ESTIMATION OF PATIENT RADIATION DOSES FROM MULTI-DETECTOR COMPUTED TOMOGRAPHY ANGIOGRAPHY PROCEDURES IN TANZANIA.

The aim of the present study was to estimate the volume CT dose index (CTDIvol), dose length product (DLP) and effective dose (ED) to patients from five multi-detector computed tomography angiography (MDCTA) procedures: brain, carotid, coronary, entire aorta and lower limb from four medical institutions in Tanzania; to compare these doses to those reported in the literature, and to compare the data obtained with ICRP 103 and Monte Carlo software. The radiation doses for 217 patients were estimated using patient demographics, patient-related exposure parameters, the geometry of examination and CT-Expo V 2.4 Monte Carlo-based software. The median values of the CTDIvol, DLP and ED for MDCTA procedures of the brain and carotids were 36.8 mGy, 1481.0 mGy∙cm and 5.2 mSv, and 15.9 mGy, 1224.0 mGy∙cm and 7.8 mSv, respectively; while for the coronary, entire aortic, and lower limbs were 49.4 mGy, 1493.0 mGy∙cm and 30.6 mSv; 16.2 mGy, 2287.0 mGy∙cm and 41.1 mSv; and 6.4 mGy, 1406.0 mGy∙cm and 10.5 mSv, respectively. The ratio of the maximum to minimum ED values to individual patients across the four medical centers were 41.4, 11.1, 4.6, 9.5 and 37.4, respectively, for the brain, carotid, coronary, entire aortic and lower limb CT angiography procedures. The mean values of CTDIvol, DLP and ED in the present study were typically higher than the values reported from Kenya, Korea and Saudi Arabia. The 75th percentile values of the DLP were above the preliminary diagnostic references levels proposed by Kenya, Switzerland and Korea. The observed wide range of examination scanning protocols and patient doses for similar MDCTA procedures within and across hospitals; and the observed relatively high patient doses compared to those reported in the literature, call for the need to standardize scanning protocols and optimise patient dose from MDCTA procedures.

Bladder injuries during cesarean section in a University Hospital: a 25-year review.

OBJECTIVES: The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. METHODS: We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983-2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. RESULTS: Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. CONCLUSIONS: Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.

High-resolution, time-resolved MRA provides superior definition of lower-extremity arterial segments compared to 2D time-of-flight imaging.

PURPOSE: To evaluate a novel time-resolved contrast-enhanced (CE) projection reconstruction (PR) magnetic resonance angiography (MRA) method for identifying potential bypass graft target vessels in patients with Class II-IV peripheral vascular disease. MATERIALS AND METHODS: Twenty patients (M:F = 15:5, mean age = 58 years, range = 48-83 years), were recruited from routine MRA referrals. All imaging was performed on a 1.5 T MRI system with fast gradients (Signa LX; GE Healthcare, Waukesha, WI). Images were acquired with a novel technique that combined undersampled PR with a time-resolved acquisition to yield an MRA method with high temporal and spatial resolution. The method is called PR hyper time-resolved imaging of contrast kinetics (PR-hyperTRICKS). Quantitative and qualitative analyses were used to compare two-dimensional (2D) time-of-flight (TOF) and PR-hyperTRICKS in 13 arterial segments per lower extremity. Statistical analysis was performed with the Wilcoxon signed-rank test. RESULTS: Fifteen percent (77/517) of the vessels were scored as missing or nondiagnostic with 2D TOF, but were scored as diagnostic with PR-hyperTRICKS. Image quality was superior with PR-hyperTRICKS vs. 2D TOF (on a four-point scale, mean rank = 3.3 +/- 1.2 vs. 2.9 +/- 1.2, P < 0.0001). PR-hyperTRICKS produced images with high contrast-to-noise ratios (CNR) and high spatial and temporal resolution. 2D TOF images were of inferior quality due to moderate spatial resolution, inferior CNR, greater flow-related artifacts, and absence of temporal resolution. CONCLUSION: PR-hyperTRICKS provides superior preoperative assessment of lower limb ischemia compared to 2D TOF.

Obstetric complications and perinatal outcome in triplet pregnancies.

The incidence of multiple pregnancies with more than two fetuses has significantly increased since the introduction of ovulation agents and assisted reproductive technologies. Over a 15-year period there were 35 triplet pregnancies beyond 24 weeks that delivered at the King Fahad Hospital, an incidence of 1 in 1,099 deliveries. Early diagnosis is important for improving the rate of fetal salvage in triplet pregnancy. These pregnancies were managed on an outpatient basis. Prophylactic interventions were not utilised. A total of 91% of the pregnancies had at least one antenatal complication, pre-term labour being the most common (80%) followed by anaemia (43%). The average gestational age at delivery was 31.7 weeks (SD 4.2 weeks). A total of 94.3% of the patients were delivered by lower segment caesarean section. The mean birth weight of the neonates was 1,552 g (SD 510 g) and mean 5-min Apgar score was 7.6 (SD 0.8). The corrected perinatal mortality rate in the study was 152/1,000. Pregnancy outcome did not vary with birth order or mode of conception. Higher rate of pre-term births among triplet pregnancies make considerable demands on the neonatal intensive care unit. All methods of assisted reproduction should aim at prevention of multifetal pregnancies.

Maternal mortality: a twenty-year survey at the King Faisal University Hospital, Al-Khobar, Eastern Saudi Arabia.

This was an institutional study of all maternal deaths that occurred among 56422 total births at the King Faisal University Hospital, Al-Khobar, Saudi Arabia, between 1983 and 2002. The underlying cause of each maternal death and potentially avoidable factors were analysed. There were 16 maternal deaths in the hospital during the study period, giving a maternal mortality rate of 28.4/100,000 births. The leading cause of death was haemorrhage in seven (43.75%) patients, followed by pulmonary embolism in four (25%) and general anaesthesia in two (12.5%) mothers. The risk factors noted were maternal age 35 years and parity 5 coupled with iron deficiency anaemia. The main avoidable factors were failure of the patients to seek timely medical care and to follow medical advice. More than half the number of direct obstetrical causes of death was thought to be preventable. A rapidly changing attitude of women towards childbirth is occurring through progressively increasing female education and community health programmes in the region. Further reduction of maternal mortality rates in the community is envisaged through greater patient acceptance of medical advice, family spacing and proficient obstetric services.

Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital.

Fifty-two women with a rectovaginal fistula were managed over a period of 15 years. All the fistulae were caused by obstetric injury commonly resulting from breakdown of the repair of complete perineal tears or from unrecognised injury during forceps or precipitate delivery. In five patients the fistula healed spontaneously within 12 weeks of the injury. Thirty-nine patients underwent transvaginal purse-string repair by standard technique and eight patients had perineoproctotomy and sphincteroplasty for large fistulae associated with anal incontinence. Surgical repair was successful in all the 47 patients including two patients who had previous failed repair elsewhere. The routine postoperative follow-up period of the patients ranged between 6 months and 8 years. There were no residual symptoms of anal sphincter weakness in the patients treated with transvaginal purse-string repair. Two of the patients who underwent perineoproctotomy and sphincteroplasty complained of varying degrees of postoperative incontinence of flatus that resolved by 8 weeks postoperation. In our experience the transvaginal purse-string method of repair for small, low rectovaginal fistulae proved highly satisfactory with 100% cure rate. Perineoproctotomy and sphincteroplasty for larger fistulae associated with anal incompetence was equally successful with minimal postoperative morbidity.

Pregnancy complicated by maternal cardiac disease: a review of 274 patients.

The outcome of 274 viable pregnancies in 229 patients with cardiac disease that delivered at the King Fahad Hospital, Al-Khobar, Saudi Arabia, between 1982 and 1998 was reviewed. The incidence was 0.6% of deliveries. Rheumatic heart disease complicated 208 (75.9%) pregnancies, congenital heart lesion in 49 (17.9%) and the remaining 17 (6.2%) pregnancies were a miscellaneous group that included supraventricular tachycardia, ectopic beats, ischaemic heart disease and cardiomyopathies. The NYHA grading was between 1-2 in 243 (88.7%) pregnancies antenatally. Thirty-one patients developed heart failure, most commonly in the antenatal period, 29 of whom were of Grade 1-2. One mother in the series died from heart failure following a cesarean section. She had had a mitral valvotomy before pregnancy and was categorised as Grade 2, antenatally. The perinatal mortality rate was 14.6/1000 deliveries in the study group. Prophylactic antibiotics were given to all the patients an hour before delivery. There were two instances of bacterial endocarditis in the series.

Outcome of pregnancy in women with idiopathic thrombocytopenic purpura.

The obstetric management and haematological problems in 28 pregnancies of 23 mothers with idiopathic thrombocytopenic purpura (ITP) are analyzed. There was no maternal death and only 1 stillbirth occurred in the series. Ten infants were born by Caesarean section and 18 were delivered vaginally. Neonatal cord bloodplatelet counts showed thrombocytopenia in 12 infants, but in only 4 (14.3%) was the cord blood platelet count <50 x 10(9)/L. None of the 27 liveborn infants died, although 4 required supportive treatment with corticosteroids and IgG. No maternal characteristics could be used to predict the neonatal platelet count. These results are comparable with other studies reported in the literature. The rarity of poor neonatal outcome in mothers with ITP does not justify obstetric intervention solely on the basis of their platelet counts. The management of patients should be individualized and carefully planned.

Lipid peroxidation and human sperm motility: protective role of vitamin E.

Asthenospermia is the main factor of male infertility among patients consulting the Asir Infertility Center in Abha, Saudi Arabia. Lipid peroxidation occurring in both the seminal plasma and spermatozoa was estimated by malondialdehyde (MDA) concentration. Spermatozoal MDA concentration was higher in men with decreased sperm motility. The MDA concentration in the seminal plasma exhibited no relationship with sperm concentration, sperm motility, the number of immotile spermatozoa, or even the absence of spermatozoa. The MDA concentration in sperm pellet suspensions of asthenospermic and oligoasthenospermic patients was almost twice that of the normospermic males. The MDA concentration in the sperm pellet suspension from normospermic or oligospermic patients was about 10% that in the seminal plasma. However, the MDA concentration in the sperm pellet suspension of asthenospermic or oligoasthenospermic patients was about 15% that in the seminal plasma. Treatment of asthenospermic patients with oral Vitamin E significantly decreased the MDA concentration in spermatozoa and improved sperm motility. Eleven out of the 52 treated patients (21%) impregnated their spouses; nine of the spouses successfully ended with normal term deliveries, whereas the other two aborted in the first trimester. No pregnancies were reported in the spouses of the placebo-treated patients.

Evaluation of an intensive care unit in a teaching hospital in Saudi Arabia.

Intensive Care Units (ICU) in general hospitals have become a standard requirement in tertiary care centres. However, the appropriateness of their use is not widely known. We have used the Therapeutic Intervention Scoring System (TISS) to evaluate a multidisciplinary ICU in a teaching hospital in Saudi Arabia. The average occupancy rate was 79%, the nurse: patient ratio was 1:1.4, duration of stay 4.1 +/- 3.5 days, and mortality was 1.4%. The distribution of severity of illness was as follows: Classes I & II, 82%, and Classes III & IV, 18%. The average TISS points were: daily per patient 15.1 +/- 2.7 (range 11.5-21.7), total per day 125.6 +/- 38.2 (range 35-211), and patient points per nurse was 21.1. We conclude that, although less than 20% of patients required unique ICU services, the use of our ICU was appropriate to the current medical and manpower training needs of the community it was designed to serve, but the basis of nurses' complaints of overwork remains to be determined.

Microbiology of postoperative wound infection: a prospective study of 1770 wounds.

A prospective study of postoperative wound infection was carried out over a 12-month period. Intra-operative swabs from the patients' anterior nares, the opened viscus and parietes were cultured using standard bacteriological techniques. Of the 1770 wounds studied, 167 (9.4%) became infected. Wound infection rates, according to clinical wound types, were clean 5.9%, clean-contaminated 10.7%, contaminated 24.3% and dirty 52.9%. The figures according to microbiological wound types were clean 4.7%, and potentially, lightly and heavily contaminated 15.3%, 22.1% and 30.2% respectively. The commonest causative organisms were Staphylococcus aureus 23.7%, Escherichia coli 16.9%, Staphylococcus epidermidis 13.5% and Pseudomonas aeruginosa 13.0%. When isolated intra-operatively, Enterobacter spp., Proteus spp., Klebsiella spp. and P. aeruginosa appeared to have a high probability of causing postoperative wound infection, but the intra-operative isolation of Bacteroides sp. was a poor predictor of subsequent wound infection.

Urinary hydroxyproline and serum alkaline phosphatase in sickle cell disease.

Serum alkaline phosphatase, alkaline phosphatase isoenzymes, and urinary hydroxyproline excretion were studied in 20 young adult sickle cell patients and 58 matching normal controls. Total alkaline phosphatase was significantly higher in the sickle cell patients than in controls. Heat inactivation test and isoenzyme electrophoresis indicated that bone is the predominant isoenzyme in patients. Hydroxyproline excretion was significantly higher in the sickle cell patients than in controls. Serum total alkaline phosphatase correlated well with urinary hydroxyproline excretion in sickle cell patients (r = 0.73). Both alkaline phosphatase and hydroxyproline increased with age in the sickle cell patients. This study suggests that delayed growth and/or bone destruction may contribute to the elevated levels of alkaline phosphatase and urinary hydroxyproline.

Ovarian tumours in pregnancy.

Ovarian tumours associated with pregnancy were reviewed for the period 1982-1991. The overall incidence of this complication was 1:653 deliveries; 62.7% of the tumours were diagnosed in the first and second trimesters of pregnancy. The value of routine pelvic examination and ultrasonic scan as a diagnostic aid in early pregnancy is emphasized; 25.4% of patients presented as an acute emergency; 23.9% of the tumours were incidentally discovered at Caesarean section which underlines the importance of examining the ovaries at operation. Benign cystic teratomas were the most common ovarian tumours found, followed by serous cystadenomas. The incidence of malignant tumours was 4.5%. Whenever an ovarian tumour is found, the possibility of malignancy should always be borne in mind. Treatment of ovarian tumours in pregnancy should be tailored according to the age of the patient, parity, clinical presentation, gestational age and biology of the tumour.

Laparoscopy in the management of women with chronic pelvic pain.

A review of 232 women who had diagnostic laparoscopy for chronic pelvic pain was undertaken. Diagnostic error in the preoperative pelvic examination in the series varied from 21% to 61%; of 135 patients who had normal pelvic examination findings preoperatively, 82 (61%) were found to have pelvic pathology on diagnostic laparoscopy, whereas 21 of 97 women (21.6%) who had abnormal pelvic examination, had normal findings on laparoscopy. The overall incidence of pelvic pathology in the series was found to be 69%. Our results suggest that there is poor correlation between findings of pelvic examination and the existence of pelvic disease. Laparoscopy has a definite place in the evaluation of patients with chronic pelvic pain and certainly justifies its increasing use in their management.

Effect of acute ethanol consumption on hepatic lysosomal enzymes and calcium concentration during rat liver regeneration.

Effect of alcohol consumption on the activity of two lysosomal nucleases, deoxyribonuclease II (DNAase II) and ribonuclease II (RNAase II) and calcium concentration have been studied during liver regeneration of Sprague-Dawley rats over a period of 10 days following 70% partial hepatectomy. Liver weight was completely restored in partially hepatectomized rats at 8 days in both sexes, but ethanol treatment resulted in only a partial restoration of liver weight at 10 days. Specific activity of DNAase II in partial hepatectomized animals increased by 50-75% at 6-12 hrs above sham operated controls, and the specific activity of RNAase II increased 2.3 fold at 6 hr, while calcium concentration decreased by 50% at 6-12 hrs. Ethanol treatment masked and/or delayed the increase in the specific activity of both enzymes at early stages of liver regeneration and also masked the decrease in calcium concentration. These results indicate that ethanol consumption delays the process of liver regeneration by altering the activity of lysosomal nucleases and calcium concentration.

Screening for gestational diabetes in a teaching hospital in Saudi Arabia.

This study was undertaken to determine the incidence and severity of gestational diabetes in our hospital population which is predominantly Arab; 455 consecutive patients were screened by a 3-hour glucose tolerance test in the third trimester of pregnancy. The overall incidence of gestational diabetes was found to be 11% and the incidence increased with increasing maternal age, parity and weight. A high prevalence of more severe degrees of gestational diabetes was noted among the Arabs. Glucose intolerance was observed in 2 patients in the absence of any risk factor. The most common high risk factor in patients found to have gestational diabetes was maternal age of 30 years or more.

Shoulder dystocia--a clinical study of 56 cases.

A retrospective analysis of 17,127 singleton vaginal deliveries revealed 56 cases of shoulder dystocia giving an incidence of 0.3%. Although an increasing incidence of shoulder dystocia was noted as the infant birth-weight increased, 41% of shoulder dystocia occurred in infants of average birth-weight (2,500-3,999g). Diabetes mellitus, postmaturity, maternal weight above 90 kg were each factors associated with a large sized infant which should signal the possible occurrence of shoulder dystocia. In the present series shoulder dystocia occurred in 2.7% of all infants weighing 4,000 g or more. Diabetic women experienced shoulder dystocia more often than non-diabetics. In the diabetics 15.7% of neonates of birth-weight 4,000 g and above sustained shoulder dystocia compared to 1.6% in the nondiabetic patients. Immediate neonatal injury was apparent in 43% of infants with shoulder dystocia, Erb palsy being the commonest injury. The perinatal mortality rate in the series was 54/1,000 deliveries. There was no maternal death. To avoid the potentially lethal and dangerous complications of shoulder dystocia, all clinical and technological methods available should be utilized to detect the excessive sized infants so that abdominal delivery may be performed before it is too late.

Outcome of treatment with bromocriptine in patients with hyperprolactinaemia.

Results in 136 hyperprolactinaemic women who presented with infertility, amenorrhoea, menstrual irregularities and/or galactorrhoea are reported. There was radiographic evidence of pituitary microadenoma in 21 (15.4%) patients and 5 (3.7%) had macroadenoma. Four patients were taking antidepressants, 2 antihypertensive drugs and 7 had taken oral contraceptives for a period of 6 months to 5 years. The remaining patients had no obvious cause for elevated prolactin levels. Patients with pituitary adenoma had a significantly higher (p less than 0.001) baseline serum prolactin level (182 +/- 4.6 ng/ml) than those with no adenoma (59.2 +/- 4.2 ng/ml). All patients in the study were treated with bromocriptine (2.5-10 mg) to normalize serum prolactin or to achieve a pregnancy. The patients without an adenoma required a significantly smaller dose of bromocriptine (2.5-5.0 mg) (p less than 0.005) than those with an adenoma. Galactorrhoea disappeared in all 64 patients within 2-4 months of treatment, sixty-six (71%) of the 93 patients who desired pregnancy achieved it within 3 to 8 months of bromocriptine therapy; 32 of these patients received additional treatment with clomiphene and human chorionic gonadotrophins for induction of ovulation. In the remaining 70 patients menstruation became regular and ovulation was evident in 40% of them. There was no significant difference in the pregnancy rate between the patients with or without pituitary adenoma. Similarly, presence of galactorrhoea or a high level of prolactin did not influence the pregnancy rate. No complications were observed during pregnancy related to pituitary adenomas; 8 (12%) pregnancies ended in first trimester abortion. No lethal congenital fetal abnormalities were observed in the patients treated with bromocriptine.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia.

The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a 4-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47 per 1000 total births. Fetal malformations occurred in 29 (17.57%) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within 1 week of delivery. Spontaneous premature labor was the commonest cause of death (23.52%) followed by birth trauma (11%) and maternal diseases (9.55%). The cause of death was not known in 22 (16.17%) cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce the perinatal mortality rate.