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Postgraduate district hospital training in Zambia
966
FREQUENCY OF AMI, DEATHS DUETO AMI, GASTROINTESTINAL BLEEDING, AND BLEEDING DUODENAL ULCERS IN SPLIT HOSPITAL IN COMPARABLE PERIODS IN 1990, 1991, AND 1992
efficiency needed to cope with the serious health problems challenging east and central Africa. Management Sciences for Health, 165 Allandale Road, Boston, Massachusetts 2130, USA
R. O. LAING
Department of Community Medicine, University of Zimbabwe Medical School,
C. H. TODD
Harare, Zimbabwe
G!B==gastromtestma! bleed Ing; DUB=duodenal ulcer bleedmg. *Total no of admissions’ 1990=600 ; 1991 =545; 1992-688. total no of admissions. tPercentages are of no of AMIand GIB, respectively. ip < 0.01 vs 1991.
Percentages
are
year, and 1992, when the war in Bosnia and Hercegovina began to have an effect (table). Contrary to the experience in IsraeF and Zagreb, we noted no rise in the frequency of AMI in the study period; not even in September when the first sirens were sounded, preventing patients from reaching hospital. Nor did mortality in AMI patients in hospital rise, possibly because of our policy of not evacuating the coronary care unit unless it was clearly endangered. We have only once evacuated, when shells from battleships were landing within 500 m of the hospital. During the study period a slight unexpected decrease in the incidence of gastrointestinal bleeding was noted. However, a substantial increase in bleeding duodenal ulcers was found in the following year (1992), possibly indicating the effects of chronic psychosocial stress in postwar Croatia, and the continuing war in neighbouring Bosnia and Hercegovina. We suggest that adequate consideration should be given to the inevitable psychological and physical stress of evacuation and its negative affect on survival in AMI patients and that it should be avoided whenever reasonably possible. Clinical Hospital Split, 58 000 Split, Croatia
ZVONKO RUMBOLDT DINKO MIRIC IVO BOZIC
Box-plots
of
LOVEL GIUNIO STOJAN POLIC ANTE TONKIC
1. Bergovec M, Mitiatov S, Prpic H, Rogan S, Batarelo V, Sjerobabski V. Acute myocardial infarction among civilians in Zagreb city area. Lancet 1992; 339: 303. 2. Meisel SR, Kutz I, Dayan KI, et al. Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 1991; 338:
SIR,-Dr Campbell (March 20, p 763) comments on my use of the term 95 % CI in my commentary on box-plots and suggests that I had confused statistics of estimation and description. I had intended to suggest that it had become common to give the values that would include the inner 95% of the data, based on the mean ± 1.96 x SD. I did not mean the "confidence interval of the mean" which would have to be calculated from the SE. It seems that the term 95 % CI cannot be used for the inner 95 % range of data, and I thank Campbell for his correction. Department of Clinical Microbiology, University College Hospital, London WC1E 6AU, UK
A. P. R. WILSON
Anaphylactoid reaction after injection of alteplase SIR,-Because alteplase (recombinant tissue plasminogen
[rt-PA], Boehringer Ingelheim) is structurally identical to endogenous t-PA, its administration should not cause anaphylactic reactions. We report a 69-year-old beekeeper who had an acute myocardial infarction. He received glyceryl trinitrate 500 J..lg, nifedipine 10 mg, and aspirin 150 mg orally. A 200 J direct-current shock corrected ventricular fibrillation outside hospital and was followed by intravenous lignocaine before an intravenous bolus of alteplase 50 mg. 25 min later, the patient had gross facial, tongue, and neck oedema. He was unable to speak. Urticaria occurred on the chest and arms. Chlorpheniramine 10 mg and hydrocortisone 200 mg were administered intravenously with resolution of signs over activator
the next hour.
is
Investigations revealed normal functional and quantitative Cl inhibitor, and total haemolytic and C3 and C4 components of complement. Circulating immune complexes were absent. Serum IgG, IgA, and IgM were normal but IgE was 1133 kU/L (normal < 120). His history included atopy. Radioallergoimmunosorbent test (RAST) to honey-bee venom was strongly positive. Plasma samples were taken on days 10 and 90 for t-PA antibody measurement by competitive enzyme-linked immunosorbent assay, by radioimmunoprecipitation, and by a
of districts. In addition to the Zambian initiative there are two other activities addressing the issue. The University of Zimbabwe Medical School has started an innovative programme with support from the Rockefeller Foundation and Centers for Disease Control. This programme, which is aimed at experienced graduate health workers, combines intensive short courses with supervised field work over two years, resulting in the award of an MPH degree. The curriculum is competency-based, with a major emphasis on health services management. Another initiative is by Management Sciences for Health, a Boston-based, non-profit-making health consulting and training organisation. They will be offering an intensive one-month course on management decentralised health services in Harare, Zimbabwe, in June and July, 1993. The course is aimed at providing the management skills needed by clinically trained staff who are in management positions. By recognising the need to improve management skills of district managers, donors have been able to support the improvement in
dot-blot method with radiolabelled t-PA. All three methods yielded detectable antibody while, where appropriate, a positive control rabbit t-PA antibody could be detected at a dilution of 107. Oral aspirin and glyceryl trinitrate were reintroduced while dilute solutions of the contents of a nifedipine capsule, a vial of alteplase (which also contains L-arginine, phosphoric acid, and polysorbate 80), and 0-5 ml lignocaine 2% provoked no allergic response when inoculated intradermally. The patient was discharged on terfenadine 60 mg three times a day and has subsequently reported a decrease in urticarial symptoms. Because testing proved negative, we believe this anaphylactoid reaction was not due to an anribody-anrigen or direct chemical reaction to any of the administered preparations. There is another case report of this reaction in an atopic individual with a history of urticarial rashes, positive RAST to elm-bark pollen, and elevated serum IgE who was infused with rt-PA. This individual also tested t-PA antibody negative with normal Cl esterase inhibitor.! Plasmin is formed in quantity after the administration of rt-PA and activates complement cascade, especially C3a and C5a, which release histamine and other inflammatory mediators. Plasmin also activates the kinin system. In most patients, these effects are clinically insignificant, but our atopic patient had significant activation. Serial measurements of Clr and Cls consumption, and C3a and C5a production during the reaction and measurement of urinary histamine production would have been helpful.
660-61.
Postgraduate district hospital training in Zambia SiR,—The experience in Zambia that you record (Jan 16, p 168)
typical of many east and central African countries. A major difficulty is that doctors are trained in hospitals mainly by clinicians, but when posted to the districts they are expected to act as managers. They may be called district medical officers, but they are responsible for planning, budgeting, allocating resources, supervising staff, monitoring, and evaluating. They have these responsibilities against a background of increased decentralisation
esterase
no
FREQUENCY OF AMI, DEATHS DUETO AMI, GASTROINTESTINAL BLEEDING, AND BLEEDING DUODENAL ULCERS IN SPLIT HOSPITAL IN COMPARABLE PERIODS IN 1990, 1991, AND 1992
efficiency needed to cope with the serious health problems challenging east and central Africa. Management Sciences for Health, 165 Allandale Road, Boston, Massachusetts 2130, USA
R. O. LAING
Department of Community Medicine, University of Zimbabwe Medical School,
C. H. TODD
Harare, Zimbabwe
G!B==gastromtestma! bleed Ing; DUB=duodenal ulcer bleedmg. *Total no of admissions’ 1990=600 ; 1991 =545; 1992-688. total no of admissions. tPercentages are of no of AMIand GIB, respectively. ip < 0.01 vs 1991.
Percentages
are
year, and 1992, when the war in Bosnia and Hercegovina began to have an effect (table). Contrary to the experience in IsraeF and Zagreb, we noted no rise in the frequency of AMI in the study period; not even in September when the first sirens were sounded, preventing patients from reaching hospital. Nor did mortality in AMI patients in hospital rise, possibly because of our policy of not evacuating the coronary care unit unless it was clearly endangered. We have only once evacuated, when shells from battleships were landing within 500 m of the hospital. During the study period a slight unexpected decrease in the incidence of gastrointestinal bleeding was noted. However, a substantial increase in bleeding duodenal ulcers was found in the following year (1992), possibly indicating the effects of chronic psychosocial stress in postwar Croatia, and the continuing war in neighbouring Bosnia and Hercegovina. We suggest that adequate consideration should be given to the inevitable psychological and physical stress of evacuation and its negative affect on survival in AMI patients and that it should be avoided whenever reasonably possible. Clinical Hospital Split, 58 000 Split, Croatia
ZVONKO RUMBOLDT DINKO MIRIC IVO BOZIC
Box-plots
of
LOVEL GIUNIO STOJAN POLIC ANTE TONKIC
1. Bergovec M, Mitiatov S, Prpic H, Rogan S, Batarelo V, Sjerobabski V. Acute myocardial infarction among civilians in Zagreb city area. Lancet 1992; 339: 303. 2. Meisel SR, Kutz I, Dayan KI, et al. Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 1991; 338:
SIR,-Dr Campbell (March 20, p 763) comments on my use of the term 95 % CI in my commentary on box-plots and suggests that I had confused statistics of estimation and description. I had intended to suggest that it had become common to give the values that would include the inner 95% of the data, based on the mean ± 1.96 x SD. I did not mean the "confidence interval of the mean" which would have to be calculated from the SE. It seems that the term 95 % CI cannot be used for the inner 95 % range of data, and I thank Campbell for his correction. Department of Clinical Microbiology, University College Hospital, London WC1E 6AU, UK
A. P. R. WILSON
Anaphylactoid reaction after injection of alteplase SIR,-Because alteplase (recombinant tissue plasminogen
[rt-PA], Boehringer Ingelheim) is structurally identical to endogenous t-PA, its administration should not cause anaphylactic reactions. We report a 69-year-old beekeeper who had an acute myocardial infarction. He received glyceryl trinitrate 500 J..lg, nifedipine 10 mg, and aspirin 150 mg orally. A 200 J direct-current shock corrected ventricular fibrillation outside hospital and was followed by intravenous lignocaine before an intravenous bolus of alteplase 50 mg. 25 min later, the patient had gross facial, tongue, and neck oedema. He was unable to speak. Urticaria occurred on the chest and arms. Chlorpheniramine 10 mg and hydrocortisone 200 mg were administered intravenously with resolution of signs over activator
the next hour.
is
Investigations revealed normal functional and quantitative Cl inhibitor, and total haemolytic and C3 and C4 components of complement. Circulating immune complexes were absent. Serum IgG, IgA, and IgM were normal but IgE was 1133 kU/L (normal < 120). His history included atopy. Radioallergoimmunosorbent test (RAST) to honey-bee venom was strongly positive. Plasma samples were taken on days 10 and 90 for t-PA antibody measurement by competitive enzyme-linked immunosorbent assay, by radioimmunoprecipitation, and by a
of districts. In addition to the Zambian initiative there are two other activities addressing the issue. The University of Zimbabwe Medical School has started an innovative programme with support from the Rockefeller Foundation and Centers for Disease Control. This programme, which is aimed at experienced graduate health workers, combines intensive short courses with supervised field work over two years, resulting in the award of an MPH degree. The curriculum is competency-based, with a major emphasis on health services management. Another initiative is by Management Sciences for Health, a Boston-based, non-profit-making health consulting and training organisation. They will be offering an intensive one-month course on management decentralised health services in Harare, Zimbabwe, in June and July, 1993. The course is aimed at providing the management skills needed by clinically trained staff who are in management positions. By recognising the need to improve management skills of district managers, donors have been able to support the improvement in
dot-blot method with radiolabelled t-PA. All three methods yielded detectable antibody while, where appropriate, a positive control rabbit t-PA antibody could be detected at a dilution of 107. Oral aspirin and glyceryl trinitrate were reintroduced while dilute solutions of the contents of a nifedipine capsule, a vial of alteplase (which also contains L-arginine, phosphoric acid, and polysorbate 80), and 0-5 ml lignocaine 2% provoked no allergic response when inoculated intradermally. The patient was discharged on terfenadine 60 mg three times a day and has subsequently reported a decrease in urticarial symptoms. Because testing proved negative, we believe this anaphylactoid reaction was not due to an anribody-anrigen or direct chemical reaction to any of the administered preparations. There is another case report of this reaction in an atopic individual with a history of urticarial rashes, positive RAST to elm-bark pollen, and elevated serum IgE who was infused with rt-PA. This individual also tested t-PA antibody negative with normal Cl esterase inhibitor.! Plasmin is formed in quantity after the administration of rt-PA and activates complement cascade, especially C3a and C5a, which release histamine and other inflammatory mediators. Plasmin also activates the kinin system. In most patients, these effects are clinically insignificant, but our atopic patient had significant activation. Serial measurements of Clr and Cls consumption, and C3a and C5a production during the reaction and measurement of urinary histamine production would have been helpful.
660-61.
Postgraduate district hospital training in Zambia SiR,—The experience in Zambia that you record (Jan 16, p 168)
typical of many east and central African countries. A major difficulty is that doctors are trained in hospitals mainly by clinicians, but when posted to the districts they are expected to act as managers. They may be called district medical officers, but they are responsible for planning, budgeting, allocating resources, supervising staff, monitoring, and evaluating. They have these responsibilities against a background of increased decentralisation
esterase
no