Critical Assessment of Myelography Practices: A Call for Rational Guideline Revision.

BACKGROUND AND PURPOSE: Patient preparation for myelography and postprocedural monitoring varies widely between practices, despite published guidelines. Our aim was to examine the current practice variations in discontinuing reportedly seizure threshold-lowering medications before myelography and to assess the reported incidence of postmyelographic seizures. MATERIALS AND METHODS: An e-mail survey was sent to American Society of Neuroradiology members concerning the number of postmyelographic seizures experienced in the past 5 years, the presence of an institutional policy for discontinuing seizure threshold-lowering medications, and the type of myelographic contrast used. We compared the postmyelographic seizure frequency in the responses. RESULTS: Of 700 survey responses, 57% reported that they do not discontinue seizure threshold-lowering medications before myelography. Most (97%) indicated never having a patient experience a seizure following myelography. The number of postmyelographic seizures between those who discontinue seizure threshold-lowering medications and those who do not was not statistically significant (OR = 2.13; 95% CI, 0.91-4.98; P = .08). Most (95%) reported using nonionic hypo-osmolar agents. CONCLUSIONS: Survey results revealed widely variable practices for patient myelography preparation and postprocedural monitoring. We found no difference in reported seizures between those who discontinued seizure threshold-lowering medications and those who did not. In light of our findings, we propose that discontinuing reportedly seizure threshold-lowering medications is not warranted with the current nonionic water-soluble contrast agents and may be potentially harmful in some instances. This work supports revision of existing recommendations to withhold such medications before myelography.

Pituicytoma: diagnostic features on selective carotid angiography and MR imaging.

We report a case of pituicytoma, a rare primary tumor of the neurohypophysis. A 64-year-old man presented with progressive visual complaints, bitemporal hemianopsia, and headache. Imaging studies revealed distinctive features of a mass lesion that thickened the pituitary stalk with a bilobed protrusion extending into the hypothalamus. Angiography demonstrated tumor vascular supply from the superior hypophyseal arteries representing the diencephalic branches of the internal carotid arteries. We discuss the imaging and pathology of this unusual tumor.

Health status in the Caribbean. Has the faculty of medical sciences made a difference?

The Faculty of Medical Sciences has contributed to improvements in health status in the Caribbean through its research, training, and service and outreach programmes. Basic and applied research has yielded important scientific data and information that has guided health care, resulting in decreases in morbidity and mortality. Physicians graduating from its undergraduate programme and successfully completing its graduate programmes, and nurses and other professionals trained in the Faculty, are widely dispersed throughout the Caribbean and, together with Faculty staff members, have collaborated with others to formulate and implement health policies, and to provide the facilities for health education and promotion, and for the care of ill patients. Outreach programmes include organising and/or participating in projects, conferences, workshops or consultations for or with countries or organisations. Collaboration and partnership for all of these activities have been important. The problems and challenges are discussed, with an outline of some of the plans being employed to resolve them.

Health status in the Caribbean. Has the faculty of medical sciences made a difference?

The Faculty of Medical Sciences has contributed to improvements in health status in the Caribbean through its research, training, and service and outreach programmes. Basic and applied research has yielded important scientific data and information that has guided health care, resulting in decreases in morbidity and mortality. Physicians graduating from its undergraduate programme and successfully completing its graduate programmes, and nurses and other professionals trained in the Faculty, are widely dispersed throughout the Caribbean and, together with Faculty staff members, have collaborated with others to formulate and implement health policies, and to provide the facilities for health education and promotion, and for the care of ill patients. Outreach programmes include organising and/or participating in projects, conferences, workshops or consultations for or with countries or organisations. Collaboration and partnership for all of these activities have been important. The problems and challenges are discussed, with an outline of some of the plans being employed to resolve them.

A case-control study of risk factors for seropositivity to human T-lymphotropic virus type I (HTLV-I) in Jamaica.

BACKGROUND: We investigated behavioural and environmental risk factors for seropositivity to human T-lymphotropic virus type I (HTLV-I). METHODS: A nested case-control study of 201 HTLV-I seropositive subjects and 225 age- and sex-matched seronegative controls was performed using questionnaire data from the enrollment visit of a cohort study in 1987-1988. HTLV-I serostatus was confirmed using enzyme-linked immunosorbent assay (ELISA) and Western blot. RESULTS: Among women, the number of lifetime sexual partners (P < 0.05, chi 2 trend) and the number of different men fathering a child by the woman (P < 0.06, chi 2 trend) were associated with HTLV-I seropositivity. Use by the female subject of an intrauterine device (IUD) was associated with an increased risk of seropositivity (odds ratio (OR) = 2.67, 95% confidence interval (CI): 1.13-6.23); condom use was rare in this population. Among male subjects, a larger number of lifetime sexual partners was also associated with HTLV-I seropositivity (P < 0.05, chi 2 trend). No association was found between HTLV-I seropositivity and educational attainment, income, or occupation. Having been breastfed as a child or receipt of a blood transfusion had elevated but imprecise OR due to very high and low prevalence of the risk factors, respectively. Several variables relating to insect or animal exposure showed no association with HTLV-I seropositivity. CONCLUSIONS: These data confirm that heterosexual intercourse is a major route of HTLV-I transmission, but do not support suggestions of insect or environmental vectors.

Health effects of human T-lymphotropic virus type I (HTLV-I) in a Jamaican cohort.

BACKGROUND: Other than adult T-cell leukaemia (ATL) and HTLV-I associated myelopathy (HAM), the health effects of infection with human T-lymphotropic virus type I (HTLV-I) are not well defined. METHOD: A cohort of 201 confirmed HTLV-I seropositive Jamaican food service workers and 225 seronegative controls of similar age and sex from the same population was examined. A health questionnaire, physical examination, and laboratory tests were performed at enrollment into the cohort in 1987-1988. RESULTS: One of 201 HTLV-I seropositives, but no controls were diagnosed with HAM, for a prevalence of 0.5% (95% confidence interval) (CI) 0.01-2.7%); no cases of ATL were diagnosed. While there was no difference in current symptoms, the HTLV-I seropositive group was more likely to report a past medical history of hepatitis or jaundice (OR = 3.49, 95% CI: 0.93-13.08), malaria (OR = 2.13, 95% CI: 0.96-4.73), and dengue fever (OR = 1.37, 95% CI: 0.82-2.29); however, these differences were of borderline statistical significance. Low income HTLV-I seropositive women had lower body weight (P < 0.01) and body mass index (P < 0.009) than their seronegative counterparts; similar differences were seen in the smaller male group. A trend toward higher prevalence of severe anaemia (haemoglobin < 10 g/dl) (12.6% versus 7.7%, P < 0.105) and a significantly lower prevalence of eosinophilia (1.0% versus 6.3%, P < 0.004) was seen among HTLV-I seropositives compared to controls. CONCLUSIONS: Although most HTLV-I seropositives are asymptomatic, HAM may be diagnosed in approximately 0.5% of carriers. Chronic HTLV-I infection may also exert subtle effects on body mass and haematological parameters.

Blood safety in developing countries.

This study, based on responses to a questionnaire, was undertaken to define problems in and formulate solutions for improving blood safety in developing countries as part of an effort to monitor the status of blood transfusion services globally. Despite improvements between 1988 and 1992, only 66% of developing countries (DGCs) and 46% of least developed countries (LDCs) screen all blood donations for antibodies to human immunodeficiency viruses; 72% DGCs and 35% LDCs test all donations for hepatitis B surface antigen and 71 and 48%, respectively, for syphilis. The antihuman globulin test is performed routinely in 62% DGCs and 23% LDCs, and inadequate quality assurance in all aspects of preparatory testing is a major weakness in many countries. The blood supply is usually insufficient: none of the LDCs and 9% of the DGCs collect 30 units or more per 1,000 of the population annually. Blood donor systems are totally voluntary and non-remunerated in 15% DGCs and 7% LDCs; 80% DGCs and 93% LDCs rely totally or partially on replacement donors and 25% of both groups on paid donations. The proportion of repeat donors is low (medians: 47% in DGCs, 20% in LDCs), and discard rates for collected blood are often high (up to 33%). Most of the blood collected is transfused as whole blood, and most DGCs and LDCs have inadequate supplies of plasma substitutes for management of acute haemorrhage. The reasons for these problems and suggested solutions are discussed.

PIP: As part of an effort to monitor the safety of global blood transfusion services, the World Health Organization circulates a questionnaire for use in a database on blood safety. In 1992, 67% of countries responding to the survey (100% of developed, 66% of developing, and 46% of less developed countries) were screening all blood donations for HIV antibodies and 87% of these countries (100% of developed, 92% of developing, and 63% of less developed countries) carried out supplementary testing to confirm positive results. All developed countries, 72% of developing, and 35% of less developed countries screen blood for hepatitis B surface antigen and 94%, 71%, and 48%, respectively, screen for syphilis. The primary reasons for inadequate blood testing are the cost of test kits and reagents and the unreliability of supplies. The proportion of safe donors is highest in systems where all donors are voluntary and nonremunerated--conditions that exist in 85% of developed countries but only 15% of developing and 7% of less developed countries. Blood safety would also be improved by more appropriate use of transfusions and the provision of alternatives such as saline and colloids. Other problems include insufficient blood supply (e.g., none of the less developed and only 9% of developing countries collect 30 units or more per 1000 population per year) and inadequate quality assurance in all aspects of preparatory testing.

Pautas para la organización de un servicio de transfusión de sangre / Guidelines for the organization of blood transfusion services / Pautas para la organización de un servicio de transfusión de sangre

Los servicios de transfusión de sangre pueden variar considerablemente en organización y complejidad, ya que van desde los centros sencillos y elementales hasta las instituciones sumamente adelantadas en cuanto a su radio de accion, pueden pertenecer a hospitales o tener alcance regional o nacional. Ahora bien, cualquiera que sea su naturaleza, todos tiene como meta la atención de la creciente necesidad clínica de productos sanguíneos inocuos y eficaces. La clave para el logro de esa meta está en la organización y la coordinación

Este manual toca todos los aspectos del servicio de transfusión, desde la captación de donantes hasta el uso clínico de la sangre y los productos sanguíneos. Se hace hincapiè en la organización indispensable para la seguridad de donantes y receptores. Por ello, hay capítulos relativos a selección y atención de donantes, procedimientos de toma y almacenamiento de sangre, análisis para detección de enfermedades transmisibles, técnicas de determinación de grupo sanguíneo y pruebas de compatibilidad, elección y mantenimiento de equipo de laboratorio, y métodos de garantía de la calidad de todos los derivados de la sangre

Pautas para la organización de un servicio de transfusión de sangre

Este manual toca todos los aspectos del servicio de transfusión, desde la captación de donantes hasta el uso clínico de la sangre y los productos sanguíneos. Se hace hincapié en la organización indispensable para la seguridad de donantes y rectores. Por ello, hay capitulos relativos a selección y atención de donantes, procedimientos de toma y almacenamiento de sangre, análisis para detección de enfermedades transmisibles, técnicas de determinación de grupo sanguíneo y pruebas de contabilidad, elección y mantenimiento de équipo de laboratorio, y métodos de garantía de la calidad de todos los derivados de la sangre (AU)

Human T-lymphotropic virus type I (HTLV-I) seroprevalence in Jamaica. I. Demographic determinants.

During 1985 and 1986, the authors measured antibodies to human T-lymphotropic virus type I (HTLV-I) in a cohort of 13,260 Jamaicans from all parts of the island who applied for food-handling licenses. HTLV-I seroprevalence was strongly age and sex dependent, rising from 1.7% (10-19 years) to 9.1% (greater than or equal to 70 years) in men and from 1.9% (10-19 years) to 17.4% (greater than or equal to 70 years) in women. In a logistic regression analysis, women were more likely to be seropositive than were men, and farmers, laborers, and the unemployed were more likely to be HTLV-I seropositive than were those reporting student or professional occupations. In men, African ethnicity was associated with HTLV-I seropositivity in the univariate analysis but was not a risk factor after adjustment for age and sex. There was a trend toward higher age-stratified HTLV-I seroprevalence among younger women who reported more pregnancies, but older multigravidas had lower rates of HTLV-I seropositivity. Persons born outside Jamaica had significantly lower seroprevalence than did those born in Jamaica, but they were of slightly different ethnic and occupational compositions than those born in Jamaica.

Human T-lymphotropic virus type I (HTLV-I) seroprevalence in Jamaica. II. Geographic and ecologic determinants.

An island-wide cohort of 13,260 Jamaicans who applied for food-handling licenses during 1985 and 1986 were tested for antibodies to human T-cell lymphotropic virus type I (HTLV-I). Demographic and residence history data were linked to geographic and ecologic measures of elevation, rainfall, crop-growing areas, population density, and additional measures of urbanization and correlated with HTLV-I antibody status. By logistic regression analysis (performed separately for men and women), men and women who currently resided at low elevation (less than or equal to 1,000 ft (305 m)) were more likely to be HTLV-I infected than were those residing at high elevation. Men, but not women, who were born in citrus-growing areas were more likely to be HTLV-I infected than were men who were born in other areas. By univariate analysis, there was a significant positive trend of increasing HTLV-I seroprevalence with increasing amount of annual rainfall associated with birthplace and primary residence areas. However, these associations did not remain significant after adjusting for age and sex. These environmental associations raise the possibility of new modes of viral transmission or host response to infection, although they may simply be surrogates for socioeconomic status, breastfeeding habits, or sexual behavior, which are known determinants of HTLV-I zero prevalence.

Parasitic infections in young Jamaicans in different ecological zones of the island.

Data are presented for the first country wide prospective study on gastrointestinal tract parasitic infections done in Jamaica. Samples from 2,947 young Jamaicans drawn from all ecological zones and from all parochial divisions of the island were analyzed. Pica was practised by 8.6%. Generally, prevalence of organisms was as follows: Trichuris trichiura (12.3%), Ascaris lumbricoides (9.5%), hookworm (2.2%), Strongyloides stercoralis (0.3%), Giardia lamblia (6.3%) and Entamoeba coli (7.7%). Several other spp. of protozoans were recorded. Prevalence of A. lumbricoides, T. trichiura and Necator americanus was significantly greater in upland than in lowland (both urban and rural), while the situation was reversed for G. lamblia-infections. Greatest variations were age-related. A. lumbricoides and T. trichiura reached peak prevalence of 15.3 and 20.5% respectively in 5-9-year-olds, while hookworm peaked later at 15-19 years of age. Suggestions are made for a national and even regional antihelminthic program for the mass treatment of pre- and primary school age children.

Sexual transmission of human T-lymphotropic virus type I (HTLV-I).

STUDY OBJECTIVE: To study the seroprevalence of human T-lymphotropic virus type I (HTLV-I) in a sexually active population and to determine sexual behavior risk factors for infection. DESIGN: Cross-sectional seroprevalence study using enzyme-linked immunosorbent assay (ELISA) and Western blot. Risk-factor data were gathered by administered questionnaire and chart review. SETTING: Two urban, primary care clinics for persons with sexually transmitted diseases run by the Jamaican Ministry of Health. PATIENTS: Of the 2050 consecutive patients presenting with new episodes of sexually transmitted disease, 1977 patients were eligible for analysis. MEASUREMENTS AND RESULTS: Overall HTLV-I seroprevalence was 5.7%; prevalence increased with age from 1.6% (age, 14 to 19 years) to 5.1% (age, 30 years and older) in men and from 5.3% (age, 14 to 19 years) to 14.1% (age, 30 years and older) in women. Compared with a reference cohort of food service employees, age-adjusted HTLV-I seroprevalence was increased in female patients with sexually transmitted disease (odds ratio = 1.83; CI, 1.41 to 2.83) but not in male patients with sexually transmitted disease. Independent risk factors for HTLV-I infection in women included having had more than ten lifetime sexual partners (odds ratio = 3.52, CI, 1.28 to 9.69) and a current diagnosis of syphilis (odds ratio = 2.12; CI, 1.12 to 3.99). In men, a history of penile sores or ulcers (odds ratio = 2.13; CI, 1.05 to 4.33) and a current diagnosis of syphilis (odds ratio = 3.56; CI, 1.24 to 10.22) were independent risk factors for HTLV-I infection. Of 1977 patients, 5 (0.3%) had antibodies to human immunodeficiency virus type 1 (HIV-1), including 2 with HTLV-I and HIV-1 coinfection. CONCLUSIONS: We conclude that HTLV-I is transmitted from infected men to women during sexual intercourse. Our data are consistent with the lower efficiency of female-to-male sexual transmission of HTLV-I, but penile ulcers or concurrent syphilis may increase a man's risk of infection.