Rational use of therapeutic drugs in the Caribbean

The concept of "Rational drug use" means the selection of the most appropriate and cost effective drugs, carefully prescribed, with an understanding of patient education needs and compliance problems. Caribbean experience and recent Drug Utilisation Review (DUR) studies indicate that drug use for common problems like hypertension, diabetes and arthritis could be greatly improved. Applying the principles of rational drug use can save money, improve treatment and bring effective drugs to more of our populations. Emphasis must be on education rather than regulation, which leads to other adverse consequences. Skilled professionals and National Drug and Therapeutics Committees are essential, to steer a rational path between the pressures of the drug industry and the realities of economies in crisis (AU)

Low prevalence of rheumatoid arthritis in Black-Caribbeans compared with whites in inner city Manchester

OJECTIVES- to compare the prevalence of rheumatoid arthtitis (RA) in Black-Caribbeans and whites living in the same urban area. METHODS- cases of inflammatory joint disease were ascertained initially from a postal screening survey of 1851 blacks and 1829 age and sex-matched non-Blacks identified from general practices in the Moss Side and Hulme districts of Manchester. The ethnicity of the respondents was confirmed using data from a postal screening questionnaire. Those reporting joint swelling or a history of arthritis were reviewed by a rheumatologist at surgeries held in each practice. The clinical records of the questionnaire non-responders and questionnaire-positive non-attenders at surgery were reviewed. RESULTS- in an adjusted denominator population of 1046 Black-Caribbeans and 997 whites, the cumulative prevalence of RA was 2.9/1000 in Black-Caribbeans and 8/1000 in whites, representing a prevalence in Black Caribbeans of 0.36 times that found in whites (95 percent confidence interval 0.1-1.3). CONCLUSIONS- rheumatoid arthritis occurs less commonly in Black-Caribbeans than in Whites. The findings are consistent with published studies showing a low RA prevalence in rural black populations (AU)

Agricultural practices affect arthritis

It has been suggested that boron deficiency in food may be a cause of some arthritis (Newnham 1979). Epidemiological studies were done to try to ascertain why some countries have more or less arthritis than other countries. Jamaica, Mauritius, Fiji and Israel were visited with a view to ascertaining the boron levels of locally consumed food as it was suspected that excessive use of soluble chemical fertilizers had damaged the soils of the sugar producing lands. Food grown on these soils were found to have low boron level. By contrast the food consumed in Isreal had high boron concentrations associated with a low incidence of arthritis. South African work has shown that people who eat mostly maize have more arthritis when eating processed maize grown with fertilizer. Brief references is made to the role of boron in human diets. There are bound to be geographical differences in dietary boron, but even in the USA levels have dropped considerably in 50 years. Arthritis is increasing, especially juvenile arthritis. The increased use of fertilizers and genetic selection of plants has led to a wide range of changes in the quality of foodstuffs and their nutrient content. The identification of the parallel loss of boron may reflect vital changes in trace elements and other nutrients (AU)

Arthritis in childhood: a report on 65 consecutive cases observed at the University Hospital of the West Indies

In a two-year period (October 1985 - September 1987), 65 children presented to the Child Health Department and/or rheumatology clinic at the University Hospital with arthritis. Eighteen children (28 percent) had juvenile chronic arthritis, ten (15 percent) rheumatic fever, eight (12 percent) systemic lupus erythematosus and thirteen (20 percent) had self-limiting arthritis. Systemic onset of juvenile chronic arthritis occurred only in one child; nine children has polyarticular and eight pauci-articular onset of disease. The self-limiting arthritis was difficult to differentiate from juvenile chronic arthritis; therefore serological testing for bacterial and viral infections should be performed before anti-rheumatic therapy is undertaken. Arthritis in childhood is not uncommon in Jamaica. However, the outcome appears to be generally favourable except in a few cases of juvenile chronic arthritis (AU)

Lupus nephritis at U.H.W.I., Kingston, Jamaica: a 10-year experience - abstract

The case records of seventy-five patients who had systemic lupus erythematosus (SLE) and renal involvement on renal histology were reviewed. There were 70 females and 5 males and the majority of patients were in their second or third decades of life. It was distinctly uncommon in patients below 10 years of age and above 50 years of age. Over 80 percent of the patients developed renal involvment within one year of diagnosis of SLE. The commonest presenting features were arthritis - 78 percent and rash - 48 percent. The 2 commonest presenting renal features were proteinuria and renal failure - 60 percent and 55 percent respectively. When the renal histology was classified according to the WHO classification, 20 percent had class II, 12 percent had class III, 48 percent had class IV, and 17 percent had class V. Three percent had glomerular sclerosis and so were unclassifiable. The acute nephritic syndrome was seen in 83 percent of class IV cases, whole renal failure was seen in 61 percent of class IV cases. In class V no patient had the acute nephritic syndrome, whereas 62 percent had the nephrotic syndrome and 44 percent had renal failure. The 5 year survival rate was 100 percent in classes II & V combined and sixty-two percent in classes III & IV combined (AU)

Arthritis in Jamaica - abstract

Presented are data on 241 patients who attended the Rheumatology Clinic U.H.W.I. over a 5-month period. Two hundred and eight (86 percent) of the patients were female. The ages ranged from 7 to 87 years (mean 41 years). Seventy-eight (32 percent) had rheumatoid arthritis. Their mean age was 47 years (range 18-84 years). Only 2 patients were male. Twenty-one (27 percent) were negative for the rheumatoid factor, and 7 (9 percent) had anti-nuclear antibodies. Twenty-seven patients (11 percent), all female, were diagnosed as having systemic lupus erythematosus. Their mean age was 30 years (range 10-50 years). Two patients were consistently negative for anti-nuclear antibodies. Other diseases frequently diagnosed were: degenerative joint disease in 26, juvenile rheumatoid arthritis in 12, mixed connective tissue disease in 8, spondylitis in 7. Forty-one patients were seen with arthralgia and/or myalgia without evidence of an inflammatory process (AU)

Aspects of obesity in suburban Kingston women

This community study compared obese (Quetelet index o 25 kg/mý) women in two lower-middle income suburbs of Kingston, Elletson Flats and Mona Commons. Weight, height, mid-upper arm circumference and skinfold thickness at 4 sites (triceps, biceps, subscapular and suprailiac) were measured. Factors associated with obesity, prevalence of, knowledge of and attitudes to degenerative diseases; and of possible aetiological significance, obstetric history, dietary and activity patterns, were investigated using a questionnaire. The sample comprised 140 obese and 137 non-obese women aged 20 - 81 years, stratified by decade. The majority (71.2 percent) of the obese women were overweight, (25 - 29.9 kg/mý) and 28.8 percent were moderately (30 - 39.9 percent kg/mý) obese. The obese were significantly shorter, heavier and had larger mid-upper arm circumferences and skinfold thicknesses than the non-obese women. Younger women were significantly taller but had smaller mid-upper arm circumferences, Quetelet indices and suprailiac skinfold thicknesses than the 40+ year olds. The triceps skinfold thicknesses ranked highest among the skinfold thicknesses of both groups. The study also indicated an obesity prevalence of 32 percent and 49 percent among 30+ and 20+ year olds in Elletson Flats and Mona Commons respectively. Socio-economic status, parity and number of meals eaten showed no association with obesity while number of snacks eaten showed a positive association (P = 0.002). More obese (36.4 percent) than non-obese (12.4 percent) women had a preference for sweet foods while more non-obese preferred fruits and vegetables and meat and fish. Obesity was not associated with the women's obstetric and gynaecological history. However, although more obese women said they had gained weight during pregnancy 43 percent of obese women perceived themselves as being fat since they were young (< 10 years old). More obese than non-obese women had a family history of obesity (P< 0.001). The obese had significantly more complaints (P = 0.003), more of them were taking prescribed drugs (P< 0.001) and attended public health facilities more often than the non-obese women. Diabetes mellitus, heart disease and varicose veins were not associated with obesity but there was an increased prevalence of arthritis and hypertension among the obese (P< 0.001). Moreover, obese women were cognizant of the relationship between overweight and ill health and had attempted to slim, presumably more for health than social reasons. Overall activity patterns showed no association with obesity although more controls (34.3 percent ) than obese women (19.3 percent ) undertook moderately active pursuits during their leisure time (P< 0.005). It can therefore be concluded that frequent snacking, preference for sweet foods, maintenance of weight after delivery and family history of obesity are factors contributing to the genesis of obesity in this community. Although there was an association between morbidity and obesity, especially moderate obesity, the similarity between obese women and controls in disease experience was striking. This suggests that mild obesity or overweight is a benign condition in Jamaican women. Multiparity cannot be used to explain obesity in these women. There is need for further epidemiological research aimed at elucidating the aetiology and consequences of obesity in Jamaican women (AU)

Non-gouty arthritis in sickle cell disease: report of 37 consecutive cases

Arthritis in association with sickle cell disease was seen in 37 patients in a 21/2-year period. Cases of gout and of avascular necrosis of the femoral head were excluded. In 12 patients a non-inflammatory effusion occurred during the course of a painful crisis, in 12 patients an ankle effusion occurred in association with spontaneous development or deterioration of leg ulceration and in 13 patients there was a group of miscellaneous arthritides. Ankle arthritis with leg ulceration has not been previously recognised and its association with spontaneous ulceration, which is presumed to have a vaso-occlusive origin, is compatible with ischaemic synovial damage. The aetiology may therefore be similar to that believed to account for effusions in association with the painful crisis. (AU)

Observations on lymphogranuloma venereum

Lymphogranuloma venereum is a venereal disease caused by a virus belonging to the lymphogranuloma-psittacosis group. This disease is by no means limited to tropical countries. Acute infections with lymphogranuloma venereum show a conspicuous predilection for the male sex, whereas the later stages, elephantiasis genito-anorectalis and esthiomene, are much more frequent in the female. The value and limitations of Frei's intradermal test are discussed. The significance of transmission of the virus to animals and the results of virus research and their bearing on Frei's test and C.F.T. are surveyed. The three clinical stages of lymphogranuloma venereum are described and reference is made to the general manifestations of the disease as seen in eyes, joints and skin. A short evaluation of diagnostic procedures is presented and the principles of modern treatment of the disease are outlined. Some personal observations derived from the author's experience during war service in the Far East are mentioned (AU)