Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock.

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

Kicking the habit - how can we improve the routine care for patients who are well controlled living with HIV?

The objective is to improve and standardise HIV care for people with well-controlled HIV across the region by comparing monitoring within services to UK audit standards. This was a retrospective case note review from 01.01.2018 to 31.12.2018. The standards were sourced from the British HIV Association (BHIVA), the British Association for Sexual Health and HIV (BASHH), and the Faculty of Sexual and Reproductive Health (FSRH). Six services took part with 228 patient records being audited. Two of the 5 national standards were met (blood pressure and medication review). From the 8 areas previously audited in 2014, 6 showed improvements (offer of STI screen, medication review, urinalysis, mental health screen and influenza vaccination documentation). Cardiovascular disease (CVD) risk and transmission risk had poorer documented outcomes. In addition, nearly one-third of patients were over-tested regarding their CD4 count. We recommend that letters should include a standard message about U = U (undetectable = untransmittable) and vaccinations; CVD risk and FRAX should be calculated once a year in place of a routine letter; an annual summary letter should be written in place of a letter after each clinic visit; and consistent use of a proforma, with BHIVA/BASHH/FSRH recommendations on monitoring included.

HIV-associated fatigue in the era of highly active antiretroviral therapy: novel biological mechanisms?

OBJECTIVE: The aim of the study was to determine the prevalence and risk factors for HIV-associated fatigue in the era of highly active antiretroviral therapy (HAART). METHODS: A cross-sectional survey of 100 stable HIV-infected out-patients was carried out. Severity of fatigue was measured using the Fatigue Impact Scale (FIS). Symptoms of orthostatic intolerance (dysautonomia) were evaluated using the Orthostatic Grading Scale (OGS). Data for HIV-infected patients were compared with those for 166 uninfected controls and 74 patients with chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (encephalopathy) (ME). RESULTS: Ninety-one per cent of HIV-infected patients were on HAART and 78% had suppressed plasma HIV viral load (≤ 40 HIV-1 RNA copies/mL). Fifty-one per cent of HIV-infected patients reported excessive symptomatic fatigue (FIS ≥ 40), and 28% reported severe fatigue symptoms (FIS ≥ 80). The mean FIS score among HIV-infected patients was 50.8 [standard deviation (SD) 41.9] compared with 13.0 (SD 17.6) in uninfected control subjects, and 92.9 (SD 29.0) in CFS patients (P < 0.001 for comparison of HIV-infected patients and uninfected controls). Among HIV-infected patients, fatigue severity was not significantly associated with current or nadir CD4 lymphocyte count, HIV plasma viral load, or whether on HAART. Prior dideoxynucleoside analogue (d-drug) exposure (P = 0.016) and the presence of clinical lipodystrophy syndrome (P = 0.011) were associated with fatigue. Additionally, fatigue severity correlated strongly with symptomatic orthostatic intolerance (r = 0.65; P < 0.001). CONCLUSIONS: Fatigue is very common and often severe in HIV-infected out-patients, despite viral suppression and good immune function. In a subgroup of patients, prior d-drug exposure may contribute to fatigue, suggesting a metabolic basis. Dysautonomia may also drive fatigue associated with HIV infection, as in other chronic diseases, and CFS/ME, and should be further evaluated with the potential for a shared therapeutic approach.

Starting treatment according to guidelines evaluation: a multicentre audit of HIV patients in the UK.

The aim of this audit was to assess whether HIV patients are being started on antiretroviral therapy (ART) according to British and European guidelines. Data were collected from the Survey of Prevalent HIV Infections Diagnosed (SOPHID) return for 2010 at five major HIV management centres in the UK. Data from this 3873 patient cohort revealed 52 patients who should have been receiving ART according to the guidelines but were not. Of these, 23 patients elected not to start ART despite clinical advice to the contrary. Information required to assist in the decision for earlier ART initiation (CD4 count 350­500 cells/mL) was missing for some patients. Clinicians must pay attention to the regular assessment of patients with a CD4 count of 351­500 cells/mL so that all those who may benefit from earlier treatment are identified. Future research should investigate patient barriers to initiating therapy following recommendation by a clinician.

IL-6, DHEA and the ageing process.

The age-related increase in circulating IL-6 levels in humans which has been attributed to a decline in DHEA production by the adrenal gland is currently attracting attention because of its possible relevance to the aetiology and management of a number of age-related clinical disorders. The potential importance of these observations and suggestions has prompted us to perform more detailed studies on the relationship between IL-6 and DHEA. Using immunoassay techniques we have found in normal healthy individuals over the age of 40 an inverse relationship between plasma DHEA levels and the presence of detectable levels of IL-6 (more than 1 pg/ml). In vitro, studies also revealed that low dose (10(-6)-10(-8) M) of DHEA and DHEAS inhibited the production of IL-6 in unstimulated human spleen cell suspension cultures whilst enhancing its release by explant cultures of the same tissue. In contrast they had no effect on immunoglobulin production. These studies suggest that there is a real, but complex relationship between IL-6 production and DHEA levels which warrants further investigation.

One hundred cases of hypoglycaemia - abstract

The purpose of this paper is to report a review of the aetiology, clinical features and differential diagnosis in 100 cases of hypoglycaemia seen at the General Hospital, Port-of-Spain. A retrospective study was made of 100 admissions with a final diagnosis of hypoglycaemia. Only cases with a blood sugar of 50 mgm percent/2.77 mmol/1 or less, or in which there was a definite response to intravenous glucose, were included. Although the majority of cases occurred in association with diabetes mellitus, at least 19 percent were in patients with excess alcohol intake. There is often a delay in diagnosis; in 11 cases the delay was 12 hours or more, and in 3 over 24 hours. A wide range of clinical features included bad feelings, fits, hemiparesis, dysphasia, confusion, strange or aggressive behaviour, neck stiffness and unequal pupils. The differential diagnosis included encephalitis, meningitis, epilepsy, subdural haematoma, poisoning, hypertensive encephalopathy, psychosis and diabetic coma. In 39 cases a diagnosis of CVA was made. Hypoglycaemia may produce clinical features of psychiatric, neurological and neurosurgical disease and is an important differential diagnosis to be considered in cases with disturbance of consciousness. The diagnostic and therapeutic use ofi.v. dextrose in advocated, in order to avoid missing hypoglycaemia which is an eminently treatable condition , and which if untreated may produce permanent neurological deficit and death (AU)

Epilepsy at the General Hospital, Port-of-Spain - abstract

In 1987, the discharge diagnosis on 264 patients admitted to 5 medical wards at the General Hospital, Port-of Spain was fits/epilepsy/seizures. This prompted us to review the cases of epilepsy attending the Neurology Clinic at the institution over a 3-month period, May-August, 1988. There were 182 cases aged 8 to 80 years. Common seizure patterns were tonic/clonic 124 (685), and complex partial become generalized 37 (21 percent). Monotherapy was used in 117 (64 percent), 2 drugs in 51 (28 percent), and 3 drugs in 6 (3 percent) patients. The most commonly used drug was dilantin, drugs included phenobarbitone in 49 cases, mostly in combination and tegretol in 42 cases (21 cases each, singly and in combination). The commonest combination was dilantin and phenobarbitone in 31 cases (17 percent). Antiepileptic drug (AED) levels were done on 297 Specimens from 107 patients and, overall, 117 (39 percent) were in the therapeutic range. Only 59 patients (32 percent) were in good control, i.e. there were no seizures in the 6 months prior to the visit. Epilepsy is not satisfactorily controlled in these patients. This partly reflects lack of compliance, lack of regular supplies of medication, supervision by staff not well-informed in the management of epilepsy, frequent change of clinic staff and lack of awareness of the nature of the illness by patients (AU)

Multiple sclerosis in Trinidad and Tobago - abstract

No studies have been reported on the incidence or prevalence or multiple sclerosis in Trinidad and Tobago. This paper reports on 15 cases presenting between 1976 and 1986, seen either at the Port-of-Spain General Hospital (9) or privately (6) by one of us (P.R.). All the cases fit into one of the categories defined by Poster et al (1983): 3 are laboratory supported, definite; 9 are clinically definite; and 3 are clinically probable. One is an expatriate who was born and lived in Scotland for more than 30 years. Fourteen were born in the West Indies - 3 in Jamaica and 11 in Trinidad. The male: female ratio is 12:2. Of the 11 patients from Trinidad, 4 are of East Indian origin; 1 of African origin and 6 mixed (at least 1 grandparent white). Of the 3 born in Jamaica, 2 are mixed and one probably of pure African origin. The age of onset of symptoms was between 11 and 39 years. Most of the patients were diagnosed within 2 years of their first symptoms. Three died, 2 of African origin (aged 37 and 43), both 6 years after diagnosis and 1 East Indian, 4 years after diagnosis. Of the 14 West Indian born patients, 64 percent presented with visual symptoms; 78 percent had optic neuritis/atrophy during the illness. In temperate climates, the prevalence of optic neuritis is 25-40 percent. Tests for HTLV-1 antibodies were done in 8 patients; 1 case was positive. CSF from 5 patients was examined for oligoclonal banding and 3 were positive. The fact that 8 of the 14 patients are of mixed (African and White) ancestry is a point in favour of some predisposing gene from a white ancestor (AU)

Massive ascites due to omental endometriosis

Endometriosis associated with massive ascites is an unusual combination. Only 12 cases have been reported since its first description by Brews in 1954. The authors report the first case where radical surgery was avoided because of successful hormonal therapy.(Summary)

Racial and other characteristics of human T cell leukemia/lymphome (HTLV-1) and AIDS (HTLV-111) in Trinidad

Adult T cell leukaemia/lymphoma was first recognised as a clinical entity in southwest Japan. Subsequently the Caribbean has been found to be another area where the disease is endemic, and sporadic cases have been identified in different parts of the world. The human T cell leukaemia/lymphoma virus (HTLV-1) is causally related to adult T cell leukaemia/lymphoma. A sub-group of HTLV, designated HTLV-111, has recently been isolated from many patients with the acquired immunodeficiency syndrome (AIDS) and preAIDS, and there is now evidence that this variant is the primary cause of AIDS. This is the first report from Trinidad to describe twelve cases of adult T cell leukaemia/lymphoma and 14 of AIDS. All were in patients of African descent. No cases were seen in subjects of East Indian descent, who, like those of African descent, comprise as much as 40 percent of the population

Cerebrovascular accidents in Trinidad - abstract

Cerebrovascular accidents (CVA) are the commonest cause of death in Trinidad and the purpose of this paper is to determine the incidence of CVA among patients admitted to a large general hospital, and to examine the age, sex and racial distributions, mortality rate and roles played by hypertension and diabetes in this disease. There were 279 patients over the age of 10 years who were admitted to the Port-of-Spain General Hospital with CVA in 1968 and 1969. There were almost equal number of males as females. Of 246 patients 23 percent were East Indian and 77 percent non East Indian in ethnic origin. 58 percent of patients were 60 years and older and only 2.5 percent were under 40 years of age. 46.5 percent of patients died during admission and of the survivors 69 percent stayed up to 2 weeks in hospital. There was a past history of hypertension in 35 percent of patients, though about twice that number had a diastolic pressure over 100. A previous stroke had occurred in 12.5 percent of patients. In 15.7 percent of patients there was a past history of diabetes mellitus which is a much higher incidence than that reported from Nigeria and Senegal. Because of the importance of hypertension and diabetes as diseases associated with CVA, it is concluded that better management of these 2 diseases would be an important preventative measures in combining CVA (AU)

Accidental poisoning among children in Trinidad

During 1962, 224 cases were admitted to the General Hospital in Port of Spain with but one fatality. The highest incidence was in the age group 1-2 and 60 percent of these were male. Kerosene poisoning accounted for 49 percent of the cases, other household substances for 14 percent and physic nut for 10 percent. Proper storage of drugs at home and an educational campaign against accidental poisoning were stressed as the best means of preventing future trouble (AU)

Accidental poisoning in Trinidad

A retrospective study was made of accidental poisoning in children under age 10 admitted to the General Hospital, Port Of Spain, during 1962. Only one death occured in the 224 cases reported. In contrast with reports from USA and England poisoning from internal drugs was low accounting for only 9 percent of cases. On the other hand poisoning from household agents was responsible for 71 percent of the cases and this included 49 percent due to kerosene which was the commonest single agent. The highest incidence was in the 1- 2- year age group, and 60 percent of all cases were in boys. An appeal made for greater awareness among parents, health visitors, doctors, nurses, pharmacists, teachers and social workers of the problem of accidental poisoning so that the prevalence could be reduced. (AU)