The rationale for the need to study sodium-glucose co-transport 2 inhibitor usage in peritoneal dialysis patients

The wave of kidney and heart outcome trials, showing multiple potential benefits for sodium-glucose co-transport 2 (SGLT2) inhibitors, have excluded patients with an estimated glomerular filtration rate below 25 ml/min/1.73 m2. However, dialysis patients are at the highest risk of cardiovascular disease and would benefit most from effective cardioprotective therapies. There is emerging evidence from experimental studies and post hoc analyses of randomised clinical trials that SGLT2 inhibitors are well tolerated and may also be effective in preventing cardiovascular and mortality outcomes in patients with severe chronic kidney disease, including patients receiving dialysis. As such, extending the usage of SGLT2 inhibitors to dialysis patients could provide a major advancement in their care. Peritoneal dialysis (PD) patients have an additional unmet need for effective pharmacotherapy to preserve their residual kidney function (RKF), with its associated mortality benefits, and for treatment options that help reduce the risk of transfer to haemodialysis. Experimental data suggest that SGLT2 inhibitors, via various mechanisms, may preserve RKF and protect the peritoneal membrane. There is sound physiological rationale and an urgent clinical need to execute robust randomised control trials to study the use of SGLT2 inhibitors in PD patients to answer important questions of relevance to patients and healthcare systems.

830 A Case of Colo-Colonic Intussusception Secondary to A Large Lipoma in An Adult

Colonic lipomas are benign tumours, most commonly in the right colon or caecum, usually detected incidentally at colonoscopy and are often asymptomatic not requiring treatment. Lipomas leading to intussusception have previously been described in case reports, but it remains a rare occurrence, no specific incidence data has been documented. We present the case of a patient with a 7cm colonic lipoma that developed an intussusception.

This patient suffered non-specific pulling pain along the right and upper abdomen for many years. A distal ascending colonic lipoma was identified, on repeated imaging and colonoscopy and biopsied. It was concluded that the abdominal pain was due to gallstones, diverticulitis and adhesions from previous pelvic surgery. In early December 2020, the patient was reviewed and listed for elective cholecystectomy. Later the same month, the patient was admitted with severe abdominal pain, watery and bloody diarrhoea. CT scan showed the colonic lipoma had acted as the lead point for an intussusception, with the lipoma and surrounding colon having intussuscepted into the transverse colon. Patient had an open right hemicolectomy and anastomosis for colo-colic intussusception secondary to the lipoma. Subsequently, the patient developed anastomotic breakdown requiring relook laparotomy with resection of ileo-colic anastomosis and end ileostomy formation.

Adults presenting with intussusception is rare and associated with nonspecific signs and symptoms. Variability in clinical presentation highlights the need for a low index of suspicion in people with known colonic masses. In addition, early surgical intervention should be considered in masses >4cm as previously suggested in the literature.

Adapting Nephrology Training Curriculum in the Era of COVID-19

PURPOSE OF REVIEW

The COVID-19 pandemic has widespread implications not only for clinical practice but also for academic medicine and postgraduate training. The need to promote physical distancing and flexibility within our department has generated important revisions to the core curriculum for the Adult Nephrology Training Program in Vancouver, Canada.

SOURCES OF INFORMATION

We reviewed available educational resources and objectives to develop curricular adaptations informed by staff and trainee feedback.

METHODS

Many facets of the program including clinical rotations, scholarly activities, evaluation, and wellness have been impacted, and thus revised for online delivery where possible. Trainees have personalized a learning plan based on individual goals and supplemented by a list of internet-based resources for independent review. Changes in learning objectives and methods for specific rotations have occurred and are described. Ongoing evaluation will be undertaken.

KEY FINDINGS

Curriculum adaptation in the era of COVID-19 is necessary to ensure ongoing high-quality education for future nephrologists. We describe existing changes to formal training in British Columbia (BC), which will be tailored as the pandemic evolves, and anticipate them to have lasting impact on the way we structure training programs in the future. Standardization and harmonization of modified curriculum may be possible across Canada with sharing of these learnings.

LIMITATIONS

Formal evaluation of these changes in terms of knowledge acquisition and examination performance has not yet been undertaken. Next steps will include assessing and documenting the impact of this curricular transformation to further optimize scheduling, educational yield, and trainee wellness.

A prospective study of tea drinking temperature and risk of esophageal squamous cell carcinoma

Previous studies have reported an association between hot tea drinking and risk of esophageal cancer, but no study has examined this association using prospectively and objectively measured tea drinking temperature. We examined the association of tea drinking temperature, measured both objectively and subjectively at study baseline, with future risk of esophageal squamous cell carcinoma (ESCC) in a prospective study. We measured tea drinking temperature using validated methods and collected data on several other tea drinking habits and potential confounders of interest at baseline in the Golestan Cohort Study, a population-based prospective study of 50,045 individuals aged 40-75 years, established in 2004-2008 in northeastern Iran. Study participants were followed-up for a median duration of 10.1 years (505,865 person-years). During 2004-2017, 317 new cases of ESCC were identified. The objectively measured tea temperature (HR 1.41, 95% CI 1.10-1.81; for ≥60°C vs. <60°C), reported preference for very hot tea drinking (HR 2.41, 95% CI 1.27-4.56; for "very hot" vs. "cold/lukewarm"), and reported shorter time from pouring tea to drinking (HR 1.51, 95% CI 1.01-2.26; for <2 vs. ≥6 min) were all associated with ESCC risk. In analysis of the combined effects of measured temperature and amount, compared to those who drank less than 700 ml of tea/day at <60°C, drinking 700 mL/day or more at a higher-temperature (≥60°C) was consistently associated with an about 90% increase in ESCC risk. Our results substantially strengthen the existing evidence supporting an association between hot beverage drinking and ESCC.

Eugenia jambolana extract reduces the systemic exposure of Sitagliptin and improves conditions associated with diabetes: A pharmacokinetic and a pharmacodynamic herb-drug interaction study

Eugenia jambolana (EJ) is an Indian traditional herb widely used for the treatment of diabetes mellitus. This herb is globally marketed as single or multi herb formulations. Many diabetes patients consume EJ extract oral hypoglycemic drugs together. This calls for a need to assess risks versus benefit of this co-administration.

In present investigation, pharmacodynamic and pharmacokinetic interactions of aqueous extract of EJ seeds at the dose of 400 mg/kg are studied with 10 mg/kg of oral hypoglycaemic drug sitagliptin (SITA) by co-administrating them for 28 days in streptozotocin (STZ) induced diabetic rats. The pharmacokinetic parameters of SITA were determined using HPLC-ESI-MS/MS and it was found that the combination treatment reduces the systemic exposure of SITA by showing 38.70% reduction in concentration maximum (Cmax) and 22.40% reduction in area under curve (AUC). Despite low levels of SITA, the combination demonstrated a significant reduction in blood glucose level when compared with individual drug and individual extract administered groups during pharmacodynamic study. In addition, the liver function, the kidney function and the lipid parameters were found to be significantly improved and beneficial effects were found with respect to food intake and water intake and urine output in case of combination treatment groups when compared with individual treatment groups. Histopathological examination of pancreatic tissue suggests its significant recovery of having normal acinus with better cell protection in combination treatment. In conclusion, the combination treatment demonstrated reduced systemic exposure of SITA without compromising on its antihyperglycemic activity and improvement in conditions associated with diabetes.

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth

BACKGROUND

Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth.

METHODS

Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified.

RESULTS

We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%.

CONCLUSIONS

There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed.

A survey of ward round practice

Aims and Method

A postal questionnaire was sent to consultant psychiatrists in the West Midlands to establish their current ward round practice. This questionnaire addressed ward round etiquette, practical issues and educational function. Consultants received only one mailing.

Results

A total of 96 (out of 139) consultants replied (69% response rate). The majority of consultants saw patients on the ward round (97%) and all consultants introduced both themselves and team members to the patient; 72% explained the purpose of the ward round. A median of seven professionals attended the ward round with psychology (6.5%) and pharmacy services (0%) being underrepresented. When consultants added comments, the recurrent themes were that ward rounds were an effective use of professional time but were often daunting for patients.

Clinical Implications

Our results indicate some uniformity in the conduct of ward rounds. The lack of representation at ward rounds for certain professional groups may adversely affect the range of opinions and therapies for patients. Changes could be made to incorporate the views of users, which would make ward rounds more productive for users and professionals.

Evaluation of A 12-Month Pilot of Long-Term and Temporary Assisted Peritoneal Dialysis

Background

Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts.

Methods

Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible).

Results

Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient.

Conclusions

Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.

Midpoint Results of National Surveillance of Childhood Tuberculosis

BACKGROUND: There is little detailed epidemiologic and clinical data about tuberculosis (TB) disease in children in Canada.

OBJECTIVES: To characterize the epidemiologic, clinical, and treatment data for all cases of TB in children under age 15 in Canada through the Canadian Pediatric Surveillance Program’s (CPSP) Childhood Tuberculosis Study. The initial results of the 3 year study presented here includes cases from September 2013 to October 2015.

DESIGN/METHODS: TB cases were identified through a monthly form sent by the CPSP to approximately 2500 active pediatricians, pediatric subspecialists, and select non-pediatricians who manage childhood TB. For cases meeting inclusion criteria, a detailed questionnaire was sent to collect clinical, epidemiological, and treatment data, followed by 6-month follow-up surveys until 6 months after treatment completion.

RESULTS: Of 164 unique incident cases reported, 84 met inclusion criteria and returned a detailed questionnaire. Selected demographic data is shown here:

Mesenchymal stem cell (MSC) viability on PVA and PCL polymer coated hydroxyapatite scaffolds derived from cuttlefish

In the present study, cuttlefish bones are used to prepare highly porous hydroxyapatite (HA) scaffolds via hydrothermal treatment at 200 °C.

Association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with GDM

AIM

There is evidence that arthrosclerosis may originate at birth, so assessment of serum lipid levels in cord blood might be important. The aim of this study was to investigate the association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with gestational diabetes mellitus (GDM) and to compare these parameters with those in newborns of non-diabetic.

METHODS

The study group included 112 women (singleton pregnancy, and GDM diagnosed following WHO criteria), and as controlled subjects, 159 matched healthy pregnant women and their newborn babies were selected. A sample of cord blood was obtained at delivery. The cord blood's insulin, glucose, and lipids (total cholesterol, high-density cholesterol, low- density cholesterol, and triglyceride) were determined. The relationships between these metabolic parameters and large for gestational age (LGA) were also assessed.

RESULTS

There were no significant differences between total cholesterol (TC), HDL cholesterol (HDL -C), triglyceride (TG) and glucose levels between two groups but the LDL-C level, LDL/HDL ratio and insulin level were significantly higher in newborns of mother with GDM. LGA newborns of diabetic mothers, show the HDL-C level were significantly lower and LDL-C level were significantly higher than AGA (Appropriate for Gestational Age).

CONCLUSION

These results show that GDM altered neonatal plasma lipids metabolism and so newborns of diabetic mothers may be predisposed early in life to LDL hypercholesterolemia and thus may be at a greater risk of developing coronary heart disease later in life.

Increased nuchal translucency and pregnancy outcome

BACKGROUND

To study the outcome of cases with nuchal translucency (NT) ≥ 95th centile in the first trimester of pregnancy.

METHODS

This cross sectional study was performed at Iranian Fetal Medicine Foundation (FMF) between January 2009 and December 2011. Totally, 186 cases with NT≥ 95th centile who attended for the first trimester screening were studied. All cases with increased NT including those with normal karyotype were followed up with anomaly scan at 18-22 weeks and fetal echocardiography at 22-24 weeks. Pregnancy outcome was extracted from delivery records and pediatrics notes and telephone interviews.

RESULTS

Of screened cases, 186 fetuses had an NT≥95th centile, of them 19.8% were abnormal karyotype, including 29 cases of trisomy 21, three of trisomy 18, two of trisomy 13, three of Turner syndrome. 77.8% did not show any abnormalities on follow-up examinations. 4.6% of cases were found to have malformation antenatally and 4% cases postnatally. 11.4% women elected termination of pregnancy without further follow up. There were 4.6% fetal loss and 1.3% hydrops fetalis.

CONCLUSION

In this unselected population, the study showed one out of four fetuses with enlarged NT had an adverse pregnancy outcome (miscarriage, fetal loss, and fetal abnormalities), however the chance of having a normal child after exclusion of chromosomal abnormalities and adverse pregnancy outcome was 95%.

Coincidence of trisomy 18 and robertsonian (13; 14)

This case report presents a coincidence of trisomy 18 and balanced Robertsonian translocation (13;14). Aneuploidy was suspected based on anomalies detected in ultrasound scan and confirmed with karyotype. In a 31 years-old healthy woman with a history of one miscarriage, second trimester ultrasound scan reported IUGR (<3rd percentile) with normal amniotic fluid, bilateral choroid plexus cysts, suspicious agenesis of corpus callosum and clenched hands. Amniocentesis was performed and karyotype was 46xx,der(13;14) (q10;q10),+18. Maternal karyotype was 45xx,der(13;14)(q10;q10). Pregnancy was continued due to legal limitation for termination after 20 weeks gestation. Delivery was done at 36 weeks gestation. A female newborn was borned and a physical feature was hypotonia, small mouth, prominent occiput, low-set and posteriorly rotated ears, clenched hands with overlapping fingers and rocker bottom feet. Ultrasound scan and echocardiography detected agenesis of corpus callosum and VSD, ASD, PDA and cardiomegaly. These features are typical of trisomy 18. Balanced Robertsonian translocation usually has no phenotypic expression. Genetic counseling and prenatal diagnosis for future pregnancy was recommended.

First-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency, nasal bone, tricuspid regurgitation and ductus venosus flow combined with maternal serum free β-hCG and PAPP-A: a 5-year prospective study

OBJECTIVE

To investigate the performance of first-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency thickness (NT), nasal bone (NB), tricuspid regurgitation (TR) and ductus venosus (DV) flow combined with maternal serum free β-human chorionic gonadotropin (fβ-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at a one-stop clinic for assessment of risk (OSCAR).

METHODS

In total, 13,706 fetuses in 13,437 pregnancies were screened for chromosomal abnormalities during a period of 5 years. Maternal serum biochemical markers and maternal age were evaluated in combination with NT, NT + NB, NT + NB + TR, and NT + NB + TR + DV flow data in 8581, 242, 236 and 4647 fetuses, respectively.

RESULTS

In total, 51 chromosomal abnormalities were identified in the study population, including 33 cases of trisomy 21, eight of trisomy 18, six of sex chromosome abnormality, one of triploidy and three of other unbalanced abnormalities. The detection rate and false-positive rate (FPR) for trisomy 21 were 93.8% and 4.84%, respectively, using biochemical markers and NT, and 100% and 3.4%, respectively, using biochemical markers, NT, NB, TR and DV flow.

CONCLUSION

While risk assessment using combined biochemical markers and NT measurement has an acceptable screening performance, it can be improved by the integrated evaluation of secondary ultrasound markers of NB, TR and DV flow. This enhanced approach would decrease the FPR from 4.8 % to 3.4 %, leading to a lower number of unnecessary invasive diagnostic tests and subsequent complications, while maintaining the maximum level of detection rate. Pre- and post-test genetic counseling is of paramount importance in either approach.

Primary closure versus T-tube drainage after open choledochotomy

BACKGROUND

Choledochotomy followed by T-tube has long been a standard surgical treatment for choledocholithiasis. It is still a preferred choice in many hospitals where minimal invasive procedures are not feasible. The use of T-tube is not without complications. To avoid the complications associated with T-tube, we have performed primary closure of the common bile duct (CBD) after exploration. This pilot study assesses the safety of primary closure of CBD, which would help form a basis for implementation on a wider scale.

OBJECTIVE

To compare the clinical results of primary closure with T-tube drainage after open choledochotomy and assess the safety of primary closure for future application on a greater mass.

PATIENTS AND METHODS

This comparative study was conducted at surgical unit IV Liaquat University of Medical and Health Sciences, Jamshoro, from January 2007 to December 2007. Thirty-five patients were included in the study of which 16 patients underwent primary closure.

RESULTS

Thirty-five patients were included in the study. The mean age of patients who had primary closure done (n = 16) was 46.0 +/-16.8 and there were two (12.5%) males and 14 (87.5%) females. After primary closure of the CBD, bile leakage was noted in one patient (6.3%), which subsided without any biliary peritonitis as compared to the T-tube group in which two patients (10.5%) had bile leakage. Postoperative jaundice was seen in one patient (5.3%) who had a T-tube because of a blockage of CBD. Not a single patient had a retained stone in both groups as well as no recurrence of CBD stones. The postoperative hospital stay after primary closure was 5.56 +/-1.1 days as compared to after T-tube drainage which was 13.6 +/-2.3 days. The total cost of treatment in patients who underwent primary closure was USD194.5 +/-41.5 but after T-tube drainage it was USD548.6 +/-88.5. The median follow up duration for both groups was 6 months.

CONCLUSION

Primary CBD closure is a safe and cost effective alternative to routine T-tube drainage after open choledochotomy.

Role of clinical and ultrasound findings in the diagnosis of retained products of conception

OBJECTIVE

To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage.

METHODS

This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed.

RESULTS

Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups.

CONCLUSION

The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

Intrapartum maternal glucose infusion and fetal acid-base status

OBJECTIVE

To compare the effects of an intrapartum infusion of a lactated Ringer solution or a glucose-boosted saline solution on the acid-base status of umbilical arterial blood.

METHOD

In a prospective clinical trial 178 women in labor were randomized to receive intravenously either a lactated Ringer solution or a saline solution boosted with 5% glucose. Umbilical arterial blood was then assessed for acid-base status.

RESULTS

There were significant differences between the lactated Ringer group and the glucose group in umbilical artery pH values (7.25+/-0.07 vs. 7.28+/-0.06; P=0.008), pCO2 values (44.8+/-5.6 mm Hg vs. 41.6+/-4.1 mm Hg; P=0.001), and base excess (-7.3+/-2.1 mEq/L vs. -6.6+/-1.8 mEq/L; P=0.02).

CONCLUSION

Intrapartum intravenous fluid containing a 5% glucose solution reduces umbilical cord acidemia and hypercarbia.

Topical nasal steroids for intermittent and persistent allergic rhinitis in children

BACKGROUND

Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. There has been a significant increase in prevalence among children over the last two decades and this increase has been accompanied by a parallel increase in comorbid illnesses such as asthma.

OBJECTIVES

To evaluate the therapeutic effectiveness and adverse event profiles of topical nasal steroids for intermittent and persistent allergic rhinitis in children.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1950 onwards) and EMBASE (1974 onwards) on 5(th) September 2005. CINAHL, mRCT(a meta-database of controlled trials), NRR (the National Research Register), LILACS, MedCarib, KOREAMED, IndMed, Samed, Panteleimon, Zetoc, ISI Proceedings, the GlaxoSmithKline Clinical Trials Database and the websites of AstraZeneca, Schering Plough and Aventis were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing topical nasal steroid preparations against each other or placebo, prescribed for allergic rhinitis in children.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the included trials. The limited and variable quality of reported data precluded any pooling of results and only a descriptive summary is presented.

MAIN RESULTS

Three trials involving a total of 79 participants were included. All three trials, which compared topical nasal steroids against placebo for perennial rhinitis, provided some, albeit limited data, relevant to our primary outcomes; but in two of the trials the data analysis was flawed and in the third trial it was incomprehensible. None of the trials provided data relevant to our secondary outcomes. There were no adverse events reported from any of the interventions.

AUTHORS' CONCLUSIONS

The three included trials provided some weak and unreliable evidence for the effectiveness of Beconase(R) and flunisolide used topically intranasally for the treatment of intermittent and persistent allergic rhinitis in children. The reduction of severity in symptoms as assessed by the trialists could not be confirmed with the data provided and decisions on the use of these medications should, until such time as more robust evidence is available, be guided by the physician's clinical experience and patients' individual circumstances and preferences.

Gastroprotective effect of cardamom, Elettaria cardamomum Maton. fruits in rats

Cardamom, the fruits of Elettaria cardamomum Maton. (Zingiberaceae) commonly known as "Heel khurd" is used in Unani system of medicine to treat gastrointestinal disorders. A crude methanolic extract (TM), essential oil (EO), petroleum ether soluble (PS) and insoluble (PI) fractions of methanolic extract, were studied in rats at doses of 100-500, 12.5-50, 12.5-150 and 450 mg/kg, respectively for their ability to inhibit the gastric lesions induced by aspirin, ethanol and pylorous ligature. In addition their effects on wall mucus and gastric acid output were recorded. All fractions (TM, EO, PS, PI) significantly inhibited gastric lesions induced by ethanol and aspirin but not those induced by pylorus ligation. TM proved to be active reducing lesions by about 70% in the EtOH-induced ulcer model at 500 mg/kg. The PS fraction reduced the lesions by 50% at 50 and 100mg/kg (no dose response was observed) with similar effect than the PI fraction at 450 mg/kg. In the aspirin-induced gastric ulcer, the best gastroprotective effect was found in the PS fraction, which inhibited lesions by nearly 100% at 12.5mg/kg. In our experimental conditions, the PS extract at doses >or=12.5mg/kg proved to be more active than ranitidine at 50mg/kg.

The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross-sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in subjects aged 25 years and above in India. The study was carried out in 77 centers (40 urban and 37 rural). 18363 (9008 males and 9355 females) subjects were studied. 10617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 h and 2 h after 75 g of oral glucose. Subjects were categorized as having IGT or DM using the World Health Organisation (WHO) (1999) criteria. The standardized prevalence rate for DM in the total Indian, urban and rural populations was 4.3, 5.9 and 2.7%, respectively. The corresponding IGT rates in the three populations was 5.2, 6.3 and 3.7%, respectively. The urban prevalence of DM and IGT was significantly greater than in the rural population (P < 0.001 in both instances). The prevalence of DM was significantly, more than that of IGT (P < 0.001) within both the rural and urban populations. Type 2 diabetes is a major health problem is India.

A rare case of chondrosarcoma of the clavicle

Although all types of tumour and tumour-like conditions have been described to occur in the clavicle, they only contribute to less then 0.5% of all skeletal tumours. The incidence of primary chondrosarcoma of the clavicle is extremely rare. To our knowledge it has not been reported in Malaysia. We would like to highlight the possibility of chondrosarcoma as a differential diagnosis for a clavicular lesion.

Comparing the ADA 1997 and the WHO 1999 criteria: Prevalence of Diabetes in India Study

This random multistage cross-sectional population survey was undertaken to determine the prevalence of type 2 diabetes mellitus (DM) in subjects aged 25 years and above in India. The study was carried out in 77 centres (42 urban and 35 rural) to reflect the size and heterogeneity of the Indian population. 18,363 (9008 male and 9355 female) subjects were studied. 10,617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 and 2 h after 75 g of oral glucose. Subjects were categorized as having impaired fasting glycemia (IFG) or DM using the 1997 ADA or having impaired glucose tolerance (IGT) or DM using the 1999 WHO criteria. The age- and gender-standardized prevalence rate for DM using the ADA criteria was 3.6% whilst that using the WHO criteria was 4.3% (P < 0.001). The respective standardized prevalence of DM, using the two criteria was, 4.7 and 5.6%, respectively (P < 0.001) in the urban Indian population and 2.0 and 2.7% (P < 0.02) in the rural Indian population. Using the WHO criteria, 581 subjects were newly diagnosed whilst the ADA criteria newly diagnosed 437 subjects. The respective numbers for the urban population were 425 and 323, and for the rural population were 146 and 114, respectively. The ADA criteria could diagnose 75.2, 76.0 and 73.0% of the subjects who had DM as per the WHO criteria. Of 739 Indian subjects who had IFG, 106 (14.3%) were diagnosed as having DM by the WHO criteria whilst 505 (68.3%) had values compatible with a diagnosis of IGT. Of the 536 urban subjects with IFG, 74 (13.8%) had DM and 350 (65.3%) had IGT using the WHO criteria. Of the 302 rural subjects with IFG, 32 (15.8%) had DM and 155 (76.3%) had IGT using the WHO criteria. 505 (49.9%) of 1012 Indian subjects with IGT as per the WHO criteria had IFG. 350 (47.7%) of 733 urban subjects and 155 (55.5%) of 279 rural subjects with IGT had values compatible with IFG as per the ADA criteria. Type 2 diabetes is a major health problem is India. The use of the ADA criteria would underestimate the prevalence of DM by not diagnosing subjects showing a poor response to a glucose challenge. This along with the discrepancies between subjects showing IGF or IGT could be a challenge to any prevention program.

The burden of diabetes and impaired fasting glucose in India using the ADA 1997 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired fasting glycemia/glucose (IFG) in subjects aged 25 years and above in India. The study was carried out in 108 centers (49 urban and 59 rural) to reflect the size and heterogeneity of the Indian population. 41,270 (20,534 males and 20,736 females) subjects were studied. 21,516 (10,865 males and 10,651 females) were from urban areas and 19,754 (9669 males and 10,085 females) from rural areas. Blood samples were taken after a fast of 10-12h and the subjects were categorized as having IFG or DM using the 1997 American Diabetes Association criteria. The age and gender standardized prevalence rate for DM and IFG in the total Indian population was 3.3 and 3.6% respectively (P < 0.001). The standardized prevalence of DM and IFG in urban areas was significantly higher than that for the rural population (urban DM prevalence 4.6% versus rural DM prevalence 1.9%, P < 0.001; urban IFG prevalence 4.8% versus rural IFG prevalence 2.5%, P < 0.001). There was no statistically significant difference in the prevalence between DM (4.6%) and IFG (4.8%) in the urban population. The rural prevalence of IFG (2.5%) was significantly (P <0.001) more than the rural prevalence of DM (1.9%). Type 2 diabetes is a major health problem is India.

High and low dose oxytocin in augmentation of labor

OBJECTIVE

To compare the efficacy and safety of high dose oxytocin in the augmentation of labor.

METHOD

Two hundred pregnant women requiring augmentation of labor were randomly assigned to receive oxytocin by either a low dose protocol (1.5 microm/min initially, increased by 1.5 microm/min every 30 min) or a high dose protocol (4.5 microm/min initially, increased by 4.5 microm/min every 30 min).

RESULTS

High dose of oxytocin was associated with a significant shortening of labor 4 (1.10-10) vs. 6 (1-10) h, p<0.0001 without a significant difference in cesarean delivery rate, neonatal and maternal outcome.

CONCLUSION

The use of high dose oxytocin is associated with significantly shorter labor without any adverse fetal and maternal effects.

Massive bleeding on a bladder protectant: a case report of pentosan polysulfate sodium-induced coagulopathy

Pentosan polysulfate sodium (Elmiron; Alza Pharmaceuticals, Mountain View, Calif) is an oral preparation of pentosan polysulfate used in the symptomatic management of interstitial cystitis. While pentosan polysulfate has a known heparin-like effect in its parenteral form, there have been no previous reports of coagulopathy with oral use. We present an interesting case of inadvertent systemic anticoagulation resulting in serious bleeding complications in a young woman taking oral pentosan polysulfate for interstitial cystitis.

Leber's congenital amaurosis with anterior keratoconus in Pakistani families is caused by the Trp278X mutation in the AIPL1 gene on 17p

BACKGROUND

Leber's congenital amaurosis (LCA) represents the earliest and severest form of retinal dystrophy leading to congenital blindness. A total of 20% of children attending blind schools have this disease. LCA has a multigenic basis and is proving central to our understanding of the development of the retina. We describe the clinical and molecular genetic features of four inbred pedigrees from neighbouring remote villages in northern Pakistan, in which some of the affected members have concurrent keratoconus.

METHODS

History-taking and physical and eye examinations were performed in the field. Venipuncture, DNA extraction, studies of linkage to known LCA genes, automated sequencing and polymorphism analyses for haplotype assessments were done.

RESULTS

We examined 12 affected and 15 unaffected family members. By history, there were an additional nine blind people in the four pedigrees. In each pedigree a consanguineous marriage was evident. We found a homozygous nonsense mutation in the AIPL1 gene, which replaces a tryptophan with a stop codon (Trp278X). The phenotype is severe and variable, despite the common molecular genetic etiology in each family. Affected patients had hand motion to no light perception vision and fundus findings ranging from maculopathy to diffuse pigmentary retinopathy. Three affected members had definite keratoconus, and two were suspects based on mild cone formation in the cornea of at least one eye.

INTERPRETATION

We have identified four Pakistani families with a severe form of LCA that is associated with severe keratoconus in some affected members. The molecular etiology in all four families is a homozygous nonsense mutation, Trp278X, in the photoreceptor-pineal gene AIPL1. To our knowledge, this is one of the first phenotype-genotype correlations of AIPL1-associated LCA.

Hemodialysis Utilization in a Single in-Center Dialysis Unit, in the Kingdom of Saudi Arabia

This study was performed to find out the trends in the demand for regular maintenance hemodialysis (HD) and to assess the utilization with reference to selected variables. In a retrospective cohort study, data from a single in-center HD unit of a secondary care hospital located in the south-western part of the Kingdom of Saudi Arabia, were analyzed. Cases of end-stage renal failure (ESRF) registered for regular maintenance HD from the commencement of the HD services in this center (1987 to 2000) formed the subjects of this study. Utilization of the in-center HD was assessed by annual growth rate, death rate, renal transplantation rate and utilization rate. Simple descriptive statistics were used for data analysis. During the study period, 393 cases were registered for regular maintenance HD. There were 183 males (46.6%) and 210 females (53.4%). The mean and median ages of the patients at the initiation of HD were 40.7 and 35 years respectively. Saudis constituted 75.1%(295) over the years studied. The mean annual growth rate, death rate, renal transplantation rate and utilization rate were 7.44, 9.3, 4.33 and 139.57% respectively. Demand for maintenance HD was more from young individuals, which is similar to the national figures. Annual growth rate of those requiring HD was far higher than population growth of this region during the period of study caused primarily by an increased number of new entries coupled with low death and transplantation rates. We conclude that HD utilization studies help to unearth the problems, understand the needs, communicate with the authorities (with facts and figures), find out solutions, and create a network between providers and consumers.

The story of Lot and the Qur'ăn's perception of the mortality of same-sex sexuality

Discussion of the morality of same-sex sexuality in Islam is beginning to come to the forefront. It is a controversial topic that evokes differing views in Islam and, as such, needs to be addressed and understood. This study narrows the scope of the investigation to the use of moral terminology in the Lot story and elsewhere in the Qur'ăn. The method of semantic analysis that shall be applied is similar to the one espoused by Toshihiko Izutsu. In order to acquire a better understanding of how same-sex practices are qualified morally in the Qur'ăn, same-sex activities shall also be looked at in comparison to other opposite-sex and non-sexual practices. It is my contention that, in the Qur'ăn, same-sex practices are viewed no differently from certain opposite-sex and non-sexual activities. In quoting from the Qur'ăn, I will give my own translation of the Arabic terms that shall be analyzed. In general, however, I adopt Qur'ănic passages from Arthur J. Arberry, The Koran Interpreted, and where necessary, modify Qur'ănic passages with my own translations. I will also use Arberry's verse numbering, following that of Flügel.

Pruritus among End-Stage Renal Failure Patients on Hemodialysis

Pruritus is commonly encountered in individuals with end-stage renal failure (ESRF) on dialysis. This study was performed in order to find out the prevalence and pattern of pruritus in patients on regular maintenance hemodialysis (HD) as well as to analyze its relationship to age, sex of the patient, site of itching and timing of hemodialysis. One hundred patients with ESRF (age ranging from 13 to 80 years) free from systemic, skin or psychiatric disorders and other secondary causes attributable to pruritus, undergoing maintenance HD (duration on HD 7-141 months; mean 49.9 and median 43 months) at Samtah General Hospital, Samtah, Gizan, Kingdom of Saudi Arabia were evaluated for pruritus on two occasions at one week interval by each author independently. The data were analyzed by simple descriptive statistics viz mean, median and chi-square test. Pruritus was observed in 27 of 40 males (67.5%) and 40 of 60 females (66.7%) with an overall prevalence of 67%. It was mild in 34 (50.8%), moderate in 22 (32.8%) and severe in 11 (16.4%). Sub-group analysis with reference to age and sex revealed that pruritus was significantly more in women aged 45 years and above, when compared with men of similar age-group (p < 0.05) or women below 45 years (p < 0.02). Pruritus was predominant in spinal dermatomes. Discomfort of pruritus was more during HD in three (two men and one woman) and HD gave relief for the day in 10 other individuals (four men and six women). Our study suggests that pruritus is observed in all age-groups and of both sexes of ESRF patients on HD although the intensity and site of itching and relationship to HD sessions varied with individuals.

Nail changes in end-stage renal failure patients on hemodialysis

To evaluate the fingernail changes in patients with end-stage renal failure (ESRF) on regular hemodialysis (HD), we reviewed 69 patients (male 25, female 44; age 40 +/- 14.8 years) who have been on HD at Samtah General Hospital, Gizan, Kingdom of Saudi Arabia for a mean of 4.3 +/- 3.06 years. They were free from congenital, systemic or primary skin disorders contributing to nail changes. The patients were also free from ornamental dyes like henna, traumatic injuries or infections in the fingernails. They were also clinically free from features suggestive of the carpal tunnel syndrome or vascular steal syndrome secondary to arteriovenous fistula (AVF) created for vascular access. Their nails were examined under bright day light by the authors independently. The findings consistent among all three observers were taken for analysis. Hemoglobin and serum albumin levels were also estimated. We compared these changes according to age, sex, and duration on chronic hemodialysis, AVF, and the levels of serum albumin and hemoglobin. One or more nail changes were observed in 44/69 (64%) patients. The commonest abnormality was the so-called "Half-and-half nail changes", which was observed in the finger nails of 18/69 (26%) of the study patients (males to female ratio was 2:1). Typically, the half-and-half nails are nails where the distal portion of the nail bed is red, pink or brown, occupies 20-60% of the total nail length and is always sharply demarcated with the proximal portion. The latter has a dull whitish ground glass appearance and when pressure is applied, the distal discoloration does not fade completely. Non-specific nail changes were observed 26/69 (38%) patients. The hemoglobin and serum albumin levels were not significantly different of those with 'half-and-half' nail, non-specific nail changes or no nail changes. We conclude that various fingernail changes are observed in ESRF patients on HD. These nail changes are independent of the age of the patient, duration on HD, AVF or hemoglobin or albumin levels. However, a gender dependent trend was noticed and the half-and-half nail seems to be characteristic of uremia.

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.

Wegener's granulomatosis. First case report in Bahrain

Formerly a fatal condition, Wegener's granulomatosis is now treated with good results. Although the annual incidence of Wegener's granulomatosis in the general population is not known, most European and American studies revealed an incidence in the range of one for every 250,000 of the population. The estimated total population of Bahrain as of June 1997 is 586,110; here we report the first diagnosed case of Wegener's granulomatosis in Bahrain. Our patient presented with epistaxis, and from the clinical features, the very high ESR, the operative, histopathological and the radiological findings, and a high index of suspicion we could confirm the diagnosis along with the appropriate immunological test (positive cANCA). Standard treatment with cytotoxic agents and corticosteroids has been used. On follow-up the patient has shown a progressive improvement in her clinical and laboratory parameters.

Lower-extremity saphenous vein transposition arteriovenous fistula: an alternative for hemodialysis access in AIDS patients

Arteriovenous access for long-term hemodialysis in patients with the acquired immunodeficiency syndrome (AIDS) represents a special challenge. Many of these patients are chronic intravenous drug abusers and do not have patent superficial upper-extremity veins available for conventional arteriovenous fistulas. This group of patients is also particularly prone to infections, which contraindicates the use of prosthetic grafts. Over a period of 13 months, five lower-extremity saphenous vein transposition arteriovenous fistulas (SVTAFs) were performed. Four patients had a diagnosis of AIDS at the time of operation; all of these were intravenous drug abusers. Three patients were male, two were female, and their age ranged from 34 to 66 years (mean, 48). Three patients had a SVTAF as their first hemodialysis access, and in two it was performed after multiple failed upper-extremity accesses. Four fistulas remain patent to date, after a mean follow-up of 11 months (range, 4 weeks to 16 months). One fistula thrombosed 4 weeks postoperatively, due to a hematoma that occurred after premature venipuncture for dialysis. There were no other major complications. We conclude that SVTAF is a suitable alternative to the limited hemodialysis venous access sites, especially in the AIDS population.

Familial hyperamylasaemia

A six year old boy underwent extensive investigation for recurrent abdominal pain and was found to have a persistently raised serum amylase. Endoscopic retrograde cholangiopancreatography was normal and macroamylasaemia was excluded. Serum amylase concentrations were found to be raised in other family members spanning three generations, all of whom were asymptomatic. Clearance studies suggested no evidence of a renal tubular defect and serum lipase concentrations were normal. This is the first report of apparently familial hyperamylasaemia and the mode of inheritance is consistent with an autosomal dominant pattern.

Non-neoplastic changes in gastric antrum: are they different in distally located intestinal and diffuse-type gastric adenocarcinoma?

A total of 126 cases of primary adenocarcinoma of distal (antrum and/or adjacent body) stomach were reviewed. These cases were collected from the histopathology laboratory of Asir Central Hospital, Southwestern Saudi Arabia over an 8 year period (1987-94). Only gastrectomy specimens with non-neoplastic antral mucosa available for histological examination were included. Of 126 cases, 85 (67.5%) were of the intestinal type and 41 (32.5%) were of the diffuse type. Histological examination of the non-neoplastic antral mucosa showed: gastritis in 100% of these cases; Helicobacter pylori in 103/126 cases (81.8%); multifocal atrophic gastritis (MAG) in 53/126 cases (42.1%); intestinal metaplasia (IM) in 62/126 (49.2%); and type III intestinal metaplasia in 30/62 cases (47.7%). None of these non-neoplastic changes of antral mucosa was significantly different when the prevalence of these changes in intestinal and diffuse type gastric adenocarcinoma were compared using the chi 2 test. The prevalence of these non-neoplastic lesions were calculated in a 126 dyspeptic age- and sex-matched control patients and were as follows: H. pylori 91%; gastritis 78%; MAG 7.4%; IM 19% and type III IM 1.6%. The prevalence of H. pylori bacilli and gastritis was not significantly different between the cancer patients and the controls. The prevalence of MAG, IM and type III IM was significantly higher among cancer patients compared with the control group.

A chimeric disposition of the elongation factor genes in Rickettsia prowazekii

An exceptional disposition of the elongation factor genes is observed in Rickettsia prowazekii, in which there is only one tuf gene, which is distant from the lone fus gene. In contrast, the closely related bacterium Agrobacterium tumefaciens has the normal bacterial arrangement of two tuf genes, of which one is tightly linked to the fus gene. Analysis of the flanking sequences of the single tuf gene in R. prowazekii shows that it is preceded by two of the four tRNA genes located in the 5' region of the Escherichia coli tufB gene and that it is followed by rpsJ as well as associated ribosomal protein genes, which in E. coli are located downstream of the tufA gene. The fus gene is located within the str operon and is followed by one tRNA gene as well as by the genes secE and nusG, which are located in the 3' region of tufB in E. coli. This atypical disposition of genes suggests that intrachromosomal recombination between duplicated tuf genes has contributed to the evolution of the unique genomic architecture of R. prowazekii.