Agreement between ambulance paramedic- and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients.

BACKGROUND AND PURPOSE: Patients with suspected stroke first assessed by ambulance paramedics require early recognition to facilitate appropriate triage and early treatment. We determined paramedic's accuracy in detecting acute stroke signs by comparing agreement between neurological signs recorded in the Face Arm Speech Test (FAST), a stroke recognition instrument, by paramedics on the scene and by stroke physicians after admission. METHODS: Suspected stroke patients admitted by ambulance paramedics directly to an acute stroke unit through a rapid ambulance protocol were examined by a trainee stroke neurologist or admitting stroke physician over a 1-year period. Recorded neurological signs (facial weakness, arm weakness, speech disturbance) in confirmed acute stroke/transient ischemic attack (TIA) cases were compared between paramedics and the stroke neurologist/physician. RESULTS: Ambulance crews referred 278 suspected stroke patients of whom 217 (78%) had confirmed stroke (n=189) or TIA (n=28); 95% were examined by the stroke neurologist (median 18 hours after paramedic assessment). Recorded signs and agreement between paramedics and stroke physicians in confirmed stroke group were: facial weakness, 68% versus 70% (kappa=0.49; 95% CI: 0.36 to 0.62); arm weakness, 96% versus 95% (kappa=0.77; 95% CI: 0.55 to 0.99); and speech disturbance, 79% versus 77% (kappa=0.69; 95% CI: 0.56 to 0.82). Interrater agreement was complete for arm weakness in 98% cases. CONCLUSIONS: Recognition of neurological deficits by ambulance paramedics using FAST shows good agreement with physician assessment, even allowing for temporal evolution of deficits. The high prevalence and good agreement for arm weakness suggest that this sign may have the greatest usefulness for prehospital ambulance triage and paramedic-based neuroprotective trials.

High prevalence of GBV-C hepatitis G virus infection in a rural South African population.

A novel virus, GBV-C/hepatitis G virus (GBV-C/HGV), has been cloned and characterised recently. GBV-C/HGV global epidemiology and risk factors for acquisition are currently unclear. We aimed to establish the determinants of this infection in a rural South African (SA) population. The study population included two samples, namely a community-based sample, and consenting persons from a nonspecialist outpatient department in the same district. A questionnaire regarding demographic details and putative risk factors was administered; blood samples were taken on which a polymerase chain reaction (PCR) was performed for both 5'NCR and NS5a regions of GBV-C/HGV using commercially available primers and probes. Two hundred and forty-nine people were studied with a mean GBV-C/HGV prevalence of 10.4%. Outpatient department and community prevalences differed significantly (18.0% and 6.3%, respectively, P = 0.004). GBV-C/HGV infection was associated with excessive alcohol consumption (P = 0.02; OR, 4.18) and a lack of waterborne sewerage (P = 0.04). PCR amplification of the NS5a region of all but two South African GBV-C/HGV positive samples showed poor reactivity. The prevalence of GBV-C/HGV in rural SA appears to be higher than that reported from Europe and North America. Infection appeared to be associated with excess alcohol intake and a history of previous blood transfusion. The discrepant NS5a and 5'NCR PCR sensitivity in this study raises the possibility of genetic differences in southern African GBV-C/HGV.

Thyroid dysfunction in the elderly.

OBJECTIVES: To determine the prevalence of thyroid dysfunction in institutionalised elderly people in Cape Town and to assess the usefulness of an abnormal thyroid-stimulating hormone (TSH) concentration as a screening test in this group. DESIGN: Cross-sectional survey. SETTING: Four old-age homes in Cape Town. SUBJECTS: Old-age home residents aged 60 years and over. OUTCOME MEASURES: Serum concentrations of TSH, free thyroxine and free tri-iodothyronine. RESULTS: Serum TSH estimations were performed on 658 participants, and were abnormal in 103 (15.6%)-41 (6.2%) being elevated (> 5.0 microU/ml) and 62 (9.4%) being low (> 0.4 microU/ml). There were 3 newly diagnosed cases of hyperthyroidism and 7 of hypothyroidism. Subclinical disease was diagnosed in 40 subjects. The overall prevalence of thyroid dysfunction in this population was 11.2%. In 22 (3.4%) this had previously been recognised, while in 50 (7.8%) the dysfunction was newly diagnosed by the current survey. The positive predictive value of a TSH concentration > 20 microU/ml in predicting hypothyroidism is 67%, while it will predict 100% of cases of subclinical hypothyroidism. A TSH concentration < 0.1 microU/ml will predict 23% of cases of hyperthyroidism, but 81% of cases of subclinical disease. CONCLUSIONS: The prevalence of thyroid dysfunction in institutionalised elderly people in Cape Town is similar to that reported for elderly people in other centres. Thyroid dysfunction had not previously been recognised in approximately two-thirds of the subjects in this study. The serum TSH concentration is a reliable screening test for thyroid dysfunction in the elderly, but is less useful if used to identify biochemical thyroid disease. An elevated TSH concentration is a better predictor of thyroid dysfunction in the elderly than a depressed TSH concentration.

Hepatitis E in South Africa: evidence for sporadic spread and increased seroprevalence in rural areas.

Hepatitis E virus (HEV) is a major cause of non-A, non-B hepatitis in developing countries. Factors influencing sporadic spread of hepatitis E are unclear. We examined anti-HEV seroprevalence and demographic data from 407 urban and 360 rural black South African adults living in formal housing, squatter camps, or mud huts. Anti-HEV sero-prevalence ranged from 5.8% to 19.1% (mean 10.7%) in the different regions. Mean urban and rural rates were 6.6% and 15.3%, respectively (P = 0.0001). Rural mud hut dwellers, using unchlorinated river water, were at greater risk (17.4%) than rural villagers (5.3%; P = 0.008). A linear relation was found between seroprevalence and age, suggesting sporadic spread. The high prevalence in mud hut dwellers suggests that contaminated water plays a major role in HEV spread in South Africa. Routine chlorination or boiling of river drinking water before consumption may reduce HEV infection.

Spirometry of healthy adult South African men. Part I. Normative values.

AIM: To determine normative spirometric values for black and white South African men. METHODS: A population of 796 bank personnel were subjected to spirometry and anthropometric measurements. An exhaustive questionnaire and radiographic screening process was used to identify a healthy population. Spirometry was performed using two calibrated instruments, a sleeve sealed piston spirometer (Autolink) and a bellows spirometer (Vitalograph). The methodological guidelines of the American Thoracic Society were observed. In the regression analysis Mallow's CP statistic was used to identify the best prediction models. RESULTS: Compelling evidence was found in support of incorporating sitting height in prediction equations. For the Autolink studies the prediction equations (based on age, standing height and weight) for forced vital capacity (FVC) (litres) were as follows: blacks: 0.053 height-0.030 age- 3.54; and whites: 0.056 height-0.038 age-3.07; for forced expiratory volume in the 1st second (FEV1) (litres) blacks: 0.036 height-0.032 age-1.18; and whites: 0.042 height-0.038 age-1.45. For the Vitalograph the equations were: FVC: blacks 0.048 height-0.024 age- 3.08 L; whites 0.056 height-0.031 age-3.42; FEV1: blacks 0.029 height-0.027 age-0.535; whites 0.042 height-0.036 age-1.84. CONCLUSION: The Vitalograph yielded significantly lower values than the Autolink for FVC measurements despite absolute consistency in methods. In view of the fact that the present study was conducted on healthy men, free from noxious industrial exposure, using state-of-the-art methods, these prediction equations may be regarded as the definitive norms for adult South African males.

Spirometry of healthy adult South African men. Part II. Interrelationship between socio-environmental factors and 'race' as determinants of spirometry.

AIM: To examine the interaction of socio-environmental background, 'race' and anthropometry on spirometry. METHODS: A study population of white and black bank workers with broadly comparable current socio-economic circumstances was identified. Detailed questionnaires regarding a number of indicators of socio-environmental status (SES) were administered in addition to anthropometric and spirometric measurements. Multiple linear regression analyses were performed. The Kappa statistic was used to determine the best predictors of SES. RESULTS: 'Race' was found to be the best predictor of SES. Within the black group a sub-classification of high and low SES was possible. In all respects the white SES indicators were higher than those of the black high SES group. Multiple regression analysis showed that sitting height was a better anthropometric predictor of spirometry than standing height. Replacing 'race' with other indicators of SES gave similar measures of prediction (by Mallow's CP statistic) of spirometry in the over-30-year age group. CONCLUSION: The impact of 'race' on spirometry can be reduced substantially by incorporating sitting height and indicators of SES in the regression equations. This observation lends support to the hypothesis that 'race' is not a direct genetic predictor of lung size, but may have an influence because of SES and anthropometric features associated with 'race'.

Informant questionnaires as screening measures to detect dementia. A pilot study in the South African context.

OBJECTIVES: There is currently no appropriate cognitive screening test available to diagnose dementia cross-culturally in South Africa. The aim of this pilot study was to investigate the efficacy of an informant questionnaire in detecting cognitive decline in the elderly. DESIGN: The Deterioration Cognitive Observee (DECO), an informant questionnaire previously used abroad, was administered to relatives of elderly patients. Relatives were also asked a series of open-ended questions about the patient's cognitive abilities and behaviour. The DECO results were compared with patients' scores on the Mini-Mental State Examination (MMSE), the cognitive measure currently used to assess a patient's level of cognitive decline, as well as with the clinicians' diagnosis. SETTING: The interviews were completed at the Groote Schuur Hospital Geriatric Clinic during the months of May and June 1994. SUBJECTS: The subjects were patients (N = 20) and their relatives (N = 20) attending the Geriatric Clinic. RESULTS: DECO scores correctly predicted normal functioning in 7 patients and dementia. In 8. The DECO scores correlated with the MMSE scores (r = 0.625; P < 0.01) and MMSE scores correlated with the clinicians' diagnosis (chi 2 = 0.114; df = 1; P = 0.73). Open-ended questions confirmed the clinicians' diagnosis. CONCLUSION: The DECO was found to predict dementia correctly in all but the severely demented patients. As the DECO appears to be a suitable alternative to cognitive testing, it should be considered as a possible screening measure for dementia in elderly people in South Africa.

Relative efficacy of hydrocortisone and methylprednisolone in acute severe asthma.

The relative clinical efficacy of different types of intravenous glucocorticosteroids in acute severe asthma is not clear in published studies. We conducted a randomised prospective study of asthma unit admissions over a 3-month period. Therapy consisted of 4-hourly nebulised salbutamol, intravenous aminophylline and either intravenous hydrocortisone 200 mg 4-hourly or intravenous methylprednisolone 125 mg 12-hourly. Three hundred and eighty-six patients were admitted to the asthma unit. After exclusions, 191 patients were included in the analysis (hydrocortisone--91, methylprednisolone--100). The groups were comparable in respect of baseline data. The median time to maximum peak expiratory flow rate was 19 hours for hydrocortisone and 23 hours for methylprednisolone (median test, P = 0.21). Median duration of asthma unit stay was 30 hours for hydrocortisone and 36 hours for methylprednisolone (median test, P = 0.01). A similar difference was evident on comparison of the trial medications in patients who had previously been on oral maintenance steroids. We conclude that, at the dosages selected, hydrocortisone is more effective than methylprednisolone in acute severe asthma.

Relative efficacy of nebulised ipratropium bromide and fenoterol in acute severe asthma.

In a double-blind, randomised, controlled clinical trial of 145 patients with acute asthma, the efficacy of nebulised 4-hourly ipratropium bromide plus 4-hourly fenoterol (group I, 50 patients), 2-hourly fenoterol (group II, 50 patients) and 4-hourly fenoterol (group III, 45 patients) was assessed. All patients received an optimal infusion of aminophylline and 81 patients (27 in each group) received hydrocortisone for clinical indications. It was found that cholinergic side-effects in group I were not more common than in group II. Tremor was more common in group II. Assessment of bronchodilator efficacy was confined to the 81 patients whose therapy included hydrocortisone. Peak expiratory flow rate, forced expiratory volume in 1 second, and forced vital capacity were expressed as a percentage of predicted for each individual and the mean values for each group plotted. It was found that the response rate, as assessed by the area under the curve, was significantly more rapid in group I compared with both group II (P less than 0.001) and group III (P less than 0.005). These findings were consistent for all three lung function measurements. However, there was no significant difference in the responses between group II and group III. It is concluded that adding ipratropium bromide to conventional regimens is likely to benefit patients with acute asthma.

Respiratory health of brickworkers in Cape Town, South Africa. Radiographic abnormalities.

A cross-sectional study utilizing internal controls based on dust exposure determinations was performed on 268 brickworkers. Smoking, age, and other information from a detailed respiratory questionnaire and results from a physical examination and pulmonary function tests were investigated in relation to radiographic abnormality. The prevalence of pneumoconiosis was near 4%. The roles of smoking, workplace dust exposure, and age as factors predicting radiographic abnormality are discussed.

Epidemiologic studies of Scottish oil shale workers: I. Prevalence of skin disease and pneumoconiosis.

In an epidemiologic study of 6,359 oil shale workers, 1,664 (46.7%) of 3,566 survivors were investigated. No excess of skin disease (as reported in response to a questionnaire) was found in men exposed to oil or dust, whether compared to men who were not exposed to oil or dust or to coalminers. A low prevalence of simple pneumoconiosis was found in workers exposed to dust, while progressive massive fibrosis occurred in approximately 1% of miners and retort workers. Comparisons of responders with nonresponders revealed no serious bias in terms of age or work experience, though nonresponders were likely to have been less healthy in general.