Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection

BACKGROUND

Sampling variability on liver biopsy has been demonstrated in a variety of liver diseases. The objective of this study was to determine whether sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection.

METHODS

Two separate tissue samples were obtained from the right lobe of the liver, through a single skin puncture, in 29 patients (22 M, mean age 43.4 +/- 8.1 years) with chronic HCV infection. The biopsies were assessed using a descriptive histological reporting system and Knodell's Histological Activity Index (HAI) and compared for differences in necroinflammatory activity (grade) and fibrosis (stage).

RESULTS

Thirteen (44.8%) patients had a difference of > or = 1 grade between the 2 biopsies on the descriptive system and 13 differed by > or = 1 stage. On the HAI, 20 (69.0%) patients had a difference of > or = 2 in the necroinflammatory activity score and 10 (34.5%) had a difference of > or = 4; whereas, 11 (38.0%) patients had a difference of > or = 1 in the fibrosis score and 6 (20.7%) had a difference of > or = 2. The mean difference between the two sets of biopsies was 2.4 +/- 2.1 (range 0-7) for the necroinflammatory activity and 0.6 +/- 0.9 (range 0-3) for fibrosis. Spearman's correlation coefficient (r) was moderate for both necroinflammatory activity (r = 0.53, P < 0.01) and fibrosis (r = 0.62, P < 0.0001).

CONCLUSIONS

Sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection and should be taken into consideration when decisions regarding prognosis and therapy are made based on biopsy, and when defining histological response to antiviral regimens.

Psychotherapy and the recovery of memories of childhood sexual abuse: U.S. and British practitioners' opinions, practices, and experiences

Licensed U.S. doctoral-level psychotherapists randomly sampled from the National Register of Health Service Providers in Psychology (Surveys 1 and 2, n = 145; Council for the National Register of Health Service Providers in Psychology, 1992) and British psychologists sampled from the Register of Chartered Clinical Psychologists (Survey 2, n = 57; British Psychological Society, 1993) were surveyed regarding clients' memories of childhood sexual abuse (CSA). The 3 samples were highly similar on the vast majority of measures. Respondents listed a wide variety of behavioral symptoms as potential indicators of CSA, and 71% indicated that they had used various techniques (e.g., hypnosis, interpretation of dreams) to help clients recover suspected memories of CSA. Across samples, 25% of the respondents reported a constellation of beliefs and practices suggestive of a focus on memory recovery, and these psychologists reported relatively high rates of memory recovery in their clients.

Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors

BACKGROUND/AIMS

Angiotensin-converting enzyme inhibitors (ACEI) are the antihypertensives of choice in patients with chronic renal failure (CRF). ACEI by decreasing the synthesis of aldosterone, the main regulator of serum potassium, predispose to the development of hyperkalemia. Although hyperkalemia with administration of ACEI is uncommon in patients with a normal renal function, a preexisting abnormality in potassium hemostasis, as seen in patients with chronic renal failure, may increase the risk of hyperkalemia.

METHOD

To determine the predictors of development of hyperkalemia (K >5.1 mEq/l) in patients on ACEI, we retrospectively reviewed medical records of 119 patients followed in our renal clinic.

RESULTS

The mean age of the patients was 56 +/- (SD) 13 (range 20-84) years. Sixty-three percent were males, and 37% were females. Sixty-seven percent had a history of diabetes. Eighty five percent of the patients had CRF [creatinine clearance (CrCl) <80 ml/min]. The baseline serum Cr was 2.3 +/- 1.2 (range 0.6-6.9) mg/dl, and the CrCl was 50 +/- 27.5 ml/min. Of the 119 patients 46 (38.6%) developed hyperkalemia (mean K 5.68 +/- 0.3, range 5.2-6.7 mEq/l). Ninety-six percent of the patients who developed hyperkalemia had CRF, and 84% were diabetics. Pearson product-moment correlation revealed a significant positive correlation of hyperkalemia with Cr and a negative correlation of hyperkalemia with CrCl and HCO(3) (Cr: r = 0.42, p < 0.0001; CrCl: r = -0.34, p < 0.0001; HCO(3): r = -0.41, p < 0.0001). Multivariate logistic regression analysis revealed diabetes and serum creatinine to be the main predictors of hyperkalemia. In 31 patients hyperkalemia resolved either with a low-potassium (2 g/day) diet or with diet and a decrease in the dose of ACEI. In 15 patients ACEI had to be discontinued due to persistent hyperkalemia.

CONCLUSIONS

We conclude that hyperkalemia is common in patients with CRF on ACEI. The majority of the patients who develop hyperkalemia on ACEI have CRF and diabetes. A large number of patients with CRF require discontinuation of ACEI due to hyperkalemia and are deprived of their renoprotective effects.

Age differences in accuracy and choosing in eyewitness identification and face recognition

Studies of aging and face recognition show age-related increases in false recognitions of new faces. To explore implications of this false alarm effect, we had young and senior adults perform (1) three eye-witness identification tasks, using both target present and target absent lineups, and (2) and old/new recognition task in which a study list of faces was followed by a test including old and new faces, along with conjunctions of old faces. Compared with the young, seniors had lower accuracy and higher choosing rates on the lineups, and they also falsely recognized more new faces on the recognition test. However, after screening for perceptual processing deficits, there was no age difference in false recognition of conjunctions, or in discriminating old faces from conjunctions. We conclude that the false alarm effect generalizes to lineup identification, but does not extend to conjunction faces. The findings are consistent with age-related deficits in recollection of context and relative age invariance in perceptual integrative processes underlying the experience of familiarity.

Incidence of hip fracture in Kuwait

BACKGROUND

Hip fracture as a consequence of osteoporosis is an important cause of morbidity and mortality among the elderly. Due to improving life expectancy, the number of elderly individuals is increasing more rapidly in the developing countries of Asia, the Middle East, Africa, and South America. Incidence of hip fracture, which rises exponentially with age, varies substantially between countries and according to the age, sex, and ethnic distribution of the population. Highest rates are observed in Scandinavia and in whites in the US, intermediate in western Europe, and the lowest rates in Asia. Little is known about the epidemiology of hip fractures in the Middle Eastern populations. In particular, there are no published reports from any of the Arab countries. We have therefore estimated the incidence of hip fracture in Kuwait and compared it with other populations.

METHODS

The study was conducted at a specialized orthopaedic hospital which provides services to residents in the three governorates--representing about 70% of the total population of Kuwait. All new hip fracture patients who were operated on or treated conservatively during the 4-year period (1992-1995) were included in the study. Hip fracture was defined as clinical and radiological evidence of fracture of the proximal femur. For comparison with other populations, age-specific incidence rates in females and males aged > or =50 years were standardized to the 1985 US population.

RESULTS

A total of 513 cases of hip fracture (205 females, 308 males) were recorded during the study period: 293 (57.1%) cases occurred among Kuwaiti nationals and 220 (42.9%) among non-Kuwaitis (expatriates). Age-standardized rates (per 100,000) of hip fractures were, in Kuwaitis, 295 for females (95% CI: 238.8-350.8) and 200 for males (95% CI: 163.3-236.5)--much higher than those observed in other Asian countries such as Korea, Singapore, China, Malaysia, and Japan (41-202 for females, 49-100 for males). Rates in Kuwaiti females were similar to those observed in some of the European countries (Italy, UK, France) and in Asian females in the US. In contrast, rates in Kuwaiti males, which were relatively high, were almost equal to those observed in white males in the US. Rates of hip fracture in non-Kuwaitis (374 for females [95% CI: 247.6-500.8], 215 for males [95% CI: 126.5-302.9]), who predominantly (96%) originate from southeast Asian and Arab countries, were similar to those observed in Kuwaiti nationals.

CONCLUSIONS

The incidence of hip fracture in the Kuwaiti population is higher than that reported from other countries in Asia and is comparable to the incidence in some of the western European and North American populations.

Benign thyroid disease and dietary factors in thyroid cancer: a case-control study in Kuwait

We conducted a population-based study of 313 case-control pairs in Kuwait to examine the aetiology of thyroid cancer, the second most common neoplasm among women in this and several other countries in the Gulf region. Among the demographic variables, individuals with 12+ years of education had a significantly reduced risk of thyroid cancer (OR=0.6; 95% CI: 0.3-0.9). The average age at diagnosis (+/-s.d.) of thyroid cancer was 34.7+/-11 years in women and 39+/-13.4 years in men. History of thyroid nodule was reported only by cases (n=34; 10.9%; lower 95% CI: 12.0); and goitre by 21 cases and four controls (OR=5.3; 95% CI: 1.8-15.3). There was no significant increase in risk with history of hypothyroidism (OR=1.8) or hyperthyroidism (OR=1.7). For any benign thyroid disease, the OR was 6.4 (95% CI: 3.4-12.0); and the population attributable risk was about 26% (95% CI: 21.1-30.9). Stepwise regression analysis showed that high consumption of processed fish products (OR=2.2; 95% CI: 1.6-3.0) fresh fish (OR=0.5; 95% CI: 0.4-0.7) and chicken (OR=1.7; 95% CI: 1.2-2.3) were independently associated with thyroid cancer with significant dose-response relationships. Among the thyroid cancer patients who reported high consumption of fish products, a large majority also reported high consumption of fresh fish (98%) and shellfish (68%). No clear association emerged with consumption of cruciferous vegetables. These data support the hypothesis that hyperplastic thyroid disease is strongly related to thyroid cancer; and that habitual high consumption of various seafoods may be relevant to the aetiology of thyroid cancer. The association with chicken consumption requires further study.

Aging and lineup performance at long retention intervals: effects of metamemory and context reinstatement

Young (18-30 years) and older (62-79 years) adults (N = 96) engaged in a 20-min live interaction with the future target in a lineup task. One month later, participants were interviewed about the events in the prior encounter (with or without context reinstatement), and then they saw a target-present (TP) or target-absent (TA) lineup. The lineup was followed by the Benton Face Recognition Test (A. Benton, A. Sivan, K. Hamsher, N. Varney, & O. Spreen, 1994), which correlated positively with accuracy in TP, especially for young adults. False identification in TA was associated with (a) higher scores on a memory self-efficacy scale and (b) higher recall of information about the initial event, although only for seniors. Results suggested that age-related increases in false identification generalize to ecologically valid conditions and that seniors' performance on lineups is negatively related to verbal recall as well as to self-reports of satisfactory experiences with memory in life.

The value of permixon in benign prostatic hypertrophy

A double-blind trial comparing the effect of Permixon (160 mg bd) against placebo in the treatment of benign prostatic hypertrophy is described. In both groups a significant improvement in flow rate and subjective assessment of symptoms was seen. There was no significant difference between the results of treatment in either group.

Facile synthesis of laccase mimic Cu/H3BTC MOF for efficient dye degradation and detection of phenolic pollutants

Herein, we report an effectual method for designing a novel form of nanozyme laccase mimic namely Cu/H3BTC, using copper ions and 1,3,5-benzene tricarboxylic acid (1,3,5-H3BTC). This Cu-based metal-organic framework (MOF) was synthesized through a simple procedure of mixing of two usual reagents at room temperature. Amido Black 10B (AB-10B) was chosen as a model dye for degradation consequences. Results showed that Cu/H3BTC MOF revealed significantly higher catalytic efficacy under certain conditions like high pH, extreme temperature and high salt conditions and it has long-term storage stability, which can lead to a significant decline in catalytic activity of laccase. In addition, the degradation of AB-10B was up to 60% after ten cycles, showing good recyclability of Cu/H3BTC MOF. The UV-visible spectral changes clearly showed that Cu/H3BTC MOF is an effective laccase mimic for the degradation of azo dye AB-10B, which was degraded more easily within the time duration of 60 min. The Cu/H3BTC MOF also possessed fundamental activities like laccase with regard to oxidation of the phenolic compounds. Moreover, a technique for the quantitative detection of epinephrine by Cu/H3BTC MOF was established. These findings help to understand the laccase-like reactivity and provide a basis for the future design and application of metal-based catalysts.

A 10-year experience of managing ureteric calculi: changing trends towards endourological intervention--is there a role for open surgery?

OBJECTIVES

To study changing practices in the management of ureterolithiasis with the introduction of newer technologies, the efficacy and safety of endourology, extracorporeal shock wave lithotripsy (ESWL) and open surgery, and to determine if any indication remains for open ureterolithotomy in a tertiary endourology unit.

PATIENTS AND METHODS

A 12-year retrospective review (1987-1998) was conducted of all primary ureteric stones treated by ESWL, endoscopy, intracorporeal shock wave lithotripsy (ISWL) administered via ureteroscopy, and open surgery.

RESULTS

In all, 1195 patients were treated for primary ureteric stones, 44% by ESWL, 37% by ureteroscopy and ISWL, and 20% by open surgery. At the 3-month follow-up the stone-free rates for ESWL monotherapy, ureteroscopy and open surgery were 95%, 85% and 97%, giving an efficiency quotient of 73%, 64% and 94%, respectively. The overall complication rate for ESWL was 13%, for ISWL 32% and for open surgery 13%, but the complications of open surgery were often serious and potentially life-threatening.

CONCLUSIONS

With recent advances in endourology the indications for open surgery have decreased considerably, from 26% in 1987-95 to 8% in 1996-98. However, the remaining indications for open ureterolithotomy include failure of less invasive modalities, the presence of medical/anatomical abnormalities, a concomitant open procedure, and the presence of large impacted calculi for which patients prefer to avoid multiple procedures.

Dental health knowledge, attitudes and behaviour among students at the Kuwait University Health Sciences Centre

OBJECTIVE

The aim of the study was to determine the extent of dental health knowledge among students at the Kuwait University Health Sciences Centre (HSC), as well as their attitudes toward dental health and their oral hygiene habits.

METHODS

A structured questionnaire was distributed to 450 of the 800 students enrolled in 3 faculties of the HSC from March to April 2000. The questionnaire was completed anonymously by the students.

RESULTS

Four hundred and ten students (91.1%) completed the questionnaire. Of these, 64.6% believed that the main cause of tooth decay was 'not brushing properly'. Only 19.3% of the students believed that sugar could cause dental decay. Half of the students did not know if sugar-free drinks are harmful to their teeth, and 29.5% did not know about any measures to prevent gums from bleeding. Self-assessment questions showed that 84.5% of the students were satisfied with their dental health. A large majority of the students (94.8%) brushed their teeth at least once a day. Female students brushed their teeth more frequently than male students, as did those students who had visited a dentist in the past 6-12 months and those who rated their dental health to be very good. The main reason given for a dental visit was toothache (70.0%). Coffee was consumed daily by 68.9% of students, 76.6% of whom added sugar to their coffee.

CONCLUSIONS

The findings indicate that although most of the students at the HSC seem to be satisfied with their dental health, they did not have correct knowledge about the causes and prevention of dental diseases. In general, female students were more aware and concerned about dental health issues and more engaged in dental behaviour than male students.

Eyewitness performance in cognitive and structured interviews

This paper addresses two methodological and theoretical questions relating to the Cognitive Interview (CI), which previous research has found to increase witness recall in interviews. (1) What are the effects of the CI mnemonic techniques when communication techniques are held constant? (2) How do trained interviewers compare with untrained interviewers? In this study, witnesses (college students) viewed a short film clip of a shooting and were questioned by interviewers (research assistants) trained in conducting the CI or a Structured Interview (SI)--similar to the CI except for the "cognitive" components--or by untrained interviewers (UI). The CI and SI groups recalled significantly more correct information compared to the UI group. However they also reported more errors and confabulated details. Theoretical and practical implications of the results are discussed in terms of precisely identifying the CI facilitatory effects and consequent good practice in the forensic setting.

Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan

In Pakistan, male sex workers are predominantly transvestites and transsexuals known as Hijras. In 1998 in Karachi, Pakistan, we studied the seroprevalence of HIV, HBsAg and syphilis and associated risk factors in Hijras. Study subjects were verbally administered a structured questionnaire that determined risk behaviours for sexually transmitted and blood-borne diseases and knowledge of AIDS/STDs. After pre-test counselling, verbal consent was taken for serological testing. The results were provided on a one-on-one post-test counselling session. Three hundred male transvestites were approached; all agreed to answer the questionnaire, 208 consented to blood testing. Of 300, 81% acknowledged commercial sex with men. Of 208, prevalence of syphilis was 37%; HBsAg 3.4%; HIV 0%. The prevalence of HIV and hepatitis B virus (HBV) is low in transvestite sex workers but that of syphilis is high. Intervention programmes implemented at this stage can have an impact on HIV and STD prevention.

Three-dimensional visualization of the craniofacial patient: volume segmentation, data integration and animation

The research goal at the Craniofacial Virtual Reality Laboratory of the School of Dentistry in conjunction with the Integrated Media Systems Center, School of Engineering, University of Southern California, is to develop computer methods to accurately visualize patients in three dimensions using advanced imaging and data acquisition devices such as cone-beam computerized tomography (CT) and mandibular motion capture. Data from these devices were integrated for three-dimensional (3D) patient-specific visualization, modeling and animation. Generic methods are in development that can be used with common CT image format (DICOM), mesh format (STL) and motion data (3D position over time). This paper presents preliminary descriptive studies on: 1) segmentation of the lower and upper jaws with two types of CT data--(a) traditional whole head CT data and (b) the new dental Newtom CT; 2) manual integration of accurate 3D tooth crowns with the segmented lower jaw 3D model; 3) realistic patient-specific 3D animation of the lower jaw.

Facile synthesis of alcalase-inorganic hybrid nanoflowers used for soy protein isolate hydrolysis to improve its functional properties

In this work, a facile approach was developed to synthesized alcalase-inorganic hybrid nanocomposite (alcalase@CaHPO4) by immobilizing alcalase with calcium hydrogen phosphate (CaHPO4). The nanocomposite possessed flower-like morphological features with excellent hydrolysis activity on soybean protein isolates (SPI) with 1.57 fold higher compared to free alcalase. The experiment was evident of alcalase@CaHPO4 hybrid nanoflowers with 90% sustainability after the seven cycles of reusability and 80-100% relative activity at 50-70 °C and with 65% at pH 4 in acidic condition. Soybean protein hydrolysates (SPHs) produced by immobilized alcalase possessed 70% radical-scavenging capacity at 0.8 mg/mL concentration and 20% calcium-binding capacity at pH 6. The solubility of SPHs produced by alcalase@CaHPO4 hybrid nanoflowers was also improved by 15% compared to free alcalase. The high radical scavenging capability, good calcium binding capacity and improved solubility of SPHs prepared through alcalase@CaHPO4 hybrid nanoflowers would be highly promising in food industries.

A search for unknown blood-borne oncogenic viruses

In previous decades, infants who received blood transfusions shortly after birth or in utero might have been infected at a particularly vulnerable age by some blood-borne oncogenic virus. A cohort of such infants has therefore been followed into adult life to see if they suffered any excess of neoplastic disease or of non-neoplastic mortality. A total of 12,690 infants were identified who were transfused between 1 January 1942 and 31 December 1970, in most cases for the prevention or treatment of haemolytic disease of the newborn. All but 361 (2.8%) were found to have been registered with a National Health Service (NHS) practitioner and were followed in the NHS central records until they died, emigrated, were removed from NHS lists or until 1 January 1992, whichever occurred first. Mortality and cancer incidence were compared with that expected from national rates. No marked disparity was observed and there was no excess of childhood leukaemia. The incidence of non-Hodgkin's lymphoma at 15 to 49 years of age was about twice that expected, but the excess was not statistically significant.

Cu/H3BTC MOF as a potential antibacterial therapeutic agent against Staphylococcus aureus and Escherichia coli

The objective of this study was to design a more effective antibacterial agent to overcome the problem of fast-growing bacterial resistance.

Renal lymphangiectasia

Renal lymphangiectasia is a benign disorder of renal lymphatics. Seldom observed, the pathophysiology is unclear. The clinical course may vary, and management alternatives range from percutaneous drainage in symptomatic cases to pharmacological substitutes in the form of anti-hypertensives and diuretics. We present a case of bilateral perinephric collections on imaging, which presented with gross ascites, abdominal pain and reversible hypertension. Ultrasound examination indicated ascites. Computerized tomography revealed bilateral symmetrical large perinephric collections. This is consistent with the appearance of renal lymphangiectasis (enlarged kidneys with fluid collections seen to be abutting the surrounding structures) reported in the literature. Needle aspiration of the perinephric fluid was undertaken, and laboratory analysis was carried out, which revealed a protein level of 643 mg dl(-1) and a total leucocyte count of 50, of which 80% were lymphocytes. Thereafter, a diagnosis of renal lymphangiectasia was made, and conservative treatment with diuretics and anti-hypertensives was initiated. Reassessment at subsequent follow up visits showed improvement in the patient's clinical condition.

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.

Family history of benign thyroid disease and cancer and risk of thyroid cancer

In a population-based study of 313 case-control pairs in Kuwait, we evaluated whether a family history of benign thyroid disease (BTD) and thyroid or other cancers was associated with an increased risk of thyroid cancer, the second most common neoplasm among women in this and several other Arab countries in the Gulf region. Family history of BTD was reported by 78 (24.9%) cases and 40 (12.8%) controls in 132 and 57 relatives, respectively. There was an approximately 2-fold increased risk of thyroid cancer in individuals who had a mother (Odds Ratio (OR)=2.3; 95% Confidence Intervals (95% CI): 1.1-5.1), sister(s) (OR=2.6; 95% CI: 1.3-5.3) or aunt(s) (OR=2.1; 95% CI: 0.9-5.3) with BTD; there was also a significant trend in increasing risk with an increasing number of affected female relatives (P<0.0001). Stratification by age at diagnosis of the case showed that individuals aged </= 35 years, who had an affected first- or second/third-degree relative(s), had an approximately 3-fold increased risk of the cancer. Family history of thyroid cancer was reported by 9 (2.9%) cases in 13 relatives (11 females, 2 males) and by 3 controls in 3 relatives (all females) (OR=3.0; 95% CI: 0.8-11.1). The OR for all hormone-related cancers combined was 1.5 (95% CI: 0.8-2.6). There was no clear association with family history of breast or any other common cancer. Our data suggest that a family history of BTD is associated with an increased risk of thyroid cancer, and point to the role of familial susceptibility to BTD and thyroid cancer in the Kuwaiti population.

Extracorporeal shock wave lithotripsy for urinary tract stones using MPL 9000 spark gap technology and ultrasound monitoring

Between November 7, 1988 and December 31, 1989, 881 treatments were given with the MPL 9000 lithotriptor to 513 sites in 510 renal units in 464 patients. Of the stones 447 (87.1%) were in the kidney, 64 (12.5%) in the ureter and 2 (0.4%) in the bladder. Stone size was up to 2 cm. in 58.5% of the cases, greater than 2 to 3 cm. in 25.8% and more than 3 cm. in 15.7%, including complete or partial staghorn, or multiple stones. Of the patients 54.2% received only 1 treatment, 17.6% received 2 treatments and 28.2% received more than 2 treatments (re-treatment was necessary in 45.8%). The number of shocks used varied from 610 to 4,000 at 14 to 24 kv., the usual energy used being 18 kv. Of the stones 30.2% were treated after Double-J stents were inserted. A patient was declared stone-free only when no stone particle was visible on a plain abdominal x-ray (or ultrasound if the stone was radiolucent). X-rays 3 months after extracorporeal shock wave lithotripsy (ESWL) were available for review in 397 patients (79.9%) and 72.8% were stone-free (with the aforementioned criteria) at 6 months (61.5% without ancillary procedures and 11.3% after ancillary procedures). Of a subset of 106 patients 84% were stone-free within 3 months when ESWL was restricted to a smaller stone burden, the number of shock waves administered was increased and energy was restricted to 14 to 18 kv. Over-all, 9.1% of the patients needed ancillary measures, including percutaneous nephrostomy in 1.6%, push-back for ESWL in 1.9%, ureterorenoscopy in 5.4%, percutaneous nephrolithotomy in 0.6% and pyelolithotomy/ureterolithotomy in 2.8%. The MPL 9000 device has the unique combination of electrohydraulic shock wave generation and ultrasound monitoring. The latter attribute has the distinct advantage of avoiding radiation to allow for visualization of nonopaque renal and gallbladder calculi. In addition, because there is continuous stone visualization during fragmentation accurate stone targeting can be maintained. The combination of ultrasound monitoring and spark gap technology allows for effective stone fragmentation.

Pattern and determinants of dyslipidaemia in type 2 diabetes mellitus patients in Kuwait

We conducted a clinical study to assess the pattern of dyslipidaemia in type 2 diabetic patients and to examine the demographic and clinical factors associated with dyslipidaemia. The study population comprised 206 consecutive type 2 diabetic patients attending the out-patient clinic at a major hospital in Kuwait. Clinical history and physical examination were done and fasting blood samples were taken to determine HbA1c and lipid levels. American Diabetes Association criteria were applied to define clinical targets for lipid levels and coronary heart disease risk categories. Stepwise multiple linear regression was conducted to identify the demographic and clinical factors associated with lipid levels outside of the clinical target. The large majority of the patients were either over-weight (32%) or obese (57%); the mean BMI was 32.6 kg/m2. Serum total cholesterol, LDL-cholesterol, and triglycerides were above optimal levels in 67%, 86%, and 25% of patients, respectively. For HDL-cholesterol, 63% of men and 71% of women had values below the corresponding optimal level. Only 14 patients (6.8%) had all three lipid values within the respective target level. The percentages of patients with one, two, or all three lipid values outside of target were 31%, 46%, and 16%, respectively. The most frequent (41%) pattern of dyslipidaemia was a combination of LDL-cholesterol level above target with HDL-cholesterol level below target; the second most common pattern was an isolated increase in LDL-cholesterol, observed in 21% of the patients. In the stepwise regression analyses, glycaemic control was strongly associated with dyslipidaemia (i.e. high total- and LDL-cholesterol and triglycerides); female gender were associated with low HDL-cholesterol. Kuwaiti type 2 DM patients have a high prevalence of dyslipidaemia and obesity. Weight reduction, increased physical activity, improved glycaemic control, and increased HDL-cholesterol levels, along with reduced LDL-cholesterol, should be important goals of therapy in these patients to reduce the risk of coronary heart disease.