RESUMEN

BACKGROUND: Influenza and respiratory syncytial virus (RSV) infections cause seasonal excess mortality and hospitalisation in adults (particularly the elderly) in high-income countries. Little information exists on the impact of these infections on adults in Africa. OBJECTIVES: To estimate influenza- and RSV-related adult mortality, stratified by age and hospitalisation in Soweto. STUDY DESIGN: A retrospective hospital-based study in Soweto from 1997 to 1999 to estimate influenza- and RSV-related excess all-cause deaths and hospitalisation using a rate-difference method. The study was based on influenza seasons of varying severity, provided by surveillance data. RESULTS: Influenza seasons were significantly associated with excess mortality in adults across all 3 years, except for 18 - 64-year-olds in 1998. Excess mortality was highest in those > or = 65 years of age: 82.8/100 000 population in the mild 1997 season and 220.9/100 000 in the severe 1998 season. Influenza significantly increased adult medical hospitalisation in the severe 1998 season alone. RSV did not significantly affect mortality or hospitalisation. CONCLUSION: Influenza-related mortality was substantial and disproportionately affected the elderly. Influenza vaccination for the elderly warrants consideration. The RSV-related burden was not significantly increased but merits observation over a longer period.

Asunto(s)

RESUMEN

OBJECTIVES: Little is known about the long-term outcome and mortality patterns in systemic lupus erythematosus (SLE) in sub-Saharan Africa. We undertook a retrospective study of SLE in mainly black, unemployed patients, seen at a tertiary institution in Soweto, South Africa, to determine the causes and predictors of death. METHODS: Demographic, clinical and laboratory data and outcome were extracted from the case records of patients attending the Lupus Clinic at Chris Hani Baragwanath Hospital. RESULTS: Of the 270 case records with a diagnosis of SLE, 226 met the American College of Rheumatology classification criteria for SLE. The female to male ratio was 18 : 1. The mean (s.d.) age at presentation was 34 (12.5) yrs. Arthritis, nephritis and neuropsychiatric disease had a cumulative frequency of 70.4, 43.8 and 15.9% of patients, respectively. During the course of a mean follow-up period of 54.9 months, 193 (85.3%) and 89 (39.3%) patients were treated with oral corticosteroids and immunosuppressive agents, respectively. There were 55 (24.5%) known deaths and 64 (28.6%) patients were lost to follow-up. The estimated 5 yr survival rates were between 57 and 72%, depending on whether the group of patients lost to follow-up was classified in the analysis as either alive or dead. Infection (32.7%) was the commonest cause of death followed by renal failure (16.4%). Univariate analysis revealed that nephritis, neuropsychiatric disease and hypocomplementaemia were associated with an increased mortality, but multivariate analysis showed nephritis as the only significant predictor of mortality. CONCLUSION: Our findings suggest that SLE in indigent South Africans not only carries a poorer prognosis but also the main cause of death, infection and renal failure differ from those reported recently in industrialized Western countries. Nephritis is common in our patients and is the only independent predictor of poor outcome.

Asunto(s)

RESUMEN

Total lymphocyte counts, CD4 T-lymphocyte counts and CD4/CD8 ratios were measured in 30 anti-retroviral-naive HIV-seropositive patients upon hospital admission for acute community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, and again 1 month after resolution of infection. There was a significant depression of the total lymphocyte count (p < 0.005) and CD4 T-lymphocyte count (p < 0.001) in the acute stage of CAP caused by S. pneumoniae, with a subsequent increase in 90% (27/30) of cases after resolution of the infection. There was no significant difference in the CD4/CD8 T-lymphocyte ratio on admission compared with 1 month later (p 0.9).

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: The reasons for failure of continuous ambulatory peritoneal dialysis (CAPD) are varied. Against a background of mass poverty, poor resources, and the cheaper cost of CAPD it is the primary choice of dialysis. The aims of this study were to determine infection rates and document factors responsible for CAPD failure. METHODS: We report a prospective study in a large African tertiary hospital and its community based satellite clinics. Infection rates as well as factors that may influence them were studied. Sites of infections were documented and causes of CAPD failure recorded. All patients qualifying for dialysis from January 1998 to July 1999 were included. RESULTS: Eighty-four patients were enrolled. There were 55 males and 29 females. The mean age was 39+/-10 (range 16-71) years and mean duration on dialysis at the end of the trial period was 17 months. The peritonitis rate was one episode every 27.9 patient months. Attrition to haemodialysis occurred in 16.6% of patients (n=14) and loss to follow-up in 29.8% (n=25). Fourteen patients regained renal function or were transplanted. Peritonitis appeared to be related to a poor BAD-C score (Bara Adapted Dialysis Compliance), i.e. combination of clinical status and clinic visits (P=0.07). The odds ratio for failure of CAPD with peritonitis was 5.3 times higher (confidence interval (CI) 1.7-17.1; P=0.0085). A low BAD-C score was a significant indicator of CAPD 'failure' (P=0.0001). The natural turnover rate of patients was 46%. Home conditions, employment, and education levels did not correlate with CAPD 'failure'. CONCLUSION: The peritonitis rate and aetiology are similar to the developed world. Socioeconomic factors did not appear to play a role in peritonitis rates or CAPD failure.

Asunto(s)

RESUMEN

In a sample of 100 hospitalized human immunodeficiency virus-seropositive black South African patients with CD4 cell counts of <100 cells/mm(3), the point prevalence of disseminated Mycobacterium avium complex infection was 10%, in contrast with other African studies that report that the infection is uncommon. The point prevalence of Mycobacterium tuberculosis was 54%. The clinical and laboratory features of these patients were largely unhelpful in detecting M. avium complex; the BACTEC blood culture (Becton Dickinson) was the only reliable method.

Asunto(s)

RESUMEN

OBJECTIVE: To describe recovery of renal function (RC) in Black South African patients with primary malignant hypertension (MHT) and end-stage renal failure, according to the type of dialysis provided. DESIGN: A retrospective analysis of the records of 31 patients with MHT. SETTING: A university-based, large tertiary-care hospital and its community-based satellite continuous ambulatory peritoneal dialysis (CAPD) clinics. PATIENTS: Only patients with renal failure caused by MHT and who were on dialysis between January 1997 and June 2000. There were 11 patients on peritoneal dialysis (PD) that regained renal function; 11 patients on hemodialysis (HD), none of whom recovered renal function; and 9 patients on PD who did not recover renal function during the same time period. OUTCOME MEASURES: The groups were investigated for variables that might predict RC. RESULTS: Peritoneal dialysis compared with HD was highly significant as an indicator of RC (p < 0.0001), with 60% of patients on PD regaining renal function, versus 0% on HD. Median time to recovery was 300 (150 -365) days. There was no significant difference in decline of mean arterial pressure (MAP) between the groups; MAP declined significantly in all groups (p = 0.00002). All groups received similar drug therapy. In the RC group, initial MAP, kidney size, and urine output tended to be higher and creatinine lower (p = not significant). Dialysis adequacy was similar in the different groups. CONCLUSIONS: This retrospective study suggests there may be benefit from PD as the primary form of dialysis when patients have MHT as a cause of their renal failure. Possible predictors of RC include blood pressure control, initial MAP, initial serum creatinine, initial urine output, and kidney size. Time should be allowed for RC before transplantation is undertaken. Prospective studies are needed to confirm the benefit of CAPD in patients with MHT.

Asunto(s)

RESUMEN

OBJECTIVE: To describe a safe surgical technique for the management of refractory ascites. PATIENTS AND METHOD: Two preterminal patients with respiratory compromise caused by refractory ascites had the long saphenous vein transected at mid-thigh and anastomosed to the peritoneum in the region of the internal inguinal ring. This allowed direct drainage of the ascitic fluid into the vascular system (peritoneosaphenous shunt). RESULTS: The procedure was performed successfully on two patients. The first patient, with cirrhosis, was leading a normal lifestyle without diuretic use at 7 1/2 months' follow-up. The second patient, with cirrhosis and multifocal hepatoma, was fit enough for discharge without medication. CONCLUSION: The peritoneo-saphenous shunt deserves further evaluation as a novel and safe surgical technique for the management of refractory ascites.

Asunto(s)

RESUMEN

This study assesses the long-term (mean 52+/-24 months) performance of the St. Jude Medical (SJM) valve in 200 young (mean age 31+/-13 years) rheumatic patients on low-level warfarin anticoagulation combined with dipyridamole. Follow-up was 95% complete and comprised 867 patient-years. There were 33 deaths (3.8%/patient-year). Death was valve related in 12 cases and due to left ventricular dysfunction in 10. Death due to left ventricular dysfunction occurred earlier after surgery than death due to other causes (10+/-7 vs 29+/-18 months, p <0.005); these patients had larger preoperative left ventricular dimensions than the rest of the group (end-systolic diameter 51+/-13 vs 37+/-16 mm, end-diastolic diameter 66+/-13 vs 50+/-19 mm, p = 0.006). Actuarial probability of survival was 81% at 86 months and probability of event-free survival was 71%. The median international normalized ratio was 1.88+/-0.54. Thromboembolism (13 events) occurred at a linearized rate of 1.5%/patient-year. There were 11 major bleeding episodes (1.3%/patient-year), 4 cases of prosthetic valve endocarditis (0.8%/patient-year), and 12 paraprosthetic leaks (1.4%/patient-year). No valve obstructions or reoperations occurred. Thus, the SJM valve performs well on low-level anticoagulation combined with dipyridamole. Left ventricular dysfunction was a common cause of death in the early postoperative period.

Asunto(s)

Asunto(s)

RESUMEN

The genetic abnormality of multiple endocrine neoplasia type 2A (MEN 2A) has recently been elucidated. Over 95% of families with MEN 2A have an identifiable mutation of the RET proto-oncogene on chromosome 10. This report describes a black South African woman with MEN 2A in whom a mutation of the RET proto-oncogene was identified. Current genetic knowledge and recent changes in clinical practice are presented, with specific reference to the other family members found to be carrying the mutant RET gene.

Asunto(s)