Cross-sectional analysis of adverse outcomes in 1029 pregnancies of Afro-Caribbean women in Trinidad with and without systemic lupus erythematosus

The objective of the study was to examine pregnancy outcomes in women with systemic lupus erythematosus (SLE) and population controls in Trinidad. We performed a cross-sectional analysis of adverse outcomes in pregnancies of Afro-Caribbean women with SLE and without SLE. One hundred and twenty-two female adult cases of SLE and 203 neighbourhood age-matched women without SLE were interviewed concerning details of their reproductive history, and the anticardiolipin antibody (ACL) status was established for women with SLE. A total of 1,029 pregnancies were reported (356 by women with SLE, 673 by women without SLE). In women with > or = 1 pregnancy the total number of pregnancies was similar in women with a diagnosis of SLE and women without; however, a lower proportion of women with SLE had ever been pregnant compared with women without SLE (80% versus 91%, P = 0.002). In multivariate logistic regression analyses adjusted for maternal age, district of residence, pregnancy order and smoking, SLE pregnancies were more than twice as likely to end in foetal death than non-SLE pregnancies (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2-4.7). This effect was driven by a large increase in the odds of stillbirth (OR, 8.5; 95% CI, 2.5-28.8). The odds of early miscarriage (OR, 1.4; 95% CI, 0.6-3.1) and of mid-trimester miscarriage (OR, 1.9; 95% CI, 0.4-9.5) were higher, but were not statistically significantly different, in SLE pregnancies than in non-SLE pregnancies. The odds of ectopic pregnancy (OR, 7.5; 95% CI, 0.9-62.5) and of preterm birth (OR, 3.4; 95% CI, 1.2-10.0) were higher in SLE pregnancies conceived after diagnosis than in non-SLE pregnancies. There was no evidence of raised levels of IgG or IgM ACL among the majority (93/97 women, 96%) of SLE cases who reported sporadic mid-trimester miscarriage or stillbirth, although there was evidence of high levels of IgM and IgG ACL among women reporting three or more miscarriages and three consecutive miscarriages, and of raised IgG ACL among those experiencing ectopic pregnancy. In conclusion, we found evidence for a large increase in risk of stillbirth in the pregnancies of Afro-Caribbean Trinidadian women with SLE (not accounted for by high ACL status). There was some evidence of an increased risk of preterm delivery and ectopic pregnancy in pregnancies conceived after a diagnosis of maternal SLE.

Can medical education rise to the challenge of the African crisis?

In the face of the worsening health crisis in Africa, educationalists there and beyond are challenged to identify their role in resolving the crisis. The training of doctors has to be re-orientated so that they are well equipped to lead the way towards improving the health situation and effectively participating in improving the general condition of the people. This can be achieved by medical schools having control of their duties and functions and using these powers to train doctors who are community-orientated, able to identify clinical and epidemiological problems and find suitable solutions. Doctors of the future should be comfortable working in the community with other members of health teams and confident in addressing all health-related matters in the community. During their formative years in medical school they should acquire the skills to continue self education.This paper discusses some of the important steps that should be taken by medical schools, taking into account the present situation in Africa

Commentary: getting ahead of the childhood obesity curve

Comment on: Overweight, obesity and skinfold thicknesses of children of African or Indian descent in Trinidad and Tobago. Gulliford MC, Mahabir D, Rocke B, Chinn S, Rona R. Int J Epidemiol. 2001 Oct; 30(5):989-98.

Overweight, obesity and skinfold thicknesses of children of African or Indian descent in Trinidad and Tobago

BACKGROUND: To evaluate distribution of body mass index (BMI) and subcutaneous fat in children of African or Indian subcontinent descent living in Trinidad and Tobago. METHODS: A cross-sectional survey was carried out in a nationally representative sample of 66 government schools. Measurements were made of children's heights, weights, triceps and subscapular skinfold thicknesses. Data were analysed by sex and ethnic group and comparison was made with international standards for overweight and obesity and with British (1990) reference curves for BMI. RESULTS: Data were analysed for 5688/6731 (85%) eligible children including 1934 Afro-Trinidadian, 1689 Indo-Trinidadian, and 1794 of mixed ethnicity. Afro-Trinidadian and mixed children were taller, but Indo-Trinidadian children were shorter than reference. Values for BMI were lower than reference: mean standard deviation score (SDS), (95% confidence interval) Afro-Trinidadian -0.34 (-0.39 to -0.28), Indo-Trinidadian -1.32 (-1.39 to -1.25), mixed -0.67 (-0.74 to -0.61). Overall 486 (8.5%, 7.8 to 9.3%) of children were overweight and 138 (2.4%, 2.0 to 2.9%) were obese. Triceps skinfold thickness values were lower than reference (-0.45, -0.48 to -0.42 SDS) but subscapular skinfold thicknesses were higher (0.45, 0.43 to 0.47 SDS). Higher BMI were associated with higher BMI in the child's parents, higher reported birthweight, older age of the child's mother, smaller family size, and with higher maternal educational attainment. CONCLUSIONS: Overweight was prevalent and distribution of subcutaneous fat was central. Work is needed to determine whether these findings are associated with adult patterns of fat distribution and metabolic abnormalities.

Seroprevalence of human herpesvirus-8 (HHV-8) in countries of Southeast Asia compared to the USA, the Caribbean and Africa

Seroprevalence of HHV-8 has been studied in Malaysia, India, Sri Lanka, Thailand, Trinidad, Jamaica and the USA, in both healthy individuals and those infected with HIV. Seroprevalence was found to be low in these countries. In contrast, the African countries of Ghana, Uganda and Zambia showed high seroprevalences in both healthy and HIV-infected populations. This suggests that human herpes virus-8 (HHV-8) may be either a recently introduced virus or one that has extremely low infectivity. Nasopharyngeal and oral carcinoma patients from Malaysia, Hong Kong and Sri Lanka who have very high EBV titres to show that only 3/82 (3.7 percent) have antibody to HHV-8, demonstrating that there is little, if any, cross-relativity between antibodies to these two gamma viruses. (AU)

Quality of life in children with sickle cell disease in Amsterdam area

OBJECTIVE: To determine the differences in quality of life between children with sickle cell disease and healthy immigrant children. DESIGN: Descriptive, comparative. METHOD: The quality of life of children with sickle cell disease between 5 and 15 years old being treated in the Emma Children's Hospital AMC in Amsterdam, the Netherlands, was assessed by using a questionnaire for parents (TNO-AZL Children's Quality of Life Questionnaire (TACQOL) parent form) if the child was between 8 and 15 years old. The study period was April-October 1998. The questionnaires were completed by 45 (parents of) patients. The results were compared with a healthy reference group of immigrant children. Statistical analysis was performed using the Student t-Test. RESULTS: Children with sickle cell disease as well as their parents scored signifcantly lower on the items general physical, motor and independent daily functioning and on occurrence of negative emotions. No significance was observed for the items cognitive functioning and school performance nor for social functioning or occurrence of positive emotions. CONCLUSIONS: In children, sickle cell disease leads to compromised physical and possibly also psychological wellbeing, as well as the experience of decreased independence in daily functioning, but not to compromised cognitive or social aspects of the quality of life. (AU)

Lipoprotein-genotype associations in Trinidadian neonates

OBJECTIVES: We hypothesized that common variation in the angiotensinogen (AGT), beta-3-adrenergic receptor. intestinal fatty acid-binding protein, serum paraoxonase, paraoxonase-2, hepatic lipase, apolipoprotein E (APOE), and Werner helicase (WRN) genes would be associated with variation in biochemical phenotypes in a previously unstudied neonatal sample. DESIGN AND METHODS: We examined associations of both nongenetic and genetic variables with plasma lipoprotein traits in neonates from Trinidad. RESULTS: Among nongenetic variables, we found significant associations between plasma concentrations of 1.) lipoprotein (a) [Lp(a)] and both ethnicity (p=0.037) and birth weight (p=0.001); 2)total cholesterol and gender (p=0.010); 3)triglyceride and birth weight (p=0.035); and 4)apolipoprotein A1 and gender (p=0.016). Among genetic variables, we found that: 1)common variation on chromosome 1q in AGT codon 235 was significantly associated with variation in plasma apolipoproteins Al (p<0.0001); and 3)common variation in APOE at codons 112 and 158 was significantly associated with variation in plasma triglycerides (p=0.013). CONCLUSIONS: The associations with AGT and WRN are novel and may have resulted either from direct influence of the genetic variants or through linkage disequilibrium with other functional loci, such as the familial combined hyperlipidemia locus on chromosome 1q in the case of AGT. Despite the fact that there are some limitations in making determinations from cord blood, the results suggest that there may be genetic determinants of plasma lipoproteins in neonates. (AU)

Little evidence of HLA-G mRNA polymorphism in Caucasian or Afor-Caribbean populations

HLA-G is a nonclassical class I MHC molecule of unknown function expressed on human trophoblast. The level of polymorphism at the HLA-G locus is of considerable importance, since the paternally inherited gene product is exposed to the maternal immune system during pregnancy. However, previous studies of HLA-G polymorphism using genomic DNA samples have produced conflicting results. Our aim was to investigate polymorphism in trophoblast HLA-G mRNA from pregnancies in ten Caucasian and twelve Afro-Caribbean women by RT-PCR. A similar PCR protocol was also applied to umbilical cord blood genomic DNA from two Caucasian and two Afro-Caribbean neonates. Caucasian cDNA yielded only two different sequences: G*01011, and one containing a previously reported synonymous substitution. Afro-Caribbean samples yielded these sequences as well as one previously reported conservative (leucine-to-isoleucine) substitution. PCR amplification from genomic DNA samples from both populations using previously published primer pairs generated sequences containing multiple substitutions, many of which were nonsynonymous. More than two sequences were produced from genomic DNA from each individual. In contrast, amplification from the same genomic DNA using new primers compleentary to exons of the HLA-G gene yielded the same few sequences generated from cDNA. These results suggest that polymorphism at the HLA-G locus is extremely limited in Caucasian and Afro-Caribbean populations. This suggests that spurious polymorphism has been reported in African Americans due to the use of intron-complementary PCR primers on genomic DNA samples. The monomorphic nature of HLA-G may allow trophoblast to carry out the immunological functions of class I-bearing tissues without compromising successful pregnancy.(Au)

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP)

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey against hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8 percent (95 percent CI: 44.0-65.6), increasing with age and being higher among Europe (83.6 percent vs 45.6 percent, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (48.8 percent vs 42.6 percent) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2 percent vs 40.1 percent). Seroprevalence was higher in assistant nurses than in nurses (51.3 percent vs 39.8 percent, P < .02). Among cooks and kitchen employees, 53.4 percent were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.(Au)

Ethnic differences in gastro-oesophageal reflux disease

OBJECTIVES: To see whether the anecdotal statement that gastro-oesophageal reflux disease is less common in blacks than in white Caucasians is true. DESIGN: Study of the racial origin of adult patients who, at endoscopy, have oesophageal damage due to gastro-oesophageal reflux. SETTING: Gastroenterology unit of a teaching hospital in inner city in Birmingham, UK. MAIN OUTCOME MEASURE: Ethnicity and endoscopic grade of oesophageal damage (reflux oesophagitis) were recorded in every patient in whom oesophageal damage due to gastro-oesophageal reflux was diagnosed. RESULTS: Over the eight-year period 1989-1996, 1101 patients with endoscopically diagnosed grades I-V reflux oesophagitis have been seen, of whom 893 (81.9 percent) were white, 156 (14 percent) were Indian and 52 (5 percent) were Afro-Caribbeans. There were fewer patients with reflux oesophagitis from the two non-white ethnic groups than would be expected from their prevalence in the catchment population, and severe reflux oesophagitis was less common than expected in the two non-white groups. In all groups, patients with grades III, IV and V reflux oesophagitis were older than patients with grades I and II disease. Whites tended to be older than Afro-Caribbeans or Indians. CONCLUSION: There were fewer non-whites with reflux oesophagitis than would be expected but the reasons for this are unclear. This study has been useful as a pilot but further studies are needed in ethnically mixed non-migrant populations both in hospital, primary care and the community to clarify racial differences in reflux oesophagitis.(Au)

Suicide and homicide in Caribbean nations

The suicide and homicide rates of 14 Caribbean islands in the 1970s were predicted in part by the proportion of the population of African descent.(Au)

Ancestral origin of variation in the triosephosphate isomerase gene promoter

A high frequency of nucleotide substitutions -5A/G, -8G/A, -24T/G in the triosephosphate isomerase (TPI) gene promoter has been demonstrated in African-Americans. The biological significance of these promoter variants, two of which, -8G/A and -24T/G, occur within regulatory elements essential for transcription, is controversial. The geographical distribution and frequency of allelic variation in the TPI promoter was determined in 378 unrelated normal subjects from Sub-Saharan African (n = 103), Caribbean (n = 26), Northern European (n = 57), Mediterranean (n = 55), Middle Eastern (n = 42), Asian Indian (n = 48) and Oriental (n = 47) populations. Five haplotypes were identified: the common haplotype, -5A-8G-24T, -5G, -8A, -5G-8A, and -5G-8A-24G. All, with the exception of the -8A haplotype, were present in geographically dispersed populations. The -5G allele, which was found at varying frequency in the African, Caribbean and Oriental populations. Phylogenetic comparison suggests this may represent the ancestral promoter haplotype. Homozygosity for the -5G-8A haplotype identified in four subjects confirms that these variants are not responsible for a null allele as formerly postulated. Linkage disequilibrium between related TPI promoter haplotypes, -5G, -5G-8A and -5G-8A-24G, and a single nucleotide polymorphism at nt2262 of the TPI gene supports a single ancestral origin for these mutations which preceeds the separation of African populations.(Au)

The map1 gene of Cowdria ruminantium is a member of a multigene family containing both conserved and variable genes

Heartwater is an economically important disease of ruminants caused by the tick-transmitted rickettsia Cowdria ruminantium. The disease is present in Africa and the Caribbean and there is a risk of spread to the Americas, particularly because of a clinically asymptomatic carrier state in infected livestock and imported wild animals. The causative agent is closely related taxonomically to the human and animal pathogens Ehrlichia chaffeensis and Ehrlichia canis. A dominant immune response of infected animals or people is directed against variable outer membrane proteins of these agents known, in E. chaffeensis and E. canis, to be encoded by polymorphic multigene families. We demonstrate, by sequence analysis, the map1 encoding the major outer membrane protein of C. ruminantium is also encoded by a polymorphic multigene family. Two members of the gene family are located in tandem in the genome. The upstream member, orf2, is conserved, encoding only 2 amino acid substitution among six different rickettsial strains from diverse locations in Africa and the Caribbean. In contrast, the downstream member, map1, contains variable and conserved regions between strains. Interestingly, orf2 is more closely related in sequence to omplb of E. chaffeensis than to map1 of C. ruminantium. The regions that differ among orf2, map1, and omp1b correspond to previously identified variable sequences in outer membrane protein genes of E. chaffeensis and E. canis. These data suggest that diversity in these outer membrane proteins may arise by recombination among gene family members and offer a potential mechanism for persistence of infection in carrier animals.(AU)

Low birth weight: race and maternal nativity - impact of community income

BACKGROUND: The purpose of this article is to determine the effect of community income as a co-factor in the association of low birth weight, race, and maternal nativity in New York City. METHODS: New York City birth records, 1988 through 1994, provided data on maternal and infant characteristics. There were 274,121 white and 279,826 black mothers included in this study. Black mothers were classified as US-born (South and Northeast) and foreign-born (the Caribbean, South America, and Africa). Based on the 1990 US census income data, census tracts of the city were aggregated by tertile of per capita income as low-, middle-, and high-income communities. Incidence of low birth weight was estimated by race, maternal nativity in the city as a whole, and each income community. RESULTS: Overall, black women had a substantially higher risk of low birth weight infants (<2500 g) than did whites (13.1 percent vs 4.8 percent). Foreign-born black mothers had a birth weight advantage over US-born black mothers (10.0 percent vs 16.7 percent). After controlling for socioeconomic and medical characteristics, the risks of low birth weight for blacks compared with whites were 0.95 (95 percent confidence interval: 0.86-1.03) and 0.86 (0.69-1.02) for Caribbean- and African-born black mothers, respectively. Moreover, in low-income communities, compared with white mothers, the risks for Caribbean- and African-born black mothers were 0.88 (0.79-0.97) and 0.77 (0.61-0.96), respectively. By contrast, US and South American-born black mothers had a consistently higher risk of low birth weight infants, regardless of community income level. CONCLUSION: Low birth weight was significantly less frequent among whites than among blacks. However, this overall finding masked substantial variation among blacks, determined by maternal nativity and the income level of the community in which they lived. In fact, Caribbean- and African-born black mothers had birth outcomes generally similar to and, in poor communities, even more favorable than those for whites.(Au)

Estimating African American admixture proportions by use of population-specific alleles

We analyzed the European genetic contribution to 10 populations of Africans descent in the United States (Maywood, Illinois; Detroit; New York; Philadelphia; Pittsburgh; Baltimore; Charleston, South Carolina; New Orleans; and Houston) and in Jamaica, using nine autosomal DNA markers. These markers either are population-specific or show frequency differences >45 percent between the parental populations and are thus especially informative for admixture. European genetic ancestry ranged from 6.8 percent (Jamaica) to 22.5 percent (New Orleans). The unique utility of these markers is reflected in the low variance associated with these admixture estimates (SEM 1.3 percent -2.7 percent). We also estimated the male and female European contribution to African Americans. on the basis of informative mtDNA (haplogroups H and L) and Y Alu polymorphic markers. Results indicate a sex-biased gene flow from Europeans, the male contribution being substantially greater that the female contribution. mtDNA haplogroups analysis shows no evidence of a significant maternal Amerindian contribution to any of the 10 populations. We detected significant nonrandom association between two markers located 22 cM apart (FY-null and AT3), most likely due to admixture linkage disequilibrium created in the interbreeding of the two parental populations. The strength of this association and the substantial genetic distance between FY and AT3 emphasize the importance of admixed populations as a useful resources for mapping traits with different prevalence in two parental populations (AU)

Social environment and substance misuse: a study of ethnic variations among inner London adolescents

OBJECTIVES: To explore ethnic variations in drug, tobacco and alcohol use and their correlation with other factors which operate through peer, familial and religious influences. DESIGN: Semi-structured interviews with 132 12-13-year-old young people from four ethnic groups attending secondary schools in two inner London boroughs and a follow-up interview completed approximately 17 months later. RESULTS: The data was analysed using chi-square and McNemar tests. Familial, religious and peer influence closely correlated with ethnicity. Bangladeshi young people showed lower levels of peer and higher levels of religious and familial involvement and lower levels of substance use. White young people reported higher levels of peer, lower levels of religious and familial involvement, and a higher level of substance use. Black African and Black Caribbean young people lay between the two extremes. CONCLUSION: The findings suggest that young people with lower levels of familial and religious influence, or higher levels of peer influence, have higher levels of substance consumption than other young people. Health education initiatives need to promote personal decision-making skills within the context of the young people's individual culture. Cultural diversity should be recognised within local health education needs assessment.(Au)

The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders

BACKGROUND: Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work. METHOD: The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness. RESULTS: The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings. CONCLUSIONS: The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.(Au)

Prostate cancer in black men

The aim of this paper is to emphasize the need for increase vigilance in evaluating the prostate for malignancy, and to widen the age grouping in black men. A literature search was carried out and statistics of the American Cancer Society were reviewed. Correspondence was undertaken with urologists in large and small populations of the United States of America, Africa and the Caribbean. Some mixed races (some all black) and a report on the concerns and recommendations of a joint meeting of the American Cancer Society, National Cancer Institute and Centers for Disease Control and Prevention were incorporated (November 1997, Houston, Texas).(AU)

Emergence of Western diseases in the tropical world: the experience with chronic cardiovascular diseases

Our knowledge of the disease burden components of tropical populations is fragmentary. Historically, the infectious diseases have been emphasized but, as some populations have undergone socio-economic changes, vital statistics have described a change in the pattern of disease. The picture is of a decline in infectious and a rise in chronic non-communicable disease. We focus here on the emergence of chronic cardiovascular diseases, and use hypertension as the paradigmic example. Early blood pressure surveys showed a virtual absence of hypertension among rural Africans and moderate prevalences in the Caribbean. Prevalence was highest among US and UK blacks. In a recent comparative study of blood pressure and its determinants in Nigeria, Jamaica and the US there was a steep gradient in prevalence from 15 percent through 26 percent to 33 percent. Body mass index and salt intake were the major determinants, accounting for 70 percent of the variance in hypertension prevalence. Additional information on mechanism comes from the exploration of the renin-angiotensin system across these populations. Angiotensinogen levels rise steadily from Africa to the US and are modestly associated with body mass index (BMI), and even more modestly with polymorphisms of the angiotensinogen gene. 30 percent of the variation in angiotensin-converting enzyme levels is attributable to the insertion/deletion polymorphism, and angiotensin-converting enzyme levels are modestly related to BMI and blood pressure. Thus, the steep gradient in prevalence is not attributable to the genetics as manifested in the renin-angiotensin system. The usefulness of these and other data on cardiovascular diseases include planning for primordial prevention in Africa and amelioration of existing epidemics in the Caribbean, the US and the UK. Additional long term surveillance data to define the burden and distribution of causes are necessary in Africa. Lastly, education and advocacy to transfer the information to policy makers and planners is required.(Au)