Traditional healers, treatment delay, performance status and death from TB in rural South Africa.

BACKGROUND: People in sub-Saharan Africa frequently consult traditional healers before reaching the government health services (GHS). This can lead to delays in starting effective anti-tuberculosis chemotherapy. To our knowledge, no studies have shown a direct relationship between visiting traditional healers, increased morbidity and death from TB. METHODS: All patients starting on anti-tuberculosis chemotherapy at a rural hospital in South Africa in 2003 were included in the study. TB nurses interviewed the patients and established how long they had had symptoms before treatment was started, whether they had visited traditional healers before coming to the hospital, their performance status and, later, whether they had died. RESULTS: Of 133 patients, those who attended a traditional healer took longer to access anti-tuberculosis chemotherapy (median 90 days, range 0-210) than those who went directly to the GHS (median 21, range 0-120). Patients who visited a traditional healer had worse performance status (P < 0.001), and were more likely to die (24/77 [31%] vs. 4/33 [12%], P = 0.04). CONCLUSION: Treatment delay due to visiting traditional healers can have dire consequences for patients with TB. Efforts are required to engage with health care practitioners outside the government sector to improve the prospects for patients with TB.

Unpaid community volunteers--effective providers of directly observed therapy (DOT) in rural South Africa.

OBJECTIVE: To illustrate successes and difficulties for the South African National Tuberculosis Programme in a rural area. DESIGN: Prospective cohort study. SETTING: Sekhukhuneland, Provincial Health Service Southern Region, Northern Province, South Africa. SUBJECTS: All patients diagnosed with tuberculosis (TB) in the catchment area of four rural hospitals between January 1997 and June 1999. MAIN OUTCOME MEASURES: Standard outcomes for TB treatment as defined by the World Health Organisation. Treatment failure, treatment interruption and death were grouped as poor outcomes. RESULTS: One thousand four hundred and seventy-six people were diagnosed with TB. The majority (76%) had smear-positive pulmonary disease. Treatment was given by directly observed therapy (DOT) throughout in all but 15 instances. Excluding 10 subjects with known multidrug-resistant TB (MDRTB), 723 (66%) were cured, 68 (6%) completed treatment, 73 (7%) interrupted treatment, 37 (3%) failed treatment, 66 (6%) transferred out, and 134 (12%) died. Of the 920 initially smear-positive patients who survived the first 2 months to receive DOT in the community, 693 (75%) were supervised by unpaid community volunteers. Poor outcomes were no more common among patients supervised by these volunteers than among patients supervised by professional health care workers. Male gender (odds ratio 1.38, 95% confidence interval 1.02, 1.87) was significantly associated with a poor outcome. CONCLUSION: Although there were difficulties, the national programme was successfully applied with no additional funds or facilities. Explanations for the high death rate and poor outcomes for men need to be found. Great efforts will be required to preserve the quality of the TB programme if it is devolved to primary care level.

Is the distance a patient lives from hospital a risk factor for death from tuberculosis in rural South Africa?

SETTING: Tuberculosis programmes that rely on district hospitals for diagnosis and initiation of treatment may disadvantage those living furthest away. We present an analysis of such a programme in rural South Africa to see whether those living furthest from the hospital were at greatest risk of dying from tuberculosis. METHODS: All patients diagnosed and treated for tuberculosis in three health districts in 1997 and 1998 were included. An estimate of the distance each patient travelled to get to the hospital was obtained. The distances the patients travelled were categorised into four groups. The furthest distance patients could reasonably be expected to travel to get to their nearest hospital was estimated as 60 km. Outcomes of treatment were recorded using standard definitions. The mortality of patients in each of the four groups was compared. RESULTS: Of 1187 patients started on treatment for tuberculosis in the hospitals, 877 (74%) were known to be alive at the end of treatment, whereas 158 (13%) had died. Distance travelled was a risk factor for death, but only amongst those travelling more than 60 km to get to the hospital (0-20 km: n = 313, odds ratio [OR] 1; >20-40 km: n = 436, OR 1.09, 95% confidence interval [CI] 0.71-1.67; >40-60 km: n = 205, OR 0.97, 95%CI 0.57-1.65; >60 km: n = 79, OR 2.87, 95%CI 1.59-5.17). CONCLUSION: The mortality from tuberculosis was high, even amongst those living closest to the hospital, and did not rise significantly within 60 km. The situation may be different for the relatively small number of patients who come from further away. The distance travelled to hospital for initial diagnosis does not account for the relatively high mortality amongst tuberculosis patients in this area.

Outpatient treatment with epirubicin and oral etoposide in patients with small-cell lung cancer.

To assess the efficacy and toxicity of an outpatient combination chemotherapy in small-cell lung cancer (SCLC), we treated 70 consecutive patients with epirubicin 80 mg m(-2) i.v. on day 1 and etoposide 200 mg o.d. p.o. on days 1-4 (EE) at 3-weekly intervals. The median age of patients was 64 years (range 39-84). The male-female ratio was 42:28 and 35 (50%) had metastatic disease. Fifty-seven patients were evaluable for response. The overall response rate was 64.4%, including 14 (23.7%) complete responses and 24 (40.7%) partial responses. Median time to progression was 7 months in responders and 8 months in patients with limited disease. The median survival in patients with limited disease was 10.5 months (range 0.5-70 +) and 7 months (range 0.5-24) in those with extensive disease. Improvement of symptoms occurred in 79% of patients with shortness of breath, 80% with cough, 81% with haemoptysis and 68% with pain. In 19 patients an increase in body weight was noted. Major (WHO grade 3/4) toxicities were neutropenia in 13 (18.5%) patients, alopecia in 33 (47.1%) patients, mucositis in 15 (21.4%) patients, anorexia in eight patients (11.4%), nausea and vomiting in six patients (8.5%) and diarrhoea in 4 (5.7%) patients. In conclusion, EE is an active and well-tolerated outpatient regimen in the treatment of SCLC. The survival data in this unselected group of patients were disappointing and the possible explanations for this are discussed.

Vegetarian diet as a risk factor for tuberculosis in immigrant south London Asians.

BACKGROUND: In a previous retrospective study of tuberculosis in south London among Asian immigrants from the Indian subcontinent Hindu Asians were found to have a significantly increased risk for tuberculosis compared with Muslims. This finding has been further investigated by examining the role of socioeconomic and lifestyle variables, including diet, as risk factors for tuberculosis in Asian immigrants from the Indian subcontinent resident in south London. METHODS: Using a case-control study technique Asian immigrants from the Indian subcontinent diagnosed with tuberculosis during the past 10 years and two Asian control groups (community and outpatient clinic controls) from the Indian subcontinent were investigated. Cases and community controls were approached by letter. A structured questionnaire concerning a range of demographic, migration, socioeconomic, dietary, and health topics was administered by a single trained interviewer to subjects (56 cases and 100 controls) who agreed to participate. RESULTS: The results confirmed earlier findings that Hindu Asians had an increased risk of tuberculosis compared with Muslims. However, further analysis revealed that religion had no independent influence after adjustment for vegetarianism (common among Hindu Asians). Unadjusted odds ratios for tuberculosis among vegetarians were 2.7 (95% CI 1.1 to 6.4) using community controls, and 4.3 (95% CI 1.8 to 10.4) using clinic controls. There was a trend of increasing risk of tuberculosis with decreasing frequency of meat or fish consumption. Lactovegetarians had an 8.5 fold risk (95% CI 1.6 to 45.4) compared with daily meat/fish eaters. Adjustment for a range of other socioeconomic, migration, and lifestyle variables made little difference to the relative risks derived using either community or clinic controls. CONCLUSIONS: These results indicate that a vegetarian diet is an independent risk factor for tuberculosis in immigrant Asians. The mechanism is unexplained. However, vitamin D deficiency, common among vegetarian Asians in south London, is known to affect immunological competence. Decreased immunocompetence associated with a vegetarian diet might result in increased mycobacterial reactivation among Asians from the Indian subcontinent.

Unusual cause of orthopnoea: primary tracheal tumour mimicking left ventricular failure.

An 84 year old woman who was a heavy smoker presented with clinical features suggestive of acute exacerbation of chronic obstructive lung disease complicated by left ventricular failure. She responded poorly to treatment and then the finding of stridor, only when she was in the supine position, led to the diagnosis of a primary tracheal tumour, a rare but important cause of unexplained shortness of breath.

Positional dyspnoea due to aneurysm of the thoracic aorta.

Thoracic aortic aneurysms may produce breathlessness by compressing the tracheobronchial tree. We report a patient whose shortness of breath demonstrated a marked positional component, due to varying compression of her major airways by the lesion.

Lung abscess: a neglected cause of life threatening haemoptysis.

Three cases who presented with life threatening haemoptysis are reported, all of whom required surgery to control the bleeding. In all three patients chronic lung abscess was responsible for the haemoptysis. Even in the absence of typical clinical or radiographic features of an abscess this diagnosis should be considered in any patient presenting with life threatening haemoptysis.

Risk of tuberculosis in immigrant Asians: culturally acquired immunodeficiency?

Study of the 620 Asian immigrants with tuberculosis notified in the Wandsworth area of south London between 1973 and 1988 showed a bimodal pattern of tuberculosis notifications: in 1977 there was a peak among Asians from East Africa, and in 1981 a peak among those from the Indian subcontinent. There was a mean lag time of five years between clinical presentation and immigration. Logit analysis showed that, although overall more men had tuberculosis than women, glandular tuberculosis was more common among women of all groups, and pulmonary tuberculosis was more common among Hindu women than Hindu men. Both subgroups of Asians had a substantially higher incidence of tuberculosis than white people, particularly at extrapulmonary sites. Hindus were also at a significantly greater risk of tuberculosis at all sites than Muslims (Hindu:Muslim risk ratio 5.5 for women and 3.7 for men). The increased susceptibility to tuberculosis of Hindus, particularly Hindu women, may be related to a culturally acquired immunodeficiency caused by vegetarianism and associated vitamin deficiency.

Mediastinitis and bilateral thoracic empyemas complicating adult epiglottitis.

A 32 year old woman developed life threatening mediastinitis and bilateral empyemas as a complication of adult epiglottitis. She recovered completely.

Topical nasal anaesthesia for fibreoptic bronchoscopy: patients' preference for lignocaine gel.

Two techniques for anaesthetising the nose before fibreoptic bronchoscopy have been compared. Fourteen of 16 patients given lignocaine spray found it unpleasant, compared with three of 20 patients given lignocaine gel. The two forms of local anaesthetic were found to be equally effective. Lignocaine gel is therefore recommended for topical nasal anaesthesia before fibreoptic bronchoscopy.