Comprehensive biomechanical and anatomical atherosclerotic plaque metrics predict major adverse cardiovascular events: A new tool for clinical decision making

BACKGROUND AND AIMS

Anatomical imaging alone of coronary atherosclerotic plaques is insufficient to identify risk of future adverse events and guide management of non-culprit lesions. Low endothelial shear stress (ESS) and high plaque structural stress (PSS) are associated with events, but individually their predictive value is insufficient for risk prediction. We determined whether combining multiple complementary, biomechanical and anatomical plaque characteristics improves outcome prediction sufficiently to inform clinical decision-making.

METHODS

We examined baseline ESS, ESS gradient (ESSG), PSS, and PSS heterogeneity index (HI), and plaque burden in 22 lesions that developed subsequent events and 64 control lesions that remained quiescent from the PROSPECT study.

RESULTS

86 fibroatheromas were analysed from 67 patients. Lesions with events showed higher PSS HI (0.32 vs. 0.24, p<0.001), lower local ESS (0.56Pa vs. 0.91Pa, p = 0.007), and higher ESSG (3.82 Pa/mm vs. 1.96 Pa/mm, p = 0.007), while high PSS HI (hazard ratio [HR] 3.9, p = 0.006), high ESSG (HR 3.4, p = 0.007) and plaque burden>70 % (HR 2.6, p = 0.02) were independent outcome predictors in multivariate analysis. Combining low ESS, high ESSG, and high PSS HI gave both high positive predictive value (80 %), which increased further combined with plaque burden>70 %, and negative predictive value (81.6 %). Low ESS, high ESSG, and high PSS HI co-localised spatially within 1 mm in lesions with events, and importantly, this cluster was distant from the minimum lumen area site.

CONCLUSIONS

Combining complementary biomechanical and anatomical metrics significantly improves risk-stratification of individual coronary lesions. If confirmed from larger prospective studies, our results may inform targeted revascularisation vs. conservative management strategies.

Online surgical education adopted among urology residency programs in response to COVID-19: A pilot study

OBJECTIVE

To understand the residents' perceptions of the, COVID-19 driven, newly implemented online learning systems adopted among accredited urology residency programs nationwide, and their sustainability following the pandemic era.

MATERIALS AND METHODS

A survey was designed and dispersed to urology program coordinators and directors to distribute to their residents. In the survey, Online education models was the all-encompassing term to describe any form of resident education that occurred online. Anonymous surveys were exported from Survey Monkey and data was analyzed for statistical significance.

RESULTS

Over 70% of urology residents agreed or were neutral to the statement that Online education models were equivalent to in-person learning. Only 13% of residents stated that online learning should not be continued following the pandemic. Several different parameters were assessed, and only 5 of them showed statistical significance. Stress, personal engagement, interpersonal communication efficiency and non-verbal cues were all lower with online education models. The only attribute that was scored higher by residents was network connectivity issues.

CONCLUSIONS

An overwhelming majority of urology residents in the United States believe Online education models should continue to be adopted once the pandemic is over.

Urolithiasis in pregnancy: Advances in imaging modalities and evaluation of current trends in endourological approaches

OBJECTIVE

Given the challenges involved in diagnosis and treatment of pregnant women with urolithiasis, we aim to review the imaging modalities and current endourological management of these patients.

MATERIALS AND METHODS

We performed a review of the available literature on urolithiasis in pregnancy. This included evaluation, diagnostic imaging, and therapeutic options. The databases we searched from included Google Scholar and PubMed. A total of 346 abstracts were screened. After our inclusion/exclusion criteria were met, we were left with 42 sources: 18 retrospective studies, 10 reviews/meta-analyses, 8 sets of guidelines, 5 randomized control trials, and 1 prospective cohort.

RESULTS

We begin our review with the literature available on the safety and efficacy of imaging modalities in the surgical planning for urolithiasis in pregnant patients. This includes renal ultrasound, abdominal x-ray, computed tomography scan, and magnetic resonance imaging. While computed tomography may result in an added radiation exposure, with possible safety concerns, magnetic resonance imaging seems to be safer, however a less sensitive test. We next describe safety, efficacy, and outcomes of various surgical interventions for urolithiasis in pregnant patients. This encompasses ureteral stenting, percutaneous nephrostomy, ureteroscopy, extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. Ureteroscopy is a safer approach, but percutaneous nephrolithotomy offers higher stone-free rates. Using an evidence-based approach, we propose an algorithm for management of the pregnant women with renal colic.

CONCLUSION

Management of the pregnant women with suspected urolithiasis is a unique challenge for healthcare providers. A multi-disciplinary approach should be taken to optimize outcomes through an evidence-based approach.

LA EDUCACIÓN QUIRÚRGICA EN LÍNEA IMPLEMENTADA EN LOS PROGRAMAS DE RESIDENCIA UROLÓGICA COMO RESPUESTA AL COVID-19: ESTUDIO PILOTO

Objetivo

Comprender la percepción de los residentes respecto a los sistemas de aprendizaje en línea, los cuales, impulsados por la pandemia de la COVID-19, han sido recientemente implementados a nivel nacional en los programas de residencia urológica acreditados. Adicionalmente, nos proponemos analizar su sostenibilidad tras la era de la pandemia.

Material y métodos

Se diseñó una encuesta para, a través de los coordinadores y directores de programas de urología, difundirla a los residentes de urología.

En la encuesta, los modelos de educación en línea englobaron cualquier forma de educación recibida por los residentes que se diera en línea. Las encuestas anónimas se exportaron de Survey Monkey y se analizaron los datos para determinar la significación estadística.

Resultados

Más del 70% de los residentes de urología estuvieron de acuerdo, o mostraron una actitud neutral, ante la afirmación de que los modelos de educación en línea eran equivalentes al aprendizaje presencial. Solo el 13% de los residentes afirmaron que el aprendizaje en línea no debería continuar tras la pandemia. Se evaluaron diversos parámetros, y solo 5 de ellos mostraron significación estadística. El estrés, el compromiso personal, la eficacia de la comunicación interpersonal y las señales no verbales fueron más bajos para los modelos de educación en línea. El único aspecto al que los residentes dieron mayor puntuación fue el de los problemas de conectividad a una red.

Conclusiones

La gran mayoría de los residentes de urología en Estados Unidos cree que los modelos de educación en línea deben mantenerse una vez terminada la pandemia.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Esophageal cancer epidemiology, diagnosis, and management in Sudan - A review

INTRODUCTION

In Sudan, cancer a common health challenge, is the leading cause of death after malaria and viral pneumonia. The aim of the review is to determine the risk factors associated with esophageal cancer (EC) among Sudanese population.

METHODS

All published online data concerning EC epidemiology, diagnosis, and management in Sudan were studied.

RESULTS

The prevalence of EC in Sudan is ranked fourth among cancer types in males and fifth in females. The squamous cell carcinoma is more predominant than adenocarcinoma. The dietary, dysplasia and teeth loss, cigarette smoking, age, sex, GERD, genetic and environmental interactions remain a risk for developing EC in clinical practice. A significant challenge for treatment is that most of EC patients were often diagnosed in advanced stages due to the lack of early clinical symptoms. Management of EC depends on patient fitness and tumor stage, endoscopic removal was used for early tumors, while chemotherapy, chemo-radiotherapy, surgical resection, or combinations of these were used for advanced tumors. Despite improvements in the management and treatment of EC patients, the general outcome remains very poor. Furthermore, using molecular techniques to better understand the etiology of EC, it may assist in identifying complicated and critical issues and improve therapy towards a new treatment strategy.

CONCLUSION

The remarkable factors associated with EC among Sudanese are geographical variation, environmental factors, ethnic differences, dietary and social habits.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Primary wound closure of diabetic foot ulcers by debridement and stitching

OBJECTIVE

The role of stitching in healing diabetic foot ulcers (DFUs) has little attention, with few reports published on the technique. This study aimed to report on the role of stitching in healing of neuropathic DFUs.

METHOD

This comparative study was between patients with diabetes with neuropathic foot ulcers who had undergone wound stitching and those on conventional wound care. The study was carried in Jabir Abu Eliz Diabetic Center Khartoum (JADC) during between January 1 2011 and January 1 2013. All patients presented with neuropathic diabetic septic foot on the plantar aspect or extending up the leg were included. Initial surgical sharp debridement under intravenous broad spectrum antibiotics was performed and oral antibiotics were given 3 days later after the results of the bacterial culture were received. Regular wound debridement was performed with the aim of pairing the wound edges for stitching. Primary closure was performed when the wound was clean from any necrotic tissues and partial closure when the wound was still oozy to secure drainage and avoid splaying of the wound edges. All patients were using either crutches or wheel chair initially until any sepsis cleared and then proper off-loading by shoes purpose made in our centre.

RESULTS

A 160 patients with neuropathic DFUs that needed debridement and frequent dressing changes as outpatients were included. Both groups had the same tap water wound dressing either daily, every other day or every two days according to the wound progress. Absorbent dressings and negative pressure wound therapy (NPWT) were unavailable. Half of the patients (n=80) had debridement, frequent dressing change using tap water throughout the period of study (group 1) while the rest (n=80) in addition to wound debridement underwent stitching of their wounds (group 2). Complete healing was achieved in 46 patients in Group 1 (57.5%) compared with 19 patients (23%) in group 2 (p=0.001). The average number of dressings used was 19 in stitch group compared with 30 in the non-stitch group (p=0.000). The average duration of healing in stitch group was 2.9 months compared with 5.7 months in non-stitch group (p=0.000).

CONCLUSION

Stitching of neuropathic DFUs reduced the duration of wound healing and the frequency of wound dressing change.

Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes

OBJECTIVE

The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers.

METHOD

This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up.

RESULTS

The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02).

CONCLUSION

Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time.

DECLARATION OF INTEREST

The authors have no conflict of interest to declare.

OESOPHAGEAL CANDIDIASIS IN AN IMMUNOCOMPETENT ADULT, AN ADVERSE EFFECT OF ANTIBIOTIC THERAPY FOLLOWING CARDIAC SURGERY, CASE REPORT AND REVIEW OF LITERATURE

Dysphagia following cardiac surgery is a frequently encountered problem, being most commonly due to the sternotomy incision and/or prolonged intubation. Oesophageal candidiasis is an increasing problem that is usually associated with immunosuppression or immunodeficiency. We report a 59 years age, immunocompetent lady whom had developed dysphagia and odynophagia following open cardiac surgery and long term course of antibiotics. Diagnosis of Candida oesophagitis was established after radiological, endoscopic and microbiological evidence, and successful treatment with combined topical and systemic antifungal therapy was achieved. Possibility of immunodeficiency was excluded. We believe that this lady developed oesophageal candidiasis due to a long-term course of broad spectrum antibiotics. We discuss the various diagnostic modalities and treatment options.

Extended leg infection of diabetic foot ulcers: risk factors and outcome

OBJECTIVE

To identify the risk factors for extension of infection to the leg in diabetic foot ulcers (DFU) and to evaluate its role as a prognostic measure regarding limb salvage and healing time.

METHOD

This retrospective case-control study took place in Jabir Abu Eliz Diabetic (JADC) during 2006-2008. Forty-eight patients diagnosed with a diabetic foot ulcer (DFU) with the infection extending to the leg (case group) were compared with an equal number of patients with a DFU without extension (control group). Risk factors for extension were identified by univariate analysis and both groups were compared with regard to limb salvage and healing time.

RESULTS

Previous history of toe amputation was more frequent in the case group (p=0.004). The case group patients were significantly more likely to present with fever (p=0.01), pallor (p=0.02), confusion (p=0.04), and necrosis (p=0.004). Ulcers located in the heel were more frequent in the case group when compared with controls (p=0.0001) while more toes ulcers were found in the control group (p=0.001). A significant number of patients in the case group had an ulcer of more than 5cm diameter compared with those in the control group (p=0.001). The total number of patients presented with severe disease (Wagner grade 3-5) was significantly more in the case group compared with controls (p=0.004). Patients with severe infection (grade 4) were more in the case group compared with the controls (p=0.04). There were no significant differences between the two groups with regard to major and minor amputation rate. The case group had a longer duration of healing when compared with the controls. Seventy-five per cent of the controls healed by 6 months (n=31) compared with 22% in the case group (n=8 ; p=0.001).

CONCLUSION

Toe amputation, wound located in the heel, wound size more than 5cm and advanced Wagner grade (3-5) and severe sepsis, grade 4, may be considered as risk factors for extension of infection to the leg in DFU. However, this extension did not carry a poor prognostic value to the final outcome if adequate therapeutic measures were followed.

BDN programmes and the effect of medical students' interventions to promote child health in Sudan

Basic development needs (BDN) is an approach to community development that aims at improving quality of life through the full involvement and self-management of communities, supported by intersectoral collaboration. The objective of this study was to assess the effects of BDN implementation in an area of Sudan on aspects of a programme implemented by students from the Faculty of Medicine, University of Gezira. The study revealed that the joint implementation of BDN programmes and students' interventions brought about marked improvement of family and community practices as well as greater reduction in the incidence of all assessed major childhood illnesses (diarrhoea, cough and fever) than when the students' programme was implemented alone. BDN implementation also facilitated the retrieval of good quality community-based data.

External strangulated hernia in Khartoum, Sudan

OBJECTIVES

To determine the pattern of presentation and outcome of strangulated external hernia, to predict the risk factors of strangulation, and to draw the attention towards the incidence of strangulation and its sequelae which are preventable by early repair.

DESIGN

A prospective study over a two year period.

SETTING

Khartoum Teaching Hospital, Casualty Department during the period May 2002 to May 2004.

SUBJECTS

Sixty four patients with strangulated external hernias.

RESULTS

The mean age was 42 years and the age range was between 0.5-72 years. The male: female ratio was 5:1 and males dominated all types of hernia except in incisional hernia where more females were noted. Strangulated inguinal hernia was the most common type in 35 patients, being more common on hernias of a relatively short history (<1 year). Pre-strangulation symptoms like change in size, irreducibility and pain were reported by 57 (90%) patients few days to few weeks prior to strangulation. More than half of the patients presented to the hospital 24 hours after developing the symptoms. All patients were surgically explored, 52 through an inguinal incision and 12 via formal laparotomy. The total number of bowel resection was 24 (37.5%), mainly in those presenting after 48 hours and 12 of them were between the age of 51-60 years. There were four (6.25%) deaths.

CONCLUSION

Early diagnosis of patients with hernia and elective surgical treatment may offer the best way to minimise the relatively high morbidity and mortality associated with emergency operations.

Impact of the national protocol for malaria treatment on prescribing patterns in Gezira state, Sudan

A cross-sectional study to assess the impact of the national protocol for malaria treatment was conducted in a town in Gezira state, central Sudan, in 2001. Most of the 165 doctors and medical assistants interviewed (80.0%) had not been trained in the protocol and many (57.5%) were still using their own protocols. Analysis of 410 prescriptions showed chloroquine was the most common antimalarial drug used (69.5% of prescriptions). Compared with a study before implementation of the protocol, more prescriptions met the protocol standards for correct chloroquine dose, whereas regimens for administration of intravenous quinine were still inadequate. The study showed a lack of continuous supervision, training and follow-up in the protocol guidelines and negative attitudes of hospital specialists towards the protocol.

Resting ECG abnormalities among asymptomatic Arab men and comparison with other ethnic populations

The aim of this study was to detect the frequency of the resting electrocardiogram (ECG) abnormalities among asymptomatic Arab men in Saudi Arabia, since no similar studies had been conducted in this ethnic population. The ECG tracings of 314 men (mean age 44.2 years) who attended a health clinic in Abha, Southern Saudi Arabia, were analyzed according to the definitions of the major ECG textbooks and the Minnesota code. Abnormal ECG findings were encountered in 99 men (31.5%); 39 (12.4%) had non-specific changes, while 60 (19.1%) had potentiallysignificantabnormalities. Serious abnormalities, such as ischemic changes, left ventricular hypertrophy, and atrial fibrillation were seen in only 22 subjects (7%) and were associated with hypertension and an age greater than 40 years. On the other hand, early repolarization, the most frequent abnormality encountered, and Wolf-Parkinson-White syndrome (WPW) were mostly prevalent among young subjects. The significance of these ECG abnormalities with regard to long-term morbidity and mortality in asymptomatic subjects should be considered in relation to the age of the person and the presence of any underlying cardiovascular disease.

Blood pressure control and target organ complications among hypertensive patients in southern Saudi Arabia

Blood pressure (BP) control and target organ complications (TOC) among 203 hypertensive patients attending a hospital clinic in Abha, Saudi Arabia were studied. Optimal BP control was defined as BP < 140/90 and was achieved in 99 (48.8%) patients. Diuretics and calcium channel blockers were associated with the best rates of BP control while adverse drug reactions were associated with the poorest rates. TOC were classified according to World Health Organization criteria; 62% of patients had no TOC. Retinopathy, renal impairment and left ventricular hypertrophy were the most common stage II complications. Cerebrovascular accidents and ischaemic heart disease were the most common stage III complications.

A calculus within an anal fistula tract in a diabetic patient

A non-insulin dependent diabetic patient with a chronic anal fistula underwent fistulectomy. At operation a calculus was discovered. The patient had an uneventful recovery and healing of the wound in 4 weeks duration. The only case reported previously was in a nondiabetic patient and interestingly from this department.

Intrafamilial clustering of Helicobacter pylori infection in Saudi Arabia

AIM

To study the pattern of Helicobacter pylori infection among family members in the Saudi population.

METHODS

A cross-sectional, population-based, seroepidemiological study of family members was undertaken in a Saudi population using saliva H pylori immunoglobulin (Ig) G antibodies (Helisal kit).

RESULTS

A total of 42 families comprising 271 children and 84 parents were studied (355 subjects; mean age 23 years, SD 19 years) The overall frequencies of H pylori IgG antibodies in mothers, fathers and children were 67%, 64% and 23%, respectively. There was no significant difference in the infection rate between mothers and fathers, or between boys and girls. The infection rate among children increased when one or both parents were seropositive, and the infection rate among parents was proportionally related to the number of infected children per family. The frequency of H pylori antibodies was significantly higher in spouses of seropositive parents than in spouses of seronegative parents (45% compared with 19.2%).

CONCLUSIONS

These data confirm that the intrafamilial clustering of H pylori infection in Saudi Arabia occurs in a similar pattern to that described in the developed countries, and that living conditions and social conditions lead to person to person transmission of H pylori infection.

Aminoglycoside usage and monitoring in a Saudi Arabian teaching hospital: a ten-year laboratory audit

BACKGROUND AND OBJECTIVE

In 1989, a therapeutic drug monitoring service was established in Assir Central Hospital, Abha, Saudi Arabia, by the Department of Clinical Pharmacology and Therapeutics of the College of Medicine, King Saud University Abha Branch (now King Khalid University). We report a 10-year follow-up of the results of monitoring the commonly used aminoglycosides (amikacin, gentamycin and tobramycin) obtained from our adult patients on first monitoring.

METHOD

Two educational seminars for doctors and nurses were conducted 6 months before the initiation of this study. Drug assay requests were made on specially designed forms. Drug dosages were determined by the attending physicians. Samples for peak and trough drug level determinations were drawn after the fourth dose. The results of first time monitoring were sent to the wards with appropriate comments for dosage modifications where indicated.

RESULTS

The results for 2022 patients were analysed. Of these, 929, 899 and 194 were for amikacin, gentamycin and tobramycin, respectively. Therapeutic trough concentrations were 71.2%, 28.3% and 28.3% of patients on amikacin, gentamycin and tobramycin, respectively. A total of 8.8%, 17.6% and 11.9% had trough concentrations considered toxic for amikacin, gentamycin and tobramycin, respectively. Peak therapeutic concentrations were achieved in 31.6%, 42.3% and 39.7% of patients on amikacin, gentamycin and tobramycin. A total of 53.3% of patients on amikacin, 50.3% on gentamycin and 57.2% on tobramycin had peak serum drug concentrations in the subtherapeutic range. Toxic concentrations were noticed mainly in patients aged over 60 years and in the critically ill in the intensive care, coronary care and bums units of the hospital.

CONCLUSION

To be cost-effective, intensive therapeutic monitoring of aminoglycosides in adults should continue to be monitored mainly for the old and sick patients in critical care units to optimize patient management.

Helicobacter pylori and intestinal metaplasia with its subtypes in the gastric antrum in a Saudi population

BACKGROUND

There is a close association between intestinal metaplasia (IM) and the development of gastric cancer as well as a relationship between Helicobacter pylori, IM, and gastric cancer. Our aim was to study the frequency and subtypes of IM in a Saudi population with dyspepsia, a population with a low prevalence of gastric cancer.

METHODS

Endoscopic antral biopsy specimens were histologically studied for the presence of IM and H. pylori in consecutive patients who underwent upper gastrointestinal endoscopy for evaluation of dyspepsia. Hematoxylin and eosin and Giemsa stain were used to study IM, inflammation, and H. pylori, whereas Alcian blue, pH 2.5/periodic acid-Schiff and high iron diamine/Alcian blue, pH 2.5, were used to study IM subtypes.

RESULTS

Seven hundred and seventy-eight consecutive patients were recruited in this study, 415 men and 363 women, with a mean age of 43 +/- 17.6 years. Of the 778 patients, IM was identified in 118 (15.2%). The mean ages of patients with IM (48.8 +/- 18.7) and without IM (41.9 +/- 17.4) were statistically significant (P < 0.0001), whereas the patients' sex did not influence the presence of IM. Most had type-I IM (59.3%), whereas 26.3% and 14.4% had types II and III, respectively. The overall rate of infection with H. pylori was 75.4%. There was no difference in the frequency of IM in patients with or without H. pylori (15.5% versus 14.1%; P = 0.65). Of the 118 patients with IM, the 91 patients (77.1%) who also had H. pylori were older (55 +/- 23 years) than those without H. pylori (47 +/- 17 years, P = 0.05).

CONCLUSION

This study has documented mainly that the prevalence of IM and IM subtype III is low in our population. Furthermore, we found no significant relationship between a high rate of H. pylori infection with either IM in general or with IM subtype III in particular, possibly accounting for a low incidence of gastric cancer in the Saudi population.

Anesthesia of a patient who underwent resection of small bowel leiomyosarcoma

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Patterns of atrial fibrillation at a regional hospital in Saudi Arabia

The objective of this retrospective study was to report on the clinical presentation, etiology, and laboratory tests of both chronic and acute atrial fibrillation (AF) admitted to the cardiology unit of a teaching hospital in southern Saudi Arabia. We studied 219 records; 132 (60.3%) and 87 (39.7%) had documented chronic AF (group 1), and acute AF (group 2) respectively. The mean age (SD) was significantly higher in group 1 (64.6 [SD 19.4] vs 52.9 [SD 15.6]) (P<0.001). Palpitation, dizziness and syncope were the most frequent symptoms in acute AF, while dyspnea was the most common presentation in the chronic type. On the other hand, heart failure and embolic complications were reported significantly in group 1, but the frequency of acute respiratory problems and acute myocardial infarction was similar in both groups. The most common causes of both types of AF were rheumatic valvular diseases (26%), IHD (24.2%), hypertension (23.7%), and lung diseases (13.2%); however, in 28 patients (12.8%) no cause was detected. The echocardiography findings of chamber dilatation, valve lesions, and depressed left ventricular function were significantly frequent in group 1 (P<0.01). Although rheumatic valvular diseases are still common in Saudi Arabia, ischemic heart disease and hypertension are emerging as important causes of AF in this developing nation, and therefore require prevention and control.

Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre

BACKGROUND

Thyroidectomy for a large goitre carries a relatively high risk of postoperative respiratory obstruction which may necessitate tracheostomy.

METHODS

One hundred and three patients with a large goitre who underwent thyroidectomy were studied prospectively. The presence or absence of six preoperative predictive factors for the development of serious postoperative respiratory obstruction was recorded. These factors were: goitre for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and/or deviation, retrosternal extension, difficult endotracheal intubation and thyroid cancer. Tracheostomy was performed on the basis of clinical judgement.

RESULTS

Postoperative respiratory complications occurred in 32 patients (31 per cent), and were obstructive in 24 patients and not obstructive in eight. Tracheostomy was necessary in 13 patients (13 per cent). Tracheomalacia was the most common indication (n = 5). There were no deaths. At least four of the six risk factors were present in nine of the 13 patients who underwent tracheostomy compared with two of the 90 patients who did not.

CONCLUSION

Multiple preoperative risk factors in a patient with a large goitre may be useful in predicting the need for planned tracheostomy following thyroidectomy.

Target organ involvement in hypertensive patients in Eastern Sudan

Hypertension has become a major cause of cardiovascular morbidity and mortality in both the developed and the developing nations. In a cross-sectional study we assessed the state of blood pressure (BP) control and the pattern of target organ complications in 198 Sudanese patients treated in a teaching hospital in Kassala town in Eastern Sudan, (mean age 53 years, 76% women). Excellent BP control (BP <140/90 mm Hg) was achieved in 46% of the patients. Stage 2 or Stage 3 target organ involvement, particularly albuminuria and ischaemic heart disease, were detected in one-third of the patients. These complications were found to be related to both the severity and the duration of hypertension as well as to the frequency of cigarette smoking. Factors such as poor compliance, adverse socioeconomic status, as well as obesity and cigarette smoking may account for poor BP control and hence the development of hypertensive complications. We conclude that optimal BP control is not yet achieved in the majority of hypertensives in the Sudan. Reasons for this failure should be identified and corrected in order to avoid hypertensive target organ damage.

Knowledge of blood pressure measurement among a teaching hospital staff in a developing nation

Hypertension is a common and potentially serious disease and accurate measurement of blood pressure (BP) is important for its diagnosis and management. The aim of this study was to assess the knowledge of hospital staff on the basic principles of BP measurement. Consultants, junior doctors and nurses in a large teaching hospital in southern Saudi Arabia were requested to answer a questionnaire about the most important aspects pertaining to BP measurement. The overall response rate was about 70%. There was a wide diversity of responses reflecting a poor knowledge of some of the basic techniques of BP measurement. This included inconsistencies regarding the knowledge of cuff size, recording of diastolic BP, position of the arm and rate for deflating the cuff. Overall, 60% of the respondents had insufficient knowledge. Inaccurate BP measurement can seriously affect the diagnosis and management of the patient with this common disease. Hospital staff need to improve their knowledge about BP measurement, and teaching programmes about BP measurement should be developed as part of continuing education.

Amputation and prostheses in Khartoum

One hundred and seventy patients with major lower limb amputation (MLLA) presenting to The National Prosthetic-Orthotic Centre (NPOC) in Khartoum over a 1-year period were studied. There were 141 males and 29 females giving a M:F ratio of 4.9: 1.0, with mean age of 37 years (range 5-72 years). Forty-one patients (24%) underwent amputation of diabetic septic foot, 30 patients (17.6%) underwent amputation as a result of trauma from road traffic accidents and Madura foot, and war injuries accounted for 29 amputations (17%). One hundred and eleven patients had below knee amputation (BKA), 52 had above knee amputation (AKA) and seven patients had Syme's amputation. Diabetic amputees had higher rate of revisional surgery compared with others because of sepsis and/or flap necrosis. Stump pain was reported by amputees with excessive scarring of the stump and those with undue prominence of bony ends. There are two types of prostheses provided by the NPOC for both BKA and AKA: the peg leg and the conventional prostheses. The Syme's amputees were fitted with either simple hoof or articulated prostheses with solid ankle cushion heel (SACH). The peg leg consists of a leather lined side bearing metal socket connected to a rocker base by side steels. It is used by the country natives as it suits different weather and job conditions, particularly farming, and it can be repaired locally. The urban population use the conventional prostheses which is lighter in weight, can be put on and taken off easily and is cosmetically acceptable. However, these prostheses are more expensive and require frequent repair or replacement. The functional outcome of patient's rehabilitation with the prostheses was significantly affected by the level and indication of amputation. Those with BKA and those amputated because of trauma or Madura foot experienced better functional outcome compared with the diabetics, independent of age. 50% of patients with the AKA and 19% of those with BKA reported poor functional outcome. Surgeons should be more involved with the long-term evaluation of functional outcome in such patients, to offer help if feasible and to modify their technique for future procedures.

Fat indices in high and low altitude populations in Southwestern Saudi Arabia

The present study was undertaken to determine the fat indices in high and low altitude populations in Southwestern Saudi Arabia. Measurement of weight, height, mid-upper arm circumference, mid-upper arm muscle area, and skinfold thickness over the triceps region in 261 males living at high altitude (3150 meters above sea level) and 237 males living at low altitude (500 meters above sea level) in Southern Saudi Arabia are reported. The assessment of fatness by calculation of percent body weight is supported by correlation of triceps skinfold thickness with body mass index (BMI). In both high- and lowlanders the triceps skinfold thickness has significant correlation with BMI (P<0.001 for both). BMI also showed significant correlations with body weight, mid-upper arm circumference and mid-upper arm muscle area (P<0.001 for all). The findings show that the use of skinfold thickness in the prediction of degree of fatness in both groups seems to be a practical and useful method. However, it appears that there is a need for densitometric studies among Saudi populations to enable the derivation of valid regression equations for the calculation of body fat from skinfold thickness measurements. In the absence of skinfold measurements the BMI appeared to be a reliable indicator for assessment of body fat in Saudi high- and lowlanders.

Duodenal ulcer and Helicobacter pylori infection at high altitude: experience from southern Saudi Arabia

OBJECTIVE

To study the clinical presentation, endoscopic features and prevalence of Helicobacter pylori in duodenal ulcer (DU) patients in southern Saudi Arabia, located 3150 m above sea level, and to compare results with those from low altitude regions of the Kingdom.

METHODS

Prospective study of patients with proven DU referred for upper gastrointestinal endoscopy at Asir Central Hospital, Abha, southern Saudi Arabia over an 18-month period.

RESULTS

Of 126 patients with proven DU, 72% were men and mean age was 40.4 years (range 18 to 68). Twenty-eight per cent were smokers and only 5% used nonsteroidal anti-inflammatory drugs. Thirty-eight patients (30%) presented with hematemesis or melena, and the majority had a single ulcer. Nineteen per cent of patients with dyspepsia had DU and 96% had H pylori. These results are comparable with those reported from the low altitude, warmer regions of Saudi Arabia.

CONCLUSIONS

Age of patients and the male:female ratio were similar to those in developing countries. The frequency of smoking is lower than in western countries and no patient in this report consumed alcohol. High altitude did not affect the prevalence of DU or the frequency of H pylori because the results were comparable with those from the low altitude areas of the Kingdom of Saudi Arabia and other lowland developing countries. Although great socioeconomic changes have increased the incidence of heart disease, the patterns of DU and H pylori infection assume those in developing nations.

Acute upper gastrointestinal bleeding in southern Saudi Arabia

OBJECTIVES

to study the incidence of hospitalisation, causes, and outcomes of acute upper gastrointestinal bleeding (AUGIB) in southern Saudi Arabia.

DESIGN AND METHODS

prospective study of patients admitted with AUGIB to a large district hospital in Abha City, southern Saudi Arabia, between 1991 and 1993. All patients had upper endoscopy within 24 hours of admission.

RESULTS

AUGIB was the indication for upper endoscopy in 240 (8.9%) of all upper gastrointestinal endoscopies (2,702). The patients' mean age was 44.3 years (SD 18.1; range 20-85 years). The annual hospital admission rate for AUGIB was calculated as 31 per 100,000 population over the age of 20. The commonest causes were oesophageal varices (30%), gastritis and erosions (25%) and duodenal ulcers (22%); gastric ulcers and malignancy were relatively uncommon. Liver cirrhosis due to hepatitis B and C viruses was the main cause of bleeding oesophageal varices. Patients with variceal bleeding were younger and had a higher mortality rate than non-variceal bleeders.

CONCLUSIONS

bleeding oesophageal varices are the commonest cause of AUGIB in Saudi Arabia owing to the endemicity of viral hepatitis B and C. The mortality from both variceal and non-variceal bleeding was lower than in western countries probably because the patients are younger and because of the relative rarity of malignancy and of the consumption of non-steroidal anti-inflammatory drugs.

Solitary thyroid nodule in Khartoum

Ninety four patients with solitary and significantly dominant thyroid nodules were studied. Inadequate sampling was reported in 5 patients (5.9%). In the remaining 89 patients, 64 had simple goitre (72%), 12 follicular adenoma (13.5%), 12 were malignant nodules (6 follicular, 5 papillary and one anaplastic) (13.5%) and one patient had Hashimoto's thyroiditis. The incidence of malignancy in the clinically solitary nodules was 14% (10/70) compared to 10% (2/19) for the dominant nodules which increased to 16% (8/49) versus 10% (4/40) respectively after ultrasonography and histopathological confirmation of the nature of the gland. There is a low positive predictive value for follicular neoplasm with fine needle aspiration cytology (FNAC) (44%). This is due to the fact that reports of suspicious follicular pattern is agreed not to imply definite malignancy, however total lobectomy was done for those patients whereas terms like "not suspicious" and "highly suspicious" are considered to mean, benign and malignant respectively and in those latter groups the prediction was 100%. The study stresses the importance of FNAC techniques in reducing the surgical load with minimal false negative results, increasing the yield of carcinoma and projecting the importance of a significantly dominant nodule in endemic areas.

Pattern of postoperative pyrexia in Khartoum

The pattern of postoperative pyrexia in Khartoum was prospectively studied in 260 patients who underwent a variety of surgical operations. Ninety four patients (36.1%) developed postoperative pyrexia. The commonest causes of pyrexia encountered were wound sepsis (10%), malaria (9.6%) and respiratory tract infection (7.3%). Less frequent causes were urinary tract infection, thrombophlebitis, intra-abdominal sepsis and deep vein thrombosis. In 14.6% of the patients, the cause of pyrexia was undetermined. The risk factors for postoperative pyrexia were the patient's age, diabetes mellitus, obesity, preoperative chest infection, smoking, duration of surgery, operator's surgical experience and urethral catheterisation. The postoperative pyrexia was associated with 7.4% mortality rate which was due to intra-abdominal sepsis and pulmonary embolism. The incidence of postoperative pyrexia can be minimised by adequate preoperative preparation, meticulous surgical technique and good postoperative care.

Fractures in childhood in Khartoum

A prospective study of fractures in 231 children received at Khartoum North Teaching Hospital(KNTH) was carried out for a period of six months. The incidence of child fracture rated as one per day, then it increased from the age of 5 years onwards in boys and between 6 and 8 years in girls. Most injuries were sustained during the day time, especially between late afternoon and sunset. 82% of injured children presented to a medical facility, while 18% were taken to native healers first. Non-road traffic accidents accounted for 84% of the fractures mainly due to sports, domestic injuries and falls; whereas road traffic accidents were 16% and occurred mainly in pedestrians. Forty three percent of the fractures needed only first aid and splintage while 42% needed closed reduction. Thirty one percent of all patients were treated as inpatients. The long bones were affected in 91% of all fractures, the commonest site being the distal end of the forearm (26%), followed by supracondylar fracture of the humerus (15.6%). In the upper limb, left-sided fractures predominated. The epiphyseal injuries were 3.5% of all fractures, mainly at the distal radial epiphysis. Boys were commonly affected between 13-15 years of age. Open fractures constituted 9.8% of the series and were mainly due to traffic accidents in town dwellers, the most vulnerable bones were those of the leg and foot. Pathological fractures accounted for 2.2% and were due to bone cysts and osteogenesis imperfecta. The problem of child safety and the preventive measures need to be more stressed.

Abdominal tuberculosis

The abdomen is involved in 10% to 30% of patients with pulmonary tuberculosis. The diagnosis is not difficult in societies where the disease is common and clinicians are aware of it. While previously rare in Western countries, the incidence is now rising among immigrants, and patients with AIDS. In HIV-infected patients, the disease is of a rapidly progressive nature, often fatal through usually treatable, but the diagnosis is difficult and often delayed. Treatment is essentially medical but occasionally surgical operation is necessary.

Evaluation of different MCQ-scoring-system in a medical school

The MCQ scores of final medical students in surgery for the years 1990 and 1991 were analysed. The score for a correct answer was plus 1 mark in both years. The penalty for incorrect answer for the year 1990 was minus-1 mark as had been practiced during the previous 15 years. The penalty for the year 1991 was minus 1/4 for an incorrect answer. This low penalty of minus 1/4 resulted in an inflated MCQ score as compared with the essay questions and both clinical and oral examination results. The low score recorded during the year 1990 is a genuine reflection of inadequate performance rather than bad evaluation since the MCQ bank is the same and the panel of examiners has not changed. It is concluded that minus 1 mark penalty has many advantages and therefore should be the practice.

Postoperative pain and analgesic prescription in Khartoum: evaluation of current practice

Ninety eight general surgical patients were studied prospectively to determine the degree and severity of postoperative pain during the first 18 hrs following surgery. In 93% of the patients there was some degree of postoperative pain and in 64.4% the pain was moderate, severe or intolerable. Only 64.2% of the patients complained of pain to the medical staff, the remainder kept silent despite their sufferings. Pethidine was the most commonly administered analgesic and the dose per patient was 1.2. More diligent approach to the problem of postoperative pain is needed. Adequate dosage and more frequent administrations of analgesic should be given to post-operative patients. Moreover, patients need to be taught that intolerable pain is not an acceptable postoperative sequelae in exchange for cure.

Helicobacter pylori associated dyspepsia in 208 patients from southern Saudi Arabia

The frequency of Helicobacter pylori (HP) infection in 208 patients with upper gastrointestinal tract symptoms from the Southern Province of Saudi Arabia was studied prospectively. The occurrence of HP was documented histologically and using a rapid urease test in antral endoscopic biopsies. Our results showed that 82.2% of the 208 patients included were positive for HP with a male:female ratio of approximately 1:1 (88:83). The age range was 14 to 80 years and the median age was 38.2 years. The frequencies of HP infection among Saudi and non-Saudi patients were 86% and 71%, respectively. Frequencies of HP infection were 88%, 77.5%, and 93% during the second, third, and fourth decades of life. Among the 140 patients with histologically proven antral gastritis, 128 cases (91%) were positive for HP whereas 29 cases (17%) of the 171 patients positive for HP did not show histologic evidence of antral gastritis. Our data showed that HP was present in 92.5% of patients with endoscopic diagnosis of duodenal ulceration, 81% of patients with duodenitis, 80% of patients with both duodenitis and gastritis, 69% of patients with gastric antral erythema, and 81% of patients with non-ulcer dyspepsia (normal upper gastrointestinal endoscopy). Histologically proven antral gastritis was seen in 80% of patients with endoscopic diagnosis of duodenal ulceration, 76% of patients with antral erythema, 70% of patients with both duodenitis and gastritis, 33% of patients with duodenitis only, and 66% of patients with non-ulcer dyspepsia. Among the 208 patients included in the study, gastric ulcerationw as only seen in two cases, both positive for HP.

Carcinoma of the thyroid in Khartoum

One hundred and twelve patients with thyroid malignancy seen at The Radio-isotope Centre, Khartoum (RICK) during the period 1982-1989 were studied. The female to male ratio was 2.5:1.0 with a high incidence of the disease between the ages of 40 and 70 years. Follicular carcinoma was the commonest (42%) followed by papillary (22.3%) and anaplastic (21.4%). Goitre was the main presenting symptom (92.9%). Cervical lymphadenopathy was present almost equally in these three histological types, 26.6%, 32%, and 33% respectively. Blood borne metastasis was seen in 32 (28.6%) patients in the whole series. Follicular carcinoma had the highest incidence of blood borne metastasis (21 out of 47 patients) being mostly osseous (16 patients). Anaplastic and squamous cell carcinoma showed a locally aggressive behaviour to nearby structures resulting in hoarseness of voice, dyspnoea and dysphagia indicating advanced disease. Most patients presented with advanced disease limiting the option of total thyroidectomy (40%). A high index of clinical suspicion is needed in areas of endemic goitres in order that selected cases can be subjected to surgery at an earlier stage of the disease. Doctors and medical assistants should be taught how to diagnose solitary thyroid nodules and clinically hard glands so that they can be evaluated at an earlier stage of the disease.

Differences in presentation of Hodgkin's disease in Sudan and Western countries

A retrospective study was performed dealing with clinical and histopathological aspects of Hodgkin's disease in patients presenting to the Radiation and Isotopes Centre of Khartoum (RICK) during the period from January 1984 to January 1989. A total of 105 patients were studied; this number accounted for 30.6% of all lymphoma patients and 2.0% of all cancers seen at RICK during the same period. The median age was 30 yrs, and the majority of patients were within two age groups, above 25 yrs and above 50 yrs, demonstrating a bimodal pattern. Males were commonly affected and this was more marked in children (M:F = 4.7:1.0). Two striking differences are observed between this study and those from the western world. The first was the high incidence of late clinical stages (III,IV) (70%) in this series despite the moderate duration of symptoms. The second was predominance of mixed cellularity and lymphocytic predominant sub-groups (65%) compared to reports from the western world. A possibility of a chronic stimulatory process of the lymphatic system is raised. The high incidence of late clinical stages on presentation with favourable histological types needs more work.

The surgical management and outcome of oesophageal cancer in Khartoum

One hundred and one patients with oesophageal cancer seen at a surgical firm in Khartoum were studied retrospectively. An increase in the relative frequency of the disease is noted (4.6%). Sixty-nine patients (69%) were explored and 61 (87%) of them had resection (all had locally invasive tumours). All had an Ivor Lewis type of resection using a stomach tube through the right side of the chest. The postoperative mortality after 30 days was 27.8% (n = 17) which dropped to 14% towards the end of the series (one death in 7 cases). The commonest cause of death in the surgical group was failure to recover fully from anaesthesia (n = 5). In 30 patients who could be traced for a minimum period of 12 months, 18 patients (64%) survived for 1 year and 12 patients for 2 years. Fifteen patients have been on follow-up for less than 12 months and all are doing well; 16 patients could not be traced.

Cervical lymphadenopathy in Khartoum

In this prospective study, 92 patients with cervical lymphadenopathy presenting at Khartoum Teaching Hospital were studied. The commonest cause was found to be tuberculous cervical lymphadenitis (TCA) comprising 49%, followed by malignancy (35%) including both primary neoplasm (15 cases) and metastatic lesions (17 cases). The tuberculous group were young patients mainly from low socioeconomic classes. The most affected nodes were in the posterior triangle, followed by upper jugular and supraclavicular nodes. In the malignant group, half the patients had primary reticulo-endothelial neoplasm and the other half had metastatic tumours, most often from the nasopharynx. The triad of symptoms of fever, fatigue and loss of weight was found equally in tuberculous and lymphoma patients. Hence empirical use of antituberculous therapy without histological diagnosis resulted in delay in diagnosis of malignancy. Antituberculous therapy should be preceded by histological proof wherever possible.

Management of hand infection in Khartoum

One hundred and fifty patients with hand infection seen during 6 months period at Khartoum Teaching Hospital were studied. The disease is more common among young males manual and industrial workers (M:F = 2:1). Common types of hand infections were paronychia in (41%) of patients, volar infections in (30.6%) and subcutaneous infections in (30%) of patients. 30% of patients needed hospital admission including all diabetics (n = 15). Two patients had serious complications that resulted in above elbow amputation. The first was a diabetic with spreading cellulitis and the second was a mentally retarded with gas gangrene. Initial empirical antibiotic therapy was prescribed in 89% of patients and later was modified according to sensitivity results. 90% of patients needed surgical drainage. Bacteriological examination showed Staph. aureus in 51% of cultures and the staphylococcus was resistant to penicillin in 77% of cultures. Apart from two deaths, the rest of the patients had satisfactory outcome.