Daily adjunctive therapy with vitamin D3 and phenylbutyrate supports clinical recovery from pulmonary tuberculosis: a randomized controlled trial in Ethiopia.

OBJECTIVE: Immunotherapy using vitamin D (vitD3 ) and phenylbutyrate (PBA) may support standard drug regimens used to treat infectious diseases. We investigated if vitD3 + PBA enhanced clinical recovery from pulmonary tuberculosis (TB). METHODS: A randomized controlled trial was conducted in Addis Ababa, Ethiopia. Patients with smear-positive or smear-negative TB received daily oral supplementation with 5000 IU vitD3 and 2 × 500 mg PBA or placebo for 16 weeks, together with 6-month chemotherapy. Primary end-point: reduction of a clinical composite TB score at week 8 compared with baseline using modified intention-to-treat (mITT, n = 348) and per-protocol (n = 296) analyses. Secondary end-points: primary and modified TB scores (week 0, 4, 8, 16, 24), sputum conversion, radiological findings and plasma 25(OH)D3 concentrations. RESULTS: Most subjects had low baseline plasma 25(OH)D3 levels that increased gradually in the vitD3 + PBA group compared with placebo (P < 0.0001) from week 0 to 16 (mean 34.7 vs. 127.4 nmol L-1 ). In the adjusted mITT analysis, the primary TB score was significantly reduced in the intervention group at week 8 (-0.52, 95% CI -0.93, -0.10; P = 0.015) while the modified TB score was reduced at week 8 (-0.58, 95% CI -1.02, -0.14; P = 0.01) and 16 (-0.34, 95% CI -0.64, -0.03; P = 0.03). VitD3 + PBA had no effect on longitudinal sputum-smear conversion (P = 0.98). Clinical adverse events were more common in the placebo group (24.3%) compared with the vitD3 + PBA group (12.6%). CONCLUSION: Daily supplementation with vitD3 + PBA may ameliorate clinical TB symptoms and disease-specific complications, while the intervention had no effect on bacterial clearance in sputum.

Prevalence of Helicobacter pylori infection among adult dyspeptic patients in Ethiopia.

In developing countries such as Ethiopia, where chronic gastritis and peptic-ulcer disease are the most common endoscopic findings, it is important to study the association between Helicobacter pylori infection and gastroduodenal diseases. Both invasive and non-invasive diagnostic methods were therefore used to investigate 300, consecutive, adult patients with dyspepsia, from the gastrointestinal clinic of Tikur Anbassa University Hospital, Addis Ababa. The apparent overall prevalence of H. pylori infection varied according to the detection method employed. Culture revealed H. pylori in only 69% of the patients but this pathogen appeared more common when rapid urease tests (71%), PCR-denaturating gradient gel electrophoresis (91%), histopathology (81%), silver staining (75%) or stool-antigen tests (81%) were employed. Antibodies to H. pylori were detected, both by enzyme immuno-assay (EIA) and immunoblotting, in approximately 80% of the patients, whether the antigens used were of a reference strain or from a local isolate of H. pylori. When some of the EIA-positive and EIA-negative sera were cross-absorbed with antigens of Campylobacter jejuni and re-tested by EIA, the H. pylori-positive sera remained positive and the negative sera remained negative. Dyspeptic patients in Ethiopia, like most of those previously observed elsewhere in Africa, are often infected with H. pylori. It is important that the management of these patients should not be hampered by the misinterpretation of the African epidemiology of this pathogen.

Sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling in Ethiopia.

OBJECTIVES: To describe sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling (PTC) among Ethiopian adults. METHODS: Data on socio-demographic characteristics, knowledge of HIV infection, sexual history, medical examination, and HIV and syphilis serological status were compared, through uni- and multivariate analysis, in relation to attending PTC within 60 days of HIV testing. RESULTS: Between February 1997 and June 1998, 751 factory workers were enrolled in a cohort study of HIV infection progression. Despite reporting high-risk sexual behaviours, mainly for males (64% of males and 6% of females had more than five sexual partners in their lifetime, 16% of males and 2% of females reported having had recent casual partners), and knowing that HIV is commonly transmitted heterosexually in Ethiopia (97% of answers being correct, both genders combined), only 17% of males and 2% of females acknowledged having had activities which had put them at risk of HIV infection. HIV prevalence was 12%, and did not differ by gender. Of all study participants, 327 (43.5%) returned for PTC within 60 days of HIV testing. PTC attendance did not differ by age, gender, or HIV serological status. Factors independently associated with PTC attendance in males were: good knowledge of HIV infection, [odds ratio (OR) = 1.661, belief that medical follow-up improves the course of HIV infection (OR = 2.02), history of genital symptoms (OR = 2.83), positive syphilis serology (OR = 2.62), recent weight loss (OR = 1.89), and, with a negative association, being a manual worker (OR = 0.40), and history of recent casual sexual relationships (OR = 0.35). In women, belief that HIV/AIDS can be cured (OR = 3.16), never having been married (OR = 5.02), having five or less children (OR = 2.16), having been raped (OR = 3.42), and having used health facilities in the past year (OR = 1.73) were all positively and independently associated with PTC attendance. CONCLUSION: Study participants reported high-risk sexual behaviours, yet had a low perception of individual risk. Men attended for PTC because of their knowledge of HIV infection, their past sexual history or their current health status. Women attended for PTC because of their plans for the future, marriage and/or children, rather than their past sexual exposure. Only in cases of rape were they willing to learn of their HIV status.

Evaluation of the World Health Organization staging system for HIV infection and disease in Ethiopia: association between clinical stages and laboratory markers.

OBJECTIVE: To study the association between the clinical axis of the World Health Organization (WHO) staging system of HIV infection and disease and laboratory markers in HIV-infected Ethiopians. DESIGN: Cross-sectional study. METHODS: Clinical manifestations and stage of HIV-positive individuals participating in a cohort study of HIV infection progression, and of HIV-positive patients hospitalized with suspicion of AIDS, were compared to CD4+ T-cell count and viral load. RESULTS: Of the 86 HIV-positive participants of the cohort study, 53 (62%), 16 (19%), 16 (19%), and one (1.2%) were in stage 1, 2, 3 and 4, respectively. Minor weight loss (n = 15) and pulmonary tuberculosis (n = 9) were the most commonly diagnosed conditions among the 38 (44%) symptomatic HIV-positive individuals. Although 23 (27%) HIV-positive participants had CD4+ T-cell counts less than 200 x 10(6)/l, only one was in clinical stage 4. Among 79 hospitalized HIV-positive patients, 15 (19%) and 64 (81%) were in stage 3 and 4, respectively. The majority (83.5%) had CD4+ T-cell counts < 200 x 10(6)/l. Individuals at stage 3 had lower CD4+ T-cell counts and higher viral loads when seen in hospital as compared to cohort participants (P = 0.06 and 0.008, respectively). When grouping the two study populations, the median CD4+ T-cell count decreased (337, 262, 225, 126, and 78 x 10(6)/l, P< 0.01), and the median viral load increased (4.08, 3.89, 4.47, 5.65, and 5.65 log10 copies/ml, P < 0.01), with increasing clinical stage of HIV infection (1, 2, 3 cohort, 3 hospital, and 4, respectively). Median CD4+ T-cell counts were remarkably low in HIV-negative participants (749 x 10(6)/l), and in HIV-positive participants at stage 1 and 2 (337 and 262 x 10(6)/l, respectively). CONCLUSIONS: There was a good correlation between WHO clinical stages and biological markers. CD4+ T-cell counts were low in Ethiopians, particularly during early stages of HIV-1 infection, and preliminary reference values at different stages of HIV-1 infection were determined. In HIV-infected Ethiopians, lymphocyte counts less than 1,000 x 10(6)/l in non-hospitalized individuals, and less than 2,000 x 10(6)/l in hospitalized patients, had high positive predictive value, but low sensitivity, in identifying subjects with low CD4+ T-cell counts (< 200 x 10(6)/l) who would benefit from chemoprophylaxis of opportunistic infections. The on-going longitudinal study will be useful to confirm the prognostic value of the WHO staging system.

Preliminary experience with endoscopic retrograde cholangiopancreatography in Ethiopia.

This study was undertaken to evaluate the outcome of diagnostic endoscopic retrograde cholangiopancreatography and to increase the awareness of physicians practicing in Ethiopia about the procedure. Between April 1993 and October 1997, 47 patients underwent endoscopic retrograde cholangiopancreatography at Tikur Anbessa Hospital, Addis Ababa. Cholestasis, postcholecystectomy syndrome and abdominal pain with intermittent jaundice accounted for 91% of the indications. The success rate of endoscopic retrograde cholangiopancreatography was 81%. Cholestasis provided the highest diagnostic yield followed by postcholecystectomy syndrome and abdominal pain with intermittent jaundice. The endoscopic retrograde cholangiopancreatography finding was normal in 18% of cases. The commonest abnormal findings were gall stones (45%), biliary strictures (16%) and pancreatic carcinomas (11%). Using ultrasonography and endoscopic retrograde cholangiopancreatography, choledocholithiasis was diagnosed in three (21%) and 13 (93%) cases, respectively. The endoscopic retrograde cholangiopancreatography diagnosis of choledocholithiasis was confirmed at surgery in all but one patient. Acute cholangitis and asymptomatic elevation of serum amylase and/or lipase were noted in three (6%) and four (9%) cases, respectively. Endoscopic retrograde cholangiopancreatography is generally a safe diagnostic modality and should be used more frequently for the diagnosis of biliary and pancreatic diseases.

Endoscopic injection sclerotherapy of bleeding oesophageal varices: a retrospective analysis.

To evaluate the outcome of endoscopic injection sclerotherapy, a retrospective analysis of patients with bleeding oesophageal varices who underwent emergency or elective sclerotherapy in Tikur Anbessa Hospital from 1985 to 1995 was undertaken. During the study period a total of 43 patients, 32 males and 11 females with a mean age of 46 years, had endoscopic injection sclerotherapy. Aethoxyscterol, ethanolamine oleate or absolute alcohol was used as sclerosant agent. The reduction in variceal size and eradication of varices in patients who received four or more sessions of sclerotherapy was 11% and 74%, respectively, while in patients who received less than four sessions, it was 33% and 25%, respectively. The overall reduction in variceal size and eradication of varices, however, was 23% and 47%, respectively. Rebleeding occurred in 51% of patients. The rebleeding rate in patients who received four or more sessions of sclerotherapy was 26% as compared to 71% in those who received less than four sessions. The in-hospital mortality was 49% and variceal rebleeding occurred in 57% of them. Eighty three percent of the deaths with variceal rebleeding did not achieve eradication of varices and 76% had Child's C liver disease. In conclusion, endoscopic injection sclerotherapy at short interval is effective for eradication of varices and subsequent reduction of rebleeding. The functional status of the liver and variceal bleeding are important determinants of mortality in patients with liver cirrhosis.

Colonoscopy in the investigation of colonic diseases.

A retrospective analysis of 640 patients who underwent 681 colonoscopic examinations between March 1984 and April 1996 was undertaken. The major indications were rectal bleeding (32.8%), change in bowel habit (24.7%), abdominal pain (20.1%), abnormal barium enema (9.8%) and iron deficiency anaemia (4.8%). Total colonoscopy was performed in 79.3% of cases. The colonoscopic finding was normal in 49.8% of patients. Most of the lesions were benign. Polyps and carcinoma were found in 9.2% and 7% of patients respectively. 91.3% of the lesions were located distal to the splenic flexure and of the remaining proximal lesions, polyps and carcinoma accounted for only 2.2%. Rectal bleeding produced the highest diagnostic yield (70%) followed by iron deficiency anaemia (61.3%), change in bowel habit (48.1%) and abnormal barium enema (47.6%). Lower yields were found in patients with abdominal mass (33.3%), follow up colonoscopy (28.6%) and abdominal pain (26.9%). However, the diagnostic yield of clinically significant pathology varied widely among the different indications. Therefore, selection of patients for colonoscopy based on the diagnostic yield of each indication may not be practical. Sigmoidoscopy is suggested as the first line of investigation for patients suspected to have colonic diseases, particularly where there is limited trained manpower and facility. Total colonoscopy should be reserved for sigmoidoscopy negative patients with persistent symptoms and high risk cases for malignancy.

Periampullary tumours: report of two cases.

Periampullary tumour in two Ethiopian patients are described. The first patient, a 60 year old non-insulin dependent diabetic woman with ampullary adenocarcinoma, presented with symptoms, signs and laboratory results suggestive of obstructive jaundice and iron deficiency anaemia. The second patient, a 40 year old lady with duodenal adenocarcinoma, presented with dyspepsia and weight loss of 15 kilogramme. The clinical presentation, diagnosis, and management of periampullary tumours are discussed with review of the literature.

Comparison of diagnostic methods for detection of Helicobacter pylori.

Of two hundred Ethiopian patients with dyspepsia, multiple biopsies were taken from the antrum of the stomach. Helicobacter pylori was cultured from 85% of duodenal ulcer and in 75% of chronic antral gastritis patients. The overall Helicobacter pylori positivity was 70%. The sensitivity, specificity, positive and negative predictive values of the tests as compared to culture were as follows, respectively: direct urease test 100%/87%/95%/100%, direct gram stain 60%/98%/99%/51%, histological gram stain 66%/97%/98%/56%, Giemsa stain 100%/97%/99%/100% and Gimenez stain 100%/87%/95%/100%. It is concluded that gram staining of direct tissue smear or histology is an insensitive method in the diagnosis of Helicobacter pylori. All the other tests, are shown to be valid. Urease test is an excellent test for provision of presumptive diagnosis of Helicobacter pylori while awaiting confirmation either by culture of histology.