Biosocial factors affecting vitamin D status of women of childbearing age in the United Arab Emirates.

Low serum 25-OHD in female Arab subjects, which may predispose their infants to hypocalcaemia, has been suggested to be due to inadequate sunshine exposure, but may include other sociobiological factors. The effects of duration of sunshine exposure--weighted against the magnitude of clothing (UV exposure) and other sociobiological variables such as age, education and living accommodation--on serum 25-OHD and mineral status of 33 UAE national women of childbearing age were compared with those of 25 non-Gulf Arabs and seventeen Europeans. Serum concentrations of calcium, phosphorus, alkaline phosphatase and intact parathyroid hormone among the groups were not significantly different. The serum concentration of 25-OHD in UAE nationals was 8.6 ng/ml (4.5-17.4), mean +/- 1 SD, and in non-Gulf Arabs 12.6 ng/ml (6.0-26.4); both these values were significantly lower (p = < 0.0001) than the 64.3 ng/ml (49-84.3) found in Europeans. Compared with Europeans, the UAE and non-Gulf Arabs in this study were younger, had fewer years of education and had significantly lower clothing and UV scores (p < 0.0001). Furthermore, there was a positive correlation (r = 0.59425) between serum 25-OHD and UV score, but not with length of exposure. After adjusting for other confounding variables, nationality, clothing and UV scores remained major determinants of serum 25-OHD (p < 0.0001). Therefore, limited skin exposure to sunlight appears to be an important determinant of vitamin D status in our subjects. Strategies to increase vitamin D stores should include vitamin D supplementation or advice on effective sunlight exposure.

PIP: Maternal vitamin D deficiency can aggravate development of neonatal hypocalcemia and impair fetal bone growth. Despite abundant sunshine exposure, Arab women have low serum concentrations of 25-hydroxy vitamin D (25-OHD). A study conducted in Al Ain, United Arab Emirates (UAE), compared the vitamin D status of 33 UAE nationals, 25 non-Gulf Arabs (Jordanians, Egyptians, Palestinians, and Lebanese), and 17 Europeans. Serum concentrations of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were not significantly different in these three groups. However, mean serum 25-OHD concentrations were significantly lower among UAE nationals (8.6 ng/ml) and other non-Gulf Arabs (12.6 ng/ml) than in Europeans (64.3 ng/ml) (p 0.0001). The rate of vitamin D insufficiency (5 ng/ml) was 24% among UAE nationals and 12% among non-Gulf Arabs; there were no such cases among Europeans. The ultraviolet ray (UV) exposure score, which weighted sunshine exposure against the magnitude of body coverage with clothing, was significantly higher in European women than in the two Arab groups. There was a positive correlation between total UV exposure score and serum 25-OHD level (r = 0.59425). About 35% of the variation in serum 25-OHD could be explained by the cutaneous skin exposure score. The limited exposure of Arab women's skin to sunlight as a result of their traditional, extensive clothing appears to play an important role in the high frequency of low vitamin D status in this population. Vitamin D supplementation should be considered.

The primary care anxiety and depression (PCAD) scale: a culture-oriented screening scale.

The construction of a screening scale for states of anxiety and depression among primary health care (PHC) patients is described. Most of the scale items were selected from a pool of items chosen from two international screening scales which were validated locally, namely the Self-Reporting Questionnaire (SRQ-20) and the Hospital Anxiety and Depression (HAD) Scale. A validity study of a new sample of PHC patients indicated that the scale provided a valid measure of anxiety and depressive states, and was closely correlated with the psychiatrist's clinical judgement. The scale correlated more strongly with the psychiatrist's clinical judgement than the general practitioners' assessments. Two cut-off points were established, one of which is more appropriate for clinical use and the other for prevalence estimation. The former threshold of the scale could be used to alert the busy general practitioner to the possibility that clinically significant anxiety or depression may be present.

Retesting the validity of the Arabic version of the Hospital Anxiety and Depression (HAD) scale in primary health care.

The Arabic version of the Hospital Anxiety and Depression (HAD) scale was retested and cut-off points determined in a sample of 217 patients attending a primary health care centre in Al Ain, United Arab Emirates (U.A.E.). Subjects were screened using the HAD scale and all patients were then interviewed by a single consultant psychiatrist. The scale scores were assessed against the psychiatrist's clinical evaluations. The study furnished evidence that the Arabic version of the HAD scale is a valid instrument for detecting anxiety and depressive disorders in primary health care settings. Spearman rank correlations of all items of the scale were significantly above zero. The butterflies item of the anxiety subscale had the lowest correlation coefficients. The overall Cronbach alpha measures of internal consistency were 0.7836 and 0.8760 for anxiety and depression, respectively. The cut-off points that produced a balanced combination of sensitivity and specificity appropriate for referral to a psychiatric facility by the general practitioner were 6/7 for anxiety and 3/4 for depression. Almost all other similar studies have determined a single cut-off point for both subscales of the HAD. This study also indicated that the HAD depression subscale is more consistent and more predictive than the HAD anxiety subscale. Moreover some of the problems arising from applying psychiatric research instruments across cultures are highlighted by this study.

Behaviour disorders in primary school children in Al Ain, United Arab Emirates.

A multi-stage random sample of primary school children in central Al Ain city, Abu Dhabi Emirate, United Arab Emirates was screened in January 1993 with the Rutter B2 Scale to estimate the prevalences of behaviour disorders, and to determine whether and how these were associated with the age, gender, nationality, grade and scholastic performance of the children. Of 2100 boys and girls aged between 5.4 and 16.6 years, 13.5% showed some form of behaviour disorder. The overall prevalence of disorders was significantly higher in boys than in girls (16.3% v 10.2%). Emotional, conduct and undifferentiated disorders were noted in 4.8%, 6.9% and 1.8% of all children, respectively. Conduct disorder was significantly commoner in boys than in girls (9.3% v 4.1%). In multivariate logistic regression analyses, different disorders were significantly associated with gender and/or grade and/or scholastic performance with the odds being the lowest in girls, in children in grades 3 to 6, and in children with excellent or very good scholastic performance. Nationality was not significantly associated with behaviour disorders in the children studied. A considerable proportion of young children in Al Ain manifest signs of behaviour disorders in primary school. Primary school children in Al Ain and comparable areas should be screened for behaviour disorders, and those found positive by screening tests should be assessed by health professionals to confirm the presence or absence of behaviour disorders which need expert care.

Minor psychiatric morbidity in primary health care: prevalence, nature and severity.

The Clinical Interview Schedule (CIS) (Goldberg et al. 1970) was applied in a study investigating the prevalence rate, nature and severity of minor psychiatric disorders among U.A.E. nationals attending a primary health care centre in Al Ain, United Arab Emirates (U.A.E.). The total prevalence rate of minor psychiatric morbidity, among the group of attenders who were interviewed, was 27.6%. The morbidity was higher among females (31.9%), than males (20.3%). The highest morbidity rate among the entire sample occurred among the 35-54 year age group. The commonest diagnoses encountered were neurotic depression (55%), anxiety-depressive states (13.3%) and anxiety states (11.7%). The distribution of diagnostic entities was similar among males and females except for anxiety-depressive states which were more common in females. The prevalence of neurotic depression and anxiety-depression states were highest in the middle age group, while anxiety states were highest among the young age group. The overall severity rate (OSR) among the identified cases was found to be ranging between mild and moderate severity.

Road traffic injuries in Al-Ain City, United Arab Emirates.

Road traffic injuries are the second major cause of death in the United Arab Emirates (UAE). A retrospective study for a 1 year period of all road traffic accidents and injuries was conducted in Jimi Hospital for the period 1 January to 31 December, 1990. A total of 1197 injuries were encountered at the Hospital Emergency Department. The majority of victims were males and under the age of 35 years. During the Ramadan (fasting month), the number of persons who were injured by traffic accidents was slightly higher than during other months. Excessive speed was closely related to traffic accidents and injuries. Most of the accidents and injuries occurred from 8.00 am to 2.00 pm. Head injury was the most frequently noted type of injury (40.5%), followed by limbs injury (22.1%) and chest, abdomen and pelvic injuries (14.7%). These findings suggest that there is a need to take a comprehensive approach on both excessive speed and driving habits.

Life events stress in Saudi peptic ulcer patients of the eastern province.

The frequency of stress, as measured by the occurrence of 34 life events in the year preceding evaluation, was compared between 51 Saudis with peptic ulcers, diagnosed endoscopically, and 52 Saudis without peptic ulcer. All subjects were examined at King Fahd Hospital, Al-Khobar, Eastern Saudi Arabia, and were seen between March 1985 and July 1987. The mean number of events, their frequency distribution, and their categorization into areas of activity such as bereavement and other problems relating to health, marital, financial, and undesirable circumstances were similar for both groups. With regard to individual events, the only significant differences between ulcer patients and controls were that more patients had had serious arguments with in-laws or relatives and more controls had had minor personal illness or moderate financial problems. Excessive stress, as measured by life events, does not appear to be evident in Saudi peptic ulcer patients of the Eastern Province. Anxiety and/or depression was significantly more frequent in the group of patients with ulcers.

Obesity in a primary health care centre: A retrospective study.

In a retrospective study, the heights and weights of 1072 Saudis (477 men and 595 women), aged 18 to 74 years, were studied to determine the prevalence of obesity in Saudi patients attending the primary health care center of King Fahd Hospital of the University, Al-Khobar, in the Eastern Province of Saudi Arabia. Of the total group, 51.5% (95% confidence interval, 46.5 to 56.0) of the men and 65.4% (95% confidence interval, 61.5 to 69.2) of the women were considered obese, using as the criterion a body mass index (wt/ht(2)) of greater than 25 kg/m(2). Significantly more women were obese than men. An active detection program and campaign against obesity must be mounted in the community, and this should include advice on diet and the better education of patients with regard to obesity and its complications.

Infections and sickle cell disease in Eastern Saudi Arabian children.

The rate and pattern of infections in 144 Saudi Arabian children with sickle cell disease (SCD) and matched normal control subjects are reported. All diagnoses of SCD were made at birth by means of screening blood from the umbilical cord. The children were prospectively followed up from birth to 4 years of age. Severe bacterial infections occurred in none of the children with SCD; one of the control children developed pneumococcal meningitis. Acute gastroenteritis was significantly more common among patients with SCD. For the first year of life, patients with SCD had significantly more infections than did the control children; but the reverse was true in the group that was 37 to 48 months of age. Considering all types of infections for all age groups, no difference was noted between patients with SCD and control subjects in terms of infection rate or related hospital admission. There were no deaths caused by infection in this series. We conclude that Saudi Arabian infants and young children of oasis origin with SCD are not at increased risk of infections compared with healthy children of the same age.

Atropine-edrophonium mixture: a dose-response study.

The dose-response and the doses required to prevent bradycardia in 50% (ED50) and 95% (ED95) of patients were determined for atropine after antagonism of pancuronium-induced neuromuscular blockade in 72 patients with edrophonium-atropine mixtures. Edrophonium 0.67 mg/kg (group A, n = 37) or 1.0 mg/kg (group B, n = 35) was randomly mixed with one of seven doses of atropine (ranging from 0.0125 to 0.0215 mg/kg in group A and from 0.02 to 0.04 mg/kg in group B); with dose-response curves for atropine being constructed for both groups 5 and 10 minutes after the injection of the mixture. These dose-response curves were found to be parallel in both groups. The calculated ED50 values of atropine were 1.6-2 times greater in group B, compared with those in group A. The estimated ED50 doses of atropine in groups A and B at 5 minutes were 0.018 and 0.029 mg/kg, respectively, and at 10 minutes, the ED50 doses were similar, being 0.016 and 0.032 mg/kg, respectively. The calculated ED95 doses of atropine in groups A and B at 5 minutes were 0.024 and 0.055 mg/kg, and at 10 minutes, the ED95 doses were also similar, being 0.027 and 0.05 mg/kg, respectively.

Pharmacokinetic profile of epidural meperidine with and without dextran 70.

To evaluate the effect of dextran 70 on the kinetics of epidural meperidine, 10 female patients anesthetized with nitrous oxide and halothane were studied. Meperidine, 1 mg.kg-1, was administered epidurally in either 10 ml dextran 70 in saline solution (group I) or 10 ml saline solution (group II, control subjects). Plasma concentration of meperidine was determined for 10 hours after its administration with GC. Meperidine plasma concentration-time curves could be best resolved into three exponential terms with a lag time in both groups of patients. The disposition kinetics were described adequately by a three-compartment model. This study demonstrated that apart from a significantly longer lag time and smaller k10 (apparent first-order rate constant for elimination of meperidine from the central compartment), the addition of dextran did not alter significantly the kinetic parameters of epidural meperidine.

Validity study of the Hospital Anxiety and Depression Scale among a group of Saudi patients.

The Arabic version of the HAD scale was validated in a sample of 50 Saudi patients. The scale scores were assessed against the principal author's clinical evaluations. Spearman correlations of all items of the scale, except for one, were statistically significant. The non-significance of one item was probably related to the way it was translated into Arabic. The study furnished evidence that the Arabic version was a reliable instrument for detecting states of anxiety and depression in Saudi patients in a primary health care setting.

The pattern of train-of-four fade after atracurium: influence of different priming doses.

This study was designed to investigate the effect of three different priming doses of atracurium--0.06, 0.07, and 0.08 mg/kg--followed 3 min later by the remainder of a 0.5 mg/kg dose on the relationship between the depression in the first twitch of the train-of-four (T1) and train-of-four (TOF) fade. This relationship was studied after the administration of the full dose of the relaxant in all groups. Of all the priming doses, 0.08 mg/kg atracurium, when followed 3 min later by 0.42 mg/kg atracurium, had a significantly greater fade in the TOF ratio at any given T1 value. This may indicate significant prejunctional activity. Acceleration of the onset of neuromuscular blockade was, however, evident in all groups that received atracurium in divided doses. The implication is, therefore, that prejunctional activity may not contribute significantly to the acceleration of onset of neuromuscular blockade after administration of atracurium in divided doses, as described in this study.

Cannulation of the radial and dorsalis pedis arteries.

The complications inherent in cannulation of the radial (group I) and dorsalis pedis (group II) arteries were studied in 46 patients. All the local and systemic variables which might be considered to contribute to damage of the artery were studied, from which it appeared that only the duration of cannulation, prothrombin time and partial thromboplastin time were significant in determining post-cannulation blood flow. A 20-gauge Teflon cannula was used in all patients and velocity of flow measured with a Doppler velocimeter probe. A majority of arteries showed a reduction of flow velocity for 24-72 h after the removal of the cannula, with evidence of improvement at 120 h. In six arteries--three in each group--flow ceased altogether after 24-72 h. No disability of either hand or foot resulted.

Priming with atracurium: improving intubating conditions with additional doses of thiopental.

The effects of different intubating doses of atracurium on the time of onset, and the effect of an additional dose of thiopental on intubating conditions, were studied in 72 patients divided into six groups (n = 12 in each). Stratified sampling was used to obtain an even sex distribution. Groups I, III, and V (controls) received atracurium as a single bolus dose of 0.4, 0.5 or 0.6 mg/kg respectively. Groups II, IV, and VI received an initial (priming) dose of 0.05 mg/kg followed 3 min later by 0.35, 0.45, or 0.55 mg/kg respectively. The time of onset, that is the time from the intubating dose to complete suppression of the train-of-four (TOF) response, was significantly accelerated after administration of atracurium in divided doses. Increasing the intubating dose of atracurium after an initial 0.05 mg/kg from 0.35 to 0.55 mg/kg did not result in further significant acceleration of the onset time, but resulted in prolongation of the duration of neuromuscular blockade. When divided doses of atracurium were given, administration of 2 mg/kg thiopental (in addition to the 5 mg/kg used for induction) before the injection of the intubating dose resulted in improvement of intubating conditions as reflected by statistically significant changes in intubating scores. This result was probably due to the increase by thiopental in the depth of anesthesia. Therefore, when thiopental is given as supplement, the priming technique can be made to provide better conditions for tracheal intubation in less than 90 sec.

The optimal priming dose for atracurium.

To determine the optimal priming dose for administration in divided doses, atracurium was given to 77 patients either in a single dose of 0.5 mg X kg-1 or in an initial dose of 0.04, 0.05, 0.06, 0.07, 0.08 or 0.09 mg X kg-1, followed three minutes later by the remainder of the 0.5 mg X kg-1 dose. Patients were anaesthetized throughout the study. When atracurium was given as a single bolus of 0.5 mg X kg-1, the mean time to complete neuromuscular block was 141.5 seconds. Administration in divided doses accelerated the onset time (p less than 0.01), that is the time from the intubating dose to the complete suppression of train-of-four (TOF) response. The TOF ratio decreased slightly but statistically significantly following the priming doses. When the priming dose was 0.05 mg X kg-1, the mean onset time was 70.9 seconds and priming with larger doses did not add any further advantage. It is concluded that 0.05 mg X kg-1 appears to be the optimal priming dose for the administration of atracurium in divided doses. When 0.05 mg X kg-1 is given three minutes before the intubating dose, tracheal intubation can be accomplished in less than 90 seconds.

Rapid tracheal intubation with atracurium--a comparison of priming intervals.

To determine the optimal interval between the administration of the priming dose and the intubating dose, atracurium was given to 44 patients either in a single dose of 0.5 mg X kg-1 or in an initial dose of 0.06 mg X kg-1 followed two, three or five minutes later with 0.44 mg X kg-1. When atracurium was given as a single bolus of 0.5 mg X kg-1 the time to 100 per cent twitch suppression (onset time) was 90.9 +/- 36 (mean +/- SD) seconds. When the priming interval was two minutes, the onset time of the intubating dose was 76.6 +/- 42.2 seconds (p = NS). But when the priming interval was three or five minutes, the onset times were 42.2 +/- 16.5 (p less than 0.01) and 52.6 +/- 28.8 (p less than 0.05) seconds respectively. Waiting for five minutes after the administration of the priming dose did not improve the intubating conditions. It is concluded that three minutes appears to be the optimal time interval for the administration of atracurium in divided doses. When a priming dose of atracurium is given three minutes before the intubating dose, it can provide an alternative to succinylcholine for rapid endotracheal intubation.

Antiemetic efficacy of high-dose dexamethasone: randomized, double-blind, crossover study with high-dose metoclopramide in patients receiving cancer chemotherapy.

A double-blind, randomized, crossover study was conducted to compare the efficacy and safety of high-dose dexamethasone and high-dose metoclopramide in the treatment of chemotherapy-induced nausea and vomiting. All entered patients had no prior chemotherapy and all received inpatient emetogenic chemotherapy mainly without cisplatin. Of the 40 evaluable patients, 23 (58%) had no vomiting with dexamethasone compared with only 11 (28%) receiving metoclopramide (P less than 0.025). Dexamethasone was found to have less adverse effect than metoclopramide on patient's appetite and activity (P less than 0.025 and P less than 0.01, respectively). Twenty-one patients (53%) developed mild to severe somnolence with metoclopramide compared to only seven (18%) who experienced this adverse effect with dexamethasone (P less than 0.01). Six patients (15%) developed extrapyramidal manifestations with metoclopramide, but none with dexamethasone. Furthermore, during dexamethasone therapy, patients developed less diaphoresis, insomnia, headache and dizziness. Upon questioning patients about their preference to future use of the antiemetic drug therapy, 28 patients (70%) preferred dexamethasone, two (5%) preferred metoclopramide and 10 (25%) found no difference. We conclude that high-dose dexamethasone has a greater antiemetic activity and is more safe than high-dose metoclopramide in patients receiving emetogenic chemotherapy mainly without cisplatin.

Epidural ketamine for postoperative analgesia.

Thirty-four patients of ASA physical status I or II scheduled for gall bladder surgery were studied in a comparative prospective trial to evaluate the efficacy of epidural and intramuscular ketamine for postoperative pain relief. They were divided randomly into three groups. Group I (11 patients) received 30 mg intramuscular ketamine. Group II (10 patients) and Group III (13 patients) received 10 and 30 mg ketamine in 10 ml saline respectively, through epidural catheters. Pain was evaluated every two hours for the first 24 hours post-operatively by using a linear analogue pain scale from 0-10. Ketamine was given on the patient's request and whenever the pain score exceeded three. Ketamine produced analgesia in all patients studied. The reduction of pain score after two and four hours in Group I and III was significant when compared to Group II. Seven patients (54 per cent) in Group III did not require further analgesia after the initial injection. However, following 10 mg epidural ketamine or 30 mg IM ketamine, post-operative pain was more frequent. Four patients who received epidural ketamine complained of transient burning pain in the back during injection. No patient developed respiratory depression, psychic disturbance, cardiovascular instability, bladder dysfunction or neurologic deficit. It is concluded that 30 mg epidural ketamine is a safe and effective method for postoperative analgesia.