Leprosy in Britain: 50 years experience in Liverpool.

BACKGROUND: Leprosy is a chronic infection that presents with varying dermal and neurological symptoms, and which can lead to extensive disability and morbidity, often with accompanying social stigma. AIM: To review the patients presenting to the Liverpool School of Tropical Medicine (LSTM) between 1946 and 2003, looking specifically at country of birth and of infection, details of clinical presentation, diagnosis, management and reactions. DESIGN: Retrospective record review. METHODS: We retrieved all available clinical records for patients seen between 1946 and 2003 (n = 50), consisting of letters, hospital and LSTM casenotes, and some radiographs and photographs. Any history of tuberculosis or diabetes was recorded. RESULTS: Most patients (64%) were born in the Indian subcontinent, and most were thought to have contracted the disease there (62%). Features at presentation included anaesthetic skin lesions in 19 (36%), hypopigmentation in 15 (30%), and peripheral nerve enlargement in 25 (50%). Diagnoses were made by a combination of clinical data and biopsy (60%), and slit skin smears were positive for acid-fast bacilli in 61% of multibacillary patients. Initial presentation was with a leprosy reaction in five cases (10%), and reactions were documented in 42% of all patients. Treatments were varied, progressing from traditional Eastern medicine to the WHO-approved multidrug therapy in use today, with prophylaxis for children and close contacts. DISCUSSION: Leprosy remains an important diagnosis to consider in patients with a history of work or travel in the tropics, and is a diagnosis with far-reaching medical, social and emotional consequences.

Leprosy in Britain: 50 years experience in Liverpool

BACKGROUND: Leprosy is a chronic infection that presents with varying dermal and neurological symptoms, and which can lead to extensive disability and morbidity, often with accompanying social stigma. AIM: To review the patients presenting to the Liverpool School of Tropical Medicine (LSTM) between 1946 and 2003, looking specifically at country of birth and of infection, details of clinical presentation, diagnosis, management and reactions. DESIGN: Retrospective record review. METHODS: We retrieved all available clinical records for patients seen between 1946 and 2003 (n = 50), consisting of letters, hospital and LSTM casenotes, and some radiographs and photographs. Any history of tuberculosis or diabetes was recorded. RESULTS: Most patients (64%) were born in the Indian subcontinent, and most were thought to have contracted the disease there (62%). Features at presentation included anaesthetic skin lesions in 19 (36%), hypopigmentation in 15 (30%), and peripheral nerve enlargement in 25 (50%). Diagnoses were made by a combination of clinical data and biopsy (60%), and slit skin smears were positive for acid-fast bacilli in 61% of multibacillary patients. Initial presentation was with a leprosy reaction in five cases (10%), and reactions were documented in 42% of all patients. Treatments were varied, progressing from traditional Eastern medicine to the WHO-approved multidrug therapy in use today, with prophylaxis for children and close contacts. DISCUSSION: Leprosy remains an important diagnosis to consider in patients with a history of work or travel in the tropics, and is a diagnosis with far-reaching medical, social and emotional consequences.

Use of symptoms and signs for diagnosis of Trypanosoma brucei rhodesiense trypanosomiasis by rural health personnel.

The results are described of a study of 60 patients with sleeping sickness from north-east Zambia together with 60 hospital controls and 27 nearest-neighbour controls. Eight symptoms were significantly commoner among sleeping-sickness patients than among either set of controls, and some of these symptoms were used to devise a scoring system for use by rural medical personnel. Although most patients reported a short history of the illness, almost 90% had abnormal cerebrospinal fluid, and there was a significant tendency for the cerebrospinal fluid of adults with a longer history of sleeping sickness to contain trypanosomes. Enlargement of lymph nodes was significantly more frequent among the patients than among the controls, but often the submandibular, axillary, or inguinal rather than the posterior cervical nodes were enlarged. Signs associated with involvement of the central nervous system were common, but the cheiro-oral reflex was non-specific, also occurring frequently among hospital controls.

Risk factors associated with the acquisition of sleeping sickness in north-east Zambia; a case-control study.

A case-control study identified 59 cases of Rhodesian sleeping sickness in the northern Luangwa valley of Zambia together with age- and sex-matched nearest neighbour and hospital controls. Birth outside the trypanosomiasis endemic area was not shown to increase the risk of acquiring sleeping sickness. Significantly more cases under the age of 20 years had lived outside the endemic area compared with neighbour controls, although this was not true for those over 20 years old. Ethnic group and main occupation did not differ between cases and neighbour controls. Fishing as an auxiliary occupation increased the risk infection. Members of the United Church of Zambia had a relative risk of acquiring trypanosomiasis twice as great as other religious groups, perhaps because their scattered churches involve more walking through tsetse-infected bush. Sleeping sickness cases said that there were zebras near their village significantly more often than controls, although zebras are not usually considered a likely source of infection. In a preliminary study there was no difference in blood groups or haemoglobin genotype between cases and controls.

Venom antibody levels in a patient bitten by a young puff adder (Bitis arietans) during a world record attempt.

Following a bite on the hand by a young puff adder (Bitis arietans), the 21-year-old male victim was admitted to hospital suffering from symptoms of mild envenoming comprising swelling to the elbow and painful axillary nodes. The patient was not treated with antivenom. One day after the bite, B. arietans venom was detected in small amounts in the blood; none was detected subsequently. Venom antibody was detected by ELISA on the ninth day after the bite, rising to a peak after three weeks. After a further 11 days at the same level, antibody levels gradually fell but were still significantly high 81 days after the bite, when no further samples were taken. It appears unlikely in this case that a previous bite two and a half years earlier by a different species of snake contributed significantly to the development and intensity of the antibody response.

The health status of children in a rural community in north eastern Zambia.

PIP: The level of infant mortlity, which in some rural African communities approaches 300-400/1000, has often been used as an indication of the socioeconomic status of that community. This study analyzes health status and morbidity as part of a trypanosomiasis prevalence survey in a rural population of 1413 in North Eastern Zambia. The survey took female pregnancy histories, histories of diarrhea in children under 5 years of age, and weights and heights of all children. Physicians standardized measurement technics in training sessions. The infant mortality was estimated at 229/1000 and cumulative mortality by age 5 was 340/1000, using Brass model estimates. 51% of children had diarrhea within the 2-week recall period. 88% of mothers whose children had diarrhea felt it was serious enough to seek treatment, and only 6% depended on home treatments. 27% of the children showed wasting while stunting was observed in over 80% in the 3 and 4-year-old children. The adults were found to be small for their age in this environment, mean height and weight being 162.9 cm +or- 8.3 and 59.7 kg +or- 5.7 respectively, and for females, 154.5 cm +or- 5.2 and 52.8 kg +or- 6.7. High infant and child mortality rates caused in part by malnutrition exacerbated by malaria diarrheal diseases, and other infections, are cause for improved health intervention. Given the willingness to use health facilities on the part of mothers, it is likely that improvements will hinge on greater awareness and utilization of health services.^ieng

The public health importance of African trypanosomiasis in north east Zambia.

A survey for sleeping sickness (Trypanosoma brucei rhodesiense) in villages in the northern Luangwa valley found a point prevalence of parasitaemia of 5.8 per thousand; the incidence of the disease was estimated at about 1% per annum. None of the cases found had sought treatment and pre-symptomatic cases may represent an important reservoir of infection to others. Other frequent parasitemias in the population included malaria (P. falciparum, P. malariae and P. ovale) which is hyperendemic and Dipetalonema perstans.

Diabetic surveys in Papua New Guinea - results and implications.

Glucose intolerance was found in 22% of the residents of Koki in Port Moresby, 5% of residents in the coastal village of Kalo and in 3% of 120 young civil servants. The respective prevalences of frank diabetes mellitus were 15.6%, 1% and 0%. Cholesterol and triglyceride levels were similar and low in all groups, despite both obesity and glucose intolerance in the urban-Koki residents who also had a significantly higher blood pressure. There is a need to identify those areas of Papua New Guinea where, in a similar fashion to other countries in the South Pacific, diabetes mellitus is increasing. Simple measures of dietary restriction and increased exercise may be effective in preventing diabetes from becoming a major health problem particularly in identified high prevalence areas.

Plasma cholesterol, triglyceride and uric acid in urban and rural communities in Papua New Guinea.

Fasting plasma cholesterol, triglycerides and uric acid were measured in 109 Melanesian residents of Port Moresby and 71 residents of a Papuan coastal village. Cholesterol and triglyceride levels were low, mean cholesterol 3 . 74 and 3 . 70 mM/l and triglycerides 0 . 64 and 0 . 59 mM/l respectively in urban and rural residents, with no relation to age or sex. Uric acid was higher in urban men (0 . 37 mM/l) than either urban women (0 . 26 mM/l) or rural men and women (0 . 25 and 0 . 24 mM/l). The levels of plasma cholesterol found in this study are similar to previous reports on rural populations in Papua New Guinea. The apparent failure of plasma lipids to increase significantly in urbanised residents of port Moresby who had a significantly higher prevalence of both diabetes mellitus and obesity is unexplained.

The epidemiology of road accidents in Papua New Guinea.

The number of fatal road accidents in Papua New Guinea has risen by more than 400% between 1968 and 1978. Papua New Guinea now has over thirteen times as many fatal road accidents per 10,000 registered vehicles as Great Britain. The Highlands show fatal accident rates about three times higher than those for Papua New Guinea as a whole. Of 121 road accident victims coming to post-mortem in Port Moresby between 1975 and 1978, two-thirds were young adult males. Deaths were nearly equally divided between passengers and pedestrians with drivers forming only 16% of the total. Post-mortem blood alcohol levels were above 80 mg% in 42% of the victims tested and very high levels were found in a third of the drivers. A plea is made for safer passenger vehicles, the use of seat belts and the introduction of breath testing for alcohol, along with public education to reduce the toll of accidents.

Diabetes mellitus in urban and rural communities in Papua New Guinea. Studies of prevalence and plasma insulin.

Oral glucose tolerance tests (75 g) in 185 urban residents of Port Moresby and 105 ethnically similar rural villagers showed that 15.8% of urban residents had diabetes mellitus (two hour plasma glucose > 11.0 mmol/l and a total of 22% were glucose intolerant (plasma glucose > 9.0 mmol/l), compared with 1.0% and 5.5% in rural people. - Urban men and women were significantly fatter than rural people, but within each population glucose tolerance was not significantly related to weight or to age, although the numbers of old people studied were small. Compared to Australians the Papua New Guinea subjects had a higher fasting plasma insulin (16.5 vs 10.7 microU/ml, p = < 0.05); independent of weight fasting plasma insulin was significantly higher in the rural than urban people studied. After the glucose load, plasma insulin and glucose levels were positively correlated in rural people. In contrast, for the urban group the relation best fitted a quadratic function, with decline in plasma insulin at high levels of glucose. - The prevalence of diabetes in urbanised Melanesians in Papua New Guinea appears similar to other South Pacific countries.

A study of the feeding habits and nutrition of children in Anguganak area of West Sepik.

During November/December 1976 we surveyed 255 children of known age 5 years and under, and we questioned their parents about the foods given to them. We compared our results with previous survey results from this area. Despite the much earlier introduction of solid foods, there was no significant change in the mean weights of infants in this area since 1967. Sixty-four percent of the children were below 80% of the standard weight for age, and 57% of the children over one year of age had a mid upper-arm circumference of less than 14 cm. Health education needs to be supplemented by the use of high density weaning foods and the control of infection to overcome the very high prevalence of malnutrition.