Acquired immune responses to the seasonal trivalent influenza vaccination in COPD.

Epidemiological data suggest that influenza vaccination protects against all-cause mortality in chronic obstructive pulmonary disease (COPD) patients. However, recent work has suggested there is a defect in the ability of some COPD patients to mount an adequate humoral response to influenza vaccination. The aim of our study was to investigate humoral and cell-mediated vaccine responses to the seasonal trivalent influenza vaccination (TIV) in COPD subjects and healthy controls. Forty-seven subjects were enrolled into the study; 23 COPD patients, 13 age-matched healthy controls (HC ≥ 50) and 11 young healthy control subjects (YC ≤ 40). Serum and peripheral blood mononuclear cells (PBMC) were isolated pre-TIV vaccination and at days 7 and 28 and 6 months post-vaccine for haemagglutinin inhibition (HAI) titre, antigen-specific T cell and antibody-secreting cell analysis. The kinetics of the vaccine response were similar between YC, HC and COPD patients and there was no significant difference in antibody titres between these groups at 28 days post-vaccine. As we observed no disease-dependent differences in either humoral or cellular responses, we investigated if there was any association of these measures with age. H1N1 (r = -0·4253, P = 0·0036) and influenza B (r = -0·344, P = 0·0192) antibody titre at 28 days negatively correlated with age, as did H1N1-specific CD4+ T helper cells (r = -0·4276, P = 0·0034). These results suggest that age is the primary determinant of response to trivalent vaccine and that COPD is not a driver of deficient responses per se. These data support the continued use of the yearly trivalent vaccine as an adjunct to COPD disease management.

Sharp Force Injuries at the University Hospital of the West Indies, Kingston, Jamaica: A Seventeen-year Autopsy Review.

OBJECTIVES: This study aimed to ascertain the prevalence and patterns of fatal sharp force injuries, victims' demographics, cause of death and average survival time at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. METHODS: The autopsy records for 1990-2010 were searched for fatal cases of sharp force injuries. The records for 1998-2001 were not located. A 17-year retrospective analysis was therefore performed and findings for the two periods, 1990-1997 and 2002-2010 were compared. All data were obtained from the provisional anatomical diagnoses (PAD) autopsy reports. RESULTS: During the 17-year period, 57/4264 autopsies were performed for sharp force injuries, yielding an overall autopsy prevalence rate of 1.34% (1.25%, 26/2086 (95% CI 0.77, 1.73) in Period 1 and 1.42%, 31/2178 (95% CI 0.92, 1.92) in Period 2). The majority were males (91.1%), in the age group 15-39 years (77%), mean age of 30.9 years (range = 17─65 years). Stab wounds predominated (91.3%) and the chest was the area most frequently stabbed (42.1%). In the 24 fatalities due to chest injuries only, eight (33.3%) had injuries to the heart alone. Forty-five patients (79.0%) died within 24 hours from exsanguination. Injury documentation at autopsy was deficient. CONCLUSION: Stabbing was the most common sharp force injury, mainly involving the chest and young men were at greatest risk. Most patients died from exsanguination within 24 hours of admission. Introduction of synoptic-type reports for both clinical and autopsy examination may improve documentation.

Whipple's Disease in an Afro-Caribbean National.

Whipple's disease is a rare multi-organ infectious disease caused by Tropheryma whipplei. It is fatal without treatment. We report on a 40-year old Afro-Jamaican man who presented with a six-month history of weight loss and diarrhoea. Investigations revealed iron deficiency anaemia and hypoalbuminaemia. Upper gastrointestinal endoscopy revealed white patchy lesions in the duodenum. The duodenal biopsy showed broadening and thickening of the villi by a dense infiltrate of foamy histiocytes within the lamina propria and focally extending into the attached submucosa. Periodic Acid-Schiff stains were positive. Electron microscopy was confirmatory and polymerase chain reaction testing conclusively identified the organisms as T whipplei. Antibiotic treatment resulted in resolution of symptoms. Although the diagnosis of Whipple's disease is difficult, increased awareness should lead to an increase in reported cases with the improvements in diagnostic capabilities.

Renal impairment as a complication of uterine fibroids: a retrospective hospital-based study.

Leiomyomas can cause obstructive renal impairment and renal failure. This was a retrospective study of women with renal impairment seen at the University of the West Indies Hospital, Jamaica, between 2000 and 2004, looking at aetiology and severity (group 1). We also evaluated patients, in the same hospital, with fibroids who had ultrasonography during a later period (2006-2011), comparing those who had hydronephrosis and those without (group 2). In group 1, 274 women were coded as renal impairment. Case notes for 160 patients (59%) were analysed. Uterine fibroids accounted for 13/160 (8.1%) of cases. Comparing cases with and without fibroids, none of those with fibroids were over 50 years old compared with 59.3% of the others, OR 0.02 (CI 0.00-0.35) p = 0.0001. Hospital data for renal failure showed that most mean values were significantly better for those with fibroids. Urea, 8.59 mmol/l (SD 9.89) vs 17.00 mmol/l (SD 13.41) p = 0.003; Creatinine 300.15 µmol/l (SD490.92) vs 424.05 µmol/l (SD553.29) p = 0.022 and Creatinine clearance 73.21 ml/min (SD 38.92) vs 44.25 ml/min (SD 49.71) p = 0.017. However, mean potassium values were similar, 4.52 mmol/l (SD 0.61) vs 4.85 mmol/l (SD1.03) p = 0.2. In group 2, there were 216 patients and we found 31 (14.35%) patients at ultrasonography with hydronephrosis from fibroids. These patients had significantly larger uteri than those without hydronephrosis but renal function was similar, with only urea values significantly worse. Leiomyomas can cause renal impairment, however the prognosis appears good.

Bone mineral density in Jamaican black women after hysterectomy and bilateral oophorectomy: an observational study.

OBJECTIVE: To see if black Jamaican postmenopausal women who had hysterectomy were at increased risk of osteoporosis. To assess the risk of osteoporosis in hysterectomized Jamaican postmenopausal patients. METHOD: We reviewed 809 women (403 hysterectomized and 406 controls) for cardiovascular disease risk. We did a demographic history and examination looking at blood pressure, waist hip ratio and body mass index and investigations done included fasting blood glucose and total and high density lipoprotein (HDL) cholesterol. We also measured bone density at the heel in all women using the Achilles ultrasound bone densitometer looking at T-score and Z-score. RESULTS: There was a significant association of hysterectomy status and bone mineral density (BMD) status with a smaller than expected proportion of women with osteoporosis in the hysterectomy group (χ2 = 18.4; p = 0.001). The mean T-score was significantly higher in the hysterectomized women, adjusting for age, waist circumference and sociodemographic factors. The relationship between the various predictors and BMD was explored by stepwise regression modelling. The factors that were significantly related to low BMD were hysterectomy status, age, waist circumference and being employed. CONCLUSION: Hysterectomy was not found to be a significant risk factor for osteoporosis. The osteoporosis risk among menopausal women in Jamaica appears to be due to other risk factors which probably existed prior to the operation.

Adequacy of lymph node harvesting in colorectal cancer management: improving standards, ensuring quality.

OBJECTIVE: The aim of this study was to determine the adequacy of nodal sampling in resection specimens for colorectal carcinoma in a Jamaican population. METHODS: The pathology records of all patients who underwent operation for colorectal carcinoma at the University Hospital of the West Indies (UHWI) during the five-year period, 2003-2007, were reviewed. Pertinent clinical and pathologic data were obtained and analysed. RESULTS: One hundred and ninety-one patients were identified with M:F ratio of 1.1:1 and a mean age of 66 years. There were 119 (63%) left-sided lesions and 70 (37%) right-sided lesions. Stage T3N0 lesions were the most common and accounted for 41.1% of cases. The predominant histologic type was adenocarcinoma (99.5%) with the majority being moderately differentiated. The mean number of nodes sampled in node-negative cases was 13.8 +/- 9.75 nodes for right-sided lesions and 10.64 +/- 7.25 nodes for left-sided lesions (p = 0.05, CI 95%). The adequacy of nodal sampling was acceptable in cases of N0 right-sided carcinomas but was unsatisfactory in cases of N0 left-sided carcinomas. More importantly, however in two cases from the right and 10 cases from the left, two or fewer nodes were harvested. CONCLUSION: This review suggests the need for re-examination of the adequacy of surgical resection and/or nodal sampling technique for colorectal cancer resection specimens, given the importance of nodal status in determining the need for adjuvant therapy. Less than adequate node sampling should not be accepted by the reporting pathologist or attending surgeon as this has important prognostic implications.

Cardiovascular disease risk factors in menopausal Jamaican black women after hysterectomy and bilateral oophorectomy: an observational study.

OBJECTIVE: To determine differences in prevalence of cardiovascular risks and diseases in black Jamaican postmenopausal women who had hysterectomy (hysgroup) compared with those without (control). METHOD: Eight hundred and nine (809) women (hysterectomized (HYSGRP) = 403; non-hysterectomized (controls) = 406) were enrolled. Sociodemographic information and lifestyle history, measured blood pressure, waist hip ratio, body mass index, fasting blood glucose, total and HDL cholesterol were obtained. RESULTS: Of the 809 women, complete cardiovascular risk data were available in 341 controls and 328 in the HYSGRP group. There was no difference in mean age, blood pressure and body mass indices between the subjects excluded and the subjects in the data analytical sample. A significantly lower proportion of women in the control group exercised, attained post-secondary education and were of higher parity. Systolic (mean diference with 95% CI; 6 (3, 9) mmHg and diastolic (3 (1, 5) mmHg) blood pressure were lower in the HYSGRP compared with controls but total cholesterol (0.2 (0.07 to 0.4) mmol/L was greater HDL cholesterol was not different between both groups 1.3 mmol/L (SD 0.3) vs 1.3 mmol/L [SD 0.4] (p = 0.8435). There was no difference in the prevalence of diabetes, hypertension and high waist-hip ratio in hysterectomized women compared with controls adjusting for hormone replacement therapy usage, cigarette smoking, exercise and educational status. Within the HYSGRP there was also no diference in cardiovascular disease or risk in women who had bilateral oophorectomy compared with women who had at least an ovary preserved at time of operation. CONCLUSION: Hysterectomy was not associated with an increased risk of cardiovascular disease. This must be taken cautiously since data did not allow for analysis on duration of menopause.

Venous thromboembolism as a complication of uterine fibroids: a retrospective descriptive study.

This study describes cases of fibroids with venous thromboembolism (VTE) managed at UHWI between the years 1999-2004. We examined records to find patients with fibroids and VTE diagnosed before or after surgery. We found 438 women with VTE and 72 of these (16.4%) with fibroids. A total of 1,979 patients had fibroids during the period; cases were therefore 3.63% of fibroids. Cases were younger, median age 44 years than the total cohort: the median age was 57 and the mean age was 55.43 (SD 19.87) p = 0.000 about 9.5 years older than cases. Age over 50 years was less common in cases 27% vs 52% p = 0.0001 as were other risk factors for VTE such as cancer 4.9 vs 14% p = 0.03; diabetes 8.6 vs 25.2% p = 0.004 and cardiac disease 8.6% vs 26.6% p = 0.002 . However, thrombocytosis was more frequent, 23% vs 9% p = 0.008. Other risk factors were not significantly different. A total of 21 cases (29.1%) had surgery for fibroids; 15 (71.4%) hysterectomy, and six (28.5%) myomectomy. Most cases 67/72 (93%) had VTE without surgery. Of the five cases with VTE after surgery for fibroids, none had prophylactic heparin. Of the cases, 15 died--23% of women with VTE at PM and 0.8% of those with fibroids.

Rhabdomyomatous mesenchymal hamartoma: clinical overview and report of a case with spontaneous regression.

A case of cutaneous rhabdomyomatous mesenchymal hamartoma in a 6-year-old Afro-Caribbean girl is reported with review of the literature. The lesions were fine, located on the central face and became inapparent after six months. Spontaneous regression of these lesions has not been previously reported. Although rare, continued reporting will facilitate the elucidation of the clinical features and natural history of these lesions and the relationship to disordered embryogenesis.

Venous thromboembolism in Jamaican women: experience in a university hospital in Kingston.

OBJECTIVE: To review cases of venous thromboembolism (VTE) at UHWI from 1999-2004, to identify methods of diagnosis, risk factors and to evaluate differences between survivors and fatalities. METHODS: Patients coded with the diagnosis of thromboembolism at the University Hospital of the West Indies (UHWI) from 1999-2004 were identified. The medical records were reviewed to determine the prevalence of thromboembolism and possible variables associated with this diagnosis. In addition, variables associated with fatality were examined by evaluating cases diagnosed at autopsy RESULTS: There were 959 patients coded for thromboembolism between 1999-2004 at UHWI. Of these, 657 (68.5%) were females and 302 were males (31.5%). During that period, 65,657 women and 40,826 men were admitted to hospital with prevalence rates for thromboembolism of 1% in women and 0.7% in men. Of the 657 females, 520 case notes were located (case identification 80%). Of this, 435 were analysed as confirmed thromboembolism. The median age was 51 years with a range of 2-95 years. Common associations were obesity, 53.5%; age over 50 years, 52.5%; hypertension, 44.7%; immobilisation, 36.3%; cardiac disease, 26%; diabetes, 19.4%; fibroids, 16.3%; surgery, 15.8% and cancer 14%. Recurrent venous thromboembolism occurred in 12.8% and 15.8 % of women (66) died, diagnosed with PE at post-mortem. Using logistic regression analysis, leading risk factors in fatalities compared to survivors were hypertension and increased age. Obesity and surgery were significantly more likely in survivors. CONCLUSION: Venous thromboembolism was common in this cohort of women and avoidance of risk factors and institution of prophylaxis in high risk women is important to decrease morbidity and mortality.

The positive regulatory function of the 5'-proximal open reading frames in GCN4 mRNA can be mimicked by heterologous, short coding sequences.

Translational control of GCN4 expression in the yeast Saccharomyces cerevisiae is mediated by multiple AUG codons present in the leader of GCN4 mRNA, each of which initiates a short open reading frame of only two or three codons. Upstream AUG codons 3 and 4 are required to repress GCN4 expression in normal growth conditions; AUG codons 1 and 2 are needed to overcome this repression in amino acid starvation conditions. We show that the regulatory function of AUG codons 1 and 2 can be qualitatively mimicked by the AUG codons of two heterologous upstream open reading frames (URFs) containing the initiation regions of the yeast genes PGK and TRP1. These AUG codons inhibit GCN4 expression when present singly in the mRNA leader; however, they stimulate GCN4 expression in derepressing conditions when inserted upstream from AUG codons 3 and 4. This finding supports the idea that AUG codons 1 and 2 function in the control mechanism as translation initiation sites and further suggests that suppression of the inhibitory effects of AUG codons 3 and 4 is a general consequence of the translation of URF 1 and 2 sequences upstream. Several observations suggest that AUG codons 3 and 4 are efficient initiation sites; however, these sequences do not act as positive regulatory elements when placed upstream from URF 1. This result suggests that efficient translation is only one of the important properties of the 5' proximal URFs in GCN4 mRNA. We propose that a second property is the ability to permit reinitiation following termination of translation and that URF 1 is optimized for this regulatory function.

A Caribbean perspective on Barrett's oesophagus.

The aim of this study is to evaluate the prevalence of Barrett's oesophagus at the University Hospital of the West Indies which serves a population predominantly of African descent. In order to maximize accession of all cases in this preliminary study, the broad definition of columnar metaplasia of the lower oesophagus was utilized. Nevertheless, of 18 cases identified in the 21-year period, 14/17 cases (82%) available for review had specialized columnar epithelium diagnostic of Barrett's oesophagus. There was male predominance 5:1, the mean age was 53.8 years and there were two associated adenocarcinomas. These data confirm the occurrence but low prevalence of Barrett's oesophagus in this population but with a disease pattern that is consistent with that reported in other populations, warranting systematic evaluation of the gastro-oesophageal junction even in a Caribbean population.

The translational activator GCN3 functions downstream from GCN1 and GCN2 in the regulatory pathway that couples GCN4 expression to amino acid availability in Saccharomyces cerevisiae.

The GCN4 protein of S. cerevisiae is a transcriptional activator of amino acid biosynthetic genes which are subject to general amino acid control. GCN3, a positive regulator required for increased GCN4 expression in amino acid-starved cells, is thought to function by antagonism of one or more negative regulators encoded by GCD genes. We isolated gcn3c alleles that lead to constitutively derepressed expression of GCN4 and amino acid biosynthetic genes under its control. These mutations map in the protein-coding sequences and, with only one exception, do not increase the steady-state level of GCN3 protein. All of the gcn3c alleles lead to derepression of genes under the general control in the absence of GCN1 and GCN2, two other positive regulators of GCN4 expression. This finding suggests that GCN3 functions downstream from GCN1 and GCN2 in the general control pathway. In accord with this idea, constitutively derepressing alleles of GCN2 are greatly dependent on GCN3 for their derepressed phenotype. The gcn3c alleles that are least dependent on GCN1 and GCN2 for derepression cause slow-growth under nonstarvation conditions. In addition, all of the gcn3c alleles are less effective than wild-type GCN3 in overcoming the temperature-sensitive lethality associated with certain mutations in the negative regulator GCD2. These results suggest that activation of GCN3 positive regulatory function by the gcn3c mutations involves constitutive antagonism of GCD2 function, leading to reduced growth rates and derepression of GCN4 expression in the absence of amino acid starvation.

Blood Transfusion Induced Opportunistic Adult T Cell Leukaemia/Lymphoma after Hodgkin's Disease.

A patient previously treated for Hodgkin's disease (HD) developed secondary adult T cell leukaemia/lymphoma (ATL) after blood transfusion. Immunohistochemical analysis and polymerase chain reaction support the diagnosis. To the best of our knowledge this is the first occurrence of transfusion induced ATL occurring as a second malignancy after treatment for HD. The leukaemia/lymphoma probably developed on the basis of underlying immunosuppression.

Clinical, pathologic, and immunologic features of human T-lymphotrophic virus type I-associated infective dermatitis in children.

OBJECTIVES: To define the clinical and laboratory features associated with infective dermatitis (ID) and confirm its association with human T-lymphotrophic virus type I (HTLV-I). DESIGN: A case series of patients with ID were compared with patients with atopic dermatitis (AD), which is an important disease in the differential diagnosis of ID. SETTING: Patients were recruited from dermatology and pediatric clinics at the University Hospital of the West Indies and the Bustamante Children's Hospital, Kingston, Jamaica. MAIN OUTCOME MEASURES: Clinical and laboratory features of patients with AD were compared with those of patients with ID. PATIENTS: Consecutive patients older than 1 1/2 years diagnosed as having ID (n=50) and AD (n=35) were enrolled based on clinical findings. RESULTS: The mean ages of patients with ID and AD were 6.9 and 7.8 years, respectively. Histologically, both diseases were predominantly chronic dermatitis with propensity for skin colonization with Staphylococcus aureus and beta-hemolytic streptococci; however, the distribution of sites of skin involvement differed. Infection with HTLV-I was the most distinguishing feature among patients with ID, with seropositive results in 100%; only 5 (14%) of the 35 patients with AD had results seropositive for HTLV-I. Infective dermatitis was further characterized by dermatopathic lymphadenitis in 16 (67%) of 24 patients with palpable nodes. Anemia, lymphocytosis, and low albumin and elevated serum globulin levels were more prevalent among patients with ID. Significant elevations of IgA, IgD, and IgG levels were observed among patients with ID compared with those with AD. However, both patients with AD and those with ID had levels of IgD and IgE elevated above the normal range. T-cell subsets among patients with ID revealed T-cell activation with a high percentage of HLA-DR antigen positivity, elevated CD4 (2.4 x 10(9)/L) and CD8 (1.4 x 10(9)/L) cell counts, with an increased CD4/CD8 ratio of 1:73. CONCLUSION: Infective dermatitis is a distinct clinical entity associated with HTLV-I, which plays a role in the pathogenesis and immune perturbations observed.

Mammary hamartoma--an under-recognised breast lesion.

The clinical, histological and immunohistochemical features of the first three cases of mammary hamartoma diagnosed at the University Hospital of the West Indies are reported. These tumours are innocuous and under-recognized although the mammographic features are characteristic. With increased utilization of this test in breast cancer detection in our region, it is likely that more of these lesions will be identified.

Smooth muscle tumours of the vulva in Jamaica.

Smooth muscle tumours of the vulva are uncommon and their behaviour is unpredictable. A 30-year retrospective analysis of the pathology files and patient records revealed 10 cases diagnosed at the University Hospital of the West Indies, Kingston, Jamaica, with one malignant and one recurrent tumour. Size, infiltrating margins and mitotic count are important parameters to determine prognosis. Although these tumours are of low malignancy, mitotic count may be mandatory in determining their potential for recurrence.

Amoebiasis in Jamaica. A forgotten cause of hepato-intestinal disease.

Amoebiasis still occurs in Jamaica. This paper describes the unexpected occurrence of the disease in three adult males, two with colitis and the other with an hepatic abscess. This, to our knowledge, is the first report of amoebiasis in Jamaica for over two decades and serves to underscore the continued need for the inclusion of amoebiasis in the differential diagnosis of unexplained hepato-intestinal disease.

Solitary rectal ulcer syndrome.

Solitary Rectal Ulcer Syndrome (Rectal Prolapse Syndrome) is an uncommon and imperfectly understood entity which, however, should be included in the differential diagnosis of ano-rectal symptoms. This article reports on the nine cases so far diagnosed at the University Hospital of the West Indies (UHWI), and offers a brief review of the condition.

Hepatic abscesses at the University Hospital of the West Indies. A 24-year autopsy review.

A retrospective review of all hepatic abscesses identified at autopsy over the 24-year period 1977-2000 at the University Hospital of the West Indies (UHWI), Kingston, Jamaica, was conducted. Post mortem and microbiology records were reviewed. Data collected included age, gender, predisposing factors, organisms isolated, number of abscesses and associated conditions, such as diabetes mellitus. Data for the adults was analyzed separately. Thirty-nine cases of pyogenic abscesses were identified from 7480 post-mortems. Thirty-three occurred in adults of mean age 59.5 years. Sixty per cent of the abscesses were solitary. Biliary tract disease was the predisposing factor in 33% of cases. Six per cent were cryptogenic: 11/33 patients were diabetic and these were significantly older than non-diabetics (p < 0.014) Klebsiella pneumoniae was the most common organism isolated from diabetics (6.9). Only 2/33 abscesses were diagnosed ante-mortem. The abscesses in children were more frequently multiple and associated with extra-abdominal infection. Gram positive cocci were the commonly isolated organisms in children. There were no cases of amoebic abscess. The prevalence of hepatic abscess was low. Diabetes mellitus was a significant contributing factor. A high index of clinical suspicion is therefore warranted particularly in elderly diabetics.