Psychiatric disorder in systemic lupus erythematosus

The symptoms of systemic lupus erythematosus (SLE) may include altered mental function. The present study sought to examine whether the psychiatric disorders are due to the disease itself or to the stress of having a chronic disease. Forty-five SLE patients attending outpatient clinics at the Port of Spain General Hospital in Trinidad were compared with two control groups: patients with chronic debilitating diseases similar to SLE in terms of chronicity and treatment (n = 44) and non-diseased individuals (n = 48). The Structured Clinical Interview for DSM III-R was used to identify psychiatric disorders. Both the SLE and the chronic illness groups had more psychic illness (44 percent and 39 percent, respectively) when compared with the non-diseased controls (2 percent) (p<0.001). Major depression was the most common diagnosis among both diseased groups. However, the psychotic illnesses (schizophrenic-type psychosis and bipolar disorders) were more prevalent in the SLE group (11.1 percent vs 0 percent, p=0.02). These results indicate that major depression in SLE may be related more to the effects of a chronic illness than to SLE itself. However, the occurrence of psychotic symptoms may be related to SLE disease and needs further study. (AU)

Idiopathic foca and segmental glomerulosclerosis in Jamaica: a 10 year review

Idiopathic focal and segmental glomerulosclerosis (IFSGS) in a predominantly black population does not appear to behave any differently than in Caucasian patients. Response to steroid therapy and cyclophosphamide had favourable prognostic significance. There may be a subgroup of IFSGS which responds more slowly to steroids. The duration of steroid therapy should extend beyond four months (AU)

Outcome of kawasaki disease in Barbados

Kawasaki disease (KD) often presents as an acute multisystem febrile illness which is most often self-limiting. During an 11-year period, 39 patients with KD, aged 11 weeks to 15 years (mean 2.5 years), were admitted to the Queen Elizabeth Hospital, Barbados. Eighty-seven per cent of children were less than 4 years of age. There were 26 males (67 percent) and 13 females (33 percent) with a sex ratio of 2:1. A peak occurrence was observed in 1985 and the mean hospital stay of cases was 12.7 days. Treatment regimes included antibiotics in 36 patients (93 percent), aspirin in 32 (82 percent) and steriods in 3 (7 percent). Major complications were observed in 11 patients (26 percent), with these being gastrointestinal bleeding in 1, broncho-pneumonia in 3 and cardiac abnormalities in 7 (18 percent). Among the latter were abnormal proximal coronary arteries in 5 patients (2 with dilatation and 3 with aneurysms) and carditis in 2. Other complications included croup (1), hydrops of the gallbladder (2), paralytic ileus (1), and abnormal focal neurological signs in two patients. There were no deaths. Follow-up ranged between one month and four years. Although KD often presents as a benign self-limiting illness, it is extremely important to make a diagnosis early in the course of the illness, institute appropriate therapy and be on the alert for possible fatal complications. (AU)

Inhaled steroids for asthma: topical but not free of systemic effects - abstract

Although inhaled corticosteroids are now established in the treatment of bronchial asthma, there remains controversy regarding their potential for inducing systemic effects. We evaluated the systemic glucocorticoid effects of beclomethasone dipropionate (BDP), currently the most widely prescribed agent, across a therapeutically relevant dose range (400 - 2,000 æg/day). Sixteen (16) healthy adult subjects were studied using a double blind placebo-controlled crossover design. The impact of inhaling 100, 200, 350 and 500 æg BDP q6h was measured. Treatments were assigned in random order and of 10 days' duration separated by wash-out intervals of 18 days. End points of glucocorticiod exposure were the effects upon (1) the hypothalamic-pituitary-adrenal axis (HPA) and (2) bone-formation. Short metyrapone testing revealed significant impairment of HPA responsiveness at doses 800 æg/day and above (p < 0.001). There was evidence of impaired blood biochemistry at doses 400 æg/day and greater (p < 0.05). These data suggest that inhaled steroids are associated with systemic effects even in paediatric dosages. Though not widely available in the Caribbean, this form of therapy is popular and efficacious and is likely to be increasingly used in the foreseeable future. The prescription of inhaled steroids requires as much care and attention as obtains for systemic glycocorticoid therapy (AU)

Bronchial asthma management in the 90s - abstract

Bronchial asthma is among the most common medical emergencies confronting the practising physician and, being very responsive to therapeutic intervention, it is one of the most rewarding diseases to treat. The increasing recognition that airway inflammation underlies much of the dysfunction in bronchial asthma is leading to a change of emphasis away from symptomatic bronchodilator treatment towards the earlier use of anti-inflammatory or disease-modifying strategies. Like many other disease states, asthma has numerous triggers, some of which are present in the environment and therefore avoidable. Hence one of the first considerations is to accurately define the offending allergens or culprits and to develop measures to minimise exposure to them. Bronchodilators have traditionally been considered as first-line treatment. Although the theophyllines are effective, their usefulness is limited by several side-effects. Aerosolised beta-2 agonists with a longer duration of action are currently undergoing clinical trials and are likely to be used more in furture for pro-phylaxis rather than symptomatic treatment. Corticosterois provide the mainstay of treatment for both acute and chronic asthma, although their mechanism of action is not fully understood. The problems with steroids are the well-known side-effects which complicate chronic use. This is being addressed by the development of a group of steroid-like drugs called Lazaroids which have potent anti-inflammatory effects but are free of hormonal effects and the recent availability of potents aerosolised steroids with greatly improved delivery systems. Finally, in selected cases of asthma, where allergy is playing a significant causative role immunotherapy as a treatment modality should be seriously considered (AU)

Cardiovascular disease and steroid hormone contraception in Jamaica - abstract

Since hormone contraception became widely available in the early 1960s, there has been concern about its safety. On the other hand, its role in fertility management is crucial. Several reports suggest an association between hormonal contraception and cardiovascular disease, including venous thromboembolism, strokes and myocardial infarction. As part of a WHO multicentre study, we have examined the possible association between hormonal contraceptive use and cardiovascular disease in the Jamaican population. Since February 1988, all women from 20 years to 44 years old at last birthday, admitted to any hospital in Kingston and St. Andrew for venous thromboembolism, stroke or myocardial infarction were interviewed. Women were eligible for study, if this was the first episode of such an event and they were not pregnant or puerperal and had not had surgery or confinement to bed in the previous six weeks. Information on all hormonal contraceptive use was elicited during this interview and relevant clinical information from patient records. Three age-matched controls admitted within two months of the case's admission and 2 community controls living in the same neighbourhood were selected. To December 1988, there have been 51 cases: 25 with thromboembolic disease and 26 with strokes. No myocardial infarctions were detected; 188 controls have been required. Use of hormonal contraception, past or present, was not shown to be associated with increased risk of these cardiovascular events. Contraceptive use was reported by 66 per cent of cases and 60 percent of controls. Current use (within the past 3 months) was reported in 25 percent of cases and 26 percent of controls. A history of hypertension was present more often among cases (14 percent versus 3 percent, p < 0.01). We have failed to show any association between the use of hormonal contraception and cardiovascular events in young Jamaican females. Hypertension has emerged as the only discriminating risk factor (AU)

Oral steroids and relapse of typhoid fever - abstract

Between October 1981 and February 1985, the relapse after acute typhoid fever, adequately treated with chloramphenicol (50 mg/Kg/day for 3 days, then 30 mg/Kg/day for 11 days), was 18 percent; this is twice the expected figure of 5-10 percent. On bacteriological confirmation of the diagnosis, adjuvant oral cortico-steroid was given to those cases whose symptoms were slow to resolve, as a tapering course of prednisolone over 5 days with an initial dose of 1 mg/Kg. All patients who relapsed had received cortiosteroids. From March 1985, adjuvant steroids were no longer given. Between March 1985 and September 1987, there were no relapses (p<0.01, Fisher's test). Convalescent carriage was commoner in the no-steroid group. Perhaps oral low-dose steroid converts potential convalescent carriage into relapse which can be a severe illness. Low-dose adjuvant steroids for prolonged "toxicity" in acute typhoid fever should be avoided (AU)

Physical assessment of 30 chronic cannabis users and 30 matched controls

Ganja is used extensively in the working-class population of Jamaica, particularly in certain agricultural and fishing communities. Ganja smoking is illegal but can be accepted as part of the culture in these areas. Sixty male subjects were chosen for assessment, 30 chronic smokers and 30 controls from comparable social, economic, and cultural backgrounds, and were matched for height and age. A chronic smoker had smoked a minimum of three spliffs per day for a minimum of 10 years. The subjects were admitted to the hospital for 1 week for psychologic and physical assessment. The physical assessment included a detailed medical history and examination, heart and lung radiography, electrocardiograms, respiratory, liver, and renal function tests, hematology, treponemal serology and chromosomal studies. No significant physical abnormalities were found, except in two smokers, and there was no reason to suspect that these disabilities were related to ganja. No significant differences between the two groups were demonstrated in the wide range of tests administered (Summary)

The use of steroids in pregnancy

Recent reports in the literature have stated that there is an increase risk to the foetus in the mothers who have been receiving steroids for diseases associated with pregnancy. Thirty seven cases of pregnancy associtated with diseases treatable by steroids were studied. The outcome of each pregnancy was related to the phase of activity fo the disease as well as the treatment with steroids. Of the 37 pregnancies - 22 were treated with steroids and 15 were not. In the group who had steroids there was a lower foetal loss than in the untreated group. Of the foetal loss due to abortion, stillbirths and neo-natal causes - the majority were in cases who were not receiving treatment and in whom the disease was active. The incidence of prematurity was higher when the disease process was active or further exacerbated regardless of treatment. No foetal abnormality was found. Steroids have very little adverse effect in pregnancy and should not be withheld as it is the exacerbations of the disease processes which may be detrimental to the pregnancy (AU)

Lung transplant

What is the future of lung transplantation in so far as its clinical application is concerned ? The actual surgery is not difficult but, as with all transplantations, the major problems occur post operatively. Our understanding of the immunologic response is still too superficial for us to be too optimistic about overcoming the rejection problem. In none of the human transplants discussed was rejection reported at autopsy. This is not really as encouraging a sign as it might appear, since human transplant centres report rejection only after eighteen days post operatively and none of the patients discussed above lived that long. But, many experimental units and research teams are now hard at work on the rejection problem, and at moment there could be a breakthrough, opening the way for lung transplantation as a form of therapy in chronic pulmonary disease. (Summary)

Desquamative interstitial pneumonia

The clinical radiological and pathological features of desquamative interstitial pneumonia in a 55-year old Jamaican male negro are described. Although the patient presented with progressive effort dyspnoea there were minimal abnormal chest signs but marked derangement of the respiratory function tests. The most severe radiological changes were demonstrated in the middle zones of the lung fields, and a follow-up chest film 2 months later showed slight involvement of the lower zones as well. The microscopic appearance was typical of the condition except that the vascular changes overshadowed the other abnormalities present. Although there was an excellent subjective response to steroid therapy, lung function tests repeated 2 months after the onset of the disease showed no significant change. (Summary)

Urinary 17-ketosteroids and ketogenic steroids in a mixed Jamaican population

The mean daily 17-ketosteroid excretion for a group of coloured Jamaicans was not found to be significantly different from that of Europeans living under the same conditions. Mean 17-ketogenic steroid excretion was significantly lower in the Jamaicans (Summary)