Vincristine and focal segmental sclerosis: do we need a multicentre trial?

Over the last 10 years, eight children have received vincristine for the treatment of steroid- and cyclophosphamide-resistant nephrotic syndrome at Great Ormond Street Hospital for Children, London. We present our experience of these eight cases and put forward a case for reassessing the effectiveness of vincristine in this disorder. In our series, two children treated with vincristine achieved complete remission with preserved renal function, including relapses in one. Both had primary steroid- and cyclophosphamide-resistant focal segmental glomerulo sclerosis (FSGS). Of the other cases, four also had primary FSGS, one familial FSGS and one mesangioproliferative glomerulonephritis. We discuss in general the pros and cons of vincristine therapy in nephrotic syndrome versus the cytotoxic agents that are currently used and the differences in clinical features among the responders and non-responders in this small group. In addition, we explore why this may have occurred and summarise the literature over the last 25 years, where vincristine appeared to have been beneficial, especially in secondary forms of nephrotic syndrome associated with malignancy. We conclude that vincristine therapy warrants re-examination as it could be a valuable alternative therapeutic agent in some cases of FSGS with relatively minor side effects.

Witchdoctors in Africa.

PIP: This article summarizes the experiences of medical students who spent elective time in the heart of Zululand at Charles Johnson Memorial Hospital in Nqutu, Kwazulu. It is a former mission hospital now under the jurisdiction of the Kwazulu government. The problems that the students encountered are characteristic of those in other black rural homeland hospitals and contrast greatly with those in white hospitals. There is a deep rooted conviction among many tribespeople that a withchdoctor must be visited before a visit to the hospital is considered. It is not unusual to have to treat a sick Zulu 1st for the effects of a witchdoctor's potions and only subsequently for the original complaint. Many Zulu believe also that some illnesses occur only among African peoples and so are amenable only to traditional treatment. At any such hospital the personalities of other staff are of paramount importance in influencing one's experiences and memories. Language and culture may readily obscure and frustrate in such a different environment, and attitudes, flexibility, and past experienes determine one's reactions.^ieng