Leishmaniasis in Malta and the Mediterranean basin.

Leishmaniasis is a public-health problem in most countries bordering the Mediterranean littoral. In Malta, where the disease has been recognized for many years, Phlebotomus perniciosus is the established vector and dogs act as reservoir hosts. Visceral leishmaniasis (VL) was the only form of the disease recorded in Malta until the early 1980s, when cutaneous leishmaniasis (CL) was recognized. Although the incidence of CL has recently increased, the overall numbers of cases of leishmaniasis have markedly decreased since the 1960s. Prior to 1963, almost all cases were aged < 10 years. Although leishmaniasis in Malta is still mainly a disease of children, adult cases are increasingly being recognized. HIV-VL co-infection is being seen more and more frequently in the Mediterranean basin, especially in Spain, France and Italy. During diagnosis, leishmaniasis should be suspected on the basis of the clinical picture in endemic areas and on the travel history of those patients from non-endemic areas. In Malta, VL and CL are generally confirmed by detection of the parasites in smears, of bone-marrow or, rarely, splenic aspirates and of lesions, respectively. Antimonials are the standard therapeutic agents for VL, although liposomal amphotericin B is a very effective but expensive alternative, with no significant adverse effects. In Malta, the treatment of choice for CL is cryotherapy.

The prognostic value of blood glucose in diabetic patients with acute myocardial infarction.

The aim of the study was to investigate prospectively the prognostic value of blood glucose on admission in diabetic and non-diabetic patients with an acute myocardial infarction. Three hundred and thirty-three diabetic and 565 non-diabetic patients were admitted with acute myocardial infarction during the study period of 3.5 years. There was a significant association between mortality and blood glucose on admission in diabetic patients (regression coefficient, r = 0.92, 0.5 < p < 0.02) but not in non-diabetic individuals (r = 0.69, 0.2 < p < 0.5). Age- and sex-standardized mortality was higher in the diabetic group (12.2% vs 7.4%, p < 0.03), but was identical if standardized also for blood glucose on admission. We conclude that a high blood glucose on admission is a bad prognostic indicator in a diabetic patient with an acute myocardial infarction. The excess mortality in diabetic patients with acute myocardial infarction can be attributed to the higher proportion with hyperglycaemia.

Absence of circadian variation in the onset of acute myocardial infarction in diabetic subjects.

OBJECTIVES: To investigate the circadian pattern of acute myocardial infarction in non-insulin-dependent diabetic patients and to compare it with that of controls. BACKGROUND: Previous studies have shown that there is a circadian variation in the incidence of acute myocardial infarction, but there are few data on diabetic subjects. METHODS: A hospital based prospective case-control study. RESULTS: 196 diabetic patients and 196 age and sex matched controls were admitted with a diagnosis of acute myocardial infarction during the study period. IN 32 diabetic patients and 38 controls, the time of onset of myocardial infarction was unknown; in 34, 44, 42, and 44 diabetic patients the onset was in the first to fourth quarters respectively (chi 2 = 1.66, NS). The corresponding figures for the controls were 30, 56, 45, and 27 (chi 2 = 13.9, P < 0.005). The difference between the two groups was highly significant (chi 2 = 10.3, P < 0.025). CONCLUSIONS: Diabetic subjects do not show a significant circadian variation in the onset of acute myocardial infarction.

A computerized health screening and follow-up system in diabetes mellitus.

A computerized population health problem targeting program for diabetes mellitus and other common non-communicable disease was tested at St Luke's Hospital, Malta. The program utilizes a patient questionnaire by dialogue with a computer lasting about 20 min. The system evaluates and targets health problems that are followed up through the database. During a period of 10 months, two groups of people were screened using the system, consisting of 128 recently diagnosed diabetic patients presenting consecutively and 320 people from the general population. The age distributions of the two groups were similar. The system indicated 27% of the control group as being within the Diabetes Risk Group; 5% of this control group were confirmed to have diabetes. Eighty-two percent of newly referred diabetic patients were detected, giving false positive results in 23% and a false negative result in 18% of cases. The classification rules in the system were tuned to the population of Moscow, Russia. We have since adjusted these to better suit the Maltese population. The adjusted rules now indicate 20% of the general population as being within the risk group and have correctly detected 84% of the diabetic people, giving a false positive result in 15% and a false negative result in 16% of cases.

Factors that influence outcome in diabetic subjects with myocardial infarction.

OBJECTIVE: To compare the outcome of acute myocardial infarction in NIDDM patients and nondiabetic control subjects. The relation of glycemic control, duration of diabetes, and major diabetic complications to the outcome of acute myocardial infarction in diabetic subjects was investigated. RESEARCH DESIGN AND METHODS: This was a prospective, hospital-based, case-control study. RESULTS: One hundred and ninety-six NIDDM patients and 196 nondiabetic control subjects with acute myocardial infarction were entered into the study. 23.5% of diabetic subjects and 34.2% of control subjects received thrombolytic therapy (P < 0.05). Diabetic subjects showed signs of reperfusion less often than control subjects (P < 0.05). Mortality was higher in the diabetic group (17.3 vs. 10.2%, P < 0.05). Pump failure (38.3 vs. 16.8%, P < 0.01) and cardiogenic shock (9.7 vs. 3.6%, P < 0.05) also occurred more frequently in diabetic subjects. Loss of heart rate variability was correlated with both pump failure and mortality; proliferative retinopathy was correlated with pump failure. Glycemic control and other diabetic complications did not correlate with outcome. CONCLUSIONS: Our findings confirm the higher mortality and incidence of pump failure in acute myocardial infarction with co-morbid diabetes. They suggest that the less frequent use of thrombolytic therapy, lower reperfusion rates, and more advanced coronary artery disease might be contributory. The presence of autonomic neuropathy and microvascular disease probably also contribute to poor outcome; other major diabetic complications and diabetic control did not influence outcome.

Glucose metabolism and beta receptor function in atopic asthmatics.

Severe asthma and diabetes have been reported not to co-exist in the same patient. Various studies have attributed this to the possible association of asthma with hyperinsulinism, increased responsiveness to insulin or to beta-blockade. Previous studies have not addressed all these possible mechanisms in the same patient. In this prospective study, 7 atopic asthmatics and 7 age and sex-matched healthy controls underwent glucose, insulin and glucagon tolerance tests. The results showed no evidence of hyperinsulinism or increased responsiveness to insulin. Intravenous administration of glucagon, however, showed a lesser increase of glucose and insulin in asthmatics. Since glucagon has a beta-agonist effect on the liver and activates glycogenolysis and gluconeogenesis via beta-receptor stimulation and stimulates insulin secretion by activating adenylate cyclase of pancreatic beta-cells through beta-receptors, the results of glucagon tolerance test in our study may therefore suggest the presence of partial beta-blockade in atopic asthmatics.

Lipoproteins and apolipoproteins in young nonobese Arab women with NIDDM treated with insulin.

The effects of insulin on the lipid values of nonobese non-insulin-dependent diabetic (NIDDM) Arab women requiring insulin was investigated to find whether these patients have the same coronary artery risk factor related to lipid levels. In this study, 55 NIDDM women on insulin therapy (mean age 28 +/- 8.1 yr and duration of disease 5 +/- 1.2 yr) and 70 control subjects (matched for sex, age, and body mass index) were studied for their plasma levels of lipids, lipoproteins, and apolipoproteins. Concentrations of total cholesterol, very-low-density lipoprotein cholesterol, low-density lipoprotein (LDL) cholesterol, triglyceride (TG), LDL TG, high-density lipoprotein triglyceride (HDL TG), phospholipid, glucose, glycosylated hemoglobin (HbAtc), apolipoprotein B (apoB), LDL-apoB, and apoB/apoAl were significantly elevated in diabetic women compared with control subjects. There was no significant change in the levels of apoAll in plasma and lipoprotein fractions. Concentrations of HDL cholesterol (chol), HDL2-chol, HDL3-chol, plasma apoAl, HDL2-apoAl, HDL3-apoAl, and HDL-apoAl were significantly lower in diabetic women than in control subjects. There was no significant correlation between glucose or HbAtc and most of the lipids, lipoprotein lipids, and apolipoproteins measured. Despite normal body weight and insulin therapy, abnormalities in lipids, lipoprotein lipids, and apoB persisted in NIDDM patients compared with control subjects. Our data may favor an enhanced affinity toward atherosclerosis in these patients.

Cardiovascular and pulmonary complications of epidemic typhus.

A case of typhus fever associated with cardiac and pulmonary complications is reported. The patient was a 24-year-old Egyptian female with characteristic clinical presentation of rickettsial infection, though no rash was present throughout the course of the disease. We could not find a report of such complications in the English medical literature.

Plasma dopamine beta-hydroxylase: rapid diagnostic test for recurrent hereditary polyserositis.

The diagnosis of recurrent hereditary polyserositis (RHP; also known as familial Mediterranean fever) remains one of exclusion since there has been no specific diagnostic laboratory test. A previous study suggested that the disorder is related to abnormal catecholamine metabolism. Plasma dopamine beta-hydroxylase (DBH) activity was assayed spectrophotometrically in 91 RHP patients and 162 controls. The activity was significantly higher in untreated symptom-free patients and in patients with acute attacks, than in controls (mean [SEM] 155.8 [14.1] vs 43.3 [1.9] mumol/min/1 p less than 0.0001). Colchicine treatment reduced DBH activity to control levels. The test showed a high diagnostic accuracy and specificity for RHP, whether the patient was symptom-free or having an acute attack. Moreover, it is easy to carry out.

Arachnia propionica pneumonia in hairy cell leukaemia.

Pulmonary infection caused by Arachnia propionica in a patient with hairy cell leukaemia is described. The organism is highly sensitive to penicillin but the patient succumbed to his illness despite treatment with penicillin and various other antibiotics. Various types of opportunist infections are common in patients with hairy cell leukaemia but we believe this to be the first report of infection by Arachnia propionica in such a patient.

Scleroedema diabeticorum: a minor but often unrecognized complication of diabetes mellitus.

The association of specific dermatological complications with diabetes mellitus is well recognized. Of 100 hospital-based patients with diabetes mellitus (age 48 years +/- 2SE), 14% had scleroedema diabeticorum. The affected subjects had a higher prevalence of retinopathy (p less than 0.001) and albuminuria (p less than 0.025). The duration of scleroedema correlated with the duration of diabetes (p less than 0.005). These findings highlight the relatively common occurrence of this skin condition which often goes unrecognized in people with diabetes.

Excess body fat distribution and glucose homeostasis in obese Arab women.

The relationship of body fat distribution to glucose intolerance and non-insulin-dependent diabetes mellitus in Arab women was studied in 102 obese non-diabetic and 40 obese women with diabetes. The obese women underwent a glucose tolerance test. Linear regression analysis revealed a significant correlation between the waist/hip ratio and the plasma glucose concentration at 120 min. When divided into two groups according to the median of their waist/hip ratio (0.815), obese women without history of diabetes but with high waist/hip ratio (0.86 +/- 0.07, mean +/- SD) had significantly higher prevalence of glucose intolerance and of diabetes mellitus than those with the low ratio (0.78 +/- 0.03, chi 2 = 9.32, p less than 0.001). The highest ratio (0.89 +/- 0.06) was observed in the obese women with known diabetes mellitus.

Human brucellosis in Kuwait: a prospective study of 400 cases.

The clinical pattern of 400 cases of brucellosis in Kuwait is presented. The disease was acute in 77 per cent, sub-acute in 12.5 per cent and chronic in 10.5 per cent of cases. Raw milk was the major source of infection. The major features on presentation, irrespective of the course of the disease, were fever, sweating, headache, rigors, arthralgia, myalgia, and low back pain. Hepatosplenomegaly was present in 41 per cent of cases and in 32 per cent neither liver nor spleen were palpable. The haematologic findings were not specific and hepatic dysfunction (shown by liver enzyme abnormalities) was common. Skeletal (26 per cent) and genital (8.5 per cent) changes and neurobrucellosis (7 per cent) were the major complications. The ELISA was the most sensitive and reliable diagnostic test especially in relation to chronic brucellosis and neurobrucellosis. ELISA allowed the determination of brucella-specific immunoglobulins (Ig)G, IgM and IgA in the CSF, and provided profiles of Ig, in sera, which were different in patients with chronic (elevated IgG and IgA) from those with acute (elevated IgM alone or IgG, IgM and IgA) brucellosis. Treatment with tetracycline, doxycycline or rifampicin gave a cure rate of over 91 per cent in acute and subacute brucellosis. Co-trimoxazole was associated with a relapse rate of 50 per cent. Two drug combinations of streptomycin and tetracycline, streptomycin and rifampicin or streptomycin and doxycycline were effective, but one of five patients with chronic brucellosis relapsed. A combination of streptomycin, tetracycline and rifampicin with or without steroids was used successfully in neurobrucellosis, septicaemic shock and subacute bacterial endocarditis.

Some demographic and therapeutic features of diabetes mellitus in Kuwait.

A survey of all consecutive visits to all diabetic clinics in Kuwait over a period of 4 months yielded 1,266 male and 1,838 female Kuwaiti patients. Their age structure analysis revealed percent frequencies of 1.25, 15.5, 57.8 and 25.3 for the age groups under 19, 20-39, 40-59 and over 60 years respectively. The overall female:male ratio was 1.42. The body mass index peaked in the age groups 30-39 (mean +/- SD = 31.3 +/- 7.1 for women and 29.4 +/- 6.4 for men) and was consistently higher in women than in men for all age groups. Diabetic women over 30 years of age received insulin therapy more often than men. Home urine testing was practised by only 25% of those under 30 years of age and 12% of those 30 years and over. The study showed that the majority of Kuwaiti patients were relatively young and that the women were affected more often and probably more severely than men as suggested by the higher frequencies of insulin administration.

Familial Mediterranean fever (recurrent hereditary polyserositis) in Arabs--a study of 175 patients and review of the literature.

Recurrent hereditary polyserositis (RHP) or familial Mediterranean fever (FMF) is a chronic inherited illness of obscure aetiology. The disease is characterised by paroxysmal attacks of fever, peritonitis, pleuritis or arthritis, and predominantly affects Sephardic Jews, Arabs, Turks and Armenians. In this study, we report our 11-year experience of 175 Arab patients with this disease. As with other ethnic groups, the most common manifestation (93.7 per cent) was peritonitis. Arthritis (33.7 per cent) and pleurisy (32 per cent) were next in frequency. Adult patients in this series unlike those in other ethnic groups, rarely presented with arthritis. Similarly rare were amyloidosis, rashes, splenomegaly, hepatomegaly or lymphadenopathy. The aetiology of this disease is not clear but we suspect that abnormalities in catecholamine metabolism may be a factor in the pathogenesis.

A case of ocular toxicity to ethambutol--an idiosyncratic reaction?

Optic neuritis, a well known adverse effect of ethambutol, is related to the dose and duration of the therapy. The patient described here developed rapidly progressive deterioration of vision after only 3 days of treatment with ethambutol. Such a case has not been reported before and it is suspected that this was an idiosyncratic reaction.

Takayasu's disease in Arabs.

Four cases of Takayasu's disease in female Arabs are reported. All patients had classical features of the disease. Typing for HLA phenotype showed that all patients had HLA A2, A9, BW35 and DR7 antigens, suggesting an immunogenetic basis for the disease. As far as we know, this is the first report of Takayasu's disease in this ethnic group.