Variations of the gallbladder in Sudanese subjects with literature review.

BACKGROUND: Advances in the use of laparoscopic surgery, especially in the biliary apparatus interference makes the need to revise the anatomical data of the gallbladder (GB) more important. Variations of the extra-hepatic biliary apparatus are characterized by large varieties of configurations. OBJECTIVE: The aim of this article was to study the morphology of the GB in Sudanese subjects and review the common variations. MATERIALS AND METHODS: Dissection of formalin-fixed cadavers' abdomens. RESULTS: GB is larger in Sudanese subjects than what is described in the standard text books. CONCLUSION: Congenital anomalies and anatomical variations of the extra-hepatic biliary tree, although not uncommon, can be of clinical importance. There are some differences in the only size of GB in Sudanese.

Responsiveness of the SF-36 and a condition-specific measure of health for patients with varicose veins.

Approaches to measuring patient perceptions of outcome for varicose veins were tested using a postal questionnaire incorporating a clinically derived specific measure of varicose veins severity and the SF-36 health survey. The questionnaire was administered to 373 patients with varicose veins, 287 of whom had been referred to hospital for their varicose veins and 86 who had just consulted a general practitioner for the condition. The response rate exceeded 75%. Test-retest reliability was assessed by mailing patients a similar questionnaire at two weeks. The validity of the two instruments was assessed by comparing patient scores to general practitioner ratings of symptom severity and complications associated with varicose veins. Standardized response means (mean change in scores divided by the standard deviation of the change in scores) were used to quantify and compare the responsiveness of the two measures. Levels of test-retest reliability, as assessed by the intraclass correlation coefficient, were acceptable and the instruments appear to have good levels of validity. Patients who were or were not admitted to hospital for surgery on their veins had significant improvements in perceived health status on both the specific measure and the SF-36. The specific measure was the most responsive to changes in health status for both patients who were admitted to hospital for surgery and those receiving alternative forms of management. These two approaches might be suitable as part of a package of outcome measures for use in clinical trials to assess the effectiveness of different interventions for varicose veins.

Integrated care for asthma: matching care to the patient.

The purpose of the present study was to investigate whether criteria associated with assignment of asthma patients between general practice (GP) care alone, integrated care (shared between GP care and hospital clinic) or conventional specialist review could be identified, and whether outcomes for these patients differed over the next 12 months. Seven hundred and sixty four patients with a diagnosis of asthma and previously assigned to either integrated care or clinic care were reviewed after 1 year and reassigned. These patients were then followed for another 12 months and clinical data were collected over this time. After 12 months in clinic care or integrated care, assignment to integrated care was predicted by previous participation in integrated care (OR 2.94), patient preference for integrated care (OR 3.7), no admission (OR 1.56), fewer steroid courses during the previous year (OR 0.88) and nonattendance at review (OR 0.43) in the previous 12 months. Patient discharge to GP care was predicted by higher level of forced expiratory volume in one second (FEV1) (OR 1.49), lower number of GP consultations for troublesome asthma (OR 0.78), and nonattendance for review in the preceding year (OR 2.15). In the following 12 months, the three groups of patients differed significantly in hospital admissions (Discharged = 0.008; Integrated = 0.12; Clinic = 0.31), bronchodilators prescribed (Discharged = 8.5; Integrated = 10.2; Clinic = 13.9), GP consultations (Discharged = 1.3; Integrated = 3.0; Clinic = 4.1) and oral steroid courses (Discharged = 0.62; Integrated = 1.7; Clinic = 2.4). Patients assigned to integrated care, clinic care or discharged to general practice care form three distinct patient populations differing retrospectively and prospectively in morbidity and admission risk. In particular, patients assigned to integrated care fall midway in risk and morbidity between those discharged or those retained in clinic care. These results suggest that integrated care provides general practitioners with a system of management for asthma patients, for whom they do not wish frequent specialist review but who they do not believe can safely be discharged to general practice care only.

Estimating the point accuracy of population registers using capture-recapture methods in Scotland.

STUDY OBJECTIVE: To estimate the point accuracy of adult registration on the community health index (CHI) by comparing it with the electoral register (ER) and the community charge register (CCR). DESIGN: Survey of overlapping samples from three registers to ascertain whether respondents were living at the addresses given on the registers, analysed by capture-recapture methods. SETTING: Aberdeen North and South parliamentary constituencies. PARTICIPANTS: Random samples of adult registrants aged at least 18 years from the CHI (n = 1000), ER (n = 998), and CCR (n = 956). MAIN RESULTS: Estimated sensitivities (the proportions of the target population registered at the address where they live) were: CHI--84.6% (95% confidence limits 82.4%, 86.7%); ER--90.0% (87.5%, 92.5%), and CCR--87.7% (85.3%, 90.3%). Positive predictive values (the proportions of registrants who were living at their stated addresses) were: CHI--84.6% (82.2%, 87.0%); ER--94.0% (90.9%, 97.1%), and CCR--93.7% (91.7%, 95.7%). CONCLUSIONS: The CHI assessed in this study was significantly less sensitive and predictive than the corresponding ER and CCR. Capture-recapture methods are effective in assessing the accuracy of population registers.

SF 36 health survey questionnaire: I. Reliability in two patient based studies.

OBJECTIVE: To assess the reliability of the SF 36 health survey questionnaire in two patient populations. DESIGN: Postal questionnaire followed up, if necessary, by two reminders at two week intervals. Retest questionnaires were administered postally at two weeks in the first study and at one week in the second study. SETTING: Outpatient clinics and four training general practices in Grampian region in the north east of Scotland (study 1); a gastroenterology outpatient clinic in Aberdeen Royal Hospitals Trust (study 2). PATIENTS: 1787 patients presenting with one of four conditions: low back pain, menorrhagia, suspected peptic ulcer, and varicose veins and identified between March and June 1991 (study 1) and 573 patients attending a gastroenterology clinic in April 1993. MAIN MEASURES: Assessment of internal consistency reliability with Cronbach's alpha coefficient and of test-retest reliability with the Pearson correlation coefficient and confidence interval analysis. RESULTS: In study 1, 1317 of 1746 (75.4%) correctly identified patients entered the study and in study 2, 549 of 573 (95.8%). Both methods of assessing reliability produced similar results for most of the SF 36 scales. The most conservative estimates of reliability gave 95% confidence intervals for an individual patient's score difference ranging from -19 to 19 for the scales measuring physical functioning and general health perceptions, to -65.7 to 65.7 for the scale measuring role limitations attributable to emotional problems. In a controlled clinical trial with sample sizes of 65 patients in each group, statistically significant differences of 20 points can be detected on all eight SF 36 scales. CONCLUSIONS: All eight scales of the SF 36 questionnaire show high reliability when used to monitor health in groups of patients, and at least four scales possess adequate reliability for use in managing individual patients. Further studies are required to test the feasibility of implementing the SF 36 and other outcome measures in routine clinical practice within the health service.

SF 36 health survey questionnaire: II. Responsiveness to changes in health status in four common clinical conditions.

OBJECTIVE: To assess the responsiveness of the SF 36 health survey questionnaire to changes in health status over time for four common clinical conditions. DESIGN: Postal questionnaires at baseline and after one year's follow up, with two reminders at two week intervals if necessary. SETTING: Clinics and four training general practices in Grampian region in the north east of Scotland. PATIENTS: More than 1,700 patients aged 16 to 86 years with one of four conditions: low back pain, menorrhagia, suspected peptic ulcer, and varicose veins; and a random sample of 900 members of the local general population for comparison. MAIN MEASURES: A transition question measuring change in health and the eight scales of the SF 36 health survey questionnaire; standardised response means (mean change in score for a scale divided by the standard deviation of the change in scores) used to quantify the instrument's responsiveness to changes in perceived health status, and comparison of patient scores at baseline and follow up with those of the general population. RESULTS: The response rate exceeded 75% in a patient population. Changes across the SF 36 questionnaire were associated with self reported changes in health, as measured by the transition question. The questionnaire showed significant improvements in health status for all four clinical conditions, whether in referred or non-referred patients. For patients with suspected peptic ulcer and varicose veins the SF 36 profiles at one year approximate to the general population. CONCLUSIONS: These results provide the first evidence of the responsiveness of the SF 36 questionnaire to changes in perceived health status in a patient population in the United Kingdom.

Reducing hospital admission through computer supported education for asthma patients. Grampian Asthma Study of Integrated Care (GRASSIC).

OBJECTIVE: To evaluate a personalised computer supported education programme for asthma patients. DESIGN: Pragmatic randomised trial comparing outcomes over 12 months between patients taking part in an enhanced education programme (four personalised booklets, sent by post) and patients receiving conventional oral education at outpatient or surgery visits. SETTING: Hospital outpatient clinics and general practices in north east Scotland. SUBJECTS: 801 adults attending hospital outpatient clinics, with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. MAIN OUTCOME MEASURES: Numbers of hospital admissions, consultations with general practitioner for asthma, steroid courses used, bronchodilators and inhaled steroids prescribed, days of restricted activity, and disturbed nights. RESULTS: Patients with asthma judged too severe for randomisation between clinic care and integrated care and thus retained in clinic care had 54% fewer hospital admissions after receiving enhanced education than did the control group (95% confidence interval 30% to 97%; P < 0.05) over the study year. Patients had not all spent a full year as "educated" patients within the study year: when "educated days" were controlled for, annual admission rates for the entire enhanced education group were 49% (31% to 78%) of those in the control group. Among patients with sleep variation, sleep disturbance in the education group in the week before a regular review was 80% (65% to 97%) of that in the control group. There was no significant difference in days of restricted activity, prescription of bronchodilators or inhaled steroids, use of oral steroids, or number of general practitioner consultations for asthma, and no significant interaction between ownership of a peak flow meter and education. CONCLUSIONS: An asthma education programme based on computerised booklets can reduce hospital admissions and improve morbidity among hospital outpatients.

The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS?

OBJECTIVE: To assess the validity, reliability, and acceptability of the short form 36 (SF 36) health survey questionnaire (a shortened version of a battery of 149 health status questions) as a measure of patient outcome in a broad sample of patients suffering from four common clinical conditions. DESIGN: Postal questionnaire, followed up by two reminders at two week intervals. SETTING: Clinics and four training practices in north east Scotland. SUBJECTS: Over 1700 patients aged 16-86 with one of four conditions--low back pain, menorrhagia, suspected peptic ulcer, or varicose veins--and a comparison sample of 900 members of the general population. MAIN OUTCOME MEASURES: The eight scales within the SF36 health profile. RESULTS: The response rate exceeded 75% in the patient population (1310 respondents). The SF36 satisfied rigorous psychometric criteria for validity and internal consistency. Clinical validity was shown by the distinctive profiles generated for each condition, each of which differed from that in the general population in a predictable manner. Furthermore, SF36 scores were lower in referred patients than in patients not referred and were closely related to general practitioners' perceptions of severity. CONCLUSIONS: These results provide support for the SF36 as a potential measure of patient outcome within the NHS. The SF36 seems acceptable to patients, internally consistent, and a valid measure of the health status of a wide range of patients. Before it can be used in the new health service, however, its sensitivity to changes in health status over time must also be tested.

Corpus luteum function in subdermal levonorgestrel implant users.

PIP: Occurrence of ovulation and corpus luteum function were determined in 16 women inserted with 6 silastic rods, each containing 34 +or- 2mg levonorgestrel, for 1 year. Records of all subjects indicated minimal menstrual disturbances. Mean +or- S.E. serum progesterone levels at days M -7 to M -4 of the menstrual cycle revealed: anovulation (7 subjects) with serum progesterone levels less than 3 ng/ml, inefficient corpus luteum (7 subjects) with progesterone levels of 3-5 ng/ml, and normal ovulation (2 subjects) with progesterone levels above 5 ng/ml. Mean serum estradiol levels determined in the 3 levonorgestrel subgroups were insignificantly different from each other as well as from mean estradiol levels determined in 24 normal ovulatory control women.^ieng

Subdermal levonorgestrel implants and pituitary function.

This study was designed to report changes in circulating FSH, LH, and prolactin levels in women users of subdermal levonorgestrel implants. The subjects comprised 21 women implanted with 6 silastic rods, each containing 34 mg levonorgestrel, between days M0 and M+4 of the menstrual cycle. Blood samples were drawn prior to, 1 month and 6 months after implantation, during the early follicular phase in menstruating (n=12), and randomly in amenorrheic (n=9) subjects. No significant differences were noted between the mean values of estimated hormones at the 3 intervals of estimation in both regularly menstruating and amenorrheic groups.

Treatment of asthenozoospermia by intratesticular testosterone therapy.

A single intratesticular injection of 0.5 cc of 50 mg/ml of an aqueous testosterone suspension was administered to 14 patients with asthenozoospermia. In 7 cases, injection was combined with ultrasound of 0.5 w/cm2 for 2 min weekly for 4 weeks. In another 4 cases, only ultrasound was applied. Intratesticular injection with or without ultrasound caused a significant increase of motility percentage. Sperm density improved in cases that were associated with oligozoospermia (less than 20 million/ml). Ultrasound therapy (0.5 w/cm2 for 2 min) used alone had no effect on semen parameters. Associated hormonal changes in blood plasma were evaluated.

Endocrine profiles in pediatric andrology. I. Thyroid-stimulating hormone response to thyrotropin-releasing hormone in normal and protein-calorie malnourished infants.

Thryotropin-releasing hormone (TRH) was intravenously administered to eight normal control infants and ten infants with kwashiorkor. Stimulation caused by TRH was measured at various time intervals. The basal total protein mean value +/- SE was 6.9 +/- 0.3 and 4.0 +/- 0.3 g/dl for the control and kwashiorkor groups, respectively. Serum total thyroxine was 7.7 +/- 0.6 and 4.8 +/- 0.8 micrograms/dl for the control and kwashiorkor groups, respectively. Serum levels of thyroid-stimulating hormone (TSH) were 3.2, 13.5, 9.0, 7.4, and 8.0 microU/ml for the controls before stimulation and 20, 60, 90, and 120 min after stimulation, respectively. The corresponding values for the infants with kwashiorkor were 5.7, 13.9, 14.9, 15.2, and 15.3 microU/ml, respectively. The delayed TSH response to TRH stimulation in the infants with kwashiorkor was attributed to disturbance in the hypothalamic-pituitary-thyroid axis.

Endocrine profiles in pediatric andrology. II. Insulin-dependent diabetic adolescents.

Seventy-five diabetic male and female children and 75 matched controls were classified according to pubertal staging. Blood samples were assayed for gonadotropins and gonadal hormones. The ultimate adult height in diabetic patients was 5 cm less than that of controls. Almost all diabetic children had a retarded bone age. Levels of serum gonadotropins and gonadal hormones did not differ markedly between diabetic and healthy children. The delay in growth and maturation was not due to hormonal failure, but probably to chronic undernutrition of body cells and failure to utilize the amino acids for protein anabolism related to relative insulin deficiency.

Effect of urinary bilharzial infection on male pubertal development and endocrine functions.

One hundred seventy-five males aged 9-20 years were selected. The subjects comprised two groups; controls and patients infected with urinary bilharziasis not associated with any other parasite. Pubertal development was assessed. Serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and progesterone were determined by radioimmunoassay procedure. Delay in pubertal development was evident in the normal control group as indicated by higher chronological age mean values at the various stages as compared to other world norms. Urinary bilharziasis exaggerated the delay in pubertal development as compared to that in the control group. In relation to the control group, the group with urinary bilharziasis had higher levels of serum FSH and LH, which were significant only at stages III and IV. No significant difference was noted between the two groups for serum testosterone and progesterone levels, except for the high progesterone mean value at stage V in the group with urinary bilharziasis.

Endocrine profiles in pediatric andrology. III. Human chorionic gonadotropin stimulation test in cryptorchid boys.

Serum testosterone (T) concentration and urinary 17-ketosteroid (17-KS) excretion were measured under basal conditions and after stimulation with human chorionic gonadotropin (hCG) in 36 prepubertal males (10 normal children and 26 cryptorchid patients). As a function of hCG stimulation, the increase in serum T level was evident in both groups, although the magnitude of the rise was higher in the control group than in cryptorchid boys. No significant differences in serum T or urinary 17-KS were observed between patients with unilateral and bilateral undescended testis, either before or after hCG stimulation. In spite of the wide individual variations in testicular response in all subjects, the test is valuable in assessing Leydig-cell function and in prognosis for virilization at puberty.

Corpus luteum function in medicated and non-medicated IUD users.

PIP: Serum estradiol and progesterone were determined by radioimmunoassay procedures at premenstrual days M-7 and M-6 in 30 nonlactating women: 1) control non-IUD users (n=10), 2) Lippes loop users (n=10), and 3) copper T 200 users (n=10). Results indicated ovulatory and normal corpus luteum pattern in the 3 groups. Comparable evaluation was performed at premenstrual days M-4 and M-2 in 30 lactating women: 1) control lactating (n=10), 2) copper T 200 users (n=10), and 3) Progestasert TM system users (n=10). Results indicated anovulatory figures in progesterone-releasing device users, and while about 40% of lactating controls and copper T 200 users showed evidence of ovulation, the rest were nonovulatory.^ieng

FSH, LH, E2, progesterone, and testosterone in peripheral blood, spermatic vein, and semen of subfertile men with varicocele.

Peripheral blood (PB), spermatic vein (Sp. V.), and semen samples were collected from 31 subfertile men with varicocele. Levels of FSH, LH, estradiol, progesterone, and testosterone were determined in the three biological fluid compartments using RIA. Remarkable increases in both testosterone and estradiol in the spermatic vein samples, as compared to either peripheral blood or semen, were evident. Correlation coefficient indicated significant positive correlation between PB FSH and each of PB LH, Sp. V. FSH, and Sp. V. LH. Significant positive correlation existed between PB LH and each of Sp. V. FSH, LH, and testosterone. Significant positive correlations were found between PB testosterone and each of Sp. V. testosterone and semen testosterone, as well as between PB estradiol and each of Sp. V. FSH and progesterone. Significant positive correlations between Sp. V. FSH and Sp. V. testicular progesterone was significantly correlated with seminal estradiol.

Subdermal levonorgestrel implants: serum androgens.

Serum levels of androstenedione, dihydrotestosterone, and testosterone were determined by radioimmunoassay procedures in 25 female volunteers using subdermal levonorgestrel implants as a contraceptive. Mean serum androstenedione levels were increased after 1 and 6 months in comparison with preimplantation levels, the increase being significant only after 1 month. This could be attributed to increased production from the adrenal or ovaries and/or changes in clearance rate. Testosterone levels showed approximately 24% increase above basal values after 6 months' use of levonorgestrel implants, which was attributed to concomitant increases in androstenedione levels. The implication of these results is discussed.

Serum cortisol in women users of subdermal levonorgestrel implants.

The aim of this study was to reveal changes in serum cortisol levels in users of subdermal levonorgestrel implants (Norplant). The study was undertaken on 18 regularly menstruating females subdermally implanted with 6 silastic rods, each containing 34 +or- 2 mg levonorgestrel, between days M0-M+4 of the menstrual cycle. Venous blood samples were collected between 10:00 and 11:00 a.m. under basal conditions, before and 1, 6, and 12 months after implantation. Sera were analyzed for cortisol by radioimmunoassay procedures. Mean +or- S.E.M. cortisol levels were 15.94 +or- 1.23, 10.20 +or- 0.84, 11.21 +or- 1.14, and 11.14 +or- 1.05 mcg prior to and 1, 6, and 12 months after implantation, respectively. All postimplantation values were significantly lower in comparison to basal levels. However, results obtained fell within the normal range of serum cortisol, with no subjects reporting symptoms of adrenocortical insufficiency.