A clinical evaluation of children under the age of five years who are household contacts of adults with sputum positive tuberculosis in Harare, Zimbabwe.

OBJECTIVE: To determine the prevalence and risk factors for transmission of tuberculosis in children under five years of age who are household contact of sputum smear positive tuberculosis adults in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: City Health Infectious Diseases Hospital Outpatient Department. SUBJECTS: 174 children in contact with 102 index cases. MAIN OUTCOME MEASURES: TB infection status in children according to modified WHO classification of tuberculosis. METHODS: Under five year old contacts of sputum smear positive TB adults were recruited over a three month period. A coded questionnaire was used to document the following: socio-demographic profile of caregivers, duration of stay with the index case and presenting complaints. Contacts were evaluated by clinical examination, Mantoux testing, HIV antibody testing and chest radiographs. RESULTS: Of the 174 children in contact with 102 index cases evaluated, 109 (62.6%) were Mantoux positive (> or = 10 mm), 42% had abnormal chest X-ray, with hilar lymphadenopathy being the commonest abnormality. Forty nine percent of the children evaluated had probable TB, 28% had suspected TB and 23% had no TB. High alcohol acid fast load (AAFB) in the index case was independently associated with probable and suspected TB (OR 2.27 95% CI (1.05 to 4.87). CONCLUSION: The documented high transmission rate among under five years contacts in the study justifies the need for strengthening contact tracing and appropriate therapeutic management of identified children.

Efficacy and cost-effectiveness of bronchial arterial embolisation in the treatment of major haemoptysis.

OBJECTIVE: To determine the efficacy and cost-effectiveness of bronchial artery embolisation (BAE) in the treatment of major and massive haemoptysis in HIV-positive and negative patients with pulmonary inflammatory disease. METHODS: A retrospective review of patients admitted over a period of 24 months to Wentworth Hospital with major haemoptysis treated using BAE. RESULTS: Eighty-seven patients were treated (77 males, 10 females). Bilateral disease was present in 50 patients (57%). Thirty-two patients were HIV-positive (37%). Embolisation was successfully performed in 77 patients (88.5%), and failed for technical reasons in 10 patients (11.5%). There was only one procedural complication. Fifty-seven patients had a successful outcome, with cessation of haemoptysis within 24 hours (66.5%). Haemoptysis continued in 30 patients (34%) (20 patients embolised and the 10 patients who had failed procedures). Fourteen of these patients (16%) required lobectomy or pneumonectomy as an emergency procedure. Five patients (5.7%) died from respiratory failure or pulmonary haemorrhage. Twenty-four HIV-positive patients were successfully embolised. Costing of BAE, including a 2-day ICU and 3-day ward stay, was R6,720; together with surgical resection the cost was R14,170. CONCLUSIONS: BAE is an effective treatment for major and/or massive haemoptysis in patients with pulmonary inflammatory disease who are not surgical candidates. Patients who are HIV-positive are able to tolerate the procedure well.

Pulmonary angiography and embolization for severe hemoptysis due to cavitary pulmonary tuberculosis.

PURPOSE: To identify the role of pulmonary angiography in the diagnosis and treatment of severe hemoptysis due to cavitary pulmonary tuberculosis. METHODS: Selective pulmonary angiography was performed on eight patients with severe hemoptysis uncontrolled by previous bronchial and systemic arterial embolization. RESULTS: Three (38%) patients had Rasmussen aneurysms, which were successfully embolized with steel coils. Five patients demonstrated pulmonary arterial hypoperfusion in the diseased lung. CONCLUSIONS: We recommend pulmonary angiography in cavitary tuberculous patients with severe hemoptysis who do not respond to systemic arterial embolization. Rasmussen aneurysms are effectively treated by steel coil occlusion.

Palliative treatment of oesophageal carcinoma--efficacy of plastic versus self-expandable stents.

OBJECTIVES: A prospective randomised study of patients with irresectable oesophageal carcinoma treated with self-expandable covered metal Wallstent and plastic Procter Livingstone tubes was performed. The purpose was to compare the efficacy, cost effectiveness, ease of implantation, long-term patency and complications of the two different stents. METHODS: Data recorded included dysphagia score (0-4) the day before and after stent placement, location and length of stricture, procedural time and complications, and stent patency at 1 and 3 months' follow-up. A comparative costing of materials, theatre and anaesthetic time and hospital stay was undertaken. RESULTS: Forty patients were studied over 12 months (20 in each group). Strictures were located most commonly in the middle third of the oesophagus (75%), followed by the upper third (12.5%) and lower third (12.5%). Mean stricture length was 6 cm (2-12 cm); 10 patients (25%) had strictures 8 cm or longer. Five patients had tracheo-oesophageal fistulas (3 Wallstent; 2 Procter Livingstone tube). There was effective fistula sealing in all 3 Wallstent patients, and non-sealing in 1 of the Procter Livingstone patients. The mean pre-operative dysphagia score in both groups was 3, and immediately postoperatively the score was 0 in the Wallstent group and 2 in the plastic tube group. Initial stent placement was satisfactory in all Wallstent patients, with 2 patients requiring 2 stents each for adequate tumour coverage, and in 15 patients (75%) having plastic stents. Immediate complications were chest pain in 2 patients with Wallstents and oesophageal perforation in 2 patients (10%) with plastic stents. Wallstent patency at 1 and 3 months was 90% and 88%, respectively, and plastic stent patency was 66% and 50%. Four patients (10%), 2 in each group, died during the study from massive tumour load or metastatic disease. Comparative costing of the Wallstent versus the plastic tube stent was R4 123 versus R2 146 or a factor of 1.9. CONCLUSION: Palliation with the Wallstent is effective, with excellent 1- and 3-month patency. The Wallstent is superior to the conventional plastic stent in terms of ease of implantation, better long-term patency and fewer complications. It is particularly useful for the treatment of patients with fistulas and long strictures. Accurate placement is critical in order to prevent stent migration and tumour overgrowth. However, it costs almost twice as much to implant the Wallstent as it does to implant the plastic tube.

Colour Doppler ultrasound assessment of the inferior vena cava in patients with Wilms' tumour.

OBJECTIVE: To assess the diagnostic accuracy of colour flow Doppler ultrasound in diagnosing inferior vena caval (IVC) extension of tumour thrombus in patients with Wilms' tumour. MATERIALS AND METHODS: Over a 3-year period from June 1994 to June 1997, 74 patients with Wilms' tumour were referred to our institution. In this retrospective study we reviewed the preoperative colour flow Doppler ultrasound reports of 64 of these patients and compared the reports with the intra-operative findings in 51 patients who underwent surgery. RESULTS: Vena caval extension of tumour thrombus was present in 12 patients (18.7%) and in six of these patients (9.4%) there was also atrial extension of the tumour. Colour flow Doppler ultrasound correctly diagnosed IVC extension of tumour thrombus in nine patients and correctly predicted the cranial extent of the tumour thrombus in eight patients. CONCLUSION: Colour flow Doppler ultrasound has an overall positive predictive value of 73.4% in assessing IVC patency and correctly diagnosing IVC extension of tumour thrombus, in patients with Wilms' tumour. However, non-diagnostic ultrasound examinations can occur in over 20% of patients.