Occupational health promotion amongst cattle farmers in Zambia

One of the main activities of the Italian Animal Health Programme(IAHP) in the Republic of Zambia, a bilateral project betweenthe Ministry of Agriculture of the Zambian Government and theGeneral Directorate for Development Cooperation of the ItalianMinistry of Foreign Affairs, is the control of Malignant Theileriosisin Southern Province, through immersion of cattle in dip tankscontaining an acaricide. There are potentially important healthrisks to farm workers and the environment as a result of thisintervention and these are discussed. The control measures undertaken,with special reference to health education programmes, are described.     

Primary cutaneous medium and large cell lymphomas other than mycosis fungoides. An immunohistological and follow-up study on 54 cases

Summary Primary cutaneous medium and large cell lymphomas (MLCL) other than mycosis fungoides (MF) are rare, and their prognosis and treatment are controversial. The clinical, immunohistological and follow-up data of 54 well-documented cases of primary cutaneous MLCL other than MF, seen in our institutions over a 14-year period, were retrospectively reviewed, in order to determine the prognostic factors related to these lymphomas, and to analyse the results obtained with different treatment regimens. Forty-six patients presented with a solitary tumour or with localized lesions. and eight had disseminated cutaneous lesions. According to the updated Kiel classification, 45 cases (83%) corresponded to B-cell lymphomas: centroblastic lymphomas, 32 cases; centroblastic-centrocytic lymphomas, 11 cases; immunoblastic lymphomas, two cases. Nine cases (17%) were classified as T-cell lymphomas: pleomorphic medium and large cell lymphomas, eight cases; anaplastic large cell lymphoma. one case. Four of eight patients with disseminated skin lesions had a T-cell lymphoma. whereas 41 of 46 patients with a solitary tumour had a B-cell lymphoma. Patients with disseminated skin lesions and elevated serum lactate dehydrogenase (LDH) levels had a poor prognosis. Comparison of patients' overall survival, depending on immunohistological subtype, showed that the median survival of patients with pleomorphic T-cell lymphoma was 2·5 years, whereas it was not reached at 12 years for patients with centroblastic centrocytic and centroblastic lymphoma. The eight patients with disseminated skin lesions were treated with polychemotherapy. Most patients with a solitary tumour or with localized lesions of low tumour bulk were treated by surgical excision or radiotherapy alone, and nine other patients with localized lesions of high tumour bulk were treated with initial polychemotherapy. Clinical presentation (i.e. solitary or disseminated lesions), serum LDH levels, and the immunohistological subtype, are important prognostic factors in cutaneous MLCL. Patients with disseminated skin lesions have a poor prognosis, and should be treated with intensive polychemotherapy regimens, whereas those with a solitary tumour, or with localized lesions of low tumour bulk, are adequately treated by radiotherapy.     

Limited value of the urinary phenytoin metabolic ratio for the assessment of cytochrome P4502C9 activity in vivo

Relationships between the ratio of p -hydroxyphenytoin (p-HPPH), the major metabolite of phenytoin, to unchanged phenytoin excreted in urine (the urinary metabolic ratio or MR) were compared with a number of indices of the metabolic clearances of phenytoin and tolbutamide published previously for seventeen subjects separately administered these known cytochrome P4502C9 (CYP2C9) substrates. Significant correlations ( r _s=0.50–0.60, P <0.05) were observed between the phenytoin MR, derived from either 0–24 or 24–48  h urine collections, and inverse areas under the plasma unbound concentration-time curves (measured over various time intervals) of phenytoin and with plasma unbound tolbutamide clearance. Significant correlations ( r _s =0.59–0.74) were also observed between the phenytoin MRs and metabolic unbound clearances for p -hydroxyphenytoin formation. Despite the significant correlations, variability in tolbutamide and phenytoin metabolic clearance parameters tended to account for <50% of the variability in phenytoin MR. Correlations between the renal clearance of phenytoin and the phenytoin MRs suggest that variability in the renal clearance of unchanged drug limits the usefulness of the phenytoin MR for the investigation of factors influencing CYP2C9 activity in vivo .     

Outcome after thrombolytic therapy of nine cases of myopericarditis misdiagnosed as myocardial infarction

Anecdotal reports have suggested that cardiovascular complicationsmay occur if thrombolytic therapy is performed in cases of pericarditismisdiagnosed as acute myocardial infarction. From 1980 to 1993,47 cases of myopericarditis mimicking myocardial infarctionhave been admitted to our institution. The misdiagnosis wasmade because of clinical onset characterized by a typical chestpain, and/or localized ST segment elevation. Since 1987, nine(919 males, age 40±14 years) out of the 47 patients (19%)have been treated with a thrombolytic agent (streptokinase 419,rt-PA 519) followed by intravenous heparin. This treatment wasstarted during the pre-hospital pliase (2/9) and while in hospital(7/9). No pericardial rub was present; ST segment elevationwas mainly localized in inferior and lateral leads; no Q wavedeveloped; median creatine kinase rise was 268 units (range38 to 1280), and only one patient had a small pericardial effusion.The mean level of fibrinogen after thrombolysis was 1.72 g.l^–1 (range 0.10 to 4.50). In all cases, typical ECG cliangeswere present suggesting pericarditis with a subsequent returnto a normal ECG. No severe cardiac or pericardial complicationor arrhytlxmia occurred; only one patient developed a non-compressiveand resolvable pericardial effusion. Cardiac catheterizations(coronary and left ventricular angiographies) were normal whenperformed (5/9). Long-term follow-up (mean 46±29 months)was favourable without any coronary events. In conclusion, thrombolytictherapy was uncomplicated in our patients with myopericarditissimulating evolving myocardial infarction.     

Detection of gram-negative bacteraemia in early sepsis by a quantitative chromogenic and kinetic endotoxin assay

A kinetic chromogenic limulus test was carried out in order to investigate the possibility of a sensitive and specific detection of circulating endotoxin during the first 24 h of septic shock or severe sepsis in 76 patients. Two commercial kits, Whittaeker (W) and Chromogenix (C), were used. Blood culture was taken as a reference. At 1 : 10 plasma dilution (a currently used dilution in the end point limulus test) abnormal reaction kinetics were found in 13% and 41% of tests, for C and W respectively ( P  = 0.0008), resulting in unreliable results. Retesting plasma at a greater dilution, until the reaction kinetic was identical to calibration curve control values, gave similar results between the two kits and a better accuracy. Beyond a 0.5 EU mL⁻¹ endotoxin level, the probability of Gram-negative bacteraemia was high (sensitivity = 0.53 and 0.47; specificity = 0.95 and 0.93 for C and W respectively). This kinetic limulus amoebocyte lysate (LAL) test may be useful in therapeutic decisions for treatment of endotoxaemia.     

Determinants of condom use among intravenous drug users in Spain

Attitudes to and perception of health care delivery are consideredto be important factors for patient compliance in diabetes.To Investigate insulin-treated diabetic patients' use of, experienceof and attitudes to diabetes care a questionnaire was sent to561 patients, 20–50 years old, living in northern Sweden.Four hundred and eighty-eight patients (87%) participated inthe study. Data were analysed against social, medical and geographicalbackground factors. Female patients more often than men hadseen an ophthalmologist (93 versus 87%, p<0.05), a diabetesnurse specialist (74 versus 64%, p<0.05) and a chiropodist(49 versus 30%, p<0.001) at least once during the courseof their diabetes. Women also used the services of a medicalsocial worker (17 versus 10%, p-0.05) or a psychologist (14versus 8%, p<0.01) more often. More men than women were satisfiedwith the health care they had at the onset (65 versus 38%, p<0.001),but no gender difference in attitude to their present care wasfound. Diabetic patients with chronic complications comparedto those without were less satisfied both with the care theyreceived at the onset of diabetes (40 versus 61%, p<0.001)and at the time they answered the questionnaire (59 versus 72%,p<0.01). Patients in the most sparsely populated health districtwere more seldom able to be seen by the same physician (70 versus93% and 94%, p<0.001) and patient-physician continuity waspoorer over a 3 year period (48 versus 80%, p<0.001). Basedon results of this study, we conclude that use of, experienceof and attitudes to diabetes care are primarily related to genderand sickness factors. Living in sparsely populated areas probablyaffects the use and continuity of hearth care depending on themeans available. The differences demonstrated might be an argumentfor planning more individualized care for diabetic patientsin the future.     

Cutaneous macular amyloidosis associated with multiple endocrine neoplasia 2A

Cutaneous amyloidosis and multiple endocrine neoplasia 2A (MEN 2A) have been previously reported in several families. A genetic linkage of both disorders has recently been described. Notalgia paraesthetica has been suggested to be involved in the aetiology of amyloidosis in such patients. We report such an association in a 48-year-old woman with several relatives suffering from MEN 2A. Treatment with topical capsaicin, which has been shown to be effective in notalgia paraesthetica, was not useful in our patient.     

MR imaged neurovascular relationships at the cerebellopontine angle

Improvements in MR imaging techniques allow visualisation of the anatomy of the cerebellopontine angle (CPA) in increasingly accurate detail, revealing the complex interrelationship of the neurovascular structures in this region. We wished to assess whether vessels and vascular loops intimately associated with cranial nerves VII and VIII, corresponded to any abnormality or symptom pattern, and thus had any clinical significance. The MR scans of 108 patients were retrospectively reviewed and the imaging status of VII, VIII, the vessels, presence of vascular loops and their relationship to the nerves, coded and recorded. The patients’ records were independently reviewed and the presence and ‘sidedness’ of asymmetrical hearing loss, tinnitus, vertigo, and the results of caloric and brain stem evoked responses recorded. The vessels were closely associated with VII and VIII in over 30% of this sample with vascular loops imaged in 21% of patients, and clearly imaged entering the IAM in 7% of both right and left CPAs studied. There was no statistically significant relationship demostrated between the proximity of the vessels, or vascular loops, to the nerves and a symptom, or symptom pattern. These findings should be considered a normal variant on MR scanning.     

Operational factors of maternal mortality in Zimbabwe

Most studies on maternal mortality have looked at the directclinical causes and the distribution of actual rates. Much lessattention has been given to prevailing health care systems orcommunity factors associated with such deaths. A case-controlstudy design using incident cases was used to identify the magnitudeof maternal deaths and community and health care operationalfactors in both an urban and a rural setting in Zimbabwe. Thematernal mortality ratio for the rural setting was 168 per 100000 live births and that for the urban setting was 85 per 100000 live births. For the rural setting, the major direct causesof death were haemorrhage (24.8%), abortion complications (15.2%),puerperal sepsis (13.3%), and eclampsia (4.8%). For the urbansetting they were eclampsia (26.2%), abortion complications(23.0%), puerperal sepsis (14.8%) and haemorrhage (9.8%). Whereas rural-urban variations in maternal mortality were observed,inter-rural district variations were also apparent, especiallywith poor medical resources, poor communication and delayedinterventions. Risk factors for maternal mortality were presentat each of the various levels of care. Lack of antenatal care(ANC) had a significant Odds Ratio (OR 10.7 rural and 4.6 urban)contribution to maternal mortality. When abortions and ectopicswere excluded the OR for absent ANC was 4.1 (rural) and 2.6(urban). Lack of timely transport to nearest clinic or hospitaladversely affected pregnancy outcome in both rural and urbansettings. Despite delivery place planning, predisposing healthconditions and some danger signals, few of the women utilizedthe venue originally planned for delivery. Health education, community sensitization and teaching on risksignal awareness as well as health care delivery system strengtheningare recommended for reducing the high maternal mortality rates. ⁴Includes: Dr F Ashworth, Prof Mtimavalye, Dr Chatora, Dr PNhindiri, Dr Chiwora, Sister Nyangani, Sister Mujaji, SisterMakahamadzem, Mr Mandisodza, Mr Mashu, Sister Nyoni, Mr Dauramanzi,Mrs Dengu and the late Dr Chimbira