The Effect of Acute Administration of the Aqueous Calyx Extract of Hibiscus sabdariffa on Blood pressure, Heart rate and Double Product of Apparently Healthy Human Subjects during Different Postures.

The aqueous calyx extract of Hibiscus sabdariffa (HS) is widely consumed as a beverage in Northern Nigeria and other parts of the world. HS has been reported to lower blood pressure (BP) in animals and man. However, not much is known about the effect of HS on BP in different postures. We tested the hypothesis that HS may lower BP, heart rate (HR) and heart rate-pressure product or double product (DP) by attenuating the discharge of the autonomic nervous system in different postures. Experiments were performed in accordance with the Principles of the Declaration of Helsinki. Following ethical approval and informed consent, BP and HR were measured in different postures (supine, sitting and standing) in apparently healthy human subjects (n=20) before and after (+HS) the oral administration of 15mg/Kg HS. Mean arterial pressure (MAP; taken as representative BP) and DP were calculated. Results are expressed as mean ±SEM. Paired t test and ANOVA with a post hoc Bonferroni test were used for statistical analyses. P<0.05 was considered significant. In the supine position MAP, HR and DP were significantly (P<0.0001 each) reduced in the presence of HS (85.6±1.7mmHg, 72.1±1.1/min and 8716±320mmHg.bpm) compared to its absence (89.6±2.0mmHg, 73.7±1.6/min and 8921±444mmHg.bpm). Similar trends were observed in the sitting position in the presence of HS (85.4±2.7mmHg, 73.7±1.8/min and 9098±345mmHg.bpm vs its absence: 91.4±2.3mmHg, 77.1±1.9/min and 9388±478mmHg.bpm; P<0.0001, P<0.0001 and P=0.007 respectively) and in the standing position (+HS: 89.3±2.0mmHg,         78.1±1.8/min and 10164±230mmHg.bpm vs its absence: 94.3±2.1mmHg, 81.8±2.3/min and 10742±268mmHg.bpm; P<0.0001, P<0.0001 and P=0.007 respectively). In the absence of HS, HR and DP were significantly higher in the standing posture (81.8±2.3/min, 10742±268mmHg.bpm) compared to the sitting (77.1±1.9/min, 9388±478mmHg.bpm; P<0.05 and P<0.0001 respectively) and the supine (73.7±1.6/min, 8921±444mmHg.bpm; P<0.001 each) postures while the BP remained similar. A similar trend was observed across          the three postures in the presence of HS although the parameters were significantly lower. It is concluded that HS lowered BP, HR and DP by modulating autonomic mechanisms through the inhibition of both parasympathetic withdrawal and sympathetic nervous system discharge across the postures. Also the standing posture is associated more with a higher sympathetic nervous system discharge and a higher cardiac oxygen demand and workload than the sitting and supine postures in the absence or presence of HS.

Registry for Acute Coronary Events in Nigeria (RACE-Nigeria): Clinical Characterization, Management, and Outcome.

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease-related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013-2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1-year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST-segment-elevation myocardial infarction (48.7%), non-ST-segment-elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST-segment-elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12-hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline-based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in-hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010-0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004-0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020-0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091-0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302-3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure-appropriate management guidelines.

Prevalence of echocardiographic left ventricular hypertrophy among hypertensives in a tertiary health institution in Nigeria

OBJECTIVE: Systemic hypertension remains an important risk factors for cardiovascular diseases and a major global public health problem. Left ventricular hypertrophy (LVH) is a recognized complication of hypertension and strongly predicts cardiovascular morbidity and mortality. In Nigeria, few studies evaluated the role of echocardiography in the diagnosis of LVHs among hypertensives. This study sets out to determine the prevalence of LVH among hypertensives as determined by echocardiography.MATERIAL AND METHODS: One hundred and seventy-eight hypertensives and eighty-nine age and sex-matched controls were recruited consecutively into the study. They all had echocardiography done to determine which among had LVH. The partition value for LVH for hypertensives was determined using the 97th percentile of the left ventricular mass for controls as a cutoff point. RESULTS:Echocardiographic determined the prevalence of LVH among hypertensives was 32.4%.CONCLUSION:The echocardiographic prevalence of LVH was 32.4% in the study population. This is a significant proportion among the study population considering the clinical impact of LVH among patients with hypertension.

Influence of seasonal changes on asthma exacerbation in a sudan savanna region: An analysis of 87 cases.

Background: Asthma accounts for 1 out of every 250 deaths worldwide. Many of these deaths are preventable as they occur as a result of suboptimal long-term medical care and delay in seeking help during severe exacerbation. It is believed that increased concentrations of dust, high winds, low temperatures, and low humidity may cause exacerbation of asthma. Objective: The aim of this study is to assess seasonal variation in asthma exacerbation among patients attending Usmanu Danfodiyo University Teaching Hospital, Sokoto. Materials and Methods: Eighty-seven patients aged 16 years and above with physician-diagnosed asthma were selected by systematic random sampling. Clinical information was obtained from each participant about history of asthma exacerbation and health-care utilization. Meteorological data were obtained from the Nigerian Meteorological Agency corresponding to period of patient's recruitment. Results: Eighty-seven patients comprising 60 females and 27 males aged 32.1 ± 10.8 years participated in the study. Among the study participants, 50.6%, 28.7%, and 20.7% had exacerbation during harmattan, rainy, and dry (hot) seasons, respectively. Correlation analysis shows a significant negative relationship between temperature and asthma exacerbation (r = -0.372, P < 0.01). Conclusion: This study shows that asthma exacerbation is most frequent during the harmattan season and low temperature is associated with its exacerbation.

RésuméContexte: L'asthme est responsable de 1 décès sur 250 dans le monde. Beaucoup de ces décès sont évitables car ils surviennent à la suite de soins médicaux à long terme sous-optimaux et retard dans la recherche d'aide en cas d'exacerbation grave. On pense que l'augmentation des concentrations de poussière, les vents, les basses températures et une faible humidité peuvent provoquer une exacerbation de l'asthme. Objectif: Le but de cette étude est d'évaluer la variation saisonnière exacerbation de l'asthme chez les patients fréquentant l'hôpital universitaire Usmanu Danfodiyo, Sokoto. Matériel et méthodes: quatre-vingt-sept les patients âgés de 16 ans et plus souffrant d'asthme diagnostiqué par un médecin ont été sélectionnés par échantillonnage aléatoire systématique. L'information clinique était obtenu de chaque participant sur les antécédents d'exacerbation de l'asthme et l'utilisation des soins de santé. Les données météorologiques ont été obtenues à partir du Agence météorologique nigériane correspondant à la période de recrutement des patients. Résultats: quatre-vingt-sept patients dont 60 femmes et 27 hommes âgés de 32,1 ± 10,8 ans ont participé à l'étude. Parmi les participants à l'étude, 50,6%, 28,7% et 20,7% ont eu une exacerbation pendant les saisons harmattan, pluvieuse et sèche (chaude), respectivement. L'analyse de corrélation montre une relation négative significative entre la température et exacerbation de l'asthme (r = −0,372, p <0,01). Conclusion: Cette étude montre que l'exacerbation de l'asthme est la plus fréquente pendant l'harmattan la saison et les basses températures sont associées à son exacerbation. Mots-clés: asthme, exacerbation, saison.

May Measurement Month 2019: an analysis of blood pressure screening results from Nigeria.

The aim of this study is to estimate the frequency of undetected hypertension across the six geopolitical zones of Nigeria. We conducted an opportunistic screening of adults aged at least 18 years in the month of May 2019. Participants were recruited by trained volunteers using the May Measurement Month protocol. Blood pressure (BP) was measured using validated digital and mercury sphygmomanometers. We defined hypertension as BP ≥140/90 mmHg or the use of BP-lowering medication. A total of 3646 participants (52.8% females) with a mean age of 44.5 ± 15.7 years were screened. Hypertension was present in 39.2% of the participants but only 55. 4% of these were on antihypertensive medications. Only 46.8% hypertensives who were on medications had their BP controlled (<140/90 mmHg). Previous history of hypertension in pregnancy, alcohol intake and smoking were associated with increased mean systolic and diastolic BPs. The frequency of Nigerians with hypertension is high while only about half of those on antihypertensive medications are controlled. A multi-pronged approach to reduce the burden of hypertension is needed.

May Measurement Month 2017: screening for hypertension in Nigeria-Sub-Saharan Africa.

Hypertension and its complications are now responsible for about a quarter of emergency medical admissions in urban hospitals in Nigeria. It is the commonest risk factor for stroke, heart failure, chronic kidney disease, and dementia. Furthermore, high blood pressure is the commonest cause of sudden unexpected natural death in the country. Regrettably, the rate of awareness, treatment, and control is abysmally low in the country and in many parts of the world. May Measurement Month (MMM) is a global initiative of the International Society of Hypertension aimed at raising awareness of high blood pressure (BP) and to act as a temporary solution to the lack of screening programs worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. A total of 19 904 individuals with a mean age of 40.9 years, were screened during MMM17. After multiple imputation, 6709 (36.2%) had hypertension. Of individuals not receiving anti-hypertensive medication, 4140 (25.9%) were found to have hypertension. Of individuals receiving anti-hypertensive medication, 1449 (58.8%) had uncontrolled BP. MMM17 was one of the largest BP screening campaigns undertaken in Nigeria. A significant number of the participants were identified with hypertension (but not on any treatment) and uncontrolled BP despite being treated. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Biochemical and histological changes in the heart of post-partum rats exposed to Natron.

BACKGROUND: The customary puerperal practice of Natron consumption has been identified as one of the predisposing factors in the etiology of peripartum cardiomyopathy (PPCM). This study was designed to investigate the effect of Natron in postpartum Wistar albino rats. METHODS: A total of 30 postpartum Wistar rats were exposed to different doses (50mg/kg, 100mg/kg, 200mg/kg and 300mg/kg) of Natron for 28days. After the treatment, we carried out biochemical analyses and histological evaluations of kidney, liver and heart. RESULTS: The study revealed that the exposure of postpartum rats to 100mg/kg of Natron and above significantly (p<0.05) increase the cardiac markers; myoglobin, creatine kinase-MB, troponin I and T as compared with control. The result of liver function indicated no significant difference in alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltransferase, albumin and total protein of the Natron treated groups as compared with control. However, at higher doses, the levels of total protein, globulin and alkaline phosphatase activity were significantly increased in comparison to the control. There was no significant difference in the kidney function markers of the treatment groups as compared with control. Histological examinations revealed no changes in the kidney of the treated groups. Mild portal triaditis was observed in the liver of the treated rats. The heart of the rats administered ≥100mg/kg of Natron showed myocyte hypertrophy. CONCLUSION: The study demonstrated that the administration of Natron for 28days caused changes in the heart of postpartum rats and thus may contribute to the pathogenesis of PPCM.

Metabolic syndrome in urban city of North-Western Nigeria: prevalence and determinants.

INTRODUCTION: The aim of this study was to investigate the prevalence of metabolic syndrome in Sokoto metropolis of North-Western Nigeria. METHODS: A cross-sectional community based study was carried out. Four hundred and ten subjects (201 males and 209 females) were recruited for the study using a multi-stage sampling technique. Demographic and the life style data was obtained from the participants. Evaluation of anthropometric variables, fasting blood sugar, lipid profiles, insulin resistance and blood pressure was performed. The classification of metabolic syndrome was based on the NCEP ATP III guidelines. RESULTS: The mean (SD) age of the sample population was 39.6 (14.4) years. The mean (SD) age of the male subjects was 38.4(14.9) years and that of the females was 40.8(13.9) years (p> 0.05). The overall prevalence of metabolic syndrome was 35.1% with the females having 42.83% and the males 27.36%. The frequencies of metabolic syndrome parameters in the study subjects were low HDL (56.1%), hypertension (46.1%), dysglycemia (32.7%), central obesity (28%), and elevated triglycerides (22.4%). Most of the women had low HDL (62.2%) and central obesity elevated (49.8%). CONCLUSION: Metabolic syndrome is common in residents of North-Western Nigeria, commoner in the females than males. Risk factors for metabolic syndrome should be detected in normal individuals for implementing effective preventive measures.

Characteristics, treatment and one-year outcomes of patients with acute coronary syndrome in a tertiary hospital in India.

BACKGROUND: Coronary artery disease (CAD) is a major cause of death in India. Data on outcome of CAD is scarce in the Indian population. This study determined the characteristics, treatment and one-year outcomes of acute coronary syndrome (ACS) in an Indian Cardiac Centre. METHODS: We carried out a cross sectional retrospective analysis of 1468 ACS patients hospitalized between January 2008 and December 2010 and followed up for 1 year in the Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai. Mortality at 1 year, its determinants and 1 year major adverse cardiac events (MACE) were determined. RESULTS: The patients were aged 62.2 ± 11.2 years; males (75.2%) and had ST segment elevation myocardial infarction (STEMI) (33.9%), non ST segment elevation myocardial infarction (44.2%) and unstable angina (21.9%). Key pharmacotherapy included aspirin (98.2%), clopidogrel (95.1%), statins (95.6%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (50.6%) and beta blocker (83.1%). Angiography rate was 80.6%. In the STEMI group, 53.3% had primary angioplasty, 20.3% were thrombolysed and 16.1% received sole medical therapy. Overall coronary artery bypass graft rate was 12.4%. At one year, all-cause mortality and composite MACE were 2.5% and 9.7%, respectively. MACE included death (2.5%), reinfarction (4.0%), resuscitated cardiac arrest (1.8%), stroke (1.1%) and bleeding (0.4%). Main factors associated with mortality were combined left ventricular systolic and diastolic dysfunction (OR = 20.0, 95% CI = 6.63-69.4) and positive troponin I (OR = 12.56, 95% CI = 1.78-25.23). Troponin I independently predicted mortality. CONCLUSIONS: ACS population was older than previously described in India. Evidence-based pharmacotherapy and interventions, and outcomes were comparable to the developed nations.

Type 2 diabetes mellitus and its risk factors among the rural Fulanis of Northern Nigeria.

BACKGROUND: Information about diabetes mellitus (DM) from the rural populations in Nigeria, particularly among the rural Fulanis is limited. MATERIALS AND METHODS: This was a cross-sectional study conducted in two rural districts of Sokoto State in Northern Nigeria. Using a modification of the WHO STEP wise approach to surveillance (STEPS) instrument, information on sociodemographic and anthropometric data was obtained. Either a casual or fasting plasma glucose (FPG) level was obtained in all subjects while oral glucose tolerance test was performed in a randomly selected group of 50 of the study participants. RESULTS: Three hundred and ninety-three subjects participated in the study. The prevalence rates of DM, impaired fasting glycemia (IFG), and impaired glucose tolerance (IGT) were 0.8, 6.9, and 8%, respectively. The mean (SD) FPG was higher in males (5.1 ± 0.6 mmol/L) than in females (4.9 ± 0.6 mmol/l), but not statistically significantly (P = 0.20). The major risk factors for DM among the rural Fulani were obesity and increasing age. CONCLUSION: The prevalence rates of DM and its principal risk factor obesity are low among the rural Nigerian Fulani. However, the prevalence of prediabetes is relatively high, a factor that may predispose to the future development of DM.

Comparison of metabolic syndrome variables among pregnant women with and without eclampsia.

BACKGROUND: Similarities in the pathogenesis of pre-eclampsia and metabolic syndrome have been described. This study is aimed at determining whether metabolic syndrome variables occur in eclampsia. METHODS: Consecutive 45 patients with eclampsia were prospectively compared with age, gestational age and parity-matched women with uncomplicated pregnancy. The main outcome measures included plasma lipids, glucose, electrolytes and uric acid levels. RESULTS: The patients were predominantly made up of ethnic Hausa primigravidae aged 15-30 years (mean: 19.5 +/- 4.2 years). As expected, patients with eclampsia had significantly higher blood pressure than controls: (systolic 163.0 +/- 24.7 vs. 124.8 +/- 18.1 mmHg, p = 0.001; diastolic 120.8 +/- 8.7 vs. 79.6 +/- 10.7 mmHg, p = 0.001). Compared to the controls, the eclamptics also had significantly higher total plasma cholesterol (5.1 +/- 0.7 vs. 4.6 +/- 0.4 mmol/L, p = 0.001), triglyceride (1.9 +/- 0.2 vs. 1.7 +/- 0.2 mmol/L, p = 0.01), uric acid (10.4 +/- 2.7 vs. 4.4 +/- 0.8 mol/L, p = 0.005) and blood glucose (6.3 +/- 2.3 vs. 5.0 +/- 1.0 mg/dL, p = 0.01). The risk for intrapartum eclampsia was significantly increased for women with hypercholesterolemia [odds ratio (OR) = 6.9; 95% CI: 2.5-20.7] hypertriglyceridemia (OR = 5.0; 95% CI: 1.79-14.32) and hyperuricemia (OR = 35.3; 95% CI: 9.6-14.3). CONCLUSIONS: These results demonstrate that markers of metabolic syndrome also exist in this cohort of pregnant women with eclampsia and could suggest that both conditions are linked.

Epidemiologic profile of peripartum cardiomyopathy in a tertiary care hospital.

BACKGROUND: An epidemiologic link between peripartum cardiomyopathy (PPCM) and customary puerperal practices have been described among Nigerians. It is not, however, known if these practices have changed and influenced the epidemiology of PPCM over the years. OBJECTIVES: To describe the current epidemiologic profile of PPCM. METHODS: Cross sectional analysis of prospectively recruited 65 patients with PPCM seen from January 2003 to December 2005 in a tertiary care hospital in Sokoto, northwest Nigeria. RESULTS: Incidence rate was one case per 102 deliveries. Peripartum cardiomyopathy (PPCM) constituted 2.4% of total medical admissions, 32.5% of overall admissions for heart failure, and 60% of admissions for heart failure in females. Patients were predominantly (84.6%) of Hausa and Fulani ethnic groups; and 20 (30.8%) were primiparous and 45 (69.2%) were multiparous women aged 28.2 +/- 8.1 years (range 15-45 years). Literacy rate was 6.2%. Sixty-one (93.8%) patients belonged to the low socioeconomic class. All patients presented during the postpartum period; the interval between delivery and presentation was 6.7 +/- 10.3 weeks (range .25-40 weeks, median 4 weeks). Customary puerperal practices were observed in 53 (81.5%). Hospital admission peaked during the peaks of cold harmattan and rainy seasons. Transient hypertension occurred in 18 (27.7%) patients. Complications included pericardial effusion (13.5%), intracardiac thrombosis (12.3%), and atrial fibrillation (3.1%). Stroke, pulmonary embolism, and acute lower extremity arterial occlusion each occurred in one (1.5%) patient. Mortality rate was 12.3%. Compared to the survivors, the deceased had significantly lower diastolic pressure (67.5 +/- 10.4 mm Hg vs 83.4 +/- 19.4 mm Hg; P = .04) and higher cardiothoracic index (70.2% +/- 14.4% vs 60.9% +/- 5.5%; P = .007). The outcome of PPCM correlated with cardiothoracic index (r = .7; P = .007), ejection fraction (r = .5; P = .03), and diastolic blood pressure (r = .4; P = .04). CONCLUSIONS: The epidemiologic profile of PPCM has not changed among the ethnic Hausa and Fulani groups of northwest Nigeria. Peripartum cardiomyopathy (PPCM) is an important cause of maternal morbidity and mortality in this population.

Is high density lipoprotein cholesterol useful in diagnosis of metabolic syndrome in native Africans with type 2 diabetes?

BACKGROUND: High-density lipoprotein (HDL) hypocholesterolemia predicts metabolic syndrome among Caucasians and is one of the World Health Organization (WHO) diagnostic criteria of the syndrome. Plasma lipid levels are, however, influenced by genetic and environmental factors. OBJECTIVE: To determine the relationship between HDL cholesterol and metabolic syndrome among native Africans with type 2 diabetes. METHODS: Indigenous Nigerians with type 2 diabetes (N = 254) aged 35-80 years (mean: 52.0 +/- 11.7 years) with male:female ratio of 1.5:1 were studied prospectively. Outcome measures included anthropometric indices, plasma lipid concentrations, uric acid, microalbuminuria, and predictive values. RESULTS: Of the 254 diabetic patients, 150 (54.3%) had metabolic syndrome. Dyslipidemia occurred in 184 (72.4%) patients. Of these, 54 (29.4%) had HDL hypocholesterolemia. Mean HDL cholesterol among patients with HDL hypocolesterolemia and those with normocholesterolemia were 32.4 +/- 5.7 mg/dL and 51.3 +/- 9.9 mg/dL, respectively. Prevalence of metabolic syndrome did not differ significantly between the two groups (56% vs 70.4%; P = .08). Linear regression analysis showed no association between HDL cholesterol and metabolic syndrome (r = 0.01; P = .2), body mass index (r = 0.02; P = .4), waist circumference (r = 0.07; P = .42) and microalbuminuria (r = 0.03; P = .8). A positive correlation occurred between HDL cholesterol and triglyceride concentrations (r = 0.6). The sensitivity, specificity, and positive and negative predictive values of HDL hypocholesterolemia in the diagnosis of metabolic syndrome were 25%, 84.6%, 70.4%, and 44%, respectively. CONCLUSION: High-density lipoprotein cholesterol may not be a reliable diagnostic tool of metabolic syndrome among native Africans with type 2 diabetes.

Prevalence of different skin conditions in an outpatients' setting in north-western Nigeria.

BACKGROUND: Information on skin diseases in north-western Nigeria is scanty. We therefore conducted a prospective survey of 2611 new patients seen between August 1999 and July 2001 at the consultant medical/dermatology clinics of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. METHODS: The personal bio-data of all consecutive patients with skin diseases were documented. They were examined and the diagnoses, which were based on the history of presentation and physical examination, were recorded. Bacteriologic, mycologic, and histologic confirmations were obtained as appropriate. RESULTS: Seven hundred and forty-six patients (28.6%) had skin diseases. There were 407 male and 339 female patients aged between 0.17 and 90 years; the median age was 27 years. The median ages for male and female patients were 28 and 25 years, respectively. There were 900 skin diseases seen in the 746 patients. The majority of skin diseases were found amongst the younger age group, which represented over 85% of the patients. Infectious and parasitic skin diseases accounted for 44.4% of cases; eczema, acne, papulosquamous, and pigmentary skin disorders were observed in 14.1%, 7.0%, 6.4%, and 6.0% of cases, respectively. CONCLUSIONS: Preventable skin diseases are common in north-western Nigeria and predominantly affect individuals in the highly productive age group. Health education is therefore necessary to curb their spread, reduce the associated morbidity, and improve the health status of the population. A concerted effort should be made to train health workers in the diagnosis and treatment of the more common dermatologic conditions.