Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Functional and prognostic relevance of -173 G/C gene polymorphism of macrophage migration inhibitory factor in sepsis patients in Egyptian intensive care units

This study aimed to evaluate the association of plasma MIF level and -173 G/C single nucleotide polymorphism of the MIF gene with the occurrence, severity and mortality of sepsis patients. A study was conducted in adult surgical intensive care units of Zagazig University Hospitals, Egypt on 25 patients with sepsis, 27 with severe sepsis and 28 controls. Gram-negative bacilli were the most common isolates in both severe sepsis (63.0%) and sepsis (56.0%) patients. A highly statistically significant difference was found in MIF levels between sepsis cases and controls and a statistically significant difference as regards MIF level in different genotypes of the studied groups. MIF level was significantly associated with mortality in sepsis cases. High MIF levels and MIF -173G/C gene polymorphism are powerful predictors of the severity of sepsis and its outcome.

Molecular epidemiology of avian influenza virus and incidence of H5 and H9 virus subtypes among poultry in Egypt in 2009-2011

Egypt has experienced outbreaks of avian influenza (AI) since 2006. A total of 3583 cloacal swabs were collected from chickens, ducks, geese and turkeys from commercial farms, backyards and local bird markets in Qena and Luxor governorates in South Egypt during 2009-2011. These samples were examined for the presence of AI virus (AIV) and positive samples were further subtyped for the H5 and H9 by real time RT-PCR. In this way, 202 (5.64%) samples were found to be AIV-positive of which 186 (92.08%) and 7 (3.46%) belonged to H5 and H9 subtypes, respectively. Higher infection rates were observed in backyard birds and birds from local bird markets in comparison to birds from commercial farms. In conclusion, the predominance of H5 infection indicates a need for continuous monitoring of AIV among avian species and the awareness against public health risk.

Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia

This study aimed to characterize Pseudomonas aeruginosa isolates in 2 intensive care units in Egypt and Saudi Arabia. P. aeruginosa isolates from patients' and staff hands and environmental samples were typed using antibiotyping and ERIC-PCR. In Egypt, isolates from suction apparatus tubing and drainage containers (A7) and AV tubing (A8) were linked to those from patients who had these antibiotypes. In Saudi Arabia, isolates from suction apparatus tubing (A6) and AV tubing (A7) were linked to patients with the same antibiotypes. In Egypt, patients' isolates had ERIC VII, VIll and IX patterns linked to suction apparatus tubing, AV machine tubes and drainage containers. In Saudi Arabia, patients' isolates had ERIC VIII and XI patterns linked to suction apparatus tubing and AV machines. In Egypt and Saudi Arabia, ERIC typing gave higher discriminatory indices (0.801 and 0.785 respectively) than the antibiotyping (0.7123 and 0.728 respectively). ERIC was superior to antibiotyping and should be used in tracing sources of infection.

Epidemiological and virological characteristics of symptomatic acute hepatitis E in Greater Cairo, Egypt

The aim of the study was to describe the characteristics of acute hepatitis E in Greater Cairo. Patients with acute hepatitis E were identified through a surveillance of acute hepatitis using the following definition: recent (<3 weeks) onset of fever or jaundice, alanine aminotransferase at least three times the upper limit of normal (uln), negative markers for other causes of viral hepatitis and detectable hepatitis E virus (HEV) RNA. Comparison of the liver tests between acute hepatitis E and hepatitis A virus (HAV), case-control analysis (four sex-matched and age-matched (±1 year) HAV controls per case) to explore risk factors and phylogenetic analyses were performed. Of the 17 acute HEV patients identified between 2002 and 2007, 14 were male. Median age was 16 years (interquartile range 13-22). Compared with HAV (n = 68 sex-matched and ±1 year age-matched), HEV patients had higher bilirubin (mean (SD) 10.9 (5.7) uln versus 7.5 (4.4) uln, p 0.05) and aspartate aminotransferase levels (38.6 (27.1) uln versus 18.3 (18.1) uln, p 0.02). Co-infection (hepatitis C virus RNA or hepatitis B surface (HBs) -antigen positive/IgM anti-hepatitis B core (HBc) anitgen negative) was diagnosed in four patients. In univariate matched analysis (17 cases, 68 matched controls), HEV cases were more likely to live in a rural area than HAV controls (matched OR 7.9; 95% CI 2.0-30.4). Of the 16 isolates confirmed as genotype 1, 15 belonged to the same cluster with 94-98.5% identity in the open-reading frame 2 region. Our findings documented the sporadic nature of HEV in Greater Cairo, characterized a large number of Egyptian HEV genotype 1 strains and identified living in a rural area as a potential risk factor for infection.

Upregulation of CD44 expression by interleukins 1, 4, and 13, transforming growth factor-β1, estrogen, and progestogen in human cervical adenocarcinoma cell lines

Although cervical adenocarcinoma constitutes approximately 10-20% of primary malignant tumors of the uterine cervix, its pathogenesis is less well understood than that of the corresponding squamous cancer. CD44 is a cell surface glycoprotein postulated to play a role in many biologic processes including tumor growth and metastasis. We have previously reported from immunohistochemical studies that a particular CD44 variant (CD44v5) is consistently overexpressed in endocervical neoplasia. It thus has potential as a diagnostic marker and even as a target for therapeutic approaches directed against specific epitopes. The aim of this study was to investigate which cytokines and hormones are capable of modulating CD44v5 expression, using a cell culture model. The effects of interleukin (IL)-1alpha, IL-1beta, IL-4, IL-13, transforming growth factor (TGF)-beta1, estrogen, and progestogen on CD44v5 expression were examined in cultures of three human cervical adenocarcinoma cell lines (HeLa, HeLa229, and HS588T). Expression was assessed using dual fluorescence-labeled flow cytometry and western blotting techniques. It was found that incubation of cultures for 72 h with IL-1alpha, IL-1beta, IL-4, IL-13, TGF-beta1 (all at 0.1-10 ng/mL), estrogen (5-10 ng/mL), or progestogen (5-20 ng/mL) induced significant upregulation of CD44v5. These factors are likely to exert a similar stimulatory influence in vivo and may contribute to the process of carcinogenesis.

Phase II study of neoadjuvant paclitaxel and cisplatin for operable and locally advanced breast cancer: analysis of 126 patients

In an earlier study, we have demonstrated a high clinical and pathologic response rate of neoadjuvant paclitaxel (P) and cisplatin (C) for patients with locally advanced breast cancer (LABC). The current phase II study includes larger number of patients who had longer follow-up. A total of 126 consecutive patients with noninflammatory LABC (T2 >4 cm, T3 or T4, N0–N3, M0) were included in the study. Patients were scheduled to receive three to four cycles of the neoadjuvant PC (paclitaxel 135 mg m⁻² and cisplatin 75 mg m⁻² on day 1) every 21 days. Patients were then subjected to surgery and subsequently received six cycles of FAC (5-fluorouracil 500 mg m⁻², doxorubicin 50 mg m⁻², and cyclophosphamide 500 mg m⁻²) or four cycles of AC (doxorubicin 60 mg m⁻² and cyclophosphamide 600 mg m⁻²); all drugs were administered intravenously on day 1 with cycles repeated every 21 days. Patients then received radiation therapy, and those with hormone receptor-positive tumours were given adjuvant tamoxifen intended for 5 years. The median age was 41 years. Clinically, 12, 52, and 37% of patients had T2 >4 cm, T3, and T4, respectively. The mean tumour size was 7 cm (95% CI, 7.3–8.5). The clinical nodal status was N0, N1, and N2–N3 in 32, 52, and 17% of patients, respectively. Disease stage at diagnosis was IIA (2%), IIB (32%), IIIA (28%), and IIIB (39%). Clinical assessment of the primary tumour and the axillary nodal status after primary chemotherapy showed that 35 patients (28%) achieved complete response (cCR), while 80 (63%) demonstrated partial response to PC. Of patients with evaluable pathologic data of the primary tumour (123 patients), complete pathologic response (pCR) was achieved in 29 patients (24%), and an additional nine (7%) only had a microinvasive disease. Moreover, 20 of the 122 patients (16%) had no residual disease in the primary tumour or in the axillary nodes. Failure to attain cCR predicted failure to achieve pCR. At a median follow-up of 37.5 months (95% CI, 31.5–43.3), 71% were alive with no recurrence, 16% were alive with evidence of disease, and 13% were dead. Of the 122 patients who had surgery, 36 (29%) developed recurrence including one of the patients who attained pCR. The median overall or disease-free survival has not been reached with a projected 5-year overall survival (OS) and disease-free survival (DFS) of 85% (±4%) and 63% (±5%), respectively. On multivariate analysis, clinical response of the primary tumour, pathological response of the primary tumour, and the pathological nodal status were identified as independent prognostic variables for DFS. No variable, however, was identified to prognosticate OS. PC was acceptably safe. Neoadjuvant PC as used in this phase II study in a multidisciplinary strategy was highly effective. Clinical and pathologic responses remain the most important variables that predict outcome.

Localized non-Hodgkin's lymphoma of Waldeyer's ring: clinical features, management, and prognosis of 130 adult patients

BACKGROUND

Waldeyer's ring (WR) is the primary site of non-Hodgkin's lymphoma (NHL) involvement in approximately 5% to 10% of all lymphoma patients, and it accounts for more than half of all primary extranodal lymphomas of the head and neck. Materials and Methods A retrospective review was performed of 130 adult patients with localized (stages I and II) WR-NHL seen at a single institution over 18 years.

RESULTS

Patients had a median age of 55 years, and the male-female ratio was 1:5:1. Seventy five (58%), 46 (35%), and 9 (7%) patients had primary tonsillar, nasopharyngeal, and base of the tongue lymphoma, respectively. Forty-five (35%) and 85 (65%) had stage I and stage II disease, respectively. Most patients (109 patients, 84%) had diffuse large B-cell NHL (DLC). Chemotherapy (CT) was given to 58 (45%) patients, whereas 26 (20%) received radiation therapy (RTX), and 46 (35%) were managed with a combination of chemotherapy and radiotherapy (CMT). One hundred nine (84%), 16 (12%), and 5 (4%) patients attained complete remission (CR), partial remission (PR), and treatment failure, respectively, with no difference in CR rates between the three therapeutic modalities. Of those patients with DLC, 90 (83%), 15 (14%), and 4 (3%) demonstrated CR, PR, and treatment failure, respectively. In a multivariate analysis, the modified International Prognostic Index (IPI) was found to predict the attainment of CR. Over a median follow-up of 49 months; 76 (58%) of the patients were alive and disease-free, 5 (4%) were alive with evidence of disease, and the remaining 49 (38%) were dead. Most distant relapses were in nongastrointestinal extranodal sites. The median overall survival (OS) has not been reached; however, the projected 5-year OS was 58%. No OS difference was noted between patients with stage I and stage II. Cox proportional hazards model identified primary tonsillar site and a low-risk group as defined by the modified IPI were associated with favorable OS. The median event-free survival was 82.3 months, with the primary tonsillar site, and low-risk modified IPI group were associated with favorable EFS in a multivariate analysis. Probably because of the high frequency of patients with DLC, the outcome and the prognostic factors in those patients were not distinctive from those for the whole group. The CMT was not associated with a superior OS compared with either of the single modality treatments; however, it was associated with more favorable EFS.

CONCLUSIONS

This series characterized the clinicopathologic features and outcome of adult patients with early stage WR-NHLs. No survival difference was noted between stage I and stage II, and the outcome was favorable. Primary tonsillar site and the low-risk group of the modified IPI predicted favorable OS and EFS. CMT is probably superior to single modality treatment; however, prospective studies are warranted.

Primary intestinal diffuse large B-cell non-Hodgkin's lymphoma: clinical features, management, and prognosis of 66 patients

BACKGROUND

In Saudi Arabia, primary gastrointestinal non-Hodgkin's lymphoma (NHL) is common. Recently we have reported one of the largest series of primary gastric (PG) diffuse large B-cell lymphoma (DLCL). This has prompted the analysis of another series of patients with primary intestinal DLCL to depict the clinical features and the outcome of that disease and to compare those with that for PG involvement.

PATIENTS AND METHODS

The data of 66 adult patients with primary intestinal NHL having DLCL histology were retrospectively reviewed.

RESULTS

Patients had a median age of 45 years. Of 64 treated patients, 16% and 84%, received single and multiple modality treatment, respectively. Seventy-six percent, ten percent, and fourteen percent attained complete remission (CR), partial remission (PR), and no response/progressive disease, respectively. Multivariate analysis failed to identify any variable that predict the likelihood of attaining CR. Over a median follow-up of 81 months for all 66 patients, 32 (48%) were alive and disease-free, 5 (8%) were alive with evidence of disease, and the remaining 29 (44%) were dead. The median overall survival (OS) was 101 months and it was 58% (+/- 6%) and 48% (+/- 7%) at 5- and 10-year, respectively. Of the 54 patients who achieved CR or PR, the median event-free survival (EFS) was not reached, but the predicted 5- and 10-year EFS was 61% (+/- 7%) and 52% (+/- 7%), respectively. Only low serum albumin (<30 g/l) was associated with adverse OS and EFS in a univariate analysis, however, multivariate analysis was not possible. Our analysis showed that compared with single-modality management, multi-modality strategy attained significantly higher CR, and advantageous EFS, but without a significant superior effect on OS. In comparison with patients with PG DLCL, those with primary intestinal disease demonstrated more adverse prognostic features, but had an equivalent survival.

CONCLUSIONS

This series characterized the clinico-pathologic features and outcome of patients with primary intestinal DLCL. While surgical resection in primary intestinal NHL seems beneficial, only prospective randomized studies can ascertain its precise role. Compared with patients with PG NHL, patients with primary intestinal disease had more prevalence of adverse prognostic features.

Primary intestinal diffuse large B-cell non-Hodgkin's lymphoma: clinical features, management, and prognosis of 66 patients

BACKGROUND

In Saudi Arabia, primary gastrointestinal non-Hodgkin's lymphoma (NHL) is common. Recently we have reported one of the largest series of primary gastric (PG) diffuse large B-cell lymphoma (DLCL). This has prompted the analysis of another series of patients with primary intestinal DLCL to depict the clinical features and the outcome of that disease and to compare those with that for PG involvement.

PATIENTS AND METHODS

The data of 66 adult patients with primary intestinal NHL having DLCL histology were retrospectively reviewed.

RESULTS

Patients had a median age of 45 years. Of 64 treated patients, 16% and 84%, received single and multiple modality treatment, respectively. Seventy-six percent, ten percent, and fourteen percent attained complete remission (CR), partial remission (PR), and no response/progressive disease, respectively. Multivariate analysis failed to identify any variable that predict the likelihood of attaining CR. Over a median follow-up of 81 months for all 66 patients, 32 (48%) were alive and disease-free, 5 (8%) were alive with evidence of disease, and the remaining 29 (44%) were dead. The median overall survival (OS) was 101 months and it was 58% (+/- 6%) and 48% (+/- 7%) at 5- and 10-year, respectively. Of the 54 patients who achieved CR or PR, the median event-free survival (EFS) was not reached, but the predicted 5- and 10-year EFS was 61% (+/- 7%) and 52% (+/- 7%), respectively. Only low serum albumin (<30 g/l) was associated with adverse OS and EFS in a univariate analysis, however, multivariate analysis was not possible. Our analysis showed that compared with single-modality management, multi-modality strategy attained significantly higher CR, and advantageous EFS, but without a significant superior effect on OS. In comparison with patients with PG DLCL, those with primary intestinal disease demonstrated more adverse prognostic features, but had an equivalent survival.

CONCLUSIONS

This series characterized the clinico-pathologic features and outcome of patients with primary intestinal DLCL. While surgical resection in primary intestinal NHL seems beneficial, only prospective randomized studies can ascertain its precise role. Compared with patients with PG NHL, patients with primary intestinal disease had more prevalence of adverse prognostic features.

Pregnancy-associated breast cancer: a case-control study in a young population with a high-fertility rate

Pregnancy-associated breast cancer (PABC) is not a rare event. The association frequently imposes a management challenge. We intended to review the clinical features, therapy, and outcome of patients with PABC seen at a single institution over a five-year period and to compare those with that seen in a matched control group. Data of all patients with PABC diagnosed during pregnancy were retrospectively reviewed (Group I). For each patient in Group I, three matched controls with breast cancer without pregnancy were identified (matched for age, stage, and year of diagnosis, Group II). 72 patients in Group I and 216 in Group II were identified. Their median age was similar (34 vs 35 y, respectively). The median number of prior pregnancies for patients in Groups I and II was 5. Patients had shorter duration of symptoms prior to diagnosis as compared with their controls (5.6 vs 9.4 months, P < 0.0001). 3%, 31%, 40%, and 26% of patients had Stage I to IV, respectively. A pattern that was similar to that seen in our breast cancer population. Pregnancy was terminated in 34 patients (47%), while 38 (53%) had normal spontaneous vaginal delivery. 47 patients in Group I had surgery; 37 (52%) had modified radical mastectomy and 10 (14%) had conservative surgery. In 37 patients surgery was performed after termination of pregnancy and 10 had surgery performed during pregnancy. The median number of positive lymph nodes in Group I was 4 as compared with 2 for patients in Group II. No patients in Group I had systemic chemotherapy during first trimester, while only 4 (6%) and 3 (4%) received adjuvant or neoadjuvant during second and third trimester, respectively. No congenital malformation in the newborns was diagnosed. None of the patients in Group I received radiotherapy during pregnancy. Over a median of 47.5 months, 48 (67%) patients in Group I were alive as compared to 126 (58%) in Group II, with no difference in the median survival (P= 0.79). Comparing overall survival (OS) between the two groups stage for stage also showed no significant difference. Also there was no difference in progression-free survival between the two groups. Cox proportional hazard model identified advanced stage as the only independent adverse prognostic variable that influenced OS in Group I. Despite that this series included a relatively young population with a high fertility rate, the study confirmed the lack of a survival difference between patients with PABC and their matched controls.

High complete pathological response in locally advanced breast cancer using paclitaxel and cisplatin

BACKGROUND

In an earlier study, we have demonstrated a high response rate in metastatic breast cancer using paclitaxel (P) and cisplatin (C). A phase II study using the same regimen (PC) has been conducted in locally advanced breast cancer (LABC).

METHODS

A total of 72 consecutive patients with non-inflammatory LABC (T2 > or = 4 cm, T3 or T4, N0-N2, M0). Patients were scheduled to receive 3-4 cycles of the neoadjuvant PC (paclitaxel 135 mg/m2 and cisplatin 75 mg/m2 on day 1) every 21 days. Patients were then subjected to surgery and subsequently received 6 cycles of FAC (5-fluorouracil 500 mg/m2, doxorubicin 50 mg/m2, and cyclophosphamide 500 mg/m2) or 4 cycles of AC (doxorubicin 60 mg/m2, and cyclophosphamide 600 mg/m2). Patients then received radiation therapy, and those with hormone receptor positive tumors were given adjuvant tamoxifen intended for 5 years.

RESULTS

The median age was 39 years (range, 24-78). Clinically, 7%, 58%, and 35% of patients had T2 > or = 4 cm, T3, and T4, respectively. Disease stage at diagnosis was IIB (33%), IIIA (27%), and IIIB (40%). Complete and partial clinical response to PC was demonstrated in 13 (18%), and 52 (72%) patients, respectively. Of those patients with evaluable pathologic response (68 patients), complete pathologic response (pCR) was achieved in 15 (22%) patients. At a median follow-up of 22 (+/- 3.5) months, 58 (81%) were alive with no recurrence, nine (12%) were alive with evidence of disease, and five (7%) were dead. None of the patients achieving pCR has developed any relapse. The median overall survival has not been reached for all 72 patients with a projected 3-year survival (+/- SE) of 90% (+/- 4%). The median progression-free survival (PFS) was 42.1 (+/- 4.8) months with a projected PFS of 74% +/- 7% at 3-years (for 68 patients).

CONCLUSIONS

PC regimen in LABC produced a high pCR. The contribution of the other added modalities to survival could not be assessed.

Adding high-dose tamoxifen to CHOP does not influence response or survival in aggressive non-Hodgkin's lymphoma: an interim analysis of a randomized phase III trial

PURPOSE

CHOP is the standard regimen currently used in the management of the majority of patients with aggressive non-Hodgkin's lymphoma (NHL). However, CHOP only produces 30-35% long-term survival. We hypothesized that adding high-dose tamoxifen, which is known to have multiple drug resistance-modulatory effects, to the CHOP regimen could increase the response rate, and consequently enhance the survival of patients with NHL.

PATIENTS AND METHODS

In a prospective, controlled, and randomized study, eligible adult patients with aggressive NHL were randomized between CHOP only (Group I), or CHOP plus high-dose tamoxifen (Group II). The primary aim was to assess the effect of tamoxifen on complete response (CR) rate, with the secondary evaluation of tamoxifen potential impact on survival. The interim analysis of this study is presented.

RESULTS

Fifty-one and forty-seven evaluable patients were randomized to Group I and Group II, respectively. The median age of all patients was 53 y (range 18-78 y). The two groups had comparable distributions of the pretreatment prognostic variables. The CR for patients in Group I was 80% (41 patients) as compared with 74% (35 patients) in Group II (P=0.48). Likewise, there was no apparent difference in the partial remission rates between the two groups (6% vs 15%, respectively). Of patients who initially attained CR, 15 (37%) and 10 (29%) subsequently relapsed in Groups II and I respectively (P = 0.45). The NHL International Prognostic Index (IPI) was the only factor that predicted attaining CR. At the time of this interim analysis, the actuarial-estimated overall survival (OS) probability (+/-S.E.) for the entire population at 5 y was 58% (+/-6) with no survival difference between the two groups (P=0.51). Only attaining CR and the IPI predicted OS probability. The probability of remaining event-free at 5 y (+/-SE) for those achieving CR was 72% (+/-9), and there was no significant difference between the two treatment groups (P=0.68). Toxicity profile was similar in the two groups.

CONCLUSION

Based on this interim analysis, combining high-dose tamoxifen, as used in this study, with the CHOP regimen has failed to have any favorable effect on the outcome of patients with aggressive NHL, and therefore cannot be recommended for future trials.

Primary gastric non-Hodgkin's lymphoma: clinical features, management, and prognosis of 185 patients with diffuse large B-cell lymphoma

BACKGROUND

Primary gastric non-Hodgkin's lymphoma (PG-NHL) is common in Saudi Arabia. This has prompted the analysis of a large series of patients with PG-NHL having high-grade diffuse large B-cell lymphoma (DLCL) in order to define the clinical features and outcome of this disease.

PATIENTS AND METHODS

The data of all adult patients in the series with PG-NHL having DLCL histology were retrospectively reviewed. Patients were eligible if they had biopsy-confirmed diagnoses obtained by endoscopy or following laparotomy.

RESULTS

Over a 16-year period, 185 patients with DLCL PG-NHL were identified and their data were reviewed. Patients had a median age of 54 years. In 53% of them only one initial therapeutic modality was given, while 47% were managed by a multi-modality approach. One hundred forty patients (76%), 19 (10%), and 26 (14%) attained complete remission (CR), partial remission, and no response/progressive disease, respectively. Multivariate analysis showed that poor performance status and advanced stage were negatively associated with the likelihood of attaining CR. Over a median follow-up of 54 months, 118 (64%) of the patients were alive and disease-free, 17 (9%) were alive with evidence of disease, and the remaining 50 (27%) were dead. The projected 5-year and 10-year overall survivals (OS) (+/- SD) were 68% (+/- 4%) and 61% (+/- 6%), respectively. The Cox proportional hazards model identified the same variables of response as adverse prognostic factors of survival. Using the influence of performance status, and stage, a prognostic index was constructed to recognize three prognostically distinctive risk categories with overall survival proportions of 87%, 61%, and 45%, respectively. The unadjusted International Prognostic Index, however, failed to classify patients into prognostically meaningful risk strata. Of the 140 patients who achieved CR, the median disease-free survival (DFS) was not reached, but the predicted 5- and 10-year DFS were 82% and 75%, respectively. A multivariate analysis identified poor performance status as the only independent prognostic covariate that adversely influenced DFS. Our analysis showed that compared with single-modality management, multi-modality strategy attained significantly higher CR, and advantageous OS and DFS.

CONCLUSIONS

This large series characterized the clinico-pathologic features and outcome of patients with DLCL PG-NHL. Performance status, and stage significantly influenced patient outcome. A prognostic index was developed and it identified three prognostically distinctive risk groups; however, prospective validation is warranted.

Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population

In the Kingdom of Saudi Arabia (KSA), breast cancer constitutes 18% of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA. The relative frequency of locally advanced disease among our breast cancer population and the lack of a uniform consensus in the literature about its optimal management have prompted this retrospective analysis of the medical records of patients with Stage III breast cancer patients seen at King Faisal Specialist Hospital and Research Center between 1981 and 1991. In all, 315 patients were identified. Their median age +/- SD was 46 +/- 11.6 years which is distinctly different from the 60-65 years median age in industrial Western nations. Most patients were younger than 50 years (64%) and premenopausal (62%). Patients were approximately equally divided between Stage IIIA and Stage III B. Patients received multimodality treatment, including surgery, adjuvant chemotherapy, tamoxifen, and adjuvant radiotherapy. Sixty-one patients were excluded from survival analysis as they were considered lost to follow-up. Of the remaining 254 patients, 73 (29%) were alive and disease free, and 18 patients (7%) were alive but with evidence of the disease. The remaining 163 (64%) had died from breast cancer or its related complications. Their median overall survival (OS) was 54 months, (95% CI, 27 to 121 months) and the median progression-free survival (PFS) was 28.8 months (95% CI, 14.2 to 113 months). Cox proportional hazard model identified Stage III B and the number of positive axillary lymph nodes as poor predictors of OS and PFS. Radiotherapy was the only adjuvant modality that affected survival favourably. The prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach. The overall young age of our patients may have contributed to the poor outcome. Moreover, the adverse effect of Stage III B disease (as compared with Stage III A) and axillary nodal status was evident. Whilst the favourable effect of radiotherapy on survival was demonstrated, the lack of independent efficacy of other modalities (adjuvant chemotherapy and tamoxifen) or the apparent deleterious effect of neoadjuvant chemotherapy should be addressed with discretion in such retrospective analysis. Optimal management of patients with locally advanced breast cancer disease should be appraised in well designed, prospective, randomised studies.

CD44 is a marker of endocervical neoplasia

The expression of CD44s, CD44v4, CD44v5, CD44v7-8, and CD44v10 was investigated immunohistochemically in a variety of neoplastic cervical lesions. Normal endocervical columnar cells exhibited no reactivity for any of the antibodies, whereas the subcolumnar reserve cells were strongly positive for CD44s, CD44v5, and CD44v7-8. In some cases, positive cells were identified in the stroma surrounding the endocervical glands and adjacent to reserve cells. Cervical glandular intraepithelial neoplasia and adenocarcinoma showed consistent immunoreactivity for CD44v5. There was no significant change in CD44 immunoreactivity in squamous cell carcinoma compared with normal epithelia and cervical intraepithelial neoplasia. These findings lend support to the origin of carcinoma of the cervix from a common progenitor reserve cell and suggest the origin of reserve cells from the stroma. CD44v5 may be useful as a diagnostic marker of endocervical neoplasia and could provide a target for therapeutic approaches directed against specific epitopes.

Breast cancer in the eastern province of Saudi Arabia

In the Kingdom of Saudi Arabia (KSA), hospital and population based statistics have shown that breast cancer has the highest crude frequency rate among Saudi women. The scarcity of reports about the disease in the KSA has been the impetus to this analysis about breast cancer in the eastern province of KSA. Data on female patients with invasive breast carcinoma seen at King Fahd Hospital of the University in the eastern province of KSA, were retrospectively reviewed. The analysis intended to examine the pattern of the disease and the outcome for patients. Between 1985 and 1995, 292 patients were identified. Their median age +/- SD (standard deviation) was 42 +/- 10.5 years. Most patients were younger than 50 years (78%) and were predominantly premenopausals (79%). Only 25 (9%) of patients had stage I cancer, whilst 130 (44%), 90 (30%), and 47 (16%) had stage II, III, and IV, respectively. Among patients with known axillary nodal status (242 patients), only 37% were node-negative whilst 32% and 31% had 1-3, and > or = 4 positive nodes, respectively. Adjuvant chemotherapy and tamoxifen were commonly offered; nonetheless, other adjuvant modalities were rarely utilised. The median follow-up +/- SD of all patients was 62.3 +/- 8.9 months: 152 patients (52%) were alive with no evidence of disease, 25 (9%) were alive with evidence of disease, and 115 (39%) were dead from breast cancer or its related complications. The median survival of the entire group was not obtained, but the 10-year projected survival was 55%. For stage I and II patients, 118 (76%) were alive with a projected 10-year actuarial survival of 64%. On the other hand, only 51 (57%) of patients with stage III disease were alive with a median survival of 41.5 months (95% Confidence interval (CI), 18.9 to 51.3). Patients with stage IV disease demonstrated a poor outcome with a median survival of 23.5 (95%, CI 12.2 to 31.4). Multivariate analyses were performed to explore the influence of independent variables on overall survival (OS) for patients with non-metastatic disease. Besides the expected adverse effect of disease progression, the favourable influence of adjuvant chemotherapy and tamoxifen prevailed. The amount of benefit gained from tamoxifen, however, was small. Similar analyses were undertaken to determine the influence of independent variables on progression-free survival (PFS). These analyses ascertained the adverse effects of advanced stage and the favourable impact of adjuvant chemotherapy. Breast cancer in the KSA has features that are distinctive from those of industrialised countries. Survival data, however, were comparable. The favourable influence of adjuvant chemotherapy was evident on both OS and PFS. Adjuvant tamoxifen, however, had little effect. Due to its infrequent use, the role of other adjuvant modalities could not be asserted.

Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients

The aim of this study was to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. In a prospective open study, 30 cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corp, Kenilworth, NJ) prepared as a mouthwash solution (5-10 micrograms ml-1). GM-CSF was administered within 24 hours of occurrence of oral mucositis x 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. Six patients were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 24 patients were all evaluable. Most patients had either Grade 3 or 4 gross (76%) or functional (54%) mucositis. The mean +/- SEM gross oral mucositis scores for all 24 patients combined decreased from 3.08 +/- 0.18 at baseline to 2.04 +/- 0.19 (p < 0.0001) after 2 days, 0.92 +/- 0.16 (p < 0.0001) after 5 days, and 0.25 +/- 0.09 (p < 0.0001) after 10 days of therapy. Likewise, the mean +/- SEM functional oral mucositis scores decreased from 2.71 +/- 0.18 at baseline to 1.58 +/- 0.19 (p < 0.0001) after 2 days, 0.75 +/- 0.16 (p < 0.0001) after 5 days, and 0.17 +/- 0.08 (p < 0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis score) was evident in seven (29%), 20 (83%), and 24 (100%) patients by the 2nd, 5th, and 10th day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis score) reported in 13 (54%), 19 (79%), and 24 (100%) by the 2nd, 5th, and 10th day of therapy respectively. It was found that GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosages and schedule.

Cancer in the Eastern Region of Saudi Arabia: A population-based study (1987-1988)

This study presents the findings of the first population-based tumor registry in the Eastern region (ER). Data on all cancer sites, in 1987 and 1988, were captured from all health facilities in the ER. A regional population census was obtained from regional health authorities. Cancer deaths were obtained from death registries. Age-specific rate, crude incidence rate (CIR), age-standardized incidence rate (ASR) and relative age-standardized incidence rate (%ASR) were compared with available population-based data from 137 tumor registries. 1559 primary cancer cases were captured. The CIR and ASR/100,000/year for cancer among Saudi males were respectively 59.8 and 125.7. The corresponding rates among Saudi females were 43.6 and 95.5. These rates rank very low on the international scale. Cancer sites with the highest %ASR among Saudi males were lung, lymphomas, leukemias, urinary bladder and tumors of uncertain primary. For Saudi females, these sites were breast, leukemias, tumors of brain and nervous system, thyroid and tumors of uncertain primary. Lung cancer was the leading cause of death from cancer among Saudi males. The first regional population-based cancer registry in Saudi Arabia was established in 1987. The overall cancer ASR in the ER is low. The leading cancer sites with the highest %ASR are lung in Saudi males and breast in Saudi females.

Diagnostic and therapeutic value of ERCP and prediction of outcome: a retrospective analysis

The objective is to analyze the experience of using diagnostic and therapeutic ERCP and to attempt identifying the independent factors that predict positive and useful procedures. The medical records of 198 patients seen during the period 1991-1993 were retrospectively reviewed. There were 102 males and 96 females with a mean age of 45.2 SD + 16.7 years. The main indications for performing the procedure were jaundice, abdominal pain, nausea and/or fever. Laboratory tests showed elevated direct bilirubin in 50% of patients, deranged liver enzymes in 43%, and ESR was raised in 51% and fever was documented in 52% of patients. The cannulation of both ducts was successful in 93% of all procedures. The commonest finding was gallbladder and common bile duct stones (CBD). In 54 patients out of 64 with CBD stones, stones were removed endoscopically. Stepwise regressive analyzis has identified age above 40 years, presence of jaundice (total bilirubin > 2.5 mg/ml) and raised ESR (> 25 mm in the 1st hour) as significant factors that independently predict a positive ERCP that revealed findings previously unknown (useful procedure). Diagnostic and therapeutic ERCP is an integral part in management of biliary and pancreatic ducts disorders. The validity of clinical prediction role should be tested prospectively.

Leukemia in the eastern region of Saudi Arabia: A population-based study (1987-1988)

This is the first population-based data in Saudi Arabia on the incidence of leukemias in the Eastern Region, as conducted by its regional tumor registry. Data on cancer were captured from all health facilities in the region in 1987-1988. Population census was derived from a survey. Data on cancer deaths were obtained from all death registries. Crude, age-specific, age-standardized, and relative age-standardized incidence rates were used as indicators for the incidence of leukemia. There were 124 cases of leukemias registered. The yearly average crude incidence rate was 5.2 and 3.6 per 100,000 for Saudi males and females, respectively. The age-standardized incidence rate was 7.3 and 6.1 per 100,000 per year in Saudi males and females respectively. The relative age-standardized incidence of leukemias in Saudi males and females ranked, respectively, third and second highest on the international scale. Death from leukemia among Saudis was responsible for 8.9% of the total deaths from cancer. Statistical indicators point to a high incidence rate of leukemias in the Eastern Region of Saudi Arabia among Saudis. Leukemia was the third leading cause of death from cancer. The relative age-standardized rate of leukemias among Saudis of either gender rank very high on the international scale.

Simulations model for predicting survival in women receiving adjuvant therapy for early breast cancer

PURPOSE

In 1990, a worldwide overview of the randomized trials of all aspects of the systemic treatment of early breast cancer was undertaken by the Early Breast Cancer Trialists' Collaborative Group. We used the overview data to develop a simulations model to assess and compare the potential benefits of various adjuvant therapies.

METHODS

The model consists of an expert system, a simulations module, a graphical user interface, and an output module.

RESULTS

The model has shown that tamoxifen benefited all women regardless of age or estrogen-receptor status. However, absolute gains in disease-free survival and life expectancy compared with controls were higher in women younger than 50 years of age. Prolonged chemotherapy showed absolute benefits in disease-free survival and life expectancy for all age groups and all nodal states, but the magnitude of absolute benefit appeared smaller in older women. The magnitude of the absolute gain in disease-free survival and life expectancy achieved by ovarian ablation in patients younger than 50 years of age was equal to or better than that attained by tamoxifen or prolonged chemotherapy. Ovarian ablation added to chemotherapy in young patients has demonstrated an improvement in disease-free survival and life expectancy superior to that achieved by chemotherapy alone. On the other hand, particularly for women younger than 50 years, the magnitude of the survival gain accomplished by combining tamoxifen and chemotherapy versus each modality alone was greater for disease-free survival than for life expectancy.

CONCLUSIONS

We illustrate the development process and outcome of a robust tool for reasoning and decision-making. The limitations of the model are discussed.

Chemotherapy with MECOP-B for intermediate-grade and high-grade non-Hodgkin's lymphoma in Saudi Arabia: clinical results and analysis of prognostic factors

Between August 1985 and January 1994, 73 evaluable adult patients with bulky localized or advanced-stage, intermediate- and high-grade de novo non-Hodgkin's lymphoma (NHL) were treated with MECOP-B (methotrexate and leucovorin rescue, epirubicin, cyclophosphamide, vincristine, prednisone, and bleomycin). Over a median follow-up of 32 months (range, 4-98 months), 55 patients (75%) achieved complete remission (CR) (95% confidence interval, 81-69%) and 3 attained partial remission (PR) (4%) for an overall response rate of 79%. Using a multiple regression analysis where the dependent variable was response to therapy (CR vs. PR + treatment failure), poor performance status, and the presence of a bulky disease were negatively associated with the likelihood of achieving CR. Survival analysis showed that 49 (67%) patients (95% confidence interval, 74 and 60%) were alive, of whom 47 (64%) were disease-free. While the median survival has not been reached, the actuarial survival probability at 5 years +/- SE was 64 +/- 6%. Time to treatment failure for those attaining CR was also estimated. While the median survival has not been reached, probability of freedom from treatment failure at 5 years +/- SE was estimated as 74 +/- 7%. However, the long-term CR (CR rate times disease-free survival rate) was only 48%, and the 'measurement of efficacy' was 53%. These results were inferior to those from our earlier reports. The proportional hazards model of Cox identified poor performance status, older age, and high lactate dehydrogenase as factors with an adverse effect on survival. Using the results of the model, patients were categorized into three predefined risk groups with significant differences in outcome. Toxicity of the regimen was high, but comparable to that reported in the literature with a toxic death rate of 8%. We conclude that MECOP-B is an effective therapy for patients with aggressive NHL; however, based on the current results as compared with our earlier analysis, besides the emergence of prognostic factors, therapy of NHL should be individualized. Less expensive, less toxic regimens should be used for lower-risk patients, while the use of more intense, more toxic, more expensive programs should only be offered to those with a predicted poor outcome.

Magnetic resonance imaging of tuberculous spondylitis

STUDY DESIGN

This retrospective study analyzed the magnetic resonance imaging characteristics of tuberculous spondylitis.

OBJECTIVE

To describe the magnetic resonance imaging characteristics of tuberculous spondylitis and compare the diagnostic yield of magnetic resonance imaging versus other modalities.

SUMMARY OF BACKGROUND DATA

Tuberculous spondylitis is not an uncommon occurrence with extrapulmonary disease. It requires prompt diagnosis and management. In the pre-magnetic resonance imaging era, computed tomography was used to delineate the associated radiologic changes. Data are limited that describe the magnetic resonance imaging pattern of tuberculous spondylitis and the effect of post-contrast enhancement.

METHODS

The magnetic resonance imaging characteristics of 28 vertebrae in 12 patients with tuberculous spondylitis were studied.

RESULTS

The thoracic spine was the most commonly involved region, with involvement occurring in the thoracic spine alone in 12 vertebrae (43%) and with other areas of the spine in an additional five (18%). Partial involvement was detected in the majority of the vertebral lesions (24; 86%). Magnetic resonance imaging evidence of disc space involvement was apparent in only 46% of the lesions. Paraspinal abscess and epidural extension were documented by magnetic resonance imaging in 71% and 61% of lesions, respectively. Decreased signal intensity on T1-weighted images was demonstrated in 13 vertebrae (46%), with increased signal intensity on T2-weighted images seen only in five (18%).

CONCLUSION

Magnetic resonance imaging is a useful diagnostic modality for patients with suspected tuberculous spondylitis. Partial vertebral involvement and paraspinal and epidural extension were delineated. Study of the signal intensity on T1- and T2-weighted images revealed a pattern that may be dissimilar to that commonly reported. Post-contrast enhancement adds more certainty to the diagnosis of tuberculous spondylitis.

Magnetic resonance imaging of the spine: An initial experience

Retrospective analysis was carried out for 447 magnetic resonance imaging (MRI) studies of the spine. The overall mean age +/- SD of the entire series was 38.7 +/- 12.9 years. Degenerative spinal lesions and prolapsed intervertebral disks were detected in 62% and 73% of all the studies and of those which showed spinal abnormalities respectively. Postoperative granulation tissue was the third most common abnormality detected (12%). MRI was superior to computed tomography (CT) and CT myelograms in the diagnosis of disk prolapse (97% versus 66%), degenerative disease of the spine (94% versus 48%), and postsurgical granulation tissue (100% versus 6%). Comparing the numbers of CT and CT myelograms requested in the year prior to the installation of the MRI to the numbers requested during the year where the MRI was functioning did not show any change in the frequency of ordering CT studies. We conclude that our hospital-based series has shown an interesting pattern for spinal disorders. The first year experience of the utilization of MRI in various spinal diseases has been satisfactory with prevailing diagnostic superiority for that modality.

Postmenopausal osteoporosis in Saudi women: A pilot screening

One hundred and ten radiographs of calcaneum were reviewed for postmenopausal osteoporosis in Saudi women. These patients had presented to the emergency room with unrelated complaints. The mean (+/- SD) age of this group was 58 (+/-8.9) years with a range of 45 to 80 years. Of these eighty-six (76%) patients had osteoporosis; of these, 42 had mild osteoporosis, 31 had frank osteoporosis, and 11 were diagnosed to have sever osteoporosis. Women with severe osteoporosis were significantly older than those with mild (P=0.0417) as those who were normal (P=0.002). This study indicates a high prevalence of postmenopausal osteoporosis in Saudi women and multicenter, large scale screening should be instituted to determine the incidence of postmenopausal osteoporosis among Saudi women.

Fatty infiltration of the liver: analysis of prevalence, radiological and clinical features and influence on patient management

Over a 6-year period, in 1425 adult computed tomographic studies, radiological evidence of fatty infiltration of the liver (FIL) was found in 138 patients (9.7%). Patients with FIL had a mean age +/- SD of 45.9 +/- 15.7 years and 57% were males; the majority were Saudis (73%). Most patients (95%) had one or more underlying aetiological causes. Haematological and non-haematological malignancies with or without liver involvement were the most frequently encountered aetiological factors (66% of patients). FIL contributed to hepatomegaly or was associated with abnormality in one or more of the liver function tests in 30% and 39% of patients, respectively. Assessment of the various radiological patterns showed diffuse fatty changes in 68% of patients and solitary or multiple focal changes in 9% and 22%, respectively. 13 patients (9%) showed sparing of the caudate lobe within a diffuse fatty process. Patients with diffuse FIL had significantly higher values for alkaline phosphatase (p = 0.0016) and serum asparate aminotransferase (p = 0.0251) than those who had the focal pattern. FIL in 20 patients (14%) imposed a difficulty in making an appropriate diagnosis, led to inaccurate impressions, or forced unnecessary invasive or non-invasive investigations. We conclude from our large series of patients that FIL is not uncommon in hospital practice and among those at risk should always be considered as an appropriate diagnosis.

Breast cancer in a low-risk population. The influence of age and menstrual status on disease pattern and survival in Saudi Arabia

Data on 130 women with invasive breast cancer, seen at our institution between April 1981 and November 1990, were retrospectively reviewed to assess the influence of age and menstrual status on the pattern and prognosis of their disease. Patients were mostly young (median age 40 years) and in 21 patients (16%) the diagnosis was established at the age of 30 years or younger. Eighty-six patients (66%) were under 50 and 82 patients (63%) were pre-menopausal. Pre-menopausal patients were more numerous than expected in stage III and less numerous in stage II. On the other hand, the differences between observed and expected values for both stage I and stage IV in the 2 menopausal groups were not significant. Compared with post-menopausal patients, pre-menopausal patients with 1-3 or greater than 3 positive lymph nodes were more numerous than expected. Differences between pre-menopausal and post-menopausal patients have persisted after categorizing patients into 2 age-groups with a cut-off point at 50 years. Comparable initial assessment and therapeutic modalities were offered to the 2 menopausal groups. At the time of analysis (January, 1991) all patients had a complete follow-up. Over a median follow-up of 46 months, the overall median survival (+/- SE) was 85.7 (+/- 4.4) months with a survival probability (+/- SE) at 5 years of 62% (+/- 5%). The proportional hazard model of Cox has identified advanced stage (stages III and IV) and involvement of lymph nodes as the only independent adverse predictors of survival with estimated hazard rates of 2.9 and 2.8, respectively. Unadjusted analysis, adjusted analysis and stratified survival functions failed to reveal any survival difference based on age or menstrual status. We conclude that, in a low-risk population and despite apparent baseline differences in demographic and disease characteristics between pre-menopausal and post-menopausal breast cancer patients, neither age nor menopausal status had a significant influence on survival. Our results should guide future cancer-care programs in Saudi Arabia.

Community acquired acute bacterial and atypical pneumonia in Saudi Arabia

BACKGROUND

Rational treatment of pneumonia requires knowledge of the likely aetiological diagnosis in any community. Little is known about the pattern and outcome of pneumonia in Saudi Arabia.

METHODS

A total of 567 pneumonic episodes in adult patients from the Al-Qassim area were reviewed retrospectively.

RESULTS

Patients had a mean age of 42.7 years, with 103 patients (18%) aged 13 to 20 years and 103 (18%) aged 60 or more. Almost two thirds of the episodes (64%) occurred in men. An aetiological diagnosis was established in 351 (62%) cases, with 145 episodes being due to pneumococcal infection and 129 to Mycoplasma pneumonia. Inhospital mortality was 6% (35 patients). Age over 60 years, aspiration pneumonia, and Gram negative infection were the only factors that independently predicted adverse outcome on adjusted mortality analysis.

CONCLUSION

This analysis of pneumonia in the Al-Qassim area indicates the pattern and prognosis of acute bacterial and atypical pneumonia that requires admission to hospital in the central region of Saudi Arabia. It should provide a basis for developing rational treatment for community acquired pneumonia in Saudi Arabia.

Public knowledge, misperceptions, and attitudes about cancer in Saudi Arabia

We interviewed six hundred adults to assess their awareness, attitude and misperceptions about cancer. The mean age (+/- SD) was 31.2 (+/- 8.7) years. Fifty-six percent of the participants were males and 75% were Saudis. Nationality and having a relative who had cancer were found to be insignificant predictors of attained knowledge. Despite a minor difference between males' and females' performance, gender did not influence knowledge. Education was the most significant factor that influenced individuals' knowledge and misperceptions. The most significant difference was noted between those who had university or higher education (level III, 41%) and those who were illiterate or only had primary schooling (level I, 16%). The difference between level I and level II (secondary and high school, 43%) was less obvious. The analysis also showed that individuals who were > 30 years of age generally showed more knowledge and fewer misconceptions about cancer than younger participants. Age, however, together with education deviated only 5% in the variability of the total score. A high level of misperception was observed among all respondents specifically relating to questions regarding side effects of conventional therapy and statements about unproven treatment. This analysis demonstrated that knowledge about cancer was disappointingly poor and the level of misperceptions significantly high. Possessing higher academic credentials alone, is not sufficient to acquire an optimal standard of health knowledge. The data also suggest that there should be comprehensive cancer health education and primary and secondary cancer prevention programs in Saudi Arabia. To achieve this goal, primary care physicians and community cancer centers should work jointly. Brief guidelines are proposed.

Antiemetic efficacy of cimetidine randomized, double-blind, crossover study with dexamethasone in cancer patients receiving emetogenic chemotherapy

In a randomized, double-blind, crossover study the antiemetic effect of cimetidine was compared with that of dexamethasone in cancer patients receiving emetogenic chemotherapy. Thirty-two patients were evaluable and all were chemotherapy-naive. Eight patients (25%) received high doses of cisplatin, 17 (53%) had cyclophosphamide in combination treatment, 2 (6%) received adriamycin, and 1 another chemotherapy of less emetogenic potential. Complete protection (CR) rates of 59.4% and 62.5% were achieved with cimetidine and dexamethasone, respectively. In addition, three (9.4%) and 1 (3%) patients attained partial protection with cimetidine and dexamethasone, respectively. No significant difference was noted between the two antiemetic therapies (p = 0.07). Although CR has not been achieved in any of those patients who received cisplatin, a comparable antiemetic effect was attained. Both antiemetic regimens were well tolerated with minimal side effects. We conclude that the antiemetic potential of cimetidine and its safety deserve further investigation in a larger study, perhaps in combination with other antiemetic agents.

The pattern and outcome of burn injuries at a burn unit in Saudi Arabia: Retrospective analysis of consecutive 501 patients

We retrospectively reviewed the cases of 501 consecutive patients with burn injuries who were seen between June 1983 and December 1988. The population consisted predominantly of young patients under 20 years of age (53%); 65% were males and 72% were Saudi nationals. Most burn injuries were the result of domestic accidents (75%) and scald burns were the cause in 55% of patients. There was an inhospital mortality of 8% during first hospitalizations. Multivariate analysis identified several independent adverse prognostic factors: increased total burn surface area, inhalation injury, thrombophlebitis, documented septicemia, and deep circumferential burn over the extremities. Using these poor prognostic factors, we were able to stratify patients into three risk categories, each presenting a significant difference in the probability of survival. Our analysis yielded data about the pattern of burn injuries, prognostic factors, and outcome at a dedicated burn unit in Saudi Arabia.

Evaluation of students' performance and examination procedures in final certifying examinations in internal medicine (1982-1988)

We conducted a retrospective analysis to evaluate the performance of 459 students on their final certifying examination in internal medicine. These examinations were taken during 1982 through 1988, and the failure rate was 17.6%. Two hundred and five students (44.6%) received grade D (60-69% of the total marks) and 139 (30.1%) grade C (70-79% of total marks). Only 7.7% of the students scored higher (80% or more). A temporal trend has been observed in that a higher percentage of lower grades and lower percentage of higher grades has been observed in recent (1986-1988) compared with earlier (1982-1984) years. Female students generally performed on a par with males, though males students performed better on multiple choice questions (MCQs). The analysis also showed lower mean scores for the essay, oral, and clinical components in recent (1986-1988) than in earlier (1982-1984) years. In studying the interrelationships between different examination components, the MCQs were found to have the highest correlation with other procedures. A lower correlation was observed for clinical examination. Factor analysis also showed that MCQs had the highest and clinical examinations the lowest factor loading. Low correlation and factor loading were also noted for the essay portion. While in the newly implemented curriculum the essay paper has been wisely eliminated, our data suggest that the traditional clinical examination should be replaced by a more objective and structural method. Our analysis may serve as a guide for formulation of final certifying examinations in medical schools throughout the Kingdom.

Hodgkin's disease in adults in Saudi Arabia. Clinical features, prognostic factors and an analysis of therapy. Outcome of combination chemotherapy only, for both localized and advanced disease

Fifty evaluable, previously untreated, adult patients with clinically staged (CS) early and advanced Hodgkin's disease were treated with chemotherapy alone, using various regimens. Their mean age was 31.9 years. Fifteen patients (30%) had CS I or II and 35 (70%) had CS III or IV. Eighty-eight per cent of patients had one or more of the B symptoms and 64% had an unfavorable histology. Complete remission (CR) was achieved in 43 out of 50 patients (86% with 95% confidence interval of 76% to 96%), partial remission in 3 (6%) and treatment failure in 4. Adjusted analysis, using all possible subset regression, showed that unfavorable histology, bulky disease and receiving a total dose-intensity (TDI) less than or equal to 0.80 were negatively associated with the likelihood of achieving CR. At a median follow-up of 36 months (range, 6-90), 84% of patients were alive and 82% were disease-free. The overall median survival has not been reached, but the projected 5-year survival probability was 79%. Time-to-relapse was also estimated for those who achieved initial CR. The estimated 5-year relapse-free survival was 87%. The Cox proportional hazards model predicted that unfavorable histology, bulky disease and TDI less than or equal to 0.80 had an independent, adverse influence on survival. We conclude that the results of chemotherapy alone are encouraging and the rationale is practical and acceptable in those countries where the availability of radiotherapy units is limited.

A single nocturnal dose of famotidine for the treatment of duodenal ulcer: evaluation of efficacy and safety

The efficacy and safety of a single nocturnal dose of famotidine (40 mg) was evaluated in 30 consecutive patients of duodenal ulcer (DU). Three patients were lost for follow-up and therefore were excluded. The mean age of remaining 27 patients was 34.3 (+/- 9.9) years and male to female ratio was 8:1. The mean size of the DU was 1.21 (+/- 0.79) cm. After a 4-week therapy all patients showed significant improvement and repeat endoscopy in 24 out of 27 patients (89%, 95% confidence interval; 78% to 100%) showed healed ulcer. Clinical assessment of pain relief at 4-week showed significant drop in the mean score of baseline daytime (from 1.85 to 0.13) and baseline nocturnal pain (from 1.70 to 0.10) (p less than 0.0001 and less than 0.0001, respectively). Also shown was the significant decrease in the mean gastrointestinal symptoms score from 5.89 at baseline to only 0.89 at 4-week (p less than 0.0001). Despite that all those who failed to show ulcer healing at 4-week were smokers, logistic regression analysis could not identify smoking or any other risk factors as adverse predictors of ulcer healing. None of the patients experienced significant side effects or adverse reactions. We conclude, that a single nocturnal dose of famotidine is a practical, highly effective and safe approach for the management of DU.

Hepatic granuloma in Saudi Arabia: a clinicopathological study of 59 cases

The identification of hepatic granuloma (HG) as a histiocytic or epithelioid cell collection is generally an easy task for the pathologist. However, most workers agree that arriving at a specific etiologic diagnosis, based solely on the morphology of the granuloma, may prove quite a tedious exercise. Of 404 histologically reviewed liver biopsies from 404 patients, 40 were normal, 62 showed carcinoma, and 243 revealed evidence of either acute or chronic nongranulomatous liver disease (NGLD). The remaining 59 biopsies had HG, constituting an incidence figure of 14.6%. The latter 59 patients qualified for further clinicopathological analysis, which constituted the material for this study. The HG was due to schistosomiasis in 32, tuberculosis in 19, brucellosis in four, drugs in two, and to typhoid and ruptured fat cysts (lipogranuloma) in one patient each. The study was done to delineate the histological and other features that might be of value in identifying the etiology of HG.

Helicobacter pylori-associated upper gastrointestinal disease in Saudi Arabia: a pathologic evaluation of 298 endoscopic biopsies from 201 consecutive patients

In a prospective study, histopathological examination 298 upper gastrointestinal (UGI) biopsies, obtained from 201 consecutive patients, was made. Patients were referred with mild to severe dyspeptic symptoms. The aim of the study was to compare the rate of identification of Helicobacter pylori (H. pylori) in the histologically normal gastric mucosa with that in histologically confirmed gastritis or peptic ulcer disease. The gastroduodenal mucosa was histologically normal in 35 patients (17.4%); among those patients, H. pylori was identified in only three (9%). Chronic gastritis was histologically confirmed in 162 patients (80.6%). H. pylori was identified in 123 (76%) of those patients. The difference was statistically significant (p less than 0.00001). Furthermore, when cases with a histological diagnosis of superficial chronic active gastritis (SCAG) are considered separately, the identification rate of H. pylori increases to 88% (121 of 137). When this rate is compared with that of 8% (two of 25), found in superficial chronic quiescent gastritis (SCQG), the difference is highly significant (p less than 0.00001). Of 38 endoscopically diagnosed peptic ulcers, H. pylori was identified in the gastric mucosa of 34 (89%). The organisms were always seen in the antral gastric mucosa, but never in duodenal mucosa. Identification of H. pylori correlates significantly with the histologic activity of chronic gastritis, in both peptic ulcer disease and non-ulcer dyspepsia.

Late relapse of Hodgkin's disease after 25 years

This short report documents a late relapse of Hodgkin's disease 25 years later after initial complete remission. The case represents the second longest ever reported disease-free survival that was followed by late recurrence. Data about late occurrence in Hodgkin's disease of relapses are reviewed. The biological and clinical significances of those events of late relapses are emphasized.

Splenic foam cells: a clinico-pathologic analysis of 92 splenectomized patients

Spleens from 92 patients who underwent splenectomy for various indications were examined. These indications included hematologic disease in 38 patients and nonhematologic problems in 54. Of all the group foam cells were seen in hematoxylin and eosin (HE)-stained sections of spleens from 12 patients. This number increased to 21 (23%) when the diastase periodic acid-Schiff stain was used as a screening test. The cells in these 9 additional cases were too scanty to be observed on HE-stained sections alone. All the 21 spleens with positive foam cells were from patients with hematologic disease, specifically beta-thalassemia major, hemoglobin S/beta-thalassemia, hemoglobin AS, and idiopathic thrombocytopenic purpura. None of the spleens from the 54 nonhematologic patients showed foam cells. Factors that determine the probability of presence of foam cells were calculated. Also, certain differences in the staining reactions of foam cells were observed. The results of both, and the relation of these foam cells to the 'syndrome of the sea-blue histiocyte' are presented and discussed.

Campylobacter pylori in Saudi patients undergoing upper gastrointestinal endoscopy: prevalence and effect of conventional therapy

Patients with symptoms of gastritis or peptic ulcer disease were recruited to study the prevalence of Campylobacter pylori. On the basis of the endoscopic diagnosis only, the isolation rates of the organisms in normal, gastritis or gastroduodenitis (GD), and peptic ulcer (PU) disease patients, were not significantly different among the 89 patients evaluated. However, analysis based on histopathological evaluation (in 73 out of these 89 patients) revealed a significant difference (p = 0.00016) in the isolation rate between histologically normal individuals (14%) and those with GD (89%). Also, a significant (p = 0.03) difference was observed in the C. pylori detection rate among patients with GD and those with PU disease (61%). After adjustment for multiple comparisons, only the difference in C. pylori prevalence between normal and GD patients was maintained. After conventional therapy, 23 patients who initially had GD or PU disease were submitted to re-endoscopy. In the latter group, a correlation between presence or absence of organisms and histological healing was noted. The potential pathogenesis of C. pylori in gastritis and peptic ulcer disease, and designs for future trials are discussed.

Malignant bone tumours in pregnancy (a report of two cases and review of literature)

Two cases of malignant bone tumours in pregnancy are reported. The optimum management is not clearly defined due to the rarity of the condition and limited individual experience. Our patients delivered healthy babies without any signs of maternal malignant disease. Cancer chemotherapy was instituted during the postmortem period. Pregnancy did not appear to exacerbate the tumour growth nor in any way affect the ultimate outcome of the patients.

The outcome of head injury: the Saudi experience

The outcome in 159 cases of head injury was evaluated in terms of the Glasgow Coma Scale (GCS) score, age, and computed tomographic (CT) findings. Children below the age of 10 accounted for 30% of the head-injured patients, and 69% were Saudis. 81% of the patients had a GCS score of 8 or higher, and in this group the outcomes were favorable. In contrast, 19% had an initial GCS score of 7 or less, tended to be older, and had worse outcomes, with a mortality rate of 68%. The initial GCS score, age, presence or absence of associated injuries, and the degree of midline shift according to CT were useful prognostic indices in patients with head injury.

The prevalence of allergic disorders in Saudi Arabia: preliminary analysis based on surveying 300 individuals

Prospective surveying of 300 (150 males, and 150 females) randomly selected individuals was carried out to study the pattern and prevalence of allergic disorders in the community. The mean age was 32.8 and 26.8 years for males and females, respectively. A total of 28 participants (17 males, and 11 females) (9.3%) were found to have personal history of allergic disorders. No significant sex difference was noted in the distributions of those allergies, except for more male predominance for allergic rhinitis. The latter was seen in 7 males and only one female (p = 0.033). Prevalence of bronchial asthma was rather rare as it was identified in only 2 individuals (0.7%). More males (16) than females (2) admitted a positive family history of allergy (P = 0.0005). Most of the familial history of allergic disorders was due to bronchial asthma (11 relatives). We conclude that allergic disorders are common in our local community. However, for more detailed assessment, a larger sample that includes various age distributions and different socioeconomic classes should be screened.