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The epidemiology of Strongyloides stercoralis was studied in families of clinical (reference) cases and their neighbours at endemic foci in Jamaica. Thirteen foci were studied based on the place of residence of a reference case. For each household of a reference case, the 4 most proximal neighbourhood households (spatial controls) were included in the study. Out of 312 persons contacted 244 were followed up using questionaires, stool examimation and serology. Prevalence of infection based on based on stool examination was 3.5 percent and on ELISA 24.2 percent. Prevalence increased with age but was not related to gender. Reference cases were significantly older than the general study population. The prevalence of infection based on both serology and stool examination was significantly higher in referecne than in neighbouring households (the reference cases, themselves, were not included in the analysis). Furthermore, prevalence of infection was highest among persons who shared a bedroom with a reference case and decreased significantly with increasing spatial separation. This is indicative of close contact transmission which has not been previously shown for a geohelminth, but which is common among microparasites.(AU)

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One hundred and two consecutive patients undergoing upper gastrointestinal endoscopy were tested for H. pylori by a rapid urease test, using antral biopsy specimens. There were 60 men (mean age 54 yrs) and 42 women (mean age 49 yrs). Fifty-six patients (55//) were positive for H. pylori. Of male patients, 36 (60//) and of female patients, 20 (48//) tested positive. Sixty-eight per cent of patients with antral gastritis, 65//with duodenal ulcer and 60//with gastric ulcer had H. pylori. Thirty-nine patients (70//) positive for H. pylori were from major urban areas, and 17 (30//) were from rural areas of Jamaica. In patients without H. pylori, 61//and 39//were from urban and rural areas respectively. Forty-four patients (79//) with H. pylori and 40 (87//) without H. pylori had piped water in their homes. Ninety-three per cent of all patients had electricity and 88//had refrigeration. There was no difference between patients positive or negative for H. pylori with regard to the use of alcohol, marijuana or tobacco. There was also no difference between both groups in exposure to domestic animals in the home environment. H. pylori is associated with antral gastritis and peptic ulcer disease in Jamaican patients. There are no specific environmental or social factors that seem to predispose to infection.

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One hundred and two consecutive patients undergoing upper gastrointestinal endoscopy were tested for H. pylori by a rapid urease test, using antral biopsy specimens. There were 60 men (mean age 54 yrs) and 42 women (mean age 49 yrs). Fifty-six patients (55 percent) were positive for H. pylori. Of male patients, 36 (60 percent) and of female patients, 20 (48 percent) tested positive. Sixty-eight per cent of patients with antral gastritis, 65 percent with duodenal ulcer and 60 percent with gastric ulcer had H. pylori. Thirty-nine patients (70 percent) positive for H. pylori were from major urban areas, and 17 (30 percent) were from rural areas of Jamaica. In patients without H. pylori, 61 percent and 39 percent were from urban and rural areas respectively. Forty-four patients (79 percent) with H. pylori and 40 (87 percent) without H. pylori had piped water in their homes. Ninety-three per cent of all patients had electricity and 88 percent had refrigeration. There was no difference between patients positive or negative for H. pylori with regard to the use of alcohol, marijuana or tobacco. There was also no difference between both groups in exposure to domestic animals in the home environment. H. pylori is associated with antral gastritis and peptic ulcer disease in Jamaican patients. There are no specific environmental or social factors that seem to predispose to infection (AU)

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Strongyloides sterocalis infections were examined in families of clinical cases and also in those of their most proximal neighbours. Thirteen clinical cases in Kingston, Jamaica led to the identification of thirteen endemic foci. In addition to the clinical cases, 299 persons were contacted using questionnaires, stool examination and serology. Two hundred and thirty-one persons were fully compliant. The stool prevalence of S.sterocalis was 3.5 percent, while that based on ELISA was 24.2 percent (not including the 13 clinical cases). Both estimates of infection prevalence were significantly higher in the households of the clinical cases compared with the neighbours. The clinical cases were significantly older than the general study population. Furthermore, prevalence was highest among persons who shared a bedroom with a clinical case and decreased with spatial separation. These data strongly suggest that human strongyloides is a close-contact infection. This is likely to be facilitated by the direct phase of the parasite's life cycle and has significant implications for control of infections in endemic areas (AU)_

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Epidemilogic investigations of Strongyloides stercoralis and human T lymphotropic virus type I (HTLV-I) infections were conducted. Of 312 persons contacted, 209 (67 percent) provided blood and stool samples. Prevalences of S. stercoralis and HTLV-I antibodies were 26.8 percent and 8.1 percent (n = 198), respectively, and S. stercoralis larvae were detected in 4 percent. HTLV-I antibodies were significantly more common in persons positive for S. stercoralis larvae (10 [58.8 percent] of 17) compared with seropositive larvae-negative (4 [8.9 percent] of 45) or seronegative persons (9 [6.2 percent] of145) (P< .002). IgE levels increased with age in S. stercoralis-seropositive persons who were HTLV-I negative (P, .))2). However, there was an age-related depression of serum IgE in HTLV-I-positive persons (P < .003) that was sufficient to annul the IgE level-raising effect of S stercoralis seropositivity. The data provide evidence that HTLV-I infection is associated with increased frequency of larvae in the stool of S. stercoralis-infected persons and suggest that the mechanism may involve suppression of the IgE response (AU)

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Epidemiological associations of Strongyloides stercoralis and Human T-Lymphotropic Virus Type-1 (HTLV-1) were investigated at eleven (11) foci endemic for strongyloidiasis in Jamaica. Each focus was identified on the basis of residency of a parasitologically-proved case of strongyloidiasis who presented at the University Hospital. Three hundred and twelve (312) persons were contacted, and blood and stool samples were collected for HTLV-1 and S. stercoralis serology and S. stercoralis coproculture, respectively. Overall compliance was 66.6 per cent. The prevalence of S. stercoralis in the pooled foci was 8.2 per cent including and 4.0 per cent excluding the hospital presenters, and for HTLV-1 it was 11.1 per cent and 8.1 per cent. Seroprevalence of S. stercoralis infection was 30 per cent and 26.8 per cent with and without the clinical cases, respectively. The prevalence of each infection was correlated with the age of the host (Spearman Rank Correlation, p<0.001). HTLV-1 was clustered in S. stercoralis larval shedders (58.8 per cent, n=17) compared with non-shedders (8.9 per cent, n=45) (Fisher's exact test, p<0.001), but particularly so among clinical cases 7 of whom (n=9) had HTLV-1 antibodies. The association was explained on the basis of age-related total serum IgE levels in HTLV-1/S. stercoralis infection cases. Individuals uninfected by S. stercoralis displayed a tendency for decreased IgE levels with age. This especially so in HTLV-1 carriers (ANCOVA: age * HTLV-1 interaction term t = 3.176, p<0.002). In marked contrast, S. stercoralis seropositive individuals had significantly elevated IgE titres in older persons compared with seronegative controls (ANCOVA: age * S. stercoralis interaction term t = 3.733, p<0.001). In persons seropositive for both HTLV-1 and S. stercoralis, however, the elevation of IgE levels previously observed in S. stercoralis positive individuals was completely subsumed by the negative influence of HTLV-1. It is suggested that impairment of host immunity by HTLV-1, and/or S. stercoralis in the presence of HTLV-1, exacerbates strongyloidiasis resulting in increased frequency of both larval shedding and parasite disease. Effect of S. stercoralis (S) and HTLV-1 (H) infection status on the host age/serum IgE association. This figure is designed to illustrate general trends; ungrouped data were used in statistical analyses (AU)

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Thirty-five patients with chronic pancreatitis (CP) treated with over a 15-year period were studied. There were 29 men and 6 women with a mean age of 47 years (range 21-67). Twenty-seven (77%) were chronic alcoholics, two (6%) had gallstones, one had stenosis of the Ampulla of Vater and in five (14%) no obvious cause was found. Thirty patients (86%) presented with abdominal pain. Chronic diarrhoea was present in 8 (23%), and steatorrhoea was documented in 6 of these. Fifteen (43%) had pancreatic calcifications. Five developed pseudocysts and 16 (46%) developed diabeted mellitus. Twelve patients required surgery. Three continue to have severe recurrent relapses of pain but the majority (91%) have had a relatively stable course with medical management.

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Thirty-five patients with chronic pancreatitis (CP) treated with over a 15-year period were studied. There were 29 men and 6 women with a mean age of 47 years (range 21-67). Twenty-seven (77 percent) were chronic alcoholics, two (6 percent) had gallstones, one had stenosis of the Ampulla of Vater and in five (14 percent) no obvious cause was found. Thirty patients (86 percent) presented with abdominal pain. Chronic diarrhoea was present in 8 (23 percent), and steatorrhoea was documented in 6 of these. Fifteen (43 percent) had pancreatic calcifications. Five developed pseudocysts and 16 (46 percent) developed diabeted mellitus. Twelve patients required surgery. Three continue to have severe recurrent relapses of pain but the majority (91 percent) have had a relatively stable course with medical management. (AU)

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A subsample (1.6 percent; n = 13,260) of a healthy Jamaican population of food-handlers, studied by Murphy et al. (1991), who were serologically positive (n = 99) or negative (n = 113) for HTLV-I was investigated for intestinal parasitic infection using coprological methods. Helminth infection included Ascaris lumbricoides (2.8 percent), Trichuris trichiura (7.1 percent) and hookworms (6.1 percent). Entamoeba coli was found in 21.8 percent of samples, while E. hartmanni, Giardia lamblia, Endolimax nana, Iodamoeba butschlii and Chilomastrix mesnili each occurred in less than 10 percent of responders. T. trichiura displayed a higher prevalence (10.6 vs 3 percent (chi 2 = 4.623;p = 0.03) in the HTLV-I negative group. G. lamblia was detected more frequently among HTLV-I carriers compared to controls (9.1 and 3.5 percent respectively), but the association was not statistically significant (chi 2 = 2.825;p = 0.09). Infection with intestinal parasites is likely to occur independent of HTLV-I status: however, possible HTLV-I-induced immunosuppression may lead to higher intensity infections of certain organisms thus facilitating easier detection using parasitological methods. The immunomodulatory potential of HTLV-I infection in the aetiology of non-malignant diseases requires further investigation. (AU)

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Since 1983, rapid advances in the knowledge of Helicobacter pylori have given new insights into pathogenesis of upper gastrointestinal diseases. Several methods are now available for the diagnosis of the infection. Antimicrobial therapy has emerged as a new and effective treatment for peptic ulcer disease in a proportion, as yet to be determined, of patients in the Caribbean (AU)

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M.R.C.P. (UK) and D.M. (Internal Medicine), University of the West Indies, are postgraduate qualifications that did, or now do, evaluate and set the quality of specialist Internal Physician training. Since the inception of the degree, graduates of D.M. (Internal Medicine), University of the West Indies, have developed sub-speciality interests and have been recognized as being of consultant status throughout the region and the world. D.M. is of a higher standard as it is an exit examination whereas the MRCP (U.K.) diploma is an entrance examination. Acquisition of the MRCP (U.K.) is expensive; travel to the U.K. is mandatory. Possession of MRCP (UK) is considered by most graduates of D.M. (Internal Medicine), University of the West Indies, to be unnecessary; it has not advanced their career in any discernible way. It should no longer be encouraged in any way at the University of the West Indies (AU)

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In vitro bioassay of (a) aqueous methanol extracts (AME) of the green leaves of mimosa (Mimosa pudica), love weed (Cuscuta americana), vervine (Stachytarpheta jamaicensis), chicken weed (Salvia serotina) and breadfruit (Artocarpus altilis); (b) methanol-water fraction (MWF) of breadfruit leaves, and (c) commercially available drugs albendazole, thiabendazole and levamisole were assayed for nematode inactivating potential, using filariform larvae of Strongyloides stercoralis. Test larvae were obtained from a 10-day-old charcoal coproculture. Bioassays were conducted in Locke's solution, using 100 larvae in each of three replicates. Inactivation was recorded microscopically at 1, 2, 6 and 12 hours, then every 24 hours up to 5 days' incubation. It(50) (time for inactivation of 50 percent of larvae) values read: levamisole and mimosa extract < 1 hour; love weed extract, approximately 2 hours; breadfruit (MWF), 9.5 hours; chicken weed, 20 hours; albendazole, 35 hours; breadfruit (AME), 49 hours; thiabendazole, 74 hours and vervine extract, 81.5 hours. It(95) values followed a similar trend, and were approximately double the It(50) measures. A potential role for locally available natural products in the treatment of strongyloidiasis is highlighted (AU)

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In Japan, a positive association exists between the presence of serum antibodies to HTLV-1 and S. stercoralis. Also, it has been shown in Jamaica that coincidental HTLV-I infection may influence the outcome of treatment of S. stercoralis, or even underlie development of severe strongyloidiasis in some persons. However, the relationship between HTLV-I and S. stercoralis remains unclear. This paper highlights a hitherto unreported association between the occurrence of serum antibodies to HTLV-I, to S. stercoralis, and total serum IgE and strongyloidiasis in a Jamaican community. Blood and stool samples were collected from 67 persons from 6 geographical locations in Kingston. Sera were analysed for antibodies to S. stercoralis and HTLV-I, while stool samples were subjected to charcoal coproculture. As in Japan, individuals serologically positive for S. stercoralis tended to be infected more often with HTLV-I (33 per cent) than seronegative individuals (15 per cent), but the difference was not significant (two-tailed Fisher's exact test; P = 0.15). However, parasitologically-proved strongyloidiasis and HTLV-I seroconversion were strongly associated; while occurrence of HTLV-I was 67 per cent in individuals whose stool contained S. stercoralis larvae, it was only 15 per cent in their parasitologically negative counterparts (two-tailed Fisher's exact test; P = 0.01). Analyses strongly suggest that serological status for S. stercoralis HTLV-I affect IgE titres interaction term, F = 3.54; P = 0.06). IgE titres were lower in HTLV-I seropositive than seronegative individuals in both groups with and without S. stercoralis antibodies (HTLV-I main effect, F = 11.13; P = 0.002), but more strongly so in the former group (Table). S. stercoralis infection appeared to elevate reagin levels in some individuals in the HTLV-I negative group (n=13) (one-way ANOVA, F = 2.09; P - 0.15). In contrast, however, serum IgE titres were depressed in the group (n-5) with HTLV-I and concomitant S. stercoralis infection to levels perhaps even lower than those seen in HTLV-I individuals who did not have S. stercoralis (one-way ANOVA, F = 2.39; p = 0.15). Thus, it appears that HTLV-I and S. stercoralis operate synergistically to effect a significant reduction in IgE serum antibodies in infected individuals. If expressed at the level of the intestinal mucosa, this may permit increased rates of autoinfection of the parasite and result in correspondingly greater worm loads and patient morbidity. Lower levels of IgE antibodies against S. stercoralis are known to be associated with disseminated disease (AU)

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Four hundred and nine colonoscopic examinations were performed in 335 patients over a 12-year period in Jamaica. The main indications were suspected polyps (34 percent), rectal bleeding (22 percent), and suspected carcinoma (11 percent). Total colonoscopy was performed in 33 percent of cases. The ascending colon and hepatic flexure were examined in a further 25 percent, and the transverse colon in another 21 percent. Endoscopic examination of the suspected abnormal area was possible in all cases. In 142 examinations, no abnormality was detected, reflecting a false positive Barium enema in some. Polyps were found in 135 examinations, diverticula in 69 and carcinoma in 13. There were no complications. Colonoscopy was more sensitive and specific than Barium enema. The barium enema findings were incorrect in 91 of 224 examinations (41 percent). Colonoscopy is a safe and accurate procedure which enables improved patient management (AU)

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The outcome is described of 48 entrants to a postgraduate degree course (DM) in Internal Medicine established at the University of the West Indies in 1974. Contact by postal questionnaire was established in 96 percent of 26 graduates and 82 percent of 22 non-graduates. 22 of 25 DM graduate responders have remained in the Caribbean, working in six Caribbean territories. All graduate responders developed a subspeciality interest. The graduates' primary employers are the University (9) and the Government (12). However, failure to graduate did not necessarily preclude qualification as consultant physician (7 of 18 responders). Major difficulties with the DM programme included: (1) in practice, lack of recognition by contributing territories of individual DM (Internal Medicine) graduates; (2) incomplete regional coverage; (3) lack of adequate funding for the programme; (4) an inadequate research training input; and (5) difficulties with seniority for staff who trained in Jamaica to go to work in another territory. All these problems have solutions. Overall, the international recognition of the new degree programme has been satisfactory and the graduates' own assessment of the training was complimentary. At last a system has been devised that enables postgraduates to train as internal medicine specialists in the Caribbean to practise effectively within the Caribbean health system. (AU)

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The results of oesophageal sclerotherapy (OS) in 18 patients with recurrent bleeding varices are compared with 15 patients treated medically. The total transfusion requirement pre-sclerotherapy was 112 units of blood (mean 6/patient) which decreased to 46 units (mean 2.5) after sclerotherapy treatment was started (p=0.005). In the medically treated group, total transfusion was 74 units (mean 5 units/patient). One hundred and forty-three injection sclerotherapy sesions were given, and all but one patient had significant reduction or eradication of varices. Three patients died of recurrent bleeding (17 percent) and one other required surgery. In the medically treated group, 3 patients died of bleeding (20 percent). Complications of sclerotherapy included mild bleeding (39 percent), chest pain (28 percent) and oesophageal ulcer (5.5 percent). OS reduces transfusion requirements in patients with recurrent variceal bleeding. (AU)

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Although the Doctor of Medicine programme in Internal Medicine at the U.W.I. is a structured course with several teaching formats, the optimally effective form of teaching remains unknown. An experimental didactic teaching course in Gastroenterology was preceded and followed by an examination. This was conducted to determine the effectiveness of this form of teaching. The majority of residents ranked the course favourably. The mean examination score increased by 6.4 percent, from 25.4 percent before the course to 31.8 percent at the end. Although the more senior residents scored higher than their juniors in the pre-test, this difference disappeared in the post-test. Structured didactic teaching requires close supervision, active participation by trainee and reinforcement for the full benefit to be attained. (AU)

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It is uncertain whether HTLV-I infection and Strongyloidiasis are related other than by chance. A consecutive series of Jamaican patients and controls have been analysed retrospectively for anti-Strongyloides and HTLV-1 antibodies to determine whether either influences the outcome of anti-helminthic therapy. Twenty-seven Jamaicans (16 M, 11F) mean age 50.2 years (range 16-85), who were found to have Strongyloides stercoralis infection were studied at the University Hospital of the West Indies. At the same time, a parasite-negative group of 13 patients (6M, 7F) of mean age 37.6 years, (range 23-53), with minor or no gastrointestinal disease served as controls. Pretreatment blood samples were taken from the Strongyloides group and controls. Serum was subsequently tested for IgG antibodies to filariform Strongyloides stercoralis larval antigens by ELISA and to HTLV-1 by ELISA and Western Blot. Outcome of the treatment of Strongyloidiasis with thiabendazole (25 -mg/kg b.d. orally for 10 days was determined at 2 months. Strongyloides reciprocal antibody titre was considerably higher in patients than controls, mean 870 vs 167; median 1,024 vs 8 (p<0.001). The sensitivity of the antibody test was 93 percent, but the specificity was 69 percent at best. There was no correlation with the anti-Strongyloides antibody titre and outcome with anti-helminthic therapy. HTLV-1 antibodies were found only in the Strongyloides patients, 12 of 27 (44 percent); antibody titres were high and positive with both test used: only one patient was known beforehand to have a disease associated with HTLV-1 infection. Of those 12 with HTLV-1 antibodies, 3 (25 percent) were cured, 7 still had the infection at 2 months, a further 2 had died or defaulted from follow-up. Of the 15 patients without HTLV-1 antibodies, 9 (60 percent) were cured, 3 still had the infection and 3 had died or defaulted. By chi-square analysis, the difference is significant whether one includes all the deaths and defaulters on an intention-to-treat basis or just those who were available at 2 months post-therapy. However, since none of the deaths were related to Stongyloidiasis or HTLV-1 injection, it is probably justifiable to exclude the deaths from the computation. These results show that the association of Strongyloidiasis and HTLV-1 is more than chance clustering. Not only is the prevalence of HTLV-1 antibodies far higher in the patients with Strongyloidiasis than in the normal Jamaican population, but that concurrent asymptomatic HTLV-1 infection interferes with anti-helminthic treatment (AU)

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Gallstones were detected by ultrasonography in 30/226 (13 per cent) children with SS disease, aged 5-13 years, participating in a cohort study from birth. Children with gallstones had significantly lower total haemoglobin and foetal haemoglobin and higher bilirubin levels. Further analysis revealed that the apparent effects of Hb and HbF were secondary to their relationship with bilirubin levels. Abdominal pain crises were significantly associated with gallstones but both factors appeared to reflect an increased clinical severity and were probably not casually related. No patient had symptoms specific for gallstones. An association with abdominal pain crisis should not, of itself, be considered an indication for surgery (AU)

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