian population were identified and categorised. Biological-based therapies, which included herbal therapy, were most commonly used for health problems (88.9%) and for health maintenance (87.3%). Under this category, herb-based application/herb-based beauty product/herb-based hygiene product group was most commonly used for health issues (23.6%) while pure herbs were the ones most commonly used for health maintenance (29.6%). There was no significant difference across all groups in the usage of biological-based therapies for health issues.

CONCLUSION

The study showed that there is a high prevalence of TCAM use by the Malaysian population, particularly in the use of herb-based therapies for both health issues and health maintenance. Thus, a strict guideline for herbal commercialisation as well as public education is important.

Body Mass Index (BMI) of Adults: Findings of the Malaysian Adult Nutrition Survey (MANS)

The Malaysian Adults Nutrition Survey (MANS) was carried out between October 2002 and July 2003, involving 6,775 men and 3,441 women aged 18 - 59 years. Anthropometric assessment showed that the overall mean body weight and BMI were 62.65 kg (CI: 62.20, 63.09) and 24.37 kg/m2 (CI: 24.21, 24.53) respectively. Based on the WHO (1998) classification of BMI, 12.15% (CI: 11.26, 13.10) were obese (BMI > 30 kg/m2), and 26.71% (CI: 25.50, 27.96) overweight (BMI > 25 - 29.9 kg/m2). Significantly, more women were obese [14.66% (CI: 13.37, 16.04)] while significantly more men were overweight [28.55% (CI: 26.77, 30.40)]. Ethnicitywise, prevalence of obesity was highest among the Malays [15.28% (CI: 13.91, 16.77)] while overweight was highest for the Indians [31.01% (CI: 26.64, 35.76)]. Both obesity and overweight were highest among those aged 40 - 49 years. Obesity was highest for those whose household income was between RM1,500 - 3,500 while overweight was more prevalent for those whose household income exceeded RM3,500. The prevalence of overweight was highest for those with primary education [31.90% (CI: 29.21, 34.72)]. There was no significant urban rural differential in both obesity and overweight. The study found 9.02% (CI:8.82, 10.61) with chronic energy deficiency (CED) (BMI < 18.5 kg/m2). The prevalence of CED was relatively higher in the indigenous population (Orang Asli) [14.53% (CI: 5.14, 34.77)], subjects aged 18-19 years [26.24% (CI: 21.12, 32.09)], and with monthly household income of < RM1,500 [10.85% (CI: 9.63, 12.20)]. The prevalence of CED was not significantly different among the geographical zones and educational levels, and between urban/rural areas and sexes. The results call for priority action to address the serious problem of overweight and obesity among Malaysian adults as it poses a grave burden to the country's resources and development.

Daily Energy Intake from Meals and Afternoon Snacks: Findings from the Malaysian Adults Nutrition Survey (MANS)

Meal and snack patterns are associated with energy and nutrient intakes and consequently health and nutritional status. The aim of this paper is to describe the percentage of daily energy intake from meals and afternoon snack among Malaysian adults. The study included a representative sample of adults aged 18-59 years (n=7349) from a nationwide Food Consumption Survey conducted by the Ministry of Health. Information on dietary intake was obtained using a one day 24-hour diet recall (24-HDR). Dietary data on 6886 adults were analysed using Nutritionist ProTM and statistical analysis was carried out using the SPSS 13.0. The median percentage of daily energy intake is reported only for adults consuming meals and afternoon tea and by socio-demographic characteristics as well as body mass index (BMI) status. More than 80% of Malaysian adults consumed morning meals, lunch and dinner and 54% reported having afternoon tea. The median percentage of energy intake from morning meals, lunch, dinner and afternoon tea was 29.9%, 30.5%, 32.4% and 17%, respectively. There were variations in the median percentage of energy from meals and snacks according to the socio-demographic variables and BMI status. It is important to understand the eating patterns of Malaysians as the information can assist in efforts to address obesity and diet-related chronic diseases among adults.

Energy and Nutrient Intakes: Findings from the Malaysian Adult Nutrition Survey (MANS)

Nutrition surveys based on a representative sample of the Malaysian adult population have hitherto not been reported. In 2003, the Ministry of Health, Malaysia, conducted the Malaysian Adult Nutrition Survey (MANS), the first and largest nutrition survey in the country which aimed to provide detailed quantitative information on nutritional status, food and nutrient intakes, and physical activity pattern on a nationwide representative sample of adult subjects between the ages of 18 and 59 years. The survey covered four zones in Peninsular Malaysia (Central, Southern, Northern and East Coast), Sabah and Sarawak. This paper presents the mean and selected percentiles of energy and nutrient intake of 6886 subjects by selected demographic and socioeconomic characteristics. Energy contributions by macronutrients and dietary adequacy in relation to the Recommended Nutrient Intake for Malaysians are also described. Information on dietary intake was collected by trained nutritionists using a one day 24-hour diet recall. Dietary data were analysed using Nutritionist Pro, a diet analysis software and statistical analysis was carried out using the SPSS ver. 13.0. In most of the demographic and socioeconomic groups, males had higher mean energy (1776 kcal) and nutrient intake and percent achievement of RNI than females (1447 kcal). The proportions of calories derived from macronutrients were within the recommendations for a healthy diet. Intake of micronutrients such as iron, calcium and vitamin A was about 50% of RNI particularly in women. Sodium intake of Malaysians, not reported in earlier studies, is also made available. Under-reporting using the EI/BMR ratio was found in half of the population studied. The present study provides the first national estimates of energy and nutrient intake of the Malaysian adult population. Regular nutrition surveys are needed at the national level to provide valuable information on trends in food and nutrient intake, particularly among age and ethnically diverse subgroups of the population.

Umbilical varix presenting as an incarcerated umbilical hernia--a costly mistake if not recognised

Incarcerated umbilical hernias commonly present as emergencies. Often they are diagnosed clinically and repaired surgically. In the case reported here, surgery could have been complicated by a major haemorrhage. An accurate history, high index of suspicion and attention to detail are paramount.

The effect of local anaesthetic cream (EMLA®) applied with an occlusive dressing on skin thickness. Does it matter?

EMLA cream is used in plastic surgery as a topical anaesthetic to harvest split skin grafts. It has been observed that the skin appears pale and oedematous after the application of EMLA. The aim our study was to determine the effect of EMLA with an occlusive dressing on skin thickness using a high frequency ultrasound. Twenty volunteers took part in this study after approval from the ethics committee. An area of skin was marked on both thighs and the skin thickness of each, measured using ultrasound. EMLA with an occlusive dressing was applied to one thigh. This was removed after at least 2 h of application time but at different time points and skin thickness of each thigh measured again. Data was analysed using t-test and Pearson's correlation. Mean age in years +/- SD (range) was 36.1 +/- 12.1 (23 - 61). Male:female ratio was 8:12. Mean skin thickness +/- SEM increased from 1.86 +/- 0.055 mm prior to EMLA application to 1.96 +/- 0.051 mm post-EMLA application p= 0.02. There was a significant correlation between the increase in skin thickness and duration of application of EMLA cream (p = <0.001, R2 = 0.59). The results conclude that EMLA applied under an occlusive dressing has an effect on skin tissue thickness and any surgeon who harvests split skin grafts under EMLA should be aware of this. Further research is needed to compare laser treatments performed under local anaesthetic creams against general anaesthesia as an increase in skin thickness may affect the depth of laser penetration.

Assault cases in Maiduguri metropolis: A comparative study of police and accident and emergency units' records

BACKGROUND

Information on the incidence of assault cases such as armed robbery, fights and house burglaries in most Nigerian cities are usually based on data collected from police records with little or no attempt to tap medical sources of information.

OBJECTIVE

The aim of this study was therefore to compare the rate of recording of assault cases in the Maiduguri metropolitan area by the police at the Maiduguri central police station and the Accident and Emergency unit (A and E) of the University of Maiduguri Teaching Hospital. Possible reasons why assault victims report or do not report to the police before seeking for treatment was also investigated.

METHOD

All victims of assault who attended the A and E unit of the hospital over a one year period (2002-2003) were interviewed and relevant data collected in a prepared form. Findings were compared with the record of assault cases within the same period at the Maiduguri central police station.

RESULT

185 patients presented at A and E with body injuries due to assault during period of study. 108 (58%) informed the police before attending hospital, out of which majority (38.9%) claimed an 'instinctive reaction to do so' as the reason for informing the police. A significant proportion (61%) of those that did not inform the police claimed that the feeling that 'nothing will come out of it' as the reason. Only 41% of cases reported to the police were recorded. There was a tendency by the police to record cases where gun was used or the victim was a female.

CONCLUSION

The true picture of violence in most Nigerian cities can better be assessed by collecting data from both the relevant A and E department as well as from the police. The need for the populace to develop confidence and trust in the police cannot be overemphasised.

Preliminary report on spiegelberg pre and post-operative monitoring of severe head-injured patients who received decompressive craniectomy

The monitoring of craniospinal compliance is uncommonly used clinically despite it's value. The Spiegelberg compliance monitor calculates intracranial compliance (C = deltaV/deltaP) from a moving average of small ICP perturbations (deltaP) resulting from a sequence of up to 200 pulses of added volume (deltaV = 0.1 ml, total V = 0.2 ml) made into a double lumen intraventricular balloon catheter. The objective of this study was thus to determine the effectiveness of the decompressive craniectomy done on the worst brain site with regard to compliance (Cl), pressure volume index (PVI), jugular oximetry (SjVo2), autoregulation abnormalties, brain tissue oxygen (TiO2) and cerebral blood flow (CBF). This is a prospective cohort study of 17 patients who were enrolled after consent and approval of the ethics committee between the beginning of the year 2001 and end of the year 2002. For pre and post assessment on compliance and PVI, all 12 patients who survived were reported to become normal after decompressive craniectomy. There is no significant association between pre and post craniectomy assessment in jugular oxymetry (p > 0.05), autoregulation (p > 0.05), intracranial brain oxymetry (p = 0.125) and cerebral blood flow (p = 0.375). Compliance and PVI improved dramatically in all alive patients who received decompressive craniectomy. Compliance and PVI monitoring may be crucial in improving the outcome of severe head injured patients after decompressive craniectomy.

Radiographic and anatomic locations of mental foramen in northern Nigerian adults

This study was undertaken to provide information on the most probable positions of the mental foramen among northern Nigerian adults. 157 panoramic radiographs randomly selected from patient's records at the Department of Dental Surgery, University of Maiduguri Teaching Hospital and 32 unsexed mandibles from the collection of bones in the Department of Human Anatomy, University of Maiduguri, were examined for the location of the mental foramen. The most common location was the interdental space between the first and second mandibular premolars (radiographs=34% , dry mandibles=32.8% ), closely followed by the position apical to the second premolars (radiographs=25.5% , dry mandibles=35.9% ). No significant difference in the distribution between males and females and the quantitative position was found to be bilaterally symmetrical in most cases. There is almost an equal chance of locating the mental foramen between the mandibular premolars and apical to the mandibular second premolar. This is of clinical importance with regards to the achievement of effective mental nerve block anaesthesia and the prevention of injury to the mental nerve during surgical procedures.

Fine needle aspiration cytology diagnosis of liver diseases in the University of Maiduguri Teaching Hospital, Maiduguri

The study is aimed at classifying liver diseases diagnosed by fine needle aspiration cytology (FNAC) in our environment and to emphasize the importance of the procedure for management of our patients. Forty-two patients were referred by the physicians for fine needle aspiration cytology diagnosis in Histopathology Department, University of Maiduguri Teaching Hospital between January 2001 and December 2003. There were 30 males and 12 females (2.5:1) with mean age of 44.7 years. The peak age is in the 5th decade of life. The commonest hepatic disease is primary hepatic malignancy, which accounted for 78.6% (33 patients); 3 suspicious of malignancy, one case each of metastatic carcinoma, amoebic liver abscess; liver storage disease and large cell dysplasia. The technique has gained popularity in our center because it is cheap, convenient, minimally invasive, quick and has high precision in obtaining samples. We therefore recommend this procedure in centers where liver diseases are common as a means of initial investigation.

Indications of coronary artery bypass graft in 2003

During the last 3 decades, coronary artery bypass grafting (CABG) emerged, was developed and has progressed. Additionally, recent surgical innovations have been introduced aimed at reducing the trauma without deviating from the efficiency of conventional procedure. At the same time significant evolution in preventive, medical treatment and percutaneous procedures has been observed. The introduction of new treatment has improved the result in medically treated patients. Percutaneous procedures emerged and were developed. New technologies and advances available to adjunctive medical therapies have appeared and have impacted the effectiveness initially established for percutaneous coronary intervention (PCI). Larger use of stent permits a significant decrease in restenosis and the introduction of coated stent will probably improve the

RESULTS

Indication is a moving field. Continuing improvement in medical treatment, technical procedure and development of less invasive surgery modifies the place of each treatment and continuing evaluation and comparison are necessary. Introduction of new treatment, aimed at treating ischemic cardiomyopathy like transmyocardial revascularization, cell transplantation or gene therapy will probably modify indications in the future.

Jaw fractures in Nigerian children: an analysis of 102 cases

OBJECTIVES

To present the prevalence and pattern of jaw fractures in children aged 15 years and below attending two hospitals serving as referral centres for facial injuries in North Eastern Nigeria.

DESIGN

Retrospective Cross Sectional Study.

SETTINGS

Department of Oral and Maxillofacial Surgery, University of Maiduguri Teaching Hospital, Borno State, Nigeria.

SUBJECTS

One hundred and two patients with jaw fractures aged 15 years and below.

MAIN OUTCOME MEASURES

Aetiological factors and pattern of jaw fractufes in children aged 15 years and below.

RESULTS

We retrospectively reviewed 102 patients with jaw fractures aged 15 years and below seen over a five year period at two referral centres in Maiduguri, Northeastern Nigeria. This constituted 9.5% of the total 1,074 cases of maxillofacial injuries managed during the period. The male to female ratio was 7.5:1 and there was a male responderance in all age groups. The main causes of fractures were road traffic accident (n = 55, 53.7%) followed by falls (n = 26, 25%). Other etiological factors such as fights, sports and gunshots accounted for the remaining cases. The mandible was the commonest site with the body commonly fractured (n = 74, 72.5%). No Le Fort III fractures were identified in this study.

CONCLUSION

Despite some limitations to our data, such as exclusion of patients who attended private clinics and lack of modern diagnostic methods, this report shows that there is obvious need for concern about the high prevalence of maxillofacial injuries in children caused by road traffic accidents in North Eastern Nigeria.

Changing picture of facial fractures in northern Nigeria

This was a prospective study that aimed to find out the current pattern of facial fractures in northern Nigeria and to see if changes in the socioeconomic conditions in Nigeria during the past 20-30 years have affected the aetiology, sex and age distribution of the patients, and type of facial fractures. The setting was the maxillofacial unit of the University of Maiduguri Teaching Hospital, which is the only referral centre for facial trauma in north-eastern Nigeria, serving a population of about 30 million people. All 306 patients were treated for facial fracture between January 1996 and December 1999. Most of the patients (126/306, 41%) were in the age range 21-30 years and the male to female ratio was 2.19:1. The main causes of the fractures were assault (n = 147, 48%) followed by road traffic accidents (n = 111, 36%). Other aetiological factors such as falls, and sports or industrial accidents accounted for the remaining cases. Of the assault-related injuries 102 (33%) were the result of armed robbery and 45 (15%) the result of fights, mainly on the farms. The mandible was the most common site of fractures (n = 273, 89%) and most of the mandibular fractures were in the body of the mandible. Only 44/306 patients (14%) reported to the hospital within the first 24 hours after injury. Changing socioeconomic conditions are associated with an increase in assault-related facial fractures, but the predominantly affected age group, sex and site of fracture remain relatively constant.

A novel modified pterin from a Eudistoma species ascidian

The MeOH extract of an Indonesia Eudistoma sp. ascidian contained 1,3,O(7)-trimethylisoxanthopterin (1), a novel pteridine. The purification of 1 was achieved through flash C(18) chromatography and cyano HPLC. The structure was determined primarily through the use of (1)H-(13)C and (1)H-(15)N HMBC measurements and comparison with data obtained for 1,3,7-trimethylguanine (2).

A study of the collodiaphyseal angle of the femur in the North-Eastern Sub-Region of Nigeria

The neck-shaft (collodiaphyseal) angle of 320 femora (200 males and 120 females) from indigenes of North-East sub-region of Nigeria were measured. The average collo-diaphyseal angle in males (136.70 degrees +/- 3.905) was greater than in females (126.65 degrees +/- 3.397) with a highly significant statistical difference between both sexes (P < 0.001). Regional variation has also been shown to exist in the neck-shaft angles. Knowledge of the neck-shaft angle in this region would therefore be useful to the surgeon during internal fixation of fractured neck of the femur and also in determining the sex of individual from skeletal remains for medico-legal reasons.

Distribution of body weight, height and body mass index in a national sample of Malaysian adults

We describe the distribution of body weight, height and body mass index (BMI) by age, sex and ethnicity in Malaysian adults. A national sample of 28,737 individuals aged 20 or older had usable data. They were selected by stratified 2-stage cluster sampling. Percentile tables and curves by age, sex and ethnicity are presented. The body weight and BMI distributions were right skewed, while that of height was symmetrical. BMI distribution showed the expected increase with age, while that of height decrease with age. Differences in BMI between the 2 sexes and among the 4 ethnic groups were observed. Indian had the highest BMI, followed by Malay, Chinese and other indigenous ethnic group.

Novel polyketide metabolites from a species of marine fungi

Fermentation of a marine fungal species obtained from a tissue sample of a marine sponge collected in Indonesia in October 1996, yielded the novel hexaketide compounds iso-cladospolide B (1); seco-patulolide C (2); the 12-membered macrolides, pandangolide 1 (3) and pandangolide 2 (4); and the known terrestrial fungal metabolite, cladospolide B (5).

A differential scanning calorimetry study of the interaction of lasalocid antibiotic with phospholipid bilayers

Interaction of lasalocid sodium salt (Las-Na) with dipalmitoylphosphatidylcholine (DPPC) as a membrane model was investigated by highly-sensitive differential scanning calorimetry (DSC). The insertion properties of the antibiotic were studied both in multilamellar suspensions and unilamellar vesicles, for Las-Na/DPPC molar ratios (r) ranging from 0.005 to 0.1. The effect of the antibiotic on the lipid thermotropic behavior is concentration dependent and drastically changes at a critical r of 0.04 in both model membranes. Below this ratio, Las-Na molecules interact with DPPC bilayers without disrupting the global organization of the membrane. In the multilamellar systems only the transition cooperativity is affected whereas for the mixed vesicles, a decrease in the enthalpy change suggests a different mode of insertion. Above this ratio, implantation of the antibiotic give rise to lateral phase separation in multilamellar systems. These structural modifications have repercussions on the formation of mixed LAS-Na/DPPC vesicles which seems limited to an r value of 0.04.

Trypargine alkaloids from a previously undescribed Eudistoma sp. ascidian

The MeOH extract of an undescribed Eudistoma sp. ascidian was found to contain the known beta-carboline trypargine (3); the two novel trypargine derivatives trypargimine (4) and 1-carboxytrypargine (5); and 3',5'-dibromo-4'-methoxyphenethylamine (6). The structures of the novel trypargine derivatives were elucidated through the use of mass spectrometry and NMR. The trypargine isolated in this study was found to be nearly racemic in contrast to the previously described isolate which was chiroptically pure. Other previously described compounds detected in the MeOH extract include 4-hydroxyphenylacetamide, tryptamine, 1,3,7-trimethylguanine, and tetrahydropentoxyline (7).

A new acyclic diketotriterpenoid isolated from the indonesian marine sponge hyrtios erectus

The structure of diketotriterpenoid 1, isolated from the marine sponge Hyrtios erectus collected in Indonesia, has been elucidated by spectroscopic analysis.

Successful treatment of tetralogy of Fallot with pulmonary atresia using a pulmonary homograft

A 13-year-old boy with tetralogy of Fallot and pulmonary atresia after a Waterston and Blalock-Taussig shunt underwent successful repair using a cryopreserved pulmonary homograft as a valved extracardiac conduit. Aortic transection gave a good operative field for pulmonary angioplasty and closure of the Waterston anastomosis. The cryopreserved pulmonary homograft provided excellent handling characteristics. The postoperative course was good, and postoperative echocardiography showed good function of the valved conduit.

Plakinidine D, a new pyrroloacridine alkaloid from two ascidians of the genus Didemnum

A previously undescribed red Didemnum sp. collected in Indonesia contained a novel pyrroloacridine, plakinidine D (4), along with the known compounds 3,5-diiodo-4-methoxyphenethylamine (5) and ascididemin (6), both of which had previously been isolated from ascidians of the genus Didemnum. Plakinidine D (4) and 3,5-diiodo-4-methoxyphenethylamine (5) were also isolated from Didemnum rubeum from the Republic of Palau. Interestingly, a collection of D. rubeum from Indonesia did not contain plakinidine D (4), but instead contained 3,5-diiodo-4-methoxyphenethylamine (5) and ascididemin (6). The structure of plakinidine D (4) was elucidated by analysis of its spectral data. Plakinidine D (4) is closely related to plakinidines A-C (1-3), previously isolated from the sponge Plakortis sp.

Profile of medical research publications from the GCC countries, 1990-1994

Using the CD-ROM system of MEDLINE, which contains the origins of articles that are published in about 3500 international medical journals, a survey was performed on the medical publications from the six countries in the Gulf Cooperating Council (GCC) over a period of five years (1990-1994). The Kingdom of Saudi Arabia was the largest producer of publications, with approximately 400 papers each year. In the same period the output from Kuwait declined from about 200 to a lower number, an effect probably caused by the invasion. In contrast, the United Arab Emirates, and to a lesser extent the Sultanate of Oman, have shown a growth in their publication record due to the initiation of new medical schools in these two countries. In the six GCC countries, all the colleges of medicine together were responsible for 34% of the total number of publications, hospitals and health centers published 45% of all papers, while non-medical colleges and other institutions published smaller amounts (10% and 11% respectively).

The surgical treatment of adrenal diseases

Between January 1978 to December 1993, 130 cases of adrenal diseases were diagnosed and surgically treated at the National University of Malaysia. They were 58 cases (44.6%) of Conn's syndrome, 40 cases (30.7%) of Cushing's syndrome, 20 cases (15.3%) of phaeochromocytoma and 12 cases (9.2%) of adrenocortical carcinoma (ACC). The commonest cause of Conn's syndrome was an adenoma (96.5%) which affected the left gland four times more than the right gland. Cushing's syndrome was caused by adrenocortical adenoma (32.5%), diffuse bilateral adrenal hyperplasia (40.0%), pigmented macronodular hyperplasia (20.0%) and adrenal carcinoma (7.5%). Twenty-five percent of the phaeochromocytomas were extraadrenal in origin arising mainly from the abdominal sympathetic chain. More than 50% of ACCs were non-functioning tumours. Fifty percent of the patients with ACC had inoperable tumours. The prognosis was poor even with adjuvant chemoradiotherapy. The main surgical approach was the anterior transabdominal route. There was no operative mortality or morbidity in all operated cases.

The effects of diesel oil-based drilling mud extracts on immune responses of rainbow trout

The potential suppressive effect of oil-pollution in the aquatic environment on fish immune responses was investigated by injecting rainbow trout (Oncorhychus mykiss) with an extract obtained from diesel oil-based drilling mud. To investigate the effect of the extract dose, 4 groups of 6 fish were exposed to 0, 0.6, 1.2, and 2.4 mL extract/Kg body weight (B.W.). To keep the injection volume constant, each extract dose was made up 2.4 mL/Kg B.W. with olive oil. Six weeks later the fish were sacrificed and a number of immmune parameters monitored. In a second experiment, the effect of exposure times was investigated. Fish wee exposed to 2.4 mL extract/Kg B.W., 2.4 mL olive oil/Kg B.W., or 2.4 mL saline/Kg B.W. and immune parameters were monitored 2, 4, 6 and 8 weeks post-injection. In the dose response experiment, there was no significant effect of the extract on serum immunoglobulin (Ig) levels and haemolytic complement (CH50) activity, but a suppressive effect on serum lysozyme level was found using the 0.6 mL/Kg dose. This dose also elevated proliferative activity of head kidney lymphocytes in response to the mitogen PHA. In the second experiment, investigating exposure time, again no significant overall effect on serum Ig or lysozyme level and CH50 activity was observed, although Ig levels were significantly lower at week two relative to the other groups. However, both extract- and olive oil-injected fish showed significantly lower lysozyme levels compared with the saline-injected (control) fish throughout the experiment. In contrast, at week six post-exposure, head kidney lymphocyte proliferation was significantly elevated in both the extract- and olive oil-exposed fish relative to the control fish.