A survey of antiepileptic prescribing to women of childbearing potential in psychiatry.

Antiepileptic drugs (AEDs) are teratogenic. The aim of this survey was to ascertain whether clinicians followed recently published guidelines for prescribing AEDs to women of childbearing potential in England and Wales. We reviewed the case notes of all women aged 16-47 years who were initiated on valproate or carbamazapine in the psychiatric departments of three teaching hospitals over a 12 month period. Standards of documentation regarding childbearing issues in this representative sample were poor. The results are of concern given the widespread use of antiepileptic drugs in psychiatry.

A pilot study of dental caries status in relation to knowledge, attitudes and practices in oral health in Myanmar.

This study was to determine the dental caries prevalence among the Myanmar population, and to investigate the correlations between oral clinical indices and knowledge, attitudes and practices (KAP) on oral health. Subjects were randomly selected from 140,000 people residing in the Kyauktan township in a cross-sectional community-based study. The present analysis was confined to 739 subjects (353 males and 386 females) aged 12, 35-44 and 65-74 years, who were divided into two specified groups based on urban or rural location. KAP on oral health data and social demographic information were collected, while dental caries status was assessed by DMFT. The mean number of decayed teeth (DT) in rural areas was higher than that in urban areas, while the mean number of filled teeth (FT) in rural areas was lower than that in urban areas. Mean knowledge and attitude scores for correct answers were also significantly higher for the urban than the rural subjects. There were statistically significant correlations between the correct/incorrect responses to knowledge and attitude questionnaires on oral health and the mean number of DMFT. KAP pertaining to oral health of Myanmar population, especially those of rural subjects, might not be satisfactory and related to threaten their dental caries status.

Hospital-based study of severe malaria and associated deaths in Myanmar.

The present study identifies factors that contribute to malaria deaths in township hospitals reporting large numbers of such deaths in Myanmar. Between July and December 1995, we identified a total of 101 patients with severe and complicated malaria by screening the cases admitted to hospital with a primary diagnosis of falciparum malaria. Unrousable coma and less marked impairment of consciousness with or without other severe malaria complications, in contrast to severe malaria anaemia, were associated with all malaria deaths. Adult patients with severe malaria were 2.8 times more likely to die than child patients, with the higher risk of death among adults probably being associated with previous exposure to malaria, delay in seeking treatment and severity of the illness before admission. In view of this, we consider that malaria mortality could be reduced by improving peripheral facilities for the management of severe malaria and providing appropriate education to communities, without stepping up vector control activities.

PIP: Malaria threatens about 60% of Myanmar's population with morbidity and mortality. Factors are identified which contribute to malaria mortality in township hospitals reporting large numbers of such deaths in Myanmar. During July-December 1995, 101 patients with severe and complicated malaria were identified through the screening of cases admitted to hospital with a primary diagnosis of falciparum malaria. Unrousable coma and less marked impairment of consciousness with or without other severe malaria complications, in contrast to severe malaria anemia, were associated with all malaria deaths. Adult patients with severe malaria were 2.8 times more likely to die than child patients, with the higher risk of death among adults probably associated with previous exposure to malaria, delay in seeking treatment, and the severity of illness before admission. The level of malaria mortality could be reduced by improving peripheral facilities for the management of severe malaria and providing appropriate education to communities, without stepping up vector control activities.

Response of falciparum malaria to different antimalarials in Myanmar.

The purpose of the study was to ascertain the therapeutic efficacy of different treatments for uncomplicated falciparum malaria in the hospitals in Sagaing, northern and eastern Shan, to facilitate updating the existing national antimalarial drug policy. The proposed 14-day trial for monitoring the efficacy of treatments of uncomplicated falciparum malaria is an efficient method for identifying treatment failure patterns at the intermediate level (township hospital) in the Union of Myanmar. Minimal clinical and parasitological data for days 0-14 were required to classify treatment failure and success. Clinical and parasitiological responses on day 3 and days 4-14 were used as clear examples of early and late treatment failure, respectively. Mefloquine is five times more likely to be effective than chloroquine and sulfadoxine pyrimethamine (S-P), whereas chloroquine and S-P treatments have nearly identical failure patterns. The alarming frequency of clinical and parasitological failure (failure rate > 50%) following chloroquine treatment was reported in Sagaing and following S-P treatment in Sagaing and eastern Shan.

PIP: Malaria is a major health problem in Myanmar, a country in which the resistance of Plasmodium falciparum to antimalarial drugs frustrates malaria control efforts and impedes success. Chloroquine and sulfadoxine-pyrimethamine (SP) resistance at various levels is now common throughout the country, while mefloquine resistance currently remains limited to the Thai-Myanmar border. Findings are presented from an assessment of the therapeutic efficacy of treating uncomplicated falciparum malaria in hospitals in Sagaing Division and Shan State with a view to updating the existing national antimalarial drug policy. 118 patients aged 1-58 years with acute uncomplicated falciparum malaria were recruited into the study conducted in the township hospitals of Katha, Hsipaw, and Tachileik, an overall area characterized by endemic and seasonal forest-related malaria. The most prevalent parasite species is P. falciparum. Patients were randomly assigned to receive either chloroquine, SP, or mefloquine in 14-day trials. Minimal clinical and parasitological data for days 0-14 were needed to classify treatment failure and success. Clinical and parasitological responses on day 3 and days 4-14 were used as clear examples of early and late treatment failure, respectively. Mefloquine was found to be 5 times more likely to be effective than chloroquine and SP, while chloroquine and SP treatments have almost identical failure patterns. A higher than 50% failure rate following chloroquine treatment was reported in Sagaing and following SP treatment in Sagaing and eastern Shan.

The pivotal role of carbonic anhydrase in malaria infection.

Carbon dioxide (CO2) is essential for the growth of intraerythrocytic malaria parasites to synthesize pyrimidine through CO2 fixation and to regulate intracellular pH. CO2 transport across the plasma membrane of erythrocytes is facilitated by carbonic anhydrase (CA). With the use of electron microscopy and CA-specific Hansson's stain, CA is found also in all the intraerythrocytic stages of Plasmodium falciparum. When CA inhibitors, including acetazolamide, potassium iodide, and sodium deoxycholate, were added to continuous culture of P. falciparum, they, particularly sodium deoxycholate, produced a marked reduction in parasitemia. These results explain the biochemical basis of some of the clinical conditions associated with malaria and strongly suggest that CA inhibitors have potential as a new class of antimalarials.

The prime role of plasma membrane cholesterol in the pathogenesis of immune evasion and clinical manifestations of falciparum malaria.

The pathogenesis of falciparum malaria, with its immune evasion, mechanism of immune suppression and immunological inertia, the cause of its preferential incidence in children and pregnant mothers, and the pathological basis of clinical manifestations, are discussed from biochemical, biophysical and immunological perspectives. Sequestration and recrudescence are highlighted as the evolved means by which malaria parasites survive. These discussions are based on a novel hypothesis that changes in the lipid matrix fluidity of plasma membrane, through alterations of cholesterol and phospholipid content and variation in body temperature, significantly affect the membrane functions of cells. The pathogenesis of aggressive behavior in cerebral malaria is postulated to be different from that of coma, and complicated pregnancy in malaria is also discussed as a multifactorial condition wherein hypocholesterolemia, resulting from increased membrane biogenesis of multiplying parasites, is the common underlying factor.

Intestinal helminthiasis in relation to height and weight of early primary school children in northeastern peninsular Malaysia.

Stool examination, height and weight measurements were undertaken on 249 early primary school children at two schools in North-eastern Peninsular Malaysia. Helminth infected children were treated and follow-up anthropometric measurements and stool examination undertaken on all (n = 100) children at one of the schools 16 months later; to observe the relationship between acquisition of infection and growth. Baseline Ascaris prevalence rates at the two schools were 16.0% (23/144) and 47.6% (50/105) respectively whilst Trichuris rates were 33.3% (48/144) and 52.4% (55/105). Hookworm infection was uncommon. There was no difference in weight or height for age between infected and uninfected children at any time. Acquisition of worm infection over the initial 16 month follow-up period was not associated with significant decreases in growth rates. However the small subsets of children with heavy Ascaris infection were consistently lighter and shorter at all evaluation times. They also gained significantly less weight and tended to have reduced linear growth rates between measurements. Further interventional studies are required to determine if this association is one of cause and effect or largely incidental.

Effect of intestinal helminthiasis on school attendance by early primary schoolchildren.

Stool examination of 249 early primary schoolchildren at 2 schools in north-eastern peninsular Malaysia revealed that 73 were infected with Ascaris lumbricoides, 103 with Trichuris trichiura, and 18 with hookworms. Infected children were treated with a single dose of 400 mg of albendazole. The school attendance records during a 60 d period before treatment and 2 consecutive 60 d periods after treatment were examined. The absenteeism rate did not improve more among infected children after treatment than it did among the uninfected control children. The correlation between worm intensity and the number of lost school-days was poor. There was no evidence that intestinal helminthiasis caused school absenteeism among this group of children.

Effect of intestinal helminthiasis on intestinal permeability of early primary schoolchildren.

Intestinal permeability of 246 early primary schoolchildren at 2 schools (106 of whom were infected with intestinal helminths) was assessed by using the lactulose/mannitol differential absorption test. The ratio of the urinary recoveries of lactulose and mannitol was determined after oral administration of a standard solution of the 2 sugars. Assessment of intestinal permeability was repeated on 100 infected children after treatment and on a cohort of 68 uninfected children. Infected and uninfected groups were compared with respect to baseline lactulose/mannitol ratio (L/M1) and change in lactulose/mannitol ratio between assessments (delta L/M). The correlations between baseline intensity of infection and L/M1, and between fall in intensity and delta L/M, were evaluated. Based on a crude index of socioeconomic status, each child was assigned to one of 3 socioeconomic groups; all but 3 children belonged to either groups 2 or 3. Trichuris trichiura and Ascaris lumbricoides were the 2 predominant infections; the hookworm infection rate was relatively low. The results suggested that helminthiasis exerted only a marginal effect on intestinal permeability, the impact of which in children from lower socioeconomic backgrounds was negligible in comparison with the cumulative effects of other factors.

Sequestration pattern of parasitized erythrocytes in cerebrum, mid-brain, and cerebellum of Plasmodium coatneyi-infected rhesus monkeys (Macaca mulatta).

Six rhesus monkeys (Macaca mulatta) infected with Plasmodium coatneyi were studied for parasitized red blood cell (PRBC) sequestration in microvessels of the brain. The degree of PRBC sequestration is different in the cerebral, mid-brain, and cerebellar microvessels, with sequestration occurring preferentially in the cerebellum. This pattern resembles that of PRBC sequestration in cerebral and cerebellar microvessels in human falciparum malaria. The morphologic appearance of sequestered cells under light and electron microscopy as well as the PRBC sequestration pattern bolsters the contention that the rhesus monkey infected with P. coatneyi is an appropriate primate model for the experimental study of human cerebral malaria.

Differential sequestration of parasitized erythrocytes in the cerebrum and cerebellum in human cerebral malaria.

Sequestration of parasitized red blood cells (PRBC) in the microvessels results in impairment of microcirculation with organ dysfunction in complicated human Plasmodium falciparum malaria. In cerebral malaria patients, the percentage of small blood vessels with PRBC sequestration is higher in the brain than in other organs. The clinical severity of cerebral malaria depends on the level of PRBC sequestration in the brain. In our study, postmortem samples from cerebrum and cerebellum of 16 patients who died of P. falciparum malaria were examined and compared using light microscopy. In the cerebellum, the percentage of microvessels with PRBC sequestration was higher than that in the cerebrum. The difference in sequestration rates between cerebrum and cerebellum is statistically significant (P < 0.05). There is a higher degree of vascularity in the cerebellum (7 vessels/mm2) than in the cerebrum (5 vessels/mm2), and the difference is also statistically significant (P < 0.025). Perivascular hemorrhages also occur more frequently in the cerebellum than in the cerebrum. The results of this study, which show that differential sequestration of PRBC occurs in the microvessels of the cerebrum and cerebellum, explain the varied neurologic manifestations that result from cerebral and cerebellar dysfunction in human cerebral malaria. This study also reveals the necessity of postmortem histologic examination of the cerebellum in every suspected case of cerebral malaria.

An epidemiologic study of 70 oral cancer cases at the Institute of Dental Medicine, Yangon, Myanmar, 1985-1988.

This study shows that in Myanmar, South-East Asia, the prevalence of oral cancers is a serious fact as they rank fifth among all cancers being known there. On the 70 oral cancer cases reported at the Institute of Dental Medicine, Yangon, the findings stressed that most patients, male or female, came from the metropolitan division (Yangon), had smoking and chewing habits. Also most of these patients came to hospital only at the severe and late stage. It confirms us in our opinion that early diagnosis and prompt treatment are a necessity.

Potassium and massive blood transfusion.

Sixty patients who received massive blood transfusion intraoperatively and/or in the immediate post-operative period were analysed. Six patients had hypokalemia and two had hyperkalemia. The multifactorial changes leading to electrolyte disturbances especially involving potassium are discussed in relation to hypotension, hypothermia, acidosis, pH, and release of catecholamine. Potassium changes in relation to anaesthesia are discussed. The danger of routine administration of calcium during massive blood transfusion is stressed.

Review of the phase I and phase II teaching programmes in the School of Medical Sciences, Universiti Sains Malaysia.

The Phase I and Phase II undergraduate teaching programmes of the School of Medical Sciences were reviewed at the end of the 1985/86 academic year. It was found that deviations from the School's philosophy had crept into the implementation process. Modifications were therefore made in Phase I and Phase II programmes with a view to:--(i) reducing content, (ii) promoting integration, (iii) improving clinical examination skills of students, and (iv) providing more opportunities to students for self learning, reinforcement and application of knowledge. The number of assessment items in Phase I and the frequency of assessment in Phase II were also found to be inappropriate and so modifications in assessment were made to rectify this situation.