Profile of the Geriatric Patients Hospitalised at Universitas Hospital; South Africa

Background: The elderly population in Africa is unevenly distributed across the continent; with the highest percentage of elderly living in the Southern African region. In 1996; the elderly population of South Africa (65 years and older) was roughly 6.7; and was calculated to be 10.4 by 2025. If the latter expectation is anywhere near realistic; it stands to reason that the Department of Health should make timely provision for the care of these future patients; as the prevailing disease patterns within a population change as that population ages. Thus; there is an urgent need for profiles of elderly patients in order for adequate training to be implemented and for beds and equipment to be ready when needed.Methods: A retrospective study was undertaken of all data available from a clinical audit done at Universitas Hospital's Geriatric Unit. All patients aged 65 years and older who were admitted by Internal Medicine's Geriatric Unit over four years were analysed in order to compile a profile of geriatric patients hospitalised at Universitas Hospital.Results: The study group consisted of 791 elderly patients. Their average age was 81 years (range: 65 to 101 years of age) and they were hospitalised for an average of 11 days; with an average use of five medications per patient. Women represented 66 of the patients and the mortality rate was 17 in the total study group. The main admitting clinical problems were hypertension; heart failure; ischemic heart disease and anaemia. Most of the patients did not smoke or use alcohol. Out of a group of 523(due to the fact that it was a retrospective study; data for this criteria were only available for 523 of the 791 patients); 235 (45) were self-supporting and 32 were known to use living aids. The majority of the patients were single and an equal amount were living in old age homes and with their families. The main special examinations used in their treatment were chest X-rays; nuclear examinations of the liver; ECG; heart sonar and CT of the brain; and gastroscopies. Almost all of the patients had undergone full blood count analysis and U+E determinations; and in more than 50 of cases; creatine; albumin and glucose measurements were taken.Conclusion: For successful geriatric care at Universitas Hospital there will be a need for at least 11 days hospitalisation; and a unit with good training in internal medicine; psychiatry; urology; orthopaedy and oncology. The main supporting services will be physiotherapy; occupational therapy and social welfare. Laboratory analyses will include full blood count; urea and electrolyte measurements; urine examination; and creatine and glucose measurements. Special investigations will mainly be radiology and cardiology sonar examination. How well we care for elderly patients in the future will be an indicator of the quality of our healthcare system in general. We need to redesign our social insurance and welfare systems to fit the realities of our current situation

Detection of Mycobacterium tuberculosis in serum samples using the polymerase chain reaction.

Conventional methods for the diagnosis of Mycobacterium tuberculosis infections have serious limitations. To determine whether amplification of M. tuberculosis DNA in serum by the polymerase chain reaction (PCR) might be a useful additional diagnostic tool, we tested 329 clinical specimens using primers specific for the IS6110 insertion sequence of the M. tuberculosis complex. The samples consisted of 30 serum samples from healthy controls, 114 serum samples from patients with diagnoses other than tuberculosis (including immunosuppressive disorders), 59 samples from patients with a clinical picture suggestive of tuberculosis, and 78 serum samples from patients with proven M. tuberculosis infection. Both serum, and representative samples from anatomical regions suspected of being infected, were collected from a further 48 patients for comparison with serum PCR. Serum PCR identified 72/78 (92%; 95% confidence interval CI: 84%-97%) patients with proven tuberculosis, and 49/59 (83%; 95% CI: 71%-92%) patients with suspected tuberculosis. In the group of patients with other diagnoses, 30/114 (26%; 95% CI: 18%-34%) tested positive, while none of the specimens from the healthy control group were positive (95% CI: 0%-12%). Serum PCR results also compared favourably with other clinical specimens obtained from the same patient. Serum PCR can, therefore, be a useful additional technique for the early diagnosis of M. tuberculosis infection, but it does not necessarily indicate active infection.

Efficacy and tolerability of nisoldipine coat-core formulation in the treatment of essential hypertension: The South African Multicenter ANCHOR Study. Ambulatory Nisoldipine Coat-Core Hypertension Outpatient Response (ANCHOR) Investigators.

A double-blind, placebo-controlled, multicenter trial was undertaken to assess the antihypertensive efficacy and tolerability of a controlled-release (Coat-Core [CC] tablet) formulation of the second-generation dihydropyridine calcium channel antagonist, nisoldipine. Of the 208 patients with mild-to-moderate essential hypertension, two were excluded from the main efficacy analysis, and the rest randomized into one of four treatment groups, to receive either placebo, or nisoldipine CC at doses of 10, 20, or 30 mg once daily for 6 weeks, following a 4-week placebo run-in period. Blood pressure measurements (supine, standing, diastolic, and systolic) were taken at trough plasma levels, 24 h after previous dosing at 2-week intervals throughout the study. Adverse events and laboratory parameters (plasma lipid and glucose levels, and thyroid function) were monitored. All three doses of nisoldipine CC lowered blood pressure, as compared with placebo, 24 h after dosing. At endpoint (after 6 weeks) mean changes in supine blood pressure from baseline were (systolic/diastolic) 0.9/-2.3, -8.0/-5.5, -16.9/-9.0, and -15.0/-10.3 mm Hg for the groups assigned to placebo and nisoldipine CC 10, 20, and 30 mg, respectively. The response rates were 35%, 47%, and 63% for nisoldipine CC 10, 20, and 30 mg, respectively. Twenty-four-hour ambulatory blood pressure monitoring showed that nisoldipine CC effectively controlled blood pressure throughout the dosing interval. No change in heart rate was seen for all three doses of nisoldipine CC over the 24-h dosing interval. Nisoldipine CC was at least as effective in black patients as in whites. Generally adverse events were not increased, except for peripheral edema, with rates of 7% in placebo, and 6%, 9%, and 19%, respectively, in those receiving nisoldipine CC 10, 20, or 30 mg daily. There were no clinically significant changes in blood lipids, blood glucose, or thyroid function. In conclusion, once-daily nisoldipine CC at doses of 10 to 30 mg was an effective and well tolerated antihypertensive agent, providing 24-h control of blood pressure without any increase in heart rate.

Influence of carbon particles on superoxide and hydrogen peroxide radical release during the killing of Mycobacterium bovis by alveolar macrophages.

SETTING: Diagnostic bronchoscopy performed on untreated African patients with tuberculosis revealed alveolar macrophages filled with carbon particles. It was postulated that this was the result of excessive inhalation of smoke from domestic fires and the consequent phagocytosis by alveolar macrophages. OBJECTIVE: To determine whether carbon particles influence the release of superoxide and hydrogen peroxide radicals by the alveolar macrophage during killing of Mycobacterium bovis. DESIGN: Alveolar macrophages were recovered by bronchoalveolar lavage from adult rabbits and cultured. Experimental macrophages were exposed to M. bovis and carbon particles, controls only to M. bovis. Superoxide release was measured by the superoxide dependent cytochrome C reduction method and hydrogen peroxide release by luminol dependent chemiluminescence. Significance of differences was calculated by Student's t-test for unpaired data. RESULTS: For superoxide and hydrogen peroxide release, results show a significant difference between the experiments and the controls. Hydrogen peroxide radicals are, however, released at a low constant average median value in the controls. CONCLUSION: Hydrogen peroxide is not greatly involved in the killing of M. bovis by alveolar macrophages since low concentrations are released in the controls. Ingestion of large amounts of carbon particles decreases the release of superoxide and hydrogen peroxide radicals.

The influence of carbon particles on the concentration of acid phosphatase and lysozyme enzymes within alveolar macrophages during the killing and degradation of Mycobacterium bovis.

SETTING: Diagnostic bronchoscopy performed on untreated African patients with tuberculosis revealed alveolar macrophages filled with carbon particles. It was postulated that this was the result of excessive inhalation of smoke from domestic fires and the consequent phagocytosis by alveolar macrophages. OBJECTIVE: To determine whether carbon particles influence acid phosphatase and lysozyme enzyme concentrations during the killing and degradation of Mycobacterium bovis by alveolar macrophages. DESIGN: Alveolar macrophages were recovered by bronchoalveolar lavage from adult rabbits and cultured. Experimental cultures were exposed to M. bovis and carbon particles, and controls only to M. bovis. Cultures were grown for 42 h for killing and degradation of organisms. Cells were microscopically enumerated for carbon particle content and enzyme stain intensity. The level of significance was determined by means of a statistical test for sample proportions and by using Student's t-test. RESULTS: The majority of alveolar macrophages in the experiments contained large amounts of carbon particles. The average percentage of alveolar macrophages that stained positive for acid phosphatase and lysozyme enzymes is significantly lower in the experiments than in the controls (P < 0.01 and P < 0.001 respectively). CONCLUSION: It is concluded that large amounts of carbon particles significantly decrease these enzyme concentrations intracellularly.

Coronary heart disease risk factors in a rural and urban Orange Free State black population.

OBJECTIVE: To determine and compare the prevalence of ischaemic heart disease (IHD) risk factors in a rural and an urban black population. DESIGN: A survey to determine the prevalence of hypertension, diabetes mellitus, smoking, obesity, central obesity and dyslipidaemia in black subjects 25 years and older. SETTING: The indigenous black populations of QwaQwa and Mangaung. PARTICIPANTS: A random sample of 950 households was selected from each area. From each household an unrelated male and/or female subject was selected in a standardised way. From QwaQwa 853 subjects (279 men and 574 women) and from Mangaung 758 subjects (290 men and 468 women) participated in the study. The response rate was 68% and 62% respectively for QwaQwa and Mangaung. MAIN OUTCOME MEASURES: Few urban-rural differences in the prevalence of IHD risk factors were found in this study. A low prevalence of clustering of major IHD risk factors was noted. RESULTS: The age- and sex-adjusted prevalences of hypertension were 29% in QwaQwa and 30.3% in Mangaung. Diabetes was present in 4.8% of the QwaQwa sample and 6% of the Mangaung sample. The prevalence of heavy smoking in the Mangaung sample was almost double that of the QwaQwa sample and mostly confined to men. High-risk hypercholesterolaemia was present in 12.5% of QwaQwa and 6% of Mangaung men in the 25-34-year age group. The corresponding figures for moderate-risk hypercholesterolaemia were 34% and 44.8% and both levels of risk declined with increasing age. The mean body mass index of women in both samples exceeded 25 kg/m2. CONCLUSION: All the elements for a potential epidemic of atherosclerotic cardiovascular disease are present in the study populations. The similarity of findings in the two samples may be indicative of the advanced stage of urbanisation and westernisation of the rural group. It is alarming that subjects in the younger age groups tended to have the highest prevalences of moderate and even high-risk hypercholesterolaemia.

Erythrocyte sedimentation rate in elderly blacks.

This study investigated the erythrocyte sedimentation rate (ESR) in an elderly population with the objective of establishing reference ranges and the diagnostic value of the ESR. Elderly blacks were randomly selected from communities in the Orange Free State. ESR determinations were done according to the Westergren method. Total protein, albumin, immunoglobulin and C-reactive protein (CRP) levels were measured on serum. Results were analysed by means of non-parametric statistical methods. In the group with normal CRP' and immunoglobulin levels it was found that 99% of values were below 44 mm/h for men and 62 mm/h for women. The sensitivity and specificity for these cut-off values (CRP used as 'gold standard') were 33% and 91% respectively for men and 75% and 89% respectively for women.

Psychiatric disorders in internal medicine.

All patients admitted to one firm of the Department of Medicine were psychiatrically evaluated in terms of Diagnostic and Statistical Manual of Mental Disorders (DSM III, 1980) criteria. Thirty-three per cent of the patients had treatable psychiatric disorders while only 3.5% of admissions to a comparable firm of the same department were referred for psychiatric consultation (P < 0.05). These data support the need for a more comprehensive liaison psychiatric service than a mere consultation service in the general hospital.

Socio-economic circumstances and functional abilities of elderly black persons in the Orange Free State.

A community-based epidemiological study was undertaken to determine the health profile of the elderly black population in the Orange Free State. Four hundred elderly blacks were randomly selected from 10 towns. Questionnaires on past and present illnesses, socio-economic circumstances (including formal education) and daily activities were completed. Most of the elderly blacks received a state old-age pension and 15.3% were still economically active. We found that 63% of the subjects were illiterate and that 31% did not live with their children. Inability to perform any of six activities was found in 3.2%. In view of the high number of elderly persons living alone, we feel that the development of support services should receive urgent attention.

Biochemical reference values in elderly black subjects.

Biochemical reference values for the black age group of greater than or equal to 65 years were determined from the black urban population of the Orange Free State. Biochemical investigations performed were those included in the Sequential Multiple Analyser Computer profile because it includes the 20 most requested clinical chemistry investigations. Most of the reference values corresponded to values for the same age groups in the Western world. There was no age-related rise in the alkaline phosphatase values, which suggested absence of occult Paget's disease. Reference values for serum total protein and globulin were found to be higher than values derived from elderly white groups.

[Respiratory symptoms and specific IgE in workers on a maize farm]. / Respiratoriese simptome en spesifieke IgE onder werkers op 'n mielieplaas.

A questionnaire concerning respiratory symptoms was completed for 101 workers on a maize farm; 73 railway workers were used as a control group. Symptoms suggestive of allergy were found in 90% of the farm workers compared with only 4% of the control group. However, total IgE levels of the farm workers were not significantly raised and only 40% had positive radio-allergosorbent tests against specific allergens. Smoking seemed neither to reduce nor enhance symptoms. Fungal spores and bacteria in the vicinity were sampled and identified; no evidence of an allergic response to these agents was found. Mechanisms other than allergy must be considered responsible for the farm workers' symptoms.

Double-blind study comparing indoramin and propranolol in the treatment of black patients with hypertension.

A 20-week double-blind randomised study of 50 black hypertensive patients was designed to compare the efficacy and safety of indoramin (Baratol; Wyeth/Ayerst) and propranolol in patients who did not respond to diuretic therapy alone. Indoramin (initial dose 50 mg/d) or propranolol (initial dose 80 mg/d) was added to the regimen of patients whose supine diastolic blood pressure (SDBP) remained elevated at 100- 200 mmHg after 2 weeks' treatment with a combination diuretic tablet (hydrochlorothiazide 50 mg plus amiloride HCl 5 mg). Supine systolic blood pressure (SSBP) and SDBP of all patients was successfully controlled (SDBP lowered to less than 95 mmHg) by daily doses that did not exceed 100 mg of indoramin or 160 mg of propranolol; over 90% of patients in each group achieved control with lower doses, i.e. 50-75 mg of indoramin or 80-120 mg of propranolol. Although heart rate decreased from baseline values by approximately 9/min with both agents, the decreases were not significantly different between the treatment groups, and neither agent caused orthostatic hypotension. There were no statistically significant differences between the groups in the types or frequency of side-effects. Indoramin is well tolerated and is as effective as propranolol in black patients with essential hypertension who are not controlled by a thiazide diuretic alone.

Investigation into the effect of Fenoterol on mucociliary clearance in patients with chronic bronchitis.

We investigated the effect of Fenoterol, a selective beta 2 adrenoceptor stimulant, on mucociliary clearance in 12 patients with chronic bronchitis. Mucociliary clearance was measured with a scintillation camera after inhalation of a 99mTc labelled aerosol. Fenoterol was administered one h after acquisition commenced and imaging was maintained for a further two h. Three regions of interest (ROI) were selected over each lung to generate time activity curves. Corrections for decay, alveolar deposition (using 24 h image), cough and movement of activity through each ROI were carried out. An exponential function was fitted to the clearance curves to determine clearance rates. The increase in percentage clearance after Fenoterol administration for the left and right whole lung ROI was 35% and 36% per h respectively (P = 0.006 and 0.020). Fenoterol enhances cilial clearance in chronic bronchitis patients.

Physostigmine and the adrenergic/antimuscarinic syndrome. A case report.

A 14-year-old White boy was recently admitted to the Universitas Hospital, Bloemfontein, with an adrenergic/antimuscarinic syndrome following drug overdose. The causation of the syndrome and successful management with physostigmine salicylate are discussed.

[Increased incidence of skull metastases in neuroblastoma]. / Verhoogde insidensie van skedelmetastases in neuroblastoom.

Children with neuroblastoma sometimes present with skull and peri-orbital metastases. Recent radionuclide studies confirm the increased incidence of skull metastases compared with adult metastatic carcinoma. Malignant tumours generate skeletal metastases by spread to the bone marrow. The relatively large head of a young child results in a relatively larger proportion of bone marrow in the skull, which explains the increased incidence of skull metastases in children with metastatic skeletal neuroblastoma.

Phantom tumour of the lung secondary to left heart failure. A case report.

Considerable variation in nomenclature and of interpretation exists with regard to the term 'pseudotumour of the lung'. Interlobar encysted effusions, plasma cell tumours fibrous histiocytomas, xanthogranulomas, pseudolymphomas and recently round atelectasis of the lung have all been called 'pseudotumours'. A young man was investigated twice for an encysted interlobar effusion secondary to left heart failure. Treatment of the cardiac condition after the diagnosis of a probable 'phantom tumour' had been made led to rapid clearing of the lung fields. The literature on phantom tumour and some recently accepted ideas concerning nomenclature are reviewed.

Hypersensitivity to non-steroidal anti-inflammatory drugs--asthma precipitated by zomepirac. A case report.

Non-steroidal anti-inflammatory agents can precipitate an asthma attack of varying severity. The most likely mechanism is the inhibition of the production of prostaglandin E with a concomitant increase in the production of the leukotrienes. A case in which an attack of asthma was precipitated by ingestion of 50 mg zomepirac (Zomax) and the patient responded to inhaled fenoterol is described. We conclude that zomepirac can cause reversible airflow limitation.