Management of diabetic neuropathy - abstract

Over 50 percent of diabetics have measuable neuropathy, but only about 15 percent have symptoms (Dyck et al, 1993), of which pain is the most distressing. The pain of diabetic neuropathy (DN) is thought to arise from regenerating axons and spontaneously firing small nociceptive fibres. In addition, poor diabetic control (hyperglycaemia) may reduce the individual pain threshold. Ordinary analgesics are usually ineffective and opiates should be used cautiously because both in the depressed and non-depressed but side effects are common, especially in the elderly patient. The starting dose should be 10 - 25 mg given at night to controlnocturnal exacerbations of pain. Imipramine, another tricyclic anti-depressant with less anticholinergic inhibitor, are alternatives to amitriptyline. Pain which is lancinating in quality may repond better to carbamazepine at a starting dose of 200 mg daily. Mexilitene has also been shown to be effective in painful DN. Topical capsaicin which depletes nociceptive C fibres of their neurotransmitter, substance P, may be used as an adjunct to oral therapy. The patient with painless symmetrical polyneuropathy is at risk for the development of foot ulceration at areas of abnormally high pressure which arise as a result of destruction of the small joints of the foot. Patienst education regarding daily obsessive foot care is essential. Specific strategies for the management of plantar foot ulceration include non-weight bearing, redistribution of foot pressure by the use of various plaster-of Paris walking devices, treatment of infection with appropriate antibiotics, and the use of hyperbaric oxygen where available. Some complications of autonomic neuropathy which may respond to pharmacotherapy include gastroparesis (metoclopamide, erthromycin, domperidone), nocturnal diarrhoea (tetracycline), gustatory sweating (preprandial propantheline) and postural hypotension (fludrocortisone). The results of the recently reported multicentre trial (DCCI) clearly show that risk of developing neuropathy can be significantly reduced by intensive glycaemic control. Physicians need to be aware of the various syndromes of DN in order to advise and treat complications if and when they arise (AU)

EEG diagnosis of rolandic epilepsy in Barbados - abstract

Benigh Rolandic Epilepsy (BRE) is the most common of the benign partial epilepsies of childhood accounts for 15-20 per cent of cases of childhood epilepsies. This is a retrospective study of EEG findings in BRE from January, 1988 to November, 1989. EEG records of all patients between 3 and 13 years of age (n=197) were reviewed. EEG recordings were done on a 16-channel EEG machine using both bipolar and referential montages with the patient asleep. Routine photic stimulation and hyperventilation provocation tests were performed in all cases. The EEG diagnosis of BRE was made according to criteria adapted from Dalla Bernardina et al. Fifty of 197 recordings (26 per cent) contained clear epileptiform activity of which 20 fulfilled the diagnostic criteria for BRE. Rolandic spikes were central/mid-temporal in 16, parietal/posterior-temporal in 2 and occipital in 2. There was no correlation between rolandic spike location and seizure type: partial motor (5), complex partial (9), generalized nocturnal (4) and no history of seizure in 2 patients. BRE is truly benign with infrequent seizures in many patients, often nocturnal, easily controlled with anti-epileptic medication and with an excellent prognosis for disappearance by adulthood. Early diagnosis of BRE by EEG recordings is important for both parent and child and also avoids expensive and unnecessary investigations such as CT brain scan (AU)

A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados - abstract

Following an apparent recent increase in admissions for near-drowning a ten-year review has been carried out. Of 104 cases since January, 1970 records of 98 were traced and analyzed. The incident occurred in sea-water in 86 cases and in freshwater in 11 (one was unspecified). The male/female ratio was 3.45:1. Ages ranged from two to 69, 68 percent were adults (18 years and over). Of the adults 39 (60 percent were visitors and 28 (40 percent) residents. 45 percent of adult cases occurred in the months January - March, the peak tourist season. Five residents (18 percent) of adults were documented as taking alcohol prior to the incident compared with 13 of the visitors (33 percent). Many histories were inadequate. Other at-risk groups identified included epileptics and unsupervised children. Cases were grouped according to severity (after A.D. Simcock, Practitioner, 1979, 222, p. 527). There were 22 cases in group I (no evidence of aspiration), 67 in group II (pulmonary oedema but assisted ventilation not requird), 7 in group III (assisted ventilation required and two in group IV (CPR required). Two deaths occurred in group III and two in group IV. There were 111 deaths from drowning in the same period. There is an obvious need for a more rational approach to treatment of near-drowning, which may include oxygen, assisted ventilation, sodium bicarbonate, plasma and steroids. The need for assisted ventilation should be assessed promptly and repeatedly by physician and anaesthetist. There is urgent need to warn the public and particularly the tourists of the dangers of swimming after even modest alcohol intake (AU)

A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados

Analysis of 98 cases of near-drowning seen at the Queen Elizabeth Hospital, Barbados, during the period 1970 - 1979 is presented. Most of the adults were tourists most of whom near-drowned during the winter season. School children comprised the majority of cases during the summer holidays. Alcohol intake prior to near-drowning was noted in 30 percent of adults, and tourists were particularly at risk of drinking and drowning. In the light of modern ideas on hospital management of near-drowning, close observation and respiratory support emerge as the cornerstones of management. The use of diuretics is inappropriate while antibiotics and corticosteroids have not been shown to be beneficial (AU)

Management of juvenile/adult-onset myasthenia gravis at the Queen Elizabeth Hospital, Barbados

This paper is retrospective study of the management of myasthenia gravis (MG) in Barbados. The clinical experience, including an analysis of the role of thymectomy in the management of its disease, has been reviewed. Of 41 patients who were diagnosed as having MG six were excluded because of the onset below the age of twelve. Of the 35 patients studied, 15 had severe disease (Classes III-V) and 10 of these severely affected patients underwent thymectomy, the majority (70 percent) by the trans-cervical route. Follow up was available on all of the patients undergoing thymectomy and 15 of the patients on medical therapy (Classes II-V). Patients undergoing trans-cervical thymectomy had a better overall response than those treated medically, as measured by being able to get off drugs completely or being asymptomatic on a reduced drug dosage. Two of the patients had thymomas, on benign and the other malignant. The patient with the benign thymoma is asymptomatic but still on drugs and the other patient is still in the postoperative phase. It is concluded that in severe cases trans-cervical thymectomy produces a better overall response than medical treatment alone, and carries significantly less morbidity than the transternal approach in non-thymomatous cases.(AU)

Risk of transfusion-related hepatitis and HTLV-1 in Barbados - abstract

The study was designed to determine the prevalence of hepatitis B, hepatitis C, and human T-cell lymphotropic virus type 1 (HTLV-1) among blood donors in Barbados, with a view to reviewing the blood bank screening practices currently in place. Blood samples from 1,022 consecutive blood donors were collected and stored. Samples were then tested for hepatitis B surface antigen (HBsAg), antibodies to surface and core antigens of hepatitis B (anti-HBs) and anti-HBc, respectively, hepatitis C (HCV), and HTLV-1. HBsAg was found in 0.98 per cent, anti-HBs in 7.24 per cent, anti-HBc in 8.4 per cent (n=619), anti-HCV in 2.57 per cent (n=894) and anti-HTLV-1 in 1.4 per cent (n=708). It is recommended that while screening of blood donors is adequate for hepatitis B infection, urgent consideration should be given to additional screening for hepatitis C and HTLV-1 (AU)

Neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987-1996

This paper reports on neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital (QEH) for the period November 1987 to November 1996, and is a follow up to an earlier report for the period January 1984 to November 1987. It outlines the pattern of referral, diagnoses, referral centres and costs based on examination of the files of all QEH patients transferred overseas under a government aided scheme. There were 203 transfers of 191 patients (69 males, 122 females) including 10 patients who were transferred twice and one patient who was transferred three times. Patients ages ranged from 1 to 80 years (mean 37 years). Twenty overseas centres were used during the period but most patients were transferred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center, New York, between 1989 and 1994, and Hospital de Clinicas Caracas, Venezuela (1992 to 1996). 65 percent of the referrals were for neurosurgery and 25 percent were for magnetic resonance imaging scans for diagnosis. The largest diagnostic categories were central nervous system tumors (40 percent) and subarachnoid haemorrhage (25 percent). Estimated costs reached almost BDS$11 million, but the mean actual cost was BDS$63,916 based on information from 123 patient transfers. Thus, the actual total government expenditure was probably closer to BDS$13 million. This study demonstrates the urgent need to establish a neurosurgical service at the QEH and the cost effectiveness of doing so.(AU)

Neurological/neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987 - 1996

In 1988, we reported on the neurological/neurosurgical referrals overseas in the period January 1984 to November 1987. The present study is a follow-up of the previous one and reviews overseas referrals over a 9 years period from November 1987 to November 1996. The pattern of referral, diagnoses, referral centres and costs were studied. All Queen Elizabeth Hospital patients transferred overseas between November 1987 and November 1996 under a government-aided scheme for neurological investigation or neurosurgical treatment were include. The Department of Social Services files were reviewed. No patients were transferred in November and December 1987 but 203 patient-transfers were arranged for neurological investigation and/or treatment overseas between January 1988 and November 1996. This includes 10 patients who were transferred twice and one patient three times. 191 patients, 69 males and 122 females, were included, with ages ranging from 1 to 80 (mean 37) years. Most patients were referred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center (1989 - 94), and Hospital de Clinicas Caracas, Venezuela (1992 - 96). Twenty overseas centres were used during the study period. Sixty-five percent were referred for neurological management while 48 (25 percent) had MRI scans for diagnosis. The largest diagnostic category was central nervous system tumours (40 percent) followed by subarachnoid haemorrhage (25 percent). Through the government-aided scheme more than ten million BDS dollars were pledged during the study period. Actual costs were determined in only 38 percent of cases but there was a suggestion that the mean actual cost per patient of overseas neurosurgical management and investigation had shown little change over the nine years of the study, remaining at about Bds. $60,000.00(AU)

Pott's puffy tumour and subdural empyema following frontal sinusitis

A previously healthy 17-year-old lad presented with purulent sinusitis and subsequently developed subdural empyema in association with Pott's puffy tumour. Complete resolution occurred with an intensive antibiotic regime and drainage of the subgaleal space (AU)

Review of non-Hodgkin's lymphoma at the Queen Elizabeth Hospital (QEH) - abstract

To determine the immunophenotypes and review the clinical features of non-Hodgkin's lymphomas (NHL) seen at the QEH, Barbados, 1988-89. Twenty-seven cases were diagnosed; clinical charts were reviewed in 24 (19 Barbadian residents, 5 other Caribbean territories). Immunophenotyping was performed on paraffin blocks (UWI, Mona) in 22 cases. Human T-cell lymphoma virus type I (HTLV-1) antibody status was determined by ELISA in 20 cases at CAREC. Most patients had lymph node involvement with or without hepatosplenomegaly. There was one case each where the brain, the stomach and the ovary were the primary sites. Eight tumours were B-cell and 12 T-cell phenotype; results were inconclusive in 2 cases. Of the 12 patients with T-cell lymphomas (age range 3 to 75, median 59, 4 M, 4 F), 4 were seropositive (all females) for HTLV-1, representing cases of adult T-cell lymphoma/leukaemia (ATLL), of whom one patient had tropical spastic paraparesis, 7 were sero-negative and serostatus was unknown in 1. All patients with B-cell lymphomas age range 21-89, median 44, 6M, 2F) were HTV-1 sero-negative, while one patient with inconclusive immunotyping was sero-positive. In this small study, a trend towards T-cell immunophenotype predominace was observed. There is, however, a need for further studies (AU)

Life-threatening hyperkalemia associated with postassium-sparing therapy - abstract

The clinical course of four patients with hyperkalemia and symptomatic bradycardia presenting to the Queen Elizabeth Hospital over a six-month period was studied and risk factors assessed. Four patients were seen over a six-month period who presented with symptomatic bradyarrhthymia due to severe hyperkalemia. Patients' ages were 64 (D), 66 (C), 77 (A), and 83 (B) years and had plasma creatinine concentrations of 238, 805, 195 and 129 æmol/respectively. One pateint (C) was a male. All patients were hypertensive and two (C and D) were diabetic. All four were receiving a fixed dose combined diuretic containing amiloride and hydrochlorothiazide (5 mg A/50 mg H). Three patients (A< B and C) were on this combination for several months before presentation, while case D had been treated for just 5 days. In addition, one patient (B) was receiving supplemental postassium "Slow K" 1 tablet daily (8 mmol) for one week before presentation. Two patients (A and B), both of whom survived, were also receiving nadolol 80 mg daily and one (C) was receiving digoxin 0.125 mg daily. Two patients (C and D) arrested and died shortly after admission (serum K+ 9.3 and 10.0 mmol/1 respectively) while patients B and A (serum K= 8.0 and 8.8 mmol/l respectively) were treated in the intensive care unit. Emergency therapy was given to three patients (A, B and D) based on the characteristic ECG changes. Once the diagnosis was made patients received calcium gluconate, dextrose and insulin infusions and calcium resonium resin. No patient required dialysis or pacemaker insertion. The two patients treated in the intensive care unit were discharged uneventfully. We remind clinicians that caution should be exercised in the use of potassium sparing diuretics especially in those with renal insufficiency. It would be worthwhile that all patients receiving K+ sparing diuretics should have renal function and electrolytes measured before and during therapy (AU)

Focal seizures related to non-ketonic hyperglycemia - abstract

The aim of this paper is to highlight the association of non-ketonic hyperglycemia and focal seizures. Six patients, including 3 previously undiagnosed diabetics, were seen at the Queen Elizabeth Hospital, Barbados. All patients (except Case 5) were seen by at least one of the authors, while Case 4 was an outpatient whose case notes were reviewed. Three patients showed movement-induced or kinesignetic seizures, 2 had significant post-ictal weakness of the involved limb which was the arm in 5 patients and both limbs in 3. The face was involved either alone (1 patient) or with the arm (2 patients). There was one example of Epilepsia partialis Continua and 3 patients had recurrent episodes of focal seizures when glucose control was lost. Glucose values varied from 17.8 to 55.1 mmol/l, while calculated osmolarity values were elevated in all cases to a mild or moderate extent (299.1 to 346.5 mosmoles/l). The occurrence of focal seizures in the middle-aged or elderly patient should signal the possibility of diabetes mellitus. These seizures are refractory to anticonvulsant therapy and respond best to insulin and rehydration(AU)

HTLV-I infections in Barbados: results of a 20-year follow-up study - abstract

Human T-cell lymphotrophic virus type I(HTLV-1) infection is known to be associated with adult T-cell leukaemia/lymphoma (ATL), tropical spastic paraparesis, polymyositis, arthritis, alveolitis, uveitis, and infective dermatitis. Examination of stored sera from Barbados previously identified 41 HTLV-1 seropositives among 1012 participants in a 1972 survey. We have followed up this cohort: (1) to determine the long-term persistence of antibody, (2) to ascertain the risk of seroconbersion in household contacts, and (3) to identify long-term clinical sequelae of HTLV-1 infection. There were 79 HTLV-1 seronegative household contacts from 1972. Subjects were seen without knowledge of their serostatus and those who could be traced completed a questionnaire, had a clinical examination, serological, skin and stool tests. All 16 of the initially identified HTLV-1 seropositive sujects, whowere studied, remained seropositive and all 22 of the identified seronegative household contacts remained uninfected. Of the 22 household contacts, 10 were children of HTLV-1 seropositive mothers. In conclusion, we have confirmed persistence of HTLV-1 infection over 20 years' follow-up. There was no evidence of household transmission or of occult infection with late antibody expression in this study. Many HLTV-I infections are asymptomatic but we identified HLTV-I-associated clinical disorders in 4 cases: chronic dermatitis (2), hepatosplenomegaly (1), and hepatomegaly alone (1); the latter subject also had smouldering ATL (AU)

Neuroleptic malignant syndrome among acute psychiatric admissions in Barbados

The main features of the neuroleptic malignant syndrome (NMS), a complication of neuroleptic therapy, are fever, muscle rigidity, autonomic dysfunction, and an alteration in consciousness level. We describe five cases of NMS comprising 0.6 per cent of acute neuroleptically-treated admissions to a psychiatric hospital over a one-year period. All patients, four females aged 26 to 63 years, and one male, aged 65 years, were of African origin and received multiple neuroleptic drugs, at least one of which was a depot preparation. Four were being treated for functional psychiatric disorders while one had dementia. All patients had fever and depressed consciousness level while four had rigidity and autonomic dysfunction. Serum creatine phosphokinase was elevated in 4 cases, and there was indirect evidence of myoglobinuria in 3 cases suggested by a positive urine dipstick test for blood despite the absence of red cells on microscopy. Rhabdomyolysis was associated with renal failure in one case. Both bromocriptine mesylate and dantrolene sodium were given in two cases. Three patients died in hospital, one with persistent rigidity and progressive decubitus ulceration, one from peritonitis following dialysis, and another suddenly. Early recognition of NMS is important; it should be considered in any patient on neuroleptic therapy who develops fever, rigidity or alteration in consciousness level. (AU)

Clinical and laboratory features of adult T-cell leukemia lymphoma in Barbados

We describe the clinical and pathological features of 23 Afro-Caribbean patients with adult T-cell leukemia/lymphoma admitted to the Queen Elizabeth Hospital, Barbados over a 5 year period. There were 9 males and 14 females, with a median age of 38 years (range 14-84). Twelve had acute leukemia, 10 lymphoma (including 4 with solitary extra nodal lesions) and 1 smouldering subtype. Two patients had a past history of tropical spastic paraparesis/HTLV I associated myelopathy (TSM/HAM). The prognosis was poor, with only 3 complete responses to chemotherapy (CHOP) lasting from 9 to 36 months. We conclude that ATLL in Barbados is similar to the disease in the other Caribbean islands and Japan, except that in Barbados the age of onset is over a decade younger than in Japan.(AU)

Anterior horn cell degeneration in HTLV-1 associated polymyositis in patients from Barbados - abstract

Anterior horn cell degeneration has only been noted occasionally in patients with tropical spastic paraparesis associated with human T-lymphotropic virus type I infection (HTLV-I). We report on three adult patients with HTLV-I associated polymyositis who had evidence of anterior horn cell degeneration. One patient had moderate proximal weakness in all 4 limbs, while 2 had mild upper limb weakness and profound proximal weakness in the lower limbs. Electromyographic findings indicated motor unit loss. Muscle biopsies in 2 patients showed features of denervation, as well as mono-nuclear inflammatory cell infiltration. HTLV-1 IgG antibodies were detected by enzyme-linked immunosorbent assay, and confirmed by Western-immunoblot, in serum and cerebrospinal fluid in all 3 patients. In two, cell cultures were established from peripheral blood lymphocytes and HTLV-1 antigen was identified by immunofluorescence and the ELISA antigen capture technique, using an anti-p 19 HTLV-1 mouse monoclonal antibody. These 3 cases illustrate the variety of neuromuscular disease, other than spastic paraparesis, that may occur in HTLV-1 infection. Anterior horn cell degeneration may coexist with HTLV-1 associated polymyositis and may make a significant contribution to the muscle atrophy observed in these cases (AU)

HTLV-I serology in neurological patients at the Queen Elizabeth Hospital, Barbados - abstract

A survey of the spectrum of neurological syndromes encountered in Barbados was carried out to determine the pathogenic role of human T-lymphotropic virus (HTLV-I) infection in affected patients. Since 1989, patients with chronic neurological disorders were either recalled or were selected from new referrals to the neurology clinic at the Queen Elizabeth Hospital, Barbados. With the consent of patients, serum and CSF samples were tested for IgG antibodies to HTLV-I, using an enzyme-linked immunosorbent assay method. Positive results were confirmed by Western Immunoblotting at the CAREC Laboratories, in Trinidad. Only patients native to Barbados and the Eastern Caribbean were included in the survey. Twenty-nine (29) of 170 patients tested were serpositive for HTLV-I antibodies 18(62 percent) of the HTLV-I-positive patients had tropical spastic paraparesis (TSP). Of 21 seropositive patients who also had CFS-positive antibodies status, 16(76 percent) had TSP, 2(9.5 percent) adult T-cell leukaemia/lymphoma (ATLL), and 3 (14 percent) polymyositis, including 2 with an atypical clinical profile. HTLV-I seronegative patients included 12 (8.5 percent) with ataxia, 19(13.5 percent) with a relapsing/remitting sydrome characteristic of multiple sclerosis, 8(5.5 percent) with idiopathic intracranial hypertension and 8(5.5 percent) with stroke. HTLV-I positive associated neurological diseases in Barbados consist primarily of myelopathy (TSP). Some cases present more complex patterns of neurlogical dysfunction, associated with polymyositis. (AU)

Clinical and laboratory features of adult T-cell leukaemia lymphoma in Barbados

We describe the clinical and pathological features of 23 Afro-Caribbean patients with adult T-cell leukaemia/lymphoma admitted to the Queen Elizabeth Hospital, Barbados over a 5 year period. There were 9 males and 14 females, with a median age of 38 years (range 14-84). Twelve had acute leukaemia, 10 lymphoma (including 4 with solitary extra nodal lesions) and 1 smouldering subtype. Two patients had a past history of tropical spastic paraparesis/HTLV I associated myelopathy (TSP/HAM). The prognosis was poor, with only 3 complete responses to chemotherapy (CHOP) lasting from 9 to 36 months. We conclude that ATLL in Barbados is similar to the disease in other Caribbean islands and Japan, except that in Barbados the age of onset is over a decade younger than in Japan.(AU)

Human T-cell lymphotropic virus type 1 infection in Barbados: results of a 20-year follow-up study

Forty-one human T-cell lymphotropic virus I (HTLV-1)-seropositive individuals were identified among 1,012 subjects with stored serum samples from a health and seroepidemiological survey conducted in Barbados in 1972. These 41 subjects plus 79 HTLV-1 seronegative household members were targeted in a follow-up study 20 years later. Sixteen seropositive subjects and 22 seronegative subjects were interviewed, examined, and phlebotomized. There were no changes in HTLV-1 serostatus between the 1972 and follow-up serum samples. Three (19 percent) of the seropositive subjects had HTLV-1 serostatus between the 1972 and follow-up serum samples. Three (19 percent) of the seropositive subjects had HTLV-1-associated disorders: two with dermatitis and one with <

Anterior horn cell degeneration in polymyositis associated with human T lymphotropic virus Type-1 in patients from Barbados

Anterior horn cell degeneration has only ocassionally been noted in patients with tropical spastic paraparesis associated with human T lymphotropic virus type-1 (HTLV-1) infection. We report on three adult patients with HTLV-1-associated polymyositis who had clinical evidence of anterior horn cell degeneration. One patient had moderate proximal weakness and muscle wasting in all four limbs, while two had mild upper limb weakness with more profound proximal weakness and wasting in the lower limbs. In all three patients, elctromyographic findings were compatible with motor unit loss and muscle biopsies showed mononuclear inflammatory cell infiltration; muscle cell biopsies in two patients showed features of denervation. Immunoglobulin G (IgG) antibodies to HTLV-1 were detected by enzyme-linked immunosorbent assay (ELISA) and confirmed by Western immunoblot in serum and cerobrospinal fluid in all three patients. In two, cell cultures were established from peripheral blood lymphocytes and HTLV-1 antigen was identified by immunofluorescence and the ELISA antigen-capture technique using an anti-p19 HTLV-1 mouse monoclonal antibody. The three cases illustrate the variety of neuromuscular disease, other than spastic paraparesis, that may occur in HTLV-1 infection. In some cases of HTLV-1-associated polymyositis, anterior horn cell degeneration may make a significant contribution to the muscle atrophy observed. (AU)