Acid-base alterations in heatstroke.

OBJECTIVE: To analyze the acid-base balance during heatstroke. DESIGN: Retrospective study. SETTING: Heatstroke Center, Makkah, Saudi Arabia. PATIENTS: Hundred nine consecutive heatstroke patients (mean age 55 +/- 12 years) with rectal temperature from 40 to 43.4 degrees C following exposure to hot weather. INTERVENTION: Arterial blood gases collected prospectively and analyzed using 95% confidence limits established by controlled experimental studies. Severity of heatstroke on admission assessed by Simplified Acute Physiology Score and Organ System Failure score. RESULTS: Metabolic acidosis was the predominant acid-base change followed by respiratory alkalosis (81 and 55% of the patients, respectively). The prevalence of metabolic acidosis (but not respiratory alkalosis) was significantly associated with the degree of hyperthermia: 63, 95 and 100% at 41, 42 and 43 degrees C, respectively (p < 0.0001). Patients with metabolic acidosis had a large anion gap (24 +/- 5). Arterial partial pressure of oxygen (PaO2), systolic blood pressure and Organ System Failure score were similar with or without metabolic acidosis. Although the acute physiology score was higher in patients with, than without, metabolic acidosis (15.7 +/- 3.7 vs 9.8 +/- 4.4, p < 0.001), there was no significant difference in neurologic morbidity and mortality (7.9 vs 1.1%, 5.6 vs 0%, p = 0.776 and 0.581, respectively). CONCLUSION: We conclude that metabolic acidosis is the predominant response in heatstroke.

Evaluation of the safety and efficacy of repeated sedations for the radiotherapy of young children with cancer: a prospective study of 1033 consecutive sedations.

PURPOSE: A prospective observational study to examine our current practice of either conscious sedation (C.S.) or general anesthetic (G.A.) for children undergoing radiation therapy (we use the term sedation to include both C.S. and G.A.). Specifically, the study examines the reasons for selection of patients, choice of drugs, safety and effectiveness of the procedure, side effects of repeated daily sedation, and compliance of the family with the regimen. METHODS AND MATERIALS: Recorded data included patient demographics, sedation technique, time for various stages of the procedure, breathing support required, sedation outcome, and complications. RESULTS: One hundred ninety-eight consecutive children underwent 4232 procedures involving either simulation or radiation treatment, an average of 21 procedures each. Seventy-four (37%) required sedation for a total of 1033 procedures, an average of 14 sedations each. For those patients who received sedation, the age ranged from 9 months to 14 years (median, 3.8) and 96% had a mold, (85% of the head and neck). The doctor's assessment of the need for sedation was correct 89% of the time. Thirty-seven percent required sedation at the start of treatment, but, even after 30 fractions, 15% still required sedation. Presedation status correlated with successful sedation and treatment (p = 0.0001). Ninety-six percent had some form of i.v. access, usually a portacath (76%); 883 sedations were performed with G.A. and 148 with C.S.; 93% of sedations were completed satisfactorily, 5% with some difficulty, and the patient was unable to be treated in 2%. With G.A., satisfactory sedation was achieved 97% of the time, whereas, with C.S., satisfactory sedation was achieved only 68% of the time. There were no complications for 97% of observations. Not one serious complication occurred. An endotracheal tube was used only twice during G.A. For C.S., the results for chloral hydrate, meperidine, and midazolam were, respectively, at least one complication, 23%, 0%, 5%; satisfactory sedation for treatment, 60%, 60%, 82%; and unable to treat 20%, 13%, 5%. For G.A., only 1 patient was unable to be treated. The median time from start of medication to the end of radiation treatment was a median of 10 min (75% complete within 15 min) for G.A., vs. 30 min (75% complete in 50 min) for C.S. On multivariate analysis, the only significant factor predicting a successful outcome was a G.A. using propofol (odds ratio, 20.6), vs. C.S. using either chloral hydrate, meperidine, or midazolam. (p = 0.0001). CONCLUSION: In this study, there were no serious complications of sedation in 1033 procedures. As a result of the study, we developed improved methods for better preparation of the patient and family to try to reduce the need for sedation, and reduce the indications for C.S., while confirming the safety and efficacy of a G.A. with propofol for children needing sedation for daily radiation therapy.

Double-chambered right ventricle in 73 patients: spectrum of the disease and surgical results of transatrial repair.

OBJECTIVE: To review the spectrum of double-chambered right ventricle (DCRV) and the outcome of surgical repair in patients diagnosed between February 1988 and March 1999. DESIGN: The charts of patients with DCRV were studied. SETTING: Tertiary care hospital. PATIENTS AND METHODS: A total of 73 patients were identified. Sixty-nine underwent surgical repair, while four are awaiting surgery. The repair was through a transatrial approach in 61 patients, while in eight an additional ventriculotomy was performed. MAIN RESULTS: An associated ventricular septal defect (VSD) was present in 56 of 73 patients (77%). These patients were significantly younger (P<0.05) than the 17 patients without a VSD. Among patients with a VSD, the 31 requiring patch closure were significantly younger than the 25 patients having direct closure. Five older patients among those with intact septum had impaired right ventricular (RV) function as well as higher intraventricular gradients. At surgery the intraventricular obstruction was relieved by myomectomy. There was no hospital or late mortality. Following surgery, at a mean follow-up of 13.6 months, no increase in the intraventricular gradient was detected by Doppler echocardiography. CONCLUSIONS: The development of DCRV is associated with VSD in early life. The probability of the presence of a VSD decreases with age. The disease is progressive, resulting in increased intracavitary gradient within the RV and in RV impairment if it is not treated in a timely fashion. Transatrial repair is safe with excellent midterm results. In the presence of high gradients within the RV, a ventriculotomy may be necessary to obtain acceptable results.

Differential effects of in vitro and in vivo hyperthermia on the production of interleukin-10.

OBJECTIVE: To determine whether hyperthermia activates an anti-inflammatory response. DESIGN: A prospective study. SETTING: Heatstroke Center, Makkah, and King Faisal Specialist Hospital, Riyadh, Saudi Arabia. PATIENTS: Twenty-five heatstroke patients pre-cooling (rectal temperature 42.4 +/- 0.8 degrees C) (group 1) and 13 normothermic heat-stressed subjects were studied (group 2). Twelve of the 25 heatstroke patients were also studied post-cooling (group 3). Mononuclear cells from six healthy blood donors resting at 24 degrees C were used for in vitro study. INTERVENTIONS: Mononuclear cells were cultured at a concentration of 1 x 10(6)/ml without and with lipopolysaccharide (LPS) added at concentration of 10, 100, and 1000 ng/ml. The cells were incubated for 24 h at 37, 39, 41, and 43 degrees C. ELISA was used to measure IL-10 in the supernatant and plasma from heatstroke and heat-stressed subjects. RESULTS: All patients in group 1, 40% of group 2, and 37% of group 3, showed elevation of IL-10 (1289 +/- 2519, 248 +/- 393, and 172 +/- 226 pg/ml, respectively) compared with normal control levels, (< 100 pg/ml) P < 0.05. IL-10 level on admission did not correlate with degree of hyperthermia. During 24 h incubation at 37 degrees C without LPS, no IL-10 was detected, whereas with 10 ng/ml LPS, monocytes released 658 +/- 291 pg IL-10/10(6) cells. At 39 degrees C and 41 degrees C IL-10 release was decreased to 225 +/- 114, and 245 +/- 90 pg/10(6) cells, respectively; and was completely inhibited at 43 degrees C (67 +/- 10 pg/10(6) cells), P < 0.0001. CONCLUSION: Heat-stress with and without hyperthermia is associated with anti-inflammatory response in vivo. However, it does not seem to be the direct effect of heat on monocytes, suggesting that other environmental or genetic factors may be involved.

Retinol, alpha-tocopherol and carotenoids in diabetes.

OBJECTIVE: A case-control study was conducted to evaluate the effects of diabetes mellitus on serum levels of vitamin A, alpha-carotene, beta-carotene, alpha-tocopherol, serum and urine RBP. SUBJECTS: One hundred and seven patients with Type 2 diabetes mellitus (28-74 y) were recruited from those attending a primary health care clinic in King Khalid University Hospital in Riyadh City (Saudi Arabia). They were matched for age and sex with 143 healthy individuals. METHODS: Fasting blood samples and 10h urine collections were obtained from all subjects. Levels of vitamins and carotenoids in serum measured by high performance liquid chromatography (HPLC), and of retinol binding protein (RBP) in serum and urine by an enzyme-linked immunosorbent assay (ELISA). RESULTS: The mean serum concentrations of retinol, alpha-carotene, and alpha-tocopherol were similar in both groups after correction of lipid soluble vitamins for serum lipids levels. However, serum beta-carotene concentration was significantly higher in control subjects than diabetics (P = 0.002). Serum and urine RBP concentrations were significantly higher in diabetics than in controls (P = 0.0001). In normal subjects (but not diabetics) serum concentrations of retinol and RBP were higher in men than in women (P = 0.02, P = 0.0001 respectively). In both normal and diabetic subjects, serum levels of alpha-tocopherol (P = 0.007) and urine RBP (P = 0.005), were higher in men than women. Urinary excretion of RBP was significantly higher in diabetic patients with renal impairment than other diabetics or controls (P = 0.0001). There was a negative correlation between fasting blood glucose (FBG) concentration and serum beta-carotene (P = 0.008) in the total combined group and a positive correlation between FBG and urinary RBP/creatinine (P = 0.009) in diabetic patients. CONCLUSION: Serum beta-carotene concentration was significantly lower in diabetic patients than controls. Serum retinol concentration in patients with diabetes was normal, yet serum and urine RBP concentrations were significantly higher in diabetics than in controls.

The Saudi experience with neutron therapy in locally advanced head and neck cancers.

The neutron therapy program at King Faisal Specialist Hospital and Research Center conducted a phase II study to evaluate the toxicity and efficacy of neutrons against conventional external megavoltage irradiation in patients with locally advanced head and neck malignancy. One hundred and nineteen patients were allocated to receive either photons (46/119) or neutrons (73/119). Radiation effects were scored according to the EORTC/RTOG criteria; data was collected weekly during treatment, once a month for the first year and at 6-month intervals subsequently. While acute effects were scored in all patients, only 59 were evaluable for late effects and locoregional control. A composite of the average reaction results were obtained using this information, to compare them in time, for acute and late effects in both arms of the study. The maximum acute reactions in the two groups were similar. In the majority of the patients (80%) acute skin and mucosal reactions occurred during the last week of treatment. The changes in the subcutaneous tissues and salivary glands became clinically apparent at 3 months or later. Salivary gland toxicity was more severe in the photon arm and the difference was statistically significant at 3 months (P = 0.04) but this was lost at 12 months. Late effects for skin and subcutaneous tissues were significantly more severe in the neutron arm with P values of 0.04 and 0.01 respectively. Three patients in the neutron arm died of grade 4 radiation complications. The local control and survival were similar in both groups.

Hepatitis C virus infection in hemodialysis patients: comparison of two new hepatitis C antibody assays with a second-generation assay.

The performance of two new hepatitis C virus antibody (anti-HCV) assays (a third-generation immunoglobulin (Ig)G recombinant immunoblot assay (RIBA 3.0) and hepatitis C virus core IgM (HCV IgM) in the prediction of hepatitis C viremia in hemodialysis patients was compared with that of a second-generation IgG recombinant immunoblot assay (RIBA 2.0). Forty-three patients on maintenance hemodialysis were studied. Aliquots of sera were tested prospectively for anti-HCV by RIBA 2.0, RIBA 3.0, and HCV IgM and for HCV RNA by polymerase chain reaction. Thirty-eight patients were HCV RNA positive. Among those, 7 (18%) were HCV IgM positive, 22 (58%) were RIBA 2.0 positive, and 29 (76%) were RIBA 3.0 positive. All but one viremic patients detected by HCV IgM were also detected by RIBA 2.0 and RIBA 3.0. All viremic patients detected by RIBA 2.0 were also detected by RIBA 3.0. RIBA 3.0 was more sensitive than RIBA 2.0 and HCV IgM in the detection of viremic patients (P = 0.0156 and < 0.0001, respectively). The positive predictive value for HCV IgM was 100% as compared with 96 and 97% for RIBA 2.0 and RIBA 3.0, respectively. The negative predictive value for RIBA 3.0 was 36% as compared with 24 and 14% for RIBA 2.0 and HCV IgM, respectively. At 6-months follow-up of the eight viremic patients without a detectable IgM or IgG anti-HCV response, all patients remained RIBA 2.0 nonreactive, one became RIBA 3.0 indeterminate, and one became HCV IgM positive. These data suggest that HCV IgM has poor sensitivity in the detection of hepatitis C viremia and RIBA 3.0 improves the sensitivity of IgG anti-HCV assays in the early detection of hepatitis C viremia in hemodialysis patients.

Extended transseptal versus conventional left atriotomy: early postoperative study.

BACKGROUND: Mitral valve operations require excellent exposure. The description of an extended vertical transseptal atriotomy by Guiraudon and associates promises to provide optimal exposure of the mitral valve. A prospective study was carried out to evaluate the merits of the extended vertical transseptal atriotomy in comparison with the conventional left atriotomy for mitral valve operations. METHODS: Conventional atriotomy was performed in 24 patients (group I) whereas 65 patients underwent the extended vertical transseptal offroach (group II). They were similar in age, sex, cause of disease, New York Heart Association functional class, left atrial size, and left ventricular function. The early postoperative rhythm changes in these two groups were compared. Statistical studies to analyze the significance of incidence of junctional arrhythmia in these two groups were carried out. RESULTS: Of the 24 patients in group I, 3 had development of transient junctional rhythm after operation, lasting less than 24 hours. None had this arrhythmia at the time of discharge. Of the 65 patients in group II, junctional rhythm was documented in 25, with a rate of occurrence of 38% (95% confidence interval, 27.6% to 52.2%). At the 6-week follow-up, 3 patients still had this junctional rhythm, with a failure to recover rate of 12% (3 of 25). CONCLUSIONS: The surgical exposure was considered excellent and closure of the atriotomy was thought to be easy in group II. However, this should be balanced against a significant (38%) incidence of transient junctional rhythm in the early postoperative period in group II, probably from injury to sinus node artery or atrial conduction pathways.

New insights into hepatitis C virus infection of hemodialysis patients: the implications.

The authors compared the diagnostic performance of a second-generation recombinant immunoblot assay (RIBA) (RIBA HCV 2.0 SIA) and the recently introduced third-generation RIBA (RIBA HCV 3.0 SIA) with that of hepatitis C virus (HCV) RNA by the polymerase chain reaction (PCR) in 55 patients on chronic hemodialysis. Compared with HCV RNA by PCR, RIBA 3.0 increased the sensitivity of HCV detection to 72% as compared with 56% of RIBA 2.0. Both assays underestimated the prevalence of HCV infection as determined by PCR. However, RIBA HCV 3.0 outperformed RIBA HCV 2.0, detecting all of the RIBA 2.0-positive patients plus an additional eight (8 of 22 RIBA 2.0 negative; confidence interval [CI] = [17.2%, 59.3%]). Forty-three of 51 patients with positive RIBA 3.0 or positive HCV RNA by PCR underwent a liver biopsy. Thirty (70%) had chronic hepatitis (three with cirrhosis), 10 (23%) had nonspecific changes, and three (7%) had normal liver histology. Thirty of 37 patients (81%) with hepatitis C viremia and positive anti-HCV had chronic hepatitis, whereas none of the viremic patients with negative anti-HCV had chronic hepatitis. Among the reactive antigens on RIBA 3.0, c33c was found to be most predictive of chronic hepatitis (P = 0.0002). Detection of HCV RNA continues to be the method of choice in the early phase of HCV infection. In places where a validated HCV RNA assay is not available, RIBA HCV 3.0 (soon to be commercially available) is a better alternative. Early detection of HCV infection and the implementation of an isolation strategy might be important in preventing the spread of HCV infection among hemodialysis patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Open lung biopsy provides a higher and more specific diagnostic yield compared to broncho-alveolar lavage in immunocompromised patients. Fungal Study Group.

In order to examine the feasibility and safety of undertaking a larger prospective study to compare the diagnostic yield from concurrent open lung biopsy (OLB) and bronchoalveolar lavage (BAL) in febrile neutropenic patients with pulmonary infiltrates and the impact of such knowledge on clinical outcome, a pilot exploratory study was performed. 13 immunocompromised patients (mainly with haematological malignancy or bone marrow transplantation recipients) were investigated. At least one diagnostic finding in 12 of 13 patients was provided by OLB compared to 4 of 13 patients by BAL. BAL provided 7 specific diagnoses (pneumocystis 1, fungal infection 3, bacterial pneumonia 1, pulmonary haemorrhage 2) whilst OLB provided 12 specific diagnosis (CMV 2, pneumocystis 3, fungal infection 1, bacterial pneumonia 1, pulmonary haemorrhage 4, pulmonary embolism 1). Five patients with nonspecific interstitial/alveolar inflammation were diagnosed only by OLB. The concordance that the exact same specific diagnoses present in the OLB were found in the BAL was zero. There were 2 minor complications (1 wound infection by OLB, 1 moderate haemorrhage by BAL). Mortality at 28 days was 8 of 13 patients which in no case was related to either procedure. We suggest that OLB is a safe procedure in such patients, provides superior and more complete diagnostic information compared to BAL and a larger controlled study to investigate the impact of early OLB on the outcome of these patients appears to be justified.

Peri-operative complications following surgical closure of atrial septal defect type II in 232 patients--a baseline study.

This study intends to provide a detailed overview of the types and rates of peri-operative complications after surgical correction of an isolated ASD II. The transvenous approach to the occlusion of atrial septal defects has yielded promising results during its first 5 years of clinical trials, but before it can be established as a routine measure, definite proof is needed to demonstrate that its rate of serious complications does at least not exceed that of the surgical closure. Between 1985 and 1992, 232 consecutive patients underwent surgical closure of a secundum atrial septal defect. Among the patients 118 were children (< 18 years; 79 girls and 39 boys) with a mean age of 8.9 +/- 5.2 years (4 months-17 years) and 114 adults (74 women and 40 men) with a mean age of 28.5 +/- 10.8 years (18-69 years). Pre-operatively eight children (6.8%) and eight adults (7%) were treated for right heart failure. Mean pulmonary artery pressure was 20.4 +/- 10.4 mmHg for the children and 19.3 +/- 7 mmHg for the adults. The average pulmonary artery to systemic flow ratios were 2.9:1 and 3:1 for children and adults, respectively. Thirty children (25.4%) and 15 adults (13.2%) underwent patch closure while direct suture was the method used for the remaining patients. Average cardiopulmonary bypass time was 35.7 +/- 17.9 min for the children and 41.5 +/- 19.9 min for the adults. The length of the procedure (skin to skin) was a mean of 116 min in the young group, and 141 min in the adult group.(ABSTRACT TRUNCATED AT 250 WORDS)

A characterization of the blood lead concentrations in Saudi Arabian children.

The results presented in this paper are those derived from an extensive analysis of lead in 1047 children aged 2 months to 16 years attending as outpatients at a reference hospital, taking cases from all parts of the Kingdom of Saudi Arabia. Since the distribution of blood lead data in the sample suggested the existence of two mixed sub groups among the studied children, a non-linear mathematical model was used fit to the data. More than 20% of the children had blood lead concentrations above 0.608 mumol/L (12.59 micrograms/dL).

Autologous versus allogeneic bone marrow transplantation for non-Hodgkin's lymphoma: a case-controlled analysis of the European Bone Marrow Transplant Group Registry data.

PURPOSE: A case-controlled study of patients who reported to the European Bone Marrow Transplant Group (EBMTG) was performed to investigate the relative roles and efficacy of allogeneic (alloBMT) and autologous bone marrow transplantation (ABMT) in non-Hodgkin's lymphoma. PATIENTS AND METHODS: Of 1,060 patients who reported to the lymphoma registry, 938 patients underwent ABMT and 122 patients underwent alloBMT. A case-controlled study was performed by matching 101 alloBMT patients with 101 ABMT patients. The case matching was performed after the selection of the main prognostic factors for progression-free survival by a multivariate analysis. RESULTS: The progression-free survival was similar in both types of transplants (49% alloBMT v 46% ABMT). The overall relapse and progression rate for the alloBMT patients was 23% compared with 38% in the ABMT patients. This difference was not significant statistically. In the lymphoblastic lymphoma subgroup, alloBMT was associated with a lower relapse rate than ABMT (24% alloBMT v 48% ABMT; P = .035). The progression-free survival, however, was not significantly different because patients with lymphoblastic lymphoma who underwent alloBMT had a higher procedure-related mortality (24% alloBMT v 10% ABMT; P = .06). A significantly lower relapse/progression rate was also observed in patients with chronic graft-versus-host disease (cGVHD) compared with those patients without (0% cGVHD v 35% no cGVHD; P = .02). Fourteen of 18 patients who had cGVHD also had lymphoblastic lymphoma. CONCLUSION: This study suggests that ABMT and alloBMT for non-Hodgkin's lymphoma are comparable, with the exception of lymphoblastic lymphoma in which a graft-versus-lymphoma effect may account for the lower relapse rate for patients who underwent alloBMT.

Valve repair in rheumatic mitral disease.

Emerging evidence indicates that etiology plays an essential role in the results of mitral valve repair. In an attempt to evaluate the possibilities and problems of repair in a rheumatic population, all consecutive patients treated between July 1988 and July 1990 were reviewed. Three hundred and four patients at risk of undergoing a repair were studied. The mean age was 31.3 years. In 78 patients (25.6%) the valve was considered beyond repair and immediately replaced (MVR). In 26 patients (8.5%) an unsuccessful attempt at repair was followed by replacement (attempts), and 200 (65.7%) underwent a successful repair (repair). The repair group was younger (p less than 0.001) and had less tricuspid involvement (p less than 0.005). The repair rate was highest in regurgitant lesions (79.4% repaired, p less than 0.005). The attempts group was very similar to the MVR group. The total hospital mortality was 3.2%. For MVR it was 3.8%, for attempts 19.2%, and for repairs 1.0%. The incidence of embolism was 3.34%/patient/yr for the mechanical, 3.06%/patient/yr for bioprosthesis, and 2.19%/patient/yr for repairs. Only 7.5% of repairs were anticoagulated. A reoperation was needed in 26 patients: one for bioprosthesis, one for aortic repair failure, and 24 for mitral repair dysfunction (12.1% of all surviving repairs). The reoperation incidence after repair was 26.8% in patients with an age under 20 years and 4.5% in those over 20. Eight patients had active carditis and 10 severe hemolysis. There were eight late deaths (six prosthesis and two repairs), with an actuarial total survival at 30 months of 72.46 +/- 8.45% for prosthesis and 94.41 +/- 3.74% for repairs (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative responses of plasma glucose, insulin and C-peptide following ingestion of isocaloric glucose, a modified urban Saudi breakfast and dates in normal Saudi persons.

Diabetic patients are commonly advised without scientific basis to avoid ingestion of dates. Prior to undertaking studies in diabetic persons, we considered it important to establish the metabolic consequences of date ingestion in normal Saudi subjects. Nineteen normal subjects, 11 males and 8 females, aged 29.4 +/- 1.5 (mean +/- SEM) with a body mass index (BMI) of 22.1 +/- 0.5 were fed in a random order: a) a date meal (DM) consisting of approximately 300 calories (Carbohydrates - CHO 74.5 g, proteins 3.7 g and fats 0.66 g), b) a modified urban Saudi breakfast (SBF) 300 calories (oral glucose tolerance test - OGTT), on 3 different days at least 1 week apart. Plasma glucose (G), insulin (I) and C-peptide (C) values were determined at -30,0 and then every 30 minutes for 180 minutes. Glycemic indices for DM and SBF were also determined. G, I and C area profiles were not different between DM and SBF but were when compared with OGTT. This is the first documentation of the glycemic index for dates. For the "Khalas" variety it was found to be 57.7 +/- 8.5 and was significantly lower than that for SBF which was 79.0. Contrary to the usual belief, this study refutes the notion that ingestion of date adversely affects glucose tolerance compared with SBF in normal subjects. Similar results are observed in preliminary studies in diabetic subjects in our laboratory.

Mycobacterial infection after renal transplantation--report of 14 cases and review of the literature.

During a nine-year period, 14 cases of mycobacterial infection (tuberculosis) developed in 403 renal transplant recipients at the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, an incidence of 3.5 per cent. The annual incidence of tuberculosis was about 50 times higher than that in the general population. Infection was disseminated in nine (64.3 per cent), pulmonary in four (28.6 per cent), and genitourinary in 1 (7.1 per cent). In one patient tuberculosis was transmitted by the donor's kidney. The clinical manifestations were often ill-defined and not different from that in the normal host. Cultures from all patients grew Mycobacterium tuberculosis; concomitant infection with other organisms was present in five patients (35.7 per cent). Two of 18 patients (group 1) with positive pretransplant tuberculin skin test developed tuberculosis after transplantation (11 per cent), and neither received isoniazid prophylaxis; three of 70 patients (group 2) with negative skin tests developed tuberculosis after transplantation (4.3 per cent). The difference between the two groups was not statistically significant. Review of all published cases of mycobacterial infections in renal transplant recipients revealed 130 cases. Tuberculosis was disseminated in 38.7 per cent, pulmonary in 40.2 per cent, cutaneous in 12 per cent, and miscellaneous in 9.4 per cent. Atypical mycobacteria were responsible for 29 per cent of disseminated infections, 8 per cent of pulmonary infections and all cases of cutaneous and articular tuberculosis. Invasive procedures were needed to establish the diagnosis in 21 of 33 disseminated cases but in only three of 47 cases of pulmonary tuberculosis (p less than 0.0001). The mortality rate from disseminated disease was 37 per cent and from all other forms of tuberculosis was 11 per cent (p less than 0.005). These findings (1) confirm the higher incidence of tuberculosis in renal transplant recipients, compared to the general population; (2) suggest that pretransplant skin testing probably has little value in identifying patients at risk; (3) show that disseminated tuberculosis is common after renal transplantation and requires invasive procedures for diagnosis; (4) confirm that the donor kidney may be an important source of infection; and (5) indicate that concomitant infection with other organisms is common.

Frequency of HLA genes and islet cell antibodies (ICA) and result of postpartum oral glucose tolerance tests (OGTT) in Saudi Arabian women with abnormal OGTT during pregnancy.

A consecutive series of 55 Saudi women with abnormal 75 g oral glucose tolerance test (OGTT) during pregnancy was reinvestigated 2-4 months after delivery. A 75 g OGTT was done and samples were also drawn for analysis of C-peptide concentration, islet cells antibodies (ICA) and HLA antigens. The results of these laboratory investigations and a number of patient characteristics were analyzed to identify risk factors for patients likely to have impaired OGTT after delivery. Twenty-five (45.5%) of the patients had an abnormal OGTT after delivery. The distribution of HLA antigen frequencies did not differ from a reference group of healthy Saudis. ICA were found in only one patient. Logistic regression analysis identified insulin treatment during pregnancy (p = 0.001) as the only factor to predict an abnormal OGTT after delivery.

Neutron therapy for locally advanced head and neck squamous cell carcinoma: optimum dose search.

28 patients with locally advanced primary squamous cell carcinoma of the head and neck received neutron therapy and were randomized between two dose levels: 145 cGy n gamma x twelve fractions, three fractions per week (total 17.4 Gy n gamma). 155 cGy n gamma x twelve fractions, three fractions per week (total 18.6 Gy n gamma). Acute toxicity for skin, mucous membrane, salivary and subcutaneous tissues was graded using the EORTC/RTOG scoring system. Analysis indicates 17.4 Gy n gamma as "safe". A further twelve patients are to be assigned to the higher dose (18.6 Gy n gamma) before making a final dose selection.