A neglected source of household air pollution: a preliminary, mixed methods study of purposely produced household smoke in Wollo, Ethiopia.

BACKGROUND: Ill health associated with household air pollution (HAP) is increasingly recognized as a public health problem in sub-Saharan Africa. To date, attempts to reduce HAP have focussed on smoke from cooking fires and have ignored traditional cultural practices which generate purposely produced smoke (PPS). This study aimed to investigate PPS prevalence, reasons for use and safety perceptions. METHODS: The study was conducted in Wollo, Ethiopia, and used a mixed methods approach of quantitative surveys (analysed descriptively) and qualitative interviews with householders and healthcare workers (analysed thematically). RESULTS: PPS use was reported by 99% of survey respondents and it was considered a fundamental part of life. Although reasons for use included housekeeping, culture/religion and well-being, coffee ceremony was most commonly cited (44% of respondents). Both householders and healthcare workers appeared to assume PPS is safe, except for people with certain underlying conditions. Healthcare workers felt the lack of evidence of harm from PPS meant there was no justification for intervention. CONCLUSION: This study, the first in-depth study of PPS, has shown its use to be widespread, with many perceived benefits and thus a very important part of local culture in this sample Ethiopian community. Consequently, any public health interventions aimed at reducing HAP in this setting need to consider PPS.

Prenatal and postnatal programming of body composition in obese children and adolescents: evidence from anthropometry, DXA and the 4-component model.

BACKGROUND: Low-birth weight has been proposed to programme central adiposity in childhood. However, there is little information on associations between fetal weight gain and fat distribution within obese individuals. OBJECTIVES: To investigate associations between birth weight and postnatal weight gain with body composition in a sample of obese children and adolescents. SUBJECTS AND METHODS: Body composition was measured using anthropometry, dual-emission X-ray absorptiometry and the 4-component model in 45 male and 76 female obese individuals aged 5-22 years. General linear models were used to investigate associations between birth weight standard deviation score (SDS), or change in weight SDS between birth and follow-up, and body composition, adjusting for age, pubertal status, height and gender. RESULTS: Birth weight SDS ranged from -1.86 to 3.46, and was inversely associated with current weight SDS after adjustment for height SDS. Birth weight SDS was weakly associated with waist and hip girths, but not waist-hip ratio or trunk fat, after adjusting for age, height, pubertal status and gender. Change in weight SDS was strongly associated with total and central adiposity. CONCLUSIONS: Despite incorporating substantial variability, birth weight SDS was only a weak predictor of tissue masses and their distribution in obese children. Variability in central adiposity was more strongly associated with the magnitude of postnatal growth, which in turn was weakly inversely associated with birth weight SDS. In a population uniformly characterised by excess body weight, postnatal weight gain exerted the dominant impact on adiposity and fat distribution.

Non-communicable disease clinics in rural Ethiopia: why patients are lost to follow-up.

BACKGROUND: Providing medical care for non-communicable diseases (NCDs) in rural sub-Saharan Africa has proved to be difficult because of poor treatment adherence and frequent loss to follow-up (LTFU). The reasons for this are poorly understood. OBJECTIVE: To investigate LTFU among patients with two different but common NCDs who attended rural Ethiopian health centres. METHOD: The study was based in five health centres in southern Ethiopia with established NCD clinics run by nurses and health officers. Patients with epilepsy or hypertension who were lost to follow-up and non-LTFU comparison patients were identified and traced; a questionnaire was administered enquiring about the reasons for LTFU. RESULTS: Of the 147 LTFU patients successfully located, 62 had died, moved away or were attending other medical facilities. The remaining 85 patients were compared with 211 non-LFTU patients. The major factors associated with LTFU were distance from the clinic, associated costs and a preference for traditional treatments, together with a misunderstanding of the nature of NCD management. CONCLUSIONS: The delivery of affordable care closer to the patients' homes has the greatest potential to address the problem of LTFU. Also needed are increased levels of patient education and interaction with traditional healers to explain the nature of NCDs and the need for life-long management.

Amrinone: a weaning agent in catecholamine dependence.

Amrinone, a new inotropic agent, has been used successfully in refractory chronic congestive heart failure. Intravenous and subsequently oral amrinone administered in a setting of acute myocardial infarction and dopamine dependence allowed the catecholamine to be successfully weaned after volume loading, digitalization and vasoconstrictors failed to terminate dopamine dependence. There was the expected fall in filling pressure and increase in cardiac index and ejection fraction. Intravenous amrinone may be tried in refractory catecholamine dependence after conventional weaning methods have failed.

Chest pain--prophet of doom or nagging neurosis.

A six month survey of 588 patients presenting with chest pain to our emergency room revealed some 85 different diagnoses. The most common ages were the sixties and there were more men than women. Myocardial infarction and reflux esophagitis were more common in men, esophageal spasm equally prevalent in both sexes and psychiatric disorders more common in women. Site, radiation, duration and description were helpful in presumptive diagnosis with a few surprises. The problem was common (3.7% of 15.716 visits to the Emergency Room) and frequently perplexing. Wrong diagnoses abound! An overview of the problem is presented including neural mechanisms in pain perception. Chest pain due to intrathoracic structures, the chest wall, nerve roots and extrathoracic structures are considered.

Potassium chloride: absorption and excretion.

The absorption of potassium chloride in liquid form has been studied, using urinary excretion as an index of absorption. The excretion of potassium chloride was observed after inducing a water diuresis and administering a single dose in liquid form. There is evidence that potassium chloride in liquid form is absorbed rapidly, probably from the stomach, and hence there is a good rationale for its use where rapid absorption is needed, as in digitalis intoxication.

Heparin in clinical medicine.

Heparin is a commonly-used drug administered intravenously as an anticoagulant. This article describes the pharmacological effect of the drug, indications for its use, methods of administration, and dosage.

The significance of 'snaps' and 'clicks' on cardiac auscultation.

Short, high-pitched sounds ('snaps' or 'clicks') are a frequent finding upon auscultation of both symptomatic and entirely asymptomatic patients with heart disease. These sounds very frequently indicate structural changes in the valves. While these changes may or may not be of hemodynamic significance, the patient is at considerable risk of infective endocarditis in many of these disorders. Patients presenting with these sounds should, in most cases, be advised to have antibiotics prior to any dental or surgical manipulation.

Mitral regurgitation: which patient should be referred?

Because mitral regurgitation is so commonly seen in family practice, it becomes very important to decide quickly whether a patient should be referred or not. Dr. Levene summarizes indications for referral and mentions specific important considerations of long-term management.

Angina pectoris: an approach to management.

Angina may develop on a chronic pattern or in acute episodes, necessitating judgment on differential diagnosis and rapid institution of appropriate methods of management. This article lists all necessary steps from lab tests and drug therapy to long term management plans of diet and smoking habits.

Management of heart disease in the elderly.

Many factors have to be considered when treating heart disease in the elderly if quality of life is to be maintained. Cessation of smoking or rigorous weight loss may not be worthwhile in these patients, since there is little medical evidence showing much improvement after these measures have been taken. Medication should be prescribed with particular reference to cost, since many drugs are too expensive for pensioners to buy.

Emotional problems in ischemic heart disease.

The greatest changes of life for the patient with ischemic heart disease are often emotional ones. Physicians are sometimes guilty of overlooking this problem. Judicious counselling with a minimum of changes in life-style, are usually all that is needed.

Alpha-adrenoceptor-mediated coronary artery spasm.

Selective coronary arteriography performed on a 41-year-old woman with angina pectoris demonstrated proximal stenosis of the right and left main coronary arteries that was unaffected by nitrate therapy. To exclude coronary artery spasm, the study was repeated, and a striking increase in the narrowing of the right coronary artery was observed. This 90% stenosis was virtually abolished by pretreatment with intravenously given phentolamine hydrochloride. Prolonged alpha-adrenoceptor blockade with phenoxybenzamine hydrochloride improved the patient's exercise tolerance and postexercise electrocardiographic abnormalities when compared to therapy in matched controls given placebo. These observations suggest that alpha-adrenoceptor-mediated coronary artery spasm may mimic organic lesions at coronary arteriography and may be a factor in the pathogenesis of angina pectoris in some patients.

The heterogeneity of Streptococcus viridans: therapeutic considerations in infective endocarditis.

A 24-year-old woman with Marfan's syndrome and mitral regurgitation had clinical features suggestive of infective endocarditis. The causative organism was Streptococcus viridans. Initial therapy with penicillin G, in a dose that should have been bactericidal and hence curative according to the results of the initial quantitative antimicrobial studies, became inadequate. The strain of S. viridans displayed considerable variation in both growth properties and antimicrobial sensitivity during the course of therapy. In addition, a different strain of S. viridans was cultured 1 month after treatment had begun. It is therefore important to repeat cultures and antimicrobial sensitivity testing during treatment of infective endocarditis.

Ammonium chloride poisoning in chronic renal disease.

A 58-year-old woman with a long history of renal stone disease and urinary tract infection presented to the emergency room with exhaustion and air hunger. Laboratory data confirmed profound metabolic acidosis. Unduly large quantities of bicarbonate and potassium were required for correction of the deficits. She had been taking 6 g daily of ammonium chloride as a urine-acidifying agent for a period of six months in addition to agents directed against urinary tract infection. The combination of impaired renal function and effective hydrogen ion loading resulted in profound systemic acidosis. The metabolic derangements associated with the administration of ammonium chloride and its use as a therapeutic agent are discussed.

The influence of psychological factors on chest pain associated with myocardial infarction.

This paper will discuss some of the effects that psychological factors have on chest pain during and following myocardial infarction: 1. Psychological factors and the development of a myocardial infarction; a) the relationships of personality and other high risk factors, b) the onset situation of hopelessness and helplessness, c) immediate psychological precipitants (fact and fantasy), d)denial and delay. 2. Psychological factors during recovery; a)problems associated with the Type A personality, b) critical periods, c)absence of angina and denial, d) the effect of post M.I. angina, e) co-existence of angina and psychogenic pain. 3. How reaction of the marital partner can affect the patient and his experience of pain. 4. Factors which tend to minimize psychogenic invalidism.

General anesthesia in Eisenmenger's syndrome.

The anesthetic management of a woman with Eisenmenger's syndrome undergoing abdominal hysterectomy with general anesthesia is described. Proper anesthetic management of patients with this syndrome depends on a knowledge of the pathophysiologic process and associated complications. The potential problems of systemic hypotension, pulmonary embolism and infective endocarditis are outlined. Sudden death is a common and pregnancy is a major hazard.

Vasodepressor carotid sinus syncope.

There have been few reports of vasodepressor carotid sinus syncope, as opposed to the cardioinhibitory type, and no definitive treatment has been described. A 58 year old man developed episodes of syncope after surgery and radiotherapy for a laryngeal tumour. The episodes were characterised by hypotension, sharp pain in the right neck, dizziness, and bradycardia. A temporary pacemaker failed to prevent the symptoms, but ephedrine and fludrocortisone produced substantial improvement. Of the four types of treatment used in carotid sinus syncope, irradiation was ruled out because the patient had had irradiation before developing syncope, surgery was inappropriate because of the laryngeal tumour, and pacing failed. Combined drug treatment with a vasoconstrictor and plasma volume expander produced an improvement in symptoms but did not eliminate them.

Coronary artery spasm and mitral valve prolapse.

Ten patients, representing 1.34 per cent of those patients undergoing selective coronary arteriography, were found to have unequivocal evidence of coronary artery spasm. This involved the proximal right coronary artery in eight patients, the mid-left anterior descending branch in one, and the left main coronary artery in one. Eight of these 10 patients had otherwise normal coronary arteries. Of these 10 patients with coronary artery spasm, nine had evidence of mitral valve prolapse. This involved the posteromedial scallop in six patients; the anterolateral and posteromedial scallops in one; the middle and posteromedial scallops in one; and the anterolateral, middle, and posteromedial scallops in one. These data suggest an association between coronary artery spasm and mitral valve prolapse. Coronary artery spasm may thus be an important factor in the pathogenesis of the chest pain, arrhythmias, electrocardiographic abnormalities, and sudden death, that have already been described in some patients with mitral valve prolapse.