Comparative trial of artificial and natural surfactants in the treatment of respiratory distress syndrome of prematurity: experiences in a developing country

We conducted a randomized clinical trial to compare the effects of a synthetic (Exosurf) and natural (Survanta) surfactant in infants with neonatal respiratory distress syndrome. Eighty-nine patients were randomly allocated to receive one of the two surfactants. Primary outcome variables were the acute and long-term effects of the surfactant preparations, i.e., ventilatory requirements at 24 h of age as judged by the oxygenation index (OI), and the combined incidence of chronic lung disease or death at 28 days. The OIs in the Exosurf and Survanta groups at 24 h were the same (10.1 and 7, respectively; P > 0.05). The magnitude and rapidity of response, however, were greater for Survanta than for Exosurf. When arterial/alveolar oxygen tension ratios (a/A) were compared, the Exosurf group had a significantly worse a/A ratio at 24 h than the Survanta group (0.21 Exosurf vs. 0.37 Survanta; P < 0.05). The long-term outcome as judged by the combined incidence of death or chronic lung disease was not different in the two groups (18.6% Exosurf vs. 15.2% Survanta; P > 0.05). When the complications of prematurity were compared, there were no statistically significant differences between the two groups. We conclude that both preparations are reasonable choices for the treatment of respiratory distress syndrome of prematurity.

Trends in asthma mortality in young people in southern Brazil

BACKGROUND

Mortality from asthma increased and is now declining in some countries, but little is known about these trends in South America.

OBJECTIVE

We aimed to assess trends in mortality from asthma in southern Brazil in children and young adults.

METHODS

Death certificates of 425 people in the state of Rio Grande do Sul aged between 5 and 39 years in whom asthma was reported to be the underlying cause of death during the period 1970 to 1992 were reviewed. Population data were available in 10-year age groups. Testing for trends in mortality rates was conducted using linear and log-linear regression procedures.

RESULTS

Asthma mortality rates in the age groups 5 to 19 and 20 to 39 years ranged between 0.04 and 0.39/100,000 and 0.28 to 0.75/100,000, respectively, and were nonuniformly distributed over the study period. The mean annual increase in rate in 5- to 19-year olds was +0.01 (95% CI 0.003 to 0.016), an average annual percentage increase of +6.8% (95% CI 3% to 11%), with a total increase of 352% between 1970 and 1992. This increase was not due to a shift in labeling from bronchitis to asthma. In the 20 to 39-year age group, asthma and bronchitis mortality rates showed no trend to increase or decrease.

CONCLUSIONS

Asthma mortality in southern Brazil is low, but rose significantly between 1970 and 1992 in the 5 to 19-year age group. This trend differs from that found in other states of Brazil and several other Latin American countries. Reasons for this difference remain unclear.

Respiratory symptoms and long-term risk of death from cardiovascular disease, cancer and other causes in Swedish men

BACKGROUND

Depressed respiratory function and respiratory symptoms are associated with impaired survival. The present study was undertaken to assess the relation between respiratory symptoms and mortality from cardiovascular causes, cancer and all causes in a large population of middle-aged men.

METHODS

Prospective population study of 6442 men aged 51-59 at baseline, free of clinical angina pectoris and prior myocardial infarction.

RESULTS

During 16 years there were 1804 deaths (786 from cardiovascular disease, 608 from cancer, 103 from pulmonary disease and 307 from any other cause). Men with effort-related breathlessness had increased risk of dying from all of the examined diseases. After adjustment for age, smoking habit and other risk factors, the relative risk (RR) associated with breathlessness of dying from coronary disease was 1.43 (95% CI : 1.16-1.77), from stroke 1.77 (95% CI: 1.07-2.93), from any cardiovascular disease 1.48 (95% CI : 1.24-1.76), cancer 1.36 (95% CI : 1.11-1.67) and from any cause 1.62 (95% CI: 1.44-1.81). An independent effect of breathlessness on cardiovascular death, cancer death and mortality from all causes was found in life-time non-smokers, and also if men with chest pain not considered to be angina were excluded. An independent effect was also found if all deaths during the first half of the follow-up were excluded. Men with cough and phlegm, without breathlessness, also had an elevated risk of dying from cardiovascular disease and cancer, but after adjustment for smoking and other risk factors this was no longer significant. However, a slightly elevated independent risk of dying from any cause was found (RR = 1.18 [95% CI: 1.02-1.36]).

CONCLUSION

A positive response to a simple question about effort related breathlessness predicted subsequent mortality from several causes during a follow-up period of 16 years, independently of smoking and other risk factors.

Exacerbation of premenstrual asthma caused by an oral contraceptive

BACKGROUND

The relationship between sex hormones and asthma has not been clarified. Studies have suggested a potential beneficial effect of exogenous sex hormones and/or contraceptive pills on asthma in premenopausal females whereas the data for postmenopausal females are inconsistent.

CASE REPORT

A 33-year-old woman suffering from asthma with premenstrual exacerbations had a stable course until she began taking oral contraceptives. At that time she experienced clinical deterioration of her asthma associated with decline of pulmonary function tests. No other precipitating factors were identified. After discontinuing the contraceptives, her condition returned to baseline.

CONCLUSION

We found only two reports of worsening of asthma related to hormonal therapy (estrogen in one case, contraceptive pills in the other) in premenopausal women. Our report, together with these observations, suggests that in some premenopausal women exogenous sex hormones and/or contraceptive pills may, contrary to expected, produce exacerbation of asthma.

Hyperendemic pulmonary tuberculosis in a Peruvian shantytown

Estimates of the incidence of pulmonary tuberculosis in developing countries are based on case reporting from local health laboratories or the annual risk of tuberculin skin test conversion. Because these methods are problematic, the authors used a multiple case ascertainment method to estimate the incidence of pulmonary tuberculosis from 1989 to 1993 in a Peruvian shantytown of 34,000 inhabitants. Two methods, face-to-face interview of all local inhabitants and examination of local laboratory smear records, were used for case gathering. The number of missed cases was estimated by capture-recapture analysis. Survey cases with positive smears were matched to age- and sex-matched controls and interviewed about socioeconomic conditions. The average annual incidence per 100,000 population was 364 (95% confidence interval 293-528) by capture-recapture methods. For the city encompassing the shantytown, the Peruvian Ministry of Heath reported an average annual incidence of 134 cases per 100,000 population. The authors conclude that, in Peru, alarming clusters of pulmonary tuberculosis are masked by government reports that pool zones of disparate incidence. Existing estimators of pulmonary tuberculosis incidence based on tuberculin conversion rates may be invalid in such areas. Within these hyperendemic areas, persons suitable for intensive prophylaxis efforts cannot be reliably identified by housing and socioeconomic risk factors.

Projected mortality from lung cancer in South Korea, 1980-2004

BACKGROUND

In recent years, mortality from lung cancer has increased rapidly in Korea, a South East Asian country with a high prevalence of smoking. The objectives of this study are to examine how age, period, and birth cohort effects contributed to trends in lung cancer mortality in Korea 1980-1994, and to predict lung cancer mortality rates for 1995-2004.

METHODS

Age- and sex-specific lung cancer mortality rates were obtained from annual reports of the National Office of Statistics in Korea. Poisson regression models were used to estimate age, period and cohort effects.

RESULTS

Among men, age-adjusted annual mortality rates from lung cancer (per 100000) increased from 3.7 in 1980 to 17.8 in 1994; corresponding rates for women were 1.4 and 7.0. As age increased, mortality rates from lung cancer increased more rapidly in men than in women. Within the same age group, the mortality of younger cohorts was higher than older cohorts. The average annual number of lung cancer deaths projected for the years 2000-2004 among men and women will be 15441 and 3572 respectively, while the average annual age-adjusted mortality rates from lung cancer (per 100000) will be 65.4 for men and 15.1 for women. These rates correspond to 17.7- and 10.7-fold increases over the 1980 mortality rates in men and women, respectively.

CONCLUSION

These results, in conjunction with trends in tobacco consumption, indicate that mortality from lung cancer in both men and women will increase substantially through the early part of the 21st century in Korea.

Neonatal neurological examination as a predictor of neuromotor outcome at 4 months in term low-Apgar-score babies in Zimbabwe

The predictive value of the neonatal neurological examination (NNE) adapted from Prechtl, was investigated in 139 term Zimbabwean infants born with an Apgar score of five or less at 5 min. At 4 months, seven infants had died and 13 were lost to follow-up, leaving 119 infants to undergo the Infant Motor Screen (IMS). Eighty-eight infants were diagnosed as normal, six as suspect and 25 as abnormal at screening. The sensitivity, specificity, positive predictive value and negative predictive value of the NNE were 94%, 55%, 42% and 96%, respectively. Seventeen (14%) infants had developed microcephaly at 4 months and 13 (77%) of them scored abnormal on the IMS. Twenty-three of the 48 (48%) infants who had convulsions within 48 h of birth, were diagnosed as abnormal (P < 0.0001). The NNE proved to be very sensitive in detecting neurodevelopmental abnormalities in the neonatal period and the five abnormal syndromes derived from the NNE were able to correctly identify 94% of the abnormal infants.

Lung cancer deaths in the United States from 1979 to 1992: an analysis using multiple-cause mortality data

BACKGROUND

We sought to describe trends in the presence of lung cancer at the time of death in the United States from 1979 to 1992.

METHODS

We analysed death certificate reports in the Multiple-Cause Mortality Files compiled by the National Center for Health Statistics, searching for any mention of lung cancer, lung cancer as the underlying cause of death, and comorbid conditions.

RESULTS

Of the 29,042,213 decedents in the study period, 1,892,129 (6.5%) had a diagnosis of lung cancer listed on their death certificates; of these 1,892,129 decedents, 1,734,767 (91.7%) had lung cancer listed as the underlying cause of death. Decedents with lung cancer listed as being present but not the underlying cause of death were more likely to be male (relative risk [RR] 1.16, 95% confidence interval [CI]: 1.15-1.17), and older (RR 4.61, 95% CI: 4.35-4.88 for decedents older than 85 compared to those aged less than 44), but less likely to be black than white (RR 0.88, 95% CI: 0.87-0.90). The mortality rate, age-adjusted to the 1980 population, increased 23.0%, from 47.9 per 100,000 in 1979 to 58.9 per 100,000 in 1992. Over the study period, black men had the highest mortality rates (117.3-125.2 per 100,000), followed by white men (81.7-88.7 per 100,000), men of other races (37.4-46.7 per 100,000), white women (22.1-39.1 per 100,000), black women (21.4-38.2 per 100,000), and women of other races (12.6-18.1 per 100,000). Age-adjusted, state specific rates varied threefold, from 30.4 per 100,000 in Utah to 93.9 per 100,000 in Nevada.

CONCLUSIONS

We conclude that the underlying cause of death data base, which captures almost 92% of decedents with lung cancer present, accurately tracks lung cancer mortality trends in the US. Mortality rates of lung cancer, which are decreasing among men, continue to increase among women.

Role of early postnatal dexamethasone in respiratory distress syndrome

OBJECTIVE

To study the effect of early postnatal dexamethasone therapy on severity of hyaline membrane disease.

DESIGN

Prospective, randomized, controlled, unblinded study.

SETTING

Neonatal Intensive Care Unit.

METHODS

19 babies who had hyaline membrane disease were included in this study. The inclusion criteria were clinical and radiographic diagnosis of RDS, requiring mechanical ventilation and FiO2 > 0.3. Ten babies received injection dexamethasone 0.5 mg/kg/dose 12 hourly for 3 days starting within 6 hours of birth. The control group did not receive any drug. Babies with active infection, bleeding tendency and congenital malformation were excluded. None of the babies received surfactant. The duration of ventilation and AaDO2 and FiO2 requirements from day one to five were calculated.

RESULTS

The initial AaDO2 were similar in both the groups but on day 3, 4, 5 AaDO2 were low in study group (201, 85, 70) compared to control group (236, 209, 162). The initial FiO2 were 0.66 and 0.63 in dexamethasone and control groups, respectively and remained high till day 2 and came down in study group on days 3, 4 and 5 (0.41, 0.27, 0.27) compared to control group (0.53, 0.34, 0.42). The mean duration of ventilation was shorter in dexamethasone group (87 hours) vs control group (120 hours).

CONCLUSION

Early use of postnatal dexamethasone reduces the disease severity and oxygen requirement in RDS and hence would be useful in the Indian context.

Noncommunicable disease management in resource-poor settings: a primary care model from rural South Africa

Noncommunicable diseases (NCDs) such as hypertension, asthma, diabetes and epilepsy are placing an increasing burden on clinical services in developing countries and innovative strategies are therefore needed to optimize existing services. This article describes the design and implementation of a nurse-led NCD service based on clinical protocols in a resource-poor area of South Africa. Diagnostic and treatment protocols were designed and introduced at all primary care clinics in the district, using only essential drugs and appropriate technology; the convenience of management for the patient was highlighted. The protocols enabled the nurses to control the clinical condition of 68% of patients with hypertension, 82% of those with non-insulin-dependent diabetes, and 84% of those with asthma. The management of NCDs of 79% of patients who came from areas served by village or mobile clinics was transferred from the district hospital to such clinics. Patient-reported adherence to treatment increased from 79% to 87% (P = 0.03) over the 2 years that the service was operating. The use of simple protocols and treatment strategies that were responsive to the local situation enabled the majority of patients to receive convenient and appropriate management of their NCD at their local primary care facility.

Damp housing conditions and respiratory symptoms in primary school children

There is evidence that indoor air pollution contributes to the development of respiratory symptoms. This study examined the relationships between dampness in houses and respiratory symptoms in 4,164 primary school children in the subtropical rural areas of the Kaohsiung region, Taiwan. Dampness in homes was assessed by questionnaires that reported 1) general dampness, 2) mold or mildew inside the home, or 3) flooding (appearance of standing water within the home, water damage, or leaks of water into the building). Evidence for upper and lower respiratory symptoms were also collected by questionnaires. Recorded symptoms included cough, wheezing, pneumonia, bronchitis, and asthma. Degrees of dampness were reported as 12.2%, 30.1%, and 43.4%, respectively by the parents or guardians of the study population. The prevalence of respiratory symptoms was consistently higher in homes with indications of dampness than in non-damp homes. After adjustments for potential confounders, selected respiratory symptoms among the childhood population were significantly higher in damp than non-damp homes, with the exception of pneumonia. We conclude that dampness in the home is a strong predictor of and risk factor for respiratory symptoms and constitutes a significant public health problem in subtropical area.

Nutritional and lung function profile of boys belonging to east Delhi

Nutritional and pulmonary profile of 50 boys (age group 12-15 years) belonging to slums of East Delhi were studied. Various anthropometric parameters (height, weight, total body fat) and pulmonary parameters (FVC, FEV1 and PEFR) were recorded and compared with control group of same age studying in public school of East Delhi. Regression analysis was carried out to see the correlation between body surface area (BSA) with lung functions. The lung functions were found to be compromised in boys inhabitating the slums and a positive correlation between BSA and lung functions indicates that multitude of factors like environmental pollution, nutritional status, etc, do contribute towards pulmonary morbidity.

Pneumocystis carinii pneumonia in Malawian children

Sixty children aged between 1 and 23 months admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi for diagnosis of acute lower respiratory tract infections (ALRI) were investigated for laboratory diagnosis of Pneumocystis carinii pneumonia (PCP) by indirect immunofluorescence assay on nasopharyngeal secretions. P. carinii was found in five of the 60 children. Three PCP cases had AIDS. The clinical presentation of children with PCP was of little diagnostic value and all the children were infants. Arterial oxygen saturation was significantly lower in PCP cases. Of the five PCP cases, four died, indicating that the marked hypoxaemia was associated with poor prognosis. These results indicate that an immunofluorescence assay on nasopharyngeal secretions could be used for first-line diagnosis of PCP in Africa.

The management of asthma in children in Papua New Guinea

In the last decade advances in knowledge of the aetiology and pathogenesis of asthma, and the availability of metered-dose inhalers and nebulisers, has led to a change in emphasis in both the preventive and curative aspects of the management of children with asthma. Metered-dose inhalers are available in Papua New Guinea, and can be used successfully, with spacing devices, even in children less than 2 years of age. Inhaled beta-sympathomimetics, now widely available and relatively inexpensive, may be all that is required for the majority of children with infrequent episodic asthma. For those with frequent episodic and chronic asthma, preventive therapy with inhaled steroids is available and should be given wherever practicable. In the management of acute severe asthma inhaled beta-sympathomimetics should be combined with a short course of oral or parenteral steroids (covered with isoniazid in areas where tuberculosis is prevalent). Whilst asthma classically presents with wheeze, medical personnel should be aware of its other presentations. It is possible, and should be the aim, to achieve a very high level of control for the majority of asthmatic children using currently available therapy.

Pneumocystis carinii pneumonia in human immunodeficiency virus infected patients in Bombay: diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.

Prevalence of human immunodeficiency virus infection: its impact on the diagnostic yields in exudative pleural effusions at the Kenyatta National Hospital, Nairobi

This was a descriptive cross-sectional study carried out at Kenyatta National Hospital (KNH), Nairobi, among consecutively admitted adult patients with exudative pleural effusions over a one year period. The aim of the study was to determine the prevalence of human immunodeficiency virus (HIV) infection in these patients and to compare the diagnostic yields from the pleural fluid and pleural biopsy between the HIV seropositive and HIV seronegative patients. Sixty six patients were studied, with a mean age of 33.8 (+/- SD = 15.6) years and a male to female ratio of 1.6:1. Overall, 27 patients(40.9%) were found to be HIV seropositive. The commonest cause of exudative pleural effusions, overall, was tuberculosis (78.8%) followed by neoplasms (7.6%). Comparing the aetiology of exudative pleural effusion in HIV seropositive and HIV seronegative patients, tuberculosis was still the commonest cause accounting for 42.3% and 57.7% of the cases in each of the groups respectively. Conversely, 42.3% of patients with tuberculous pleural effusions were HIV seropositive. There was no significant difference in yields from pleural fluid, pleural biopsy culture and histology in the diagnosis of tuberculosis in the two patient groups. The only two patients with empyema were HIV seropositive and the bacterial isolates were Salmonella typhimurium and Pseudomonas aeruginosa. Kaposi's sarcoma was the cause of exudative pleural effusion in the one HIV seropositive patient with a malignant effusion. The only patient with a parapneumonic effusion was HIV seronegative. No fungi were isolated.

A study of risk factors for pneumococcal disease among children in a rural area of west Africa

BACKGROUND

Pneumoccal infection is one of the leading causes of pneumonia, meningitis and septicaemia in developing countries. We have investigated possible risk factors for pneumococcal disease among children living in a rural area of The Gambia.

METHODS

A prospective case-control study was conducted in which children with pneumococcal infection were identified from among children attending out-patient and under-fives clinics and matched according to age with healthy children selected randomly from the local community. A questionnaire was used to investigate possible nutritional, medical, socioeconomic and environmental risk factors for pneumococcal disease.

RESULTS

An increased risk of pneumococcal disease was associated with poor weight gain, a history of serious illness in the previous 6 months, exposure to cigarette smoke or being carried on mother's back while cooking. The risk of pneumococcal disease was reduced among children whose mothers had a personal source of income.

CONCLUSIONS

The incidence of pneumococcal disease could be reduced by improving nutrition and taking steps to identify and rehabilitate those children whose weight is faltering or falling. Encouraging mothers to develop greater financial independence may also be beneficial. Reduced exposure to smoke should be promoted by improving ventilation in kitchens, introducing more efficient and less polluting stoves, keeping children away from smoky environments and discouraging parental smoking.

Pulmonary infections in HIV infected patients

We retrospectively reviewed causes, clinical presentations and chest radiographs of pulmonary infections in symptomatic HIV infected patients diagnosed in Srinagarind Hospital from February 1992 to 1994. We found 95 episodes of pulmonary infections in 88 HIV infected patients enrolled in our review. The three most common pathogens were Mycobacterium tuberculosis (37.2%), Pneumocystis carinii (23.8%), and Cryptococcus (15.2%). Coexistent pulmonary infections were seen in 10.5 per cent, mostly due to P. carinii and Cryptococcus neoformans. Extrapulmonary infections were also common, particularly with M. tuberculosis (49%) and C. neoformans (100%). The common clinical presentations were fever, dyspnea, and cough which frequency varied among the organisms. Chest radiographs were nonspecific, the most common finding was bilateral pulmonary infiltrates except that bacterial pneumonia usually presented with unilateral infiltrates. All patients wit PC had significant hypoxia (PaO2 < 70 mmHg). Due to nonspecific clinical and chest film presentations as well as frequent coinfections, definite diagnosis should be carried out in all HIV infected patients with pulmonary infections.

Pulmonary infection caused by Mycobacteria other than M. tuberculosis in and around Calcutta

A study was undertaken to determine the prevalence rate of atypical mycobacteria in indolent fibrocavitary pulmonary diseases. 450 sputum specimens were examined and cultured, of which 15 were identified as atypical mycobacteria on repeated culture. No previous study was recorded from Calcutta. Compared to the results of previous workers from different regions of India, the prevalence rate seems high in this part of the country.

Clinical profile and risk factors for oral candidosis in sick newborns

OBJECTIVES

To provide the clinical profile and assess the significance of various risk factors contributing to the occurrence of oral candidosis in newborns.

DESIGN

Case-control study.

SETTING

Neonatal Intensive Care Unit (NICU).

SUBJECTS

Twenty newborns with oral candidosis and an equal number of age and weight matched controls.

INTERVENTIONS

All cases of oral candidosis were treated with local application of 1% Clotrimazole.

RESULTS

Oral candidosis was documented in 3.2% (20/650) cases in the NICU. Acute pseudomembranous candidosis was the most common presentation. The mean age of onset was 10.5 days. Candida albicans was isolated in 50% cases in addition to C. tropicalis, C. paratropicalis, C. krusei, C. glabrata and C. parapsilosis. On univariate analysis, male sex, birth asphyxia and prolonged antibiotic therapy had a significant correlation with occurence of oral candidosis in neonates. Out of these, birth asphyxia was the only factor significantly associated with oral candidosis (OR 8.09, 95% CI 1.34-48.8, p = 0.0226) on multivariate analysis.

CONCLUSIONS

C. albicans was the predominant isolate in this series of oral candidosis. Clinical manifestations were evident in the second week of life and birth asphyxia was the most important associated perinatal event.

Perceived health status and morbidity and mortality: evidence from the Kuopio ischaemic heart disease risk factor study

BACKGROUND

Previous studies have reported an increased risk of death in those who report their health is poor, however, the role of underlying and subclinical disease in this association has not been carefully studied.

METHODS

The associations between perceived health status and mortality from all causes and cardiovascular disease, incidence of myocardial infarction, carotid atherosclerosis, forced expiratory volume, and maximal exercise capacity were studied in the Kuopio Ischaemic Heart Disease Risk Factor Study, a population-based study of 2682 men, aged 42-60, in eastern Finland.

RESULTS

There were strong, statistically significant, age-adjusted associations between level of perceived health and mortality from all causes (RH(bad versus good) = 3.67), cardiovascular causes (RH(bad versus good) = 6.64), and incidence of myocardial infarction (RH(bad versus good) = 3.87). Perceived health levels were strongly associated with risk factors and disease indicators. The associations with mortality and myocardial infarction outcomes were considerably weakened with progressive adjustment for eight risk factors and prevalent disease. Higher levels of perceived health were associated with less carotid atherosclerosis, and greater forced expiratory volume and maximal exercise capacity. Associations between level of perceived health and these indicators were considerably stronger in those with prevalent diseases than in those who were healthy.

CONCLUSIONS

The overall pattern of results suggests that perceived health levels mainly reflect underlying disease burden.

Morbidity of survivors of neonatal respiratory distress syndrome under four years of age

This study evaluates the morbidity of neonatal respiratory distress syndrome (RDS) survivors in the Taiwan area. Sixty-three survivors of RDS, without surfactant therapy, were followed from January 1984 to December 1994. Comparisons between RDS survivors and 102 premature controls demonstrated that allergic rhinitis and hyperreactive airway (HRA) were adversely affected in RDS infants and children, especially in patients with chronic lung disease (CLD). It is interesting that a high incidence of otitis media and hypothyroidism was not found in this study, even though these have been reported elsewhere as more frequent among RDS survivors than among control subjects.

Aerobic bacteria, Chlamydia trachomatis, Pneumocystis carinii and Cytomegalovirus as agents of severe pneumonia in small infants

The authors studied 58 infants hospitalized for pneumonia in a semi-intensive care unit. Age ranged from 1 complete to 6 incomplete months. The infants were sent from another hospital in 20 cases and from home in a further 38. Pulmonary involvement, which was alveolar in 46 cases and interstitial in 12, was bilateral in 31 children. The investigation was carried out prospectively on the etiological agents associated with respiratory infection to look for evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopy of tracheal aspirated material). The following infectious agents were diagnosed in 21 children (36.2%): Aerobic bacteria (8), Chlamydia trachomatis (5), Pneumocystis carinii (3), Cytomegalovirus (3), Cytomegalovirus and Chlamydia trachomatis (1), Aerobic bacteria and Cytomegalovirus (1). Seven cases of infection by Chlamydia trachomatis and/or Cytomegalovirus were diagnosed out of the 12 cases with pulmonary interstitial involvement.

Smoking-associated mortality in a cohort of Singaporeans observed for 20 years

Smoking is well established as a main cause of preventable mortality throughout the world, but little data are available on Asian populations and none on Singapore. This study is the first to provide data specific to Singapore on the increased mortality among smokers, and is one of the few such studies on Asians. In 1974, smoking history data were taken from a random sample of 3579 adults living in Singapore. Of these, 3361 (1522 men and 1839 women) were eligible for follow-up and vital status was determined as at 31 December 1993. Cox regression analysis was used to estimate the relative risks of variety of causes of death for smokers compared to non-smokers, adjusted for age and ethnicity. Smoking was categorized as ever or never and also as none, light or heavy. As at 31 December 1993, 330 (21.7%) of the men and 249 (13.5%) of the women had died. Relative risk values were clearly elevated for male and female smokers for all-cause mortality (1.42 and 1.52, respectively), lung cancer (13.2, 6.37) and death due to chronic obstructive pulmonary disease (COPD) (4.71, 8.50). Relative risk values for death from cancer of the larynx or oesophagus, ischaemic heart disease and cerebrovascular disease were elevated but not significantly different from 1.0. A trend of increasing risk with increasing smoking intensity was seen for all-cause mortality among men and for lung cancer and COPD mortality, among both sexes. Ethnicity was associated with ischaemic heart disease mortality among men, with elevated risks in both the Indians (2.55) and the Malays (1.66) relative to the Chinese. These results should serve to strengthen the anti-smoking campaigns in Singapore.

[The new face of tuberculosis in the context of the tuberculosis-HIV association in Abidjan, Ivory Coast]

This article reviews the main clinical aspects and progression of HIV-related tuberculosis in Abidjan. HIV prevalence in tuberculosis patients is high, estimated at 46.2% in 1992, with a clear predominance of HIV-1 over HIV-2. More than 61% of co-infected tuberculous patients meet the WHO's clinical definition of AIDS (the Bangui definition) at the time of diagnosis of tuberculosis. This rates falls to 46-51% when cough is excluded from the definition. On X-rays, the signs of pulmonary tuberculosis in co-infected tuberculous patients are atypical in the advanced stages of HIV infection, when extra-pulmonary localization, mainly mediastinal adenopathy, is frequent. Short-course chemotherapy consisting of 2 months' unsupervised daily treatment with rifampicin/isoniazid/pyrazinamide, followed by 4 months of a daily combination of rifampicin/isoniazid, applied in the Ivory Coast since 15 July 1985, has proved successful in HIV-associated tuberculosis, with treatment effectiveness rates of more than 90%.

Neonatal seizures in Nigerian infants

Nigerian newborns presenting with convulsion in University of Calabar Teaching Hospital, Calabar during the period January 1989 to December 1990 were prospectively studied to determine the aetiology and pattern of their seizures. There were 60 patients representing 4% of admissions into the Newborn Unit during the period. Birth asphyxia, infections and hypoglycaemia were the important identifiable aetiological factors which operated either singly (48% of cases) or in concert (in another 48%) of the infants. Detectable infections included meningitis and septicaemia caused predominantly by coliforms and Staphylococcus aureus. Hypocalcaemia and electrolyte imbalance did not feature. There was an unusually high prevalence (63% of cases) of the generalised type of seizures probably due to the high frequency of mixed aetiology. The mortality rate of 50% encountered appears to be related to the underlying aetiology and prematurity. Detectable caused of neonatal seizures in our environment appear to be potentially preventable by improved obstetric and neonatal care. There is dire need also to provide modern facilities for investigating newborn seizures in order to improve upon the diagnostic yield.

Effects of urban air pollutants on emergency visits for childhood asthma in Mexico City

The metropolitan area of Mexico City, Mexico, has serious air pollution problems. Although air contaminants may contribute to clinical asthma, there are at present no data on the relation between air pollution exposure and childhood asthma in Mexico City. The authors reviewed data on emergency visits from January to June 1990 at one major pediatric hospital in Mexico City. They used a Poisson regression model to study the relation between the number of daily emergency visits for asthma and air pollutant levels. The levels of ozone and sulfur dioxide-exposure were significantly associated with the number of emergency visits for asthma. After adjustment for potential confounding factors, the multivariate regression model predicted that an increase of 50 ppb in the 1-hour maximum ozone level would lead to a 43% increase in the number of emergency visits for asthma on the following day. Exposure to high ozone levels (> 110 ppb) for 2 consecutive days increased the number of asthma-related emergency visits by 68 percent. The results of this study suggest that ozone exposure is positively associated with the number of children's emergency visits for asthma in Mexico City.

Trend of HIV infection in patients with pulmonary tuberculosis in south India

SETTING

Tuberculosis is life threatening, transmissible and pandemic especially among millions of HIV infected persons. In developing countries like India where HIV infection is becoming prevalent and where tuberculosis infection has long been endemic, its incidence is increasing.

OBJECTIVE

The aim of the study was to find out the trend of HIV infection in patients with pulmonary tuberculosis in south India.

DESIGN

HIV seropositivity was assessed in 1430 radiologically and/or bacteriologically confirmed pulmonary tuberculosis patients attending major tuberculosis institutions in Madras by the AIDS Cell, Institute of Microbiology, Madras Medical College, Madras from January 1991 to May 1993.

RESULTS

HIV seropositivity was found to rise significantly from 0.77% in 1991 to 3.4% in 1993 (P < 0.05). 22 (91.67%) of a total of 24 HIV seropositive pulmonary tuberculosis patients had pulmonary cavities and 21 patients (87.5%) had bacteriological confirmation of tuberculosis.

CONCLUSION

The findings of this prospective study suggest that pulmonary tuberculosis patients with HIV infection are an in early phase of immunosuppression. This study reveals the rising trend of HIV infection; all persons with tuberculosis should therefore be questioned about the risk factors for HIV infection and urged to have an HIV test.

The effect of outdoor air pollution on mortality risk: an ecological study from Santiago, Chile

The aim of this ecological study was to investigate the effect of outdoor air pollution on the mortality risk of metropolitan inhabitants in Santiago de Chile. Cause-specific deaths by the day for the years 1988-1991 in Santiago de Chile were extracted from mortality data tapes of the National Center for Statistics. Deaths from accidents were excluded. Total and some specific respiratory diseases deaths were compared calculating the risk of death by municipality and month of the year using age-adjusted standardized mortality ratios (SMRs) controlling for socioeconomic level. Daily counts of deaths were regressed using a Poisson model on the total and fine suspended particles, SO2, CO and ozone on the preceding day, controlling for temperature and humidity. A clear pattern in the geographical distribution of risk of death, both for general mortality and specific respiratory causes (pneumonia, COPD and asthma) was found using SMR, with higher values in the most polluted areas regardless of socioeconomic and living conditions. A highly significant positive association was found between total mortality and both fine suspended particles and CO level. The association remained significant for those days with fine suspended particles levels below 150 micrograms/dl suggesting a no-threshold effect for the total number of deaths. These results are in agreement with previously reported associations, and they add to the body of evidence showing that particulate pollution is associated with increases daily mortality.

Outcome in relation to Apgar score in term neonates

Sixty four asphyxiated term babies (Apgar score of 6 or less at 5 minutes) and 90 non-asphyxiated term babies (controls) were studied. Of these, 40 cases and 48 controls could be followed up. Mortality and neurodevelopmental outcome were studied in both the cases and controls. Mortality and poor neurodevelopmental outcome correlated inversely with the Apgar scores at 5 and 10 minutes. The outcome of babies with low 5 minute Apgar scores was significantly better than those with the same scores at 10 minutes. Symptomatic neonates when compared to asymptomatic neonates with same Apgar score showed significantly poorer outcome. Babies with Apgar scores of 6 at 5 or 10 minutes behaved like the controls both in terms of mortality and neurodevelopmental outcome.

Pulmonary cryptococcosis associated with HIV-1 infection in Rwanda: a retrospective study of 37 cases

OBJECTIVES

To study the demographic, clinical, radiographic and diagnostic features, the clinical course and therapeutic response of pulmonary cryptococcosis in HIV-1-infected patients.

DESIGN

Retrospective review.

SETTING

The Department of Medicine of an urban reference hospital in Central Africa.

METHODS

All the records of HIV-1-infected patients with pulmonary cryptococcosis were reviewed retrospectively with regard to the parameters described above.

RESULTS

Over a 3-year period, pulmonary cryptococcosis was diagnosed in 37 HIV-1-infected Rwandan patients (21 men, 16 women; mean age, 35 years; range, 26-55 years). Twenty-nine patients (78%) had primary pulmonary cryptococcosis. Cough (94%), weight loss (65%), fever (51%), dyspnoea (46%), thoracic pain (30%), headache (13%) and haemoptysis (8%) were the predominant clinical findings. A diffuse interstitial infiltrate on chest radiograph was observed in 76% of the patients, an alveolar pattern in 19%, mediastinal and/or hilar adenopathy in 11%, nodules and pleural effusion each in 5%. Bronchoalveolar lavage, with a yield of 82%, was found to be the most sensitive diagnostic procedure. Screening of cryptococcal antigen in the serum failed to detect cases of primary pulmonary cryptococcosis. Twelve patients with primary pulmonary cryptococcosis treated with itraconazole as acute and maintenance therapy were all protected against disseminated cryptococcal disease; seven out of 10 (70%) of those who did not receive a specific anticryptococcal drug developed disseminated cryptococcal disease.

CONCLUSION

Pulmonary cryptococcosis is not a rare complication of HIV-1 infection in Rwanda. Its clinical and radiographic patterns are non-specific and bronchoalveolar lavage is the procedure of choice for its diagnosis. The natural history of untreated primary pulmonary cryptococcosis is disseminated cryptococcal disease. Itraconazole is highly effective in the prevention of disseminated cryptococcal disease in patients with primary pulmonary cryptococcosis.

The relation of vasectomy to the risk of cancer

We previously reported a strong positive association between vasectomy and the risk of prostatic cancer that arose in multiple comparisons made within data collected from 1976 to 1988 in an ongoing hospital-based surveillance study of many exposures and diseases. We have reassessed this association with data collected in the surveillance study during 1988-1992 from a new set of patients (355 cases of prostatic cancer and 2,048 controls with nonmalignant conditions). Because some studies have reported increased relative risks of lung cancer and testicular cancer in vasectomized men, we also used the surveillance database (4,126 men with various cancers, 7,027 men with nonmalignant conditions) to assess the relation of vasectomy to the risk of these and other cancers. In the newly collected data, the multivariate relative risk estimate for prostatic cancer in vasectomized men was 1.2 (95% confidence interval (CI) 0.6-2.7). For lung cancer and testicular cancer, the relative risk estimates were 1.3 (95% CI 0.8-2.1) and 0.8 (95% CI 0.4-1.9), respectively; for lung cancer occurring > or = 15 years after vasectomy, the relative risk estimate was 1.9 but it was not statistically significant (95% CI 0.7-5.0). For pancreatic cancer, the relative risk estimate was 1.8 (95% CI 1.0-3.1). For each of the other cancers considered--malignant melanoma, large bowel cancer, bladder cancer, kidney cancer, lymphoma, leukemia, and other cancers--the relative risk estimate was 1.3 or less and compatible with a value of 1.0. The present data provide little support for an association of vasectomy with the risk of prostatic cancer or other cancers. In addition, the data from two sets of cases of prostatic cancer and controls interviewed consecutively illustrate that increased relative risks detected in screening for statistically significant associations may tend to have an upward bias and to be lower in subsequent data.