Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST-RA database.

OBJECTIVE: To analyse associations between the clinical status of patients with rheumatoid arthritis (RA) and the gross domestic product (GDP) of their resident country. METHODS: The Quantitative Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST-RA) cohort includes clinical and questionnaire data from 6004 patients who were seen in usual care at 70 rheumatology clinics in 25 countries as of April 2008, including 18 European countries. Demographic variables, clinical characteristics, RA disease activity measures, including the disease activity score in 28 joints (DAS28), and treatment-related variables were analysed according to GDP per capita, including 14 "high GDP" countries with GDP per capita greater than US$24,000 and 11 "low GDP" countries with GDP per capita less than US$11,000. RESULTS: Disease activity DAS28 ranged between 3.1 and 6.0 among the 25 countries and was significantly associated with GDP (r = -0.78, 95% CI -0.56 to -0.90, r(2) = 61%). Disease activity levels differed substantially between "high GDP" and "low GDP" countries at much greater levels than according to whether patients were currently taking or not taking methotrexate, prednisone and/or biological agents. CONCLUSIONS: The clinical status of patients with RA was correlated significantly with GDP among 25 mostly European countries according to all disease measures, associated only modestly with the current use of antirheumatic medications. The burden of arthritis appears substantially greater in "low GDP" than in "high GDP" countries. These findings may alert healthcare professionals and designers of health policy towards improving the clinical status of patients with RA in all countries.

Operative cholangiography in laparoscopic cholecystectomy: Is it essential?

This study is to evaluate the need for preoperative cholangiography during laparoscopic cholecystectomy when endoscopic retrograde cholangiopancreatography (ERCP) is available. Over a period of four years, 1105 consecutive patients had laparoscopic cholecystectomy. All patients, in addition to their clinical assessment, had routine liver function tests (LFTs) and ultrasound (US) examination of the biliary tract. Preoperative ERCP was performed (diagnostic and/or therapeutic) in 107 (9.6%) of the patients. The indications for ERCP were one or more of the following: 1) abnormal liver function test, 74 patients; 2) jaundice, 37 patients; 3) common bile duct (CBD) stone seen in US, 36 patients, and/or CBD dilatation, 46 patients; and 4) pancreatitis, 20 patients. In 41 out of 107 (38%) patients, CBD stones were present and cleared endoscopically. Postoperative ERCP was necessary in eight patients: to remove retained stones in the CBD (two patients), to stop bile leak (two patients), and to investigate the persistent abnormal LFTs in the remaining patients. The number of patients who had evidence of retained CBD stone following laparoscopic cholecystectomy was only two. In both patients, endoscopic removal was successful. Therefore, it is clear that operative cholangiography in laparoscopic cholecystectomy is not essential if there is a reasonable facility for ERCP.

Device-day infection rates - a surveillance component system for intensive care units at Security Forces Hospital, Riyadh, Saudi Arabia.

A surveillance component system for Intensive Care Units (ICUs) designed to account for major extrinsic risk factors for nosocomial infections using device days as the denominator has been advocated. A study of the surveillance component system in ICUs was conducted in Security Forces Hospital (SFH), Riyadh, Saudi Arabia, from February 1993 to January 1994 to verify the validity and compare the device-related infection rates with the infection rates based on patient admission and patient days. The standard recommended method was used in data collection. Device-associated infection rates vary by ICU types and device exposure. The surgical ICU (SICU) had the highest pneumonia rate while the pediatric ICU (PICU) had the lowest, being 22.0 and 6.4 per 1000 ventilator days respectively. Bacteremia was highest in the PICU with 20.7/1000 intravascular catheter days. The urinary tract infection rate of 11.4/1000 urinary catheter days was the highest in the medical ICU (MICU). These were statistically significant (P>0.001). The conclusion from the demonstration of these variables is that the use of the surveillance component system gives specific information on the effect of invasive devices in the occurrence of infection related to their use in the various ICUs. It permits the calculation of risk-specific infection rates, being a marker for the unit's invasive practices. Improved handwashing and the wearing of sterile gloves reduced the central intravascular catheter bacteremia rate in PICU from 20.7 to 10.0/1000 catheter days.

The single gallbladder stone - is it innocent?

At Security Forces Hospital, 692 consecutive patients underwent surgery for gallstone disease over a period of two years. Eighty of these patients had a solitary gallbladder stone. They are compared, by their presentation, operative findings, mortality and morbidity rates, with the remaining patients harboring multiple gallstones. The demographic data were similar in both groups; however, the frequency of developing mucocele, empyema, gallbladder perforation and postoperative complications were significantly higher in the group with solitary stones than those with multiple gallstones. Furthermore, the need for emergency surgical intervention and technically difficult surgeries were also more frequent in the single stone group. It appears that a solitary gallbladder stone is associated with increased risks more than multiple stones; hence, it may be justified to offer the patient with a solitary stone more attention and surgical priority.

Laparoscopic cholecystectomy: The first year experience.

A total of 307 consecutive patients with symptomatic gallstones were admitted for cholecystectomy. Two hundred seventy patients (88%) were considered suitable for laparoscopic cholecystectomy. Forty-two of these (17%) were admitted on an emergency basis. The procedure was accomplished successfully in 246 patients (91%), while in the remaining 24 patients (9%), the attempt had to be abandoned and converted to open cholecystectomy. Postoperative complications, mostly minor, occurred in 22 patients (9%). Suspected common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP) prior to surgery. The mean operative time was 82 minutes and 70% of the patients were discharged home within 489 hours after surgery and more than 90% were sent home by the third postoperative day. The results suggest that laparoscopic cholecystectomy is feasible for the majority of patients with symptomatic gallstones.

Bariatric surgery in Saudi Arabia.

Obesity is an emerging health problems in Saudi Arabia. An increasing number of patients are being referred for surgical management of their obesity. Vertical banded gastroplasty (VBG) was performed on 39 patients as treatment for morbid obesity. The mean weight loss at one year (38 patients) was 39% in males and 33% in females. At four years (23 patients) the mean weight loss was 42% in males and 41% in female patients. The mortality rate was 2.5% while the failure rate reached 13%. Vertical banded gastroplasty is considered to be an effective treatment toa achieve and sustain near ideal body weight in morbidly obese Saudi patients.

Exudative polyserositis and acute respiratory failure following praziquantel therapy.

Praziquantel is recommended as the drug of choice for all forms of schistosomiasis. We report the first case (to our knowledge) of exudative effusive polyserositis following treatment of schistosomiasis with this drug. This involved pleura, pericardium, and peritoneum and was associated with acute respiratory failure. The latter preceded the appearance of pleural effusions. We present a brief review of the literature and attract attention to the need for close observation of patients with schistosomiasis who are treated with praziquantel.

Pheochromocytoma in the organ of Zukerkandl: I-131 MIBG scintigraphic localization.

Scintigraphic localization of an extra-adrenal pheochromocytoma in a 27 year-old female with clinical and biochemical evidence of the disease is presented. While both ultrasonography and computed tomography were negative, I-131 MIBG scintigraphy successfully localized the extra-adrenal lesion in the organ of Zukerkandl.

Turcot syndrome: report of a case and review of the literature.

We report a case of Turcot's syndrome in a 20-year old man with multiple adenomatous polyps of the colon and glioblastoma multiforme. Detailed histopathological study of all 25 polyps removed from his colon confirmed the distinct morphological and numerical features of the colonic polyposis in Turcot's syndrome. Moreover, 45% of the total polyps and all polyps with a diameter exceeding 2 cm showed malignant transformation, indicating the precancerous nature of these polyps. These findings are discussed together with data obtained from a literature review of 32 histopathologically confirmed cases of Turcot's syndrome with reference to the possible heterogeneous nature of the syndrome at the present time. The current views on the relationship of Turcot's syndrome to other polyposis coli syndromes are presented.

A review of a Plastibell device in neonatal circumcision in 2,000 instances.

The Plastibell technique is a simple, satisfactory and easily learned method of circumcision. It is important to stress the practicality of this method in the neonatal period, thus reducing both emotional trauma and financial cost of admission at a later date.

Hypoglycaemic encephalopathy following surgery on phaeochromocytoma.

Severe hypoglycaemia as a complication of excision of a phaeochromocytoma has been reported seven times in the world literature. The eighth case, reported here, is unusual for the severity of the hypoglycaemic neurological damage which persisted for 10 weeks before ultimate recovery.

Omento-myelo-synangiosis in the management of chronic traumatic paraplegia: case report.

A case of traumatic paraplegia, with almost complete motor and sensory loss up to the umbilicus, who had an operation for post traumatic arachnoiditis and diagnosed as having recurrence of arachnoiditis and traumatic syringomyelia and treated by a pedicled omental onlay graft to the spinal cord, is described. The patient made a remarkable recovery and 1 year after surgery he continues to maintain excellent progress. He is now able to walk with support and is completely independent. It is suggested that chronic paraplegics should be assessed for possible arachnoiditis and traumatic syringomyelia and if detected an omental transposition be considered as one means of increasing rehabilitation potential.

Routine or selective peroperative cholangiography.

The routine use of peroperative (pre-exploration) cholangiography was prospectively studied in 433 consecutive patients undergoing elective cholecystectomy. Satisfactory peroperative cholangiography was achieved in 396 patients using a C-arm image intensifier with image retention facility. Clinical indications for exploration of the common bile duct were noted for each patient but the decision for choledochotomy was determined by the cholangiographic results. Two hundred and forty-nine (63 per cent) patients had no clinical indications for duct exploration and cholangiographic findings were all normal. Of the 147 patients with positive clinical criteria, 39 (9.8%) had abnormal cholangiograms and required exploration of the common bile duct. In three patients duct exploration was negative giving a false positive rate of 0.73 per cent. The use of the image intensifier allowed dynamic study during cholangiography and optimum evaluation of the duct system. The results support the view that peroperative cholangiography could be restricted to patients with clinical indications for exploration of the common bile duct.