Improving indicators of tuberculosis program cascades by leveraging HIV program strategies.

BACKGROUND: To improve rates of human immunodeficiency virus (HIV) case detection and treatment, the Nigerian Ministry of Defense Health Implementation Program and the US Army Medical Research Directorate-Africa/Nigeria introduced a HIV standard of care (SOC) package. Given the integration of tuberculosis (TB) and HIV programs and evolving policies, we evaluated the impact of this strategy on TB program indicators. METHODS: Routine, de-identified program data from 27 Nigerian military hospitals were analyzed. Using Wilcoxon signed-rank test, bivariate analyses were performed to compare data from 12 months before and after implementation of the SOC package. RESULTS: Our data showed improvements post-implementation as follows: the number of individuals receiving antiretroviral therapy (ART) screened for TB increased from 14 530 to 29 467 (P < 0.001); the number of individuals with presumptive TB identified increased from 803 to 1800 (P < 0.001); the number of ART clients bacteriologically tested for TB increased from 746 to 1717 (P < 0.001); and the number of ART clients treated for TB increased from 152 to 282 (P < 0.001). Newly registered or relapsed TB cases increased from 436 to 906 (P < 0.001), the number of TB cases with known HIV status increased from 437 to 837 (P < 0.001), the number of TB-HIV co-infected cases increased from 182 to 301 (P = 0.006), and the number of TB-HIV co-infected clients who started ART increased from 101 to 176 (P = 0.003). CONCLUSION: The implementation of the updated HIV SOC package led to the improvement in key TB diagnosis and treatment indicators. When emulated, this could help improve the performance of other TB programs in countries other than Nigeria.

Prednisone improves renal function and proteinuria in human immunodeficiency virus-associated nephropathy.

PURPOSE: To determine if prednisone ameliorates the course of human immunodeficiency virus-associated nephropathy (HIV-AN). PATIENTS AND METHODS: Twenty consecutive HIV-infected adults with biopsy-proven HIV-AN (n = 17) or clinical characteristics of HIV-AN (n = 3) with serum creatinine concentrations > 177 mumol/L (2 mg/dL) or proteinuria > 2.0 g/d or both were prospectively evaluated and treated with prednisone at a dose of 60 mg/d for 2 to 11 weeks, followed by a tapering course of prednisone over a 2- to 26-week period. Serum creatinine concentration, 24-hour protein excretion, serum albumin, and steroid-related adverse effects were assessed before and after treatment. RESULTS: Nineteen patients had serum creatinine concentrations > 117 mumol/L (2 mg/dL). Two of them progressed to end stage renal disease (ESRD) in 4 to 5 weeks. In 17 patients serum creatinine levels decreased from 717 +/- 103 mumol/L (8.1 +/- mg/dL) (mean +/- SE) to 262 +/- 31 mumol/L (3.0 +/- 0.4 mg/dL) (P < 0.001). Five patients relapsed after prednisone was discontinued and were retreated. In these 5 the serum creatinine declined from 728 +/- 107 mumol/L (8.2 +/- 1.2 mg/dL) to 344 +/- 47 mumol/L (3.9 +/- 0.5 mg/dL) (P < 0.01) in response to the second course of prednisone. Twelve of 13 tested patients showed a reduction in 24-hour urinary protein excretion with an average decrement from 9.1 +/- 1.8 g/d to 3.2 +/- 0.6 g/d (P < 0.005). Serum albumin increased from 24.4 +/- 3.6 g/L to 29.3 +/- 2.6 g/L (P = NS) in the 11 patients with paired 24-hour urine collections for whom pre- and post-treatment determinations were available. In one non-azotemic patient with nephrotic syndrome, protein excretion declined from 15.2 to 2.2 g/day and the serum albumin increased from 4.0 g/L to 31.0 g/L. The 20 patients have been followed for a median of 44 weeks (range 8 to 107). Eight ultimately required maintenance dialysis. Eleven died from complications of HIV disease 14 to 107 weeks after institution of prednisone; none was receiving prednisone at the time of death. Seven are alive and free from ESRD a median of 25 weeks (range 8 to 81) from the initiation of prednisone therapy. Six patients developed a total of seven serious infections while receiving prednisone, including Mycobacterium avium-complex infection in 2 and CMV retinitis in 3. CONCLUSION: Prednisone improves serum creatinine and proteinuria in a substantial proportion of adults with HIV-AN. Corticosteroid-related side effects are not prohibitive. A prospective, randomized controlled trial is required to confirm these preliminary results.

Some observations on the oxidation phenotype status of Nigerian patients presenting with cancer.

The hypothesis is being explored that there may be an association between genetically determined oxidation status and propensity to develop carcinoma in response to environmental chemical carcinogens. For this purpose, the genetic structure of a normal, healthy Nigerian population with respect to oxidation status, has been compared with that found for a group of 59 Nigerian patients presenting with carcinoma of the liver and gastrointestinal tract. Genetically determined oxidation status was assessed by measuring the extent of oxidation of a probe drug, debrisoquine, to its major metabolite, 4-hydroxydebrisoquine. The cancer group contained a disproportionately large number of individuals who were extensive oxidizers compared to the controls (2 P = 0.0045). The findings support the view that genetically determined oxidation status may be an important host factor in influencing responsiveness to chemical carcinogens that require oxidative metabolic activation.

Alternating left anterior hemiblock without associated tachycardia.

This case report describes a 64-year-old woman with a cardiomyopathy and associated fascicular conduction disturbances partly related to digitalis therapy. Electrocardiograms showed incomplete left bundle branch block with left anterior hemiblock the latter, consistently changing in pattern and rhythm as in bidirectional tachycardia but at a relatively normal heart rate. The relationship of severe myocardial disease to the apparent likelihood of pre-existing depression of fascicular conduction in cases of bidirectional tachycardia precipitated by digitalis, is exemplified.

Early onset and significance of imcomplete left posterior hemiblock in Nigerians.

Following detailed clinical and electrocardiographic analysis, twenty-five patients with incomplete left posterior hemiblock without associated complete right or left bundle branch block are presented. First-degree atrioventricular block was relatively common in these patients and associated incomplete right or left bundle branch block was also present in a few. Hypertension was the commonest underlying cardiovascular disease but two of them, without any clinically overt cardiovascular disease, presented with a history of episodic dizziness or syncopal attacks. With the present knowledge of the anatomy and histopathology of intraventricular conduction system, the relevance of tendency for Africans to form excessive fibrous tissue has been emphasized. Considering the unexpectedly low average age of these patients, suggestions have been made with a view to reducing the rate of progression of such atrioventricular conduction defects to the need for implanted cardiac pacemakers.

Serum immunoglobulins and complement in nephrotic syndrome.

Serum concentrations of IgG, IgM and complement components C3 and C4 were estimated in thirty-one adult Nigerian patients with nephrotic syndrome; twenty-eight of whom had 'active' disease, while three were in remission. Eleven normal adults served as controls. The mean serum IgG was significantly lower, while the mean serum IgM was higher in the patients with active disease than in the controls. Similarly mean serum C3 and C4 levels were statistically significantly higher (P less than 0.05) in active disease than in normal controls. These findings in Nigerian patients are similar to those observed in Caucasians, and further support the role of a fundamental immunological defect in the pathogenesis of the nephrotic syndrome.

Role of hepatitis Bs antigen in chronic glomerulonephritides in Nigerians.

Using enzyme-linked immunosorbent assay technique (Boehring Institute Laboratory), eighty-one adult patients were studied for hepatitis Bs antigenaemia. Nine of the patients had asymptomatic persistent proteinuria, thirty-nine, nephrotic syndrome, and thirty-three had profuse proteinuria, azotoaemia and hypertension. The histopathology obtained in forty showed twenty-two with MCGN, four with focal glomerulosclerosis, three with proliferative glomerulonephritis, one with minimal change glomerulonephritis and ten with end-stage kidney disease. None of the patients had apparent clinical evidence of liver disease nor a past history of jaundice. One hundred and eighty apparently normal adults served as controls; 33.3% of the patients had positive hepatitis Bs antigenaemia, in contrast to 6% (P less than 0.001) in the normal controls. Hepatitis Bs antigenaemia was more prevalent in the groups with nephrotic syndrome and persistent asymptomatic proteinuria than in the group with advanced renal failure. Hepatitis Bs antigenaemia was detected in all histopathologic forms but was most prevalent in the MCGN (P less than 0.001) which is also the more commonly encountered lesion. The implications of these findings are discussed.

Recovery of renal function after 33 days of complete bilateral ureteric obstruction.

Bilateral ureteric ligation is a rare complication of hysterectomy. We report a case of prompt recovery of renal function following release of bilateral ureteric ligation persisting for 33 days.

Prolonged prednisolone therapy in adult nephrotic syndrome: a preliminary study.

Twenty-five adult Nigerian patients suffering from the nephrotic syndrome with normocomplementaemic mesangiocapillary glomerulonephritis were studied. Twelve of these were treated with prednisolone at a dose of 1.5 mg/kg body weight/day, with maximum dose of 90 mg/day initially for 2 weeks. Thereafter, a quarter of the daily dose was given on alternate days for a period varying from 6 to 12 months. The 13 others were similarly followed up on a dietary and diuretic regime alone. Oedema disappeared completely in all the steroid group except one, whilst it persisted in five of the controls. Proteinuria persisted in all the controls but remitted in five of the test patients. Renal function deteriorated with rising plasma creatinine in five of the controls, in contrast with one of the test patients. The beneficial effect of prednisolone observed here calls for further long-term studies.

A study of the debrisoquine hydroxylation polymorphism in a Nigerian population.

1. The metabolic oxidation of debrisoquine has been studied in a group of 123 Nigerian volunteers. 2. All subjects excreted unchanged drug together with five oxidation products, namely, 4-, 5-, 6-, 7- and 8-hydroxy-debrisoquine. 3. The 4-hydroxylation reaction exhibits polymorphism; ten subjects were defective in their ability to effect this reaction. 4. The incidence (q) of the allele governing impaired 4-hydroxylation (DL) among Nigerians was calculated as being 0.28 (95% confidence limit of 0.20-0.37). 5. An association was demonstrated between the ability to effect 4-hydroxylation and 6- and 7-hydroxylation of debrisoquine, suggesting that the alleles controlling alicyclic oxidation also influence aromatic hydroxylation.