Primary Squamous Cell Carcinoma of Urinary Bladder - A Rare Histological Variant.

Primary squamous cell carcinoma of urinary bladder is a rare histological variant of epithelial bladder tumours. Histopathological types are associated with significant disease outcome, so it is essential to find, on microscopy the exact type of urothelial carcinoma. Herewith, we present a 70-year-old male having 3 months history of difficulty in micturition, reduced frequency of urine and associated pain. On Contrast Enhanced CT scan abdomen pelvis, showed irregular large urinary bladder mass with hydroureter and hydronephrosis. Internal iliac group of lymphnodes was enlarged. On histopathology diagnosed as pure squamous cell carcinoma of urinary bladder grade II with muscle invasion. We are presenting this case for its clinical, radiological and histopathological findings.

Completing an advance directive in the primary care setting: what do we need for success?

OBJECTIVES: To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta-analytic techniques to quantify their effects. DESIGN: Extensive bibliographic searches of English-language literature published from January 1991 through July 2005 were conducted. Investigators abstracted prespecified information (e.g., design, study duration, types of interventions employed) and advance directive completion rates for intervention and control arms in each investigation and calculated absolute rate differences (i.e., difference in completion rates between the two groups) for each study. Individual study and pooled-effect sizes were also calculated, along with 95% confidence intervals (CIs). SETTING: Literature review. RESULTS: Eighteen studies were retained in the final sample. Most studies employed multimodal interventions. The most common approach consisted of educational materials directed at patients (through mailing or at visit) coupled with a patient-healthcare provider interaction in a group or individual setting (n=7). Absolute differences in completion rates varied from a high of 44% (favors intervention) to a low of -2% (favors control). Effect sizes could be calculated for 15 of the 18 studies. The pooled effect size was 0.50 (95% CI=0.17-0.83), indicating a moderate overall effect in favor of the intervention. CONCLUSION: The majority of studies demonstrated statistically significant effects associated with the advance directive intervention. The most successful interventions incorporated direct patient-healthcare professional interactions over multiple visits. Passive education of patients using written materials (without direct counseling) was a relatively ineffective method for increasing advance directive completion rates in the primary care setting.

Profile of cardiac complications of snake bite.

The present study was conducted in 30 cases of snake bite to understand fully the intricacies of the cardiac profile and to render help in the management of the problem arising out of them. All were subjected to routine and specific investigations (ECG, X-ray Chest, SGOT). The present study concluded that 57 per cent of patients of snake bite were in 2nd and 3rd decades of life. Viperine snake bite occurred in 93 per cent and elapide snake bite in 7 per cent of cases. Cardiotoxicity was seen in only 25 per cent patients with viperine bite. Seventy-six per cent of the patients presented within 24 hours of the bite. Seventy per cent of patients had haemorrhagic manifestations and 30 per cent had cardiotoxicity. The disturbance in heart rate was seen in 47 per cent, rhythm disturbance in 6.7 per cent, tachycardia in 36.7 per cent and bradycardia in 10 per cent cases. Hypertension was found in 6.7 per cent, hypotension in 16.7 per cent. Thirty per cent of patients had gallop rhythm and it persisted in 16.6 per cent patients till discharge. One patient had evidence of pulmonary edema and one had basal congestion. Cardiomegaly on chest X-ray was found in one patient and elevated SGOT titres were found in ten per cent. Common electrocardiographic changes were sinus tachycardia, sinus arrhythmia (6.6%), sinus bradycardia (10%), tall T-wave in V2 (3.3%), pattern suggestive of acute anterior wall infarction with reciprocal changes (3.3%), myocardial ischemia (10%), non-specific ST-T changes (16.7%) and atrioventricular block (3.3%). The mortality rate was 10 per cent and all these patients had bleeding manifestations and abnormal electrocardiograms.

Familial hypophosphataemic rickets: experience with 24 children from Kuwait.

Between 1982 and 1988, familial hypophosphataemic rickets (FHR) was diagnosed in 24 children, in nine during screening of the families of index patients. The average annual incidence was 0.2/1000 live births. There were 16 boys and 8 girls in 10 families, of which nine had more than one affected child. Their ages at the onset of the disease ranged between 10 months and 14 years (mean 6.9 yrs). Growth retardation and bowing of the legs were the most prominent features, observed in all index patients and in four of the patients diagnosed by screening. Treatment with 1 alpha-hydroxyvitamin D3 and phosphates was associated with acceleration of growth in all children, healing of rickets in 21, and normalization of the serum phosphate in 22. Two children with late diagnosis are now older than 16 years with a final height below the 3rd centile. Three more pubertal children are also shorter than the 3rd centile. In areas where nutritional rickets is common, FHR is likely to be missed and the treatment delayed with grave consequences; in particular, growth retardation and bone deformity.

Vitamin-D-deficiency rickets in Kuwait: the prevalence of a preventable disease.

Two hundred and fifty children with clinical, biochemical and radiological evidence of vitamin-D-deficiency rickets were studied over a period of 5 years. Their ages ranged from 1 month to 2 years. Breastfed infants formed 63% of total cases. Intramuscular therapy with vitamin D in a dose of 600,000 IU, deep intramuscular, proved to be safe and effective. In contrast, oral vitamin D did not provide such satisfactory results, presumably owing to poor patient/parental compliance. This report reveals that vitamin-D-deficieny rickets is common in Kuwait in spite of abundant sunlight all through the year because children are wrapped up and kept indoors. Insufficient intake of vitamin D is another important factor in the pathogenesis of vitamin-D-deficiency rickets in Kuwait.

Human cryptosporidiosis in the Arabian Gulf: first report of infections in children in Kuwait.

During a 3-month pilot study, we identified ten children with cryptosporidiosis; they all presented with diarrhoea, most also with fever, vomiting and dehydration. For diagnosis, the formalin-acetate concentrate of the stool, and direct smears were stained for oocysts in safranin-methylene blue (S-MB). The negative staining of oocysts in trichrome-stained specimens was indicative and was confirmed by destaining and restaining in S-MB. Constraints contributing to the absence of reports from the Arabian Gulf were the lack of awareness of Cryptosporidium sp. as a cause of diarrhoea in children, inappropriate laboratory diagnostic techniques and, possibly, the initial referral of patients to polyclinics where mild cases may go undetected. Contaminated drinking water and close contact with domestic animals are possible modes of transmission of Cryptosporidium sp. but further studies are recommended to confirm this.

A multicenter therapeutic study of 1100 children with brucellosis.

A 6-year multicenter therapeutic study was performed on 1100 children with brucellosis in order to compare several antibiotic combinations and duration of treatment. The patients were randomized to receive oral therapy with oxytetracycline, doxycycline, rifampin and trimethoprim-sulfamethoxazole (TMP/SMX) either alone or in combination with each other or combined with streptomycin or gentamicin injections. The patients were also randomized into three groups based on the duration of oral therapy: 500 patients were treated for 3 weeks; 350 for 5 weeks; and 250 for 8 weeks. When intramuscular aminoglycosides were used, streptomycin was given for 2 weeks and gentamicin for 5 days. In oral monotherapy oxytetracycline, doxycycline and rifampin showed comparable results with low relapse rates (less than or equal to 9%) and no statistically significant differences were found among 3-, 5- or 8-week durations of therapy. TMP/SMX alone showed an unacceptably high relapse rate (30%) with all durations of therapy. In combined oral therapy rifampin plus oxytetracycline, rifampin plus TMP/SMX and oxytetracycline plus TMP/SMX showed comparable results with low relapse rates ranging from 4 to 8% in patients receiving therapy for 3 or 5 weeks, no relapses occurred in patients treated for 8 weeks. When oral monotherapy was combined with either streptomycin or gentamicin, very few relapses were seen, irrespective of the duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Treadmill exercise testing in asymptomatic chronic smokers to detect latent coronary heart disease.

The treadmill exercise test has been performed in 50 chronic smokers and 50 non-smokers (93 males and 7 females) who were not having any clinical or electrocardiographic manifestation of ischemic heart disease. The test was positive in 18% chronic smokers and 4% in non-smokers, the chances of positivity of stress test was 4-5 times greater in chronic smokers than in non-smokers. The duration of smoking and number of/cigarettes/bidis smoked per day were directly proportional to the incidence of a positive stress test. There was no significant difference in the incidence of a positive exercise test amongst purely cigarette smokers (17.64%), purely bidi smoker, (16.16%), and in both bidi and cigarette smokers (20%). The study, therefore, suggests that chronic heavy smoking is more frequently associated with asymptomatic ischemic heart disease, as compared to non-smokers and stress testing of persons with coronary risk factors important for detection of latent IHD.

Congenital chloride diarrhoea in Kuwaiti children.

Congenital chloride diarrhoea was diagnosed in 16 Kuwaiti children over a 7 year period (1980-1986) with an estimated incidence of 7.6 per 100,000 live births. The mean age at diagnosis was 3.2 months (range 1 week to 5 months). There were 9 boys and 7 girls with a mean age of 3 years 10 months (range 10 months to 7 years). All children had a shortened gestational period, abdominal distension and chronic diarrhoea. The serum electrolytes in all patients prior to treatment showed hyponatraemia, hypokalaemia, hypochloraemia and metabolic alkalosis. The diagnosis was confirmed by a stool chloride content that exceeded the sum of faecal sodium and potassium. Fifteen patients survived and showed catch-up growth with adequate replacement therapy and 1 died with renal failure.

Neonatal brucellosis.

Three Arab children with neonatal brucellosis are described. The first presented with late neonatal hyperbilirubinaemia, the second with a septicoemia-like picture and the third was born prematurely and presented with respiratory distress. The diagnosis of brucellosis was based on a positive blood culture and on a high or rising titre of antibodies to the Brucella organism. All the three neonates responded well to antibiotic therapy as monitored by a Brucella titre of less than 1:40 and a negative blood culture 10 weeks after the onset of therapy. The three mothers had Brucella infections during pregnancy and the Brucella agglutination titre of the breast milk was high. No Brucella microorganism was isolated from the breast milk. The mode of transmission of brucellosis in neonates is discussed.

Probable transmission of brucellosis from breast milk to a newborn.

The first case of neonatal brucellosis is described. The baby was fed breast milk only when the mother became acutely ill with fever, arthralgia and malaise. At the same time the baby was febrile. Blood cultures grew Brucella melitensis in both mother and child. The brucella agglutination titre in the breast milk was 1:2560. Both mother and child recovered during treatment with streptomycin.

Children with acute rheumatic fever and acute poststreptococcal glomerulonephritis and their families in a subtropical zone: a three-year prospective comparative epidemiological study.

Over a period of three years (December 1980 through November 1983) the incidence and epidemiological features of acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (AGN) were studied prospectively in two regional hospitals in Kuwait serving a childhood population of 225,000. The study included 146 children with ARF and 256 family members and 125 children with AGN and 199 family members. The annual incidence of ARF and AGN were 19.6 and 17.8 respectively per 100,000 childhood population (7.3 and 6.7 respectively per 100,000 total population). Both diseases occurred sporadically throughout the year with a similar peak in winter. The clinical profile of ARF was essentially similar to that reported from temperate climates, and AGN followed mainly throat infections. Microscopic haematuria was detected in ten ARF family members (4%) and in 20 AGN family members (10%). Haematuria and low C3 were found in two (0.8%) and in seven (3.5%) ARF and AGN family members respectively. Of the nine family members with subclinical nephritis the group C streptococcus was isolated from three (33%). The geometric mean titre (GMT) of antistreptolysin O (ASO) and of antihyaluronidase (AH) in ARF and AGN patients were markedly elevated. Although the median age of ARF and AGN family members were 13 and 15 years respectively, yet the GMT of ASO and AH in the family members were slightly higher than those of the normal childhood population.

Congenital hypoplastic anaemia in Arab children (Diamond-Blackfan syndrome).

Three Arab children with congenital hypoplastic anaemia are reported. The three children presented with pallor in the first 3 months of life. All were given corticosteroids at different times. The first child is on high doses of prednisone and also needs blood transfusion every 6 weeks. The second child is on 5 mg prednisone every other day and is in remission. The third has been in complete remission for the last 5 years and is on no treatment. None of these children has associated congenital or chromosomal abnormalities.

Neonatal listeriosis: a report of seven cases.

Seven neonates with listeriosis admitted to Farwaniya Hospital, Kuwait, are reported. Six had the meningitic type and one the septicaemic type. Serotyping showed 1/4b in all neonates. The response to 2 weeks ampicillin and amikacin was excellent with no mortality or morbidity.

A study of brucellosis in childhood.

Two hundred children with brucellosis are described. The clinical characteristics on presentation included prolonged fever, arthralgia, weight loss, and malaise in the majority of the patients. Biochemical characteristics included a relative lymphocytosis in 92.9 percent of the patients and elevated liver enzymes in 83.5 percent. The Brucella agglutination titer was 1:320 or more in all the cases studied, but repeated blood cultures yielded growth of Brucella organisms in only 42 percent of the patients. Brucellosis is an important cause of fever in children living in areas where Brucella-infected animals are raised. Consumption of raw milk or dairy products made from raw milk are the main sources of infection. Education of the public and governmental control are necessary to eradicate the disease.

Brucella arthritis in children.

A study in 50 children suffering from acute brucellosis demonstrated that acute arthritis is a common and often predominant manifestation of the disease. The patients lived in an area where brucellosis is endemic: their ages ranged from six months to 12 years. All patients had a brucella agglutination titer of greater than or equal to 1:320 on admission. The knee and hip joints were most commonly affected with symptoms and findings from only one joint predominating. Associated findings of only moderately elevated ESR and normal leucocyte counts with relative lymphocytosis in the vast majority of the cases made it fairly easy to distinguish acute brucella arthritis from septic arthritis of other origin. A positive blood culture for Brucella melitensis was obtained in 35 of the patients. Treatment with tetracyclines, trimethoprim-sulphamethoxazole, with or without combination with streptomycin, resulted in a prompt recovery in all patients. No mortality was seen. Seven patients were readmitted with reinfections during a mean follow-up period of 13 months. Two patients with a history of prolonged fever, malaise and arthralgia were found to have osteomyelitis of the adjacent bone tissue. They also recovered without sequelae.

Cardiac manifestations in brucellosis.

Cardiac involvement in childhood brucellosis is rare and when present mimics findings usually noted in acute rheumatic fever with carditis. We report five children aged 6 to 11 years. Echocardiography showed mitral valve vegetations in one, functional mitral valve incompetence in two, and sluggish myocardial function in one. All the patients presented with fever, arthralgia, and malaise, four of them had leucopenia, and all five showed relative lymphocytosis. Blood cultures grew Brucella melitensis, biotype 1 in four cases and type 2 in one. Treatment with oral tetracyclines over three weeks together with streptomycin over the first two weeks was successful in all the patients, including one in whom oral trimethoprim/sulphamethoxazole was first tried but was unsuccessful as the patient developed a relapse after two months.

Sporadic pharyngitis-associated acute poststreptococcal nephritis. A four-year prospective clinical study of the acute episode.

Between December 1980 and November 1984, the acute episode was studied prospectively in 187 children under 14 years presenting with acute poststreptococcal glomerulonephritis. The mean annual incidence was 19.5/10(5) children. The disease was mainly pharyngitis-associated and occurred throughout the year but peaked in the winter. The mean age was 5.4 years, and 71 percent of children were under the age of 8 years. Gross hematuria was the presenting feature in 93.6% of cases and was usually associated with edema. Hypertension was present in 45 percent, circulatory congestion in 27 percent, and heavy proteinuria in 22 percent of cases. The C3 level was low in 97 percent of the patients tested and returned to normal within 6-8 weeks. There were no deaths. Only one patient needed peritoneal dialysis. All except one patient were asymptomatic with normal creatinine within 8 weeks. The authors adopted a very optimistic attitude in the counseling of children with the disease and of their families.