Strategic response to COVID-19 in Ethiopia.

COVID-19, the novel coronavirus, has posed a major threat to low- and middle-income countries (LMICs) due to inadequate health infrastructure and human resources. Ethiopia, a low-income country with the second largest population in Africa, has coordinated a strategic response, leveraging existing infrastructure and health systems and mobilizing public health professionals and specialist expert physicians for a multifaceted, unified government approach and adaptive response. Resource limitations, particularly in critical care, have still posed challenges, but the public health and clinical interventions thus far have prevented the catastrophic toll that many predicted. As the pandemic continues, Ethiopia expects to use a triple care model integrated at all levels, consisting of COVID-19 care, isolation care for suspected cases, and essential health services, and urges intensified non-pharmaceutical interventions alongside equitable global vaccine distribution as the ultimate answers to pandemic control. This paper draws on existing data, national planning and guidelines, and expertise from health leadership to describe this response in hopes of providing an example of how future large-scale health challenges might be faced in LMICs, using Ethiopia's successes and challenges in facing the pandemic.

COVID-19, le nouveau coronavirus, a représenté une menace majeure pour les pays à revenu faible et intermédiaire (LMIC) en raison de l'insuffisance des infrastructures de santé et des ressources humaines. L'Éthiopie, un pays à faible revenu dont la population est la deuxième plus importante d'Afrique, a coordonné une réponse stratégique, en tirant parti des infrastructures et des systèmes de santé existants et en mobilisant des professionnels de la santé publique et des médecins experts spécialisés pour une approche gouvernementale unifiée à multiples facettes et une réponse adaptative. Les ressources limitées, notamment en matière de soins intensifs, ont encore posé des problèmes, mais les interventions cliniques et de santé publique menées jusqu'à présent ont permis d'éviter le bilan catastrophique que beaucoup prédisaient. Alors que la pandémie se poursuit, l'Éthiopie prévoit d'utiliser un modèle de soins triple intégré à tous les niveaux, composé de soins COVID-19, de soins d'isolement pour les cas suspects et de services de santé essentiels, et préconise l'intensification des interventions non pharmaceutiques parallèlement à une distribution équitable des vaccins à l'échelle mondiale comme réponses ultimes au contrôle de la pandémie. Cet article s'appuie sur les données existantes, la planification et les directives nationales, et l'expertise des responsables de la santé pour décrire cette réponse dans l'espoir de fournir un exemple de la manière dont les futurs défis sanitaires à grande échelle pourraient être relevés dans les LMIC, en utilisant les succès et les défis de l'Éthiopie face à la pandémie.

Neuroleptic malignant syndrome and dopaminergic blockade.

After receiving 90 mg of haloperidol and 100 mg of chlorpromazine hydrochloride within 25 hours, a 29-year-old man was found to have neuroleptic malignant syndrome (NMS), characterized by the acute onset of hyperpyrexia, extreme muscular rigidity, autonomic instability, and coma. Subsequently, rhabdomyolysis developed, with myoglobinuric renal failure and bilateral anterior tibial compartment syndromes. The patient's initial neuroleptic levels were in the therapeutic and nontoxic ranges. He was treated with supportive measures and his clinical improvement was paralleled by decreased neuroleptic levels, a return toward normal of an elevated prolactin level, and an increased responsiveness to a dopamine hydrochloride infusion. This supports an association between NMS and dopamine receptor blockade.

Should supplemental estrogens be used as steroid-sparing agents in asthmatic women?

OBJECTIVE: To determine if supplemental estrogens should be used as steroid-sparing agents in asthmatic women. DESIGN: Case series. SETTING: Ambulatory care, community hospital. PATIENTS: Volunteer sample of three steroid-dependent asthmatic women. INTERVENTION: Addition of conjugated estrogens to existing asthma treatment. MAIN OUTCOME MEASURE: Ability to decrease oral steroid requirement. RESULTS: The mean age of the women was 55 +/- 11 years; two were former smokers (cases 1 and 2) and one was a nonsmoker (case 3). One women (case 3) was premenopausal and noted worsening of her asthma before and during menses. The other two women (cases 1 and 2) were postmenopausal. All three had been symptomatic from their asthma for 13.2 +/- 7.6 years. Each woman was being treated with maximal doses of inhaled albuterol, inhaled steroids, and therapeutic theophylline doses. Despite this aggressive management, all three women required daily supplemental steroids (mean dose, 26.7 +/- 11.5 mg of prednisone). Case 3 was started on a regimen of norethindrone/ethinyl estradiol 1/35, and cases 2 and 3 were begun on regimens of daily conjugated estrogen, 0.625 mg. Over the next 12 to 24 weeks, the conditions of all three women were symptomatically improved and their steroid therapy was discontinued. In addition, steroid-associated side effects of hypertension, weight gain, osteoporosis, and easy bruising lessened. CONCLUSION: Although this new observation of the steroid-sparing effect of estrogens remains preliminary, further study may help advance understanding of the mechanisms and treatment of asthma in women.

Severe precocious emphysema in intravenous methylphenidate (Ritalin) abusers.

Intravenous (IV) drug abuse is known to cause pulmonary tale granulomatosis. Reports have documented a syndrome of pulmonary vascular sclerosis in long-term IV methylphenidate users. Although this would be expected to produce restrictive lung disease, we hereby report six patients who have severe obstructive lung disease. All had used IV methylphenidate for at least four years. One of these patients died of progressive respiratory insufficiency and the others are clinically disabled. Their symptoms and airflow obstruction are more severe than those of most patients with chronic obstructive pulmonary disease. In these individuals, we cannot say that precocious obstructive lung disease is not due to a combination of smoking and other factors, nor can we be certain that methylphenidate is the offending agent. However, this cluster of cases among methylphenidate abusers suggests that long-term IV exposure to this drug might lead to early severe obstructive lung disease.

Laser treatment of endobronchial extramedullary plasmacytoma.

A 68-year-old man presented with an endobronchial lesion and was subsequently found to have a plasmacytoma. After systemic involvement with multiple myeloma was ruled out, a diagnosis of extramedullary plasmacytoma was made. The diagnosis and treatment of extramedullary plasmacytoma is discussed with specific attention to the new role of laser therapy in this disease.

A clinical and structural comparison of industrial methacholine and provocholine.

Methacholine, provided by industrial sources, has traditionally been used in studies of airways responsiveness. In 1986, a Food and Drug Administration approved formulation of methacholine (Provocholine) was released and replaced industrial methacholine in many pulmonary laboratories. To determine whether methacholine and Provocholine cause an equivalent degree of bronchoconstriction, a double blind, cross-over clinical trial was undertaken. After randomization, 19 medicine residents and respiratory therapists each performed methacholine challenge testing using either methacholine or Provocholine. Forty-eight hours later, each participant returned for repeat challenge testing with the alternate agent. The log of the dose-response slope (logslope) was calculated for each test. The mean logslope with methacholine (-0.15 +/- 1.84) and with Provocholine (-0.26 +/- 1.57) did not differ (paired Student's t test, p = 0.64). Further, excellent agreement was found between each subject's logslope with methacholine and with Provocholine (intraclass correlation coefficient rI = 0.82). Proton beam nuclear magnetic resonance revealed no structural differences between the two compounds. These findings suggest that methacholine from industrial sources and Provocholine are clinically and structurally similar and that the two agents may be used interchangeably in nonspecific bronchial provocation testing.

Clinical and environmental predictors of preterm labor.

OBJECTIVE: To determine the magnitude of risk for preterm labor associated with specific clinical and environmental factors. METHODS: Using a case-control design, 266 women with preterm labor and 512 controls were interviewed and their medical records reviewed. Crude and adjusted odds ratios were calculated for each risk factor. Population-attributable risks were estimated. RESULTS: Third-trimester bleeding, twin gestation, and chorioamnionitis at presentation were strongly associated with preterm labor (odds ratios 11.2-48.3). A history of a prior preterm delivery, vaginal bleeding in the first or second trimester, maternal diethylstilbestrol exposure, uterine anomalies, and urinary tract infection during pregnancy were associated to a lesser extent (odds ratios 1.6-5.4), as were cigarette smoking and drug use (odds ratios 2.0 and 3.0). Cases who had preterm labor preceded by premature rupture of the membranes had a substantially higher risk of preterm labor if chorioamnionitis, vaginal bleeding early in pregnancy, or urinary tract infection was present. By contrast, women who had intact membranes at the onset of preterm labor carried higher risk when twin gestation, placental abruption, or uterine anomaly was present. The highest population-attributable risks for preterm labor were found in patients with a twin gestation or third-trimester bleeding. CONCLUSIONS: Programs to reduce the preterm delivery rate should consider the attributable risks for the factors they are intended to modify. The attributable risks we obtained suggest that medical strategies to reduce the impact of the clinical variables, especially multiple gestation, and educational programs to decrease smoking and drug use should reduce the preterm delivery rate.

The health consequences of cigarette smoking. Pulmonary diseases.

Cigarette smoking has significant detrimental effects on both the structure and function of the lung; it is the single most important risk factor for the development of COPD. Uncertainty remains concerning the mechanisms by which smokers develop obstructive lung disease. It is speculated, however, that an imbalance between proteolytic and antiproteolytic forces in the lung or an increase in heightened airways responsiveness is responsible. Population-based studies have documented lower levels of FEV1, accelerated loss of ventilatory function, and increased respiratory symptoms and infections among smokers compared with nonsmokers. Data from both prospective and retrospective studies have consistently shown increased mortality from COPD, pneumonia, and influenza among cigarette smokers compared with nonsmokers.

Health effects of cigarette smoking.

Cigarette smoking is associated with increased overall morbidity and mortality. Smoking is a cause of cancer of the lung, oral cavity, larynx, bladder, and renal pelvis and a contributing factor in the development of cancer of the pancreas, stomach, cervix, liver, penis, and rectum. Smokers are at greater risk for coronary artery disease, cerebrovascular disease, and atherosclerotic peripheral vascular disease. Cigarette smoking is the single most important risk factor for chronic obstructive pulmonary disease and is associated with lower levels of FEV1 and increased respiratory symptoms and infections. Women who smoke during pregnancy have an increased incidence of complications, especially intrauterine growth retardation. Peptic ulcer disease is more common in smokers than in nonsmokers. Finally, involuntary smoke exposure is associated in adults with an increased incidence of lung cancer and possibly greater mortality rates from ischemic heart disease and in children with more frequent lower respiratory tract illnesses and reduced lung growth.

Adult respiratory distress syndrome complicating Plasmodium falciparum malaria.

In people who do not have clinical immunity to malaria, infection with the malaria parasite could lead to severe complications. We describe a patient who had acute and severe lung injury from malaria. A 37-year-old woman had a 24-hour history of generalized weakness and chills 2 days after returning from Nigeria. She had received mefloquine as prophylaxis, but the patient did not take the medication. On admission, a thick blood smear revealed severe Plasmodium falciparum parasitemia. She was given doxycycline and quinine, but as her parasitemia resolved, dyspnea and hypoxemia developed and she consequently required placement of an endotracheal tube. Chest radiography results showed bilateral and diffuse infiltrate. This report shows that patients with P falciparum malaria should be monitored closely and transferred to an intensive care unit for additional management if respiratory distress develops. Physicians caring for patients who have recently traveled to malaria-endemic areas need to anticipate the possible development of malaria with all of its complications, including acute lung injury.

Late-onset asthma: making the diagnosis, choosing drug therapy.

Physicians often fail to diagnose asthma in their older patients and instead attribute respiratory symptoms to aging alone or to other common diseases of the elderly. Although asthma is a common respiratory disease in older patients, its pathophysiology is poorly understood. Most elderly asthmatics are former smokers and have evidence of allergic disease. Asthma itself does not appear to increase mortality risk for the older patient. Spirometric results may show mild reversible airflow obstruction or fixed obstruction. The recommended therapy in the older patient follows that used for younger asthmatics. Inhaled corticosteroids are first-line agents, followed by inhaled anticholinergics. Smoking cessation, proper nutrition, and exercise are important nondrug therapies.

Cardiopulmonary exercise testing to assess respiratory impairment in occupational lung disease.

Exercise testing can answer several pertinent questions for the physician. It can determine whether a worker's aerobic performance is limited by respiratory or by other factors. It can also help decide whether an individual can perform a job without undue physiologic limitations and fatigue. Exercise testing has its limitations. It cannot determine the etiology of the impairment nor can it make a specific diagnosis except in rare cases. Interpretation of exercise data is not always precise, especially when the VO2max is normal but several physiologic measurements are abnormal. The VO2max achieved under laboratory conditions is probably too simplistic an estimate of the complex energy requirements of any occupation. Future research is needed to develop portable devices to assess both aerobic and anaerobic potentials of workers on the job to better determine job-specific impairment and disability. Patients who have unexplained symptoms or abnormal, but not severely reduced, static pulmonary function tests benefit most from exercise testing. For now, the AMA criteria for impairment as defined by static and exercise pulmonary function testing are the most appropriate to follow. Exercise testing has provided valuable data for epidemiologic research. Descriptive and case-control studies have documented minor physiologic abnormalities and rare respiratory limitations in workers with asbestos exposure and simple coal worker's pneumoconiosis. Additional studies are necessary to further elucidate pathophysiologic findings in patients with asbestosis and other occupationally induced pulmonary diseases.

Use of oblique chest roentgenograms in detecting pleural disease in asbestos-exposed workers.

Oblique chest roentgenograms have been recommended by some for use in screening programs of asbestos-exposed workers to increase detection of pleural fibrosis not evident on posteroanterior (PA) films. As a screening test, identification of pleural abnormalities with oblique films is especially important in subjects without evidence of other asbestos-induced abnormalities on PA films, namely, parenchymal fibrosis. To evaluate the incremental value of oblique films in the identification of pleural fibrosis, a comparison was made between PA films read alone and PA films read with both oblique views in a systematic evaluation of 489 male pipefitters examined in a screening program. Analysis of the subsets of pipefitters with and without parenchymal fibrosis showed that 2.5% of workers with normal PA films (n = 326) and 13.0% of subjects with isolated parenchymal fibrosis on PA films (n = 46) had pleural fibrosis detectable only on oblique films. In only eight (1.6%) did the oblique view represent the sole evidence of an asbestos-related roentgenographic abnormality. We conclude that oblique films should not be routinely used in screening workers for evidence of asbestos-induced disease.

Cognitive function and spirometry performance in the elderly.

A total of 65 ambulatory subjects over the age of 65 yr were studied to determine if mild impairment in cognitive function precludes reliable spirometric measures in the aged. Standardized questionnaires were used to obtain information on demographics, cigarette smoking, respiratory symptoms, and physician-diagnosed lung disease. Each subject performed several simple standardized tasks of cognitive function and underwent spirometric testing. A total of 36 women and 29 men participated. The mean age for the group was 74.9 +/- 5.6 yr; most were nonsmokers (never smokers, n = 28; former smokers, n = 29; and current smokers, n = 8). Of the 65 participants, 8 (12.3%) individuals were unable to perform at least three ATS-acceptable FVC maneuvers after suitable demonstration. These subjects were similar to the 57 subjects able to perform three acceptable maneuvers, except for worse scores on both the symbol-digit modalities test (23.3 +/- 3.6 versus 31.6 +/- 10.5, p < 0.001) and the trail-making test, Part B (244.3 +/- 87.1 versus 160.4 +/- 71.8, p < 0.01). Of the 57 subjects able to perform spirometry, 18 (31.6%) failed to meet ATS reproducibility criteria for FEV1, FVC, or both. Cognitive impairment was not associated with the ability to achieve reproducible measures. These results suggest that the vast majority of older subjects can perform reliable spirometry; those elderly unable to perform spirometry may have impairment in cognitive function requiring further evaluation.

Airway responsiveness in young black and white women.

The prevalence and severity of asthma appears to be greater in blacks than in whites. To determine if racial differences in airway responsiveness may explain these findings, methacholine challenge tests from 62 black and 238 white women 20 to 35 yr of age were evaluated. Subjects served as controls for a case-control study of the relation of airway responsiveness and preterm labor. Standardized questionnaires were used to obtain information on age, obstetrical history, education, income, cigarette smoking, medication use, and respiratory illnesses and symptoms. Total serum IgE was measured using a radioimmunoassay. Methacholine challenge testing was performed on all subjects 6 wk after delivery, and the provocative dose causing a 20% decrease in FEV1 (PD20) was calculated. Black women in the study had more pregnancies and children, were younger, less well educated and more impoverished, and reported greater cigarette smoking and less medication use than did the white women. Additionally, black women had higher geometric mean serum IgE levels (blacks: 65.4 IU versus whites: 20.0 IU; p < 0.001), lower FEV1 (blacks: 2.73 +/- 0.38 SD L versus whites: 3.19 +/- 0.39 L; p < 0.001), and greater unadjusted airway responsiveness than did white women (geometric mean PD20: blacks: 28.4 mumol versus whites: 38.8 mumol; p = 0.02). After adjusting for selective demographic and smoking differences, a significant additional effect of race on mean PD20 was found. However, after adjustment for level of serum IgE and level of FEV1, racial differences were no longer apparent.(ABSTRACT TRUNCATED AT 250 WORDS)

Early childhood predictors of asthma.

To investigate potential risk factors for the development of childhood asthma, the authors undertook a longitudinal study using a cohort of 770 children aged 5-9 years from East Boston, Massachusetts, that has been under study since 1975. The disease outcome considered was age at first onset of asthma, as determined by parental or self-reporting of a physician's diagnosis. Potential risk factors were evaluated specifically in relation to their presence antecedent to a diagnosis of asthma. Standardized questionnaires were used to obtain childhood illness histories, environmental exposures, and the asthmatic and atopic statuses of first-degree relatives. Ninety-one cases of asthma were identified from 1975 to 1988 (57 males and 34 females). Significant sex-adjusted relative risk estimates were seen for antecedent pneumonia, bronchitis, hay fever, sinusitis, parental asthma, and parental atopy. Neither bronchiolitis, eczema, croup, personal cigarette smoking, maternal smoking, paternal smoking, nor delivery complications bore an apparent relation to the development of asthma. A history of parental asthma or parental atopy did not significantly alter the sex-adjusted relative risk estimates for pneumonia, bronchitis, hay fever, or sinusitis. These results support the hypothesis that asthma is a multifactor disease whose expression is dependent on both familial and environmental influences.

Longitudinal lung function decline in subjects with respiratory symptoms.

The relation of respiratory symptoms and lung function has not been extensively investigated. To determine better the rate of FEV1 decline in subjects reporting persistent wheeze, chronic cough, chronic phlegm, and/or dyspnea, longitudinal data from an adult population sample of 3,948 subjects (1,757 men; 2,191 women) followed for 12 yr were analyzed. At the initial and subsequent follow-up visits, subjects completed a standardized respiratory questionnaire and performed spirometry using the same methods and spirometers. Subjects were categorized based on the presence or absence of self-reported respiratory symptoms (persistent wheeze, chronic cough, chronic phlegm, or shortness of breath) at the initial visit. Six-specific linear regression models were fitted to determine the effect of these respiratory symptoms on lung function. In both men and women, reporting of any respiratory symptoms was associated with both a reduction in initial lung function and more rapid decline in height-adjusted FEV1. Furthermore, after adjustment for height, age, and cigarette smoking, men with cough or phlegm and women with cough alone showed accelerated loss in FEV1. Clinicians should be aware of the predictive value of these respiratory symptoms, because therapeutic intervention may modify the associated decline in lung function.