The Impact of the Novel Coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Case Fatality Rates and Cost of Surgical Care in Brazil

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery. Following the recommendations of major surgical societies and surgical departments globally, most surgeries were widely canceled or postponed, causing significant disruptions to healthcare delivery worldwide, including in Brazil. Brazil's public healthcare system - Sistema Único de Saúde (SUS) was particularly affected, with a substantial decline in elective procedures, especially during the pandemic's early stages. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aims to analyze the case fatality rates and costs, associated with the different surgical procedure subgroups performed during the pre-pandemic, pandemic, recovery, and post-pandemic periods in all five regions of Brazil. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022. Data was divided into four time periods, named as the pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the cost of surgical procedures in the aforementioned four periods. In addition, the case fatality rates and rate ratios in the four periods stratified according to region were calculated. Results The cost of surgical procedures decreased during the pandemic and recovery period compared with pre-pandemic for all procedures except thoracic surgery where it was higher in the recovery period than pre-pandemic. No statistically significant change in cost was observed in surgeries of the central and peripheral nervous system, circulatory system, obstetric, and oncology. Case fatality rates increased among all five regions of Brazil in pandemic and recovery periods compared to pre-pandemic and post-pandemic periods. Case fatality rates increased during the pandemic and/or recovery as compared to pre-pandemic in all procedures except visual apparatus and obstetric surgeries were not affected by the pandemic in terms of case fatality rates. Conclusion The COVID-19 pandemic had a significant impact on surgical care costs and case fatality rates for surgery in Brazil. There was a decreasing trend in the costs of procedures during the pandemic, followed by a gradual recovery to baseline values, except for thoracic surgery. Case fatality rates rose initially and then declined, ultimately reaching baseline levels. The pandemic posed significant challenges to the healthcare system, affecting medical services, including surgical care.

Abnormal Calcium Levels are Associated With Worse Maternal and Fetal Outcomes; Results From an Exploratory Study

CONTEXT

Precise estimates of the incidence of hyper- and hypocalcemia in pregnancy are unknown. Abnormal calcium levels have been associated with unfavorable pregnancy-related outcomes.

OBJECTIVE

Determine frequency of hypercalcemia and hypocalcemia in pregnancy when tested and their associations with maternal and fetal outcomes.

DESIGN

Exploratory retrospective cohort study.

SETTING

Single tertiary care maternity unit.

PATIENTS

Pregnant women with expected delivery date between 2017 and 2019 and a second additional cohort of pregnant women with hypercalcemia between 2014 and 2016 and 2020 and 2021.

INTERVENTIONS

Observational.

MAIN OUTCOMES MEASURED

(1) Incidence of hyper- and hypocalcemia when calcium tested; (2) maternal outcomes: incidence of preterm delivery, emergency cesarean section, and blood loss during delivery; and (3) fetal outcomes: fetal loss (miscarriage/stillbirth), neonatal intensive care unit admission, and fetal birth weight (for term deliveries).

RESULTS

Total number of gestations and livebirths recorded were 33 118 and 20 969, respectively, with median [interquartile range] age of 30.1 [25.6-34.3] years. A total of 15.7% (n = 5197) of all gestations had albumin-adjusted calcium tested, and incidence of hypercalcemia and hypocalcemia when tested was 0.8% (n = 42) and 9.5% (n = 495), respectively. Both hypercalcemia (including additional cohort n = 89) and hypocalcemia were associated with increased incidence of preterm delivery (P < .001), emergency cesarean section (P < .001 and .019), blood loss (P < .001), and neonatal intensive care unit admission (P < .001). A total of 27% in the hypercalcemic group had an established diagnosis of primary hyperparathyroidism.

CONCLUSIONS

Abnormal calcium levels during pregnancy are common and associated with worse pregnancy-related outcomes, which raises the possible need for routine calcium testing. Prospective studies to confirm the incidence, etiology, and effects of abnormal calcium in pregnancy are recommended.

Cerebrovascular Disease Mortality Trends in Brazil: An In-Depth Joinpoint Analysis

Background Cerebrovascular disease is the second leading cause of death and the third leading cause of disability following heart disease. In 2019, there were over 101 million people living with a stroke and 12.2 million incidents of stroke globally. For the past three decades, stroke has remained the leading cause of death in Brazil, causing over 100,000 fatalities annually, along with numerous functional impairments among those who survive. The Brazilian healthcare system has witnessed notable advancements in the last decade, including the establishment of additional hospitals and a rise in the count of healthcare professionals specializing in cardiovascular and neurological surgery. However, there exists a gap in the research landscape for continuous comprehensive studies aimed at exploring the evolving mortality rates related to cerebrovascular diseases, of which the last one included data up to 2019. This study aimed to address this gap by meticulously analyzing the trends in cerebrovascular disease mortality in Brazil from 2000 to 2021, for the variables age, sex, state of residence, and geographic region. Methods This is a descriptive, ecological, and time series study. Nationwide data for annual cerebrovascular mortality from Brazil were used for the period 2000-2021. Age-adjusted mortality rates (AAMRs) by direct standardization, encompassing people above 20 years of age, were calculated and expressed per 100,000 persons. Mortality trends were assessed using joinpoint regression analysis by calculating the annual percentage change (APC) and its corresponding 95% confidence interval (CI) across categories of age, sex, and state and region of residence. Results The mortality rates decreased for the sex categories over the analyzed years. The AAMR for the categories decreased as follows: males and females (95 deaths/100,000 to 52 deaths/100,000 inhabitants), males (108 deaths/100,000 to 63 deaths/100,000 inhabitants), and females (83 deaths/100,000 to 44 deaths/100,000 inhabitants). The most substantial reduction in AAMR for males occurred in the 30-39-year age group (APC: -4.10), while the smallest decline was observed in the 20-29-year age group (APC: -1.44). All five macro-regions demonstrated statistically significant and downward AAPC values in mortality rates. The south and midwest regions decreased at a stable rate, as denoted by the same APC and AAPC values (-4.05 and -3.11, respectively). The north and northeast regions exhibited an increase in AAMR, followed by a decrease (APC: 0.68 to -1.42 and 2.63 to -2.35, respectively). Conclusions Our comprehensive analysis revealed a downward trend in cerebrovascular disease mortality rates across diverse demographic groups and macro-regions. Females experienced a more substantial reduction compared to males. Despite higher mortality rates among individuals aged 50 and above, all age groups displayed a marked decrease. The continuous decline can be attributed to policy interventions aimed at enhancing healthcare delivery, increased awareness, and healthier diets and lifestyles. With regard to the macro-regions, the regions in the southern zone demonstrated a more significant decrease as compared to the northern part. In Brazil, a more significant decline in cerebrovascular disease mortality rates could be achieved through increased focus on prevention measures and efforts toward mitigating disparities and inequalities between macro-regions.

RF18 | PSAT166 Hypercalcemia and hypocalcemia during pregnancy are associated with worse maternal and fetal outcomes

Background

Hypercalcemia during pregnancy is rare. The true incidence, however, is difficult to estimate as routine calcium screening is not recommended. Hypercalcemia is linked with various maternal and fetal outcomes but overall, the literature is conflicting.

Aims

Aim of this study is to determine the frequency of hypercalcemia in pregnancy and to determine association with early maternal and fetal outcomes.

Methods

This retrospective cohort study included all confirmed gestations with expected date of delivery (EDD) between 2017-2019 at a large tertiary maternity unit. Baseline demographic, biochemical, and clinical data collected as part of a clinical-administrative dataset was retrieved. Maternal and fetal outcomes studied were incidence of fetal loss (miscarriage/stillbirth), pre-term delivery, emergency C-section, hypertension, blood loss during delivery, neonatal intensive care unit (NICU) admission, and fetal birth weight (for term deliveries).

Results

Total number of gestations and livebirths recorded between 2017-2019 were 33,118 and 20,969, respectively, with median age of 30.1 [IQR 25.6-34.3] years. Two-thirds of pregnancies were in Caucasian women (65.9%) followed by Asians (9.6%), Afro-Caribbean (5%), and others (19.5%). 15.7% (n=5195) of all gestations had calcium tested in the preceding ten months of EDD. Of these, the hypercalcemia and hypocalcemia were noted in 42 (0.81%) and 499 gestations (9.61%) respectively. The median adjusted calcium in the hypercalcemic group was 2.75 mmol/L [IQR 2.65-2.88] and underlying diagnoses were primary hyperparathyroidism (n=17), transient hypercalcemia (n=12), suspected familial hypocalciuric hypercalcemia (n=2), sarcoidosis (n=1), and unknown (n=10). Of maternal and fetal outcomes, the incidence of pre-term delivery (20.0% v 9.2%; P=0.042), emergency C-section (42.4% v 21.4%; P=0.021), neonatal intensive care unit (NICU) admission (19.4% v 8.2%; P=0.024), and blood loss during delivery (1252 v 526 mL; P&lt;0.001) was higher in the hypercalcemic group. The incidence of fetal loss (22.5% v 18.9%; P=0.560) and hypertension (0% v 1%; P =0.561) was not different between hyper and normocalcemic groups. Interestingly, the hypocalcemic group also demonstrated higher incidence of pre-term delivery (24.2% v 9.2%; P=&lt;0.001), emergency C-section (28.6% v 21.4%; P=0.025), NICU admission (15.9% v 8.2%; P&lt;0.001), and blood loss (627 v 526 mL; P&lt;0.001), but not of fetal loss (21.0% v 18.9%; P=0.281) or hypertension (2.2% v 1.0%; P =0.054) compared to the eucalcemic group.

Conclusion

The incidence of hypercalcemia in pregnancy is low (0.81%). However, abnormal calcium levels are associated with worse maternal and fetal outcomes. Research needs to focus on whether routine calcium estimations are necessary and if treatment of these conditions improves maternal and fetal outcomes. We recommend that calcium testing should be considered in women who are at risk of worse outcomes during current or previous pregnancies.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:54 p.m. - 12:59 p.m.

Comparison between 2 futility scores in comatosed survivors of out of hospital cardiac arrest in a large tertiary centre in the United Kingdom: MIRACLE2 vs NULL-PLEASE

Background

The management of patients presenting with an out of hospital cardiac arrest (OHCA) is resource intensive, and mortality remains very high. Several scoring systems have been developed to predict mortality and adverse neurological outcomes, and thus aid decision making for patients arriving to heart attack centres. Two of the most commonly used scoring systems are NULL-PLEASE (1) and MIRACLE2 (2).

Purpose

The MIRCALE2 score predicts poor neurological outcome at 6 months, as measured by Cerebral Performance Category (CPC). The NULL-PLEASE score predicts in-hospital morality. We aimed to compare both scores in predicting their primary end-points in a large tertiary centre in the UK.

Method and results

This was a retrospective analysis of 435 patient who were admitted with OHCA via the primary PCI pathway to a large tertiary cardiac centre between January 2016 and September 2020. Only comatosed OHCA survivors requiring pre-hospital ventilatory support were included. 319 patients were eligible 238 patients had complete set of data and were included in the final analysis.

The association of the primary outcome was examined using logistic regression analysis. The predictive ability of the scores for the primary endpoint was tested using AUC analysis.

In-hospital mortality was 45% (108 patients), with 53% having good neurological outcome at 6 months (CPC &lt;3). The median MIRACLE2 score for our cohort was 5 (total score 10). The median neurological outcome measured by CPC was 2. The median NULL-PLEASE score was 2 (total 14). A ROC curve for both scores was plotted, with area under the curve at 0.73 for the MIRACLE2, and 0. 0.81 for NULL-PLEASE (figure 1 and 2). Our final analysis demonstrated a MIRACLE2 score of 5 or more had sensitivity of 67% to predict poor neurological outcome (CPC 3–5). The NULL-PLEASE, score of &gt;3 had 74% sensitivity to predict in hospital mortality.

Conclusion

To our knowledge, this is the first study to compare the MIRCLE2 and NULL-PLEASE scoring systems. Both scores did not perform as expected in our large retrospective analysis. The NULL-PLEASE was more sensitive in predicting in-hospital mortality, although MIRACLE 2 score was easier to use as it had less variables to collect.

Funding Acknowledgement

Type of funding sources: None.

66 Multicentre Study on Management of Right Iliac Fossa Pain in Young Females: A Need for Recommendation

Introduction

Right iliac fossa (RIF) pain in young women remains a diagnostic challenge. It is one of the commonest surgical emergency presentations, however a sub-group of patients have no definitive diagnosis. Current tools used includes observations, routine investigations, ultrasound, and laparoscopy. Specific recommendations for a better management of this cohort are required.

Method

Retrospective multi-centre (two different cultural backgrounds) analysis of females aged 17 to 35 acutely admitted with RIF pain over a five-month period was conducted. The length of stay, current tools used for investigation (including laparoscopy) and cost were calculated. Pregnant women and those with a definitive picture of appendicitis were excluded.

Results

A total of 154 patients with RIF pain were studied. 77 (50%) were sent home within 24 hours. Of the remaining 77 patients, 21 laparoscopies were performed, 10 had positive findings (47.6%), 9 appendicitis and 1 carcinoid tumour. Only two CT scans were performed, both indicated positive cases that required surgery. Patients without a definitive diagnosis had an average hospital stay of 4 days compared to 2 when successfully managed conservatively. Cost calculated for negative laparoscopy was £2915 and £469 for CT scan combined with one-day stay.

Conclusion

This study demonstrated that a sub-group of young females with RIF pain would benefit from early CT scan, to definitively diagnose or rule out appendicitis. This would be more cost effective and help to avoid un-necessary invasive procedure and prolonged hospital stays. Guidelines are needed for more timely diagnosis and optimization of management in this cohort.

988 A Case of Cocaine Associated Pneumomediastinum: An Unusual Diagnosis

Cocaine inhalation is an extremely rare but previously described association of spontaneous pneumomediastinum. We describe an unusual case of a previously well 20-year-old female who presented with a five-day history of central, pleuritic chest pain beginning one week after last cocaine inhalation. Blood tests were within the normal limits except for a positive d-dimer. Clinical examination was unremarkable, and a chest X-ray appeared grossly normal. A CT pulmonary angiogram revealed an extensive pneumomediastinum extending into the soft tissues of the neck and down to the peri-oesophageal region at the hiatus, without evidence of pneumothorax. The lungs and oesophagus appeared intact. The patient was admitted for observation and discharged within 48 hours. There is limited literature on this phenomenon, but almost all previous case reports suggest a benign, self-limiting course and resolution of radiological findings within 30 days. Invasive procedures are only considered if there is suspicion of oesophageal rupture or bronchial tree laceration. Spontaneous pneumomediastinum associated with cocaine inhalation is a relatively benign but uncommon condition with a predictable clinical course.

Predictors of major bleeding following an acute coronary event: insights from a national study of 5,116 consecutive patients in clinical practice

Background

Major bleeding after acute coronary syndrome (ACS) predicts a poor outcome. Although predictors of major bleeding following ACS have been validated, these have been mostly in clinical trial populations and few contemporary analyses have been undertaken in clinical practise

Methods

Major bleeding was assessed in a national study of ACS and antiplatelet choice. A total of 5116 consecutive patients [Clopidogrel (n 2,491, 2011–13) and Ticagrelor (n 2,625, 2013–16)] were enrolled in 5 UK hospitals. Clinical outcomes were identified from a national coding database (n=59.5 million) with bleeding events tracked to 11 health care facilities. Bleed severity was independently adjudicated by 2 consultant cardiologists, blinded to antiplatelet, sequence and year. Bleeding events were categorised using BARC 3–5 and PLATO criteria. A logistic regression analysis was used to define independent predictors of bleeding.

Results

The median age was 68 (IQR57–78, 30.5%&gt;75), 34% were female. 39% underwent PCI and 13% coronary artery bypass surgery. Clinical outcome data was 100% complete. 1-year mortality was 12.9%. Of 1193 icd10 codes for bleeding or anaemia 165 (3.2%) and 193 (3.8%) patients were adjudicated to have suffered a BARC 3–5 and PLATO major bleeding respectively. Independent predictors common between PLATO major and BARC 3–5 bleeding, in the year following ACS, were CRUSADE score &gt;40 (OR 1.63, CI 1.1–2.4, p=0.008) moderate left ventricular systolic dysfunction (OR, 1.65, CI: 1.2–2.4, p=0.006), age (OR per year increase in age 1.03, CI 1.02–1.05, p&lt;0.001) and subsequent coronary artery bypass surgery (OR 2.6, CI 1.8–3.8, p&lt;0.001)

Conclusion

In a broad real-world population of ACS, CRUSADE score &gt;40, incorporating simple clinical and laboratory criteria, remained an independent predictor of major bleeding using 2 internationally recognised bleed criteria

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university hospitals; North-West Educational Cardiac Group

Systems toxicology meta-analysis of in vitro assessment studies: biological impact of a candidate modified-risk tobacco product aerosol compared with cigarette smoke on human organotypic cultures of the aerodigestive tract

Systems biology combines comprehensive molecular analyses with quantitative modeling to understand the characteristics of a biological system as a whole. Leveraging a similar approach, systems toxicology aims to decipher complex biological responses following exposures. This work reports a systems toxicology meta-analysis in the context of in vitro assessment of a candidate modified-risk tobacco product (MRTP) using three human organotypic cultures of the aerodigestive tract (buccal, bronchial, and nasal epithelia). Complementing a series of functional measures, a causal network enrichment analysis of transcriptomic data was used to compare quantitatively the biological impact of aerosol from the Tobacco Heating System (THS) 2.2, a candidate MRTP, with 3R4F cigarette smoke (CS) at similar nicotine concentrations. Lower toxicity was observed in all cultures following exposure to THS2.2 aerosol compared with 3R4F CS. Because of their morphological differences, a smaller exposure impact was observed in the buccal (stratified epithelium) compared with the bronchial and nasal (pseudostratified epithelium). However, the causal network enrichment approach supported a similar mechanistic impact of CS across the three cultures, including the impact on xenobiotic, oxidative stress, and inflammatory responses. At comparable nicotine concentrations, THS2.2 aerosol elicited reduced and more transient effects on these processes. To demonstrate the benefits of additional data modalities, we employed a newly established targeted mass-spectrometry marker panel to further confirm the reduced cellular stress responses elicited by THS2.2 aerosol compared with 3R4F CS in the nasal culture. Overall, this work demonstrates the applicability and robustness of the systems toxicology approach for in vitro inhalation toxicity assessment.

Hearing loss in children with type 1 diabetes

OBJECTIVE

To examine the auditory function in a group of children with type 1 diabetes, and to study the association between hearing impairment and duration of illness, metabolic control and diabetic complication.

METHODS

Sixty-three diabetic patients below the age of 18 attending the university hospital in Khartoum, Sudan were investigated together with 63 age and sex matched non-diabetic controls. Pure-tone audiometric tests were performed using an Amplaid 300 clinical audiometer in a soundproof room. Both air and bone conduction were tested at frequencies between 250-8000 Hz and 250-4000 Hz respectively. Hearing impairment was noted at auditory threshold above 25 dB in any frequency and the magnitude of hearing loss was assessed according to auditory threshold in conversational frequencies only.

RESULTS

The hearing acuity was lower in the diabetic patients than in the control subjects in all tested frequencies, but the differences achieve statistical significance only at middle and high frequencies. The hearing loss was symmetrical, generally mild, and affects both sexes equally. Duration of diabetes, HbA1c concentration, and angiopathic complications showed positive correlation with the increased hearing thresholds; while, age at onset, insulin dose per day, presence of neuropathy, and frequency of DKA and hypoglycaemic episodes were not associated.

CONCLUSION

Hearing loss occurs early in diabetic children and is related to the duration of the disease and the degree of metabolic control. Strict glycemic control might prevent or delay this complication.

Diabetic ketoacidosis in children in Khartoum city, Sudan

Ninety episodes of diabetic ketoacidosis (DKA) in 72 Sudanese children seen during a one year period were investigated. The age of the patients ranged from 3 to 16 years with a median of 12 years. Twenty-two episodes (24%) occurred in newly diagnosed patients and 68 (76%) in previously known diabetic children. The mean observation period defined as the number of days from each one of the episodes until next episode or end of survey divided by the total number of the episodes was 180 days. During this short period of observation 18 recurrent episodes were observed giving an annual recurrent rate of 40%. The classical triad of polyuria, polydipsia and weight loss was a presentation in 83 (92%) episodes; acute abdominal pain and/or vomiting were observed in 69 (77%) episodes and drowsiness or deep coma was seen in 31 (34%) episodes. The most common precipitating causes of DKA in the studied patients with known diabetes were acute infections accounting for 38% of episodes, insulin non-availability for 34% of episodes and errors of treatment for 25%. The outcome of treatment in the whole group was good in the 69 (96%) patients who recovered without complications, but 3 (4%) patients died.

Microalbuminuria in young Sudanese patients with type 1 diabetes

Overnight urinary albumin excretion (UAE) was measured in 51 patients, nine to 18 years old, with type 1 (insulin-dependent) diabetes mellitus and in 22 healthy subjects using radioimmunoassay. Thirteen diabetic patients (25.5%) had microalbuminuria defined as UAE rate between 20 and 200 microg/min. Eleven of these patients were over 13 years of age. This gives a frequency of microalbuminuria of 42% (11/26) in the diabetic children and adolescents in the age group 14-18 years. UAE rate was positively correlated with both age at diagnosis and duration of diabetes. Arterial blood pressure, systolic and diastolic, glycosylated hemoglobin (HbA1c) and insulin dosage U.kg- 1.day-1 were significantly higher (P<0.001) in the diabetic patients with microalbuminuria compared to the diabetic patients with normal UAE rate. Retinal changes were also more common in the microalbuminuric diabetic patients than in the diabetic patients without microalbuminuria (P<0.01). This study has revealed a high prevalence of microalbuminuria in young Sudanese patients with type 1 (insulin-dependent) diabetes mellitus and emphasized the importance of routine screening of diabetic children after the age of 12 years.

Kawasaki disease in a Sudanese family

Kawasaki disease (mucocutaneous lymph node syndrome) is an acute inflammatory multisystem disease of children. The acute phase of the disease is characterized by high grade fever, conjunctivitis, exanthematous skin rash and non-suppurative lymph node enlargement. The subacute phase follows with the manifestations of arthritis, myocarditis and thrombocytosis. The disease is self-limiting in most children but is associated with coronary artery aneurysms in 15-20% of cases. The aetiology is unknown, but results of epidemiological studies suggest that an unidentified infectious agent might be the causative factor. Since the first description of the disease by the Japanese doctor, Tomisaku Kawasaki, in 1967 and his report for the English literature in 1974, thousands of cases have been reported worldwide. The highest prevalence is found in Japan and among the Japanese in Hawaii, followed by the United States. Although the disease was first reported in Africa in 1979, to date only four cases have been reported there. The following account reviews the literature and describes the manifestations of Kawasaki disease as seen in two siblings in Khartoum, Sudan.

Epidemiology of childhood type I diabetes in Sudan, 1987-1990

OBJECTIVE

To determine the incidence of type I diabetes in children 0-14 yr of age in Khartoum, Sudan.

RESEARCH DESIGN AND METHODS

Prospective registration of newly diagnosed patients in a hospital-based registry with independent validation of completeness of case ascertainment. Eligible patients were Sudanese children < 15 yr of age, who developed type I diabetes during the period 1 January 1987 through 31 December 1990, and who were living in Khartoum city at the time of diagnosis. The denominator is the stable childhood population of Khartoum city, as estimated by the National Bureau of Statistics.

RESULTS

In 4 yr, 239 cases were notified in the primary source and 268 in the secondary source. Some 196 patients were registered in both sources. Using the capture-recapture method to correct for underascertainment, the estimated total number of cases was 327, and the overall degree of ascertainment was 95%. The incidence of type I diabetes in children 0-14 yr of age increased from 5.9/10(5) in 1987 to 10.1/10(5) in 1990 (P < 0.001). Girls exhibited slightly higher incidence rates than boys in the 10-14-yr age-group throughout the 4 yr, but the differences were not statistically significant. The age distribution at onset was bimodal with a clear peak at age 12 yr in girls and age 14 yr in boys and another smaller peak at age 7 yr in both sexes. The number of new cases was markedly higher in the cooler months of the year, with a peak in January and a nadir in June (P < 0.01). This trend was consistent over the period of observation.

CONCLUSIONS

Childhood diabetes is increasing in Sudan. Our incidence figures are higher than those reported from other Arab countries and is similar to reports from France and Italy.

Clinical pattern of childhood type 1 (insulin-dependent) diabetes mellitus in the Sudan

During a 10-year period, 101 children with Type 1 (insulin-dependent) diabetes mellitus were admitted to the Department of Paediatrics of the University Hospital in Khartoum, Sudan. The age distribution of the patients showed a steady increase from age one to ten years followed by a sharper increase around puberty. A higher number of cases were diagnosed during the cooler compared to the warmer months of the year (p less than 0.05). Family history of Type 1 diabetes was reported in 14.9% of patients. Diabetic ketoacidosis was a presenting symptom in 82 patients (81.2%) and 93 patients (92.1%) have had at least two documented episodes of ketoacidosis during the follow-up period. Almost all patients were treated with bovine insulin given as a single dose per day. An initial remission period was not observed in any of the patients. Four years after diagnosis, the average daily dose of insulin used by the patients was greater than 2.0 U/kg body weight and the mean HbA1C was 13.4% (reference value 5.3-6.7%). Seventeen patients (16.8%) were known to have died during 399 person-years of observation resulting in a mortality rate of 42.6 per 1000 person-years of follow-up. Another 29 patients (28.7%) for no apparent reason did not attend a follow-up examination after discharge from hospital. Some of these patients might have died in other hospitals or at home. The study emphasizes the need for urgent measures to increase public awareness of diabetes and to improve methods of case-finding and management of diabetic patients.

Islet-cell antibodies and endogenous insulin secretion in Sudanese diabetic children

Cytoplasmic islet-cell antibodies (ICA) and endogenous insulin secretion were studied in 46 Sudanese children (mean age 11.6 years) with newly diagnosed insulin-dependent diabetes mellitus (IDDM). Islet-cell antibodies were detected both by the indirect immunofluorescence (IF) and complement fixation (CF) methods. Endogenous insulin levels were measured as C-peptide concentration using radio-immunoassays. The degree of metabolic control of diabetics was judged by the presence of diabetic ketoacidosis (DKA) at onset, glycated haemoglobin (HbA1c) level and insulin requirement, expressed as dose per kg body weight per day, at the time of presentation. Twenty-nine patients (63%) had either IF-ICA or CF-ICA or both in their sera. These figures are significantly higher than those reported for African populations. Islet-cell antibody positive patients had significantly lower C-peptide concentration, higher HbA1c level, higher insulin requirement and higher prevalence of ketoacidosis at presentation. Furthermore, the C-peptide levels were higher in CF-ICA positive patients than in subjects who showed only IF-ICA positivity. Our findings show a clear association between ICA and severity of diabetes at clinical onset and also suggest that the presence of CF-ICA at or shortly after diagnosis of IDDM is indicative of preservation of some functioning beta-cell mass.

Goitre and deaf-mutism

The occurrence of congenital deafness, mutism and goitre unassociated with cretinism or mental retardation in euthyroid patients is known as Pendred's Syndrome. It has been estimated that 4-10 % of children with congenital deafness suffer from this condition. The perceptive hearing loss is considered to be present at birth although it is frequently not recognized for several years. The cause of the hearing defect is a congenital bilateral malformation of the cochlea of the Mondini type. The goitre is not recognized clinically at birth or in early childhood. It becomes apparent in the pre-pubertal years when it presents as a colloid enlargement progressing to a nodular goitre. The thyroid defect has been shown to be a partial defect in iodine organification leading to the underproduction of thyroxine and subsequent thyroid hyperplasia. The syndrome is caused by a single mutant recessive gene responsible for both the deafness and goitre. Its autosomal mechanism gives an equal incidence in both sexes, unusual in thyroid disease. This article reviews the current aspects of pathogenesis and treatment of this syndrome and reports its occurrence in two Sudanese siblings.

Magnesium and insulin-dependent diabetes mellitus

There is accumulating evidence that the changes which occur in the metabolism of some micronutrients in diabetes mellitus might have a specific role in the pathogenesis and complications of this disease. Magnesium deficiency is the most evident disturbance of metal metabolism in insulin-dependent diabetes mellitus. Hypomagnesemia has been linked both to the acute metabolic and late chronic complication of diabetes. Of particular concern, is the association between hypomagnesemia and ischemic heart disease and severe retinopathy in humans with diabetes mellitus. Appropriate magnesium supplementation might prove beneficial in normalizing the low plasma and tissue magnesium levels and prevent or retard the development of vascular complications in diabetic patients. However, well designed and documented experiments need to be performed before the rationales for such therapy are well established.

Prevalence of IDDM in schoolchildren in Khartoum, Sudan

The prevalence of insulin-dependent diabetes mellitus (IDDM) in 42,981 schoolchildren (aged 7-14 yr) in Khartoum, Sudan, was determined. With the 1985 World Health Organization revised criteria for diagnosis and classification of diabetes mellitus, the overall crude prevalence rate of IDDM was 0.95/1000 in the age groups studied. This figure is thought to reflect the minimum prevalence of IDDM in that population, because there is an inherent tendency in the method of screening used toward underestimating the true prevalence rate. The prevalence of IDDM was found to increase significantly with age and was slightly higher in girls than boys, but this was not statistically significant. Of 41 children with IDDM detected in the survey, 7 were not known to have IDDM before but were showing suggestive symptoms at the time of the study. This study showed that IDDM in childhood is not rare in Sudan and that probably a substantial number of undiagnosed cases exist.