Jamaican vomiting sickness: a study of two adult cases.

An acute illness (Jamaican vomiting sickness) which affected two adults after eating unripe ackee fruit was investigated. Analyses of serum and urine samples were performed to compare the patterns of organic acidaemia and aciduria with those reported from childhood cases. The main conclusion from the comparison is that the toxic ackee constitutent, hypoglycin, produces essentially the same metabolic effects in adults as in children.

Impaired peritoneal fluid drainage in nephrogenic ascites.

In three chronic hemodialysis patients with nephrogenic ascites and in four patients with ascites of other causes the rate of transfer of fluid from peritoneal cavity to plasma was measured by a radio-labelled albumin method. Ascitic fluid removal rate was lower in the patients with nephrogenic ascites (median 14, range 10 to 21 ml/hr) than in those with normal renal function (median 45, range 10 to 73 ml/hr). These results suggest that lymphatic drainage of the peritoneum is impaired in nephrogenic ascites and that this may contribute to the development of the condition and to the propensity of fluid overloaded dialysis patients to develop ascites. A retained substance or one liberated from abnormal kidneys may be responsible for reversible depression of lymphatic flow in uremia.

The chest radiograph in leptospirosis in Jamaica.

A consecutive series of 44 patients with proven leptospirosis was studied to document the radiographic pulmonary abnormalities, assess their prevalence, correlate them with the clinical signs and symptoms and determine their prognostic significance. Abnormalities were found in ten patients (23%), this prevalence being less than previously noted. The abnormalities shown were non-segmental opacification (consolidation-eight cases), basal linear opacities (collapse-five cases) and pleural effusions (four cases). The first radiographic demonstration of a large pleural effusion in leptospirosis is recorded. Non-jaundiced patients had a higher prevalence (43%) of these abnormalities than jaundiced (13%). No other correlation with clinical signs or symptoms was found. The presence of these abnormalities had no prognostic significance. It is concluded that the presence of radiographic pulmonary abnormality in in-patients with leptospirosis is common. These abnormalities are non-specific and can mimic other diseases leading to diagnostic difficulty. Such abnormalities may be extensive in the absence of clinical signs and symptoms.

Is MRCP (U.K.) a redundant qualification for graduates of D.M. (Internal Medicine), University of the West Indies?

M.R.C.P.(U.K.) and D.M. (Internal Medicine), University of the West Indies, are postgraduate qualifications that did, or now do, evaluate and set the quality of specialist Internal Physician training. Since the inception of the degree, graduates of D.M. (Internal Medicine), University of the West Indies, have developed sub-specialty interests and have been recognized as being of consultant status throughout the region and the world. D.M. is of a higher standard as it is an exit examination whereas the MRCP(U.K.) diploma is an entrance examination. Acquisition of the MRCP (U.K.) is expensive; travel to the U.K. is mandatory. Possession of MRCP (U.K.) is considered by most graduates of D.M. (Internal Medicine), University of the West Indies, to be unnecessary; it has not advanced their career in any discernible way. It should no longer be encouraged in any way at the University of the West Indies.

Helicobacter pylori.

Since 1983, rapid advances in the knowledge of Helicobacter pylori have given new insights into the pathogenesis of upper gastrointestinal diseases. Several methods are now available for the diagnosis of the infection. Antimicrobial therapy has emerged as a new and effective treatment for peptic ulcer disease in a proportion, as yet to be determined, of patients in the Caribbean.

Colonoscopy in Jamaica--a 12-year experience.

Four hundred and nine colonoscopic examinations were performed in 335 patients over a 12-year period in Jamaica. The main indications were suspected polyps (34%) rectal bleeding (22%) and suspected carcinoma (11%). Total colonoscopy was performed in 33% of cases. The ascending colon and hepatic flexure were examined in a further 25%, and the transverse colon in another 21%. Endoscopic examination of the suspected abnormal area was possible in all cases. In 142 examinations, no abnormality was detected, reflecting a false positive Barium enema in some. Polyps were found in 135 examinations, diverticula in 69 and carcinoma in 13. There were no complications. Colonoscopy was more sensitive and specific than Barium enema. The Barium enema findings were incorrect in 91 of 224 examinations (41%). Colonoscopy is a safe and accurate procedure which enables improved patient management.

Success of didactic gastroenterology teaching for postgraduate medical residents.

Although the Doctor of Medicine programme in Internal Medicine at the U.W.I. is a structured course with several teaching formats, the optimally effective form of teaching remains unknown. An experimental didactic teaching course in Gastroenterology was preceded and followed by an examination. This was conducted to determine the effectiveness of this form of teaching. The majority of residents ranked the course favourably. The mean examination score increased by 6.4%, from 25.4% before the course to 31.8% at the end. Although the more senior residents scored higher than their juniors in the pre-test, this difference disappeared in the post-test. Structured didactic teaching requires close supervision, active participation by trainee and reinforcement for the full benefit to be attained.

Endoscopic sclerotherapy of bleeding oesophageal varices in Jamaica.

The results of oesophageal sclerotherapy (OS) in 18 patients with recurrent bleeding varices are compared with 15 patients treated medically. The total transfusion requirement pre-sclerotherapy was 112 units of blood (mean 6/patient) which decreased to 46 units (mean 2.5) after sclerotherapy treatment was started (p = 0.005). In the medically treated group, total transfusion was 74 units (mean 5 units/patient). One hundred and forty-three injection sclerotherapy sessions were given, and all but one patient had significant reduction or eradication of varices. Three patients died of recurrent bleeding (17%) and one other required surgery. In the medically treated group, 3 patients died of bleeding (20%). Complications of sclerotherapy included mild bleeding (39%), chest pain (28%) and oesophageal ulcer (5.5%). OS reduces transfusion requirements in patients with recurrent variceal bleeding.

Inactivation of strongyloides stercoralis filariform larvae in vitro by six Jamaican plant extracts and three commercial anthelmintics.

In vitro bioassay of (a) aqueous methanol extracts (AME) of the green leaves of mimosa (Mimosa pudica), love weed (Cuscuta americana), vervine (Stachytarpheta jamaicensis), chicken weed (Salvia serotina) and breadfruit (Artocarpus altilis); (b) methanol-water fraction (MWF) of breadfruit leaves, and (c) commercially available drugs albendazole, thiabendazole and levamisole were assayed for nematode inactivating potential, using filariform larvae of Strongyloides stercoralis. Test larvae were obtained from a 10-day-old charcoal coproculture. Bioassays were conducted in Locke's solution, using 100 larvae in each of three replicates. Inactivation was recorded microscopically at 1, 3, 6 and 12 hours, then every 24 hours up to 5 days' incubation. It50 (time for inactivation of 50% of larvae) values read: levamisole and mimosa extract less than 1 hour; love weed extract, approximately 2 hours; breadfruit (MWF), 9.5 hours; chicken weed, 20 hours; albendazole, 35 hours; breadfruit (AME), 49 hours; thiabendazole, 74 hours and vervine extract, 81.5 hours. It95 values followed a similar, trend, and were approximately double the It50 measures. A potential role for locally available natural products in the treatment of strongyloidiasis is highlighted.

Chronic pancreatitis in Jamaica.

Thirty-five patients with chronic pancreatitis (CP) treated over a 15-year-period were studied. There were 29 men and 6 women with a mean age of 47 years (range 21-67). Twenty-seven (77%) were chronic alcoholics, two (6%) had gallstones, one had stenosis of the Ampulla of Vater and in five (14%) no obvious cause was found. Thirty patients (86%) presented with abdominal pain. Chronic diarrhoea was present in 8 (23%), and steatorrhoea was documented in 6 of these. Fifteen (43%) had pancreatic calcifications. Five developed pseudocysts and 16 (46%) developed diabetes mellitus. Twelve patients required surgery. Three continue to have severe recurrent relapses of pain but the majority (91%) have had a relatively stable course with medical management.

Helicobacter pylori in patients undergoing upper endoscopy in Jamaica.

One hundred and two consecutive patients undergoing upper gastrointestinal endoscopy were tested for H. pylori by a rapid urease test, using antral biopsy specimens. There were 60 men (mean age 54 yrs) and 42 women (mean age 49 yrs). Fifty-six patients (55%) were positive for H. pylori. Of male patients, 36 (60%) and of female patients, 20 (48%) tested positive. Sixty-eight per cent of patients with antral gastritis, 65% with duodenal ulcer and 60% with gastric ulcer had H. pylori. Thirty-nine patients (70%) positive for H. pylori were from major urban areas, and 17 (30%) were from rural areas of Jamaica. In patients without H. pylori, 61% and 39% were from urban and rural areas, respectively. Forty-four patients (79%) with H. pylori and 40 (87%) without H. pylori had piped water in their homes. Ninety-three per cent of all patients had electricity and 88% had refrigeration. There was no difference between patients positive or negative for H. pylori with regard to the use of alcohol, marijuana or tobacco. There was also no difference between both groups in exposure to domestic animals in the home environment. H. pylori is associated with antral gastritis and peptic ulcer disease in Jamaican patients. There are no specific environmental or social factors that seem to predispose to infection.