Relationship between self reporting of past history of anti-tuberculosis treatment and radiographic findings in multidrug-resistant tuberculosis.

SETTING: A referral hospital for multidrug-resistant tuberculosis (MDR-TB) patients in KwaZulu-Natal, South Africa. OBJECTIVE: To investigate how self-reporting of past exposure to anti-tuberculosis therapy in MDR-TB patients relates to their chest radiographs. RESULTS: Chest radiographs of 406 patients with bacteriologically confirmed MDR-TB who were admitted to a tertiary referral hospital during 1998-2001 were reviewed. Of 245 patients with chronic radiographic changes, 91% reported previous anti-tuberculosis treatment, while of 161 patients with acute radiographic changes, 70% reported no previous history of TB treatment. CONCLUSION: Self-reporting by patients of previous anti-tuberculosis treatment relates to the duration of disease assessed radiologically, and is much more reliable than previously postulated.

Imiglucerase low-dose therapy for paediatric Gaucher disease--a long-term cohort study.

BACKGROUND: Gaucher disease is the most common lysosomal storage disorder caused by the insufficiency of the lysosomal enzyme, glucocerebrosidase. This deficiency results in absent or inefficient conversion of glucocerebroside (a membrane lipid) to ceramide and glucose. Accumulation of glucocerebroside occurs primarily in macrophage lysosomes (i.e. monocytes and macrophages) during phagocytic degradation of red blood cells. Clinical symptoms arise due to the displacement of normal cells by lipid-engorged Gaucher cells. Enzyme replacement therapy (ERT) targets the macrophage system and has been shown to be successful in the treatment of type 1 Gaucher disease in adults and children. ERT (60 U/kg) every 2 weeks decreases and often reverses organomegaly and haematological complications and improves quality of life for patients with type 1 Gaucher disease. The present study describes the course of 9 paediatric patients followed up for 2 - 10 years receiving low-dose imiglucerase therapy (+/- 10 U/kg every 2 weeks) for moderate to severe type 1 Gaucher disease. OBJECTIVES: To evaluate the efficacy of low-dose imiglucerase therapy in paediatric Gaucher disease. SUBJECTS AND METHODS: Data were recorded at a single centre for 9 paediatric patients. Assessment of response included serial measurements of haemoglobin (Hb) concentrations, platelet count, angiotensin-converting enzyme (ACE) and total acid phosphatase (TAP) levels. Growth was assessed by serial determinations of body weight and height, plotted against standard growth charts. Organ size (liver and spleen) was measured clinically and also radiologically, where possible. RESULTS: In this low-dose imiglucerase treatment group: (i) there was a significant increase in Hb over time--normal Hb levels were achieved in 7 of the 9 patients after a mean of 3.7 years; (ii) platelet counts increased over time, reaching normal levels in 7 patients; (iii) there was a significant decrease in both ACE and TAP over time; (iv) heights and weights of the subjects increased significantly over time with treatment, normalising to the expected growth percentiles; and (v) organ size (liver and spleen) reduced with therapy in all patients measured. CONCLUSION: ERT with low-dose imiglucerase (+/- 10 U/kg/fortnight) ameliorates Gaucher disease-associated anaemia and thrombocytopenia. Low-dose ERT is effective and may be considered in resource-poor clinical situations when other alternatives are not available.

Universal immunization of infants with low doses of a low-cost, plasma-derived hepatitis B vaccine in South Africa.

OBJECTIVE: To evaluate the effectiveness of universal vaccination against viral hepatitis B in South Africa among 18-month-old rural children. METHODS: Children were immunized with a course of low-dose (1.5 microg), plasma-derived hepatitis B vaccine at 6, 10 and 14 weeks of age, and blood samples from the children were tested for three hepatitis B markers: hepatitis B surface antigen (HBsAg), anti-HBs and anti-HBc. FINDINGS: One year after vaccination, a protective anti-HBs antibody titre of at least 10 IU/l was present in 669/769 (87.0%) of blood serum samples tested. Only 3/756 children (0.4%) were HBsAg positive and a fourth child was anti-HBc positive (HBsAg negative). This is a marked decrease compared to the hepatitis B prevalences reported in previous studies. Among rural migrant mine-workers, for example, HBsAg prevalence was 9.9%, and was 10.1% among children 0-6 years of age in the Eastern Cape Province. CONCLUSION: The low-dose, plasma-derived hepatitis B vaccine, which is affordable to most developing countries, was very successful in controlling endemic hepatitis B infection, where the virus is predominantly spread by horizontal transmission among infants and young children.

Social phobia subtyping with the MMPI-2.

The present article examines the utility of the MMPI-2 for the subtyping of social phobia (SP). Cluster analysis was conducted on the MMPI-2 profiles of 109 patients with SP. Clusters were compared on demographic and clinical variables prior to treatment, as well as following completion of cognitive-behavioral group therapy (CBGT). Three distinct clusters emerged. The first is characterized by an absence of significant scale elevations and appears to be consistent with the reported "circumscribed" subtype of SP. It is associated with a significantly later age at onset of SP, a higher proportion of married individuals, and lower scores on pretreatment clinical variables. Significant elevations on Scales 2 (Depression) and 7 (Psychasthenia) and moderately high scores on pretreatment clinical variables characterize the second cluster. The third cluster is characterized by significantly high elevations on Scales 8, 7, and 2, and the highest scores on pretreatment clinical variables. Patients from all three groups improved significantly following a course of CBGT.

The incremental validity of lumbar surface EMG, behavioral observation, and a symptom checklist in the assessment of patients with chronic low-back pain.

This study evaluated the comparative ability of lumbar surface EMG, behavioral observation, and a symptom checklist to correctly classify three groups of participants, (1) 18 patients with chronic low-back pain (CLBP), demonstrating excessive and/or anatomically inconsistent motor, sensory, and tenderness responses during a neurological examination, (2) 33 patients with CLBP exhibiting few or no inconsistent responses, and (3) 30 healthy matched controls. Discriminant analyses were used to develop predictive models. Correct classification rates for the individual assessments and all combinations of assessments were contrasted. Each modality predicted group membership significantly better than weighted chance (23%), with the symptom checklist approach having the highest individual correct classification rate (64%). The best combination of modalities was the symptom checklist and lumbar surface EMG (70% correct classification rate). The sensitivity and specificity of the individual assessments and all combinations of assessments are also presented.

Caesarean section rates in South Africa: evidence of bias among different 'population groups'.

OBJECTIVE: The aim of this study was to assess the effect of 'population group' classification, as a specific instance of 'racial' categorization, on caesarean section rates in South Africa. DESIGN: Information on 'population group' classification ('Black, 'Coloured', 'Indian', or 'White', as defined under apartheid legislation) and place of delivery, together with basic obstetric, sociodemographic and perinatal data, were extracted from the birth notification forms of 5456 children who made up the birth cohort of the Birth to Ten longitudinal study. This cohort included all births that occurred to mothers resident in Soweto-Johannesburg during a 7-week period in 1990. RESULTS: After accounting for differences in maternal age, gravidity, birth weight and gestational age at delivery, the rate of caesarean sections at private facilities was more than twice that at public facilities. Although there were significant differences in the utilisation of private facilities by women from different 'population groups', there was an independent effect of 'population group' classification on caesarean section rates: caesarean section rates among women classified as 'White' and 'Coloured' were significantly higher (95% confidence intervals for odds ratios: 1.40-2.42 and 1.05-1.81, respectively) than among women classified as 'Black'. CONCLUSION: 'Population group' differences in caesarean section rates among South African women are not explained by differences in demographic risk factors for assisted delivery, nor by differences in access to private health care. Instead, the differences in section rates may reflect the effect of bias in clinical decision-making, and/or differences among women from different 'population groups' in their attitude towards assisted delivery, and their capacity to negotiate with clinicians.

Training for general practice: a national survey.

OBJECTIVES: (a) To compare current vocational training in general practice with that ascertained by a survey in 1980; (b) to compare the training of trainees in formal training schemes with that of trainees arranging their own hospital and general practice posts. DESIGN: National questionnaire survey of United Kingdom and armed services trainees who were in a training practice on 1 April 1989. Questionnaires were distributed by course organisers. SETTING: Research project set up after an ad hoc meeting of trainees at the 1988 national trainee conference. SUBJECTS: 2132 Of the 2281 trainees (93%) known to be in a training practice on 1 April 1989. RESULTS: 1657 Trainees returned the questionnaires, representing 73% of all trainees known to be in a training practice on 1 April 1989. Between 1980 and 1989 there were significant improvements in the trainee year, and there was also evidence of improvements in general practice study release courses. There was no evidence of improvement in other aspects of training. General practice trainees spent an average of three years in junior hospital posts, which provided very little opportunity for study related to general practice. Training received during tenure of hospital posts differed significantly between trainees in formal schemes and those arranging their own hospital posts. During the trainee year training was almost the same for those in formal schemes and those arranging their own posts. Regions varied significantly in virtually all aspects of general practice training. CONCLUSIONS: The trainee year could be improved further by enforcing the guidelines of the Joint Committee on Postgraduate Training for General Practice. The poor training in junior hospital posts reflected the low priority that training is generally given during tenure of these posts. A higher proportion of general practice trainees should be attached to vocational training schemes. More hospital trainees could attend general practice study release courses if these were designed specifically with the needs of hospital doctors in mind.

The comparison of trends in perinatal mortality in small areas.

Year to year changes in perinatal mortality rates for small populations are difficult to interpret. Because local rates are based on small numbers of events, they are subject to apparently large fluctuations. A technique for analysing trends in mortality, for detecting changes in trends and comparing variations in trends between areas is described. It is illustrated by an analysis of perinatal mortality rates for Area Health Authorities in the West Midlands Region of England from 1974-1981, but the same techniques could be used to analyse trends at other times and in other places.