Dt Gilbert

HTLV‐1 associated polymyositis in Jamaica

The clinical, laboratory and epidemiological characteristics of 38 adult Jamaican patients with polymyositis were evaluated. Twenty‐four patients (63%) were human T‐lymphotropic virus 1 (HTLV‐1) seropositive and 14 patients (37%) were HTLV‐1 seronegative. Polymyositis runs a more protracted course in seropositive patients who had more frequent hospital admissions and a significantly longer duration of symptoms prior to presentation. Joint swelling, chest pain and dyspnoea were more frequent complaints among the seronegative patients. There was no significant difference between the two serological groups in muscle enzyme levels, antinuclear antibody positivity or frequency of Jo‐1 antibodies. HTLV‐1 infection may define a subgroup of polymyositis patients with a more insidious presentation and poorer response to corticosteroid therapy.

Prevalence of Carotid Stenosis in a High-Risk Caribbean Population

BACKGROUND AND PURPOSE The purpose of this study was to determine the prevalence of carotid stenosis among patients presenting to the University Hospital of West Indies (UHWI) Accident and Emergency Department (A&E) with an ischemic stroke or transient ischemic attack (TIA). METHODS Beginning in August 2006, all patients presenting to the UHWI A&E with an acute stroke or TIA were screened for enrollment. Patients were excluded if they had a hemorrhagic stroke or if informed consent could not be obtained. Demographic and clinical information were collected by chart review and interviewer-administered questionnaires. All participants had noncontrast head computed tomography (CT) and bilateral carotid duplex ultrasounds. RESULTS 133 patients were enrolled in the study. 90% presented with a stroke and 10% with a TIA. Mean age was 64 years, 52% were male, 96% self-identified as black. 78% had diabetes mellitus or hypertension or both, 27% were current or past smokers. 65.1% had a normal carotid ultrasound, 28.5% had <50% stenosis, 1.6% had 50% to 69% stenosis, 0.8% had >or=70% stenosis to near occlusion, 1.6% had near occlusion and 1.6% total occlusion. CONCLUSIONS The prevalence of moderate or high-grade carotid stenosis in this high-risk black Caribbean population presenting with an ischemic stroke or a TIA is 5.6%. This is lower than that described in other populations. Further studies are needed to determine the cost-effectiveness of routine screening for carotid stenosis in this population.

Guillain-Barré syndrome and its variants: a case of acute motor-sensory axonal neuropathy in Jamaica

This paper reports a case of a Jamaican young woman who experienced flaccid quadriparesis and bulbar weakness over a three-week period after a gastrointestinal illness. Nerve conduction studies confirmed an axonal type neuropathy consistent with the acute motor-sensory axonal neuropathy variant of the Guillain-Barré syndrome. Recovery, although evident, was slow and was augmented after a course of intravenous immunoglobulin. The patient was discharged from hospital after three months but was re-admitted one week later and eventually succumbed to complications of the illness. This case serves as a reminder that Guillain-Barré syndrome is now the most common cause of acute flaccid paralysis and should be considered early in all patients presenting with flaccid quadriparesis.

Cardiac Disease in Dialysis Patients in a Jamaican Hospital Echocardiographic Findings that Predict Mortality

The aim of the study was to assess, by echocardiography, the cardiac abnormalities in a group of patients with chronic renal failure and to determine the cardiovascular predictors of mortality. The study comprised forty-five patients from the Renal Unit, University Hospital of the West Indies, Kingston, Jamaica, and was undertaken between October 1, 1998 and July 31, 2000. All echocardiography was done by a single operator. The parameters assessed were systolic dysfunction, diastolic dysfunction, ejection fraction, regional wall motion abnormalities and valvular disease. Left ventricular cavity size, septal and posterior wall thickness were measured and left ventricular mass calculated. Demographic data were obtained directly from each patient by interview. The patients were mainly of African/mixed-African origin. Their mean age was 43.2 +/- 16.0 years. The average body mass index was 23.7 +/- 6.9. Twenty-eight (60.9%) patients were male and seventeen (39.1%) female. Hypertension, chronic glomerulonephritis and diabetes mellitus were the leading causes of chronic renal failure. Blood pressure was controlled at a mean value of 145/90 mm Hg pre-dialysis and 140/90 mm Hg postdialysis. The mean duration of renal failure was 2.8 years. Echocardiographic M-mode and two dimensional apical, four chamber view measurements indicated that mean left ventricular internal diameter (LVID) diastole was 55.7 +/- 7.9 mm (normal 38-56 mm) and LVID systole was 38.9 +/- 9.8 mm (normal 24-45 mm); the mean thickness of the chamber walls was 10.3 +/- 2.8 mm and 10.6 +/- 2.4 mm for the interventricular septum (normal 6-11 mm) and left ventricular posterior wall (normal 6-11 mm) respectively. Diastolic dysfunction was seen in 15 (34%) patients and systolic dysfunction in 12 (23%) patients who had ejection fractions less than 50%. The mean left ventricular ejection fraction was 56.3% +/- 16% (normal 65-85%), mean stroke volume was 82.9 +/- 27.2 mls (normal 51-96 ml). After 21 months enrolment in the study, Kaplan Meier analysis revealed a two-year mortality of 28.3%. Cox regression analysis indicated that a history of smoking current or past, low haemoglobin level, high aorta flow velocities, severity of mitral regurgitation and a negative association with serum creatinine were independent predictors of mortality. The correction of anaemia and control of other factors that impact negatively on cardiac function in dialysis patients is vital to enhance survival.

Quality of life and its correlates in chronic dialysis patients

Background: Quality of Life (QOL) is an independent risk factor for mortality in End Stage Renal Disease (ESRD). Traditional parameters such as haemoglobin concentration > 11.1 g/dl, higher socioeconomic status, educational level >10 years of study, Kt/V > 1.2 or urea reduction ratio (URR) > 65%, show a positive correlation with quality of life. Others such as age > 65 years, comorbidity, diabetes mellitus, female gender, poor socioeconomic and educational status (< 10 years duration) are risk factors for poor quality of life. Black populations within the United States of America have recorded higher QOL scores than their matched Caucasian population despite having negative predictive clinical parameters. Quality of life and its correlates in chronic dialysis patients have not been previously documented in the Englishspeaking Caribbean. We therefore undertook a QOL survey in a tertiary care hospital outpatient haemodialysis and peritoneal dialysis units. Methods: The Kidney Disease Quality of Life Short Form Questionnaire was completed by 60 haemodialysis and 10 peritoneal dialysis patients. This represented ninety per cent of both dialysis populations. Mean haemoglobin (Hb) concentration was 10.0 ± 1.8 g/dl, mean serum albumin 41± 6.4 g/dl and URR 75% ± 9 %. Results: Mean QOL scores were equivalent to the means of the sample population except in Sleep function (p = 0.03), Burden of Kidney Disease (p = 0.002) and Dialysis Staff Satisfaction (p = 0.045) which were significantly lower. Positive correlates were noted with Hb > 10g/dL (p = 0.02), URR > 65% (p = 0.01), serum albumin > 35 g/dL (p = 0.024) and high socioeconomic status (p = 0.045) but not with age > 65 years, comorbidity eg DM, nor educational level (p > 0.05). Female gender was associated with higher Quality of Social Interaction scores (p = 0.045) and Sexual Function scores (p = 0.008) while males reported higher Physical Functioning scores (p = 0.024). Higher socioeconomic status patients reported higher Quality of Social Interaction scores (p = 0.05) and Energy scores (p = 0.007) with positive correlation with Hb concentration (p = 0.02) and URR (p = 0.024). Lower income groups had worse Pain scores (p = 0.021) and Burden of Kidney Disease scores (p = 0.02). Married patients reported worse Pain (p = 0.01), Emotional wellbeing (p = 0.024) and Energy scores (p = 0.05). Higher Patient Satisfaction (p = 0.04) and Dialysis Staff Encouragement (p = 0.048) were seen among those with health insurance coverage. Age < 60 years was associated with higher Physical Functioning (p = 0.048) and Emotional Role (p = 0.002) with age > 65 years reporting lower Energy scores (p = 0.03). Multivariate analysis showed these to be independent associations. Conclusion: Overall, QOL among the chronic dialysis patients in this study is good. Positive predictive correlates were age < 65 years, Hb > 10g/dL, URR > 65%, serum albumin > 35g/dL and higher socioeconomic status.