Homozygous sickle cell disease in Uganda and Jamaica a comparison of Bantu and Benin haplotypes / La anemia de células falciformes homocigóticas en Uganda y Jamaica comparación de haplotipos Bantú y Benin

OBJECTIVE: To compare the haematological and clinical features of homozygous sickle cell (SS) disease in Bantu and Benin haplotypes in a cross-sectional study of 115 Ugandan patients attending the Sickle Cell Clinic at Mulago Hospital, Kampala, Uganda, with 311 patients in the Jamaican Cohort Study. METHODS: This involved comparison of clinical features and haematology with special reference to genetic determinants of severity including fetal haemoglobin levels, beta-globin haplotype and alpha thalassaemia status. RESULTS: The Bantu haplotype accounted for 94% of HbS chromosomes in Ugandan patients and the Benin haplotype for 76% of HbS chromosomes in Jamaica. Ugandan patients were marginally more likely to have alpha thalassaemia, had similar total haemoglobin and fetal haemoglobin levels but had higher reticulocyte counts and total bilirubin levels consistent with greater haemolysis. Ugandan patients had less leg ulceration and priapism, but the mode of clinical presentation, prevalence of dactylitis, features of bone pain and degree of delay in sexual development, assessed by menarche, were similar in the groups. In Ugandan patients, a history of anaemic episodes was common but these were poorly documented. CONCLUSION: The haematological and clinical features of the Bantu haplotype in Uganda were broadly similar to the Benin haplotype in Jamaica except for less leg ulceration and priapism and possibly greater haemolysis among Ugandan subjects. Anaemic episodes in Uganda were treated empirically by transfusion often without a clear diagnosis; better documentation including reticulocyte counts and observations on spleen size is necessary to evolve appropriate models of care.

OBJETIVO: Comparar los rasgos clínicos de la anemia de células falciformes homocigóticas (SS) en los haplotipos Bantú y Benin en un estudio transversal de 115 pacientes ugandeses que asisten a la Clínica de la anemia de células falciformes en el Hospital de Mulago, Kampala, Uganda, con 311 pacientes en un estudio de cohorte jamaicano. MÉTODOS: El estudio conllevó la comparación de los rasgos clínicos y hematológicos con referencia especial a los determinantes genéticos de la severidad, incluyendo los niveles de la hemoglobina fetal, haplotipos del gen de la globina beta, y el estado de la alfa talasemia. RESULTADOS: El haplotipo Bantú dio cuenta del 94% de los cromosomas HbS en los pacientes ugandeses, en tanto que los haplotipos Benin dieron cuenta del 76% de los cromosomas de HbS en Jamaica. Los pacientes de Uganda presentaron una probabilidad marginalmente mayor de alfa talasemia, tenían niveles similares de hemoglobina total y hemoglobina fetal, pero en cambio presentaban conteos más altos de reticulocitos así como niveles mayores de bilirrubina total, en correspondencia con una mayor hemólisis. Los pacientes ugandeses presentaban menor ulceración de las piernas y priapismo, pero el modo de presentación clínica, la prevalencia de dactilitis, los rasgos de dolor óseo, y el grado de retraso en el desarrollo sexual, evaluado por la menarquia, fueron similares en todos los grupos. Los pacientes de Uganda se caracterizaron comúnmente por una historia de episodios de anemia, pobremente documentados. CONCLUSIÓN: Los rasgos clínicos y hematológicos del haplotipo Bantú en Uganda fueron considerablemente similares al haplotipo Benin en Jamaica, salvo por una menor presencia de ulceración de las piernas y priapismo, así como posiblemente mayor hemólisis entre los sujetos de Uganda. Los episodios de anemia en Uganda fueron tratados empíricamente mediante transfusión, a menudo sin un diagnóstico claro. Se necesita una mejor documentación - incluyendo conteos de reticulocitos - así como observaciones del tamaño del bazo, a fin de desarrollar modelos de cuidado apropiados.

Pattern of pregnancy weight gain in homozygous sickle cell disease and effect on birth size / Patrones de ganancia de peso gestacional y tamaño al nacer en los casos de anemia de células falciformes

OBJECTIVES: To assess pregnancy weight gain and newborn anthropometry in mothers with homozygous sickle cell (SS) disease and normal controls. METHODS: An eleven-year retrospective review at the University Hospital of the West Indies, Kingston, Jamaica, revealed 128 singleton deliveries in women with SS disease who were matched by maternal age and birth date with 128 controls with a normal AA phenotype. Restriction to those commencing antenatal care before 16 weeks gestation resulted in the final study group of 80 SS patients and 115 AA controls. Weight and height were measured at first antenatal visit and weight at 20, 25, 30, 35 and 38 weeks gestation. Longitudinal regression used mothers'weight as the outcome, genotype as a predictor and gestational age as a random effect. Regression analyses ofmaternal weight on childhood anthropometry were repeated in separate maternal genotypes. Neonatal indices included gestational age, birthweight, head circumference and crown-heel length. RESULTS: Mothers with SS disease had lower weight and body mass index at first antenatal clinic visit (p < 0.001). Total weight gain was 6.9 kg for SS women and 10.4 kg for AA controls (p < 0.001) and weekly weight gain 0.263 kg (95% CI 0.224, 0.301) and 0.396 kg (95% CI 0.364, 0.427) respectively. A significant relationship occurred between birthweight and maternal weight gain at 25-30 weeks gestation in AA controls but this relationship appears delayed in SS disease. CONCLUSION: Different patterns of maternal weight gain in SS mothers and normal controls may have significance for the lower birthweight in SS mothers.

OBJETIVO: Evaluar la ganancia de peso gestacional y la antropometría neonatal en madres con anemia de células falciformes (CF) homocigóticas y en controles normales. MÉTODO: Un examen retrospectivo de once años en el Hospital Universitario de West Indies West Indies, Kingston, Jamaica, reveló la ocurrencia de 128 partos únicos (e.d. de un solo bebé) en mujeres con la enfermedad de CF, que fueron comparadas sobre la base de la edad materna y la fecha de nacimiento, con 128 controles de fenotipo AA normal. A partir de restricciones a las gestantes que comenzaron el cuidado prenatal antes de las 16 semanas de gestación, se llegó finalmente al grupo de estudio de 80 pacientes con CF y 115 controles con AA. El peso y la altura se midieron en la primera visita prenatal, y el peso a las 20, 25, 30, 35 y 38 semanas de gestación. La regresión longitudinal usó el peso de las madres como resultado, el genotipo como predictor, y la edad gestacional como efecto aleatorio. Los análisis de la regresión de peso materno sobre la antropometría fueron repetidos en genotipos maternos separados. Los índices neonatales incluyeron la edad gestacional, el peso al nacer y la circunferencia cefálica. RESULTADOS: Las madres con la enfermedad de CF tenían más bajo peso e índice de masa corporal en la primera visita clínica prenatal (p < 0.001). La ganancia de peso total fue 6.9 kg para las mujeres con CF y 10.4 kg para los controles AA (p < 0.001) y la ganancia de peso semanal 0.263 kg (95% CI 0.224-0.301) y 0.396 kg (95% CI 0.364-0.427) respectivamente. Una relación significativa tuvo lugar entre el peso al nacer y la ganancia de peso materna en las semanas 25-30 de gestación en los controles AA, pero esta relación parece demorada en la enfermedad de CF. CONCLUSION: Los patrones diferentes de ganancia de peso materno en las madres con CF y los controles normales, pueden tener importancia significativa para las madres con CF.

Growth curves for normal Jamaican neonates / Curvas de crecimiento en los neonatos jamaicanos normales

The aim of this study was to provide standards for the assessment of birthweight, head circumference and crown-heel length for normal, singleton newborns of predominantly West African descent. Data were collected for 10 482 or 94of all recorded births in Jamaica during the two-month period September 1 to October 31, 1986. After editing procedures, data were available for 6178 (birthweight), 5975 (head circumference), and 5990 (crown-heel length). The data presented in tables and growth curves include birthweight, head circumference and crown-heel length for males and females separately, for gestational ages 30-43 weeks. Data sets from the University Hospital of the West Indies in 1990 and 1999 were used to explore the possibility of secular change over the period 1986-1999. In conclusion, these ethnic and gender-specific growth curves are based on the most extensive dataset currently available in Jamaica for babies of West African descent.

Medical paediatric admission patterns at the University Hospital of the West Indies: issues for future planning / Patrones de ingresos médico-pediátricos en el Hospital Universitario de West Indies: agenda para planes futuros

An understanding of the epidemiological trend in hospital admissions, including morbidity and mortality patterns and the economic impact, is critical for healthcare planning and appropriate resource allocation. Data were collected on all admissions to the paediatric unit of the University Hospital of the West Indies during the period 1999. Each observation included demographic data, admission and discharge data and billed cost of care. There were 1350 admissions (570 female and 715 male, p < 0.001). Admissions [quot ]lows[quot ] were observed in February, April and July; minor peaks in March and June and the major peaks between October and January coincided with admissions due primarily to respiratory conditions. The evening shift was generally the busiest, with the night shift having the lowest average number of admissions in any one-week period Occupancy was uniformly high between November and April, with minor lows in May and August/September. The total cost for a typical patient was J$9708 per admission and the total daily cost for a typical patient was J$1823 (US$1 = J$39 in 1999). The findings could assist with resource allocation and rationalization of health services.

Entender la tendencia epidemiológica en los ingresos al hospital, incluyendo los patrones de morbilidad y mortalidad así como el impacto económico, resulta fundamental a la hora de planificar la atención a la salud y asignar los recursos de forma apropiada. Los datos fueron recopilados en todos los ingresos a la unidad pediátrica del Hospital Universitario de West Indies durante el periodo de 1999. Cada observación incluyó los datos demográficos, los datos de ingreso y alta, y los costos facturados para la atención médica. Hubo un total de 1350 ingresos (570 hembras y 715 varones, p < 0.001). Los periodos “bajos” de ingresos se observaron en febrero, abril, y julio; los picos menores en marzo y junio, y los picos mayores en octubre y enero coincidían con ingresos debidos fundamentalmente a problemas respiratorios. El turno de la tarde-noche era generalmente el más ocupado, teniendo el turno de la noche el número promedio más bajo de ingresos en cualquier período de una semana. La ocupación del hospital se mantuvo uniformemente alta entre noviembre y abril, con bajas en los meses de mayo y agosto/septiembre. El costo total de un paciente típico fue de J$9708 (dólares jamaicanos) por ingreso, y el costo total diario por cada paciente típico fue de J$1823 (US$1 = J$39 en 1999). Los hallazgos podrían ser de utilidad en relación con la asignación de recursos y la racionalización de los servicios de salud.

The prevalence of marijuana smoking in young adults with sickle cell disease: a longitudinal study / Prevalencia del hábito de fumar marihuana en los adultos jóvenes con enfermedad de células falciforme un estudio longitudinal

BACKGROUND: The active ingredients of marijuana may have beneficial properties in the treatment of chronic pain and inflammation and is being used by sufferers of chronic pain and arthritis in some settings. Anecdotally, marijuana is believed by some sickle cell disease (SCD) patients to improve their health. This study aimed to determine the prevalence of marijuana smoking in the Jamaica Sickle Cell Cohort Study (JSCCS) in the years 2000 and 2004. The perception that marijuana use ameliorated the complications of SCD was also investigated. METHODS: All patients in the JSCCS were invited to attend an annual review, and during the 2000 and 2004 reviews, participants with homozygous sickle cell (SS) disease and sickle cell haemoglobin-C (SC) disease were asked whether they smoked marijuana, and if they smoked, whether it was used for medicinal purposes related to SCD. The authors compared smoking prevalence by gender, disease, and year of review. The association of smoking with a measure of pain frequency was also examined. RESULTS: The prevalence of marijuana smoking was higher among men and among SC participants. The proportion of either gender reporting smoking of marijuana increased in 2004 compared to 2000, and this use was not related to a simple measure of clinical severity of SCD. CONCLUSIONS: Marijuana smoking is common in adults with SCD but its usage is unrelated to clinical severity of the disease.

ANTECEDENTES: Los ingredientes de la marihuana pueden tener propiedades beneficiosas para el tratamiento del dolor e inflamación crónicos, y en algunos lugares esta planta está siendo usada por enfermos que sufren de dolor y artritis de manera crónica. De forma anecdótica, se dice que algunos pacientes de la enfermedad de células falciformes (ECF) creen que la marihuana les mejora la salud. Este estudio se propuso determinar la prevalencia del hábito de fumar marihuana en el Estudio de Cohorte Jamaicano de Células Falciformes (ECJCF) en los años 2000 y 2004. Los autores también examinaron la creencia de que el uso de la marihuana guarda relación con la percepción de que la misma mejora los casos con complicaciones por ECF. MÉTODOS: A todos los pacientes en el ECJCF, se les invita a asistir a un examen anual, y durante los exámenes de los años 2000 y 2004, a los participantes con enfermedad de célula falciforme homocigótica (SS) y con la enfermad de célula falciforme hemoglobina C (SC), se les preguntó si fumaban marihuana, y si la usaban con fines medicinales en relación con la ECF. Los autores compararon la prevalencia por género, enfermedad, y año de examen. Asimismo, examinaron la asociación del hábito de fumar marihuana con una medida de frecuencia de dolor. RESULTADOS: La prevalencia del hábito de fumar marihuana fue más alta entre los hombres y entre los participantes SC. La proporción de ambos géneros que reportó hábito de fumar, aumentó en el año 2004 en comparación con el año 2000, y el uso de la marihuana no estuvo relacionado con una simple medida debida a la gravedad de la ECF. CONCLUSIONES: El hábito de fumar marihuana es común en adultos con ECF, pero su uso no guarda relación con la gravedad de la enfermedad.

Skin test reactivity to aeroallergens in Jamaicans: relationship to asthma / Reactividad de la prueba cutánea frente a aeroalérgenos en los jamaicanos: relación con el asma

BACKGROUND: Asthma causes significant morbidity and mortality in the developing world. It is thus important to identify modifiable risk factors. OBJECTIVES: To undertake a cross-sectional study to determine the prevalence of skin test reactivity to aeroallergens in Jamaican children and adults and the relationship of the diagnosis of asthma to the pattern of skin test positivity. METHODS: One hundred and sixty subjects without the sickle cell gene (genotype AA), eighty adults and eighty children, were recruited. Skin testing to seven aeroallergens was undertaken (atopy being diagnosed if there were at least one positive reaction). Asthma status was determined by a questionnaire and/or medical records. RESULTS: Twenty-seven (34) of the children and forty-one (51) of the adults were skin test positive to at least one aeroallergen. The most common positive responses in both age groups were to Dermatophagoides farinae, Dermatophagoides pteronyssinus and cockroach mix-(German and American). All adult asthmatics with current symptoms reacted to cockroach allergen. CONCLUSIONS: Appropriate steps to reduce cockroaches and cockroach sensitization might positively impact on asthma morbidity in Jamaica.

ANTECíENTES: El asma causa morbilidad y mortalidad significativas en el mundo en desarrollo. Por lo tanto, es importante identificar los factores de riesgo modificables. OBJETIVOS: Llevar a cabo un estudio transversal a fin de determinar la prevalencia de la reactividad de la prueba cutánea frente a los aeroalérgenos en niños y adultos jamaicanos, y la relación del diagnóstico del asma con el patrón de positividad de la prueba cutánea. MÉTODOS: Se reclutaron ciento sesenta sujetos AA (sin genes falciformes), ochenta adultos y ochenta niños. Se llevaron a cabo pruebas cutáneas frente a siete aeroalérgenos (diagnosticándose atopia si se producía al menos una reacción positiva). El estatus asmático se determinó mediante encuestas y/o historias clínicas. RESULTADOS: Veintisiete (34%) de los niños y cuarenta y uno (51%) de los adultos, resultaron positivos en la prueba cutánea, al menos a un aeroalérgeno. Las respuestas positivas más comunes en ambos grupos de edad fueron frente a Dermatophagoides farinae, Dermatophagoides pteronyssinus, y mezcla de cucarachas (alemanas y americanas). Todos los asmáticos adultos con síntomas usuales reaccionaron al alérgeno de la cucaracha. CONCLUSIONES: Medidas apropiadas a fin de reducir las cucarachas y la sensibilización a las cucarachas podría tener un impacto positivo en la morbilidad por asma en Jamaica.

Anaesthesia for operative deliveries at the University Hospital of the West Indies: a change of practice / La Anestesia en los Partos Operativos en el Hospital Universitario de West Indies Un Cambio de Práctica

There has been an increasing trend worldwide to use regional anaesthesia for operative deliveries. The Confidential Enquiry into Maternal Deaths in the United Kingdom has demonstrated a steady decline in the anaesthesia-related deaths since the introduction of regional anaesthesia. There are lower morbidity profiles in mothers delivering under regional anaesthesia as well as better infant Apgar scores. In 1997, a decision was taken to have at least 60% of all elective Caesarean sections done at the University Hospital of the West Indies (UHWI) performed under spinal anaesthesia. This is a review of the anaesthetic technique for Caesarean sections at the UHWI since 1996. The Deliveries and Anaesthetic Books on the labour ward were reviewed and the type of anaesthesia for elective and emergency Caesarean sections recorded for the period January 1996 to December 2001. At the beginning of the period under study, more than 90% of the Caesarean sections were being done under general anaesthesia. By the middle of 1998, spinal anaesthesia was more commonly employed than general anaesthesia for Caesarean sections and by December 2001, more than eight out of every ten Caesarean sections were being done under spinal anaesthesia. The main reasons for the successful change of practice were that it was consultant-led, there was good communication between relevant departments, the junior staff were properly trained, there was a consistent supply of appropriate drugs and there was a high level of patient satisfaction

Ha habido una tendencia creciente mundial a usar la anestesia regional en los partos operativos. La Encuesta Confidencial sobre las causas de las muertes maternas en el Reino Unido, ha demostrado un descenso constante de los casos de muertes relacionadas con la anestesia, a partir de la introducción de la anestesia regional. Los perfiles de morbosidad son más bajos en las madres que dan a luz con anestesia regional, en tanto que los infantes presentan una mejor puntuación Apgar. En 1997, se toma la decisión de que al menos el 60% de todas las secciones cesáreas electivas en el Hospital Universitario de West Indies (UHWI) fueran realizadas bajo anestesia espinal. El presente trabajo constituye un resumen que examina la técnica anestésica aplicada en las cesáreas practicadas en el UHWI desde 1996. Se examinaron los Registros de Partos y Anestesia del salón de partos, tomándose nota del tipo de anestesia usado en las cesáreas electivas y de emergencia en el período de enero de 1996 a diciembre de 2001. A principios del periodo bajo estudio, más del 90% de las secciones cesáreas se hacían con anestesia general. A mediados de 1998, la anestesia espinal se empleaba más comúnmente que la anestesia general en las cesáreas. Y para diciembre de 2001 más de ocho de cada diez cesáreas se realizaban con anestesia espinal. Las razones principales para el cambio exitoso de práctica consistieron en que se llevo a cabo bajo la dirección de un consultante, hubo buena comunicación entre los departamentos pertinentes, el personal subalterno estaba debidamente entrenado, hubo un suministro consistente de los medicamentos apropiados, y finalmente un alto nivel de satisfacción de los pacientes.

Triage decisions and outcome among the critically ill at the University Hospital of the West Indies / Decisiones de Triage y Resultados Clínicos en los Pacientes Graves del Hospital Universitario de West Indies

The worldwide scarcity of intensive care therapy leads to the rationing of this expensive resource. This prospective study investigates the rationing of intensive therapy at the University Hospital of the West Indies (UHWI) by recording triage decisions for intensive care unit (ICU) admission and the impact of these decisions on patient outcome. Between June 2001 and May 2002, all patients triaged for admission to a multidisciplinary ICU were studied For each patient, data were collected including APACHE II score, ICU resource availability and patient survival. There were 356 eligible requests, and 285 (80%) were admitted to the ICU, with 73 (26%) of these admitted patients receiving intensive care outside of the ICU due to space limitations. The APACHE II score was the strongest predictor of ICU admission, with admission more likely as the score decreased (odds ratio = 0.94, 95% confidence interval 0.91, 0.98, p = 0.001). Of 311 requests considered suitable for admission, 26 (8%) were refused admission due to resource limitations. Mortality among these eligible refusals was 81%, compared to 34% among admitted patients (p < 0.001). Although triage decisions are based predominantly on a patient's disease severity, the demand for ICU space exceeds supply, and patient care is negatively impacted by this imbalance

La escasez mundial de terapia de cuidados intensivos conduce al racionamiento de este recurso costoso. Este estudio prospectivo investiga el racionamiento de la terapia intensiva en el Hospital Universitario de West Indies (HUWI) a partir del registro de las decisiones de triage respecto a los ingresos en la unidad de cuidados intensivos (UCI), y el impacto de estas decisiones en la evolución clínica de los pacientes. Entre junio 2001 y mayo 2002, se estudiaron todos los pacientes seleccionados tras una clasificación de triage para ingresar en una UCI multidisciplinaria. De cada paciente se recopilaron datos que incluían: puntuación APACHE II, disponibilidad de recursos en términos de UCI, y supervivencia del paciente. Se produjeron 356 solicitudes elegibles, de las cuales 285 (80%) obtuvieron ingreso a la UCI, para lo cual fue necesario ofrecer el cuidado intensivo a 73 (26%) de estos pacientes fuera de la UCI, debido a limitaciones de espacio. La puntuación APACHE II fue el predictor mayor en los ingresos a la UCI, siendo el ingreso tanto más probable cuanto menor se hacía la puntuación (odds ratio = 0.94, 95% intervalo de confianza 0.91, 0.98, p = 0.001). De 311 solicitudes para las cuales era aconsejable el ingreso, a 26 (8%) se les negó a la admisión debido a limitaciones de recursos. La mortalidad entre los rechazados elegibles fue de 81%, en contraste con un 34% entre los pacientes ingresados (p <0.001). Aunque las decisiones del triage se basan predominantemente en la gravedad de la enfermedad del paciente, la demanda de espacio para la UCI se halla muy por encima de la oferta, y la atención al paciente se ve afectada negativamente debido a esta falta de equilibrio.

Tuberculosis and HIV co-infections in Jamaican children

BACKGROUND: There has been a worldwide increased prevalence of tuberculosis (TB) in recent years, with a similar trend observed in Jamaica and more recently in children admitted to the University Hospital of the West Indies, Jamaica. Data regarding paediatric TB, especially as it relates to all aspects of HIV co-infection, are needed from developing countries in diverse geographic settings to enhance prevention and treatment policies (National Institutes of Health, Office of AIDS Research, FY 2005 Budgetary Planning Meeting, March 11, 2003, Washington, DC). OBJECTIVE: To determine associated factors and outcomes of tuberculosis in HIV-infected and noninfected children in Jamaica. METHOD: We reviewed records of children aged 0 - 12 years attending the University Hospital of the West Indies during January 1999 to December 2002. Associated factors and outcomes in HIV-infected and HIV-negative cases with TB were compared using exact statistical methods to account for the small number of children and an adjustment for multiple testing. TB diagnosis was determined using modified World Health Organization (WHO) criteria. RESULTS: There was a significant increase of active TB cases from 1999 to 2002 with 24 children diagnosed over this period All 24 children (100) had received the Bacillus-Calmette-Guerin (BCG) vaccine. Eleven (46) of these were HIV-infected, all via mother-to-child transmission. HIV-infected children were statistically more likely to be older than non-infected children (mean 4.2 vs 2.6 years), and also to have failure to thrive, digital clubbing, hepatomegaly, splenomegaly, generalized adenopathy and negative Mantoux tests. Appropriate in-hospital anti-TB therapy was given. Hospital stay was longer (median 7.4 vs. 2.8 months) and death was more likely (7/11 vs 2/13) in HIV-infected vs non-infected children. Triple antiretroviral therapy was given in three of the 11 HIV-infected cases and this markedly improved outcome. Household family members with active TB were identified in twelve cases. CONCLUSIONS: HIV and TB co-infection is an increasing problem in Jamaican children. Severity of illness and death is greater in HIV-infected children, despite appropriate anti-TB therapy. Antiretroviral drugs must be made available to this population. Efforts must be enhanced to reduce mother-to-child-transmission of HIV/AIDS and to strengthen the public health management of TB (contact tracing and completion of TB therapy by directly observed therapy)

Antiretroviral drug therapy in HIV-infected Jamaican children

BACKGROUND: The study describes a cohort of HIV-infected Jamaican children receiving antiretroviral therapy (ART) and reports the outcome. METHOD: An observational prospective study was conducted on HIV-infected Jamaican children receiving anti retroviral drug therapy (ART). The outcome measures, weight, height, hospital admissions and length of stay were compared at initiation and within six months of commencing ART. RESULTS: There were 37 (33.6) of 110 HIV-infected children receiving ART during 2001 to 2003. The median age at commencement was six years (age range 1-16 years) with 54.1 (20) males and 48 AIDS orphans. Care was home-based for 68 of all cases with the University Hospital of the West Indies managing 27 (73) and the Bustamante Hospital for Children 10 (27). The distribution by Centers for Disease Control and Prevention (CDC) clinical class was C (severely symptomatic), 22 (59.5); B (moderately symptomatic), 8 (21.6); A (mildly symptomatic), 6 (16.2) and N (asymptomatic), one (2.7). Among 14 (36) children with CD4 counts, 8 (57) were CDC immune class 2 (moderate immunodeficiency) and 6 (43) were class 3 (severe immunodeficiency). After commencing ART the mean difference in admissions was--1.5+/-2.55 admissions (95 CI -2.3, -0.6; p < 0.001) and in length of stay was -12.9+/-21 day (95 CI -19.9, -0.5.9; p < 0.001). Antiretroviral therapy resulted in a mean weight gain of 2.8 kg+/-4.9 kg (95 CI 1.0, 4.5; p < 0.003) and a mean gain in height of 1.7 cm+/-2.6 cm (95 CI 0.6, 2.8; p < 0.003). Five children required second line therapy. CONCLUSION: The introduction of antiretroviral therapy has resulted in improved outcomes and is being initiated in older children cared for mainly at home. Limitations in accessing affordable second line agents underscore the need for compliance with first line therapy

CDC-defined diseases and opportunistic infections in Jamaican children with HIV/AIDS

OBJECTIVE: To document the frequency of Centers for Disease Control and Prevention (CDC)-defined clinical conditions, opportunistic and co-infections among children with HIV/AIDS. METHODS: This prospective, observational study reports the findings of 110 HIV-infected children followed in multicentre ambulatory clinics during September 1, 2002, to August 31, 2003, from the 239 children enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica. We describe the clinico-pathologic characteristics of these children with HIV/AIDS, using the CDC criteria. RESULTS: The client distribution by clinic site was as follows: the University Hospital of the West Indies, 71 (64.6), Bustamante Hospital for Children, 23 (20.9), Comprehensive Health Centre 13 (11.8/) and Spanish Town Hospital, 3 (2.7). The median age of the 110 children with HIV/AIDS was 6.0 years (range 0.9-17.5). Mode of transmission was primarily mother-to-child (88.0) and only 4 maternal/infant pairs received antiretroviralprophylaxis. Grouped by CDC category: 17 (15.4) were asymptomatic (N), 22 (20.0) mildly symptomatic (A), 30 (27.3) moderately symptomatic (B) and 41 (37.3) severely symptomatic (C). The most common CDC-defining symptoms were lymphadenopathy (12, 42.8) and asymptomatic (6, 21.4) in category N; lymphadenopathy (30, 29.7), dermatitis (20, 19.8) and persistent or recurrent upper respiratory tract infections (20, 19.8) in category A; bacterial sepsis (18, 34.6) and recurrent diarrhoea (11, 21.2) in category B; and wasting (28, 30.0), encephalopathy (26, 27.9), and serious bacterial infections (15, 16.1) in category C; Pulmonary tuberculosis (7, 7.5) and Pneumocystis (jiroveci) carinii pneumonia; (5, 5.4) were the most frequent opportunistic infections. Streptococcus pneumoniae (10, 30.3) was the most common invasive bacterial pathogen causing sepsis and Escherichia coli (14, 34.2) was the most common bacterial pathogen causing urinary tract infections, among the cohort. Thirty-three per cent commenced antiretroviral drugs (ARVs). There were 57 hospitalizations and five deaths. CONCLUSIONS: The study is an important step toward documentation of the natural history of paediatric HIV/AIDS in a primarily ARV-naive population from a developing country. It promotes training in paediatric HIV management as we move toward affordable access to antiretroviral agents in the wider Caribbean and the implementation of clinical trials

Uptake of interventions, outcomes and challenges in caring for HIV-exposed infants in Kingston, Jamaica

BACKGROUND: In a few Caribbean islands, prevention of mother-to-child transmission (pMTCT) of HIV with zidovudine prophylaxis has reduced transmission rates from 27 - 44 to 5.5 - 9 . OBJECTIVES: To highlight the uptake of interventions, preliminary outcomes and challenges in caring for HIV-exposed infants in a pMTCT HIVprogramme in a resource-limited setting. METHOD: A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Greater Kingston through HIV counselling and testing and enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Antiretroviralprophylaxis with zidovudine or nevirapine was given to the HIV-positive women and their newborns along with formula feeding. Some infants were enrolled retrospectively and followed irrespective of whether they had or had not received antiretroviral prophylaxis. A multidisciplinary team at the paediatric centres supervised protocol-driven management of the infants. Infants were followed for clinical progress and definitive HIV-infection status was to be confirmed at 18 months of age by ELISA or the Determine Rapid Test. RESULTS: During September 1, 2002 through August 31, 2003, 132 HIV-exposed infants were identified. For those infants prospectively enrolled (78), 97 received antiretroviral prophylaxis and 90 were not breastfed For all HIV-exposed children, 90 received cotrimoxazole prophylaxis and 88 continued follow-up care. Ninety-two per cent of all the infants remained asymptomatic and five died; of these deaths one is possibly HIV-related (severe sepsis at 11 weeks). This infant was retrospectively identified, had received no antiretroviral prophylaxis and was breastfed The main programme challenges, which were overcome, included the impact of stigma, compliance with antiretroviral chemoprophylaxis, breast-milk substitution and follow-up care. Financial constraints and laboratory quality assurance issues limited early diagnosis of HIV infection. CONCLUSION: Despite the challenges, the expected outcome is to prevent 50 new cases of HIV/AIDS in children living in Greater Kingston per year (300 over six years)

Socio-demographic characteristics of HIV-exposed and HIV-infected Jamaican children

BACKGROUND: In the face of the continuing pandemic of HIV/AIDS, the burden of the disease is now largest in the resource-poor developing world. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has listed the adult prevalence rate for the Caribbean as second only to Sub-Saharan Africa. OBJECTIVE: To document the socio-demographic characteristics of paediatric and perinatal HIV/AIDS in Kingston, Jamaica. METHODS: A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Kingston and St Catherine and were enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Infants born to mothers within the programme were prospectively enrolled. Infants and children identified after delivery, whether HIV-exposed or infected, were also enrolled (retrospective group). All were followed according to standardized protocols. RESULTS: We report on a total of 239 children, 78 (prospective group) and 161 (retrospective group). Among the retrospective group, 68 were classified as infected. For the prospective group, the patients were recruited within twenty-four hours of birth in 98.7 of cases, whereas in the retrospective group, the median age of recruitment was 2.6 years. The median age of the mother was 27 years and that of the father was 33 years. There were seven teenage mothers. Twenty-six per cent of the children were in institutional care. Family size ranged from one to nine children--the median was two children. For those parents where occupation was reported, the majority held semi-skilled or unskilled jobs. Patients attended their regional clinics. CONCLUSION: HIV/AIDS represents a significant human and financial burden on a developing country such as Jamaica and this underscores the need for urgent and sustained interventions to stem the epidemic

Paravertebral anaesthesia for breast surgery an initial experience at the University Hospital of the West Indies

Paravertebral blockade (PVB) is a regional anaesthetic technique that allows the injection of local anaesthetic agents into the paravertebral space. It has been used for acute and chronic pain relief and as an anaesthetic technique for unilateral surgery of the chest, breast, shoulder, kidney, and inguinal region. Paravertebral blockade has been performed on a limited basis for breast surgery at the University Hospital of the West Indies (UHWI) since 1998. This retrospective review was undertaken to report the initial experience with this block. We reviewed the notes of all patients who were given a PVB alone, or in combination with general anaesthesia (GA). Twenty-one patients had P VB: twenty females and one male, with age range of 24 to 90 years. Six were attempted with PVB alone, but two of these needed supplementation with a GA. Fifteen were done in combination with GA. No complications were recorded The initial experience shows that the performance of PVB is both possible and safe; it may offer an alternative to GA for breast surgery. A randomized prospective study is underway to allow a detailed comparison between the two methods

Paediatric HIV/AIDS in Jamaica. A hospital-based description

The continuing worldwide epidemic of adult HIV/AIDS has led to an increase in the number of HIV-positive children mainly through perinatal transmission. Although national data are available, there is no published report of the epidemiology of HIV/AIDS in children in Jamaica. A multicentre retrospective analysis of 183 HIV seropositive children admitted to hospitals in Jamaica between 1990 and 1996 was conducted. Ages at diagnosis were available for 172 patients with 61 diagnosed in the first year of life. Clinical histories were available for 129 patients with the primary presenting symptoms of infected children being failure to thrive, pneumonia, diarrhoea, dermatitis and lymphadenopathy. Classification was possible in 128 patients: 49 were exposed, 76 were infected and three were seroreverters. Infected children had a longer hospital stay than those classified as exposed or seroreverters. As of December 31, 1997, 125 patients had defaulted, nine patients were alive and 51 were reported dead with a median age of death of 12 months. From these data, it is estimated that the hospital-based HIV incidence among children in Jamaica increased from 0.149 per 10,000 person years in 1990 to 1.331 per 10,000 person years in 1996. This study demonstrates a rise in the estimated incidence of HIV/AIDS but we were unable to estimate survival reliably since the data required were not available for 75 of children identified. These data highlight the urgent need for targeted interventions to reduce vertical transmission of HIV as well as a need for prospective studies to establish reliable data on incidence and long-term outcome for HIV-infected children.

Patients' desire for peri-operative information: Jamaican attitudes

The desire for peri-operative information has been examined in patients from other countries. This study was undertaken to assess the peri-operative information needs in Jamaican patients and to compare them to those from other populations. A questionnaire examining the desire for information about impending anaesthesia was administered to 93 patients awaiting elective surgery at the University Hospital of the West Indies. Responses were assessed across age and gender, and were compared to results from five industrialized countries. Although Jamaican patients expressed a desire for information concerning anaesthesia and surgery, they did not regard it as their right to get information, and this was the most important factor in the Jamaican sample providing a significantly less positive response than patients from other nations (p < 0.01 versus each country). Information priority was given to practical aspects of anaesthesia and post-operative outcome-mobility, pain, and the consumption of food and drink. Meeting the anesthetist was high on the list of desires. Female patients were 1.9 (Confidence Interval 1.4, 2.5) times more likely to express a positive desire for information. There were no age-related differences.

Psychological distress among younger siblings of patients with homozygous sickle cell disease in the Jamaican cohort study

The presence of a chronically ill family member may adversely affect the psychological health of siblings. This study used the General Health Questionnaire and the Modified Social Adjustment Scale to assess psychological distress in 20 younger siblings (4 AA, 16 AS genotypes), aged 16-19 years, of patients with homozygous sickle cell (SS) disease. The results were compared with those previously obtained in the 20 older siblings with SS disease and in 89 controls with a normal haemoglobin (AA) genotype. High levels of psychological distress occurred among all three groups. Greater psychological distress and poorer social adjustment occurred among siblings compared to AA controls but these differences disappeared after adjusting for the reduced age of sibings. The two measures were similar in SS patients and AA controls. The level of psychological distress among siblings of SS patients did not differ from that in SS patients or AA controls.