University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 7 Number 2: April - June 2000

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[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Dr. Andrew Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Ms. Nora Mweemba, Consultant-Information: World Health Organisation-Zambia
Mr. Sikwanda Makono, Specialist, Health Education, Ministry of Health
Ms. Christine Kanyengo, Medical Librarian (Acting): University of Zambia Medical Library

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The Zambia Health Digest is produced to provide current information to health workers who have little access to current health related publications and information.

The abstracts of journal articles published in this quarterly Digest are obtained from the Medline database provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.

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Using the MEDLINE compact disc databases, custom searches can be done on any health issue to obtain the most up-to-date information available. Readers are encouraged to submit requests for searches on relevant health problems which they face. Requests should be sent to the Medical Library, attention Christine Kanyengo

TABLE OF CONTENTS:

EDITORIAL

 Xerophthalmia is a disorder that results in dry eyes, hazy corneas, reduced tear production, and roughness of the conjunctiva. The primary cause of xerophthalmia is vitamin A deficiency resulting from dietary deprivation or an interference with absorption, storage, or transport of vitamin A. Treatment involves correcting the cause and administering vitamin A in therapeutic doses. Abstracts included in this issue cover a wide range of topics regarding xerophthalmia; its diagnosis management and treatment.

In this issue we have included articles on Progestron only contraceptives and vaginal bleeding; HIV testing and counselling as well as HIV infection and it relationship with tuberculosis.

May we take this opportunity once again to appeal to our readers to send in requests for information on any topic of their choice by filling in the request form at the back of this Digest. We promise to respond to each and every request in the shortest possible.

Thank you.

Xerophthalmia (Current Abstracts of Journal Articles -- MEDLINE)

Hyporetinolemia and acute phase proteins in children with and without xerophthalmia.
Semba RD, Muhilal, West KP Jr, Natadisastra G, Eisinger W, Lan Y, Sommer A
Am J Clin Nutr 2000 Jul;72(1):146-153

Validation of self-reported complications by bone marrow transplantation survivors.
Louie AD, Robison LL, Bogue M, Hyde S, Forman SJ, Bhatia S
Bone Marrow Transplant 2000 Jun;25(11):1191-6

Self-administered Questionnaires are commonly used to measure exposures and outcomes in epidemiological research and thus need good validity. With increasing numbers of cancer survivors, there is interest in the ongoing assessment of therapy-related complications. A medical record validation of patient-reported complications following bone marrow transplantation (BMT) was performed using a self-administered questionnaire. The study population consisted of 100 patients who had undergone BMT at the City of Hope. The following self-reported complications were validated using medical records: ocular, endocrine, cardiovascular, musculoskeletal, pulmonary, gastrointestinal, neurological, graft-versus-host disease, and subsequent cancers. Using information from medical records as the standard, sensitivities ranged from 52.9% for subsequent cancers to 100% for avascular necrosis and hypothyroidism. Specificities ranged from 75.4% for ocular complications to 100% for avascular necrosis. There was intermediate to excellent agreement (kappa = 0. 4-1.0) for all complications evaluated. Thus, the agreement between self-reporting and medical records was good for complications with clear diagnostic criteria that are easily communicated to the patient, but was diminished for complications with non-established diagnostic criteria (xerophthalmia) or a fluctuating course (peripheral neuropathies and hypertension). Overall these results suggest that cancer survivors can self-report serious complications with an acceptable level of accuracy in epidemiological research. Publication Types: Multicenter study

Fexofenadine HCl is safe and effective for treatment of chronic idiopathic urticaria. Nelson HS, Reynolds R, Mason J.
Allergy Asthma Immunol 2000 May;84(5):517-22

Publication Types: Clinical trial Multicenter study Randomized controlled trial

Annular erythema of Sjogren's syndrome in a white woman.
Haimowitz JE, McCauliffe DP, Seykora J, Werth VP
:J Am Acad Dermatol 2000 Jun;42(6):1069-72

Annular erythema of Sjogren's syndrome (AE-SS) is believed to be the Asian counterpart of subacute cutaneous lupus erythematosus (SCLE) in white persons. We report the second case of a white person with AE-SS, diagnosed by clinical and serologic findings, as well as the absence of histologic criteria for SCLE. The diagnosis of AE-SS was established by symptoms of xerophthalmia and xerostomia, as well as by examination of skin and salivary gland biopsy specimens. Evaluation showed the presence of anti-Ro(SS-A) and anti-La(SS-B) autoantibody, with the presence of anti-Ro(SS-A) antibody against the 60-kd, but not the 52-kd, epitope, a pattern frequently seen in both the Asians with AE-SS and in white patients with SCLE. Both skin and sicca symptoms were alleviated with combination antimalarial therapy, which included hydroxychloroquine and quinacrine. This case demonstrates that AE-SS can occur in white patients and that the autoantibody profile is similar to that described in Asians with this disease.

National Vitamin A Prophylaxis Programme: need for change in current age strategy.
Khandait DW, Vasudeo ND, Zodpey SP, Kumbhalkar DT, Koram MR
Indian J Pediatr 1999 Nov-Dec;66(6):825-9

Child survival and Safe Motherhood Programme emphasises on giving vitamin A prophylaxis upto three years of age only, contrary to earlier practice of its administration upto six years of age, based on the assumption of reduction of serious manifestations of vitamin A deficiency three years of age onwards. A cross-sectional study enrolling 1094 children was done to investigate vitamin A deficiency in under six children in urban slums of Nagpur city in Central India in post CSSM scenario. Clinical as well as subclinical (detected by abnormal conjunctival impression cytology) assessment of vitamin A status was performed according to standard procedures, as per WHO recommendations. The overall prevalence of xerophthalmia was 8.7%. Only milder manifestations of xerophthalmia were observed. Significantly higher prevalence of xerophthalmia was observed in more than three years of age. Although nonsignificant, higher prevalence of subclinical vitamin A deficiency was observed in above three years of age group. In view of current age strategy for vitamin A supplementation (< or = 3 years) and observed higher prevalence of clinical and subclinical vitamin A deficiency above three years of age in this study (also endorsed by earlier studies) a call for review of current age strategy for vitamin A supplementation is warranted.

Dental and periodontal status of Sjogren's syndrome.
Boutsi EA, Paikos S, Dafni UG, Moutsopoulos HM, Skopouli FN
J Clin Periodontol 2000 Apr;27(4):231-5

Nutrition education and mega-dose vitamin A supplementation in Nepal.
Pokharel GP, Pant CR, Tilden RL, Pokhrel RP, Atmarita, Curtale F
Indian J Pediatr 1998 Jul-Aug;65(4):547-55

Two approaches to improve vitamin A nutriture are compared: nutrition education and mega-dose capsule distribution. The impact of these programmes on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality are compared for approximately 40,000 children who were assigned to either intervention cohorts or a control group from 75 sites within seven districts in two ecological settings (Terai, or lowland, and hills) of Nepal. Twenty-four months after the implementation of the project, the reduction of risk of xerophthalmia was greater among children of mothers who were able to identify vitamin A-rich foods [relative risk (RR) = 0.25; 95% CI = 0.10-0.62] than among children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at two years was reduced for both the nutrition education cohort (RR = 0.64; 95% CI = 0.48-0.86) and capsule distribution cohort (RR = 0.57; 95% CI = 0.42-0.77). The nutrition education program, however, was more expensive to deliver than the capsule distribution programme. High rates of participation in the supplementation programme were achieved within a short period. The nutrition education message spread rapidly throughout the study population, although practice was slower to change. Where maternal literacy was low and channels of communication were limited, the capsule programme appeared to be more cost-effective. However, economies of scale for nationwide programmes exist for nutrition education programmes that do not exist for capsule distribution programmes. A comprehensive national programme requires both dietary supplementation and nutrition education. Publication Types: Clinical trial

Malnutrition and xerophthalmia in rural communities of Ethiopia.
Haidar J, Demissie T
East Afr Med J 1999 Oct;76(10):590-3

Extrahepatic manifestations associated with hepatitis C virus infection. A prospective multicenter study of 321 patients. The GERMIVIC. Groupe d'Etude etde Recherche en Medecine Interne et Maladies Infectieuses sur le Virus de l'Hepatite C.
Cacoub P, Renou C, Rosenthal E, Cohen P, Loury I, Loustaud-Ratti V, Yamamoto AM, Camproux AC, Hausfater P, Musset L, Veyssier P, Raguin G, Piette JC
Medicine (Baltimore) 2000 Jan;79(1):47-56

From January 1996 to January 1997, 321 patients with an average age of 46 +/- 16 years and chronically infected with hepatitis C virus (HCV) were prospectively enrolled in a study designed to determine the prevalence of extrahepatic manifestations associated with HCV infection in a large cohort of HCV patients, to identify associations between clinical and biologic manifestations, and tocompare the results obtained in human immunodeficiency virus (HIV)-positive versus HIV-negative subsets. In a cross-sectional study, clinical extrahepatic manifestations, viral coinfections with HIV and/or hepatitis B virus, connective tissue diseases, and a wide panel of auto antibodies were assessed. Thirty-eight percent (122/321) of patients presented at least 1 clinical extra hepatic manifestation including arthralgia (60/321, 19%), skin manifestations (55/321, 17%), xerostomia (40/321, 12%), xerophthalmia (32/321, 10%), and sensory neuropathy (28/321, 9%). Main biologic abnormalities were mixed cryoglobulins (110/196, 56%), thrombocytopenia (50/291, 17%), and the presence of the following autoantibodies: antinuclear (123/302, 41%), rheumatoid factor (107/280, 38%), anticardiolipin (79/298, 27%), antithyroglobulin (36/287, 13%) and antismooth muscle cell (27/288, 9%). At least 1 autoantibody was present in 210/302 (70%) of sera. By multivariate logistic regression analysis, 4 parameters were significantly associated with cryoglobulin positivity: systemic vasculitis (p = 0.01, odds ratio OR[ = 17.3), HIV positivity (p = 0.0006, OR = 10.2), rheumatoid factor positivity (p = 0.01, OR = 2.8), and sicca syndrome (p = 0.03, OR = 0.27).

A definite connective tissue disease was noted in 44 patients (14%), mainly symptomatic mixed cryoglobulinemia and systemic vasculitis, HIV coinfection (23%) was associated with 3 parameters: anticardiolipin (p = 0.003, OR = 4.18), thrombocytopenia (p = 0.01, OR = 3.56), and arthralgia or myalgia (p = 0.017, OR = 0.23). HIV-positive patients presented more severe histologic lesions (p = 0.0004). Extrahepatic clinical manifestations in HCV patients involve primarily the skin and joints. The most frequent immunologic abnormalities include mixed cryoglobulins, rheumatoid factor, antinuclear, anticardiolipin, and antithyroglobulin antibodies. Cryoglobulin positivity is associated with systemic vasculitis and rheumatoid factor and HIV positivity. HIV coinfection is associated with arthralgia or myalgia, anticardiolipin antibodies, and thrombocytopenia.

Vitamin A deficiency disorders.
McLaren DS
J Indian Med Assoc 1999 Aug;97(8):320-3

The major cause of blindness in children worldwide is xerophthalmia caused by vitamin A deficiency. In addition it has other adverse effects, including increased mortality and the term vitamin A deficiency disorders (VADD) has been introduced to cover the whole clinical spectrum of disease. The ocular manifestations of xerophthalmia have been classified and a set of prevalence criteria for the detection of a problem of public health magnitude has been in use for more than two decades. The global prevalence of VADD is now well documented and World Health Organisation (WHO) receives information continuously for updating its data base on the subject. The pathogenesis of the disease is still imperfectly understood, it is not at all clear precisely why certain subjects in vulnerable communities develop xerophthalmia, while the majority are spared. A schedule for treatment of the established case has been available for a long time, but at both clinic and hospital level concentrated sources of vitamin A for treatment are frequently not available. More emphasis needs to be laid on prevention and a choice of methods consisting of large dose supplementation, fortification of food, control of precipitating infections and dietary improvement. The advantages and drawbacks of each are discussed.

Parasympathetic failure does not contribute to ocular dryness in primary Sjogren's syndrome.
Barendregt PJ, van Den Meiracker AH, Markusse HM, Tulen JH, Boomsma F, van Der Heijde GL, Veld AJ
Ann Rheum Dis 1999 Dec;58(12):746-50

Primary Sjogren's syndrome: salivary gland function and clinical oral findings.
Pedersen AM, Reibel J, Nordgarden H, Bergem HO, Jensen JL, Nauntofte B
Oral Dis 1999 Apr;5(2):128-38

Sjogren's syndrome.
Chan SY, Louie MC, Piccotti JR, Manoussakis MN, Moutsopoulos HM
Otolaryngol Clin North Am 1999 Oct;32(5):843-60

Sjogren's syndrome is a rather common autoimmune disease primarily characterized by the dysfunction and destruction of exocrine glands associated with lymphocytic infiltrations. The disorder has a quite broad clinical presentation, ranging from glandular disease to systemic involvement and to the development of lymphoid malignancy. This article reviews the current aspects in clinical diagnosis and management and the immunopathogenesis of the disorder.

Evaluation of tear secretion and tear film stability in pseudoexfoliation syndrome.
Kozobolis VP, Detorakis ET, Tsopakis GM, Pallikaris IG
Acta Ophthalmol Scand 1999 Aug;77(4):406-9

[Which are the vaccines that human immunodeficiency virus infected patients must receive] [Article in Spanish]
Valencia Ortega ME, Gonzalez Lahoz J
An Med Interna 1998 Aug;15(8):439-42

Primary Sjogren's syndrome (pSS): subjective symptoms and salivary findings. J Oral Pathol Med 1999 Aug;28(7):303-11 Pedersen AM, Reibel J, Nauntofte B Department of Oral Function and Physiology, School of Dentistry, University of Copenhagen, Denmark. We studied the relationship between dry mouth, general health and objective findings in 16 patients having primary Sjogren's syndrome (pSS) according to the 1993 European classification criteria as well as in healthy controls. Serum autoantibody to SSA/SSB (AB) was correlated to unstimulated whole saliva flow (UWS) and labial salivary gland focus score (FS). All patients had dry mouth symptoms and UWS < or = 0.10 ml/min, but patients with UWS < 0.05 ml/min and AB had more complaints of oral and ocular dryness. These patients also tended to have more exocrine and non-exocrine manifestations, and oral dryness had a greater impact on their self-reported general health than in patients with UWS > or = 0.05 ml/min. Accordingly, we consider rating of oral dryness by visual analogue scales or categorised questionnaires to be valuable for the evaluation of oral involvement in pSS.

Viral induction, transmission and apoptosis among cells infected by a Human Intracisternal A-type retrovirus.
Deas JE, Thompson JJ, Fermin CD, Liu LL, Martin D, Garry RF, Gallaher WR. J
Virus Res 1999 May;61(1):19-27

Sjogren's Syndrome, a systemic autoimmune disease, is characterized by lymphocytic infiltration of the salivary or lacrimal glands, producing xerostomia or xerophthalmia. Although definitive proof of viral etiology has not been established, a cell line containing viral particles termed Human Intracisternal A-type Particles (HIAP) resulted from co-culture with patient lip biopsies. We stimulated these chronically infected cells with phorbol myristate acetate (PMA) in an effort to enhance production of viral particles for further characterization. We report that the virus present in the HIAP cell line can be induced to become lytic when subjected to PMA and that there is a difference in the effects of PMA on H9 and HIAP cell groups, with apparent protection from apoptosis due to PMA being exerted by viral presence. Delayed apoptosis may prolong exposure of the foreign/self complex, thus enhancing an autoimmune response. Polyacrylamide gel electrophoresis (PAGE) revealed the presence of new peptides in pellets of supernatants of PMA-stimulated HIAP cells, with prominent bands at 55 and 43 kDa, and several fainter ones. HIAP infection was transferred by cell-free filtered supernatants from stimulated cells to H9 cells, which became identical to parent HIAP cells by PAGE and fluorescence activated cell sorter.

Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome.
Barton A, Pal B, Whorwell PJ, Marshall D
Am J Gastroenterol 1999 Jul;94(7):1898-901

Lung adenocarcinoma in lymphocytic interstitial pneumonitis associated with primary Sjogren's syndrome.
Takabatake N, Sayama T, Shida K, Matsuda M, Nakamura H, Tomoike H
Respirology 1999 Jun;4(2):181-4

We experienced a rare case of lung adenocarcinoma associated with lymphocytic interstitial pneumonitis caused by primary Sjogren's syndrome. A 78-year-old woman was referred to our hospital because of progressive sicca syndrome and nodular opacities in the right lower lobe on chest radiograph. This patient was diagnosed as primary Sjogren's syndrome by a labial gland biopsy and classical clinical features including xerophthalmia, xerostomia and immunoserological findings. Pathological findings including immunohistochemical studies in a surgically resected lung revealed adenocarcinoma in lymphocytic interstitial pneumonitis associated with primary Sjogren's syndrome. There was no evidence of malignant lymphoma in the lymph nodes or resected lung tissue. Pulmonary involvement of Sjogren's syndrome is now regarded both clinically and histopathologically as a wide spectrum of lymphoproliferative disorders ranging from benign to malignant. However, lung cancer associated with primary Sjogren's syndrome, as in our case, has apparently not been reported previously.

Vitamin A intake and xerophthalmia among Indian children.
Khandait DW, Vasudeo ND, Zodpey SP, Ambadekar NN, Koram MR
Public Health 1999 Mar;113(2):69-72

Randomized double-blind placebo-controlled trial of homoeopathic 'proving' for elladonna C30.
Goodyear K, Lewith G, Low JL
J R Soc Med 1998 Nov;91(11):579-82

Homoeopathic drug pictures are developed by recording the symptomatic effects of homoeopathic remedies given to healthy volunteers (a 'proving'). In a double-blind randomized controlled trial we tested the hypothesis that individuals using an infinitesimal dilution of Belladonna (thirtieth potency, C30) would record more true symptoms, on a questionnaire that contained both true and false Belladonna proving symptoms, than those receiving placebo. 60 volunteers entered the study and 47 completed data collection. We were unable to distinguish between Belladonna C30 and placebo using our primary outcome measure. For the secondary outcome measure we analysed the number of individuals who proved to the remedy according to our predefined criteria: 4 out of 19 proved in the Belladonna C30 group and 1 out of 27 in the placebo group (difference not statistically significant). This pilot study does not demonstrate a clear proving reaction for Belladonna C30 versus placebo, but indicates how the question might be further investigated.

Low-dose radiotherapy for lymphoid lesions of the orbit and ocular adnexa.
Kennerdell JS, Flores NE, Hartsock RJ
Ophthal Plast Reconstr Surg 1999 Mar;15(2):129-33

Validity of the saliva ferning test for the diagnosis of dry mouth in Sjogren's syndrome.
el-Miedany YM, el-Hady SM, el-Baddin MA
Rev Rhum Engl Ed 1999 Feb;66(2):73-8

Childhood blindness.
Steinkuller PG, Du L, Gilbert C, Foster A, Collins ML, Coats DK
J AAPOS 1999 Feb;3(1):26-32

Comparison of the efficacy and safety of two eye gels in the treatment of dry eyes: Lacrinorm and Viscotears.
Bron AJ, Daubas P, Siou-Mermet R, Trinquand C
Eye 1998;12 ( Pt 5):839-47

Perspectives from micronutrient malnutrition elimination/eradication programmes
Underwood BA
Bull World Health Organ 1998;76 Suppl 2:34-7

Micronutrient malnutrition cannot be eradicated, but the elimination and control of iron, vitamin A and iodine deficiencies and their health-related consequences as public health problems are currently the targets of global programmes. Remarkable progress is occurring in the control of goitre and xerophthalmia, but iron-deficiency anaemia (IDA) has been less responsive to prevention and control efforts. Subclinical consequences of micronutrient deficiencies, i.e. "hidden hunger", include compromised immune functions that increase the risk of morbidity and mortality, impaired cognitive development and growth, and reduced reproductive and work capacity and performance. The implications are obvious for human health and national and global economic and social development. Mixes of affordable interventions are available which, when appropriately adapted to resource availability and context, are proven to be effective. These include both food-based interventions, particularly fortification programmes, such as salt iodization, and use of concentrated micronutrient supplements. A mix of accompanying programmes for infection control, community participation, including education, communication and information exchange, and private sector involvement are lessons learned for overcoming deterrents and sustaining progress towards elimination.

Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group.
Vivino FB, Al-Hashimi I, Khan Z, LeVeque FG, Salisbury PL 3rd, Tran-Johnson TK, Muscoplat CC, Trivedi M, Goldlust B, Gallagher SC
Arch Intern Med 1999 Jan 25;159(2):174-81

Phenotype in retinol deficiency due to a hereditary defect in retinol binding protein synthesis.
Seeliger MW, Biesalski HK, Wissinger B, Gollnick H, Gielen S, Frank J, Beck S, Zrenner E.
Invest Ophthalmol Vis Sci 1999 Jan;40(1):3-11

Subclinical vitamin A deficiency in undersix children in Nagpur, India Southeast Asian
Khandait DW, Vasudeo ND, Zodpey SP, Kumbhalkar DT, Koram MR
J Trop Med Public Health 1998 Jun;29(2):289-92

The present cross sectional study was carried out to estimate prevalence of subclinical vitamin A deficiency among undersix children by using conjunctival impression cytology in urban slums of Nagpur city in central India. The study population included 308 non-xerophthalmic undersix children selected randomly. Conjunctival impression cytology was performed by standard procedure. Out of 308 children 110 (35.7%) had subclinical vitamin A deficiency. Increasing prevalence of subclinical vitamin A deficiency was non-significantly associated with advancing age. Higher prevalence of subclinical vitamin A deficiency was observed in severely malnourished children. The prevalence of subclinical vitamin A deficiency observed in this study (35.7%) is much more than the criteria laid down by WHO, which warrants community wide intervention. This problem assumes more significance because they are apparently healthy and if timely vitamin A supplementation is not given, any intercurrent infection is likely to worsen the vitamin A status and result in known consequences of xerophthalmia.

(+/-)-cis-2-methylspiro[1,3-oxathiolane-5,3'-quinuclidine] hydrochloride, hemihydrate (SNI-2011, cevimeline hydrochloride) induces saliva and tear secretions in rats and mice: the role of muscarinic acetylcholine receptors.
Iga Y, Arisawa H, Ogane N, Saito Y, Tomizuka T, Nakagawa-Yagi Y, Masunaga H, Yasuda H, Miyata N
Jpn J Pharmacol 1998 Nov;78(3):373-80

We investigated effects of (+/-)-cis-2-methylspiro[1,3-oxathiolane-5,3'-quinuclidine] hydrochloride, hemihydrate (SNI-2011, cevimeline hydrochloride), a rigid analogue of acetylcholine, on saliva and tear secretions in rats and mice to evaluate its therapeutical efficacy for xerostomia and xerophthalmia in patients with Sjogren's syndrome and X-ray exposure in the head and neck. Intraduodenal administrations of SNI-2011 increased saliva secretion in a dose-dependent manner at doses ranging from 3 to 30 mg/kg in normal rats and mice, two strains of autoimmune disease mice and X-irradiated saliva secretion defective rats. The salivation elicited by SNI-2011 was completely inhibited by atropine. A similar atropine-sensitive response was observed in tear secretion. In rat submandibular/sublingual gland membranes, [3H]quinuclidinyl benzilate (QNB) binding was saturable, and Scatchard plot analysis revealed a single population of binding sites with a Kd of 22 pM and a maximal binding capacity of 60 fmol/mg protein. The competitive inhibition curve of the [3H]QNB binding by SNI-2011 was obtained, and its dissociation constant value calculated from IC50 was 1-2 microM. These results suggest that SNI-2011 increases saliva and tear secretions through a direct stimulation to muscarinic receptors in salivary and lacrimal glands, and they suggest that SNI-2011 should be beneficial to patients with Sjogren's syndrome and X-ray exposure in the head and neck.

N-linked glycoside and glucuronide conjugates of the retinoid, acitretin, are biologically active in cornea and conjunctiva.
Ubels JL, Woo EM, Curley RW Jr
J Ocul Pharmacol Ther 1998 Dec;14(6):505-16

The purpose of this study was to test two water-soluble, synthetic retinoids, glucoseamido acitretin and glucuronamido acitretin, for biological activity in cells of the cornea and conjunctiva. Vitamin A-deficient, xerophthalmic rats were treated topically with these retinoids, and corneas were examined histologically for effects on epithelial keratinization. The effect of these retinoids on the proliferation of rabbit conjunctival fibroblasts in culture was also investigated. Glucoseamido acitretin treatment restored a normal cornea after eight to nine days of treatment, while no improvement was observed in the vehicle-treated corneas. Likewise, glucuronamido acitretin application restored a normal corneal surface and reversed keratinization after eight to ten days of treatment. These retinoids caused no irritation of the eye or ocular adnexa. In culture, exposure of conjunctival fibroblasts to glucoseamide acitretin inhibited cell proliferation. Cultures exposed to glucoseamido acitretin at 10(-8) M or 10(-6) M had cell densities 77.3% and 51.9% of control, respectively, after seven days. Glucuronamido acitretin also inhibited cell proliferation. Cultures exposed to glucuronamido acitretin at 10(-8) M had a cell density of 69.2% of control at day seven, while at 10(-6) M this retinoid completely inhibited cell proliferation. These results show that glucoseamide acitretin and glucuronamido acitretin are biologically active in the cornea and conjunctiva, and may be considered for ophthalmic use in diseases involving abnormalities of ocular surface cell differentiation or hyperproliferation of fibroblasts.

Complications following blepharoplasty
Black J
Plast Surg Nurs 1998 Summer;18(2):78-83

Surgical correction of eyelid deformities yields a very high level of aesthetic improvement, and fortunately, complications following blepharoplasty are rare. But diligent care is required by nurses to assure that these complications remain uncommon. This article will describe the major and minor complications of traditional blepharoplasty and discuss the nurse's role in risk management to reduce the incidence of these complications.

Child feeding and care behaviors are associated with xerophthalmia in rural Nepalese households.
Gittelsohn J, Shankar AV, West KP Jr, Faruque F, Gnywali T, Pradhan EK
Soc Sci Med 1998 Aug;47(4):477-86

The study examined caregiver-child interactions, intrahousehold food allocation and general child care behaviors and their effect on children's xerophthalmia status in the rural Terai region of Nepal. Seventy-eight households with a child having a history of xerophthalmia (cases) were matched with 78 households with a child of the same age having no history of xerophthalmia (controls). Seven day-long continuous monitoring observations were performed in each household (over 15 months) by trained Nepali observers, focusing on feeding and care of a focus child and his/her younger sibling. Nineteen different behavioral variables were operationalized, including serving method, second helpings, serving refusals, encouragement to eat, request intensity, meal serving order, food channeling, food sharing, positive social behaviors, negative social behaviors, and positive health behaviors. Automatic serving and request intensity were strongly negatively correlated, especially among younger siblings. Children who serve themselves receive less encouragement to eat. Those children who are refused in their requests for food tend to ask for food more frequently, for a longer time, and be less likely to self-serve. Children who eat from a shared plate are less likely to interact with a food server and more likely to self-serve. Negative social behavior towards children is associated with the child having to request food more frequently and a greater likelihood of being refused food. Children who receive positive health care from their caregivers are also more frequently asked if they would like food by the server and are encouraged to eat. Several caregiver child feeding behaviors were related to a child's risk of having past vitamin A deficiency. Controls were much more likely to be served food automatically. Cases were more likely to serve themselves food and have multiple servings of food. Cases were nearly two times more likely than controls to be treated with neglect or harshly, and much less likely than controls to have their health needs receive attention. Examining intrahousehold behavior is critical for understanding the causes of vitamin A deficiency in rural Nepalese children, and has great potential for identifying and improving interventions to improve children's diets and care.

Ocular and orbital complications following the treatment of retinoblastoma
Anteby I, Ramu N, Gradstein L, Miskin H, Pe'er J, Benezra D
Eur J Ophthalmol 1998 Apr-Jun;8(2):106-11

Rheumatic manifestations and immunological abnormalities in patients with chronic hepatitis C. A study in the Middle East.
al-Awadhi A, al-Jarallah K, Hasan F, Olusi S, al-Attiyah R, Sugathan TN, al-Salem I, Attiyah Y, Sedequi H, Ahmed AH
Rev Rhum Engl Ed 1998 Jun;65(6):372-7

Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems. We compared the prevalence of extrahepatic clinical manifestations and immunological disorders in 40 patients with chronic hepatitis C and in 42 carefully matched healthy controls. Polyarthralgia or polyarthritis was the most common rheumatic manifestation (35%) in the cases, followed by cutaneous vasculitis (15%). Glomerulonephritis and xerophthalmia were uncommon, and none of the cases had systemic vasculitis. Immunological abnormalities included serum rheumatoid factor (47.5%), cryoglobulins (30%), and one or more antitissue antibodies (37.5%). The prevalences of polyarthralgia, cutaneous vasculitis, rheumatoid factor, cryoglobulinemia, and anti-tissue antibodies were significantly higher in the hepatitis C group than in the control group. Our data suggest that patients in the Middle East who present with features of rheumatic or autoimmune diseases should be screened for hepatitis C.

Eating from a shared plate affects food consumption in vitamin A-deficient Nepali children.
J Nutr 1998 Jul;128(7):1127-33
Shankar AV, Gittelsohn J, West KP Jr, Stallings R, Gnywali T, Faruque F

This case-control study evaluates the relationship between shared-plate eating behavior in young Nepali children (aged 1-6 y) and risk of vitamin A deficiency. Day-long observations of dietary practices were conducted on 7 d over a 15-mo period in 162 households: 81 households with a child with a known history of mild xerophthalmia (cases) were matched with 81 having a non-xerophthalmic child of similar age (controls). Shared-plate eating occurred in 25% of all feeding episodes and at least once in 65% of all days observed. Overall, children engaging in shared-plate eating were significantly more likely to consume grains, vegetables, carotenoid-rich vegetables, pulses, fruits, meats and fish, and dairy products and had significantly larger portion sizes for grains, vegetables, fruits, pulses and dairy products, compared with children who ate alone. In general, feeding behaviors between case and control children tended to be similar. However, shared-plate feeding episodes among case children were significantly less likely to include meats or fish [odds ratio (OR) = 0.5, confidence interval (CI) = 0.3-0.8], dairy products (OR = 0.6, CI = 0.4-0.9) or pulses (OR = 0.7, CI = 0.5-1.0).

Individual-plate feeding episodes among case children were more likely to include vegetables (OR = 1.3, CI = 1.0-1.6) than those of control children. Case children were more likely to share a plate with a male adult (OR = 1.7, CI = 1.0-2.8), but less likely to eat from a plate shared with females of any age compared with controls (female adult: OR = 0.6, CI = 0.4-0.9; female child: OR = 0.6, CI = 0.4-1.0). Shared-plate eating may benefit a young child's dietary intake, but the identity of the food sharer may modify this influence.

Characteristics of rheumatoid arthritis patients with self-reported sicca symptoms: evaluation of medical, salivary and oral parameters.
Jensen JL, Uhlig T, Kvien TK, Axell T
Oral Dis 1997 Dec;3(4):254-61

Association of xerophthalmia, flecked retina, and pseudotumor cerebri caused by hypovitaminosis A.
Panozzo G, Babighian S, Bonora A
Am J Ophthalmol 1998 May;125(5):708-10

Prevalence of the diffuse infiltrative lymphocytosis syndrome among human immunodeficiency virus type 1-positive outpatients.
Williams FM, Cohen PR, Jumshyd J, Reveille JD
Arthritis Rheum 1998 May;41(5):863-8

Cystic fibrosis and lens opacity.
Fama F, Castagna I, Palamara F, Roszkowska AM, Ferreri G
Ophthalmologica 1998;212(3):178-9

Cystic fibrosis (CF) is a fairly common lethal genetic disease in whites, inherited via an autosomal recessive pattern. Several clinically evident anomalies of the eye such as xerophthalmia, papilledema, retinal alterations and optic neuropathy have been described. In the present study we investigated lens changes in 40 patients affected by CF, to relate the results to the stage of digestive insufficiency. Each patient underwent an accurate ocular examination including visual acuity, slit-lamp examination, and measurement of lens transparency with the Opacity Lens Meter 701. The results were compared with those of an age- and sex-matched control group. The comparison between the lens opacity values obtained in the CF patients and those measured in the control group showed a statistically significant difference; moreover, lens transparency was more decreased in patients with severe digestive insufficiency.

Undifferentiated connective tissue diseases: the clinical and serological profiles of 91 patients followed for at least 1 year.
Mosca M, Tavoni A, Neri R, Bencivelli W, Bombardieri S
Lupus 1998;7(2):95-100

The objective of this work was to evaluate the clinical and serological profiles of patients with undifferentiated connective tissue diseases (UCTD) who had been followed for at least 1 year. The retrospective analysis (197495) was based on UCTD patients diagnosed on the basis of clinical manifestations suggestive of a connective tissue disease, and the presence of at least one non-organ-specific autoantibody. A total of 91 patients were evaluated. The condition of 79 remained stable during the follow up, while in 12 the UCTD evolved to systemic lupus erythematosus (SLE) within a mean period of 3 years (min. 1 year, max. 8 years, median 2 years) after the onset of the disease. At baseline none of the variables, considered alone, showed an association with the future development of SLE. Multiple regression analysis, however, suggested that the association of sicca symptoms, Raynaud's phenomenon and/or photosensitivity was inversely correlated with the development of SLE (P = 0.0012, Fisher's exact test). The most common clinical manifestations of UCTD included arthritis, arthralgias, Raynaud's phenomenon, xerostomia, xerophthalmia and leukopenia. The stable UCTD patients showed a simple autoantibody profile characterized by a single autoantibody specificity in 82% of the cases 30% with anti-Ro/SSA alone and 28% with anti-RNP alone. This profile remained stable during the follow up. Anti-RNP antibodies alone correlated with the presence of Raynaud's phenomenon and arthritis (P < 0.001 and P < 0.01, respectively), while anti-Ro/SSA antibodies alone correlated with xerostomia and xerophthalmia (P < 0.01). In conclusion, the UCTDs in most of our patients seem to represent distinct clinical entities with a limited autoimmune repertoire rather than the early phases of definite connective tissue diseases. They could therefore provide an ideal model for the study of the clinico-serological correlations in autoimmune diseases.

Xerophthalmia and vitamin A status.
Sommer A
Prog Retin Eye Res 1998 Jan;17(1):9-31

The existence of 'fat-soluble A' has been known for over 80 years. But until recently clinicians were almost wholly absorbed by the ocular changes accompanying deficiency (xerophthalmia), and scientists with the vitamin's metabolic role in the rhodopsin cycle. The past two decades have witnessed a revolution in clinical and scientific concerns. Xerophthalmia is now recognized as a late manifestation of severe deficiency rather than of early, mild deficiency; as the mechanism responsible for half or more of all measles-associated blindness; and as the cause of half a million or more cases of pediatric blindness worldwide. Milder deficiency increases the severity of infectious morbidity, exacerbates iron deficiency anemia, retards growth, and is responsible for one to three million childhood deaths each year. Scientists are now busy unraveling vitamin A-dependent gene regulation to explain the myriad manifestations accompanying deficiency, while clinicians are designing and supervising programs to improve vitamin A status in over 60 countries, up from only three countries two decades ago. Control of vitamin A deficiency is now a major health challenge and goal of both UNICEF and the World Health Organization (WHO). Reaching that goal requires better parameters for assessing vitamin A status, increased understanding of metabolic pathways responsible for corneal dissolution (keratomalacia) and the molecular and cellular basis by which vitamin A status mediates resistance to infection. These issues are detailed elsewhere (Sommer and West, 1996).

Weak association between subjective symptoms or and objective testing for dryeyes and dry mouth: results from a population based study.
Hay EM, Thomas E, Pal B, Hajeer A, Chambers H, Silman AJ
Ann Rheum Dis 1998 Jan;57(1):20-4

Bilateral corneal ulcers in primary vitamin A deficiency.
Macsai MS, Agarwal S, Gamponia E
ea 1998 Mar;17(2):227-9

An erythema multiforme-like eruption caused by exposure to 1-chloromethylnaphthalene.
Urano S, Tokura Y
J Dermatol 1998 Jan;25(1):13-8

A young male patient developed an erythema multiforme-like eruption following an accidental exposure to 1-chloromethylnaphthalene (1-CMN). In addition to the skin lesion, he suffered from liver involvement and tear insufficiency. Positive results of a patch test with 1-CMN and an in vitro lymphocyte transformation test suggested that direct exposure of the skin to chemical compounds was the probable cause of his symptoms.

Conjunctival impression cytology in xerophthalmia among rural children.
Singh M, Singh G, Dwevedi S, Singh K, Kumar D, Tiwari A, Aggarwal M
Indian J Ophthalmol 1997 Mar;45(1):25-9

The advent of Conjunctival Impression Cytology (CIC) has opened a new chapter in the detection of Vitamin A deficiency as it is a simplified field technique. The need for such a technique was of paramount importance in India where as estimated 5 to 7 percent children suffer from eye signs of Vitamin A deficiency. In the present study the results of clinical evaluation of apparently healthy children and those having clinical sings and symptoms of Vitamin A deficiency have been compared with CIC results. Serum Vitamin A levels have also been estimated wherever possible.

The findings indicate that CIC results are superior to the clinical assessment and it is suggested that CIC can be used as screening tool for children of school going age (and earlier) for early detection and correction of Vitamin A deficiency.

Serial gadolinium-enhanced magnetic resonance imaging and assessment of facial nerve function in Bell's palsy.
Engstrom M, Abdsaleh S, Ahlstrom H, Johansson L, Stalberg E, Jonsson L
Otolaryngol Head Neck Surg 1997 Nov;117(5):559-66

Eleven patients with mild or moderate acute idiopathic peripheral facial palsy, so-called Bell's palsy, were serially examined by gadolinium-DTPA-enhanced MRI on mean days 11, 40, and 97 (third examination, n = 10) after the onset of palsy. Results of the clinical and neurophysiologic assessment of facial nerve function were compared with the gadolinium-enhanced MRI findings. Eight of the 11 patients demonstrated contrast enhancement of the facial nerve at the initial examination, but in 7 of them, the enhancement had disappeared by the time of the serial follow-up gadolinium-enhanced MRI scans. The disappearance of facial nerve enhancement was found to be related to clinical and neurophysiologic improvements in facial nerve function during recovery from Bell's palsy. The three patients whose scans were negative at the initial gadolinium-enhanced MRI examination had the same clinical severity of palsy, but initially they had milder neurophysiologic involvement than those who demonstrated enhancement; these three patients did not exhibit enhancement at serial follow-up scans. These findings indicate that the presence of enhancement at the initial MRI scan is not necessarily indicative of a poor prognosis for recovery.

Sampling designs for xerophthalmia prevalence surveys.
Katz J, Yoon SS, Brendel K, West KP Jr
Int J Epidemiol 1997 Oct;26(5):1041-8

Diagnosis of MALT lymphoma by conjunctival biopsy: a case report.
Kurz-Levin MM, Flury R, Bernauer W
Graefes Arch Clin Exp Ophthalmol 1997 Sep;235(9):606-9

Comparative study of tear substitutes and their immediate effect on the precorneal tear film.
Avisar R, Creter D, Levinsky H, Savir H
Isr J Med Sci 1997 Mar;33(3):194-7

Dry eye patients present with instability of the precorneal tear film which breaks up much earlier than normally. The instability of the precorneal tear film leads to dry eye symptoms such as the sensation of sand in the eye, recurrent blurred vision, itching, smartness, and the sensation of dryness. The stability of the precorneal tear film can be evaluated by the break-up-time test (BUT).

The aim of treatment of dry eye is to increase the precorneal tear film stability. Tear substitutes are the most frequent medication for dry eye patients, who request life-long treatment. Therefore, we estimated the influence of tear substitutes on the precorneal tear film stability. The influence of unpreserved artificial tear substitute containing 0.1% sodium hyaluronate (Healon 0.1%) was compared with that of 7 different available tear substitute preparations containing preservatives.

The results of the present study show that Healon 0.1% has the best influence on the precorneal tear film stability. These data were found to be independent of the viscosity property of Healon 0.1%.

Effects of vitamin A on growth of vitamin A-deficient children: field studies in Nepal.
West KP, LeClerq SC, Shrestha SR, Wu LS, Pradhan EK, Khatry SK, Katz J, Adhikari R, Sommer A
J Nutr 1997 Oct;127(10):1957-65

Inconsistencies have been observed in the impact of vitamin A (VA) supplementation on early child growth. To help clarify this issue, a cohort of 3377 rural Nepalese, nonxerophthalmic children 12-60 mo of age were randomized by ward to receive vitamin A [60,000 microg retinol equivalents (RE)] or placebo-control (300 RE) supplementation once every 4 mo and followed for 16 mo. VA had no impact on annual weight gain or linear growth. However, arm circumference (AC) and muscle area (MA) growth improved in VA recipients, by 0.13 cm and 25 mm2, respectively, over controls. Growth of children with xerophthalmia, who were treated with >/= 120, 000 RE at base line, was also compared to that of nonxerophthalmic children, stratified by initial wasting status, and adjusted for sex, baseline age and measurement status. Among initially nonwasted children (AC >/= 13.5 cm), VA-treated xerophthalmic children (n = 86) gained 0.7 cm more in linear growth than nonxerophthalmic children. Among initially wasted children (AC < 13.5 cm), VA-treated children (n = 34) gained additional weight (672 g), height (approximately 1 cm), muscle (76 mm2) and fat (79 mm2) areas, and subscapular skinfold (1.3 mm) compared to changes observed in nonxerophthalmic children. Relative increments in soft tissue growth occurred within 4 mo of VA treatment, while the effect on linear growth was gradual. Moderate-to-severe VA deficiency, marked by xerophthalmia, is likely to impair normal physical growth, but milder stages of deficiency may not have this effect in rural South Asia.

Assessment of bromhexine as a treatment regimen in Sjogren's syndrome-like disease in the NOD (non-obese diabetic) mouse.
Nanni JM, Nguyen KH, Alford CE, Robinson CP, Stewart CM, Maeda N, Humphreys-Beher MG
Clin Exp Rheumatol 1997 Sep-Oct;15(5):515-21

Rheumatologic and autoimmune manifestations in patients with chronic hepatitis C virus infection.
Romero Portales M, De Diego Lorenzo A, Rivera J, Garcia Monforte A, Piqueras Alcol B, Garcia Duran F, Cos Arregui E, Clemente Ricote G
Rev Esp Enferm Dig 1997 Aug;89(8):591-8

Hepatitis C virus (HCV) has been associated with several autoimmune and rheumatologic disorders. The aim of this study was to determine the incidence of these abnormalities in patients with chronic HCV. We studied 56 patients, 29 of whom (52%) had biochemical abnormalities that suggested immunological disorders. Cryoglobulinemia was detected in nine patients (22%), antinuclear antibodies in eleven (20%), rheumatoid factor in seven (19.27%) and hypocomplementemia in fourteen (29.16%). The most common clinical manifestations were: arthralgias (52%), myalgias (16%), xerostomia (28.5%) and xerophthalmia (14%). These results indicate the existence of a relationship between HCV and rheumatologic disorders. We conclude that HCV may play a role in the pathogenesis of these autoimmune phenomena, but more studies are required to define the extent of this role.

Botulinum toxin increases tearing in patients with Sjogren's syndrome: a preliminary report.
Spiera H, Asbell PA, Simpson DM
J Rheumatol 1997 Sep;24(9):1842-3

Three patients with Sjogren's syndrome (SS) who had severe xerophthalmia and blepharospasm received botulinum toxin injections for the treatment of their blepharospasm. They had a remarkable increase in tearing, measured by Schirmer's test, and a decrease in signs and symptoms of dry eyes after botulinum toxin injection periorbitally for blepharospasm. The mechanism for this increased tearing is unclear, but suggests a potential treatment for patients with severe xerophthalmia with SS.

Infant feeding practices reflect antecedent risk of xerophthalmia in Nepali children.
Gittelsohn J, Shankar AV, West KP Jr, Ram R, Dhungel C, Dahal B
Eur J Clin Nutr 1997 Jul;51(7):484-90

Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.
Patel BC, Patipa M, Anderson RL, McLeish W
Plast Reconstr Surg 1997 Apr;99(5):1251-60

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

Vitamine--vitamin. The early years of discovery.
Rosenfeld L
Clin Chem 1997 Apr;43(4):680-5

In 1905, Cornelius Adrianus Pekelharing found that animals fed purified proteins, carbohydrates, fats, inorganic salts, and water would thrive only if small amounts of milk were added to the diet. He concluded that the milk contained some unrecognized substance that in very small quantities was necessary for normal growth and maintenance. In 1911, Casimir Funk isolated aconcentrate from rice polishings that cured polyneuritis in pigeons. He named the concentrate "vitamine" because it appeared to be vital to life and because it was probably an amine. Although the concentrate and other "accessory food substances" were not amines, the name stuck, but the final "e" was dropped. In 1913 two groups discovered a "fat-soluble" accessory food substance. Initially believed to be a single vitamin, two separate factors were involved. One, effective against xerophthalmia, was named vitamin A; the other, effective against rickets, was named vitamin D. The factor that prevented scurvy was isolated in 1928. Known as "water-soluble C," it was renamed ascorbic acid.

Tear film stability of protein extracts from dry eye patients administered a sigma agonist.
Schoenwald RD, Vidvauns S, Wurster DE, Barfknecht CF
J Ocul Pharmacol Ther 1997 Apr;13(2):151-61

Fourteen dry eye volunteers placed one to two drops of 0.15% AF2975 (N,N-dimethyl-2-phenylethylamine HCl) in one eye and the vehicle in their other eye four times a day for 21 days. AF2975 is a sigma agonist known to stimulate the release of tear proteins after instillation in rabbit eyes and was tested for its ability to stabilize protein film extracted from dry eye volunteers. After day 7 and again after day 21, Schirmer test strips were inserted in each eye for 5 minutes, measured for wetting, and stored at -20 degrees C for protein analysis.

A volume of 600 microliters was used to extract total protein. A portion of the extract was analyzed for total protein. The remainder was used to measure surface tension, to determine in vitro break up time (in vitro BUT) in a newly designed apparatus, and to further analyze for tear lipocalin, formerly known as presystemic tear albumin. Statistically significant differences were obtained between the drug treated eye and the vehicle treated eye for measurements determined for days 7 and 21.

Tear extracts from the drug treated eye showed statistically significant decreases in surface tension and increases in vitro BUT. Extracts from the drug treated eye also showed statistically significant increases in protein content and tear lipocalin. The results suggest that AF2975 may be able to stabilize the tear film by increasing the concentration of proteins in human tears.

PROGESTOGEN ONLY CONTRACEPTIVES AND VAGINAL BLEEDING

More than 20 million women worldwide use progestogen -only methods of contraception. The most widely used method among them is the injectable depot-medroxyprogesterone acetate (DMPA) with some 13 million users. The only other progestogen-only injectable, norethisterone enantate, has fewer than one million users.

Other progestogen-only methods of contraception include the implantable Norplant, which is currently used by about six million women, and the intrauterine system Mirena which has about one million users. Both these methods release levonorgestrel. Other methods are becoming available such as lmplanon, the singlerod implantable system delivering etonogestrel (first registered in Indonesia in 1998), and other injectable and implantable systems are under development.

Progestogen-only injectable and implantable methods have several features in common. On the positive side they are very effective, and the fact that they are long-lasting makes them easy to use. On the other hand, they cause disturbances in the normal bleeding pattern. For instance, after one year of use it was found that less than 10% of women who used DMPA and Mirena, and only 25% of users of Norplant, experienced regular monthly bleeding. Other users reported various patterns of bleeding ranging from no bleeding through infrequent bleeds to irregular, frequent and prolonged bleeding. Women normally accept that use of a contraceptive method may involve making a tradeoff between benefits and disadvantages. However, many women are not prepared to tolerate unpredictable, irregular or prolonged bleeding.

A wide range of treatments have been tried in order to overcome disturbances to the bleeding patterns of women who use progestin-only methods. Surveys in the 1980s and 1990s show that treatment regimens have included estrogens, combined oral contraceptives, nonsteroidal anti-inflammatory agents, vitamins, iron and anxiolytics. The use of a combined oral contraceptive may help to regularize the bleeding of Norplant users, but women may doubt the advantage of using time and the use of a method containing estrogen negates the advantage of an estrogen-free progestogen method.

Clearly, alternative more effective ways need to be found to meet women’s concerns over disturbance of their bleeding patterns. Amenorrhea may be a more feasible goal than regular bleeding for the users of progestogen-only methods. However, in view of the concern of many women to have regular menstruation, further research w2ill be needed to find out whether amenorrhea would be an acceptable goal for women of different sociocultural backgrounds.

HIV COUNSELLING AND TESTING

By: Ignatius Kayawe and Michael Kelly (Kara Counselling and Training Trust)

As the HIV problem intensifies, the issues of care and support for affected individuals, and of prevention of HIV transmission to those who are not infected, become ever more critical. Voluntary HIV counselling and testing (VCT) is now seen as a key entry point for a range of interventions in HIV prevention and care.

Following breakthroughs in beneficial interventions for people living with HIV/AIDS, there is more reason for VCT to be promoted. Although high prices make antiretroviral drugs unattainable for most such people in developing countries, other interventions are relatively cheap and can reduce the degree of sickness. These include tuberculosis preventive therapy, and treatment with the drug cotrimoxazole, used to prevent several HIV-related infections. VCT is the entry point for these interventions. When people know what their status is, they can cope better and make plans for their own and their family’s future.

A recent study from Thailand showed that “short course” treatment with zidovudine can reduce HIV transmission from mother to child by 50%. This drug may soon be made more widely available for seropositive mothers in developing countries.

Lusaka, the capital of Zambia, has been severely affected by HIV. The seroprevalence among women, as shown by anonymous antenatal screening surveys, is around 30%, and recent community surveys indicate that 26% of both men and women aged 15 to 30 years are HIV seropositive. HIV affects almost everybody, directly or indirectly, in Zambia. There are tens of thousands of AIDS orphans and most households have to care for sick family members or for the children of relatives who have died.

In industrialized countries, where HIV seroprevalence is low, VCT is widely available. In contrast, developing countries often have a high prevalence but VCT is rarely available. One exception in Africa is the AIDS Information Centre in Uganda, where more than 450 000 people have received VCT.

Kara Counselling Trust
Zambia’s first VCT centre, the Kara Counselling and Training Trust, was established in November 1992 and offers a variety of support services outside the workplace or medical centre. These include a skills training programme for people with HIV, a post-test club, a clinic for basic medical problems, and a referral service for people with more complicated medical problems or for those requiring home-based care services. Kara also has an active peer education programme run by the Positive and Living Squad (“the PALS”).

In high-prevalence countries, many people may think that they are positive yet find they are in fact negative. Many have reported that discovering they were negative encouraged them to change their sexual behaviour in order to stay negative. Those who test seropositive benefit greatly from psychological support and referral for care. Counselling helps them to cope and plan ahead.

“I did not really understand about HIV before I saw the counsellor. You see what I knew was that I had a lot of girlfriends-a bout 14- and, like the posters say, that is how you get AIDS. So when the result came back negative I thought it must be wrong. The counsellor explained to me that I had been luck- but it could happen next time. She suggested we repeated it, which I did and it was negative too”. M., aged 21, Lusaka

At Kara, many men who had been tested said that they would use safer sex to reduce HIV transmission to partners or to prevent themselves from being infected by their sexual partners. Women, however, still face considerable barriers because of unequal status in sexual decision-making.

It is often difficult for women to ask their husbands to use condoms. So even if they test negative, they may be at continuing risk of HIV infection from their husband, especially if he has other sexual partners. “I am faithful to my husband. I can’t force him to have a test – he refuses. But although my husband says he is faithful to me, I doubt it….. but what can I do? F., aged 23 Lusaka

Why do people decline HIV testing? Three principal reasons are put forward:

The Challenge
More than 20 million of the 30 million people estimated to be living with HIV at the end of 1997 live in sub-Saharan Africa. UNAIDS estimates that more than 90% of these are unaware of their infection. There are individual benefits that stem from knowing one’s HIV status, and there are also huge potential benefits for society. There is a strong environment of stigma and denial in parts of Africa, and this is tacitly supported by policy-makers and health care staff.

HIV is rarely entered as a cause of death in African death certificates, yet treatment decisions are made on the assumption that a patient is infected. Increased availability and use of voluntary counselling and testing would be an important step towards normalizing attitudes to HIV and improving the environment for prevention of transmission.

Although the demand for VCT has increased in Zambia and other countries in sub-Saharan Africa, there are still barriers to be overcome, not least the fear that receiving a positive result will be of little benefit and lead to discrimination and abandonment. VCT would overcome these barriers if it were integrated with medical and support services for people with HIV.

Experience at Kara has shown that VCT helps people to cope with their HIV infection, to get access to care and to plan for the future. All too often the opportunity to prevent transmission has already been missed. A wholehearted promotion of voluntary HIV testing for young people, before they are pregnant or sick, would offer greater chances of preventing transmission.

© World Health Forum No.6 Nov-Dec 1998
A posting from: health-l@hivnet.ch

HIV INFECTION AND TB

Four levels of interaction can be identified between HIV infection and tuberculosis, and these have implications for the Epidemiology, clinical manifestations, treatment and prevention of both diseases. The word synergy is derived from the Greek word synergos, which means working together. Synergism has been defined as “the interaction of discrete conditions such that the total effect is greater than the sum of individual effects.” This type of interaction accurately describes the relationship between tuberculosis (TB) and infection with the human immunodeficiency virus (HIV). Both infections are long-term and both may remain silent for long periods.

Tuberculosis infection is acquired by inhalation of Mycobacterium tuberculosis, a highly infectious organism which is transmitted as an aerosol when a person with pulmonary TB disease coughs; in developing countries more than half the population may be infected with M. tuberculosis. The ability of the human immune system to contain latent TB infection results in only about 10% of infected persons developing active TB at some point in their lives; nevertheless TB still caused about one-quarter of the preventable adult deaths in developing countries before the HIV/AIDS pandemic. The introduction of effective therapy for TB in the 1950s led to optimism about the prospects for global TB control, but some eight million cases of active TB and three million deaths continue to occur annually.

HIV infection greatly increases susceptibility to TB, and this has led to a tremendous increase of TB in areas where both infections are prevalent. Around 15 million persons worldwide are infected with both HIV and M. tuberculosis, of whom over two-thirds reside in sub-Saharan Africa. By the year 2000, some 1.4 million cases, or 14% of the global total, will be associated with HIV infection. Several African countries have seen their TB caseload double or treble since the HIV/AIDS pandemic began.

The synergistic relationship between HIV and M. tuberculosis has taken the world from a position of optimism about TB elimination to one of crisis, especially in sub-Saharan Africa, but also in Latin America, the Caribbean, and South and South-East Asia. HIV – associated TB has also increased in the industrialized world, especially in southern Europe and the United States, but the public health infrastructure there has been able to contain the problem. A further hazard has been the emergence of multidrug-resistant TB, that is, disease caused by strains resistant to reifampicin and isoniazid, the most potent anti-tuberculosis drugs available. This has disproportionately affected HIV-infected persons in some industrialized countries, and would be disastrous if it took hold in developing countries.

Interactions
Four levels of interaction can be considered;

HIV-infected persons with latent TB infection have an annual risk of developing active TB disease that may be as high as 5-10%, the risk being higher the more advanced the stage of immune deficiency. HIV-infected persons are also at risk of progressive disease immediately after infection with M. tuberculosis, and are vulnerable to reinfection. Finally, active TB may adversely affect the clinical course of HIV disease itself.

TB is the commonest opportunistic infection that complicates HIV infection in much of the developing world, and is responsible for one-third or more of HIV-associated deaths in sub-Saharan Africa. Clinically, HIV infected persons with TB mostly show symptoms similar to those of HIV-negative persons, such as fever, cough and weight loss

The diagnostic and therapeutic approach to TB is the same whether people are HIV-positive of HIV-negative. National programme guidelines used, but certain principles apply internationally. Treatment is initiated with standard regimens of three or four drugs, including rifampicin and isoniazid, for an initial intensive phase of two months, followed by a continuation of four to six months of treatment with two drugs. Side-effects to medications are more common in HIV-infected persons, the most severe and common being associated with thioaceta-zone, which should not be used in those infected with HIV.

Prevention and Control
WHO has proposed the DOTS (directly observed treatment, short course) strategy for global TB control. The Key elements are government commitment, sputum smear microscopy to detect infectious cases, standardized short-course treatment, a secure supply of drugs, and a recording and reporting system. This should be considered the minimum strategy to reduce transmission of TB and prevent the emergence of drug resistance.

To prevent the synergistic relationship between HIV and M. tuberculosis, both infections need to be prevented, so HIV/AIDS and TB programmes need to collaborate more closely. Early recognition and treatment of persons with active TB are critically important to prevent further TB transmission.

Treatment of HIV-infected persons without active TB for six to twelve months with isoniazid reduces their incidence of TB in the short term by two-thirds. Unfortunately, it is difficult to provide such treatment in many developing country settings. BCG vaccination reduces the risk of disseminated tuberculosis in children, but contributes little more to overall Tb control. Finally, infection control measures such as separating patients with active TB for the first two weeks of treatment from others, especially HIV-infected persons, should be attempted.

Despite adequate measures to treat TB, HIV-infected persons are likely to develop other complications, and will require HIV testing and counselling, personal and family support, and further medical care. The HIV pandemic has had a dramatic effect on the epidemiology of TB, especially in sub-Saharan Africa and parts of Asia. DOTS currently offers the best chance of limiting the damage and preventing drug resistance, but still further efforts will be required in areas of high HIV prevalence where TB continues to increase. There is an urgent need for greater investment in TB control and new tools, specifically an effective vaccine, better diagnostics and better drugs.

Malaria Documents and Journal Articles now Free of Charge

The number of deaths caused by malaria in Africa is second only to AIDS. Information needed to combat the disease is inaccessible to many health professionals in the sub-Region. Under a new pilot project of the U.S. National Library of Medicine (NLM) and the Medical Library of the University of Zimbabwe (UZML), malaria researchers in Central and East Africa can request the malaria-related documents and journal articles they need through the UZ's Medical Library.

THE REQUESTS WILL BE FILLED either locally or at the NLM as quickly as possible, by Internet, e-mail, fax or air- mail. This service will be provided free of charge, thanks to a pro- gram funded by the Communications Working Group (CWG) of the Multi- lateral Initiative on Malaria (MIM) at the NLM.

Target Countries: Countries targeted under this service are: KENYA, MALAWI, TANZANIA, UGANDA, ZAMBIA, and ZIMBABWE.*

This new service is intended to serve malaria researchers via a range of options, with or without access to information and communications technologies:

During an online search, researchers can select journal references relating to their malaria research interests and request these references electronically using the PubMed's Loansome Doc feature. Note that some journals are linked full text to PubMed references and can be obtained directly online (e.g., British Medical Journal). For more details of how to use the Lonesome Doc feature, contact the UZ Medical Library.

Special Malaria Web Site: Researchers with Internet WWW access are invited to visit a new web site of useful resources and links relating to malaria research, which is being developed under the auspices of the Communications Working Group (CWG) of the Multilateral Initiative on Malaria (MIM).

For further information or to submit your document requests please contact:

Mr. Hammer Bamhare, UZ Medical Library's Outreach Librarian/ or
Mrs. Helga Patrikios, UZ's Medical Librarian, a member of the CWG.
Medical Library
PO Box A178, Avondale
Harare, Zimbabwe
Tel: +263-4-791-631 or 708140
Fax: +263-4-795-019
email: University of Zimbabwe Medical Library or
Mrs. Helga Patrikios

Alternatively contact:

University of Zambia Medical Library
Box 50110 Lusaka
Phone: 250801
Fax: 250753
Email: Christine Kanyengo or
UNZA Medical Library

We will be glad to assist in getting the documents for you.

REQUEST FORM FOR FULL LENGTH TEXT OF ARTICLES:

1) ABSTRACT TITLES FOR DESIRED ARTICLES:
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2) COMMENTS: (Send us your thoughts and letters about this digest or any health related issue facing Zambia today and we may even print them!)

3) ADDRESS YOU WOULD LIKE US TO SEND ARTICLES TO:
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4) SEND THIS FORM (OR A COPY) AND YOUR LETTERS TO THE FOLLOWING ADDRESS:
Zambia Health Information Digest
Medical Library
University of Zambia, School of Medicine
Tel: 01-250801
Fax: 01-250753
P.O. Box 50110
Lusaka, Zambia
medlib@unza.zm

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Send comments and/or suggestions to: medlib@unza.zm or lenny@library.health.ufl.edu
Copyright © 1996-2001, The University of Zambia Medical Library and Lenny Rhine
Guide to Medical Resources WWW site: http://www.medguide.org.zm/

Last updated November 14, 2000