Use of blood in elective surgery: An area of wasted hospital resource.

Unavailability of blood is a common cause of canceled operations but clinicians' blood ordering habits have been shown to waste hospital resources. A prospective audit was set up in a blood bank in a teaching hospital in Saudi Arabia. Data were separately logged on blood transfusion for all surgical operations between August 1991 and December 1992. Standard terminology was employed. During the 16 months, 565 consecutive operations were logged. Only two of eight departments met the criterion of efficient blood ordering, vis-a-vis a C:T ratio (units crossmatched divided by units transfused) of 2.5:1. Similarly, in the four most frequently performed operations, the transfusions index (Ti) was <0.25, indicating that blood would have been required for <25% of these cases. The study confirms other's experience of inefficiency in blood ordering for surgical operations, plus its attendant waste of resources. It is recommended that unless written and binding guidelines are published on a nationwide basis, clinicians' inefficient methods in ordering blood are unlikely to alter rapidly.

Breast cancer in a low-risk population. The influence of age and menstrual status on disease pattern and survival in Saudi Arabia.

Data on 130 women with invasive breast cancer, seen at our institution between April 1981 and November 1990, were retrospectively reviewed to assess the influence of age and menstrual status on the pattern and prognosis of their disease. Patients were mostly young (median age 40 years) and in 21 patients (16%) the diagnosis was established at the age of 30 years or younger. Eighty-six patients (66%) were under 50 and 82 patients (63%) were pre-menopausal. Pre-menopausal patients were more numerous than expected in stage III and less numerous in stage II. On the other hand, the differences between observed and expected values for both stage I and stage IV in the 2 menopausal groups were not significant. Compared with post-menopausal patients, pre-menopausal patients with 1-3 or greater than 3 positive lymph nodes were more numerous than expected. Differences between pre-menopausal and post-menopausal patients have persisted after categorizing patients into 2 age-groups with a cut-off point at 50 years. Comparable initial assessment and therapeutic modalities were offered to the 2 menopausal groups. At the time of analysis (January, 1991) all patients had a complete follow-up. Over a median follow-up of 46 months, the overall median survival (+/- SE) was 85.7 (+/- 4.4) months with a survival probability (+/- SE) at 5 years of 62% (+/- 5%). The proportional hazard model of Cox has identified advanced stage (stages III and IV) and involvement of lymph nodes as the only independent adverse predictors of survival with estimated hazard rates of 2.9 and 2.8, respectively. Unadjusted analysis, adjusted analysis and stratified survival functions failed to reveal any survival difference based on age or menstrual status. We conclude that, in a low-risk population and despite apparent baseline differences in demographic and disease characteristics between pre-menopausal and post-menopausal breast cancer patients, neither age nor menopausal status had a significant influence on survival. Our results should guide future cancer-care programs in Saudi Arabia.

Utilization of digoxin and theophylline assays in the eastern province.

The utilization of therapeutic drug monitoring (TDM) for serum digoxin and theophylline was assessed with respect to the indication, time of sample collection and contribution to patient care. A total of 585 serum drug level determinations of digoxin (275) and theophylline (328) were done in a four month period. Reasons for requests were subtherapeutic response (27.5%), suspected toxicity (3.8%), baseline data (26.7%), patients at risk for toxicity (7.7%), and for the remaining 34.4% of orders, no reason was stated. The highest number of requests 246 (42.1%) were from the inpatient ward (INP), followed by emergency room (ER) 32.6%, outpatient department (OPD) 13% and intensive care unit (ICU) 12.3%. Repeated assays accounted for 363 determinations of which 55.9% had levels similar to the previous ones. In this study, we found a high incidence of inappropriateness in patient selection (34.4%), time of serum sample collection (28.4%), and dosage adjustment (46.8%). However, when these audit criteria were analyzed together, the overall appropriateness was as low as 33.5%. This indicated that serum drug monitoring was poorly utilized and did not contribute much to the patient's care. This results in an estimated financial loss per year (for inappropriate use of digoxin and theophylline levels) of about 37,344 Saudi Riyals (US $9,956.00). Corrective educational programs for the staff, based on standard guidelines for TDM, have been initiated and this study is a baseline for future prospective audits.

Unusual presentation of cancer.

The large bowel is the most frequent primary site for metastases in inguinal hernial sacs. We report four cases, two due to carcinoid of unknown primary, and one each due to adenocarcinoma of colon, stomach and pancreas. We recommend that all hernial sacs, particularly in the elderly, be examined microscopically.

Fistula-in-ano: A pathological study.

A review of 229 cases of fistula-in-ano in our institution has shown that nonspecific inflammatory tissue lines the majority of tracts. Epithelial lining was present in 50 cases and was encountered proportionately more frequently in subjects under 10 years of age, thus supporting a congenital origin as well as infection of anal glands, earlier proposed by other workers. Intestinal contents may have a role in the foreign body response seen in many cases. Locally endemic infectious conditions do not appear to play a significant role in the cause of the disease.

Nasopharyngeal carcinoma. A comparative study.

A comparative study of Ghanaian and Saudi hospital cases of nasopharyngeal carcinoma (NPC) shows a higher occurrence among younger subjects in the Ghanaian group, with the peak age incidence in the Saudi group being similar to those reported from other parts of the world. In view of the known high prevalence of Burkitt's lymphoma among Ghanaian children, it is suggested that the much higher proportion of younger Ghanaian subjects with NPC may be related to early exposure to the Epstein-Barr virus which is known to be associated with both malignancies.

Histiocytic necrotising lymphadenitis (Kikuchi-Fujimoto disease) in Saudi Arabia.

Five cases of histiocytic necrotising lymphadenitis (Kikuchi-Fujimoto disease) are described. As the condition appears to be poorly recognised in Saudi Arabia, an extensive review of the histological features is presented, in order to improve pathologists' awareness and to minimise the risk of diagnosing prognostically less favourable conditions such as malignant lymphoma. Etiologic and pathogenetic features of the disease are also discussed.

Erythrocyte pyruvate kinase deficiency in newborns of eastern Saudi Arabia.

Cord blood specimens from 513 normal Saudi neonates from the Eastern Province were screened for the deficiency of erythrocyte pyruvate kinase enzyme using the fluorescent spot test. The enzyme activity of the deficient specimens and 108 randomly selected samples was assayed spectrophotometrically. The results indicate that the incidence of this enzyme deficiency is 3.12% which is higher than that reported previously. The findings are compared with those reported by others and the possible factor responsible for the high incidence of this deficiency is discussed.

Splenic foam cells: a clinico-pathologic analysis of 92 splenectomized patients.

Spleens from 92 patients who underwent splenectomy for various indications were examined. These indications included hematologic disease in 38 patients and nonhematologic problems in 54. Of all the group foam cells were seen in hematoxylin and eosin (HE)-stained sections of spleens from 12 patients. This number increased to 21 (23%) when the diastase periodic acid-Schiff stain was used as a screening test. The cells in these 9 additional cases were too scanty to be observed on HE-stained sections alone. All the 21 spleens with positive foam cells were from patients with hematologic disease, specifically beta-thalassemia major, hemoglobin S/beta-thalassemia, hemoglobin AS, and idiopathic thrombocytopenic purpura. None of the spleens from the 54 nonhematologic patients showed foam cells. Factors that determine the probability of presence of foam cells were calculated. Also, certain differences in the staining reactions of foam cells were observed. The results of both, and the relation of these foam cells to the 'syndrome of the sea-blue histiocyte' are presented and discussed.

Primary paranasal Aspergillus granuloma in Saudi Arabia.

Respiratory aspergillosis has been described in many parts of the world; but primary paranasal aspergillus granuloma (PPAG), a recognised, distinct entity, has been described almost exclusively in Africa--specifically in the Sudan. The first case of PPAG in Saudi Arabia with bilateral involvement of paranasal sinuses is described. In view of the geographical similarities between Northern Sudan and Saudi Arabia, it is suggested that some of the granulomatous inflammatory conditions occurring in Saudi Arabia for which no definite aetiological agent has been ascribed may fall into this category. Increased awareness of the condition, together with the use of serological methods currently in use in the Sudan may help in defining the condition properly in this locality.