A clinico-pathological study of Cushing's syndrome at the University Hospital of the West Indies and a review of literature

Cushing's syndrome is an uncommon but important disease. Twenty-one confirmed cases of spontaneous Cuching's syndrome were documented at the University Hospital of the West Indies over a 21-year period. They were predominantly young females (F:M ratio of 17:4; mean age 25 years and three months). The commonest presenting symptoms were amenorrhoea (41 percent) and obesity (19 percent). Common clinical features were cushingnoid features (95 percent), hypertension (76 percent) and hirsutism (82 percent). Twenty-nine per cent had frank hyperglycaemia. Cushing's syndrome was due to Cushing's disease in 10 cases, adrenal adenoma in 3 and adrenal carcinoma in 2 cases. In 4 cases with presumed adrenal hyperplasia, the histology was either unavailable or was not consistent with the diagnosis. Two cases appear now to have had ectopic ACTH syndrome. Adrenalectomy was the commonest treatment offered. There were no intra-operative or post-operative deaths but recurrence was common after subtotal adrenalectomy in Cushing's disease. Twenty-seven per cent of the patients developed Nelson's syndrome, which was fatal in 50 per cent. Long-term hormone replacement therapy was unnecessary after surgery for adrenal adenomas. Treatment of Cushing's syndrome was well tolerated by the patients. (AU)

C breath testing in diagnosis of H. pylori in Guyana

Many techniques for diagnosing H. pylori (HP) have emerged. Serum immunoglobin FlexSure (F/S) is promoted for screening and C Breath Test (B/T) for confirmation of active HP infection. B/T confirmed HP in 97/106 F/S +ve dyspeptic patients in an earlier study. No correlation of pretreatment B/T with eradication of HP was documented. In this study B/T was compared with CLO test and culture, to evaluate the C Breath Test in the diagnosis of active HP infection in dyspeptic patients. The C Breath Test (Tri Med Specialities, Virginia) and HP culture were undertaken in 54 F/S +ve CLO +ve dyspeptic patients who were gastroscoped. B/T+ve was > 100dpm. Repeat B/T were performed 4 weeks and 6 months after a treatment regimen consisting of lanzaprasole, metronidazole and calrithromycin of 7 days. 4/54 were B/T -ve and 3 of the 4 (also culture -ve) were classified false -ve B/T. Total culture positivity was 51.8 percent (28/54). B/T confirmed eradication in 43/50 (86 percent) with no recurrences at 6 months' follow up.(AU)

Histological diagnosis of H.pylori in dyseptic patients: Warthin-Starry and haemotoxylin and eosin stains

This study was designed to correlate the presence of the Helicobacter pylori (HP) organism with histological grade of gastric antral biopsy and with endoscopic appearance. 80 dyspeptic patients were upper-endoscoped. Antral gastric biopsy samples taken were examined histologically for HP by an uniformed pathologist. Warthin-Starry staining technique (W-S) identified HP organisms. Histological grade of inflammation was evaluated by the haematoxylin and eosin staining technique (H&E): grade 0 (normal), grade 1 and 2 [superficial chronic quiescent gastritis (SCQG)] and grade 3 [superficial chronic active gastritis (SCAG)]. HP organisms (HP+ve) were identified in 31/80 (38.8 percent) of specimens examined by W-S. On H&E 13/31 were grade 3 (SCAG), 17 grade 1,2 (SCQG) and 1 grade 0. Of the 49/80 specimens negative for HP (HP-ve) organisms by W-S, 3 were grade 3, 43 (grade 1,2) and 3 grade 0. Of the 31 HP+ve patients, 4 had peptic ulcer disease (PUD), 20 gastritis and 7 normal mucosa. Of the 49 HP-ve patients, 4 had PUD, 32 gastritis and 13 normal mucosa. We concluded that W-S diagnosis of HP infection (38.9 percent of dyseptic patients studied) had 41.9 percent correlation with the H&E histologic grade 3 (SCAG). Secondly, endoscopic findings were a poor discriminant between HP+ve and HP-ve patients.(AU)

Diagnosis and treatment of Helicobacter pylori in Guyana - abstract

This study was designed to assess usefulness of an HP, igG serum blot immunoassay, "Flex-sure test" (F/S) in accurately guiding treatment of HP infection, to compare metronidazole 500mg bd, omeprazole 20 mg bd and clarithromycin 500 mg bd orally (MOC); and amoxicillin 500 mg bd, omeprazole 20 mg bd and clarithromycin 500 mg bd orally (AOC) for 10 days, ineradicating HP 115 of 322 patients with moderate to severe dyspeptic symptoms who were screen with the F/S test were positive and were randomly assigned to 2 treatment regimes. C14 breadth test (B/T) was performed to confirm infection at the start of the treatment, 4 weeks and 6 months after the treatment. 12/115 patient (10.4 percent) were withdrawn from the study after three confirmatory B/T were negative. 6/115 patients (5.2 percent) did not return for treatment. Ninety-seven (97) F/S and B/T positive patients were treated and followed up for 6 months. The most significant symptomatic relief occurred at the first month post-treatment. Bitterness, headache, nausea and diarrhea were the major symptoms experienced. The recurrent rate of HP at 6 months was 2/97 (2 percent). We conclude that F/S assay is a good and fairly accurate screen to commence primary therapy and that MOC and AOC are equally effective in eradicating HP after 10 days of oral theraphy with low recurrence at 6 months. (AU)

Correlates of HIV infection among women attending a sexually transmitted disease clinic in Guyana - abstract

A prospective study was conducted among 351 women who attended the Genitourinary Medical clinic in Georgetown for the first time between February and April, 1993 to determine the prevalence of HIV infection and describe the factors associated with HIV infection among these women. Information on demographics, sexual behaviour and medical and reproductive history was collected using a structured questionnaire. Blood samples were collected for testing HIV (320), syphilis (335) and Hepatitis B (318). HIV seropositivity was observed in 6.6 percent (21/320). 3.1 percent (10/318) tested positive for Hepatitis B surface antigen and 18.5 percent (68/335) had a positive serologic test for syphilis. The HIV seropositivity rate was significantly higher among single women (8.7 percent vs 2.6 percent, p=0.035) and women who thought they were at risk of HIV (9.9 percent vs 2.7 percent, p=0.0097). 6.95 percent of the women who lived in Georgetown tested positive for HIV compared to 6.01 percent of those who lived outside of Georgetown (p=0.75). 8.9 percent of those women who reported ever having used a condom tested HIV positive as compared to 5.5 percent of women who never used a condom. The prevalence of HIV infection did not vary significantly with age (p=0.299) nor level of education (p=0.476). Conclusion: This study demonstrated a high prevalence of HIV infection among women attending a sexually transmitted disease clinic in Guyana. These findings indicate that any effective strategy for the control of HIV spread in Guyana must include targeting of STD clinic attenders(AU)

Cardiovascular risk factors among Afro-Guyanese in a bauxite mining community - abstract

A cross-sectional study of a bauxite mining community was conducted between August and November, 1992, to determine the prevalence of specified cardiovascular risk factors. It was carried out by interns and staff of the Faculty of Health Sciences, University of Guyana. Three Hundred and eighty-five subjects out of an over-18-year-old population (4,400) were randomly selected from the electoral register. A risk profile was recorded for each subject with general data on age, gender, ethnicity, marital status and occupation. Other data collected and evaluated included family history of heart disease, daily cigarette smoking, height, hypertension (blood pressure level > 140/90 mm Hg), hypercholesteraemia (serum cholesterol > 230 mg percentage) and diabetes mellitus (fasting blood sugar > 120 mg percentage). Analysis of resultls of 242 (63 percent) cases, so far, of the 385 subjects, revealed 50.8 percent males and 49.2 percent females; 78 percent Afro-Guyanese, 12.8 percent Mixed and 7.9 percent Indo-Guyanese; 11.9 percent 65 years and over. Prevalence rates of 32.3 percent for hypertension, 14.5 percent for hypercholesteraemia, 2.9 percent for diabetes mellitus and 21.5 percent for obesity were observed, while 27.7 percent of the subjects smoked, 50.4 percent drank alcohol and 38 percent had at least one family member with heart disease. When risk factors for cardiovascular disease in hypertensive subjects were compared to those in nonhypertensive subjects were compared to those in nonhypertensives, it was found that hypercholesteraemia was 4.7 times greater and that obesity and diabetes mellitus was twice as great. This study indicates that risk factors for cardiovascular disease in a predominantly Afro-Guyanese mining community in Guyana are common and that educational and other strategies should be undertaken to reduce this risk (AU)

Knowledge of acquired immune deficiency syndrome (AIDS) and sexual practices among STD Clinic attenders in Georgetown Hospital, Guyana - abstract

Knowledge of AIDS and sexual practices were assessed among 604 men who presented at the Genitourinary Medicine Clinic, Georgetown Hospital, Guyana, with a new STD complaint from July, 13 to September 25, 1992, through a structured pre-coded questionnaire. Television (34.6 per cent) and radio (34.2 per cent) emerged as the major sources of information about AIDS. Almost all (99.17 per cent) of the respondents reported that they had heard of AIDS and 392/599 (65.4 per cent) thought they were at risk of catching the disease. Five hundred and sixty-one (93.7 per cent) persons suggested that they would be able to recognise an HIV/AIDS patient through appearances alone although only 38 (6.3 per cent) persons reported ever being questioned by a partner as to their HIV status. One hundred and ninety-five (32.3 per cent) persons did not know how long it takes to develop AIDS after acquiring the infection, while 276 (45.7 per cent) thought it took > 4 years and 130 (21.4 per cent) suggested ó 4 years. Homosexuality, unprotected sex and sharing of i.v. needles were recognized as ways in which HIV could be transmitted while 23.6 per cent and 17.4 per cent, respectively, implicated kissing and mosquitoes. Multiple (o 3) sex partners appeared to be the norm while only 45 per cent of persons admitted previous condom use. AIDS education needs to be intensified in Guyana. Promotion of a healthy sexual life style and stable family relationship are strongly indicated among the at-risk group for STD in Guyana (AU)

HTLV-1 seroprevalence among blood donors and food handlers in Guyana - a preliminary report - abstract

The aim of this study was to determine the prevalence of HTLV-1 seropositivity in those blood donors, food handlers and patients with symptoms suggestive of HTLV-1 infection who were seen at the Georgetown Hospital from July 15 to September 30, 1992. Sera were tested for HTLV-1 antibodies at the Caribbean Epidemiology Centre. Three hundred and fifty-four subjects were studied of whom 279 (79 per cent) were blood donors and 75 (21 per cent) food handlers; 3.9 per cent of the former (11/279) and 12.0 per cent of the latter (9/75) were seropositive with an overall seropositivity of 5.6 per cent. Although Indo-Guyanese accounted for about 40 per cent of the total sample there was only one Indo-Guyanese who was seropositive for HTLV-1. The presence of signs and symptoms associated with HTLV-1 infection was not a useful predictor of the disease (AU)

Syndrome of inappropriate antidiuretic hormone secretion in a patient with intrasellar neurofibroma of the sixth nerve

The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been described in a wide range of neurological and other disorders. We wish to add an extremely rare case of a solitary, large invasive neurofibroma of the sixth cranial nerve extensively destroying the sella turcica in the skull base and causing inappropriate secretion of antidiuretic hormone in a 44-year-old black man in the absence of neurofibromatosis. (AU)

Is there an association of achalasia with chagas' disease in Guyana? - abstract

Achalasia of the cardio-oesophageal junction is uncommon. Six cases were seen in a two-year period in a gastroenterology practice in Georgetown, Guyana. All of these patients were, however, from outside of Georgetown, with four females and two males, three Indo-Guyanese, two Afro-Guyanese and one mixed, with ages at diagnosis ranging from 14 to 49 years and a mean of 30 years. All had a barium swallow and oesophagoscopy was performed. Oesophageal dilatation was performed with initial good response. Three had a trial of nifedipine treatment as well. Chagas' disease is endemic in Brazil, parts of Venezuela and other Latin American countries. This paper looks at preliminary data on Chagas' disease in achalasia which seem to suggest that achalasia may be idiopathic in Guyana (AU)

Development of medical education in Guyana - abstract

The School of Medicine, University of Guyana commenced in September 1985 with a total enrolment of 63 students to date. It was conceived to help satisfy local requirements for medical practitioners. Over the years, comparatively few Guyanese trained in medicine abroad returned until training was undertaken in Eastern block countries. Unfortunately, many doctors eventually left the system for North America and elsewhere. The Ministry of Health, Guyana, eventually decided to train doctors locally and the University of Guyana was mandated to structure such a programme. Following visits by the team to a number of medical institutions utilising problem-based learning (PBL) methodology in medical institutions (Columbia, Mexico, Guatemala and Canada) and visits to Guyana by international consultants, the programme was designed, using a problem-based learning (PBL) methodology and community orientation. Workshops on the curriculum and PBL methodology were conducted by visiting international consultants from McMaster University, Mexico, Cuba and elsewhere. This presentation reviews the outcome of the first batch of 20 students in relation to educational background and some problems experienced in the implementation of the programme. The enrolment of students to date is 63 (AU)

Diet-related gastrointestinal disease at Georgetown Hospital, Guyana: a preliminary report (1980-1984) - abstract

Guyana has 2 predominant ethnic groups, Indo-Guyanese (51 percent) and Afro-Guyanese (30.0 percent). The dietary pattern is different in these two groups. The prevalence of some disorders, diabetes mellitus and ischaemic heart disease in particular, seems to be related to ethnic origin. Is there a difference in the spectrum of gastrointestinal disorders in these two groups? What relationship is there to dietary pattern? Before undertaking prospective studies to answer the above questions, a preliminary study using records from Georgetown Hospital, 1980-1984, was undertaken. Peptic ulcer disease, which was almost exclusively duodenal ulcer, was the commonest disorder; there were over 200 cases seen annually. It occurred mainly in Afro-Guyanese males. Appendicitis (ruptured, 157: inflammed, 167: normal, 17) was more prevalent in Indo-Guyanese; gallstones (59) were twice as common in Indo- as in Afro-Guyanese; gastric cancer (37) was relatively common; diverticular disease (36) affected the Afro-Guyanese; 5 of the 7 cases of ulcerative colitis were of African origin whereas 3 of 4 cases of Crohn's disease were of Indian origin; colonic cancer was frequently suspected. However, only 8 cases (6 African and 2 Indian) were diagnosed over the 5-year period. Using the population of the catchment area for Georgetown as the denominator, appropriate adjustments were made for population ethnic distribution. There seems to be some indication of a pattern of distribution in gastrointestinal disease related to ethnic origin, and perhaps dietary intake. Prospective work with improved diagnostic techniques is needed to investigate this further (AU)

Pregnancy in chronic active hepatitis with cirrhosis

Pregnancy in chronic active hepatitis and cirrhosis is rare. There is an appreciable perinatal mortality and the effect of pregnancy on the underlying liver disease remains uncertain. Two patients with autoimmune chronic active hepatitis with cirrhosis who became pregnant during an active stage of their disease while on therapy are described. Both had an uneventful pregnancy with successful deliveries. One of the patients had two other prenancies but the pregnancy had to be terminated because of clinical deterioration. With close supervision patients with chronic active hepatitis and cirrhosis may have successful pregnancies. (AU)

Cerebro-vascular complications of sickle cell disease in Jamaica - abstract

Homozygous sickle cell disease is an uncommon but important cause of hemiparesis and subarachnoid haemorrhage. A 24-year review showed that 42 cases of hemiparesis and 9 cases of subarachnoid haemorrhage had been seen at the University Hospital of the West Indies. All living patients (32) were examined in 1984 for residual defects. Twenty-two males and 20 females, with a median age of 7 years (range 8 months to 36 years) had had a stroke. Most (69 percent) were under 10 years of age at the time of the first stroke. No haematological or clinical predictor for stroke was identified, although transient ischaemic episodes prior to the onset of a complete stroke were seen in one 13-year-old. Recurrence clustered within the first 30 months with 10 of the 17 cases occurring in the first year. Contralateral occurrences were commonest (14) and resulted in death in 13. Subarachnoid haemorrhage was seen in 5 males and 4 females, aged 6 to 57 years (median 19 years), and 3 patients died. At re-evaluation of 32 patients, 8 had complete recovery, 20 residual hemiplegia and 4 quadriplegia. It is concluded that cerebro-vascular accident, though uncommon in sickle cell disease, affects a young age group and is associated with devastating consequences (AU)

A clinico-pathological study on phaeochromocytoma at the University Hospital of the West Indies

Phaeochromocytoma was confirmed in 16 patients at the University Hospital of the West Indies between 1963 and 1983. The duration of symptoms varied from 1 week to 6 years. The most common were palpitations, headache, exertional dyspnoea and dizziness; and 19 percent had hypertension detected for the first time when seen with this diagnosis. All tumours were intra-abdominal; 10 were intra-adrenal and two were malignant. The dignosis was confirmed histologically in all cases. All but one were catecholamine-producing tumours, but two were diagnosed at post-mortem only, indicating the importance of a high index of suspicion in the clinical evaluation of the hypertensive patient. Surgery produced a significant improvement in blood pressure control in 53 percent although it was felt that better results would have been obtained with earlier diagnosis (AU)

Acquired immune deficiency syndrome (AIDS) in a Jamaican

The acquired immune deficiency syndrome (AIDS) is a new disease of epidemic proportions, especially in the U.S.A. Although Haitians living in the U.S.A. are reported to be at special risk, other Caribbean populations do not seem to be so predisposed. The case presented here is the first seen at the University Hospital in Jamaica and serves to focus attention on some of the common manifestations of AIDS in order to increase physician awareness of this unusual disorder (AU)

Cushing's syndrome and its differential at the University Hospital of the West Indies - abstract

Crushing's syndrome is a rare condition with a potential for morbidity and mortality. During a 20-year retrospective review of patients with the diagnosis confirmed at the University Hospital, 20 cases were seen. There were 5 men and 15 women with an age range of 15 to 60 years and a mean age of 27 years. Sixty per cent of cases were due to hyperplasia, 15 percent to adenoma, 10 percent to carcinoma and 5 percent(1 case) was of ectopic origin in a patient with bronchogenic carcinoma. The zona fasciculata was involved in 90 percent of cases of hyperplasia. The clinical features of these black patients were as described elsewhere but we noted hypopigmentation alone in 45 percent of patients, with hyperpigmentation in 33 percent. One female patient, age 38, had a 13-year history of hypertension and later developed psychiatric symptoms. A 30-year-old man, who had severe hypertension of recent onset, developed congestive cardiac failure, and an adenoma compressing the renal artery was found at laparotomy. Difficult to control diabetes mellitus in a 27-year-old female was followed 3 years later by the development of cushionoid features. The mean time interval between the onset ofsymptoms and the confirmation of the diagnosis was 2 years 8 months. Serum cortisol levels with loss of diurnal variation and the dexamethasone suppression tests are still quite useful in confirming the diagnosis. Urinary cortisol and serum ACTH levels are not available here. Venography is the commonest and better-used method for localisation. Ultrasonography recently available has so far not been found to be helpful. Sixteen patients underwent successful surgery; two were scheduled for surgery, and one refused. Three patients developed Nelson's syndrome 1 to 4 years after surgery and two of them died, one in the perioperative period after transphenoidal resection of the pituitary tumor. Twenty-seven patients investigated for cushing's Syndrome during the same study period showed the cause to be simple obesity in 21 and Stein-Leventhal Syndrome in 6. It is concluded that blacks in Jamaica with cushing's syndrome present with similar clinical features as elsewhere, except for hypopigmented skin lesions. The zona fasciculata site involved. The serum cortisol and dexamethasone suppression tests are satisfactory in establishing a diagnosis (AU)

Phaeochromocytoma at the University Hospital of the West Indies - abstract

Phaeochromocytoma is an uncommon but treatable cause of hypertension. During a 20-year retrospective review of patients with the diagnosis confirmed at the University Hospital, 17 cases were seen. There were 9 males and 8 females, with an age range of 19 to 66 years and a mean age of 35 years. The commoner symptoms were palpitations, headache, dizziness, chest pains, and exertional dyspnoea and 50 percent had hypertension detected for the first time when seen for their complaints. The duration of these symptoms varied from one week to eight (8) years. One patient had a stroke 10 years prior to presenting with symptoms attributable to sympathetic overactivity. Two patients had malignant hypertension with papilloedema. One patient was in cardiac failure when first seen. First patients had an abdominal mass on initial examination, and one female had the diagnosis made during pregnancy. One patient had severe fluctuations of her blood pressure during gynaecological surgery which resulted in her being investigated and diagnosed as phaeochromocytoma. Prior to the 1960's, a biological assay of urinary catecholamines was used to confirm the diagnosis but since then the 24-hour urinary VMA assays have been used. It is possible that with more refined methods and a higher index of suspicion by clinicians for diagnosis the number of confirmed cases of phaeochromocytoma at the University Hospital of the West Indies may increase. Two patients died in the perioperative period and a third died one month after a successful adrenalectomy. In most cases, surgery resulted in improvements in symptoms and control of hypertension. In one male patient, symptoms of phaeochromocytoma recurred post-operatively (AU)

Sexual experiences and perceived risk of HIV infection of females attending a Genitourinary Medicine Clinic in Georgetown, Guyana - abstract

Data on socio-demographics, past medical history, sexual activity and perceived risk of HIV infection were collected from 344/377 consecutive new clinic attenders during the period February 2 to April 22, 1993, using a structured pretested questionnaire. Most (79.4 percent) were between 15 and 29 years old and 65 percent were single. Virtually all (99.4 percent) had at least a primary school education and one-half (51.7 percent) attended secondary school. One-half (56.4 percent) were unemployed, 50.7 percent reported their age of first sexual intercourse as ó16 years, 30.6 percent between 17 and 18 years and 18.7 percent as o19 years. The mean age of first sexual intercourse was 18.4 (SD ñ3.5) years for those who were > 40 years old and 15.5 (SD ñ 1.6) years for those who were 10 - 19 years old. For those aged 20 - 29 years and 30 - 39 years, the mean ages of first sexual intercourse were 17.1 (SDñ 2.4) years and 17.3 (SD ñ 2.8) years, respectively. The majority (89.2 percent) reported "a single steady sex partner". One hundred and eighty-four women (53.6 percent) thought they were at risk of becoming HIV-infected. Women who had two or more sex partners during the previous year and three or more lifetime partners were significantly more likely to report being at risk. The apparent low sexual negotiating power of these women seems to produce behaviour which is conducive to the spread of HIV infection. These women as well as the men who visit them should be targeted for special education (AU)