Analysis of Mortality Data due to Infectious Diseases: Life Table Methods Complementary to Direct Rates

Life table methods are employed complementary to standard rates to analyse Kuwaiti mortality data due to infectious diseases. The procedure comprises total mortality, multiple-decrement, cause—elimination and cause—delay life tables. To improve reliability of estimated age-specific death rates, the numerator was based on the three-year average of deaths (1981-83), while the denominator was the mid 1982 population projected from the 1980 and 1985 population censuses. To overcome the difficulty of age heaping, both mortality and census data were graduated using the natural cubic spline approach. Proportional mortality was maximum in intestinal infectious diseases particularly in the rural Jahra Governorate. Infectious diseases caused 29.4 and 37.1% of male and female deaths respectively in infancy and early childhood. The male and female life expectancy at birth were 67 and 72 years, respectively.

The multiple-decrement life tables showed that 3,346 men and 2,986 women out of the birth cohort (100,000) will ultimately die from infectious diseases. The average number of years lost due to infectious diseases were 0.75 years in both men and women. Relating this loss to the affected (saved) subpopulation only, large gains in life expectancy occur (22.3 and 25.2 years in men and women respectively).

Behavioural risk factors for non communicable diseases among adults in Kerala, India

BACKGROUND & OBJECTIVE

Cardiovascular and other chronic diseases are becoming the major causes of morbidity and mortality in most of the third world countries including India, especially in the southern Indian States, like Kerala, where most of the health indicators match closely with those of any developed country. Various behavioural risk factors (BRF) namely smoking, unhealthy diet, stress at home and work place, consumption of alcohol, sedentary life style, etc., are known to be risk factors for many such diseases. The present study was carried out to estimate the prevalence of various behavioural risk factors for chronic diseases, and to identify their biosocial correlates.

METHODS

A cross-sectional study was done in which the data were collected from a sample of 6579 individuals of age 30 to 74 yr, randomly selected following a stratified multi-stage cluster sampling design covering Kerala State. The important factors investigated include various behavioural risk factors, presenting chronic diseases and family histories among close relatives. The data were analysed using both univariate and multivariate analyses.

RESULTS

The two major risk factors observed among males were smoking and alcohol consumption. About two fifths (40%) of them were current smokers as well as current users of alcohol (41%). The median age at initiation was 21 yr for both smoking habits and for alcohol consumption. Nearly a quarter of the target population were inactive (23% males and 22% females) based on work and leisure time activities. More than one-fifth of them (23%) reported stress. Obesity was found more among females (33%) than males (17%). Low socio-economic background was found to be a high predictor (high risk group) for habit of smoking, alcohol consumption, stress and unhealthy diet.

INTERPRETATION & CONCLUSION

Substantially high levels of the various behavioural risk factors among adults in Kerala suggests an urgent need for adopting healthy life style modifications among the population in general. The increased risk observed among the younger generation for behavioural risk factors such as smoking and alcohol consumption calls for urgent corrective steps and measures for long-term monitoring of all major risk factors as well as the major chronic disease conditions.

Prevalence of known and undetected diabetes and associated risk factors in central Kerala--ADEPS

Amrita Diabetes and Endocrine Population Survey (ADEPS) was conducted as a community-based cross-sectional survey to assess the prevalence of undetected diabetes mellitus (DM) and impaired glucose tolerance (IGT) and their possible relationship with various risk factors in an urban South Indian population. An initial house-to-house survey of adults between ages 18 and 80 years (n = 3069) was followed by a second phase consisting of health check-up and biochemical evaluations of participants (n = 986). DM and IGT were diagnosed as per WHO criteria. Reported prevalence of known diabetes mellitus in the survey was 9.0% (276/3069); (M-8.7% and F-9.2%). Among the screened subjects who underwent blood testing, the prevalence of newly diagnosed diabetes was 10.5%. The prevalence of IGT was 4.1% and IFG was 7.1%. Increasing age, obesity, positive family history of diabetes, abnormal subscapular triceps skin fold ratio and presence of acanthosis nigricans (AN) were all found to be associated with increased risk of DM. The finding of high prevalence of newly detected DM and IGT in this population of Kerala with the highest standards of health care and literacy level compared to other states of India, emphasizes the need for routine screening of high-risk groups for early detection of the disease. A simple cutaneous sign, acanthosis nigricans was independently associated with increased risk of type 2 diabetes in this survey and can be used as indication for screening for DM and IGT.

Utilization of the pulmonary function test laboratory in the evaluation of respiratory disorders in the Al-Amiri Hospital: a secondary medical center

OBJECTIVE

The aim of this study was to describe the current use of pulmonary function tests (PFT) and the degree of matching between the diagnoses at referral and after the test.

SUBJECTS AND METHODS

A pre-test questionnaire was administered to 464 (5-88 years) patients referred to the PFT laboratory followed by a complete PFT test. The results of the patients' tests were analyzed in terms of the diagnosis before the test, its relation to symptoms, and the rate of concordance between the diagnoses before and after the test.

RESULTS

The most referrals were from the medical Outpatient Department; 61%) and the most frequent diagnosis before the test was asthma (31.8%). Of the 464 patients, 34% were currently smoking cigarettes, and the most common symptoms were chronic dyspnea (30.2%) and chronic cough (19.6%). The chronicity of symptoms showed some association with the diagnosis before PFT in the case of chronic obstructive pulmonary disease (COPD) showing the symptom of dyspnea (p = 0.05), and COPD and restrictive lung disease with cough (p < 0.05). The overall rate of concordance in matching diagnoses before and after the test was 60.4% by consultant physicians and 51.9% by non-consultants, with an overall rate of 55% by all physicians.

CONCLUSION

Our findings show that there should be better utilization of the PFT laboratory by physicians in all sub-specialities and there is a need to facilitate its use to make a better functional diagnosis.

Comparison of lactose intolerance in healthy Kuwaiti and Asian volunteers

OBJECTIVE

To study and compare the incidence of lactose intolerance among Kuwaiti and Asian healthy volunteers as measured by breath hydrogen level following challenge with lactose drink.

SUBJECTS AND METHODS

The study involved 70 Kuwaiti and 79 Asian healthy volunteers. The volunteers were physicians, medical students and other hospital workers. The study was carried out prospectively at Amiri Hospital, Kuwait. None of the volunteers was sick or had taken antibiotics or any other drug that could influence breath hydrogen level 2 weeks prior to the study. After an overnight fast 20-ml baseline samples of exhaled air were collected from each volunteer prior to oral administration of 40 g of lactose drink. Following this, the same amount of exhaled air was collected at 30-min intervals for 2 h. All samples were analyzed for hydrogen level using a Quintron microlyzer. Hydrogen level of 20 ppm more than baseline value was considered positive.

RESULTS

The basal breath hydrogen levels were 12.49 +/- 8.4 and 6.97 +/- 6.9 for Kuwaitis and Asians, respectively. Thirty-three (47%) of the 70 Kuwaitis and 46 (58%) of the 79 Asians were positive for the breath hydrogen test. The clinical symptoms of flatulence, abdominal pain, and diarrhea were associated with high levels of breath hydrogen.

CONCLUSION

The findings indicate that the Kuwaiti volunteers had higher breath hydrogen levels than Asians, but the incidence of lactose intolerance was similar in both groups.

Efficacy and reliability of fundus digital camera as a screening tool for diabetic retinopathy in Kuwait

OBJECTIVE

Many screening and follow-up methods are available for detecting diabetic retinopathy (DR). However, once patients develop retinopathy, it is unclear as to what method should be used for their review. This study is designed to assess the correlation between fundus digital image and clinical examination and to develop a screening program for the early detection of sight-threatening DR using a Canon CF 60 UV fundus camera.

METHODS

Patients who were not treated for DR earlier were enrolled in the study. All patients underwent digital fundus photography. The photographs were evaluated and compared with the clinical findings as recorded by retinal specialists. DR and macular edema were analyzed separately, and the correlation was statistically measured. The kappa statistic was used to estimate the extent of the agreement between the two procedures.

RESULTS

A total of 92 eyes of 51 patients were eligible to be entered in the study. Comparison of the digital image of the fundus and the examination by an ophthalmologist showed a good correlation. The kappa score for retinopathy was estimated to be 93% with 95.6% concordance. The kappa score for diabetic maculopathy was 88% with concordance of 92.2%.

CONCLUSION

We conclude that digital images provide an efficient method for diagnosing and classifying sight-threatening DR, particularly proliferative diabetic retinopathy (PDR). However, agreement between the digital fundus camera and clinical examination by an ophthalmologist for diabetic maculopathy detection, though substantial statistically, was not very satisfactory. It was also felt that the digital photographs can be used as a tool for teleophthalmology and can be integrated as a screening system in Kuwait.

Influence of smoking on cutaneous delayed-type hyper sensitivity reaction by tuberculin skin test

Tuberculin test (purified protein derivative) is currently accepted as a standard investigation used in the diagnosis of tuberculosis (TB). Although the sensitivity of the test is reliable, a substantial number of those subjected to screening for TB by such test are cigarette smokers. This study is designed to investigate the effect of smoking on cell-mediated delayed-type cellular hypersensitivity (DTH) reaction by PPD. Prospective, case-control study was conducted at the Chest and TB unit of Chest Hospital Kuwait. The study population consisted of 357 healthy volunteers serving as controls and 200 in-patients under direct medical supervision and treatment for tuberculosis as cases. The mean age was 33.69 +/- 8.6 SD; 286 were current smokers and 271 were lifetime non-smokers. PPD test was done using 2TU RT23 SSI-Denmark on all subjects. Median PPD was significant among the cases (P=0.03) between smokers and non-smokers and was highly significant among the healthy controls (P<0.001). No significant difference was seen between median pack years of smoking and PPD levels among the patient group (P=0.264) but the difference was significant among the control group (P<0.001). Univariate analysis of variance (ANOVA) on PPD, taking into account age, pack years of smoking, ethnic groups and BCG scar showed sufficient response but was not statistically significant to all these factors. Smoking habit does not appear to influence the cutaneous delayed type hypersensitivity reaction by tuberculin skin test.

Effect of increased glucose load on maternal-fetal transport of alpha-aminoisobutyric acid in the perfused human placenta: in vitro study

The role of hyperglycemia on modulation of maternal-fetal transport of amino acids in humans is little understood. Hence, we have explored the effect of increased glucose load on transport kinetics of a model non-metabolizable amino acid, alpha-aminoisobutyric acid (AIB), in the human placenta in vitro. Transport kinetics of AIB in maternal-fetal direction was studied using perfusion of isolated human placental lobules. NCTC (National Culture and Tissue Collection)-135 medium, diluted with Earle's buffered salt solution was used as the perfusate and tritiated water was used as the reference marker. Effect of increased glucose load on transport kinetics of study and reference substances was studied in normal term placentae (n=5; gestational age, 38.5 +/- 0.5 weeks) in succeeding experimental phases, after a control perfusion phase with physiological glucose concentration. AIB transport fraction (TF), relative to tritiated water TF, averaged 54.8% in control euglycemic phase while in hyperglycemic concentration phases of 27.8 and 55.6 mM, the AIB TF index averaged 42.4% and 38.2%, respectively. Analysis of variance revealed that the difference was statistically significant. Similarly, absorption rate index of the amino acid was also significantly lower in the hyperglycemic perfusion phases compared to control euglycemic phase. We conclude that hyperglycemia may play a deleterious role in limiting maternal-fetal transport of A-type amino acids in the in vivo state.

Performance of monolayered cervical smears in a gynecology outpatient setting in Kuwait

OBJECTIVE

To compare ThinPrep (TP) Papanicolaou smears (Cytyc Corp., Box-borough, Massachusetts, U.S.A.) with matching conventional Papanicolaou (CP) smears for specimen adequacy, cytologic quality, diagnostic accuracy and screening time.

STUDY DESIGN

In this prospective study of 1,024 women a split-sample, matched-pair design in favor of CP slides based on single-blind criteria was followed with a smear on a glass slide for CP and the remaining material collected in Preserv-Cyt solution (Cytyc) for a TP smear. A Cytobrush (Medscand, Hollywood, Florida, U.S.A.) was used for smear preparation for CP. TP smears were processed in ThinPrep 2000 (Cytyc). Smears were stained with Papanicolaou stain and were interpreted according to the Bethesda system.

RESULTS

The number of satisfactory but limited (SBL) cases with TP were 77 (7.5%) as compared to 127 (12.4%) with the CP method. This reduction in SBL smears with the TP method and consequent increase in satisfactory smears were highly significant (P < .001) by McNemar's test. As regards unsatisfactory smears in discordant pairs, although the number of unsatisfactory smears was higher with TP (41 cases) as against CP (27 cases), the difference was not statistically significant (P < .05). The split-sample method showed a high correlation between the CP and TP diagnoses. TP smears had a significant advantage over CP smears in the reduction in the number of ASCUS and AGUS cases (14 vs. 29) (P < .05) and increased the pickup rate of LSIL, 6 vs. 1. Time taken to screen the TP smears was half that of CP smears. No cases of LSIL or HSIL were missed on TP smears.

CONCLUSION

The liquid-based processor significantly improved the adequacy and quality of smears, resulting in fewer recall cases for SBL smears, leading to more definitive diagnoses in atypical cases, increasing the pickup rate of LSILs and reducing the screening time. A machine handling multiple specimens automatically would decrease cost and be an asset to a cytopathology laboratory.

Effect of insulin on transport kinetics of alpha-aminoisobutyric acid in the perfused human placental lobule in vitro

BACKGROUND

The limited data available on the role of insulin on maternal-fetal transport of amino acids prompted us to undertake this study.

METHODS

Transport kinetics of a model amino acid, alpha-aminoisobutyric acid (AIB) was investigated in perfusion of isolated human placental lobules in vitro in non steady-state conditions and the effect of therapeutic dose of insulin was assessed in parallel series of perfusions. National Culture and Tissue Collection medium diluted with Earle's buffered salt solution was used as the perfusate and tritiated water was used as the reference marker for comparison.

RESULTS

In five successful perfusions with insulin, differential transport rate indices of AIB for 10, 25, 50, 75 and 90% of efflux fractions in the fetal venous outflow averaged 0.76, 1.03, 1.02, 1.09, 1.04 and 1.03 times those of reference values, respectively. The indices differed significantly than in controls for 10, 25 and 50% efflux fractions, but not in the case of 75 and 90% efflux values. The AIB transport fraction (TF), expressed as percentage of injected maternal dose, averaged 29.4 +/- 5.4% and 38.7 +/- 6.2% of the corresponding reference marker value in control and insulin series, respectively. With regards to the pharmacokinetic transport parameters, the absorption and elimination rates of the amino acid were significantly higher in the study group than in the control.

CONCLUSION

We conclude that insulin, in physiological and therapeutic doses, stimulates maternal-fetal AIB transport in vitro, in the perfused human placental lobule.

The association of skin test reactivity, total serum IgE levels, and peripheral blood eosinophilia with asthma in Kuwait

There is evidence that elevated serum immunoglobulin E (IgE) and eosinophilia correlate well with allergic skin test reactivity. These parameters have been used as alternative methods to characterize atopic subjects. Skin test reactivity is the only measure used routinely in clinical practice in Kuwait to reflect atopy in asthma patients. This study examines the usefulness of the two other parameters of atopy in patients with asthma, and to determine the most common allergens involved in Kuwait. Between 1998 and 1999, 101 asthma patients and 33 healthy controls were recruited for this study. Skin sensitivity test, serum total and specific IgE, total blood eosinophil count (B-EOS), and eosinophil cationic protein (ECP) tests were performed in patients and controls. Nine allergens known to be prevalent in this environment were selected for the skin test and specific IgE test. Spirometry was also measured. These parameters were repeated after 4 weeks of therapy in the patients only. Skin test reaction was positive in 81% of the patients, while total IgE above 200 kU/L was obtained in 63% of cases. B-EOS above 300 x 10(3)/L was found in 75% of cases. House dust mite reactivity (positivity) was the most frequently encountered skin allergy, occurring in 28% of the patients. IgE correlated positively with B-EOS and ECP. B-EOS similarly correlated positively with ECP. There was a negative correlation between ECP and forced expiratory volume in 1 sec (FEV1) (% predicted) as expected. At least one positive parameter of atopy was found in 95% of the patients. In 48% of the patients, all three parameters of atopy were found to be positive. Skin test reactivity and elevated IgE were found together in 62% of the cases. This study reveals a significant degree of allergy among patients with asthma in this environment. Skin testing was found to be the most effective measure of atopy in this environment, and correlates well with the other more sensitive newer tests.

Factors associated with the initiation of smoking by Kuwaiti males

PURPOSE

To estimate the age patterns in cumulative probability of smoking initiation among Kuwaiti adult males and to study the differentials in smoking initiation in relation to factors such as age-cohort, marital status, educational level, income, type of residence, and history of smoking among family members and friends.

METHODS

A stratified three stage cluster sampling design was implemented for the selection of the sample. A self-administered questionnaire was completed by 1798 Kuwaiti adult males working in different ministries.

RESULTS AND IMPLICATIONS

Of the 1798 respondents, 34.4% were classified as current smokers, 17.7% as former smokers and 47.9% as non-smokers. The highest probability of smoking initiation (among current and former smokers) was found for the age group 15-20 years, where almost 29% of the respondents initiated smoking. In the univariate analysis, marital status, education, income, type of residence, and history of smoking among family members and friends showed significant variation in the age-patterns of initiation. In the Cox proportional hazard regression model, education, type of residence, and history of smoking among family members and friends were found to be independently associated with the risk of initiation. The highest risk of initiation (Relative Risk (RR) = 1.85; 95% CI: 1.62-2.10) was found among those who had a history of smoking in family and friends. Individuals in the lowest education category (RR = 1.64; 95% CI: 1.32-2.04) and those residing in apartments (RR = 1.65; 95% CI: 1.43-1.92) were at a higher risk of initiation compared with those who had university education or those who resided in villas. The results of the study should prompt further efforts to develop tobacco control policies in Kuwait and the other Arabian Gulf countries to help establish norms for not initiating smoking through persistent messages to not start or to stop smoking. There is also a need to enhance awareness about the influence of smokers in family or friends on other people to initiate smoking.

Spot urine concentrations of type I collagen cross-linked N-telopeptides and deoxypyridinoline in psoriatic arthritis

The main objectives of this study were to investigate whether the spot urine concentrations of type I collagen cross-linked N-telopeptides (NTx) and deoxypyridinoline (Dpd) can be used to distinguish between active and suppressed disease in psoriatic arthritis (PsA) and to study the relationship between these markers of bone resorption and disease activity indices. Using enzyme-linked immunosorbent assays, concentrations of NTx and Dpd were estimated in spot urine samples from 25 patients with active disease, 10 patients with suppressed disease and 35 age- and sex-matched healthy control subjects. In patients with active disease, urine concentrations of NTx and Dpd were significantly elevated (p<0.001) compared with healthy controls and there were no significant differences (p>0.05) when compared with those with suppressed disease. In active disease, there was no significant positive correlation between urinary NTx and erythrocyte sedimentation rate (ESR) (r = 0.025, p>0.05) nor between Dpd and ESR (r = -0.208, p>0.05). In conclusion, NTx and Dpd concentrations in spot urine have no association with disease activity in patients with PsA.

Epidemiology of smoking among Kuwaiti adults: prevalence, characteristics, and attitudes

INTRODUCTION

In 1996 we conducted a cross-sectional survey to study the epidemiology of smoking among Kuwaiti adults.

METHODS

The 4000 participants were selected using a three-stage stratified cluster sampling design. Altogether 3859 participants (1798 males, 2061 females) returned a completed self-administered questionnaire.

RESULTS

The prevalence of smoking was 34.4% (95% confidence interval (CI) = 32.2-36.6) among men and 1.9% (95% CI = 1.3-2.5) among women. Among men, the highest prevalence (56.5%; 95% CI = 36.2-76.8) was observed in the youngest age group (< or = 20 years). Among women the highest prevalence was observed in one of the older age groups (46-50 years) (7.1%; 95% CI = 3.1-11.1). Multiple logistic regression analysis showed that the following factors were independently associated with smoking: lower levels of education (odds ratio (OR) 3.5; 95% CI = 1.5-8.4), lower employment grade (OR = 4.1; 2.5-6.7), and being a separated, divorced, or widowed woman (OR = 4.9; 95% CI = 2.0-11.8). The majority of smokers (68%) began smoking when younger than 20 years; significantly more men (70%) than women (33%) began smoking at these ages (P < 0.0001). On average, men began smoking at an earlier age (18 years vs 21 years; P < 0.001) and therefore had smoked for a longer period (15 years vs 12 years; P < 0.05); men also consumed a higher number of cigarettes each day (26 vs 17; P < 0.05). A large proportion of smokers were ignorant about the health consequences of passive smoking: about 77% of those with children reported that they smoked in the presence of their children. Almost half (47%) of all smokers stated that they wanted to stop smoking, and about 56% had attempted to quit. The biggest perceived barrier to quitting was uncertainty about "how to quit". A total of 338 respondents (8.8%; 95% CI = 5.8-11.9) were classified as former smokers. About half of the former smokers had quit between the ages of 20 and 29 years; the average age of quitting was 28 years. Former smokers were more likely to have smoked fewer cigarettes per day and to have smoked for significantly less time than current smokers.

DISCUSSION

Given the fact that free education is provided at all levels by the government, anti-tobacco education and awareness should be included as an integral part of the curriculum in schools and colleges.

The effect of corticosteroid therapy on blood eosinophils and eosinophilic cationic protein in patients with acute and chronic asthma

There is evidence that eosinophils are involved in inflammation in asthma, a correlation having been observed between blood eosinophil (B-EOS) count and pulmonary function. It has been suggested that eosinophils, and its product, eosinophil cationic protein (ECP), can serve as markers of disease activity. This paper examines this hypothesis. B-EOS count, serum ECP level, and peak expiratory flow (PEF) were estimated in two groups of asthmatics and controls at three visits in 4 weeks. The mean B-EOS count in acute and stable asthmatic groups was higher than in controls at presentation; the difference was statistically significant (p<0.02). Similarly, mean ECP was higher in the two groups than in controls, but with no statistically significant difference. The B-EOS count and serum ECP level within the groups fell between week 0 and week 4 because of treatment. There was positive correlation between ECP and PEF and also between B-EOS and ECP and PEF. The findings reveal that blood eosinophils reflect some degree of activity in asthmatic patients in the acute and chronic state.

Effect of glucose load on the transport kinetics of palmitic acid in the human placenta: an in vitro study

1. A paucity of data relating to free fatty acid (FFA) transport in the human placenta in non-steady state conditions prompted us to undertake the present study. 2. The transport kinetics of palmitic acid in non-steady state conditions have been investigated in vitro using human perfused placental lobules. The effects of varying glucose concentrations on maternal-foetal transport of the FFA were also investigated to mimic the hyperglycaemic states of human diabetic pregnancies. 3. National Cancer Tissue Culture medium diluted with Earle's buffered salt solution was used as the perfusate. [14C]-Palmitic acid, along with tritiated water as a reference, was injected as a bolus into the maternal arterial perfusate and perfusate samples were collected from the venous outflow for a period of 5 min. 4. The transport fraction (TF) of palmitic acid, expressed as percentage of the injected bolus, averaged 3.45 +/- 0.15% in five perfusions, representing 9.2 +/- 1.3% of the corresponding reference marker TF. Kinetic parameters, as well as TF indices of palmitic acid expressed in relation to the reference substance, did not differ significantly between perfusions with a physiological glucose load and those with hyperglycaemic concentrations of glucose of 27.8 and 55.6 mmol/L. 5. The present study shows that hyperglycaemia per se does not significantly alter palmitic acid transport kinetics in vitro in the human perfused placental lobule.

Serum eosinophil cationic protein as a predictor of disease activity in acute and chronic asthma

BACKGROUND

Eosinophils may contribute to airway hyper responsiveness in asthma through the effects of eosinophil derived granular proteins in the bronchial epithelium. Increased concentration of eosinophil cationic protein (ECP) has been reported in patients with acute and chronic asthma.

OBJECTIVE

To examine if ECP can serve as a marker of disease activity in acute and chronic asthma patients.

DESIGN

Prospective case control study.

PATIENTS

Sixteen non smoking asthmatics in exacerbation (group 1); twenty two in relatively stable state (group 2); and sixteen normal control subjects (group 3) were recruited into the study.

SETTING

Casuality and outpatients departments, Mubarak hospital, Kuwait between August 1997 and July 1998.

MAIN OUTCOME MEASURES

The mean serum ECP, blood eosinophil count and peak expiratory flow rate (PEFR).

RESULTS

There was a statistically significant difference between the groups in blood eosinophil count (p < 0.01) and in PEFR (p < 0.0001). At week four, the mean ECP and blood eosinophil count fell as a result of therapy in group 1. The difference in PEFR values between week 0 and 4 in group 1 reached statistical significance (p < 0.05). In group 2 patients, the mean serum ECP, blood eosinophil count and PFER values between week 0 and 4 did not show any significant difference. A correlation was observed between ECP and PEFR in group 1 (p < 0.05) and between ECP and eosinophil count in group 2 (p < 0.01).

CONCLUSION

Serum ECP has the potential to serve as a marker for predicting and monitoring the clinical course of asthma. Further studies are required to verify these baseline findings in our environment.

The predictive value of provisional clinical diagnosis in the evaluation of respiratory disorders

BACKGROUND

Many non-pulmonary physicians in hospital and family care practice base the diagnosis of pulmonary disorders on clinical impressions made from the history and physical examination. Experience has shown that relying on these parameters alone is not adequate, since this may result in missing a significant number of diseases, or in the unnecessary treatment of others. This study set out to compare the sensitivity, specificity and positive predictive value of the clinical assessment (provisional clinical diagnosis or PCD) with the combined clinical assessment and other investigations, including pulmonary function test (PFT).

PATIENTS AND METHODS

One thousand and fifteen (1015) patients referred for PFT to the pulmonary function laboratory of a teaching hospital were involved in the study. The referring physicians were asked to fill a specially prepared form giving details of the patientsâ history and clinical assessment. The PFT was performed using an Erich-Jager Master Lab.

RESULTS

Analysis of the final diagnosis revealed that only 51% of patients with a pre-evaluation diagnosis of asthma were actually confirmed to have asthma after further tests. Similar findings of 59% and 52% of patients with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis were observed, respectively. The positive predictive value of PCD for asthma and lung fibrosis was 64.1% and 61.9%, respectively, while that for COPD was 74.2%.

CONCLUSION

This study showed conclusively that the predictive value of provisional clinical diagnosis in the evaluation of pulmonary disorders is usually inadequate, and needs to be augmented with additional simple investigations such as PFT, in order to establish a more accurate diagnosis.

Age patterns of smoking initiation among Kuwait university male students

The present study is a detailed evaluation of age at smoking initiation among university male students in Kuwait based on a random sample of 664 students selected from all students during 1993. The Acturial Life Table analysis revealed that almost one tenth of the students initiated cigarette smoking between ages 16 and 17 with the rate of initiation increasing rapidly thereafter and reaching 30% by age 20 and almost 50% by the time they celebrate their 24th birthday. The most important environmental risk factor positively associated for smoking initiation was observed to be the history of smoking among siblings with a relative risk of 1.4. Compared to students of medicine and engineering, the students of other faculties revealed a higher risk in smoking initiation with an RR = 1.77 for sciences and commerce and 1.61 for other faculties (arts, law, education and Islamic studies). The analysis revealed a rising generation trend in cigarette smoking. There is a need for reduction of this trend among young adults in Kuwait and throughout other countries in the region.

Left atrial appendage function in mitral stenosis: is a group in sinus rhythm at risk of thromboembolism?

OBJECTIVE

To study the left atrial appendage (LAA) function and potential for embolization in severe mitral stenosis (MS).

BACKGROUND

Patients with MS and atrial fibrillation or in sinus rhythm develop systemic emboli. LAA function has not been well studied in sinus rhythm.

METHODS

Forty consecutive patients with MS (valve area < or =0.7 cm2/m2) were studied. LAA ejection fraction and peak emptying velocity were measured along with other data.

RESULTS

Patients were subgrouped according to LAA Doppler flow pattern. Group I (n=13) in sinus rhythm had biphasic high velocity > or =25 cm/s. Group II (n=13) in sinus rhythm had biphasic low velocity <25 cm/s. Group III (n=14) in atrial fibrillation had multiphasic irregular flow <25 cm/s or no definite flow. The LAA ejection fraction and peak emptying velocity were strikingly different in all groups. They were lower in group II when compared to group I. Group II had intermediate risk for thromboembolism compared to Group I and III as judged by systemic embolization, spontaneous echo contrast, thrombus in left atrium and LAA.

CONCLUSION

A subset of mitral stenosis in sinus rhythm at increased risk of embolization can be suspected by Doppler transesophageal echocardiographic LAA flow profile.

Assessment of D-glucose transport kinetics in the perfused human placenta: an in vitro study

BACKGROUND

There have been no reports to date on glucose transport kinetics and the effect of graded hyperglycemia in the human placenta in non-steady-state conditions.

METHODS

The transport kinetics of D-glucose in the human placenta was investigated in non-steady state conditions in vitro using perfusion of isolated placental lobules. National Cancer Tissue Culture (NCTC) 135 culture medium, diluted with Earle's buffered salt solution was used as the perfusate. 14C-Labeled D-glucose and water as reference were injected as a single bolus into the maternal arterial perfusate. Perfusate samples were collected and analyzed from the maternal and fetal venous outflows.

RESULTS

In four successful perfusions, differential transport rates of glucose in the maternal-fetal direction averaged 1.03, 1.02, 1.09, 1.04 and 1.03 times those of corresponding tritiated water transport rates for 10, 25, 50, 75 and 90% of efflux fractions, respectively. Glucose transport fraction, expressed as percentage of injected maternal dose averaged 84 +/- 3.1% of water transport fraction in the four perfusions. Glucose kinetic parameters expressed as area under the curve, elimination constant (Kel), clearance, time for maximum response, absorption rate and elimination rate averaged 0.25, 0.29, 3.96, 1.02, 0.25 and 0.18 times that of the corresponding tritiated water value, respectively. Neither the different kinetic parameters nor the transport fraction indices differed significantly when glucose concentrations in the same perfusions were raised successively from 5.56 to 27.80 and then to 55.6 mmol/L.

CONCLUSIONS

We speculate that within physiological limits, hyperglycemia per se plays no significant part in altering glucose transport kinetics across the human placenta in the maternal-fetal direction.

Rheumatic manifestations and immunological abnormalities in patients with chronic hepatitis C. A study in the Middle East

Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems. We compared the prevalence of extrahepatic clinical manifestations and immunological disorders in 40 patients with chronic hepatitis C and in 42 carefully matched healthy controls. Polyarthralgia or polyarthritis was the most common rheumatic manifestation (35%) in the cases, followed by cutaneous vasculitis (15%). Glomerulonephritis and xerophthalmia were uncommon, and none of the cases had systemic vasculitis. Immunological abnormalities included serum rheumatoid factor (47.5%), cryoglobulins (30%), and one or more antitissue antibodies (37.5%). The prevalences of polyarthralgia, cutaneous vasculitis, rheumatoid factor, cryoglobulinemia, and anti-tissue antibodies were significantly higher in the hepatitis C group than in the control group. Our data suggest that patients in the Middle East who present with features of rheumatic or autoimmune diseases should be screened for hepatitis C.

Reference intervals for some serum biochemical markers of bone metabolism in Kuwait

Using the Hitachi 717 Selective Multichannel analyser, we established reference intervals for serum albumin (37-9 g/l); measured serum calcium (2.14-2.54 mmol/l); corrected serum calcium (2.25-2.60 mmol/l); serum phosphate (0.74-1.60 mmol/l); and alkaline phosphatase (47.0-289.6 U/l) in the Kuwaiti population. The mean concentrations of calcium and phosphate decreased with increasing age in both sexes except for a sudden increase in women at about menopause. Although there was a skewed distribution of alkaline phosphatase in both sexes there was a significant increase in enzyme activity in women after the age of 50 years. Using corrected serum calcium we found that 15% of women in the reproductive age group in Kuwait had hypocalcaemia.

Comparison of two immunization schedules with recombinant hepatitis B vaccine and natural immunity acquired by hepatitis B infection in dialysis patients

In a prospective study over a 2-year period we compared two practical dosage schedules to vaccinate dialysis patients against hepatitis B virus (HBV) infection using a yeast-derived recombinant hepatitis B vaccine (Engerix-B). In addition, the natural history of this acquired immunity was compared with that developed through HBV infection in dialysis patients and healthy subjects. Patients on dialysis treatment (haemo or peritoneal) who were tested to be negative for hepatitis B surface antigen (HBsAg), anti-HBs and anti-HB core were allocated at random to receive HB vaccine according to one of the two schedules. The two groups receiving the vaccine were matched for age, sex, mean duration on dialysis and the form of dialysis treatment received. The group of patients who received a four-dose schedule (at 0, 1, 2 and 6 months) of 40 micrograms of HB vaccine each time (group 2) achieved a seroconversion rate of 79% 1 month after the last dose (at month 7) compared with a seroconversion rate of 55% in those who received three doses (at 0, 1 and 6 months) of 40 micrograms each (group 1). Healthy controls who received half the amount of vaccine on a three-dose schedule (group 3) attained 100% seroconversion (p < 0.05). When retested at 24 months, 30% of seroconverters in group 1 had lost their protective immunity, compared with only 6% in group 2 and 15% in group 3. The magnitude of antibody response (total and anti-(a)-specific) was assessed in the vaccinees at 24 months and compared with that of two other control groups, dialysis patients (group 4) and healthy volunteers (group 5), who had acquired immunity from HBV infection. In general, the total and anti-(a)-specific HBs titres in the dialysis patients (groups 1, 2 and 4) were lower than in their corresponding healthy controls (groups 3 and 5), irrespective of whether the protective immunity was acquired by vaccination or HBV infection. However, the anti-HBs titres in dialysis patients who received four doses were significantly higher than in those who received only three doses (p < 0.05), which indicated a better protective immunity in favour of the former regime. The magnitude of antibody response in the vaccinees of groups 2 and 3 compared well with their respective controls, groups 4 and 5, who had acquired their immunity through HBV infection. This implied that the yeast-derived vaccine was sufficiently immunogenic and provided lasting protection in patients and healthy subjects vaccinated by an appropriate dosage schedule.(ABSTRACT TRUNCATED AT 400 WORDS)

End-stage renal disease and renal replacement therapy in Kuwait--epidemiological profile over the past 4 1/2 years

Data on end-stage renal disease (ESRD) patients in Kuwait were collected retrospectively and prospectively starting in mid-1988. The study period covered 4 1/2 years from 1 January 1986 to 30 June 1990. Epidemiological characteristics of ESRD patients and their disposal by dialysis and transplantation were analysed and compared with previous reports from Kuwait, neighbouring countries, Europe, and USA. A total of 647 patients received renal replacement therapy (RRT) in Kuwait during the study period. This gave an incidence rate of 72 patients per year per million of population. The prevalence rate for patients on maintenance dialysis was 80.6 per million population in mid-1988. Nearly one-fifth of total patients (19.6%) were older than 60 years of age and one-third (30.8%) were identified as 'high risk' category. As for Kuwaiti nationals alone on RRT 29.7% were above 60 years of age and 44.2% were high-risk patients. We have noticed a steady decline in the number of patients who accepted continuous ambulatory peritonial dialysis (CAPD) for dialytic support. Chronic tubulointerstitial disease resulting from atrophic pyelonephritis was the leading cause of ESRD amongst both Kuwaiti nationals and expatriates. Though diabetic nephropathy was only the third leading cause of ESRD (14.7%) in the total population, it was more frequent (21.2%) among Kuwaitis. The gross mortality rate on dialysis was 14.7%. The major causes of death were related to cardiovascular diseases (60%) and sepsis (24.2%).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute renal failure in Kuwait--a prospective study

This prospective study was conducted over a period of 18 months (February 1989 to July 1990) in the State of Kuwait. It covered a population of 1,024,211 and eight multidisciplinary hospitals with an in-patient admission of 118,079 per year. Two hundred and twenty-six adult patients with acute renal failure (ARF) were seen and followed up by nephrologists. This made the calculated annual incidence of ARF 14.7 per 100,000 population, nearly five times that reported by the EDTA registry (Biesenbach et al. 1991). Drugs, sepsis and volume depletion were the most frequent causes, with sepsis resulting in 36% cause specific mortality compared to zero mortality with the other two. The overall mortality rate was only 14% which clearly indicated a markedly improved prognosis in cases of ARF. The prognosis in ARF depended on two major factors, viz. the type of aetiological insult and the presence of predisposing associated medical illnesses. Multiple insults, though common, do not affect the mortality rate. Secondary sepsis or gastrointestinal bleeding as a cause of death in ARF was rarely seen in our study. Those who required dialytic support for renal failure had a 45% patient mortality rate in general. Over 40% of our patients were 60 years or older compared with only 3.5% in the local population. This indicated old age as a major risk factor in the development of ARF. The overall mortality in the elderly did not differ from that in the young, but sepsis in the elderly carried a mortality rate of 60% compared to only 14.8% in the younger age group.

Analysis of underlying and multiple-cause mortality data

"A variety of life table models were used for the analysis of the (1984-86) Kuwaiti cause-specific mortality data. These models comprised total mortality, multiple-decrement, cause-elimination, cause-delay and disease dependency. The models were illustrated by application to a set of four chronic diseases: hypertensive, ischaemic heart, cerebrovascular and diabetes mellitus. The life table methods quantify the relative weights of different diseases as hazards to mortality after adjustment for other causes. They can also evaluate the extent of dependency between underlying cause of death and other causes mentioned on [the] death certificate using an extended underlying-cause model." (SUMMARY IN FRE AND ITA)

Penicillamine in systemic sclerosis: a reappraisal

In a 36-month prospective trial 21 patients with systemic sclerosis (diffuse systemic sclerosis 16 patients and 5 subjects with limited cutaneous subtype) were treated with D-penicillamine. In all patients with diffuse systemic sclerosis there was objective improvement. The degree and extent of skin involvement decreased significantly (p less than 0.001), whereas no objective improvement was noted in patients with limited cutaneous subtype. Further, no systemic progression of the disease was observed during the study period. Our results suggest that a prolonged treatment with D-penicillamine in small doses is not only beneficial and effective but also free of side-effects, if used at an earlier stage.

Association between HLA-DR antigens and rheumatoid arthritis in Arabs

Eighty five Arab patients with classical and definite rheumatoid arthritis were typed to determine the prevalence of HLA A, B, C, and DR antigens. A significant increase in the prevalence of HLA-A10, B8, B21, and DR3 was found in comparison with a control population matched for age and sex. HLA-DR5 was significantly decreased in the patient group. The classical association of HLA-DR4 with rheumatoid arthritis could not be confirmed in the Arab patients resident in Kuwait, supporting reported observations in different ethnic groups of associations with HLA antigens other than HLA-DR4 and indicating a heterogeneous genetic susceptibility to rheumatoid arthritis.

Reliability of death certificate diagnoses

Consistency between death certificates and clinical records from 5 general hospitals in Kuwait was studied for 470 deaths with the following underlying or associated causes: hypertensive (HYP), ischaemic heart diseases (IHD), cerebrovascular diseases (CVD) and diabetes mellitus (DM). Direct causes were not considered since they are of little interest analytically. Only deaths with definite or most probable ascertainment were included. One cardiologist, who was provided with the WHO criteria and relevant documents on death certification, independently reviewed the records. To test the reviewer's bias and the reliability of his judgement, an adjudication process was effected by having one senior cardiologist re-review a random subsample of 140 records. The two reviewers showed good agreement. Specific diagnoses criteria for deciding the underlying cause of death in multiple morbid conditions by the reviewer were followed. Due to possible reviewer bias, we aimed at measuring the difference between initial certifiers and the reviewer rather than measuring the diagnostic accuracy of initial certifiers in reference to the reviewer. The agreement index kappa showed poor agreement between original and revised certificates. The original certificates under-estimated CVD as an underlying cause of death by 69.2%, DM by 60%, IHD by 33.5% and HYP by 31.8% in our sample. Associated causes were also consistently under-estimated by initial certifiers as compared with the reviewer. This bias calls for basing mortality statistics in Kuwait on hospital death committees' reports rather than on initial certifier death certificates, use of multiple-causes of death instead of one underlying cause and adequate training of the medical profession on the value and process of death certification.

Histocompatibility antigens (A, B, C, and DR) in Arabs with rheumatoid arthritis

Eighty-five Arab patients in Kuwait with classical and definite rheumatoid arthritis were typed to examine the frequency of HLA-A, B, C, and DR antigens. The results showed a significant increase in the frequency of HLA-A10, B8, B21, and DR3 antigens when compared to an age- and sex-matched control population. HLA-DR3 was present in 34 per cent of the patients compared with 2 per cent of the controls (p less than 0.001). The association of RA in the Arab population with HLA-DR3 rather than HLA-DR4 or HLA-DR1 as reported in other ethnic groups emphasizes further the complexity of the genetics of RA.

Scleroedema diabeticorum: a minor but often unrecognized complication of diabetes mellitus

The association of specific dermatological complications with diabetes mellitus is well recognized. Of 100 hospital-based patients with diabetes mellitus (age 48 years +/- 2SE), 14% had scleroedema diabeticorum. The affected subjects had a higher prevalence of retinopathy (p less than 0.001) and albuminuria (p less than 0.025). The duration of scleroedema correlated with the duration of diabetes (p less than 0.005). These findings highlight the relatively common occurrence of this skin condition which often goes unrecognized in people with diabetes.

Brucellosis in Kuwait: a clinico-epidemiological study

The 160,000 population in Adan area, Kuwait, is served by Adan Regional Hospital. During the 6 months period mid-December, 1983 to mid-June, 1984, 68 cases of brucellosis were admitted to the hospital, an annual incidence of 85/100,000 population. Of these, 84% were Kuwaitis and Bedouins. The mean age was 32 years, range 12-70 years. The male female ratio was 1.4:1. 55 patients gave histories of consuming raw milk and 4 had close contact with animals. The highest incidence of the disease coincided with the animal delivery season and the desert camping period of Kuwaiti families. It appears that air transmission of contaminated soil is one of the main routes of Brucella infections in Kuwait.

Effects of acute doses of ethanol on pre- and postnatal development in the mouse

Investigators on fetal alcohol syndrome (FAS) both clinical and experimental, have generally concentrated attention on chronic alcoholism. In an attempt to elucidate the effects of binge drinking on pre- and postnatal development, single doses of 0.01, 0.02 and 0.03 ml/g body weight of alcohol solutions (25% v/v of ethanol in saline) were administered intraperitoneally to groups of mice on days 8-12 of gestation. Controls were untreated or starved for 6 h. Fetuses collected on day 18 revealed retardation, fetal mortality and craniofacial and digital malformations. While growth retardation and fetal mortality were dose-dependent, malformations were stage-dependent. The 0.01-ml group exhibited only postaxial polydactyly of the forepaw. The reduction in fetal weight of 0.03-ml groups corresponded well with that of umbilical cord length. Following administration of single doses of 0.01 ml/g of ethanol solution on days 8-12, groups of mice were allowed to deliver. Controls were untreated or pairfed and pair watered. Pups were reared by the respective mothers and their survival and growth were observed till postconception day 71 and thereafter brother/sister matings were carried out. At least one pup in each litter remained extremely stunted and failed to reproduce. No significant differences in mortality, growth rates and reproductive capacity of the rest of the pups were observed. It is concluded that single but heavy doses of ethanol during organogenesis leads to a situation reminiscent of human FAS.

Critical performance analysis of rotating resident doctors in Iraq

The present study was undertaken to evaluate the competence of rotating residents in handling clinical problems, falling under the purview of the major clinical disciplines, which they come across during their routine work. Three hundred and one rotating residents (55% of the total) who graduated in June 1981 from the four universities of Iraq, namely, Mustansiryia, Basrah, Mosul and Baghdad, and were currently undergoing their residency posting in the various hospitals of Iraq were selected for the study. Two approaches were used to assess the level of competence: first, on the basis of the resident's responses to fifty simulated patient-management problems and, secondly, their critical performance in patient care adjudged by their respective supervisors. A minimum passing level (MPL) was fixed for patient management problems (PMP). The score for the consultant's observations could range from -70 to +100 to represent the very poor and the very good performance. Only 2% of the residents were found to have reached the minimum pass level of competence taking their overall performance in the various disciplines. No significant variation in performance was observed in relation to the university of graduation. None of the residents could reach the MPL in the case of obstetrics and gynaecology. In the case of medicine and medical emergency the findings were almost similar. The residents put up a much better performance in orthopaedics and paediatrics (45.0% and 27.5% respectively). According to the supervisors' assessment nearly two-thirds of the residents secured at least 50% of the maximum score. The study underscores the need to redefine our educational objectives specifically, with aim of developing competences at a defined level in the learner befitting the needs of the health system through a competency-based curriculum.

Demographic and health characteristics of a rural Iraqi population

The population of 2 representative villages in Abu-al-Khasib field practice area of the College of Medicine, Basrah in Southern Iraq was surveyed during 1979 for baseline information relating to demographic and health characteristics. The total population covered was 3399. Women of child bearing age together with children under 15 years of age accounted for 68% of the population. The birth rate was 49 and death rate, 14.5 per 1000. Nearly 10% of the morbidity was evident among women of child bearing age. The enquiry revealed a general awareness concerning the existing health care facilities available in the area. Local health centres were utilised mainly for treatment of childhood illnesses. Only 12% of the mothers used them for care during pregnancy.