Informal gold miners with mercury toxicity: Novel asymmetrical neurological presentations

Mercury is a highly toxic heavy metal that may cause neurological, respiratory, gastrointestinal and dermatological illnesses. Previously described neurological manifestations of mercury toxicity are symmetrical, and include a pancerebellar syndrome, generalised seizures and encephalopathy. Mercury is used in the gold mining process, and in artisanal or illicit gold mining, often without necessary protection. Here we describe the cases of two artisanal gold miners from western Johannesburg, South Africa, who presented with atypical neurological manifestations of mercury toxicity. Patient 1 presented with focal seizures, an asymmetrical cerebellar syndrome and an acute encephalopathy. Patient 2 had unilateral cerebellar ataxia. Both patients had toxic mercury levels, with no other cause identified for their symptoms. Patient 1 responded well to chelation therapy, but patient 2 refused admission and further medical treatment. The neurological manifestations of mercury toxicity are typically symmetrical, whereas our two patients presented with markedly asymmetrical features. It is important to maintain a high index of suspicion for mercury poisoning, even in patients with atypical and unilateral or asymmetrical presentations. A prompt diagnosis and the commencement of early chelation therapy have the potential to produce good outcomes.

Sub-lethal toxicity assessment of the phenylurea herbicide linuron in developing zebrafish (Danio rerio) embryo/larvae

Due to run-off and rain events, agrochemicals can enter water catchments, exerting endocrine disruption effects and toxicity to aquatic organisms. Linuron is a phenylurea herbicide used to control a wide variety of vegetative weeds in agriculture in addition to residential applications. However, there are few studies that quantify its toxicity to early developmental stages of fish. The objectives of this study were to assess the acute toxicity of linuron to zebrafish embryos/larvae by measuring mortality, morphological deformities, oxidative respiration, gene expression, and locomotor activity via the Visual Motor Response test. Zebrafish embryos at ~6-h post-fertilization (hpf) were exposed to either embryo rearing medium (ERM), or one dose of 0.625, 1.25, 2.5, 5, and 10 μM linuron for up to 7 days post-fertilization (dpf) depending on the assay. Zebrafish larvae exposed to linuron displayed pericardial edema, yolk sac edema, and spinal curvature. Oxidative respiration assessments in embryos using the Agilent XF^e24 Flux Analyzer revealed that linuron decreased mean basal respiration and oligomycin-induced ATP-linked respiration in 30 hpf embryos at 20 μM after a 24-hour exposure. In 7 dpf larvae, transcript abundance was determined for 6 transcripts that have a role in oxidative respiration (atp06, cox1, cox4-1, cox5a1, cytb, and nd1); the relative abundance of these transcripts was not altered with linuron treatment. A Visual Motor Response test was conducted on 7 dpf larvae to determine whether linuron (0.625 to 5 μM) impaired locomotor activity. Larval activity in the dark period decreased in a dose dependent manner and there were indications of hypoactivity as low as 1.25 μM. Transcript abundance was thus determined for tyrosine hydroxylase (th1) and glutamic acid decarboxylase 67 (gad1b), two rate limiting enzymes that control the production of dopamine and gamma-aminobutyric acid respectively. The mRNA levels of gad1b (p = 0.019) were reduced with increasing concentrations of linuron while th1 (p = 0.056) showed a similar decreasing trend, suggesting that neurotransmitter biosynthesis may be altered with exposure to linuron. This study improves knowledge related to the toxicity mechanisms for linuron and is the first to demonstrate that this anti-androgenic chemical impairs oxidative respiration and exerts neurotoxic effects associated with neurotransmitter biosynthesis during early development. These data are significant for environmental risk assessment of agrochemicals.

Otorrhoea - a parotid connection

A 36-year-old patient presented with an 18-month history of intermittent right parotid swelling accompanied by otorrhoea. The symptoms started subsequent to a palm leaf injury to the right ear. At right parotidectomy, a fistula connecting the right external auditory canal and the right parotid was demonstrated. A small fibrotic mass probably due to a remnant of the palm leaf was found intraoperatively. The symptoms resolved completely after the mass was excised by superficial parotidectomy, and the fistula closed spontaneously.

Trans-oral penetrating trauma to the neck: the innocuous pen cap and the value of CT Scan

A significant number of otorhinolaryngological emergency visits are caused by foreign bodies, and occasionally they can result in life-threatening injury. This report highlights the value of neck CT in the evaluation of suspected radiolucent foreign bodies penetrating the neck from the oral cavity. This guided the surgical approach to remove the foreign body safely without complication.

Lingual Fibrolipoma - A rare clinicopathological entity

Lipoma is a relatively common benign tumour occurring at sites of the body which are rich in adipose tissue. Due to sparsity of adipose tissue within the oral cavity, lipoma rarely presents in this region. Fibrolipoma of the tongue is a rare lesion. There are only 14 cases reported in the literature. An 85-year-old patient presented with a painless mass on the tongue interfering with eating. There were no risk factors for malignancy and no family history of malignant diseases. Although intraoperatively the lesion was locally infiltrative, histopathology revealed a rare benign fibrolipoma. Mainstay of treatment is surgical excision, but the lesion may pose a dilemma for Surgeons as difficulties associated with removal, due to the fibrous and adherent nature of the growth to surrounding tissue, may be mistaken for a cancerous growth.

Chest physiotherapy and rebound exercise for sputum in patients co-infected with TB and HIV

Patients co-infected with human immunodeficiency virus and tuberculosis find difficulty producing sputum for microscopy culture and sensitivity test.

Experience with a gonadotrophin-releasing hormone agonist prior to myomectomy--comparison of twice- vs thrice-monthly doses and a control group

The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.

Brief Images: Massive pericardial effusion

Significant pericardial effusions are an uncommon but very important disorder in childhood. In our patient, cross-sectional imaging demonstrated a massive pericardial effusion. The underlying etiology here was connective tissue disease causing recurrent pericardial effusion. An associated left-sided pleural effusion was noted. Clinicians must be aware of this disorder in the pediatric age group, performing a thorough evaluation in all children with large pericardial effusions, and managing appropriately.

Retinopathy in subjects with type 2 diabetes at a tertiary diabetes clinic in Durban, South Africa: Clinical, biochemical and genetic factors

Aim

To determine the prevalence of clinical and laboratory variables and genetic polymorphisms in association with diabetic retinopathy (DR) in subjects with type 2 diabetes attending a tertiary referral diabetes clinic in Durban, South Africa.

Methods

Cross-sectional study on 292 Indian and African patients with type 2 diabetes (71.5% women). The presence of DR was determined by direct ophthalmoscopy. Clinical and laboratory data were collected and polymorphisms in the NOS3 (rs61722009, rs2070744, rs1799983) and VEGF (rs35569394, rs2010963) genes were determined.

Results

DR was present in 113 (39%) subjects. Those with DR were older (60.6 ± 9.6 vs. 55.4 ± 12.9 years, p = 0.005), had longer duration diabetes (18.5 ± 8.8 vs. 11.9 ± 9.2 years, p < 0.0001), higher HbA_1c (9.2 ± 1.8 vs. 8.8 ± 1.7%, p = 0.049), serum creatinine (106.3 ± 90.2 vs. 75.2 ± 33.4 μmol/l), triglycerides (2.1 ± 1.2 vs. 1.9 ± 1.6 mmol/l, p = 0.042), proteinuria (72% vs. 28%, p = 0.001), and used more insulin (78% vs. 39% p = 0.0001), anti-hypertensive (95% vs. 80%, p = 0.0003) and lipid-lowering therapy (70% vs. 56%, p = 0.023). There was no association between DR and any of the NOS3 or VEGF gene polymorphisms studied, although there were ethnic differences. After adjustment, diabetes duration (OR 1.05, 95% CI 1.01–1.08), presence of proteinuria (OR 4.15, 95% CI 1.70–10.11) and use of insulin therapy (OR 3.38, 95% CI 1.60–7.12) were associated with DR.

Conclusion

Hyperglycemia, duration of diabetes and proteinuria are associated with DR in Indian and African patients in South Africa, whereas NOS3 and VEGF gene polymorphisms were not associated with DR.

Satisfaction with pharmacy services and its relationships with the control of selected chronic diseases

OBJECTIVE

To assess the level of satisfaction with pharmacy services and whether satisfaction/dissatisfaction had any effect on two common chronic diseases. Proper control of chronic diseases requires a management regime which includes promotive, preventive, curative and rehabilitative services through primary, secondary and tertiary preventive intervention measures and a wide range of support services.

METHODS

A cross-sectional descriptive study with both quantitative and qualitative components was designed to collect data from among all diabetic and hypertensive patients (n = 150) attending 3 health centres in the parish of St Thomas on the days that data were being collected. The questionnaires were interviewer administered. Qualitative data were obtained from focus group discussions which explored themes related to the objectives.

RESULTS

Though there was overall satisfaction with the pharmacy services studied, the level of control of the two diseases was unsatisfactory. There was no relationship between hypertension control and satisfaction with pharmacy services while the relationship with diabetes mellitus control was limited to a very weak negative association with the rating of the pharmacists' instructions on how to take the prescribed medications.

CONCLUSION

"Satisfactory Pharmacy Services" could be improved by the employment of additional staff improvement in how drugs are stocked, greater availability of generic drugs and more utilization of health cards.

The need for gender specific tobacco control strategies KAP survey findings on environmental tobacco smoke exposure among women in the reproductive age group

OBJECTIVE

The study was done to assess knowledge, attitudes and practices of women within the child bearing age with regard to smoking and exposure to environmental tobacco smoke (ETS) on children's health.

SUBJECTS AND METHODS

A cross-sectional study with quantitative and qualitative components was designed to collect data from women in the child-bearing age. The sample comprised of persons from the two largest combined family planning and antenatal clinics in Kingston, Jamaica.

RESULTS

The women surveyed had a fair level of knowledge about ETS health risks, negative attitudes to smoking in general, and most supported a ban on smoking in public places. Significant knowledge differences existed between young and older women and between smokers and non-smokers.

CONCLUSION

Women with the highest level of knowledge were the non-smokers: of the low knowledge score group (current smokers), 50% were in the 15-24-year age range. There is a need for more public education on smoking and the consequences of environmental tobacco smoke exposure on children's health.

Chorionicity determination in twin pregnancies: how accurate are we?

OBJECTIVES

To determine the accuracy of antenatal prediction of chorionicity in twin pregnancies in our institution.

METHODS

Antenatal chorionicity was determined using the number of placental masses, the presence or absence of a twin peak sign and the fetal sex. The gestational age at assessment was documented. Postnatal diagnosis of chorionicity was determined by neonatal sex and placental pathology.

RESULTS

Chorionicity was correctly determined in 95% of cases (n = 131); 91% of the monochorionic and 96% of the dichorionic pregnancies were correctly determined. If chorionicity was assessed prior to 14 weeks' gestation (n = 96) the correct diagnosis was made in all except one case.

CONCLUSIONS

Ultrasound assessment of chorionicity has a high sensitivity and specificity. This is further improved if the assessment is performed prior to 14 weeks' gestation.

Obturator hernia repair--a new technique

Obturator hernia is a rare condition with few reports in the world literature. There appears to be no consensus on the ideal approach and repair for such a condition. We report a simple, quick technique via a lower midline incision using an autogenous peritoneal fold. It is ideal for the contaminated case and in settings where mesh is not readily available.

Eating problems and the observed quality of mother-daughter interactions among girls with type 1 diabetes

This study examined how eating problems are linked to autonomy and intimacy in the observed interactions of 88 diabetic girls (M = 14.9 years) and their mothers. On the basis of self-reported symptoms, teens were classified as having no eating problems (n = 40), mild eating problems (n = 30), and frequent eating problems (n = 18). Mothers and daughters participated in 2 videotaped problem-solving tasks (1 diabetes related and I a general parent-teen issue) that were rated with a macroanalytic coding system (Autonomy and Intimacy Rating System). Compared with interactions among mothers and daughters with no eating problems, interactions among mothers and daughters with eating problems simultaneously constrained the expression of autonomy and intimacy. Findings support clinical theory that links eating problems to emotional misattunement in the mother-daughter relationship, which is postulated to interfere with the teen's capacity for individuation.

Interval between fetal measurements in predicting growth restriction

OBJECTIVE

To determine the influence of the interval between fetal measurements on performance of fetal growth velocity for predicting infants with anthropometric features of fetal growth restriction (FGR).

METHODS

Two hundred seventy-four low-risk women had serial fetal biometry at scheduled intervals. Growth velocity of the fetal abdominal area for each was calculated with 2-, 4-, and 6-week scan intervals in which the second measurement was the last scan before delivery. Fetal abdominal area velocity over a 4-week interval in the early third trimester also was included. Fetal growth restriction was defined as skinfold thickness under the tenth percentile, ponderal index under the 25th percentile, midarm circumference-to-occipitofrontal circumference ratio of under -1 standard deviation (SD). Test performance was expressed as likelihood ratios with 95% confidence intervals (CI).

RESULTS

Fetal abdominal area velocity calculated over a 4-week interval predicted FGR with a likelihood ratio of 10.4 (95% CI 3.9, 26) for skinfold thickness; 9.5 (95% CI 4.6, 19) for ponderal index; and 4.7 (2.3, 8.4) for midarm circumference-to-occipitofrontal circumference ratio. Intermeasurement intervals of 6 weeks had a likelihood ratio of 8.5 (95% CI 4, 17) for skinfold thickness; 7.5 (95% CI 3.4, 16.1) for ponderal index; and 14 (6.7, 28) for midarm circumference-to-occipitofrontal circumference ratio. The likelihood ratios for the 2-week interval and the early third trimester 4-week interval were all less than 5.

CONCLUSION

Four- and 6-week measurement intervals were useful for predicting infants with FGR and were superior to a 2-week interval. Fetal growth velocity is influenced by proximity of the last fetal measurement to date of delivery, which adversely affects clinical use of growth velocity for predicting FGR.

Eating disorders in young women with type 1 diabetes. Prevalence, problems and prevention

Disordered eating attitudes and behavior are common and persistent in adolescent and young adult females with type 1 diabetes, and are associated with impaired metabolic control and a higher risk of diabetes-related complications. Specific aspects of diabetes and its management, e.g. weight gain associated with initiation of insulin treatment or improved metabolic control, and dietary restraint, may trigger the body dissatisfaction and drive for thinness that accompany eating disturbances. Health care providers should be aware of the possible association between eating disturbances and diabetes, and also of the types of behavior, particularly insulin omission for weight loss, that are common in these young women. Therapy will depend on the severity of the eating disturbance. Group psychoeducation, incorporating a nondeprivational approach to eating, may prove effective, especially in those with milder degrees of eating and weight psychopathology.

Successful anticoagulation with dalteparin in a patient with mechanical heart valves

BACKGROUND

Standard thromboprophylaxis of patients with mechanical heart valves is achieved using warfarin. In certain patients this may be very difficult; thus, alternative pharmacotherapy must be used.

OBJECTIVE

To report a case of a patient who successfully used dalteparin, a low-molecular-weight heparin, for anticoagulation.

CASE SUMMARY

A 58-year-old white woman with mechanical aortic and mitral heart valves initially received warfarin for anticoagulation. Thromboprophylaxis was very challenging. Her international normalized ratios (INRs) were erratic and occasionally responded paradoxically to changes in dose. Finally, she experienced a left hemispheric stroke when her INR was extremely subtherapeutic. Subsequently, despite best efforts, her INR again was subtherapeutic; warfarin was discontinued and dalteparin was initiated with daily self-administered subcutaneous injections of 16 000 units. No complications have arisen since initiation of the new pharmacotherapy approximately 18 months ago.

DISCUSSION

The use of low-molecular-weight heparin for the treatment and prevention of venous thromboembolism is well described. There are few reports of its use for thromboprophylaxis of patients with mechanical heart valves. Our patient has been managed successfully with dalteparin.

CONCLUSIONS

Dalteparin was effectively and safely used for the thromboprophylaxis of a patient with mechanical heart valves whose anticoagulation was previously difficult to manage with warfarin. Dalteparin deserves further study in patients who are unable to tolerate warfarin.

Family factors in adolescent unipolar depression

This paper reviews the current literature on the contribution of family factors to unipolar depression among adolescents. Research which examined the following factors was reviewed and evaluated: genetic transmission, parental depression, parental death, quality of attachment and family interaction. Studies had to meet the following criteria to be included: publication must have been between the years 1985 and 1992; the evaluation had to be empirical with some form of control; a dependent measure of family characteristics or functioning; the adolescent had to be between the ages of 13 to 19; and the adolescent had to meet the recognizable criteria for unipolar depression. Recent literature suggests that adolescents suffering from depression share a number of risk factors: a family history of affective disorder, inept or inadequate parenting, abrasive interactions within the family and insecure attachments. At this time, there is no evidence that these aversive interactions predate the disorder. Weaknesses in the current literature are identified and strategies for improving future research are proposed.