Birth weight may influence susceptibility to oedematous forms of severe protein-energy malnutrition [abstract]

OBJECTIVE: To determine whether an association exists between reported birth weight and oedematous forms of severe protein energy malnutrition (PEM). METHODS: Severe PEM continues to be a major public health problem worldwide. However, the causes of oedematous PEM (OPEM) have not yet been elucidated. Recently, birth weight was reported to be associated with risk of ischaemic heart disease and Type 2 diabetes mellitus in adults. It is possible that the examination of the relationship between birth weight and OPEM in children may give clues, not only about the mechanisms underlying the developing of OPEM, but also about the mechanism by which associations between birth weight and adult disease may arise. As part of a larger project to create a database containing information on children admitted to the ward of the Tropical Metabolism Research Unit, the authors reviewed the clinical records of 884 children. Children were categorised as having either OPEM or non-OPEM. Multiple logisitic regression was used to examine the relationship between reported birth weight and the odds ratio (OR) for having OPEM. RESULTS: In this sample of children, the OR for having OPEM was 1.40 (95 percent CI 1.15 - 1.70) for each increase of 1 pound in birth weight. Birth weight remained significant even after inclusion of gender, mother's age and birth rank in the mutliple logistic regression model. CONCLUSION: These results suggest that among children with severe PEM, higher birth weights are associated withan increased risk of oedematous malnutrition. Replication of this result in a large sample is required.(Au)

Vasoactive alterations in lower limb subcutaneous resistive arteries from Caribbean patients with atherosclerosis

OBJECTIVE: This study was performed to investigate the endothelium-dependent relaxation and contractile responses to endothelin-1 in subcutaneous resistive arteries from Caribbean patients with advanced atherosclerotic femoro-crural arterial disease. DESIGN AND METHODS: Small subcutaneous arteries (inner diameter 200 um) from control subjects (n=8) and atherosclerotic patients (n=8) were dissected from fat biopsies obtained at routine vascular surgery and mounted in vitro on a wire-myograph measuring parietal tension under isometric conditions. RESULTS: Acetylcholine-induced relaxation (10-6 M) was significantly reduced in pre-contracted arteries from atherosclerotic patients (24 + or - 16 percent vs 17 percent in control, p<0.001). Smooth muscle relaxation to sodium nitroprusside was comparable in both groups. Contractions elicited by endothelin-1 (10-9 M) were significantly lower and almost suppressed in both the atherosclerotic group (1.2 + or - 0.8 Kpa) and in the hypertensive subgroup of control subjects (n=4, 1.2= 0r - 1.2 Kpa) comparatively to normotensive control subjects (12.3 + or - 6.9 Kpa, p<0.001). Contractile responses induced by endothelin-1 at higher concentrations (10-8 - 10-7 M), noradrenaline and hyperosmolar potassium were comparable in both groups. CONCLUSIONS: These data suggest a specific impairment of both endothelium-dependent relaxation and contractility in lower limb subcutaneous resistive arteries from Caribbean patients with atherosclerotic femoro-crural arterial disease. These changes in vessels which largely determine proximal vascular resistance may contribute to ischaemic complications in this vascular bed including skin ulcerations and gangrene.(Au)

The prevalence, aetiology and treatment of congestive cardiac failure in Antigua and Barbuda

A retrospective review of the cases of congestive heart failure admitted to Holberton Hospital in Antigua in 1995 and 1996 was undertaken. Two hundred and ninety-three (293) patients were identified by International Statistical Classification of Diseases, 10th revision (ICD-10) coding as having congestive cardiac failure in the period but only 138 charts were either available or fitted the definition of congestive cardiac failure and these provided the basis for this analysis. The average age of patients admitted for congestive cardiac failure was 69 years (range: 5 months to 99 years), and 63 percent were female. The aetiology of congestive cardiac failure was hypertension (41 percent), ischaemia (3 percent), valvular (12 percent), alcohol related (2 percent), idiopathic (5 percent) and mixed (7 percent). Treatment included diuretics (95 percent), angiotensin converting enzyme inhibitors (78 percent), digoxin (75 percent), nitrates (34 percent), calcium channel blockers (25 percent), other vasodilators (7 percent) and antiarrhythmics (5 percent). Of those with congestive heart failure, diabetes was present in 38 percent, atrial fibrillation in 19 percent, renal insufficiency in 17 percent, elevated cholesterol in 11 percent, obesity in 9 percent and tobacco use in 7 percent. The in-hospital mortality in the 2-year period was 17.4 percent (females 15 percent, males 22 percent, 11 percent < 65 years, 20 percent > 65 years, 14 percent for those with 1 to 3 admissions and 83 percent for those with > 3 admissions, 19 percent for those with atrial fibrillation and 16 percent for those without). The prevalence of congestive cardiac failure utilizing the data analysed in this study (138 patients) was 0.21 percent of the population of 40 to 65-year-age group and 4 percent in those > 65 years of age. The patients in this study represented only those with New York Heart Association (NYHA) classes 3 and 4, hence the true prevalence would be higher than recorded here. Congestive cardiac failure is emerging as a significant health problem in Antigua and Barbuda.(AU)

Ethnicity and excess mortality

The study examines and assesses the excess mortality from cerebrovascular disease, ischaemic heart disease, diabetes, hypertensive disease, injury and poisonings in City and Hackney descendents by country of birth used as proxy of ethnicity. The five year specific death rates for descendents aged 35 to 84 yars for England and Wales during the period 1986-90 was used as the standard to celebrate standardised proportional mortality ratios for these diseases. Mortality odds ratios were computed using the United Kingdom born descendents as the comparison group and all causes of death except genitourinary neoplasms, cirrhosis of the liver and the causes of interest as the auxillary (controls) cause of death. African Caribbean groups contribute 95 percent of the excess mortality from hypertensive disease. Caribbean and Indian groups account for over half the excess deaths from diabetes. All three groups contribute the excess deaths from cerebrovascular disease. Indian females appear to have twice the mortality risk of the England and Wales women, but this excess is hidden by the deficits of the Caribbean, British and younger Indian male groups who show deficit deaths from this cause. Mortality differentials are demonstrable by ethnic group at district level and may be greater than other available sources indicate. Standardised mortality odds ratios may be valuable tool for examining data sets lacking denominator data.(AU)

Differences in risk factors in black and white patients with acute ischaemic stroke

BACKGROUND: UK black subjects have an increased incidence of stroke and death from stroke as compared with white subjects. Such differences may reflect differences in risk factors. Methods: Details on demographics and risk factors were recorded prospectively on all patients with ischaemic stroke admitted to King's College Hospital (KCH) during the three year period June 1993 to May 1996. KCH serves a population a population of 220,000 of whom 15 percent are black: about 70 percent of stroke patients are admitted. Patients who were not CT scanned (9 percent) were excluded. RESULTS: 666 patients were admitted with ischaemic stroke; 542(18 percent) were white and 124(19 percent) black. Black patients were younger, median 66 (12) years versus 73 (12) years, p<0.001, and had a slight male preponderance (52 percent versus 47 percent, p=0.25). Blacks had an increased prevalence, as compared with whites of certain vascular risk factors including hypertension (67 percent versus 51 percent, p=0.001) and diabetes mellitus (41 percent versus 16 percent, p

Epidemological transition in Trinidad and Tobago 1953-1992: dissociation of trends in mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease

This study aims to describe trends in age-specific mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease in Trinidad and Tobago between 1953 and 1992 and to relate them to earlier changes in infant motality rates. Average annual age-specific mortality rates per 100,000 were calculated for five time periods from 1953-7 to 1988-92 and plotted by mid-year of birth for cohorts born 1874-1882 to 1944-1952. Regression analyses were performed to test associations between adult mortality rates, infant mortality rates for the same birth cohorts, and period of death. Infant mortality declined from 180 per 1000 in 1901 to 10 per 1000 in 1992. Age-standardised mortality from diabetes mellitus increased, in men from 60 in 1958-62 to 278 in 1988-92, in women the increase was from 89 to 303. Mortality from hypertension declined, in men, from 232 in 1953-57 to 73 in 1988-92, in women, from 206 to 67. Cerebrovascular mortality increased, in men from 341 in 1953-57 to 451 in 1963-67 before declining to 224 in 1988-92. In women cerebrovascular mortality increased from 292 in 1953-57 to 361 in 1963-67 before declining to 196 in 1988-92. There was evidence of deceleration in cerebrovascular mortality for cohorts born after 1908 to 1918. Ischeamic heart disease mortality remained constant. Mid-cohort infant mortality rates were not associated with adult mortality after adjusting for age and period of death. Declining infant mortality was subsequently associated with declining mortality from cerebrovascular disease and hypertensive disease and increasing mortality from diabetes mellitus but there was no association with ischaemic heart disease mortality. These relationships were confounded by secular changes associated with year of death. [AU]

Epidemiological transition in Trinidad and Tobago, West Indies 1953-1992

BACKGROUND: This study aimed to describe trends in age-specific mortality from diabetes mellitus, hypertension, cerebrovascular disease and ischaemic heart disease in Trinidad and Tobago between 1953 and 1992 and to relate them to earlier changes in infant mortality rates. METHODS: Average annual age-specific mortality rates per 100 000 were calculated for 5-year time periods from 1953 -1957 to 1988-1992 and plotted by mid-year of birth for cohorts born 1874-1882 to 1944-1952. Regression analyses were performed to test associations between adult mortality rates, and infant mortality rates for the same birth cohorts and period of death. RESULTS: Infant mortality declined from 180 per 1000 in 1901 to 10 per 1000 in 1992. Age-standardized mortality from diabetes mellitus increased, in men, from 60 in 1958-1962 to 278 in 1988-1992, in women the increase was from 89 to 303. Mortality from hypertension declined, in men, from 232 in 1953-1957 to 73 in 1988-1992, and in women, from 207 to 67. Cerebrovascular mortality increased, in men, from 341 in 1953-1957 to 451 in 1963-1967 before declining to 224 in 1988-1992. In women cerebrovascular mortality increased from 292 in 1953-1957 to 361 in 1963-1967 before declining to 196 in 1988-1992. There was evidence of a deceleration in cebrovascular mortality for cohorts born after 1908-1918. Ischaemic heart disease mortality remained constant. Mid-cohort infant mortality rates were not associated with adult mortality after adjusting for age and period of death. CONCLUSION: Declining infant mortality was subsequently associated with declining mortality from cerebrovascular disease and hypertensive disease and increasing mortality from diabetes mellitus but there was no association with ischaemic heart disease mortality. These relationships were confounded by secular changes associated with year of death.(AU)

Myocardial perfusion scintigraphy using Tc99m labelled compounds: correlation with coronary angiography

The increasing incidence of ischaemic heart disease with high mortality rate and the recent introduction of Tc99m labelled myocardial perfusion imaging agents, along with the advent of a coronary angiography programme in Trinidad and Tobago, prompted the comparison of the sensitivity and specificity of myocardial perfusion scintigraphy (MPS) with coronary angiography (CA). Using a standard one-day code-differential imaging protocol single photon emission computed tomography (SPECT), images of the left ventricular myocardium of 30 patients were obtained at rest and following exercise: These images were analyzed for perfusion defects to assess each of the three main coronary arteries; the left anterior descenting artery (LAD), the right coronary artery (RCA) and the left circumflex artery (LCx). The data were then correlated with the angiographic findings. MPS yielded an overall sensitivity of 97.5 percent and a specificity of 83.6 percent when compared to CA. Discordant data were obtained in the analysis of nine vascular territories with scintigraphy producing eight false positive and one false negative. The false positive cases were seen in two males and four females. Of the males, one was discovered to have intramyocardial tunnelling of the LAD artery and the other demonstrated differential perfusion between the LAD and LCx arteries. Of the females, one was classified as having Syndrome X and another demonstrated differential perfusion between the LAD and LCx arteries; the other two cases were attributed to breast attenuation. The one false negative was obtained in a patient who demonstrated good collateral circulation on angiography. MPS thus compares very well with CA in assessing the three main myocardial vascular territories (AU)

Hypoxic ischaemic encephalopathy at the Mount Hope Women's Hospital, Trinidad - abstract

Hypoxic Ischaemic Encephalopathy (HIE) is a clinical syndrome which develops following foetal distress and a poor response by the infant to the birth process. Severe HIE can lead to death and severe neurological abnormalities. The aim of this study was to determine the incidence and outcome of babies who developed HIE over two 3-year periods, 1982-1984 and 1990-1992, at the Mt. Hope Women's Hospital (MHWH), Trinidad. The records of all inborn babies admitted to the Neonatal Unit, MHWH, with a diagnosis of HIE were studied. Those with proven meningitis, hypocalcaemia, irritability and hypoglycaemia were also excluded. Information collected included maternal characteristics, labour, birth and infant development up to 1 year. The overall incidence for the two study periods was 3.85 per 1000 live births (1982-1984) and 5.19 per 1000 live births (1990- 1992), which was not statistically significant. There was no statistical difference with regard to maternal age, parity, gestation, ethnicity, marital status, antenatal problems, foetal distress, infant gender and Apgar scores at 1 and 5 minutes. Significantly more mothers had antenatal care and more babies developed normally during the second study period. Significantly more mothers had Stage 1 of labour lasting longer than 15 hours in the first study period. There was no difference in the proportion of babies who died during the two study periods and a significantly higher proportion of babies were normal up to one year in the second study period. Like the perinatal mortality rate, HIE did not change with time at the Mt. Hope Women's Hospital (AU)

Stress-induced sudden death or ischaemia - abstract

A few cases of acute coronary syndrome precipitated by stress are described. A 34-year-old female survived seventeen minutes of ventricular fibrillation and CPR, threatened anterior myocardial infarction, LV dysfunction, with normal coronary arteries and normal LV function later demonstrated. This was entirely emotional stress induced. A 45-year-old patient developed severe ischaemia (marked ST elevation on ECG, and angina), with the stress of venipuncture and was later shown to have normal arteries at heart cath. One other patient with known coronary artery developed severe ischaemia during venipuncture, with ST elevation in the V-leads that resolved. Another patient, age 42 with emotional stress induced chest discomfort, developed very abnormal exercise test indicative of ischaemia, but later was shown to have normal coronary arteries. 1. Patients with normal coronary arteries, like patients with coronary artery disease, are at risk for acute coronary syndromes including sudden death, unstable angina, myocardial infarction, all during not so severe stress. 2. Health care workers should be aware of the potential for stress-induced symptoms, and stress-induced acute cardiac syndromes, even with simple procedures such as venipuncture. 3. Patients should be counselled that acute coronary syndrome, like chronic stress, can be cardiotoxic (AU)

A hospital based study of patient and physician response to acute myocardial ischaemia - abstract

A prospective study was undertaken to investigate whether current patient and physician response to acute myocardial ischaemia was suffiently expedient to allow for thrombolysis within the first 6 hours of evolving acute myocardial infarction. During the 1-month study period, 70 patients with chest pain syndrome presented to the Accident and Emergency Department, General Hospital, Port-of-Spain (A&E, POSGH). Data were available on 67 patients, of whom 38 (57 percent) were found to have definite myocardial ischaemia by E.C.G. criteria. The modal time of arrival was 1-3 hours after the onset of chest pain. Sixty-four per cent of all patients arrived within 6 hours of the onset of chest pain. The corresponding figure for the subgroup with confirmed ischaemia was 68 percent. The mean time for evaluation and disposition of patients with confirmed ischaemia in the A&E, POSGH was 47.5 minutes (range 20-112 minutes). Furthermore, the longer time taken for triage of patients who did not have an eventual diagnosis of myocardial ischaemia (57.6 vs 47.5 min) is consistent with the urgency of physician management and the likelihood of ischaemia. The result of this study suggest that the majority of patients presenting to the A&E, POSGH for the treatment of acute myocardial ischaemic s

Post-myocardial infarction ischaemia - abstract

The incidence of excercise-induced ischaemia, arrhythmia and exercise status in patients following acute myocardial infarction was investigated in order to formulate a clinical profile to predict patients with a positive result. Sixty consecutive patients, in one unit, with clinical electrocardiographic and enzymatically confirmed acute myocardial infarction were studied prospectively. They were given the Bruce Protocol Treadmill Exercise Stress Electrocardiogram at approximately six to twelve weeks post-infarction. Holter monitoring was done when indicated. The clinical and risk factor data of the patients were analysed for predictors of post-infarction ischaemia. There were 60 patients, 55 men and 5 women with an age range of 31 to 78 years (mean age 500. Twenty-nine (48 percent), were aged under 50 years and four (7 percent), over seventy. In 57, it was the first myocardial infarction. Myocardial infarction locations were: inferior wall, 30 (50 percent); extensive anterior wall, 15 925 percent); anteroseptal, 9 (15 percent); anterolateral, 5(8 percent): and true posterior wall, 2(3 percent). Twenty-three patients (38 percent) had a Positive Stress Electrocardiogram: 3 mild, 8 moderate, 11 severe and one critically positive. Only six (27 percent) achieved Stage III exercise level. three had moderate and one critical ventricular irritability. Three of this positive group had subsequent re-infarction of whom two died. Six patients had coronary angiography of whom three aortocoronary bypass surgery and one percutaneous transluminal coronary angioplasty. Thirty-seven (62 percent) had a Negative Stress Electrocardiogram. Of these, thirty-three (90 percent) were able to achieve at least Stage III. Only three showed mild ventricular irritability. Age, sex, location of infarction, diabetes mellitus, hypertension, family history of ischaemic heart disease, stress and obesity were comparable in both groups. Only cigarette smoking was higher (57 percent vs 38 percent) in the group with group with positive exercise-induced ischaemia. Coronary artery ischaemia persists in over one-third of patients following an acute myocardial infarction. Based on the patient's profile and risk factors, it is difficult to predict which patients are so affected (AU)

Treadmill exercise stress testing in the assessment of severity and management of ischaemic heart disease - abstract

Patients with definite ischaemic heart disease were subjected to treadmill exercise stress testing to assess the severity of their disease. Twelve lead electrocardiographic recordings were done and Standard Bruce Protocol used. Critical disease was diagnosed with profound ST segment depression beginning within three minutes, at low heart rates, with angina, and attenuated or hypotensive blood pressure response. Disease was considered severe with marked ST depression beginning within 6 minutes and persisting the full duration was regarded as moderate positivity. Mild disease showed mild definite significant ST depression persisting for longer than 4 minutes with or without angina. Thirty six patients (32 M, 4 F) were studied over a six month period, Thirteen (36 percent) showed critical disease by the above criteria and urgent coronary angiography (C.A.) with a view to aorto-coronary bypass surgery (A.C.B.S.) was recommended. So far six had C.A. (ages 44-68); all showed critical left main equivalent disease. Five necessitated urgent A.C.B.S., a total of 16 gragts being used. There were six severly positive tests and C.A. has also been recommended for this group. One had myocaridal infarction 3 months after assessment. Medical therapy was regarded as optimal therapy for eight with moderate, and nine with mild disease. One had thallium stress test which did not show significant myocardium in jeopardy. Treadmill exercise stress testing is a useful non-invasive tool in selecting patients who will benefit from C.A. and A.C.B.S. as opposed to continuing medical therapy (AU)

The arrhythmias in consulting practice - abstract

An investigation was made of the incidence and aetiology of the arrhythmias in a private consulting practice. The case histories and ECGs of all cases referred for a cardiac consultation in the last six years were examined. Of 1,800 cases, 575 cases had normal ECG's, 774 had abnormalities of the ECG other than arrhythmias and 451 presented arrhythmias of whom 36 showed more than one type. The arrhythmias were as follows - Sinus tachycardia 135 cases, Sinus bradycardia 5, Sinus arrhythmia 29, sinus arrest 1, coronary sinus rhythm 1, supra-ventricular premature beats 46, ventricular premature beats 118, paroxysmal atrial tachycardia 3, paroxysmal ventricular tachycardia 1, atrial flutter 5, flutter fibrillation 8, Atrial fibrillation 37, Sino-auricular block 1, atrio-ventricular block 42, right bundle branch block 40 left bundle branch block 11, Wolff-Parkinson-White syndrome 5. Approximately 20 percent of the arrhythmias were due to ischaemic heart disease and of all the cases of ischaemic heart disease seen, approximately 20 percent showed an arrhythmia. Of 29 cases of sinus arrhythmia 21 were older than 15 and 14 older than 20. 4.4 percent of cases of sinus tachycardia were due to alcoholism. In both the group of ventricular premature beats and the group of supra-ventricular premature beats about 1/3 showed no other evidence of heart disease and about 1/4 showed evidence of ischaemic heart disease. On of the five cases of atrial flutter and one of the eight cases of flutter fibrillation had artificial mitral valves. Of six cases of acquired heart block, the youngest was 59 years of age (AU)

A cardiovascular survey of adults of African and East Indian origin living in two communities in Guyana - abstract

The aims of the investigation were to determine: (1) If the unexpectedly high prevalence in Jamaica of ECG abnormalities sometimes attributable to ischemic heart disease also occures in Guyana and, if possible, their causation. (2) The influence of racial origins on cardiovascular disease. A survey of two communities, Annandale and Buxton, was undertaken and 843 subjects of African and East Indian origin aged 35-54 years were examined. The prevalence of S-T and T wave changes in ECGs were of the same order in both races as in Jamaica. They were more common in subjects with hypertension, obesity and high serum cholesterols and in men with occupations involving little physical activity but all these characteristics were inter-related and the relative importance of hypertension, coronary heart disease and other conditions could not be determined. From clinical experience in Guyana, hypertension would be expected to be the most important aetiological factor. Mean blood pressure levels were higher in Africans than East Indians but there was no evidence that hypertensive heart disease was more common. In the ECGs left ventricular R waves were taller in Africans but no consistent racial differences were apparent for other abnormalities. At the present time surveys of this type have only a limited value for assessing the types of cardiovascular disease in a community (AU)