Comparison of doctor and patient assessments of asthma control.

INTRODUCTION: The objective of asthma management is to control the condition. However, world-wide surveys reveal that only 5% of asthmatics are well controlled. One reason for this phenomenon is the fact that patients and doctors consistently over-estimate control. This study compared patient and doctor assessment of asthma control. METHODS: A random sample of asthmatics was identified by practitioners in South Africa. Patients completed an Asthma Control Test (ACT) and provided a list of medications currently being taken. The doctor also provided an assessment of control which was summarised into the categories - 'not controlled' and 'controlled' and listed all medications prescribed. RESULTS: The mean ACT score was 12.8 where doctors assessed the patients as being 'not controlled' and 20.7 where doctors assessed the patients as being 'controlled'. Half of the patients classified themselves as being 'not controlled' (ACT score <20, category 1), while doctors classified only 33% of patients as being 'not controlled'. Although only 7% of patients disagreed with the doctor's classification of 'not controlled', 29% disagreed with the doctor's assessment of being 'controlled'. There was a significant difference in ACT score between the sexes (p < 0.0001). Most therapeutic interventions (with the exception of combination products [ICS + LABA]) performed poorly with regard to level of control. CONCLUSION: This study suggests that asthma still appears to be relatively poorly controlled in South Africa, although levels of patient control appear to have improved compared to previous surveys, and confirms that physicians and patients differ in their assessments of asthma control.

Pseudomonas aeruginosa bacteraemia in an academic hospital in South Africa.

OBJECTIVES: The aim of the study was to determine the clinical manifestations, outcome of and prognostic factors associated with Pseudomonas aeruginosa bacteraemia at Chris Hani Baragwanath Hospital, Johannesburg, during the period 1998 - 1999, to describe and quantify resistance to antipseudomonal drugs, to characterise bacteraemic isolates, and to investigate the clustering and genotype distribution of drug-susceptible and multiply-resistant strains in the hospital. METHODS: Clinical and laboratory investigations, culture and antimicrobial susceptibility testing were performed. Bacteraemic isolates were typed by endonuclease macrorestriction. Those with > or = 97% band pattern similarity were assigned genotype status. RESULTS: Of 91 P. aeruginosa blood isolates, 52 (57.1%) were nosocomially acquired. Underlying conditions associated with episodes were burns in 24 (28%) and HIV infection in 21 (24%). Multidrug resistance was present in 14 (15.4%) of isolates from 91 episodes. In 79 episodes where the outcome was known, 37 (46.8%) of the patients died. Case fatality rates were 75% in adults and 25% in children. Being a child, receiving appropriate antimicrobial treatment and admission to a specialised care unit were significantly associated with improved prognosis. CONCLUSION: P. aeruginosa bacteraemia was associated with outbreaks caused by two multiply-resistant genotypes. Eighteen antimicrobial-susceptible isolates from bacteraemic episodes in paediatric wards, 9 in HIV-seropositive children, could be linked to small outbreaks in both hospitalised and community-based children.

Microbiological impressions of teeth, saliva and dietary fibre can predict caries activity.

OBJECTIVES: Mutans streptococci and Lactobacilli on impressions of teeth and caries tests were used to identify caries prone subjects. METHODS: Twenty-seven dental students were examined for caries initially and after 4 years. At the initial examination plaque index; saliva flow, buffering capacity and lysozyme; sucrose and fibre consumption; Lactobacilli and mutans streptococci in saliva and on alginate impressions were measured. Data was analysed using Kruskal-Wallis, Wilcoxon-Mann-Whitney and Spearman's Rank correlation tests and linear discriminant analysis. RESULTS: The best predictor of caries increment was decay. Nine subjects had no caries or restored teeth with caries (Group A); 9 had restored teeth with no caries but developed an average of 8 new decayed surfaces (Group B); 9 had an average of 4.4 decayed surfaces and developed a further 9.6 (Group C). Group A had fewer filled surfaces than Group B (p=0.02) and Group C (p=0.024) a higher flow rate of stimulated saliva than Group B (p=0.02) and Group C (p=0.012). Microorganisms were cultured from all decayed teeth, 98% that developed decay, 89% filled and 69% sound teeth. Fibre intake, saliva flow and the percentage of teeth or sound teeth with Lactobacilli and mutans streptococci gave a specificity of 89%, a sensitivity of 100% and predicted an increase in decay in all Group B subjects while one subject from Group A was misclassified. When teeth with microorganisms were excluded four subjects were misclassified. CONCLUSIONS: Growth of cariogenic microorganisms on alginate impressions, saliva flow and dietary fibre predicted caries activity in most subjects.

Procalcitonin and C-reactive protein levels in HIV-positive subjects with tuberculosis and pneumonia.

Pulmonary tuberculosis (PTB) and pneumococcal community-acquired pneumonia (PCAP) are common causes of lower respiratory tract infections in HIV-seropositive patients and may have similar clinical and radiological features. This study aimed to assess the value of serum procalcitonin (PCT) and C-reactive protein (CRP) levels in HIV-seropositive patients with pneumonia, and to investigate their potential role in differentiating pneumococcal from mycobacterial infections. HIV-seropositive patients admitted with pneumonia were evaluated prospectively, 34 with PTB and 33 with PCAP. All 33 patients in the PCAP group and 20 of 34 patients in the PTB group had elevated PCT levels (>0.1 ng x mL(-1)). All patients in both groups had elevated CRP levels (>10 mg x L(-1)). The PTB group had significantly lower CD4 T-lymphocyte counts, lower CRP levels, lower white cell counts, and lower PCT levels than the PCAP group. Receiver operating characteristic analysis showed that optimal discrimination between PTB and PCAP could be performed at a cut-off point of 3 ng x mL(-1) for PCT (sensitivity 81.8%; specificity 82.35%) and 246 mg x L(-1) for CRP (sensitivity 78.8%; specificity 82.3%). In conclusion, HIV-seropositive patients with pneumococcal community-acquired pneumonia had significantly higher procalcitonin and C-reactive protein levels than those with pulmonary tuberculosis. A procalcitonin level >3 ng x mL(-1) and a C-reactive protein level >246 mg x L(-1) were both highly predictive of pneumococcal infection.

Contamination of chicken carcasses in Gauteng, South Africa, by Salmonella, Listeria monocytogenes and Campylobacter.

The presence of the foodborne pathogens, Salmonella spp., Listeria monocytogenes and Campylobacter spp., on 99 fresh and frozen chicken carcasses sourced from various retailers in Gauteng, South Africa, was investigated. Using culture methods, 60.6% of the carcasses were found to be contaminated with one or more pathogens, with 19.2%, 19.2% and 32.3% of the carcasses being found to harbour Salmonella, L. monocytogenes and Campylobacter, respectively. The extent of contamination with one or more pathogens was not significantly different (p>0.1) between fresh or frozen samples or between samples from butcheries, supermarkets or street vendors. Significantly more (p<0.1) fresh carcasses from butcheries than from other outlets were contaminated with Salmonella, while more fresh carcasses from supermarkets were contaminated with Campylobacter. The proportion of carcasses with L. monocytogenes from all sources were similar. Polymerase chain reaction (PCR) results indicate an even higher extent of pathogen contamination, but the PCR techniques need to be further refined before they can be used routinely.

Coronary artery disease and risk factors in Black South Africans--a comparative study.

OBJECTIVE: The purpose of this study was to identify and compare coronary risk factors in different South African ethnic groups with angiographically documented significant coronary artery disease (CAD). DESIGN: An observational retrospective analysis. METHODS: Hospital records of 500 consecutive patients with no previous coronary interventions who underwent coronary angiography at Chris Hani Baragwanath Hospital, Soweto over a 2-year period were reviewed. Patients with significant CAD were selected for this study. Data analyzed included demographics, presenting diagnoses, coronary risk factors, number of coronary arteries significantly affected and extent of CAD, left ventricular ejection fraction (LVEF), and the main treatment modality for CAD. RESULTS: Of the 206 patients with significant CAD, 85 were Africans and 121 were non-Africans. There were significantly more females in the African group (31% vs 12%, P=.0023) and hypertension was more prevalent in the same group (78% vs 55%, P=.0006). Serum total (TC) and low-density lipoprotein (LDL) cholesterol were significantly lower in African than in non-African patients [189.5 (96.67-313.2) vs 228.2 (127.6-464) mg/dL; P=.0006 and 100.5 (34.8-282.3) vs 146.9 (42.54-313.2) mg/dL; P=.0001, respectively]. CONCLUSION: Cholesterol levels in this group of African patients with angiographically significant CAD are within the target range recommended by the adult treatment panel III (ATP III) guidelines of the National Cholesterol Education Program (NCEP). These data have implications for risk assessment using cholesterol and the role of cholesterol lowering treatment in populations of developing countries.

Periodontal pathogens in subgingival plaque of HIV-positive subjects with chronic periodontitis.

Many putative periodontal pathogens associated with periodontal disease in human immunodeficiency virus (HIV)-infected patients also occur in non-HIV-infected individuals. This study examined the prevalence of eight periodontal pathogens in HIV-positive and HIV-negative patients with chronic periodontitis using the 16s RNA polymerase chain reaction technique. The results showed a significant prevalence of Porphyromonas gingivalis and Treponema denticola among HIV-negative patients compared to HIV-positive patients. Sixty percent of the patients in both groups were colonized by five to six species. Odds ratio analysis revealed a statistically significant positive association between three of the 28 possible combinations in the HIV-positive group. They included Prevotella nigrescens/Campylobacter rectus, P. nigrescens/P. gingivalis and P. nigrescens/T. denticola. Although the prevalence of periodontal pathogens is similar in both the groups, the combination of certain periodontal pathogens may be responsible for chronic periodontitis seen in HIV-infected adults.

Reproductive behavioral changes during the ovarian cycle of lesser bushbabies (Galago moholi) in captivity.

Behavioral patterns were quantified in seven heterosexual lesser bushbaby (Galago moholi) pairs during the estrous cycle to determine the relative significance of behavioral and nonbehavioral components of female sexuality in mate attraction. Increases in the occurrence of several male behaviors indicating female attractiveness were initiated during vaginal swelling when the female was sexually nonreceptive. Female behavioral estrus, as indicated by intromission, was confined to a portion of vaginal opening coinciding with proestrous and vaginal estrous smears. Female attractiveness was maintained for much of the period of vaginal opening, whereas female receptivity ended a day or two earlier than attractiveness. Female receptive and proceptive behaviors were not well defined or extensive, and few female behaviors exhibited significant changes during the cycle. Scent-marking behaviors, such as urine washes, and male grooms, were generally elevated outside the behavioral estrous period. In G. moholi, male sexual arousal appears to be elicited primarily by female attractiveness, while behavioral components of female sexuality appear to be less important in influencing mate attraction.

Pediatric admissions with human immunodeficiency virus infection at a regional hospital in Soweto, South Africa.

The prevalence and clinical spectrum of HIV disease in hospitalized African children has not been adequately characterized in Southern Africa. This study aimed to determine the prevalence and disease profile of HIV infected children under 5 years of age admitted to a tertiary care hospital in Soweto, South Africa and to assess the impact of pediatric HIV on health services. Over a 6-month period, serial pediatric admissions to one of the children's wards were screened for HIV. Data on demographics and disease profile were recorded for all patients. A total of 549 patients were admitted, of whom 507 were tested for HIV; 29.2 per cent were considered to be truly infected. Previous admissions to hospital were more frequent in the HIV infected group, 48 per cent compared with 20.4 per cent of HIV uninfected children (p < 0.01), with a median length of stay of 8 days compared with 6 days (p < 0.01). There were more malnourished children in the HIV infected group (65.8 per cent compared with 33.1 per cent) (p < 0.01) and more died (17 per cent compared with 4.6 per cent) (p < 0.01). The most common reasons for admission in all children were infectious diseases such as pneumonia and gastroenteritis (85 and 31.9 per cent compared with 51 and 22.5 per cent, respectively in the HIV infected and uninfected groups, p < 0.01 and p < 0.03). It was concluded that pediatric HIV infection accounts for almost a third of childhood admissions to this hospital and has become a significant burden on the health service.

CD4+ T cell enumeration in HIV infection with limited resources.

The incidence of human immunodeficiency virus (HIV) infection continues to increase in South Africa. Limited resources are available for diagnosis and management of the disease and the development of affordable strategies is required. Absolute CD4 counts are used locally predominantly to monitor disease progression and institute prophylaxis against opportunistic infections. A dramatic increase in demand for CD4 counts prompted an investigation for a more cost-effective flow cytometry method than those currently recommended by the Centers for Disease Control (CDC). CD4 counts generated by two different single tube methods using CD3/CD4/CD8 [1(3)] and CD4 [1(1)] antibodies, respectively, were compared to the CDC recommended 6 tube 2 colour panel [6(2)]. Whole blood analysis using the Coulter Multi-Q-Prep system and an Epics XL Flow Cytometer (Coulter, Hialeah, FL) was performed for each of the three methods. Random samples from HIV positive adult patients were compared. A mean difference in the absolute CD4 counts of less than 10x10(6)/l was generated by both of the alternative panels when compared with the 6(2) panel. The precision of the three methods is comparable. In reagents alone, the 1(3) and 1(1) methods represent a cost saving of 76% and 93%, respectively, over the 6(2) method. The 1(3) and 1(1) panels would permit more affordable CD4 counts to be determined by the gold standard methodology of flow cytometry with no clinically significant sacrifices in accuracy or precision.

Pregnancy- and lactation-related folate deficiency in South Africa--a case for folate food fortification.

OBJECTIVE: Characterisation of patients presenting with megaloblastic anaemia according to clinical, sociological, haematological and aetiological aspects of their disease, and use of these findings to increase awareness among clinicians and to make recommendations regarding changes in national health policy. METHODS: This study included 104 patients presenting with megaloblastic anaemia to a large referral hospital over a 1-year period. Data were collected and analysed in terms of age, gender, parity, gravidity, duration of lactation, socio-economic status, geographical origins, diet, previous haematinic treatment, clinical presentation and haematological measurements. RESULTS: The most common cause of megaloblastic anaemia was pernicious anaemia or probable pernicious anaemia (50%), followed by pregnancy- and lactation-related folate deficiency (32%); of these patients, the majority (28) presented postpartum while lactating; 5 patients were in the immediate puerperal period of 6 weeks, and a further 16 were seen during the first year and 7 during the second year following delivery. Only 4 patients were pregnant, and it is noteworthy that 2 of these were still lactating at 34 weeks' gestation. CONCLUSION: Pregnancy- and lactation-related folate deficiency up to 2 years after delivery remains a common cause of megaloblastic anaemia in South Africa. Certain communities in rural South Africa have recently been shown to have high incidences of both neural tube defects and folate deficiency. The fortification of a staple food (e.g. maize or flour) with folic acid is feasible, inexpensive, safe and likely to be beneficial. This practice should reduce the prevalences of megaloblastic anaemia in fertile women, neural tube defects, other congenital abnormalities, intra-uterine growth retardation, prematurity and possibly cardiovascular disease. There is urgent need for a national policy in this regard.

The value of the intrinsic factor antibody test in diagnosing pernicious anaemia.

OBJECTIVE: Assessment of the usefulness of the intrinsic factor antibody (IF Ab) test in comparison to the Schilling test in diagnosing pernicious anaemia (PA) in patients with vitamin B12 deficiency. DESIGN: This study was designed to compare the If Ab test to the Schilling test using results obtained of patients presenting with megaloblastic anaemia and low serum vitamin B12 levels to a large referral hospital. SETTING: The Chris Hani Baragwanath Hospital, Soweto, Gauteng, South Africa. SUBJECTS: Results from 77 patients with megaloblastic anaemia, low serum vitamin B12 levels and with both Schilling and IF Ab test results available were included. MAIN OUTCOME MEASURES: The sensitivity and specificity of the IF Ab test was compared to the Schilling test with regard to making a diagnosis of PA in patients presenting with megaloblastic anaemia and low serum vitamin B12 levels. RESULTS: Relevant statistical analysis showed that in the correct clinical setting, a confident diagnosis of PA could be made without Schilling tests in patients with megaloblastic anaemia, vitamin B12 deficiency and positive IF Ab tests. In a small proportion of patients in whom the IF Ab is negative, Schilling tests still need to be performed. CONCLUSION: With the increased concern over rising medical costs and where limited facilities are available, the IF Ab, in the correct clinical setting, is a cost effective and reliable test for diagnosis of PA.

Effects of suboptimal intra-uterine growth on preterm infants between 30 and 32 weeks' gestation.

OBJECTIVE: To investigate the affects of suboptimal intra-uterine growth on the outcome of low-birth-weight (LBW) infants. DESIGN: Prospective observational study. SETTING: Neonatal unit of a tertiary care hospital. PATIENTS: A total of 104 LBW infants with a gestation of 30-32 weeks were selected from a larger cohort that had previously been studied to ascertain the prevalence of respiratory distress syndrome (RDS) and periventricular-intraventricular haemorrhage (PV-IVH). OUTCOME MEASURES: Multivariate analysis was used to examine the association between RDS, PV-IVH and death, and the adequacy of intra-uterine growth. RESULTS: Infants with a higher birth weight ratio or birth weight > or = 25th percentile had an increased risk of developing RDS, particularly where ventilatory support was required. However, PV-IVH was associated with immediate perinatal events and not with intra-uterine growth. Mortality was not affected by intra-uterine growth, since those < 25th percentile. In spite of being at lower risk for RDS, showed a trend towards more infection-related deaths. CONCLUSIONS: The 'intra-uterine stress' experienced by infants with suboptimal intra-uterine growth appears to protect partially against RDS, but confers no overall advantage in terms of survival.

Biochemical aspects of a study of 100 obese white subjects.

The effect of a 7 100 kilojoule diet (50% of the energy derived from carbohydrate, mainly unrefined, 30% from fat, mainly unsaturated, and 20% from protein) on 100 overweight subjects was investigated. It was found that 45% of subjects did not complete the study, 9% continued with the study but did not lose weight, 25% lost weight moderately well and 21% responded very well and lost a mean of 15,9 kg over a 6-9 month period. Very little indication of water retention was found. The following biochemical changes occurred during the study period: 1. There was a marked improvement in the glucose tolerance of the groups that lost weight effectively. 2. This improvement in glucose tolerance was associated with a very marked decrease in the secretion of immuno-reactive insulin. 3. The tendency for serum cholesterol and triglyceride levels to decrease during the study was also evidenced in the changes which occurred in the lipoprotein electrophoresis patterns. Stepwise discriminant analysis performed on biochemical, clinical and psychological data failed to provide a practical means of discriminating in advance between the likely response of subjects to this dietary therapy with acceptable accuracy.