DIFFERENCES IN HLA-DR ASSOCIATION WITH RHEUMATOID ARTHRITIS AMONG MIGRANT INDIAN COMMUNITIES IN SOUTH AFRICA

Previous surveys among Indians with RA have shown a significantassociation with HLA DR4 in North India and with HLA DR1 inthe UK. We studied a migrant Indian population in South Africato determine their genetic associations with RA. A group of121 unrelated RA patients from three communities (Hindi, Muslimsand Tamils) were studied. The Muslims showed a significant associationwith DR4 but the Hindi and Tamils showed a significant associationwith DR10. This survey shows that the Indian community is aheterogenous group regarding their HLA associations with RAand different associations are noted in the various communities. KEY WORDS: Rheumatoid arthritis, HLA antigens, Indians, Ethnic groups     

Clinic-based PHC auxiliaries: an overlooked category of health worker?

The author's personal negative experience of village-based primaryhealth care (PHC) auxiliaries has recently been corroboratedinternationally by a number of other authors. In this paper,it is argued that health planners and policy-makers should criticallyreassess the potentials and problems of village-based auxiliaries.The reasons for their introduction into PHC services are discussed,and the likelihood of their being successful is explored. Thepossibility of introducing specially trained clinic-based PHCauxiliaries is then suggested as a strategy to overcome someof the problems often associated with the more ‘fashionable’village-based auxiliaries. Finally, the author mentions somespecific precautions which should be taken to prevent misuseof clinic-based PHC auxiliaries.     

5Effect of gastric electrical stimulation on cerebral blood flow in patients with gastroparesis

Introduction: Gastric electrical stimulation is a safe and efficient treatment option in medically refractory gastroparesis. Several controlled and open label trials have shown the effectiveness of gastric electrical stimulation in symptom palliation for patients with gastroparesis. Initial settings were established based on experiences in the animal model. We reviewed our experience using higher stimulator settings on symptom reduction after implantation of gastric electrical stimulators. Methods: 42 consecutive patients (38 females and 4 males, mean age 43 ± 1.8 years) with medically refractory gastroparesis were followed after implantation of gastric electrical stimulator between 1999 and 2005. The 42 patients included 29 patients with idiopathic gastroparesis and 13 patients with diabetic gastroparesis Baseline stimulation settings were 14 Hz, 5 mAmps, 330 micro‐sec pulse width, 0.1 sec on, and 5 sec off. At each follow‐up gastrointestinal symptom scores were assessed. If symptoms were unsatisfactory, stimulator settings were increased according to a standardized protocol. Dose response relationships were evaluated. Results: After a mean follow‐up of 19 ± 2.6 months, 83% of patients had higher settings (p < 0.001, Fisher's exact test). Solid gastric emptying time during this period decreased from 195 ± 45 to 106 ± 38 minutes (T1/2 value, p < 0.05, paired t‐test) along with an average weight change from 64 ± 5.3 to 62 ± 5.6 kg (p > 0.05, paired t‐test). There were 258 stimulator interrogations with a stepwise improvement in total symptom score (R² = 0.08, p < 0.001). Multivariate regression analysis showed that frequency of electric stimulation was independently associated with improvement of total symptom score (R² = 0.06, p < 0.02). A prolonged cycle on time correlated with worsening of nausea score (R² = 0.09, p < 0.02) and vomiting score (R² = 0.13, p < 0.001). A measurement of high impedance independently correlated with a low vomiting score (R² = 0.19, p < 0.0001). Though not statistically significant, most patients’ symptoms were optimized at mean current of 10 mAmps, frequency of 55 Hz, pulse width of 330 micro‐sec, cycle on time of 0.1 sec, and cycle off time of 1 sec. Conclusion: The majority of patients seem to benefit from higher than baseline settings. Optimal settings of the implanted device must be determined on an individual basis, but based upon experience in humans seem to be 10 mAmps, 55 Hz, 0.1 sec on, 0.4 to 1 sec off.