The incidence and causes of diarrhoea among critically ill patients receiving enteral tube feeding were investigated. Sixty acutely ill surgical or medical intensive care patients who had had a minimum of 48 hrs bowel rest were entered into the study. They were randomly assigned to receive one of two lactose free liquid formula diets - "Ensure", a commercially available feed containing 825 kCal/L and 34 g/L of protein with an osmolality of 441mOsm/1 or "Casilan Oil", a home-made feed containing 840 kCal /L and 45g/L of protein with an osmolality of 383 mOsm/1. The feeds were administered by constant nasogastric infusion. Patients received 1000ml at a rate of 40ml per hour for the first day and up to 2000ml at 80 ml per hour for the remainder of the study period. Investigations included documentation of medical history, medications administered and clinical details for each patient. Serum albumin was measured and the nutritional status of each patient was assessed using anthropometric measurements. Feeds were tested for bacterial contamination on the three days following the start of feeding and small intestinal bacterial overgrowth was assessed by the 1 g-¹⁴C Xylose breath test of Toskes and King. Twelve of the sixty patients had to be withdrawn from the trial within 24 hours of the start of enteral feeding for medical reasons. The remaining forty eight patients completed at least three days on enteral feeding and thereby became eligible for analysis. In 10/48 patients (21%) diarrhoea was present before enteral feeding began. Four of these 1 O patients continued to pass loose stools when enteral feeding was started while the remaining 6 settled. Diarrhoea developed in a further 10 patients (21%) after enteral feeding began. The overall incidence of diarrhoea in the group of critically ill patients studied was therefore 42% (20/48). However, of the fourteen patients who experienced diarrhoea during enteral feeding four had diarrhoea before feeding began. Therefore, the true incidence of diarrhoea related to enteral feeding was only 10/38 (26%). Furthermore, in 7 of these 10 patients, another possible cause of diarrhoea was present. There was no significant association between diarrhoea and nutritional status, hypoalbuminaemia, sepsis, length of bowel rest, sucralfate and antibiotic therapy other than amikacin. Twenty one patients received Ensure and 27 received Casilan Oil. Despite the differences in the composition of the feeds, the incidence of diarrhoea was similar on the Ensure and the Casilan Oil. No particular factor pertaining to the composition of the feeds was associated with diarrhoea. Significant contamination of feeds was universal but there was no constant relationship between bacterial counts, or types, and the occurrence of diarrhoea. Certain other factors were found to be significantly associated with diarrhoea. Abdominal injury was positively associated with the occurrence of diarrhoea (p<0.05). Diarrhoea could have been attributed to the underlying disease state in 7 of the patients. All three patients who were receiving lactulose as treatment for liver failure developed diarrhoea. While no association was noted between diarrhoea and antibiotic therapy in general, treatment with the antibiotic, amikacin, correlated significantly, albeit marginally, with the occurrence of diarrhoea (p<0.05). Twenty six patients were tested for small intestinal bacterial overgrowth. Only one patient, with an elevated excretion of ¹⁴CO₂, indicative of small intestinal bacterial overgrowth, developed diarrhoea. There was, however, a positive association between diarrhoea and decreased excretion of ¹⁴CO₂. It would appear that the bacterial flora was suppressed in patients with diarrhoea. Amikacin therapy was also associated with decreased excretion of ¹⁴CO₂. This may suggest that amikacin could have altered the bowel flora with resultant development of diarrhoea. While abdominal injury and disease were associated with the development of diarrhoea and amikacin was a possible factor associated with diarrhoea, the results of the present study indicate that enteral tube feeding with either the commercial feed, Ensure or the home-made feed, Casilan Oil was not a cause of diarrhoea in the majority of critically ill patients assessed. Furthermore, in most patients who commenced the trial with diarrhoea, improvement was noted on enteral feeding.

Objective: Paraquat is a commonly used herbicide worldwide and is a well-documented cause of pulmonary fibrosis in studies of laboratory animals and in humans following high dose exposure (usually accidental or as parasuicide). The respiratory effects of long-term, low dose paraquat exposure have not been fully evaluated. We set out to evaluate the possible effects of paraquat spraying among deciduous fruit farm workers in the Western Cape, South Africa. Methods: A cross-sectional study of 126 workers was performed. Administered questionnaires generated information on exposure, respiratory symptoms and confounding variables. Spirometry and gas transfer were measured and chest radiographs performed. Oxygen desaturation on exercise testing was by oximetry during a modified stage one exercise test. Results: No association was found between long-term paraquat exposure and reported symptoms, spirometry (FVC, FEVl, FEVl/FVC) and gas transfer (TLco and Kco) or chest radiography. Multivariate analysis showed a significant relationship between measures of long-term paraquat exposure and arterial oxygen desaturation during exercise (p < 0.05). Conclusion: Previous studies have also not shown a significant relationship between measures of paraquat exposure and standard tests of lung function. Arterial oxygen desaturation during exercise represents a more sensitive test. Our findings indicate that working with paraquat under usual field conditions for a long period is associated with abnormal exercise physiology in a dose dependant fashion.

Photocopies of journal articles. * Agrichemical safety practices on farms in the Western Cape. London L. SA Med J 1994 ; 84 : 273-278. * Notification of pesticide poisoning in the Western Cape 1987 - 1991. London L, Ehrlich R, Rafudien S, Krige F, Vurgarellis P. SA Med J 1994 ; 84 : 269-272. * Critical Issues in agrichemical safety in South Africa. London L, Myers JE. Am J Ind Med 1995 ; 27(1) : 1-14. * Repeatability and validity of a field kit for estimation of cholinesterase in whole blood. London L, Thomson ML, Sacks S, Fuller B, Bachmann OM, Myers JE. Occupational and Environmental Medicine 1995; 52 : 57-64. * Biological Monitoring of workers exposed to organophosphate pesticides: Guidelines for field application. London L. Occupational Health Southern Africa July/August 1995 ; 1(4) : 13-17. / Despite playing an important role in crop protection and increasing food production, chemicals used in agriculture may have a range of unanticipated effects on human health. Such effects may range from overt and acute poisonings to gradual-onset chronic morbidity. In South Africa, data on such morbidity are sparse, and subject to much underreporting as one of the included papers illustrates. The dearth of such data has much to do with the marginalised living and working conditions in agriculture and the lack of attention to occupational and environmental health on farms in the country. We have little sense of the extent of hazardous exposures in agriculture, nor of their health impacts on rural populations. Even less so, have methods for the control of poisoning by pesticides been investigated amongst farm workers in South Africa. A public health response to this problem should aim at all levels of prevention (primary, secondary and tertiary), by characterising the extent and distribution of the problems caused by pesticides, identifying risk factors and groups at highest risk for poisoning, as well as testing intervention strategies and technologies. The set of papers presented below attempts to do that by linking a series of investigations into different aspects of agrichemical hazards in South Africa, with a focus on the Western Cape. The first paper examined various aspects of potential exposure to agrichemicals on farms in the Stellenbosch region, taking into account both environmental and occupational routes of exposure. The second paper describes the profile of agrichemical poisoning in the province from 1987 to 1991, identifying high risk groups and characterising the completeness and nature of reported poisonings. The third paper developed from the author's growing realisation of the need to contextualise problems related to agrichemical exposures and effects within the overall legislative and public health framework in South Africa. This paper therefore identifies the key public health issues that need addressing with regard to pesticide safety. Finally, the last two papers address aspects related to workplace interventions for the prevention of agrichemical poisoning. One paper deals with the evaluation of a field kit (for validity and repeatability) for monitoring workers exposed to organophosphate and carbamate insecticides, while the last paper elaborates guidelines for the use of cholinesterase testing in the primary and secondary prevention of organophosphate and carbamate poisoning. In this series, therefore, the papers attempt to address the problem of agrichemical hazards within a public health framework, tracing the problem from potential exposure to acute outcomes, through reviewing the legislative and occupational health environments, through to technologies and policy guidelines related to workplace intervention. In doing so, the papers use the term "agrichemical" to refer to all chemicals used in agriculture for pest and weed control. This supersedes the term "pesticide" which has ambiguous meanings in the technical environment. Readers are therefore advised to understand the term "agrichemical" to include the generic aspects of chemical usage on crops in agriculture. The research on which these papers was based was spawned by the involvement of the author in a larger research project investigating long-term neurobehavioural effects of organophosphate exposure on deciduous fruit farm workers over the period 1991 - 1994. This latter piece of research is not referred to here as it was the basis for another degree at the University of Cape Town.

This report from Groote Schuur therefore sets out to review cases of postradiation sarcomas, including malignant mixed mullerian tumors (MMMT), presenting to the Radiation Oncology Departments of Groote Schuur Hospital and the affiliated hospitals (Frere Hospital, East London and Provincial Hospital, Port Elizabeth) or known to have occurred in patients initially treated in these hospitals. It aims [1] to establish the features of the initial malignancy as well as the latent period for the development of postradiation sarcoma, the type of postradiation tumor and the outcome of the disease; [2] to establish as accurately as possible dose levels at which the postradiation tumors have developed; and [3] to briefly describe possible risk factors such as a genetic predisposition to the development of malignancy, repeated courses of radiotherapy, surgery as part of the treatment of the initial tumor, and chemotherapy. Questions regarding the genesis of postradiation sarcomas cannot be answered by a review of 20 cases, even when combined with an analysis of literature. This review aims to add relevant information to the body of data from which the final answers may come. In view of the late diagnosis often made in cases of postradiation sarcoma (25, 94) the review also aims to heighten awareness of the condition so that it may be more often reported at a curable stage.

Many South African psychiatrists, and particularly those working in psychiatric hospitals with Black and Coloured patients, have the firm clinical impression that in many of these patients acute psychotic illness is associated with the abuse of cannabis. Most of the previous work in this field had been done by clinicians of Eastern countries where the use of cannabis has been endemic for thousands of years. However, those workers were handicapped because they lacked both the sophisticated techniques for standardized psychiatric evaluation and the availability of an assay to confirm cannabis use. It was decided to investigate acute psychoses in Cape Coloured males admitted to Valkenberg Hospital with the following aims: i. To identify a cohort of acutely psychotic patients who had recently been using cannabis and to compare them with a matched control group who were free of any drugs. The recently available EMITR immunochemical analytical technique was used for the detection of urinary cannabinoids. To exclude the contribution of other psychotropic agents to the aetiology of the psychoses, gas chromatography was performed to detect ethanol and thin-layer chromatography to screen for other psychotropic agents. ii. To assess the comprehensive mental state of patients on admission and then again after a 7-10 day period the Present State Examination (PSE), a well validated and standardized diagnostic instrument, was used. iii. To determine serum creatinine phosphokinase (CPK) and serum lactate dehydrogenase (LDH) levels (indicators of muscle damage) in view of the published reports of elevated levels in psychotic patients.

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The P2Y inhibitor, ticagrelor, has been shown to prevent thrombotic events and hence, improve morbidity and mortality in patients with acute coronary syndrome following coronary artery stent placement. Despite many clinical benefits, ticagrelor has been associated with several adverse effects, including dyspnea, easy bruising, and gastrointestinal bleeding. We report the case of a 67-year-old patient with an acute coronary artery syndrome requiring percutaneous coronary artery intervention with stenting who developed ticagrelor-induced diarrhea. The patient's ticagrelor medication was replaced with clopidogrel, and his diarrhea completely resolved within one week with no complications observed at his one-month follow-up visit. Clinicians should be aware of this adverse effect of ticagrelor so as to guide them toward possible underlying etiologies and appropriate workup of chronic diarrhea.

No description available.