Myasthenia gravis in Jamaican children: a 12-year institutional review.

BACKGROUND: Myasthenia gravis is uncommon in children. The clinical characteristics in children of the English-speaking Caribbean have not been documented previously. OBJECTIVE: To describe the clinical characteristics and outcome of children with myasthenia gravis at two tertiary hospitals in Jamaica. METHODS: The case-notes of all children with a diagnosis of myasthenia gravis managed at the University Hospital of the West Indies and Bustamante Hospital for Children between January 1994 and December 2005 were reviewed. RESULTS: There were 34 children; mean age of onset of illness was 7.5 years and mean period of follow-up was 38.5 months. The male-to-female ratio was 1:1.3. Nineteen (59%) presented with ocular manifestations; 47% of these developed signs of generalised involvement. Most were treated with pyridostigmine and prednisone. Eight patients had thymectomy. Four patients (12%) entered remission. There were two deaths. CONCLUSIONS: Myasthenia gravis in Jamaican children is similar to that in other populations. It is more common in female children. Most children present with ocular manifestations and remission occurs infrequently.

Recent upsurge of tuberculosis in paediatric admissions at the University Hospital of the West Indies.

These case reports describe the clinical course of eight children who were admitted to the University Hospital of the West Indies, Kingston, Jamaica, between July 2000 and November 2001 because of a diagnosis of tuberculosis. This represented an increase in the incidence of the disease in children at this institution. The purpose of this report is to make healthcare workers aware of the resurgence of tuberculosis. The diagnosis of paediatric tuberculosis is challenging and requires a high index of suspicion in the presence of suggestive clinical and laboratory findings. The diagnosis should not be limited to the immunocompromised patient, as in this report the majority of the patients were HIV negative.

Recent upsurge of tuberculosis in paediatric admissions at the University Hospital of the West Indies

These case reports describe the clinical course of eight children who were admitted to the University Hospital of the West Indies, Kingston, Jamaica, between July 2000 and November 2001 because of a diagnosis of tuberculosis. This represented an increase in the incidence of the disease in children at this institution. The purpose of this report is to make healthcare workers aware of the resurgence of tuberculosis. The diagnosis of paediatric tuberculosis is challenging and requires a high index of suspicion in the presence of suggestive clinical and laboratory findings. The diagnosis should not be limited to the immunocompromised patient, as in this report the majority of the patients were HIV negative

Primary malnutrition. Can we always tell?

Patterns of disease in the English-speaking Caribbean have changed considerably over the past two decades. There has been a decrease in the incidence of common infectious diseases, an increase in the prevalence of chronic non-communicable disorders and an increase in the incidence and prevalence of HIV/AIDS. However, published estimates suggest that malnutrition continues to be a serious public health problem. It is possible that changing patterns of disease within the epidemiological transition may affect patterns of presentation of severe forms of childhood malnutrition. We have examined records of 435 children admitted to the clinical research ward of the Tropical Metabolism Research Unit (TMRU) from January 1, 1990, to December 31, 1999; among these were 25 children who were subsequently found to have severe childhood malnutrition (SCM) due to a defined medical or surgical disorder (i.e. secondary SCM). Among children with secondary SCM, the HIV/AIDS group was the largest and comprised 60% of these admissions. Regression analyses show that, over the ten-year period, there was a small, non-significant decline in the number of cases of primary SCM (incidence rate ratio, IRR = 0.99, 95% confidence interval = 0.96, 1.02, p = 0.98), while the number of cases of secondary SCM increased (IRR = 1.18, 95% CI = 1.03, 1.35, p = 0.02). These data are indicative of the need for continued vigilance in the evaluation of children who have clinical features of the syndromes of severe malnutrition and draw attention to the potential impact of HIV/AIDS in yet another area of healthcare delivery.

Primary malnutrition. Can we always tell?

Patterns of disease in the English-speaking Caribbean have changed considerably over the past two decades. There has been a decrease in the incidence of common infectious diseases, an increase in the prevalence of chronic non-communicable disorders and an increase in the incidence and prevalence of HIV/AIDS. However, published estimates suggest that malnutrition continues to be a serious public health problem. It is possible that changing patterns of disease within the epidemiological transition may affect patterns of presentation of severe forms of childhood malnutrition. We have examined records of 435 children admitted to the clinical research ward of the Tropical Metabolism Research Unit (TMRU) from January 1, 1990, to December 31, 1999; among these were 25 children who were subsequently found to have severe childhood malnutrition (SCM) due to a defined medical or surgical disorder (i.e. secondary SCM). Among children with secondary SCM, the HIV/AIDS group was the largest and comprised 60 of these admissions. Regression analyses show that, over the ten-year period, there was a small, non-significant decline in the number of cases of primary SCM (incidence rate ratio, IRR = 0.99, 95 confidence interval = 0.96, 1.02, p = 0.98), while the number of cases of secondary SCM increased (IRR = 1.18, 95 CI = 1.03, 1.35, p = 0.02). These data are indicative of the need for continued vigilance in the evaluation of children who have clinical features of the syndromes of severe malnutrition and draw attention to the potential impact of HIV/AIDS in yet another area of healthcare delivery.

Lead posisoning in a rural community in Jamaica

OBJECTIVE: A proliferation of "backyard battery repair shops" in Frazer's Content (Red Pond), St Catherine led to a number of cases of lead poisoning in that community. A lead decontamination project was instituted by Blue Cross of Jamaica Environmental Health Foundation in 1994 to address this problem. The aim of the present study was to evaluate the impact of that intervention. METHODS: Questionnaire were developed and filled in during interviews with 214 volunteers in Frazer's Content. Volunteers awareness of the environmental effects of lead and the success of the socioeconomic programmes were assessed. The medical records from five nearby hospitals were also checked for new cases of lead poisoning. In addition, soil and water samples were collected and analyzed by atomic absortion spectrophotometry for levels of lead. RESULTS: The results indicated that knowledge of lead poisoning had increased significantly since 1994. However, there was a marked decrease in entrepeneurial activities. Two new cases of lead posioning were noted. Seven of the soil samples had elevated lead levels (123-317 ppm) but none of the water samples had lead concentration above the critical level (10 hg/l). CONCLUSION: Based on these findings, it would appear that the decontamination and education projects done in 1994 were mostly successful in achieving their objectives. Entrepreneurial initiatives were not sustained.(Au)

The changing face of paediatrics in the English-speaking Caribbean.

Childhood mortality and morbidity patterns in the English-speaking Caribbean have changed significantly over the past 40 years. Acute respiratory illness, physical injury and conditions originating in the perinatal period have replaced malnutrition, gastroenteritis and other infectious diseases as major causes of illness and death in Caribbean children. Although population growth has slowed down, about one-third of the population of the English-speaking Caribbean remains under the age of 15 years. Infant mortality rates have also fallen but the major contributor to this decline has been a reduction in post-neonatal deaths. The decrease in mortality and morbidity from infectious diseases has led to a prominence of disorders originating in the perinatal period, psychosocial problems and chronic childhood disorders. Adverse economic conditions are held culpable for the re-emergence of protein energy malnutrition (PEM) and pulmonary tuberculosis in some territories. There is an urgent need to focus attention on the areas of perinatal and adolescent health, childhood disability, accidental and non-accidental injury, sexual abuse and human immunodeficiency virus (HIV) infection. Immunization programmes also require continuing support and expansion. These tasks cannot be accomplished without meaningful long term investment of financial and human resources in the health and educational services of the region.

The changing face of paediatrics in the English-speaking Caribbean

Childhood mortality and morbidity patterns in the English-speaking Caribbean have changed significantly over the past 40 years. Acute respiratory illness, physical injury and conditions originating in the perinatal period have replaced malnutrition, gastroenteritis and other infectious diseases as major causes of illness and death in Caribbean children. Although population growth has slowed down, about one-third of the population of the English-speaking Caribbean remains under the age of 15 years. Infant mortality rates have also fallen but the major contributor to this decline has been a reduction in post-neonatal deaths. The decrease in mortality and morbidity from infectious diseases has led to a prominence of disorders originating in the perinatal period, psychosocial problems and chronic childhood disorders. Adverse economic conditions are held culpable for the re-emergence of protein energy malnutrition (PEM) and pulmonary tuberculosis in some territories. There is an urgent need to focus attention on the areas of perinatal and adolescent health, childhood disability, accidental and non-accidental injury, sexual abuse and human immunodeficiency virus (HIV) infection. Immunization programmes also require continuing support and expansion. These tasks cannot be accomplished without meaningful long term investment of financial and human resources in the health and educational services of the region.

Pregnancy complications in natural family planning users.

A multicenter cohort study was designed to assess pregnancy outcome among natural family planning (NFP) users, and provide the opportunity to address complications in NFP users by planning status and by timing of conception with respect to day of ovulation. There were 877 singleton births in this sample. Complications evaluated were abnormal vaginal bleeding, urinary tract infection, vaginal infection, hypertension of pregnancy, proteinuria, glycosuria, and anemia. There was no significant difference in the mean age, number of prenatal visits or birth weight among optimally and non-optimally timed pregnancies or for planned and unplanned pregnancies. There were higher incidences of "parity 2 or more" and current smokers in the non-optimally timed pregnancies and lower incidences of prior pregnancy loss and "currently employed" in the non-optimally timed pregnancies. There was little difference in pregnancy complications with respect to pregnancy timing, with the exception of a significant increased risk of vaginal bleeding late in pregnancy among non-optimally timed conceptions (11.5%) compared to optimally timed pregnancies (5.2%, RR = 2.2, 95% CI 1.3-3.7). More differences were observed in pregnancy complication rates by planning status. Unplanned pregnancies were associated with significantly more late pregnancy bleeding, vaginal infections, proteinuria, glycosuria and medication use than planned pregnancies. Unplanned pregnancies had lower incidences of maternal anemia. Complications of pregnancy were low in this NFP population, irrespective of planned versus unplanned status. Women with planned pregnancies had even fewer complications during pregnancy than women with unplanned conceptions, suggesting that women using NFP to plan their reproduction may be at particularly low risk.

The relative distribution of T cell subsets is altered in Jamaican children infected with human T cell lymphotropic virus type I.

Early childhood infection with human T cell lymphotropic virus type I (HTLV-I) has been suggested to be involved in the pathogenesis of infective dermatitis and adult T cell leukemia/lymphoma. Since only a very small percentage of HTLV-I-infected children develop disease later in life, identification of early interim markers for persons at risk for developing disease would enable monitoring and might provide insight into the pathophysiology of the various diseases associated with HTLV-I infection. A cross-sectional study analyzed T cell subsets in 35 HTLV-I-seronegative and 16 HTLV-I-seropositive Jamaican children 11-31 months old. HTLV-I seropositivity was associated with an increase in the mean percentage of CD4 cells expressing HLA-DR, a marker for T cell activation (P = .02). This increase was positively correlated with duration of infection (r = .74, P = .009). These data demonstrate perturbation of regulatory cells of the immune system in HTLV-I-infected children.

Tropical spastic paraparesis occurring in HTLV-1 associated infective dermatitis. Report of two cases.

An association between HTLV-1 infection and infective dermatitis (ID) a relapsing eczematous condition of Jamaican children, was reported in 1990. These patients are at risk of developing other known HTLV-1 related diseases. We have observed the development of HTLV-1 associated myelopathy/tropical spastic paraparesis in two patients, ages 14 and 35 years, who were diagnosed with ID at ages 2 and 10 years, respectively. Infective dermatitis of children serves as an early marker of HTLV-I infection and may predict later development of either the malignant outcome, adult T-cell leukaemia/lymphoma or the neurologic manifestation HAM/TSP among adult carriers of HTLV-1 infection.

Tropical spastic paraparesis ocurring in HLTV-1 associated infective dermatitis: report of two cases

An association between HTLV-1 infection and infective dermatitis(ID), a relapsing eczematous condition of Jamaican children, was reported in 1990. These patients are at a risk of developing other known HTLV-1 related diseases. We have observed the development of HTLV-1 associated myelopathy/tropical spastic paraparesis im two patients, ages 14 and 35 years, who were diagnosed with ID at ages 2 and 10 years, respectively. Infective dermatitis of children serves as an early marker of HTLV-1 infection and may predict later development of either the malignant outcome, adult T-cell leukaemia/lymphoma or the neurologic manifestation HAM/TSP among adult carriers of HTLV-1 infection

Parkinsonian-like tremors in the recovery phase of kwashiorkor.

Kwashi shakes is described in a 17-month-old Jamaican male infant. This is the first reported case seen at the Tropical Metabolism Research Unit at the University of the West Indies, Mona, Jamaica and the first documented case in the West Indian literature.

Reversible hypertrophic cardiomyopathy associated with nesidioblastosis.

An infant with persistent hyperinsulinism had hypertrophic cardiomyopathy that progressed until near-total pancreatectomy was performed. After pancreatectomy the condition resolved. Hyperinsulinism may be a cause of treatable cardiomyopathy.

Levels and determinants of early neonatal mortality in Natal, northeastern Brazil: results of a surveillance and case-control study.

An institution-based surveillance and nested case-control study was conducted in Natal, Northeastern Brazil to estimate the level and determinants of early neonatal mortality. The early neonatal mortality rate was 25.5 per 1000 live-birth, 75% of early neonatal deaths were premature low birthweight infants, and the mortality rates were 591 and 318 per 1000 respectively, for preterm small for gestational age (PT-SGA) and preterm appropriate for gestational age (PT-AGA) infants. Mortality was 50 per 1000 for term low birthweight, and 8.6 for term normal birthweight AGA infants. In addition to prematurity and low birthweight, the main risk factors associated with early neonatal death were maternal smoking, complications during pregnancy or intrapartum, and inadequate antenatal care. The associations were weaker for prepregnancy factors such as single marital status or low maternal body weight, and no significant associations were observed with socioeconomic status. These findings suggest that in this population, efforts to reduce early neonatal death should focus on improved maternal care and the prevention of prematurity.

PIP: To facilitate health service planning, a surveillance and case-control study were conducted of births in 3 hospitals and 2 maternity clinics in the city of Natal in northeastern Brazil. The surveillance study revealed 285 early neonatal deaths among the 111,171 singleton live births recorded in the study institutions from September 1984-February 1986, for a rate of 25.5/1000. 75% of these early neonatal deaths involved premature infants. The mortality rates were 591/1000 for preterm small-for-gestational age infants and 318/1000 for preterm appropriate-for-gestational age infants, while this rate was 50/1000 for term low-birthweight infants and only 8.6/1000 for term normal birthweights infants. The case-control study indicated that the maternal risk factors of body weight under 50 kg and single parent status significantly increased the likelihood of early neonatal mortality, while maternal age, parity, prior reproductive loss, and socioeconomic status did not have a significant effect on this outcome. Pregnancy-related factors that substantially increased the risk of early neonatal death included smoking, bleeding during the first or second trimester, toxemia, less than 5 prenatal care visits, and congenital malformations. These pregnancy-related risks exerted a more substantial effect than maternal characteristics, suggesting the feasibility of a strategy focused on preventing preterm births through prenatal care rather than a high-risk approach of screening women prior to pregnancy.

House dust mites in the West Indies.

The purpose of this study was to determine the role of the house dust mite. Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df), in allergic diseases on the island of St. Lucia. Dust samples were taken from living quarters of patients and hospital volunteers. The level of Df antigen in these living quarters was measured by RAST inhibition. All samples showed Df antigen within a large range of values. Prick tests were done to house dust mite and molds on 91 patients with suspected allergic disease with 63 (69%) reacting to at least one antigen. Of these, 56 (88.9%) reacted to one or both mites. House dust mite is a major allergen in St. Lucia.

A case-control study of stillbirths in northeast Brazil.

An institution based case-control study to determine risk factors for stillbirths was conducted in the city of Natal, NE Brazil, where 90% of deliveries take place in health facilities. Two hundred thirty-four singleton stillborn cases were compared to 2555 liveborn singleton control infants of normal birth-weight and gestational age. Information was obtained by postnatal interview and anthropometry, and review of medical records. Univariate analyses revealed a large number of potential risk factors, but after adjustment by logistic regression only six factors remained significantly associated with stillbirth. These were low maternal weight, less than or equal to 50 kg and a history of pregnancy loss, both with odds ratios (OR) of 1.8, inadequate prenatal care defined as less than five visits (OR = 1.9), gestational complications (OR = 14.2), intrapartum complications (OR = 2.0), and congenital malformations (OR = 8.7). There was also an increased risk of stillbirth among older mothers who smoked (OR = 1.4), and evidence of an interaction between smoking and complications of pregnancy. From the public health perspective, the most important factors amenable to intervention were inadequate prenatal care and antenatal or intrapartum complications which were associated with substantial attributable risks (23.8%, 35.2%, and 10.2%, respectively). Thus, in this population, future reductions of the high stillbirth rate (27.2 per 1000 births) will largely depend on the coverage, utilization, and quality of antenatal and intrapartum care.

Determinants of preterm delivery and intrauterine growth retardation in north-east Brazil.

A case-control study was conducted in Natal, north-east Brazil to determine the risk factors for low birthweight (LBW). Cases were 429 preterm and 422 intrauterine growth retarded (IUGR) singleton infants. Controls were 2555 infants of normal birthweight and gestational age. The prevalence of LBW was 10% (5.1% preterm and 4.9% IUGR). Logistic regression was used to estimate the adjusted odds ratios of LBW, and attributable risk per cent (AR%) was used to estimate the proportion of LBW that might be prevented. The preventable determinants of preterm delivery were births to women less than 20, (AR = 7.1%), low maternal weight less than 50 kg (AR = 20.5%), smoking during pregnancy (AR = 14.6%) and infrequent antenatal visits (AR = 28.1%). Other important determinants of preterm delivery were prior LBW births, gestational illness and vaginal bleeding. The main preventable causes of IUGR were low maternal weight (AR = 17.8%), low maternal education (AR = 11.6%), smoking (AR = 14.8%), and inadequate antenatal care (AR = 11.6%). Other risk factors for IUGR include primiparity, prior LBW births, and illness during gestation. In this population, the focus of short-term preventive programme should be improvement in maternal nutrition, cessation of smoking, reduction of births to women under 20, and improved antenatal care.

Interpregnancy interval and low birth weight: findings from a case-control study.

In a case-control study in Natal, northeast Brazil, conducted between September 1984 and February 1986, 303 cases of intrauterine growth retardation and 282 cases of preterm delivery were compared with 1,710 normal controls to ascertain the effects of the preceding birth-to-conception interval on pregnancy outcome. The risk of intrauterine growth retardation associated with interpregnancy intervals of six months or less was 1.38 (95% confidence interval (CI): 1.02-1.86) after adjustment for maternal age, education, smoking, and prior fetal loss or low birth weight. When maternal postpartum body weight was introduced into the logistic model, the risk of intrauterine growth retardation decreased slightly to 1.25 and was no longer significant (95% CI: 0.91-1.72). Short interpregnancy intervals (six months or less) were more frequently observed in women with postpartum body weight of less than 45 kg (31.1%) than in women weighing 50 kg or more (18.9%), which might suggest that the effect of short intervals on the risk of intrauterine growth retardation is mediated through maternal nutritional status. No association was found between birth-to-conception intervals and preterm delivery.