Hypercalcaemia caused by a carcinoid tumour.

Humoral hypercalcaemia resulting from carcinoid tumours is uncommon. We report a case of hypercalcaemia because of excessive secretion of parathyroid hormone-related protein (PTHrP) in a 77-year-old woman with an advanced carcinoid tumour. Fibroblast growth factor 23 levels were also elevated. The hypercalcaemia responded to adjunctive therapy with long-acting octreotide analogue therapy, bisphosphonates and steroids. The role of PTHrP in humoral hypercalcaemia of malignancy, its association with neuroendocrine tumours, as well as the therapeutic use of somatostatin analogues are reviewed.

Acceptability of the tuberculosis service: scale development.

Health workers require reliable, easily administered and scored measures to evaluate acceptability of a health service. A 13-item attitude scale was developed to determine acceptability of the tuberculosis (TB) service. The objectives of this study were to: ascertain reliability (internal consistency) of the scale and confirm, through factor analysis, that acceptability of the TB service was based on cognitive and affective reactions. The sample comprised 487 black adult interviewees (67 TB patients on ambulatory therapy and 420 non-TB community members) from two urban townships in the Transvaal, South Africa. The reliability coefficient revealed a high level of internal consistency for the scale (r = 0.84). A principal components analysis, with orthogonal and oblique rotations, was conducted. Two factors accounted for 45.4% of the variance. The highest loadings on Factor I involved an empathic dimension (friendly, helpful, encouraging and communicative). Factor II tended to focus on the organizational elements of the system, such as availability, consistency of information, length of waiting time and maintenance of contact. It was concluded that this scale was a reliable, easily administered and scored measure of acceptability, with underlying affective and cognitive components.

Depression and self-esteem: rapid screening for depression in black, low literacy, hospitalized tuberculosis patients.

One hundred black hospitalized tuberculosis (TB) patients (75 males and 25 females) were interviewed to ascertain levels of depression and self-esteem. The standard of literacy for 65% of the sample was such that they were unable to complete a self-report inventory. Reliability (internal consistency) was good for the 21-item Beck Depression Inventory (BDI: r = 0.79), the 13-item shortened BDI (ABDI: r = 0.76) and the Rosenberg Self-Esteem scale (RSE: r = 0.78). There was a significant positive relationship between the BDI and the ABDI (r = 0.92, P = 0.0001). The recommended ABDI cut-off scores established no depression for 32 patients, mild depression for 22 patients, moderate depression for 38 patients and severe depression for 8 patients. There were significant negative relationships between the BDI and the RSE (r = -0.54, P = 0.0001), and between the ABDI and the RSE (r = -0.56, P = 0.0001). Self-esteem scores dropped in accordance with category of depression, revealing that low self-esteem is a characteristic feature of depression. It was concluded that the ABDI was a reliable, rapid, initial screening device for depression in black persons with low literacy levels.

A comparison between the disease status of hospitalized dogs from developed and those from developing communities.

The health status of canine populations within developed and those within developing communities was studied in a retrospective survey and compared. There were significant differences in the prevalence of disease amongst the hospitalised dogs from the 2 communities. Dogs from developing communities were mainly young cross-bred dogs which suffered from infectious diseases (44%), trauma (22%) and parasitic diseases (11%). There was a high mortality rate (30%) and 82% of these patients suffered from diseases that could have been prevented. The dogs from developed communities were mainly adult or old pure-bred dogs that suffered mainly from organ diseases (57%). There was a low mortality rate (10%) while only 31% suffered from diseases that could have been prevented. Based on the epidemiological findings, it was evident that owners of dogs in the developing communities required education in primary and secondary prevention of disease.

Expressed health education needs of black adults living in Ivory Park (Gauteng).

The overall aim of this study was to ascertain African male and female expressed needs for health education programmes. A random sample of 599 adults (229 males and 370 females over 15 years of age) from an informal settlement area (Ivory Park, Gauteng) was interviewed. Out of the 599 respondents, 467 (78%) said that they had received health education, usually through the radio or at a clinic/hospital. Ninety three per cent stated that they would like to receive health education; 52 topics were mentioned. Responses were grouped into six categories: AIDS (32%); Specific Diseases (31%); Child Health (13%); Family Planning (12%); General Health (10%); and Other (2%). Gender and age group were not related to health education category. Doctors and nurses were the preferred presenters of health education at a hospital, clinic or community health centre, through a talk or TV/Video. It was concluded that: (1) there was a definite need for health education, with a focus on AIDS, tuberculosis, child health and family planning; (2) men wanted to be involved in health education programmes; and (3) innovative delivery options need to be developed.

Job satisfaction and self-esteem of South African nurses.

The overall aim of this study was to investigate job satisfaction and self-esteem among South African nurses. The objectives of the study were to: (1) ascertain South African nurses' satisfaction with their work, pay, promotion, supervision and co-workers; (2) compare job satisfaction of South African nurses with that of North American nurses; (3) determine levels of self-esteem; and (4) test the direct and indirect effects of self-esteem on job satisfaction. A postal survey was conducted on a random sample of 2,000 nurses registered with the South African Nursing Council; 396 persons returned the questionnaires (Group 1). A subsample of 93 nonrespondents was traced and agreed to complete the questionnaire (Group 2). Minimal differences justified combining the groups and conducting subsequent analyses on total sample scores. Nurses were most satisfied with supervision and co-workers and least satisfied with promotion and pay. Reliability coefficients for the five job satisfaction subscales and overall scale ranged between 0.79 (work) and 0.93 (overall scale). South African nurses were significantly less satisfied with all aspects of their jobs than their American counterparts. Coefficient alpha for the self-esteem scale was 0.72, 0.87 for the work-related needs scale and 0.80 for the social approval scale. High self-esteem nurses were more likely to attend to work-related needs in judging their job satisfaction than low self-esteem nurses. The best model for predicting job satisfaction was the linear incorporation of self-esteem and work-related needs. It was concluded that: (1) the Job Descriptive Index (JDI) was a useful measure of job satisfaction; (2) the quality of life in the South African nursing profession was lower than their American counterparts; (3) nurses had high levels of self-esteem; and (4) self-esteem directly and indirectly affected job satisfaction.

Parental HIV Disclosure in Burkina Faso: Experiences and Challenges in the Era of HAART

Increasingly parents living with HIV will have to confront the dilemmas of concealing their lifelong treatment or disclosing to their children exposed to their daily treatment practices. However; limited data are available regarding parental HIV disclosure to children in Burkina Faso. Do parents on antiretroviral therapy disclose their HIV status to their children? What drives them? How do they proceed and how do children respond? We conducted in-depth interviews with 63 parents of children aged seven and above where the parents had been in treatment for more than 3 years in two major cities of Burkina Faso. Interviews addressed parental disclosure and the children's role in their parents' treatment. The rate of parental HIV status disclosure is as high as that of non-disclosure. Factors associated with parental disclosure include female sex; parent's older age; parent's marital history and number of children. After adjustment; it appears that the only factor remaining associated with parental disclosure was the female gender of the parent. In most of the cases; children suspected; and among non-disclosers many believed their children already knew without formal disclosure. Age of the children and history of divorce or widowhood were associated with parental disclosure. Most parents believed children do not have the necessary emotional skills to understand or that they cannot keep a secret. However; parents who disclosed to their children did not experience blame nor was their secret revealed. Rather; children became treatment supporters. Challenges to parental HIV disclosure to children are neither essential nor specific since disclosure to adults is already difficult because of perceived risk of public disclosure and subsequent stigma. However; whether aware or not of their parents' HIV-positive status; children contribute positively to the care of parents living with HIV. Perceptions about children's vulnerability and will to protect them against stigma lead parents to delay disclosure and not to overwhelm them with their experience of living with HIV. Finally; without institutional counselling support; disclosure to children remains a challenge for both parents and children; which suggests a need for rethinking of current counselling practices

Cognitive and affective reactions of black urban South Africans towards tuberculosis.

SETTING: The core concepts of tuberculosis (TB) control programmes are case-finding (voluntary presentation) and case-holding (compliance for both patient and system). Voluntary presentation and compliance are complex behaviours that depend upon symptom recognition and evaluation, cultural and social influences and enabling factors such as time, money, skills and appropriate/accessible health services. It was hypothesised that cognitive and affective reactions towards TB were based on perceived prevalence, perceived seriousness and perceived social stigma. OBJECTIVES: To ascertain the underlying dimensions that are used when people react cognitively and emotionally to TB, and to determine possible restricting social influence factors on voluntary presentation and case-holding. DESIGN: A questionnaire was designed to obtain information on background details, perceptions of TB (transmission, prevention, diagnosis and treatment), and a 19-item cognitive/affective scale. 19 trained interviewers administered the questionnaire. Interviews were conducted with 487 black adults (67 TB patients on ambulatory therapy and 420 non-TB community members), from two urban townships in the Transvaal, South Africa. RESULTS: The majority of respondents were aware of the infectious nature of TB, that it could be cured and the length of treatment. The most problematic issues were isolation for TB sufferers and the harm TB sufferers do to others. Cognitive/affective reactions were similar for TB patients and community members. 10 items out of the 19-item cognitive/affective scale had communality estimates > or = 0.30. 3 factors were extracted. The first factor seemed to combine personal threat (high personal and family risk) with social rejection by the immediate family and community for TB sufferers. Factor 2 had strong overtones of social stigma, with its emphasis on dirt, poverty and poor nutrition. Factor 3 rejected alcohol and tobacco consumption as causal agents of TB. CONCLUSIONS: The predominant cognitive/affective reactions towards TB were personal threat, social rejection and social stigma, providing partial support for the hypothesis. The powerful force of social rejection and social stigma cannot be underestimated. These inhibiting factors require urgent attention to improve voluntary presentation and compliance behaviour.

Cardiac disease during pregnancy--a Free State perspective on maternal morbidity and mortality.

AIM: Description of maternal outcome of pregnancies complicated by cardiac disease. SETTING: Pelonomi Hospital, Bloemfontein. POPULATION: Black African women of low socio-economic background who presented with cardiac disease during pregnancy. SAMPLE: All patients who delivered from 1 January 1990 to 1 January 1995. DESIGN: Descriptive retrospective study. RESULTS: Cardiac disease complicated 0.6% of pregnancies. Rheumatic valvular disease dominated in this population. The maternal mortality rate was 9.5% while the maternal morbidity rate ranged from 50% to 100% for the various lesions. CONCLUSIONS: Cardiac disease in pregnancy has high maternal mortality and morbidity rates. Hypertension, anticoagulation therapy, late referrals and inadequate counselling were important contributing factors. A high priority should be given to meticulous contraceptive counselling in patients with cardiac disease. Collaboration between obstetricians, physicians and cardiothoracic surgeons in imperative.

Continuing education for dental practitioners.

Attendance of continuing education courses by dentists is important for the practitioner, the profession and the patient. This survey was undertaken to determine the attendance pattern and discipline preferences for such courses during the period 1985 to 1989. A total of 2674 questionnaires were sent to dentists and 706 (26.4 per cent) were returned. Courses were attended by 88.5 per cent of the respondents. The most popular disciplines were Operative Dentistry, Aesthetic Dentistry and Fixed Prosthodontics.

Spectrophotometric absorbance of follicular fluid: a selection criterion.

PURPOSE: The aim of this study was to ascertain the absorbance profiles of uncontaminated follicular fluids (FF) vs blood and medium contaminated FF, and to test the hypothesis that blood contamination alters the biochemical status of FF. METHODS: FF (n = 655) from 230 patients were scanned spectrophotometrically during an ongoing in vitro fertilization (IVF) program. Based on spectrophotometric evaluation, blood contaminated and uncontaminated FF (n = 39 patients/FF) were analyzed for electrolyte content, inorganic phosphate, glucose, creatine, urate, total protein, albumin, bilirubin, cholesterol, alkaline phosphatase, gamma-glutamyltransferase, alanine aminotransferase, aspartate transaminase, and lactate dehydrogenase by means of a SMAC analyzer. RESULTS: Laparoscopic aspiration resulted in the collection of significantly more clear FF compared to the transvaginal procedure (P = 0.001). Uncontaminated fluid depicted a single mean absorbance at 458.0 nm. Blood contaminated FF could be identified by spectrophotometry and revealed three peaks at 418.12, 540.13, and 575.32 nm, respectively, according to the degree of blood contamination. Follicular fluid diluted with Earles Balanced Salt Solution (EBSS) displayed an additional mean peak at 561.4 nm. Potassium, glucose, and all of the above mentioned enzymes revealed significantly higher levels in blood contaminated FF (P < 0.05). CONCLUSIONS: From this study, it is concluded that blood contamination and dilution with culture medium influence the biochemical composition as well as the absorbance spectrum of follicular fluids. This procedure is advocated as a prerequisite before quantifying FF content.

An assessment of the statistical procedures used in original papers published in the SAMJ during 1992.

OBJECTIVE: To assess the statistical procedures used in original papers published in the SAMJ. DESIGN: Descriptive study based on a random sample of 100 papers from the 153 papers with methodological content that were published in the SAMJ during 1992. RESULTS: This review showed that 34% (95% CI (25%; 43%)) of papers used no statistical procedure at all or used simple descriptive statistics only. In sampling methods, there was a predominance of the use of the period sampling method as opposed to probability sampling methods. Inappropriate statistical methods were used in 15% (6%; 24%) of papers, while in 16% (9%; 23%) statistical procedures and in 13% (6%; 20%) the sampling methods used could not be identified. Inaccurate graphical methods were used in 17% (6%; 28%) of papers. Confidence intervals and power calculations are used far too infrequently, in 33% (19%; 47%) and 11% (3%; 19%) of appropriate papers respectively. If the Journal's readers are at least familiar with simple descriptive statistics, contingency table analysis, simple epidemiological statistics, t-test procedure and confidence interval calculation and interpretation, they will have a complete understanding of the statistical content of 60% of original articles published in the Journal. CONCLUSION: Guidelines for the statistical treatment of reported data and the statistical review of articles before publication will assist substantially in improving the quality of statistical analysis. More intensive use of available biostatistical and epidemiological expertise at the study design and analysis stages is needed to shift the emphasis from descriptive research to analytical investigation.

Epididymal markers in an andrology clinic.

The ability of the markers alpha-glucosidase, carnitine, and glycerylphosphorylcholine to indicate epididymal obstruction was studied. alpha-Glucosidase was found to be the best discriminant, with 93.4% correct classifications. The possible interrelationship between alpha-glucosidase activity, sperm ATP, and epididymal function was then studied. alpha-Glucosidase correlated positively with the percentage of motile sperm (p = 0.0212) and with the percentage of sperm with good forward progression (p = 0.0374), but correlated negatively with the sperm ATP (p < 0.0500). It was concluded that lower ATP and higher alpha-Glucosidase may be markers of efficient epididymal function. The possible epididymal origin of detached ciliary tufts (DCTs) was studied by determining ATP and alpha-glucosidase activity in patients with DCTs. The mean ATP in patients with DCTs was significantly higher (p = 0.009), but the alpha-glucosidase activity significantly lower (p = 0.0412) than in the control group. These results seem to support the epididymal origin of DCTs.

Efficacy and safety of rifabutin in the treatment of patients with newly diagnosed pulmonary tuberculosis.

The efficacy and safety of rifabutin (RBT) and rifampicin (RMP) were compared in 298 patients with newly diagnosed pulmonary tuberculosis. In the initial 8-wk phase, all patients received isoniazid 400 mg/d, ethambutol 1200 mg/d, and pyrazinamide 2 g/d and were randomly allocated to receive either RMP 600 mg/d or RBT 300 mg/d. In the 16-wk continuation phase, patients received intermittent treatment (twice weekly) with isoniazid 600 mg/d, ethambutol 2400 mg/d and either RMP 600 mg/d or RBT 300 mg/d. Two hundred twenty-five (RMP = 118; RBT = 107) patients completed the 24-wk treatment period (evaluable patient population). Bacteriologic conversion rates in the RMP and RBT groups were 87.7 versus 92.0% at Week 8, 99.1 versus 99.0% at Week 12, 93.5 versus 93.8% at Week 24, and 89.8 versus 95.3% at the last valid observation. The mean time to first bacteriologic conversion was 14.1 wk in the RMP group and 14.3 wk in the RBT group. None of these differences was significant. Adverse events were reported by four patients (five events) in the RMP group and six patients (six events) in the RBT group. Those events thought to be associated with RMP were increased SGOT and leucopenia and, with RBT, increased SGOT and thrombocytopenia. Two hundred four patients entered the follow-up phase, and, of these, 95 (RMP = 49; RBT = 46) completed the scheduled 24-mo period. The overall rate of relapse was 3.8% (4/106) for the RMP group and 5.1% (5/98) for the RBT group. These differences were not significant. All relapsed patients, except for two who could not be traced, were successfully retreated. We conclude that the efficacy and tolerability of RBT is equivalent to that of RMP in the treatment of newly diagnosed uncomplicated tuberculosis, and that RBT can be effectively administered in a part-daily, part-intermittent dosage schedule.

[Attitude of a group of South Africans toward advertising by dentists in private practice]. / Die houding van'n groep Suid-Afrikaners teenoor advertensie deur tandartse in die privaatpraktyk.

The advertising of dental services in South Africa is controlled by rules and regulations of the South African Medical and Dental Council. According to these, advertising is not permissible with the exception of specified professional information which may be made known only by means of a nameplate and an entry in a telephone directory. Questionnaires were sent to a randomised sample of 2,100 persons in order to determine the attitude of South Africans towards advertising by private practitioners. According to information obtained from this study there is a strong indication that consumers of dental services prefer a freer form of advertising by dentists in the private practice.

Congenital anomalies in black South African liveborn neonates at an urban academic hospital.

STUDY OBJECTIVE: The aim was to study the spectrum of clinical problems and outcomes in infants born at an urban academic hospital. In consequence, as part of the overall study, the incidence of congenital anomalies and the outcomes of affected infants were recorded. DESIGN: This was a prospective, hospital-based study, undertaken on liveborn infants born over a 3-year period, 1 May 1986 to 30 April 1989. SETTING: Kalafong Hospital, Pretoria. MAIN RESULTS: A total of 17,351 liveborn infants was examined and the total congenital anomalies incidence was 11.87 per 1,000 livebirths. The central nervous system was the system most frequently involved (2.30 per 1,000 livebirths), followed by the musculoskeletal system (2.13 per 1,000 livebirths). The commonest individual congenital anomaly was Down syndrome (1.33 per 1,000 livebirths), followed by neural tube defects (0.99 per 1,000 livebirths) and ventricular septal defects (0.69 per 1,000 livebirths). In 11% (2.25 per 1,000 livebirths) of neonatal deaths, infant loss was attributable to congenital anomalies. CONCLUSIONS: The incidence of congenital anomalies in black South African neonates, born in an urban setting, is as high as in other First- and Third-World countries, and the incidence of some individual congenital anomalies is higher. This study indicates the need for further research and the establishment of prenatal, genetics and paediatric facilities to manage these problems.

Early thyroidectomy for medullary thyroid carcinoma in children and young adults with the multiple endocrine neoplasia type 2A (MEN 2A) syndrome.

A South African family, at risk for the multiple endocrine neoplasia type 2A (MEN 2A) syndrome, was identified. The Bloemfontein MEN Study Group was founded, inter alia, to study the effects of early detection of medullary carcinoma of the thyroid (MTC) and treatment by total thyroidectomy in children and young adults with MEN 2A. Genotypes were identified by DNA probe and MTC diagnosed by basal and stimulated calcitonin levels. Between 1986 and 1989, 10 members of the family underwent total thyroidectomy and central lymph node dissection for MTC. There were 6 female and 4 male patients (mean age 22,0 years; range 10 - 35 years). Histological examination of the resected thyroid revealed MTC in all patients; 8 had bilateral disease and 2 unilateral. Lymph nodes were negative for MTC in all patients. None of the patients suffered injury to the recurrent nerve, while 1 experienced transient hypoparathyroidism postoperatively. Replacement therapy is maintaining thyroid hormone levels in all patients. Screening should probably begin at the age of 1 year, and total thyroidectomy should be performed when an elevated calcitonin level is observed.

Experience with a provocative test of calcitonin release as a prospective screening for preclinical medullary thyroid carcinoma in MEN type 2A family members.

We report our experience with a provocative test of calcitonin (CT) release using a combined stimulus of intravenous 10% CaCl2 solution and pentagastrin on 34 normal adults (15 females: age 41 +/- 12.3 years and range 22-65 years; and 19 males: age 43 +/- 9.1 years and range 23-60 years) and in 44 family members of three proven multiple endocrine neoplasia type 2A syndrome (MEN 2A) patients. A commercial radioimmunoassay was used to determine the serum CT levels. Peak CT levels were reached within 2 to 5 minutes after administration of the stimulus in all subjects tested. In the group of normal subjects there was no significant difference in the mean basal CT levels between males (54.8 +/- 21.7 pg/ml) and females (56.5 +/- 34.8 pg/ml), whilst the mean peak response values for males was 146.3 +/- 120.6 pg/ml, which was significantly different from the mean value of females, namely 71.6 +/- 39.0 pg/ml. We did not find significant correlations between the basal CT level, peak CT response, and age. Of the 44 family members tested, 9 showed an exaggerated CT response to the combined stimulus and subsequently had a total thyroidectomy. Histological examination confirmed C-cell hyperplasia (CCH) in one and medullary thyroid carcinoma (MTC) in the other 8. Three of the 9 had high basal plasma CT levels. The 9 patients were retested postoperatively and all showed a flat response to the combined stimulus. Those family members with histological proof of MTC or CCH were screened for genetic linkage to the disease gene for MEN 2A using probe MCK2, and showed correlation in each instance.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple endocrine neoplasia type 2A (MEN 2A) syndrome in a South African family. Biochemistry and molecular genetics.

Multiple endocrine neoplasia type 2A (MEN 2A), an uncommon heritable disease, was investigated in an Afrikaner kindred. Serum calcitonin levels after combined pentagastrin and calcium chloride stimulation were measured to determine thyroid involvement, as were urinary metadrenalin levels to determine adrenal gland involvement. MEN 2A genotype status was determined using the DNA probe MCK2 (D10S15). The index patient, who showed both thyroid and adrenal gland involvement, died of phaeochromocytoma complications. Thirty-four of his 114 family members, in 4 generations, were investigated. Nine had positive histological and calcitonin tests and were predicted to be MEN 2A genotypes by DNA analysis. One asymptomatic individual had a positive calcitonin test after being predicted to be a MEN 2A genotype with the probe MCK2. In 3 DNA-positive cases calcitonin stimulation tests were negative. Preclinical detection of the heritable form of MEN 2A will be facilitated by utilising the DNA probe MCK2 to determine carrier status in this large South African family. It is also the first South African family in which biochemical and molecular genetic techniques were used to facilitate diagnosis.