Body dysmorphic disorder: case report

The desire for self-mutilation in the absence of any discernible psychopathology is relatively rare. Self-mutilation is most commonly a manifestation of an underlying psychopathology such as depression, schizophrenia, personality disorder, transexuality, body dysmorphic disorder and factitious disorder. In this article, a case in which a 29-year-old single Kenyan lady of African origin demanded a surgical operation to modify and reduce the size of her external genitalia is presented. Although female genital mutilation is still widespread in the country, this case is of interest in that the woman did not seek the usual circumcision but sought to specifically reduce the size of her labia minora so that she could feel like a normal woman. The unique challenges in her management are discussed. Possible aetiological factors in patients who demand surgical removal or modification of parts of their bodies without an obvious cause is discussed.     

Outcome of poor prognostic phenotype non-Hodgkin’s lymphoma treatment in relation to human immunodeficiency virus serostatus

Background

The risk of developing aggressive phenotype non-Hodgkin’s lymphomas is high among HIV infected individuals and is associated with worse prognosis than among non-HIV infected ones. Effective antiretroviral therapy has more recently been reported to greatly improve outcome among these patients. A retrospective review of treatment outcome for aggressive and highly aggressive phenotype non-Hodgkin’s lymphoma patients was carried out. The objective was to compare outcome of treatment for poor prognosis subtypes of non-Hodgkin’s lymphomas in relation to HIV-serostatus. The setting was Hurlingham Oncology clinic, a private oncology clinic in Nairobi, Kenya. The main study endpoints were complete remission rate and overall survival.

Results

Thirty-two patients (42.7%) were HIV-positive, 32 (42.7%) were HIV-negative and 11 (14.7%) had HIV serostatus undetermined. Seven (21.9%) of HIV positive patients achieved complete remission compared with 24 (75%) of HIV negative ones. This difference was highly significant (P < 0.0001). Five (15.6%) of HIV-positive patients died during first-line treatment compared with none of the HIV-negative counterparts. The difference again was highly significant (P < 0.0001). The median survival time was 19 months among HIV-negative patients and 6 months among positive cases.

Conclusion

Complete remission rate among HIV-negative patients in this series was the same as reported from well established centres, but the rate among HIV-positive patients was lower than expected. Patients with HIV infection were more likely to die from toxicity during induction and had inferior survival compared with HIV-negative cases.     

Taste impairment in chronic rhinosinusitis

Background

Though many patients with chronic rhinosinusitis (CRS) describe disturbances in smell and taste, there have been no studies specifically assessing taste impairment in CRS. This study sought to objectively assess taste dysfunction in CRS patients and determine whether taste impairment correlates with olfactory dysfunction. Additionally, this investigation sought to determine the impact of taste dysfunction on quality of life (QOL) in CRS and identify the clinical factors that influence taste.

Methods

Sixty‐eight CRS patients were prospectively enrolled and completed several QOL surveys in relation to taste, smell, overall sinus‐specific QOL, and depression. Validated taste strips were used to determine gustatory dysfunction pertaining to sweet, sour, salty, and bitter. Olfactory testing was assessed using the Sniffin’ Sticks Test while both Lund‐Kennedy and Olfactory Cleft Endoscopy Scoring (OCES) systems were used for endoscopic evaluation.

Results

The overall prevalence of dysgeusia was 28%, with scores significantly lower for sour compared to other subgroups. No correlation was observed between taste scores and objective olfactory metrics including olfaction tests and OCES. Taste scores were better in younger patients (r = 0.28, p = 0.02), female patients (p = 0.004), and never smokers compared to former smokers (p = 0.01). Taste scores did not correlate with patient‐reported outcome measures or CRS disease severity metrics.

Conclusion

Taste dysfunction is a common complaint in CRS. This cohort shows prevalence of gustatory loss to be about 28% using ideal normative values. This dysfunction correlated with male gender, smoking history, and older age. Taste dysfunction did not correlate with measured olfactory outcomes.

     

Explanatory model of psychosis: impact on perception of self-stigma by patients in three sub-saharan African cities

Background

Most cultures in sub-Saharan Africa subscribe to the belief that the root cause of psychosis is supernatural. Individuals in the community who hold a religiomagical explanatory model of causation have been shown to exhibit more stigmatizing attitudes towards people with psychosis. Self-stigma among individuals with psychosis is less frequently studied.

Method

We used a mixed-method approach, consisting of key informant’s interviews to elicit information on explanatory models of causation of psychosis and questionnaire assessment of internalized stigma with an adapted version of the Scale for Internalized Stigma of Mental Illness. Twenty-four, 31, and 30 subjects with recent experience of utilizing the service of traditional or faith healers for severe mental disorders in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya), respectively, were interviewed.

Results

About 44 % (42.1 %) of the Nigerian respondents had a high (severe) level of self-stigma with the respective proportions among Ghanaian and Kenyan respondents being 20.7 and 37.5 %. Compared with 4 out of a total of 12 respondents (33.3 %) who reported low self-stigma reported supernatural attribution, 14 out of 20 respondents (70 %) with the highest level of self-stigma reported supernatural attribution across the three sites. When low scorers ascribed supernatural causation, it was often with a religious focus.

Conclusion

There is a greater tendency for persons with high levels of self-stigma than those with low levels to ascribe supernatural attribution to their experience of a severe mental health condition.

     

Interaction of Mycobacterium tuberculosis-Induced Transforming Growth Factor β1 and Interleukin-10

Mycobacterium tuberculosis is associated with the activation of cytokine circuits both at sites of active tuberculosis in vivo and in cultures of mononuclear cells stimulated by M. tuberculosis or its components in vitro. Interactive stimulatory and/or inhibitory pathways are established between cytokines, which may result in potentiation or attenuation of the effects of each molecule on T-cell responses. Here we examined the interaction of transforming growth factor beta1 (TGF-beta1) and interleukin-10 (IL-10) in purified protein derivative (PPD)-stimulated human mononuclear cell cultures in vitro. TGF-beta1 induced monocyte IL-10 (but not tumor necrosis factor alpha) production (by 70-fold, P < 0.02) and mRNA expression in the absence but not in the presence of PPD. Both exogenous recombinant (r) IL-10 and rTGF-beta1 independently suppressed the production of PPD-induced gamma interferon (IFN-gamma) in mononuclear cells from PPD skin test-positive individuals. Synergistic suppression of IFN-gamma in cultures containing both rTGF-beta1 and rIL-10 was only seen when the responder cell population were peripheral blood mononuclear cells (PBMC) and not monocyte-depleted mononuclear cells and when PBMC were pretreated with rTGF-beta1 but not with rIL-10. Suppression of PPD-induced IFN-gamma in PBMC containing both rTGF-beta1 (1 ng/ml) and rIL-10 (100 pg/ml) was 1.5-fold higher (P < 0.05) than cultures containing TGF-beta1 alone and 5.7-fold higher (P < 0.004) than cultures containing IL-10 alone. Also, neutralization of endogenous TGF-beta1 and IL-10 together enhanced PPD-induced IFN-gamma in PBMC in a synergistic manner. Thus, TGF-beta1 and IL-10 together potentiate the downmodulatory effect on M. tuberculosis-induced T-cell production of IFN-gamma, and TGF-beta1 alone enhances IL-10 production. At sites of active M. tuberculosis infection, these interactions may be conducive to the suppression of mononuclear cell functions.     

Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda

OBJECTIVE: To study the differences in sexual practices, hygienic behaviors, and other HIV risk factors between circumcised and uncircumcised men. DESIGN: A cross-sectional study of men >17 years of age selected by single stage cluster sampling in the Industrial Borough, Mbale, Uganda. METHODS: Using a structured questionnaire, 188 circumcised and 177 uncircumcised consenting Ugandan men were interviewed in one of four native languages during April and May, 1997. RESULTS: Among non-Muslims, circumcised men had a higher risk profile than uncircumcised men in that they were more likely to drink alcohol in conjunction with sex (odds ratio [OR], 1.86: 95% confidence interval [CI], 1.09-3.16), to have sexual contacts with women on the first day of meeting (OR, 2.37; 95% CI, 1.39-4.04), to have had sexual contacts in exchange for money or gifts (OR, 2.08; 95% CI, 1.21-3.09), to have experienced episodes of pain on urination or to have experienced penile discharge (OR, 1.68; 95% CI, 1.07-2.64), had an earlier age at sexual debut (15.7 versus 16.9 years), and had more extramarital sex partners in the last year (1.13 versus 0.62). Circumcised men also reported a preference for nonwet sex. Muslims generally had a lower risk profile than other circumcised men except they were less likely to have ever used a condom (OR, 0.34; 95% CI, 0.15-0.78) or to have used a condom during the last sex encounter (OR, 0.37; 95% CI, 0.14-0.87). CONCLUSIONS: These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted.     

Improving adherence to ante-retroviral treatment for people with harmful alcohol use in Kariobangi, Kenya through participatory research and action

ABSTRACT: BACKGROUND: Harmful alcohol use has been linked to the spread of HIV in Kenya. It also adversely affects those on antiretroviral (ARV) treatment through poor compliance. This study using participatory research and action (PRA) methods sought to understand factors related to alcohol abuse and non-adherence and to formulate appropriate interventions in a sample of people living with HIV and AIDS (PLWHA) who were also abusing alcohol, at Kariobangi in Nairobi, Kenya. METHODS: Entry into the community was gained through previous PRA work in that community and PLWHA were recruited through snowballing. Working together with the community members, the researchers explored the participants' understanding of alcohol use problem, its effects on compliance to ARV treatment and discussed possible action areas through PRA techniques that included focus group and market place discussions; visual aids such as spider diagrams, community mapping and ranking. Follow-up meetings were held to discuss the progress. RESULTS: By the final meeting, 67 PLWHA and 19 community members had been recruited. Through discussions, misconceptions regarding alcohol use were identified. It emerged that alcohol abuse was poorly recognised among both the community and health workers. Screening for alcohol use was not routinely done and protocols for managing alcohol related disorders were not available at the local health centres providing ARVs. The study participants identified improving communication, psychoeducation and screening for alcohol use as possible action areas. Poverty was identified as a major problem but the interventions to mitigate this were not easy to implement. CONCLUSION: We propose that PRA could be useful in improving communication between the health workers and the clients attending primary health care (PHC) facilities and can be applied to strengthen involvement of support groups and community health workers in follow up and counselling. Integrating these features into primary health care (PHC) would be important not only to PLWHA but also to other diseases in the PHC setting . Longer term follow up is needed to determine the sustained impact of the interventions. Problems encountered in the PRA work included great expectations at all levels fostered by handouts from other donors and cognitive impairment that interfered with constructive engagement in some of the PLWHA.     

Neoplastic cells of Hodgkin's disease show differences in EBV expression between Kenya and Italy

The Epstein-Barr Virus (EBV) has been implicated in the pathogenesis of Hodgkin's disease (HD). However, the association of EBV with this disease varies greatly from series to series and from country to country. Epidemiological studies have shown differences in HD occurring in different parts of the world. In particular, it has been reported that HD in developing countries differs from HD in Western countries in terms of epidemiological, pathological and clinical characteristics. These discrepancies among populations suggest an interaction with environmental factors and a direct role of different etiological agents. At present, there are no data on the frequency of association of EBV with HD in equatorial Africa. In this study, a large series of HD cases have been collected at the University of Nairobi, Kenya, and at the Universities of Bologna and Siena, Italy. The cases have been reviewed and classified according to the REAL Classification and the presence of EBV has been assessed by in situ hybridization (ISH). A statistical difference in EBV expression was found between HD from Kenya and HD from Italy. EBV-positive neoplastic cells were detected in 92% of Kenyan cases, whereas only 48% of Italian cases showed EBER1/2 positivity in the neoplastic cells. Our results suggest that, in Kenya, EBV plays a more direct role in the pathogenesis of HD, as it does for endemic Burkitt lymphoma. © 1996 Wiley-Liss, Inc.     

Intrarectal transmission, systemic infection, and CD4+ T cell depletion in humanized mice infected with HIV-1

Intrarectal infection between men who have sex with men represents a predominant form of human immunodeficiency virus (HIV) transmission in developed countries. Currently there are no adequate small animal models that recapitulate intrarectal HIV transmission. Here we demonstrate that human lymphocytes generated in situ from hematopoietic stem cells reconstitute the gastrointestinal tract of humanized mice with human CD4(+) T cells rendering them susceptible to intrarectal HIV transmission. HIV infection after a single intrarectal inoculation results in systemic infection with depletion of CD4(+) T cells in gut-associated lymphoid tissue and other pathologic sequela that closely mimics those observed in HIV infected humans. This novel model provides the basis for the development and evaluation of novel approaches aimed at immune reconstitution of human gut-associated lymphoid tissue and for the development, testing, and implementation of microbicides to prevent intrarectal HIV-1 transmission.