African Journals Online
Nigerian Quarterly Journal of Hospital Medicine

Volume 12 Nos 1- 4 Jan-Dec 2002
ABSTRACTS

Hepatitis C Infection And Risk Of Chronic Liver Disease In Lagos

¹O. A. Lesi, ²M.O. Kehinde, ³E. E. Anomneze and ⁴S. S. Wali

Department of Medicine, College of Medicine, University of Lagos

²Mount Pleasant Medical Center, 65 Ojuelegbe Rd, Lagos

³Department of Medicine, Aminu Kano University Teaching Hospital, Kano

Correspondence: O. A. Lesi

Abstract

Objectives: This case-control study sets out to investigate the prevalence of antibodies to hepatitis C virus (anti-HCV) and its association with the presence of hepatitis B surface antigen (HBsAg) in Nigerians with chronic liver disease.

Method: Seventy-four (74) biopsy proven cases of chronic liver disease and 74 age and sex matched controls without liver disease were evaluated. Questionnaire interview for risk factors was administered to all subjects. Anti-HCV was determined using a highly sensitive third generation enzyme immuno-assay (ELISA 3, Ortho Diagnostics Systems Gmbh, Germany). Hepatitis B surface antigen was evaluated using an ELISA test system (Murex Diagnostics Limited, UK).

Results: The prevalence of anti-HCV was significantly higher in patients with chronic liver disease than in the controls (12.2% vs 1.4%, p=<0.02). Anti -HCV was detected more frequently in HBsAg negative cases: 26% (8/31) compared with 2.3% (1/43) in HBsAg positive cases (p=0.003). The co-existence of anti-HCV and HBsAg was unusual and noted in only one (1.4%) patient. Twenty-three (31.4%) of the seventy-four patients had neither HBsAg nor antibodies to HCV.

Conclusion: HCV infection, like HBV appears to be an independent risk factor for CLD. It however occurs most frequently in HBsAg negative patients. Dual infection with both HBV and HCV appears uncommon in Nigerian patients with chronic liver disease.

KEYWORDS: Hepatitis B and C infection, case-control, liver cirrhosis, hepatocellular carcinoma

The Interaction Between Carotid Baroreceptor and Chemoreceptor Relexes on Cardiopulmonary Responses in Anaesthetized Cats

¹S.O Elias and ²O.A. Sofola

Department of Physiology

Lagos State University College of Medicine, Ikeja, Lagos, College of Medicine, University of Lagos, Nigeria.

Correspondence:S. O. Elias

Abstract

Hypertension and hypoxia often occur together in the clinical setting implying that the carotid baroreceptor and carotid chemoreceptors are affected simultaneously. This work was designed to study the effects of increased reflex sympathetic activity following carotid baroreceptor and chemoreceptor stimulation on reflex cardiopulmonary responses. The effects of unilateral carotid occlusion and chemoreceptor stimulation by intracarotid injection of sodium dithionite were studied singly and combined in 15 anaesthetized cats. Combined activation of the receptors resulted in responses that were generally more than the individual responses to activation of the receptors. We conclude that there is an interaction between the carotid baroreflex and chemoreflex but this, though synergistic is not additive.

Does Diagnosis of Hypertension Prevent Stroke? A Preliminary Investigation of Relative Frequency of Undiagnosed and Previously Diagnosed Hypertension Before First Stroke in a Lagos Hospital

¹N. U. Okubadejo,² F. I. Ojini, ³C. O. Dawoda and ⁴M. A. Danesi

Department of Medicine, College of Medicine, University of Lagos, Nigeria.

Correspondence: N. U. Okubadejo

Abstract

Introduction: The present study was designed to determine the relative frequency of previously diagnosed and undiagnosed hypertension in first stroke in order to evaluate if previous diagnosis of hypertension can prevent stroke.

Patients and Methods: One hundred and twenty nine first stroke patients presenting at the emergency unit of a tertiary hospital in Lagos, Nigeria, were prospectively studied. Presence of hypertension and other modifiable risk factors was documented. History of diagnosis of hypertension before onset of focal neurological features was sought to categorize patients as having either known (previously diagnosed) or unknown (previously undiagnosed) hypertension.

Results: Significantly higher percentage of the 102 first stroke patients with hypertension were known hypertensives (77.4% versus 22.6% unknown). This was so irrespective of whether the patients had other modifiable risk factors.

Conclusion: Majority of our patients presenting with stroke were previously diagnosed hypertensives. Thus, diagnosing hypertension alone does not prevent stroke. Further studies are required to clearly define the impact of inadequate blood pressure control after diagnosis of hypertension (including poor drug compliance) and other risk factors.

Effects of Malaria on Blood Pressure, Heart Rate, Electrocardiogram and Cardiovascular Response to Change in Posture

C. N. Anigbogu and O. A. Olubowale

Department of Physiology,College of Medicine, University of Lagos, Idi- Araba, Nigeria.

Correspondence: C. N. Anigbogu

Abstract

The effect of malaria on blood pressure, heart rate, electrocardiogram and the cardiovascular responses to postural change were studied in malaria patients. Blood pressure was measured by the sphygmomanometric-auscultatory method. Standard ECG machine was used to record the electrocardiogram. Heart rate was obtained from the radial pulse or computed from the ECG.

Systolic blood pressure was lower in malaria patients compared with normal control subjects (106±3.4mmHg cf 120±2.0mmHg, p<0.05), Mean arterial pressure (MAP) was also lower (75±3.1 cf 91±1.7mmHg, p<0.05). Heart rates were higher in malaria patients (98±1.8 beats/min cf 66±2.1 beats/min, p<0.01). Change in posture from supine to standing resulted in immediate fall in blood pressure this was more pronounced in malaria patients. Heart rate showed little or no change in the control group but fell significantly, (from 98±1.0beats/min to 86±1.9beats/min, (p<0.05), in the first minute in malaria patients. Thereafter blood pressure and heart rate recovered completely within the 6min observation period. The ECG pattern showed little or no difference in control and malaria groups, however the amplitude of the QRS complex was lower in the malaria patients (2.2±0.2mV cf 2.9±0.3 mV, p<0.05). There was also a slight reduction in amplitude of the T waves (0.3±0.06mV cf 0.5±0.04mV, p<0.05). These results show that malaria may lower blood pressure, cause tachycardia and affect response to change in posture. Malaria may also reduce electrical activity of the heart.

Keywords: Blood pressure, Heart rate, ECG, Malaria, change in posture

Perinatal Mortality Among Twins In Lagos University Teaching Hospital : Associated Risk Factors.

¹E. N Ekure and ²E. O Iroha

Department of Paediatrics, Lagos University Teaching Hospital, P. M. B. 12003, Lagos, Nigeria.

Correspondence: N. Ekure

Abstract

Background: Perinatal mortality rate is reported to be higher in twins than in singletons. More than two decades ago, Abudu and Agarin reported a twinning rate of 21.1/1000 maternities and perinatal mortality rate of 142.6/1000 among twins in Lagos.

Objective: To determine the current perinatal mortality rate and risk factors that influence perinatal mortality among twins in Lagos University Teaching Hospital, Nigeria.

Materials and Methods: Babies weighing >1000grammes delivered by twin pregnancy between January 1996 and December 2000 in Lagos University Teaching Hospital were retrospectively studied. Routinely collected data from nurses and doctors registers in the departments of Obstetrics and Paediatrics on all twin deliveries was analysed.

Results: Out of 5,947 deliveries, there were158 set of twins’ giving a twinning rate of 26.6/1000 for the institution. Fifteen of the babies weighed <1000g and so were excluded leaving 301 babies. Twenty-seven babies weighing >1000g died perinatally giving a perinatal mortality rate of 89.7/1000.

The significant risk factors for perinatal mortality identified in twins were lack of antenatal care (P=0.005), low gestational age and premature delivery (P<0.005), low birth weight especially <2000g (<0.001), like-sex pair (P=0.01) and breech presentation (P=0.05).

Conclusion: All multiple pregnancies should be supervised in institutions with facilities for premature care and babies who weigh <2000g, belong to like-sex pair or have breech presentation should be specially cared for by personnel trained in neonatal care because of a significant risk of perinatal mortality.

Serum Levels of Thyroid Hormones and Thyrotropin in Some Sickle Cell Anaemia Patients in Lagos

^*I. I. Olatunji-Bello and E. Igbinovia

Department of Physiology,  College of Medicine of the University of Lagos, P. M. B. 12003, Lagos

E-mail: [email protected] 

Correspondence: I. I. Olatunji-Bello

Abstract

Previous studies have shown that the rate of erythropoiesis is increased in sickle cell anaemia patients and that erythropoietin, which stimulates this process, is influenced by the thyroid hormone. This study was therefore designed in order to elucidate levels of the thyroid hormones in some patients with sickle cell anaemia attending a Lagos based Clinic.

The serum levels of the thyroid hormones (T₄ and T₃) and thyrotropin (TSH) were measured by radio-immunoassay (RIA) in the steady state of 10 homozygous sickle cell anaemia patients and 10 normal subjects of the same age group in years (15-25) who were the control group.

The results showed that sickle cell disease resulted in a decrease in serum triiodothyronine (T₃) from 1.68 ± 0.14 ng/ml in the control to 1.22 ± 0.18ng/ml in sickle cell disease. This was however, not significant (P= 0.059). The serum thyroxine (T₄) level was also slightly lower in the sickle cell anaemia patients (84.8 ± 4.70 ng/ml as compared with 95.8 ± 5.20ng/ml in the control subjects (P = 0.134). However, the serum TSH was significantly higher (P = 0.015) in the sickle cell anaemia patients with a value of 3.90± 0.32 µIU/ml when compared with that of the control which was 2.68 ± 0.32 µIU/ml.

The results indicate that although there was an increase in TSH, the thyroid gland was unresponsive to its effect thus the thyroid function remained unchanged in sickle cell anaemia.

Clinical Electrocardiographic and Echocardiographic Features of Atrial Fibrillation in Nigerians: An Analysis of 39 Patients Seen at the Lagos University Teaching Hospital

A. C. Mbakwem, J. N. A, Ajuluchukwu and D. A. Oke

Department of MedicineCollege of Medicine, University of Lagos, Nigeria.

Correspondence: A. C. Mbakwem

Abstract

Purpose: To evaluate the clinical, electrocardiographic (ECG) and echocardiograhic features of adult Nigerians presenting with atrial Fibrillation (AF) at the cardiology unit.

Method: All consenting patients presenting to the cardiology unit of LUTH from September 2000 to September 2001 with ECG evidence of AF were recruited into the study. Demographic and anthropometric data were obtained. The subjects had a full clinical examination. 2D and M-mode echocardiogram was performed on the subjects.

Result. Of the 39 subjects analysed there were 22 females and 17 males with a mean age of 54.49±14.60. The underlying heart disease distribution was as follows: hypertensive heart disease 46.2%; dilated cardiomyopathy 20.8%; rheumatic heart disease 17.9%; thyrotoxic heart disease 7.7%; hypertrophic cardiomyopathy 5.1%, lone 2.6%. About 23% were asymptomatic for the arrhythmia at diagnosis. Congestive cardiac failure was present in 74% of the subjects with a mean NYHA class of about III. Embolic phenomenon was observed in 15% of the subjects; 12.8% cerebral events and 2.6% limb embolism. Abnormal QRS axis was noted in 33.3%. Ectopic ventricular beats were as follows: uniform ectopics 30.8%; multiform ectopics 10.3% and unsustained ventricular tachycardia 7.7%. Abnormal echocardiographic features are as follows: dilated left atrium 33( 84.62%); abnormal thickness of the interventricular septum and posterior wall 12(30.77%) and 19(48.71%) respectively;Increased left ventricular internal diameter in diastole 20(51.3%) and in systole 25(64.10%); reduced fractional shortening 30(76.9%); spontaneous echoes 7(18.0%) and intramural thrombus 2(5.1%)

Conclusion: Commonest underlying heart disease for AF in this study was hypertensive heart disease. Congestive cardiac failure was a frequently documented clinical feature and cerebral embolism remains a very common complication.

School Health: A New Awakening Needed

¹A. O. O. Oduwole and ²E. Odomokwu

¹Department of Paediatrics,Lagos University Teaching Hospital

²Clinique-De- Mercy specialist hospital, Lagos.

Correspondence: A. O. O. Oduwole

Abstract

This study was designed to observe the pattern of health problems and prevalence of audio-visual disability in two selected private nursery and primary schools attended by middle to high - income social class children. To also compare their Body Mass Index (BMI) with the BMI growth chart 2000 of the United States of America.

From the study the most common clinical problem was Acute Respiratory Infection, which was seen in 5.46% of the studied population. Allergy, in the form of allergic rhinitis, conjunctivitis, dermatitis and bronchial asthma constituted 18.49% of the studied population. Analysis of their BMI showed that they were not overweight or obese and compared favourably with children from developed nations.

Admission Blood Pressure of Stroke Patients and Its Relationship to One-week Case Fatality - A Preliminary Study

¹F. I. Ojini, ²N. U. Okubadejo, ³S. A. Ogun, ⁴S. I. Akokhia and ⁵M. A. Danesi

^1,2,5Department of Medicine, CMUL

³Ogun State University Teaching Hospital, Sapmay

⁴Lagos University Teaching Hospital, Lagos Nigeria

Correspondence: F. I. Ojini

Abstract

Background: High blood pressure is often said to be associated with poor outcome in stroke. However, there remains some uncertainly about the relationship of blood pressure to mortality in stroke.

Objective: This study seeks to determine the influence of admission blood pressure on early mortality of stroke patients at the Lagos University Teaching Hospital (LUTH).

Methods: Clinical and laboratory data were collected prospectively according to a standardized protocol, from stroke patients admitted to LUTH in 1999 and 2000, and information obtained about the time of onset of stroke, history of hypertension, level of consciousness, admission blood pressure, ECG findings of left ventricular hypertrophy, and one-week outcome.

Results: hypertension was present in 87.3% of strokes on presentation. Strokes with mild to moderate hypertension had the lowest case fatality of 5.6%, while those with isolated systolic hypertension had the highest fatality of 40%. There was a u-shaped relationship between admission blood pressure and one-week case fatality, with strokes that had mild to moderate hypertension having a significantly lower one-week case fatality than strokes with normal blood pressure and severe hypertension

Conclusion: Most patients with stroke have hypertension on presentation. It appears that mild to moderate hypertension on presentation is associated with a significantly better one-week outcome for stroke patients than other categories of blood pressure.

Jatropha Curcas Seed Oil Linn (Euphor Biaceae): Contraceptive Activity And An Oral Formulation.

Odusote OM¹, Abioye AO², and³ Rotibi MO.      

Department of Pharmaceutics¹ and Pharm.Technology² School of Pharmacy, College of Medicine, University of Lagos, Nigeria.

Correspondence: Mercy O. Odusote

Abstract

The pharmacological screening of the oil of Jatropha curcas revealed a remarkable contraceptive activity. Doses up to 1g/kg have promising contraceptive activity without any form of toxicity. However, doses from 2g/kg caused significant acute toxicity in rats. None of the rats administered with J. curcas seed oil produced pup compared to control group, which produced a total of 10 pups. It was evident that the contraceptive activity in rats was due to the J. curcas seed oil. The contraceptive activity of the seed oil increase with concentration to a maximal at 1g/kg. Toxicity also increased with concentration, and 0.5g/kg, a concentration where no death was recorded was chosen as a relatively safe dose in rats. Attempts were made to formulate a stable oral emulsion from the oil. Formulations with 2; 2:1 oil, water, gum ratio gave better stability than those with 4: 2:1 ratio over a study period of 5 weeks. It was obvious that J. curcas seed oil is a volatile oil. It was also observed that tragacanth formed more stable primary emulsions than acacia gum. It was concluded that Jatropha curcas seed oil has significant contraceptive activity and it could be formulated into stable oral emulsion at doses not exceeding 0.5g/kg.

An Investigation into the Effect of Testosterone on Plasma Triglyceride and Cholesterol Levels.

Adegoke O.A ¹ and Nweke M.L.²

Department of Physiology, College of Medicine, University of Lagos, Nigeria.

Correspondence: O.A. Adegoke

Abstract

Studies have shown that in the male, tissue fat storage increases with age and the accompanying decrease in testosterone level. It is also widely accepted that elevated plasma levels of triglycerides and cholesterol are important risk factors for the development of cardiovascular diseases. The present work was therefore designed to study the effect of testosterone on plasma triglyceride and cholesterol levels.

Experiments were carried out on 30 intact adult male rats weighing 200-300gm. The rats were divided randomly into six groups that received different treatments of testosterone, adrenaline, and propranolol. Blood samples were obtained from all the rats by cardiac puncture and plasma samples were assayed for triglyceride and cholesterol.

Results of the study showed that testosterone caused a significant elevation of plasma triglyceride, and also enhanced an adrenaline-induced increase in plasma triglyceride. Propranolol treatment inhibited the increase in plasma triglyceride induced by testosterone. Plasma cholesterol level did not change with testosterone treatment although a combined treatment of testosterone and adrenaline caused a significant increase in cholesterol level, suggesting a synergistic action.

The Impact of Housing in Paediatrics Burns Cases: A Review of Health Implication of Habitat in Centre Families in Lagos.

¹U. E. Afiomah, ²O. A. Oduwole and ³J. K. Renner

¹National Hospital, Abuja

²Lecturer Lagos University Teaching Hospital

³ Senior Lecturer, Lagos university Teaching Hospital

Correspondence: U. E. Afiomah

Abstract

Objective: To determine the impact of housing on paediatric Burns Cases in Lagos

Design: Prospective Study

Subject: 40 children aged 10 days to 10 years admitted for Management after sustaining burns

Main Outcome Measurements: Housing plays a significant role in paediatric Burns Cases.

Results: 70% of a total of 40 Paediatric burns patients had moderate severe burns. These were from one apartment room while only two of them lived in a two-room apartment. 85% of the patients were from low social-economic cadre. All the burns occurred intramural.

Conclusion: Housing plays a significant role in burn cases in Urban Lagos. This is related to the poor housing situation which has a direct bearing on the Social Status of the parents of victims.

Antimicrobial Activities of Some Medicinal Plants from Soba-Zaria, Nigeria.

¹J. D. Dada, ²P. I. Alade, ³A. A. Ahmad, and ⁴L. H. Yadock

Department of Microbiology, Ahmadu Bello University, Zaria

²Department of Clinical Pharmacology, University of Ilorin Nigeria

Correspondence: J. D. Dada

Abstract

Six medicinal plants commonly used by traditional herbalists for treatment of various microbial infections in soba- Zaria, were collected for a study of their antibacterial activities. The plants studied are: Jacaranda mimosaides (J. mimosaides); Striga hermonthetica (S. hermonthetica); Psidium quajava (P. quajava); Azadiractha indica (A. indica); Citrus lemon; and Indigofera arrecta (I. arrecta).

Crude extracts of the plants were tested against clinical isolates of Salmonella typhis Neisseria gonorrhoea and Shioella dysenteriae. Their minimum inhibition concentration (M.I.C.) were determined by the serial dilution technique.

Crude extracts of the plants were found to have some activity against the test organisms. S. hermothetica used for livestock liver disease showed activity against Shigella dysenteriae at a very low broth dilution.

A. Indica, and J. Mimosaides; showed activity against Salmonella typhi and Shigella dysenteriae at low concentrations. Citrus lemon and I. arrecta did not show activity against any of the test organisms. Some of the results provide scientific evidence for the use of the plants by the traditional herbalists in the treatment of microbial infection.

The Miracicidal and Cercaricidal Activity Of the Methanolic Extracts Of Lagenaria breviflora Robert Family Cucurbitaceae Fruit On Schistosoma mansoni.

^1*G. O. Ajayi, ²N. C. Awujo and ³L. E. Abulu

¹Departments of Pharmacogonosy and

²Medical Microbiology and Parasitology, College of Medicine, University of Lagos, P. M. B. 12003,Lagos, Nigeria.

Correspondence: G. O. Ajayi

Abstract

Experiments were conducted on the miracicidal and cercaricidal activity of various concentrations of the methanolic extracts of the seed and pulp of Lagenaria breviflora on Schistosoma mansoni miracidia and cercariae using the methanolic extract of Tetrapleura tetraptera (Aridan) as control, 1mg/ml of aridan, the seed and pulp extracts of L. breviflora each resulted in a 100% kill of both the miracidia and cercariae at 60 minutes. At this same exposure period, lower concentrations (0.25mg/ml) of Aridan, seed and pulp extracts of L. breviflora eliminated 0%, 100% and 40% of the miracidia respectively. Lower concentrations (0.125mg/ml) of the extracts of the seed and pulp of L. breviflora eliminated 100% and 80% of the cercariae respectively. Higher concentrations of these extracts were potently miracicidal and cercericidal. The results obtained indicate that the use of the methanolic extracts of Lagenaria breviflora as miracicidal and cercaricidal substances even at concentrations lower than that of the control (Aridan), a known miracicidal and cercaricidal agent, will be an additional effective agent in the control of the transmission of schistosomiasis.

KEYWORDS: Schistosoma mansoni, cercariae, miracidia, Lagenaria breviflora.

Evaluation of Chest Pain in Ambulatory Patients in Lagos, Using the Rose Questionnaire and Resting Electrocardiogram.

J. N. A, Ajuluchukwu and A. C. Mbakwem

Department of Medicine, College of Medicine, University of Lagos, Nigeria.

Correspondence: J. N. A. Ajuluchukwu

Abstract

Purpose: Using the Rose Questionnaire, we aimed to study the characteristics of chronic chest pain in ambulatory care, to find patterns that are consistent with a diagnosis of angina pectoris.

Methods: Patients: Consecutive patients, referred to the Cardiac Out-patient clinic with a major complaint of chest pain of more than one month were included. Exclusion criteria consisted of the presence of congestive heart failure, or recent use of digitalis or beta blockers. The questionnaire for this study was that of the World Health Organisation Cardiovascular Survey/ Rose Questionnaire (RQ) with an additional section designed to obtain data on demography, and descriptive characteristics of chest pain. Angina was according to RQ definition. Health professionals trained in the use of the RQ, administered the instrument. Sub-group analysis was based on the presence and absence of angina.

Results: There were 214 patients, a male : female ratio of 0.8: 1; an average age of 44 years (age range of 16-70 years); 48% were obese (body mass index [BMI]>27 kg/m2) and 59% were over 40 years. The median duration of chest pain was six (6) months. Characteristic features of angina were present as follows: retrosternal location - 40%; pressure - like/constricting pain: 43%; and chest pain aggravated by exertion – 35%. Angina was diagnosed in 7%, whose pain stopped within 10 minutes of “stopping and resting”. Underlying diseases were hypertension-14.9%, Diabetes: 1%, and hypercholesterolaemia: 5.6%. Electrocardiographic (ECG ) abnormalities were common: left ventricular hypertrophy: 59%, ST elevation –25%, T wave inversion-6.5%. No ST depression was noted. Bundle branch block, prolonged PR interval axis deviation were found in less than 1%.

Age, sex, and BMI were comparable in those with and without angina. Features of chest pain without significant association with angina were location, character, duration of single episodes, and aggravation by emotion. However, aggravation by food and exertion distinguished the angina groups (p<0.05), but no ECG features did.

Discussion and conclusion: Prevalence of RQ – detected angina is 7%, indicating that a majority of patients with chronic chest pain had non-cardiac or atypical chest pain. Presence of underlying diseases, pain characteristics, or ECG features did not distinguish those with and without RQ - angina. Further studies are required to elucidate the causes, and prognosis of RQ- angina, in our environment.

Risk of Seizures in First Degree Relatives of Probands with Epilepsy.

N. U. Okubadejo and M. A. Danesi

Department of Medicine, College of Medicine, University of Lagos, Nigeria.

Correspondence: N. U. Okubadejo

Abstract

Objective: To determine the risk of seizures in first degree relatives of epileptic patients. To relate the risk to several clinical characteristics in the probands. Such information is useful for genetic counselling.

Methods: A prospective case-control study of 648 FDR of 88 probands attending the neurology out-patient clinic of a tertiary hospital in Lagos, Nigeria, and 308 FDR of 44 age and sex-matched controls was carried out. History of seizures in all FDR was sought using a survey questionnaire either directly filled by the FDR, probands or both. The risk of seizures in FDR was related to some clinical variables in the probands.

Results: Overall risk of seizures was slightly but insignificantly higher (3.6%) in FDR of probands with epilepsy compared to controls (2.3%) (chitest; p > 0.05). Risk of seizures was highest in offspring of probands (4.3%), and FDR of female probands (4.0% compared to 3.1% in males), probands with seizure onset below 10 years (5.1% compared to 3.1% >10years) and probands with complex partial seizures (4.9% compared to 3.9% for generalized tonic-clonic seizures). The differences did not however reach statistical significance in comparison to the control group (chitest; p > 0.05).

Conclusion: The risk of seizures in FDR of Nigerian probands with epilepsy has a similar profile with that in other environments such as Europe and North America in that it is marginally higher but not significantly different from the risk in the normal population.