Determinants of severity of menopausal symptoms among Saudi women in Riyadh city.

OBJECTIVE: To determine the relationship between sociodemographic, reproductive and lifestyle factors and the severity of menopausal symptoms among Saudi women attending a university hospital in Riyadh city. METHODS: A cross-sectional survey was carried out during 2010 in Riyadh city. Women aged > 40 years attending or accompanying their relatives in outpatient clinics in King Khalid University Hospital were invited to participate in the study. The English version of the Menopause Rating Scale (MRS) was used to assess the severity of menopausal symptoms after translation and validation on a sample of 30 women. RESULTS: A total of 490 women were included. Severe urogenital symptoms were more common among housewives compared to working women (odds ratio (OR) 2.27, 95% confidence interval (CI) 1.12-4.68) and women living in apartments or small houses compared to women living in villas (OR 1.70, 95% CI 1.90-2.64). Nulliparous women had more severe somatic symptoms compared to those who had been pregnant (OR 2.83, 95% CI 1.10-7.69). Women who exercised regularly were less likely to experience severe somatic and urogenital symptoms (OR 0.57, 95% CI 0.37-0.86; OR 0.65, 95% CI 0.44-0.98, respectively). Obese women experienced more severe psychosomatic symptoms compared to those of normal body mass index (OR 2.01, 95% CI 0.96-4.93). CONCLUSION: Women who are housewives, living in apartments, not exercising regularly and obese are more likely to suffer from severe symptoms of menopause.

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients.

BACKGROUND: Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months. METHODS: Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction. RESULTS: The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring. CONCLUSION: FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Indoor carbon monoxide and PM2.5 concentrations by cooking fuels in Pakistan.

UNLABELLED: In developing countries biomass combustion is a frequently used source of domestic energy and may cause indoor air pollution. Carbon monoxide (CO)and particulate matter with an aerodynamic diameter of 2.5 lm or less (PM2.5)were measured in kitchens using wood or natural gas (NG) in a semi-rural community in Pakistan. Daytime CO and PM2.5 levels were measured for eight continuous hours in 51 wood and 44 NG users from December 2005 to April 2006. The laser photometer PM2.5 (Dustrak, TSI) was calibrated for field conditions and PM2.5 measurements were reduced by a factor of 2.77. CO was measured by an electrochemical monitor (Model T15v, Langan). The arithmetic mean for daytime CO concentration was 29.4 ppm in wood users; significantly higher than 7.5 ppm in NG users (P < 0.001). The arithmetic mean for daytime PM2.5 concentrations was 2.74 mg/m3 in wood users; significantly higher than 0.38 mg/m3 in NG users (P < 0.001). Higher peak levels of CO and PM2.5 were also observed in wood users. Time spent in the kitchen during fuel burning was significantly related to increasing CO and PM2.5 concentrations in wood users.These findings suggest that cooking with wood fuel may lead to hazardous concentrations of CO and PM2.5. PRACTICAL IMPLICATIONS: Biomass combustion is frequently used in developing countries for cooking. This study showed very high level of air pollution in kitchens using wood as the cooking fuel. Many people, especially women and children, are vulnerable to exposure to very high levels of air pollutants as they spend time in the kitchen during cooking hours.

Maternal characteristics in relation to income in a semi-rural community in Pakistan.

Women's health and socioeconomic status is fundamental to development. The aim of this study was to evaluate the relationship of monthly household income with demographic, nutritional and social characteristics in women living in a semi-rural location near Karachi. Thus 1111 mothers with at least 1 child under 5 years of age were interviewed. Self-reported monthly income was positively associated with gravidity, mid upper-arm circumference, cooking frequency per day and self and spousal literacy; it was negatively associated with number of occupants per room, wood used as cooking fuel, and spouse in a skilled occupation. Income is dependent on non-income factors such as literacy, and the nutritional and reproductive health status of women.

Maternal characteristics in relation to income in a semi-rural community in Pakistan

Women's health and socioeconomic status is fundamental to development. The aim of this study was to evaluate the relationship of monthly household income with demographic, nutritional and social characteristics in women living in a semi-rural location near Karachi. Thus 1111 mothers with at least 1 child under 5 years of age were interviewed. Self-reported monthly income was positively associated with gravidity, mid upper-arm circumference, cooking frequency per day and self and spousal literacy; it was negatively associated with number of occupants per room, wood used as cooking fuel, and spouse in a skilled occupation. Income is dependent on non-income factors such as literacy, and the nutritional and reproductive health status of women

Melanoma patients evaluated by four different positron emission tomography reconstruction techniques.

One hundred and nineteen patients with malignant melanoma were studied using 2-[ F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET). The images were reconstructed using ordered subset expectation maximization with and without attenuation correction and filtered backprojection with and without attenuation correction. The most probable draining lymph node chains were surgically explored and the tumour volume was quantified at histology. The four different reconstructions of the PET images were retrospectively graded on a five-point scale by two blind readers and compared with the tumour volume. The readers agreed within +/-1 grade 93% (529/568) of the time. Comparing the areas under the receiver operating characteristic (ROC) curves gave 0.698, 0.668, 0.694 and 0.684 for the four reconstruction techniques. The lowest value comparing any pair of the four reconstruction techniques was P=0.371. Thus, none of the reconstruction techniques gave significantly better results than any of the others. The sensitivity of detection was 85% for tumour volumes of 113 m or more (about 6 mm in diameter), but only 4% for tumours less than this size. It can be concluded that the use of attenuation correction gives aesthetically more pleasing images, but the sensitivity and specificity are not significantly improved.

Hormone replacement therapy menopause with a better future--a survey of views on hormone replacement therapy (HRT).

OBJECTIVE: To assess the views and prescribing practices of doctors regarding hormone replacement therapy (HRT). METHODS: In April 1999, 103 doctors from a teaching hospital participated in a survey. Using a self-administered questionnaire, subjects were contacted at the departments of Internal Medicine, Family Medicine, Obstetrics and Gynaecology, and Orthopaedics. RESULTS: Seventy-two percent were below 40 years of age and 67% of the respondents were male. Most doctors believed that HRT decreases the risk of subsequent osteoporosis (97%), ischaemic heart disease (77%) and depression associated with menopause (64%). Doctors generally considered menopausal symptoms (90%), premature menopause (87%), surgical menopause (85%) and osteoporotic fracture (77%) as clear indications for hormone replacement therapy. Absolute contraindications to the therapy were stated as recent breast cancer (82%) and recent endometrial cancer (84%). Among the specialities covered, there were differing views on proposed duration of HRT. It was generally believed that a pelvic examination, cervical smear and mammography were pre-requisites when initiating and monitoring HRT. Majority (69%) felt that HRT should be offered to all menopausal women, assuming no contraindications and most (73%) did discuss HRT with their patients. However, less than 10% of the menopausal patients under their care were using HRT. Those doctors not in favor of universal offering of HRT (31%) considered unreliable patient follow up to be the main reason. Females were two times more likely to discuss HRT with their patients (p = .08). Doctors who discussed HRT with their patients were four times more likely to consider HRT for themselves or their spouses (p = .13). Gynecologists were eight times more likely to prescribe HRT than non-gynecologists (p = .001). CONCLUSION: Doctors are positively disposed to the universal offering, and use of HRT. Further studies are needed to understand a possible gap between perceived and actual prescribing practice.

The value of good medical student teaching: increasing the number of radiology residency applicants.

RATIONALE AND OBJECTIVES: The authors attempted to define the value of good medical student teaching to the profession of radiology by examining the effect of radiology course improvements on the number of 4th-year students applying to radiology residencies. MATERIALS AND METHODS: Course evaluation and residency application data were obtained from six consecutive classes of 4th-year medical students at the study institution, and these data were compared with national data. RESULTS: Between 1995 and 2000, the number of 4th-year U.S. medical students applying to radiology increased 1.6 times. At the study institution, that number increased 4.5 times, a statistically significant difference (P = .020, chi2 test). Student survey data indicate that this increase reflects a general increase in the quality of radiology teaching in the study institution and specific changes in a required 2nd-year medical school course. CONCLUSION: These results strongly suggest that good medical student teaching pays important dividends, not only to the departments that provide it but also to the profession of radiology as a whole. Exposing students to good radiology teaching early in their medical school careers is especially important. Radiology departments that provide outstanding medical student education should be studied to help develop a model of educational best practices.

Paan without tobacco: an independent risk factor for oral cancer.

Oral cancer is the second most common cancer in women and the third most common in men in Pakistan. Tobacco is smoked and chewed extensively in Pakistan. Paan is a quid of piper betel leaf that contains areca nut, lime, condiment, sweeteners, and sometimes tobacco, which is also used extensively. We did this study to clarify the independent association of paan and oral cancer. Between July 1996 and March 1998, we recruited biopsy-proven, primary cases of oral squamous-cell carcinoma, from 3 tertiary teaching centers in Karachi, Pakistan, and controls pair-matched for age, gender, hospital and time of occurrence, excluding persons with a past or present history of any malignancy. There were 79 cases and 149 controls. Approximately 68% of the cases were men, 49 years old on average, the youngest being 22 years old and the eldest 80. People with oral submucous fibrosis were 19.1 times more likely to develop oral cancer than those without it, after adjusting for other risk factors. People using paan without tobacco were 9.9 times, those using paan with tobacco 8.4 times, more likely to develop oral cancer as compared with non-users, after adjustment for other covariates. This study identifies an independent effect of paan without tobacco in the causation of oral cancer. Its findings may be of significance in South Asian communities where paan is used, and among health-care providers who treat persons from South Asia.

Clinical applications of technetium Tc 99m hexamethyl propylene amine oxime leukocyte scan in children with inflammatory bowel disease.

BACKGROUND: Labeled leukocyte imaging is a helpful diagnostic tool in the detection of inflammation and sepsis. The technetium Tc 99m hexamethyl propylene amine oxime (99mTc HMPAO)-labeled leukocyte scan has been found to be more sensitive than the Indium-111 labeled leukocyte scan in detecting inflammatory bowel disease, with reported sensitivities of 95% to 100%. Experience with the 99mTc HMPAO-labeled leukocyte scan was examined and its clinical applications evaluated in the immediate treatment of patients with inflammatory bowel disease. METHODS: A retrospective chart review was undertaken that included pediatric patients who underwent 99mTc HMPAO-labeled leukocyte scan at the James Whitcomb Riley Hospital for Children. The disease activity of patients with inflammatory bowel disease was assessed. The leukocyte scan was performed according to the manufacturer's specifications, and images were obtained 30 minutes and 2 hours after administration of the radiopharmaceutical. RESULTS: During the period of July 1996 through November 1997, 41 scans were performed in 35 patients. Twenty-nine patients had histologically proven inflammatory bowel disease: 24 with Crohn's disease, 4 with ulcerative colitis, and 1 with indeterminate colitis. Active inflammatory bowel disease was suspected in 24 patients when the leukocyte scan was performed. Twenty of the 24 patients (83% sensitivity) had abnormal findings in leukocyte scans that prompted more aggressive management in 15 (75%). Six of the 15 who were receiving maximum medical therapy underwent surgical resection of severely affected bowel segments, and medical treatment was intensified in the other 9. The remaining 5 patients were receiving optimal medical therapy, instituted at their recent visit, and did not require further medication adjustments. Four of the 24 patients with active inflammatory bowel disease had normal leukocyte scans (17% false-negative rate), 3 of whom were receiving corticosteroid therapy at the time the scans were performed. All of the 11 patients in whom inflammatory bowel disease was in remission and 6 patients who did not have inflammatory bowel disease had normal findings in leukocyte scans (100% specificity). CONCLUSIONS: Although a tissue diagnosis is still recommended, obtained during upper and lower gastrointestinal endoscopic examinations, and contrast radiography of the small bowel for the initial work-up of patients with suspected inflammatory bowel disease, the 99mTc HMPAO-labeled leukocyte scan is a safe and useful diagnostic adjunct for subsequent evaluation of patients known to have inflammatory bowel disease. The results of 99mTc HMPAO-labeled leukocyte scans directly influenced treatment of 75% of the study patients with active inflammatory bowel disease, which included the decision to refer patients for surgical intervention.

A short echo 1H spectroscopy and volumetric MRI study of the corpus striatum in patients with obsessive-compulsive disorder and comparison subjects.

OBJECTIVE: It is likely that the corpus striatum is involved in obsessive-compulsive disorder (OCD). Prior studies have inconsistently found alterations in caudate volumes in patients with OCD. This study was undertaken in the hope that N-acetylaspartate and volumetric measures together would elucidate the presence and nature of corpus striatum volumetric abnormalities in OCD. METHOD: Thirteen patients meeting the DSM-IV criteria for OCD, who had been medication free for a minimum of 6 weeks, and 13 psychiatrically normal matched comparison subjects participated in the study. Short echo 1H magnetic resonance spectroscopy (1H-MRS) was used to measure levels of N-acetylaspartate and several other cerebral metabolites from a 4.5-cm3 volume in the left corpus striatum of all 26 subjects. Metabolite levels were estimated by fitting the time domain spectroscopy data with a noninteractive computer program. Volumes of the left and right head of the caudate nucleus in each subject were determined by semiautomatic segmentation of the volumetric images. RESULTS: N-Acetylaspartate levels from the left corpus striatum were significantly lower in the patients with OCD than in the comparison subjects. There were no differences in either left or right caudate volume between the two groups. CONCLUSIONS: Despite the lack of differences in caudate volumes between the OCD patients and the comparison subjects, the lower level of N-acetylaspartate in the left corpus striatum of the patients suggests reduced neuronal density in this region. Inconsistent volumetric findings among prior studies may reflect a poorer sensitivity of magnetic resonance imaging morphometry for detecting neuronal loss compared with 1H-MRS measurement of N-acetylaspartate.

High rates of discitis following surgery for prolapsed intervertebral discs at a hospital in Pakistan.

OBJECTIVES: To confirm the presence of an outbreak of postoperative infections following laminectomy and to determine the infection rate after interventions were instituted. DESIGN: Retrospective cohort study. Medical records were reviewed, personnel interviewed, and premises examined. SETTING: Surgical unit of hospital A in Pakistan. SUBJECTS: Patients who had surgical laminectomy between January 1993 and July 1994. INTERVENTION: Instructive program for nursing and medical staff in December 1993. RESULTS: From January to December 1993, 6 (15%) of 41 laminectomy patients developed postoperative discitis. The risk of discitis varied significantly by surgeon (P = .016); patients who had one particular surgeon, surgeon A, were nine times more likely to develop postoperative infections than patients who did not have surgeon A. Patients were not consistently cleaned or shaved before coming to the operating room, and personnel moved back and forth between the operation theater and other parts of the hospital without changing their gowns or slippers. After the instructional intervention, between January and July 1994, 2 (6%) of 31 laminectomy patients developed postoperative discitis, a rate not significantly lower than in the preceding 12 months (P = .45). Overall, from January 1993 through July 1994, female patients were more likely to develop discitis than males (31% vs 7%; relative risk, 4.4; 95% confidence interval, 1.3-15.6; P < .032). CONCLUSION: Endemic conditions require that laminectomy at hospital A be limited to those situations where the benefits of the surgery exceed the considerable risk of postoperative discitis.

Contamination of the pleural surfaces in childhood sarcoma. Use of colloidal P-32 to reduce radiation dose to the whole lung.

Children with pulmonary sarcomas who have diffuse contamination of the pleural cavity present a difficult management problem for the radiation oncologist. Doses required to control even microscopic disease exceed lung tolerance. We report on the use of intracavity colloid P-32 in an attempt to treat the pleural surface and spare normal lung parenchyma and tissues of the chest wall. Three children--18 months, 12 years, and 3 years of age--had spillage of pulmonary sarcomas into the chest cavity. All children were treated with systemic chemotherapy. Initially, 0.5 mCi of technetium sulfur colloid (99mTc-sulfur colloid) was instilled into the pleural space to ascertain even distribution of isotope. This was then followed by installation of 5.0 mCi of colloidal P-32. Uniform distribution was then confirmed by bremsstrahlung scanning. All three patients are in complete remission 3.5 years, 3 years, and 1 year after treatment, respectively. The major toxicity was asymptomatic pleural thickening, which could be confused with disease. This was confirmed histologically to be fibrous in the first patient. The process diminished or stabilized with time in all 3 patients over the period of observation. In this small series, intrapleural colloidal P-32 appeared to be safe and well tolerated and would be expected to be less toxic than wide-field external beam in the treatment of spilled pulmonary sarcomas.

Imaging modalities in pediatric oncology.

Many imaging modalities are available for the diagnosis, follow-up, and sometimes treatment of pediatric oncology diseases. The advantages and disadvantages, indications and contraindications, techniques, and patient preparations of the most commonly used modalities are discussed in this article. The role of sedation and the most widely used drugs are also discussed.

Visual presentation of the staging of pediatric solid tumors.

Staging systems are used in staging most pediatric solid tumors outside the central nervous system. Common solid, nonneurologic pediatric tumors include liver tumors, Hodgkin disease, non-Hodgkin lymphoma, Wilms tumor, rhabdomyosarcoma, neuroblastoma, Ewing sarcoma, and osteosarcoma. Traditional staging of pediatric tumors depends on the anatomic distribution of the malignant disease. Almost all staging systems are based on the spread of the local primary tumor, metastasis to regional lymph nodes, and distant blood-borne metastatic spread. There is some variability as to how tumor spread is assessed. Such assessment may be performed before or after surgery. There are many potential problems with tumor staging systems. The systems vary in complexity and clinical usefulness, and there is some variation in the criteria used in the different systems. It is important for radiologists to have a sound working knowledge of staging systems to facilitate accurate staging. Imaging is an important aspect of every staging system.

Quantification of intrahepatic portosystemic shunting after placement of a transjugular intrahepatic portosystemic shunt.

PURPOSE: To quantify portosystemic shunting and hepatic portal perfusion after placement of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: Technetium-99m macroaggregated albumin (MAA) was injected directly into the portal veins of nine asymptomatic patients 3 months after TIPS placement. Portosystemic shunting was quantified by comparing counts in the lungs with those in the liver. One cirrhotic patient and one healthy patient who received portal MAA injections were used as controls. RESULTS: No portosystemic shunting was found in the healthy patient. In the cirrhotic control patient, 77% of the injected activity was in the lungs. Patients with portosystemic shunts had even more activity in the lungs. Even stenotic shunts diverted greater than 80% of portal blood flow systemically. Flow through the TIPS ranged from 84% to 100% (average, 93%); these fractions of flow correlated inversely with portosystemic pressure gradients. CONCLUSION: Cirrhotic livers may divert much of the portal blood systemically before TIPS placement. Afterward, this proportion rises, and most portal flow is diverted into the pulmonary circulation.

Hürthle cell carcinoma in an autonomous thyroid nodule in an adolescent.

A 16-year-old girl presented with a palpable thyroid nodule which was found to be functioning autonomously by radioiodine (123I) scintigraphy. After needle biopsy proved non-diagnostic, surgical excision showed the nodule to be Hürthle cell carcinoma. Functional thyroid nodules are rarely malignant, thyroid carcinoma is rare in childhood, and Hürthle cell carcinoma is a rare thyroid neoplasm, so the presence of these three rare conditions in one patient makes it a very unusual case.

Osteomyelitis and pyogenic infection of the sacroiliac joint. MRI findings and review.

Acute pyogenic sacroiliac joint infection and osteomyelitis of adjacent bones often present with severe, poorly localized lower back, pelvic or hip pain. Five cases of sacroiliac joint infection or sacroiliac bone osteomyelitis were evaluated by MRI. MRI may be a helpful diagnostic tool to evaluate early changes of infection in the sacroiliac area. It is very sensitive for detecting bone marrow abnormalities; however, it is non-specific and can not accurately differentiate osteomyelitis from sacroiliitis.

Prospective study of magnetic resonance imaging and SPECT bone scans in renal allograft recipients: evidence for a self-limited subclinical abnormality of the hip.

We recently reported that typical abnormalities of avascular necrosis (AVN) in magnetic resonance images (MRI) of the hips of asymptomatic renal transplant recipients whose plain radiographs are normal may improve spontaneously and even disappear completely. We present the results of serial bone scans, most of which were performed with single-photon emission computed tomography obtained over periods as long as 24 mo after transplantation in 72 of these patients. Three paired imaging studies (i.e., MR and bone scan performed within 30 days of each other) were available for each of these patients. In three patients, both the MR images and the bone scans showed changes consistent with bilateral AVN within 4 mo after transplantation. All three patients developed hip pain which was bilateral in two and unilateral in one. Two patients (three hips) required surgical intervention at which time AVN was found on pathologic examination of all three hips. None of the remaining 69 patients developed hip pain during the study. However, in nine patients whose MR studies were consistently normal, at least one bone scan was abnormal (13 hips). The presence of AVN was pathologically confirmed in each of the hips subjected to surgery. Where the imaging findings were identical to those in the asymptomatic patients as well as those in whom the imaging abnormality regressed, we suggest that the subclinical imaging abnormalities represent mild AVN, which is reversible in some cases. Since the process was identified in 10 hips by MRI and in 13 hips by bone scan, both studies are needed to detect subclinical AVN. This may be important if treatment of subclinical disease is clearly shown to prevent progression to symptomatic AVN.

Isotope studies in children: an update.

Hepatobiliary scintigraphy is an accurate, simple, and relatively noninvasive method for the diagnosis of biliary atresia, a condition in which early diagnosis is of paramount importance. Radionuclide gastrointestinal transit studies are useful in devising the surgical approach in children with suspected gastroesophageal reflux. Renal scintigraphy in the newborn period is used to decide the need for surgical intervention in a hydronephrotic kidney. Relatively new radiopharmaceuticals such as metaiodobenzyleguanidine, thallium, and deoxyglucose are useful in detecting tumors and in predicting the viability.