Tuberculosis in Patients Infected with the Human Immunodeficiency Virus

A retrospective study of tuberculosis was undertaken among 125patients infected with human immunodeficiency virus (HIV) whoattended our regional infectious disease unit between 1986 and1989. Nine TB-positive patients (five English, three Africans,one Indian) were identified. In three patients who presentedwith pyrexia of unknown origin and no objective evidence ofany organ involvement, the diagnosis of TB was established fromexamination of sputum induced by nebulized hypertonic saline.Four other patients had extrapulmonary disease while anothertwo had only pulmonary manifestations of TB. Chest radiographsfrom five patients were normal, while the other four showedcavities with consolidation, pleural effusion, miliary opacitiesand hilar enlargement, respectively. All but two mycobacterialisolates were fully sensitive to standard first-line chemotherapeuticdrugs. Response to treatment was rapid and only complicatedin one patient. There were no relapses following treatment withoutmaintenance therapy after a mean follow-up of 22.2 months (range9–48). Three patients died, of causes unrelated to TB.Tuberculosis may occur at any stage of HIV disease and is animportant cause of fever in HIV-infected British patients, evenwhen chest radiographs are normal and previous BCG vaccinationhas been performed.     

Chronic pericardial disease in patients with rheumatoid arthritis: a longitudinal study

We have reviewed the clinical and investigative findings in 13 patients with chronic pericardial disease and seropositive rheumatoid arthritis. In eleven cases the diagnosis was made on clinical grounds, while the diagnosis was confirmed only at post-mortem in two patients. Pleural effusions were present in seven patients, while pulsus paradoxus was found in only one case. Echocardiograms were undertaken in ten patients and all showed evidence of pericardial effusions, which were usually small and sited posteriorly. A delayed ventricular filling pattern indicating abnormal ventricular relaxation was seen in two patients with cardiac tamponade. The surviving 11 patients were reviewed a median of three years after diagnosis of their pericardial disease. Pericardectomy had been performed in six, all of whom were asymptomatic and had a normal chest radiograph. Steroids alone had been given to the other five, and three of these remained dyspnoeic with cardiomegaly. The clinical features distinguishing chronic pericardial disease from other causes of right heart failure in rheumatoid arthritis patients are subtle. As management is fundamentally different, serious consideration should be given to the diagnosis of chronic pericardial disease in any patient with rheumatoid arthritis who presents with right-sided heart failure.     

Radiographic presentation of pulmonary tuberculosis in severely immunosuppressed HIV-seropositive patients

Although the presence of typical postprimary or “reactivation” pattern tuberculosis (TB) on chest radiograph (CXR) strongly suggests TB infection in adults, the sensitivity of this finding, particularly in severely immunosuppressed human immunodeficiency virus (HIV) patients, is unclear. To investigate this issue, HIV status, CD4 counts, and CXR findings of all adult patients with culture-proven TB admitted to a tertiary-care hospital over a 2-year period were retrospectively studied. CXRs were classified as typical for postprimary TB if they showed upper lobe opacities with or without cavitation. No attempt was made to correlate the actual clinical phase of TB infection (primary versus postprimary) with CXR patterns, largely because differentiating primary from postprimary TB in HIV patients is difficult due to high anergy rates and inability to skin-test-convert. Of 46 patients who had chest radiographs and medical records documenting HIV status available for review, 23 were HIV-seropositive and 23 were HIV-seronegative. Of 22 HIV-seropositive patients whose CD4 counts were available, 18 (82%) had CD4 counts of <200 cells/μL. Only 2 of these 18 (11%) had CXRs showing a typical postprimary TB pattern, whereas all 4 (100%) patients with CD4 counts of 〉200 cells/μL and 18 of 23 (78%) non-HIV patients had CXRs typical for postprimary TB (P < .005). It was concluded that HIV-seropositive patients with TB and CD4 counts of <200 cells/μL frequently present with chest radiographs atypical for postprimary TB, including normal CXRs. Typical postprimary TB CXR findings are not sensitive for diagnosing pulmonary TB in this population.     

Tuberculosis, HIV and the developing world

This article reviews the immunology, genetics, epidemiology and treatment of two of the most important infectious diseases in the world, HIV and tuberculosis (TB). The pandemic of TB has been greatly magnified by the advent of the HIV epidemic. In the developing world, probably 50% of HIV seropositive individuals are co-infected with TB. The TB epidemic has expanded both because of increased susceptibility of patients to new tuberculous infection and also because of the greater chance of a primary complex leading to disseminated disease. The evidence that TB has had any effect on the HIV epidemic is less clear in the developed world with effective antiretroviral therapy. In resource-poor countries, many HIV infected individuals die prematurely of TB. Both organisms infect immunologically competent cells, and the control of infection in both has a large genetic component. The complex immunological response and process of cytokine release has a marked impact on both control of disease and the pathological effects of infection. Treatment of TB was associated with the development of resistance until the need for combination chemotherapy was recognised. It was then realised that one of the major factors making treatment of TB difficult was poor long-term adherence. Exactly the same sequence of events in terms of our understanding of the treatment of HIV infection has occurred more recently. These two infections undoubtedly present the most serious challenge to public health across the world, and are likely to be controlled only by a global mobilisation of resources not seen since the end of the last European war.     

Acromegalic heart disease: influence of treatment of the acromegaly on the heart

In a series of 256 patients with acromegaly, 10 had evidence of heart disease for which no explanation apart from the acromegaly could be found. Heart disease presented with effort dyspnoea, cardiac failure, palpitation, ECG changes or cardiomegaly. Initial chest radiographs showed cardiac enlargement in seven patients. Electrocardiograms were abnormal in nine patients with repolarisation disorders or intraventricular conduction defects. Rhythm disturbances were found in six. Echocardiograms were performed on six patients; all were abnormal showing left ventricular hypertrophy or impaired function. In five patients radionuclide ventriculography was also performed. Cardiac catheterisation was undertaken on seven patients; all showed either hypertrophy or dilatation of the left ventricle. Coronary arteries were widely dilated in two patients and in another there was dilation of the proximal segment only. In six of the 10 patients, acromegaly was cured by transsphenoidal surgery. This resulted in limited improvement of cardiac function in two patients only. Of the four patients who were not cured, three died and one was lost to the study. Four patients in total died and autopsies were obtained in two: one showed changes suggesting myocarditis and the other diffuse fibrosis. It is concluded that acromegaly may infrequently lead to heart disease, and that if recognised at an early stage progression may, in a proportion of patients, be arrested by successful treatment.     

Chronic Pericardial Disease in Patients with Rheumatoid Arthritis: a Longitudinal Study

We have reviewed the clinical and investigative findings in13 patients with chronic pericardial disease and seropositiverheumatoid arthritis. In eleven cases the diagnosis was madeon clinical grounds, while the diagnosis was confirmed onlyat post-mortem in two patients. Pleural effusions were present in seven patients, while pulsusparadoxus was found in only one case. Echocardiograms were undertakenin ten patients and all showed evidence of pericardial effusions,which were usually small and sited posteriorly. A delayed ventricularfilling pattern indicating abnormal ventricular relaxation wasseen in two patients with cardiac tamponade. The surviving 11patients were reviewed a median of three years after diagnosisof their pericardial disease. Pericardectomy had been performedin six, all of whom were asymptomatic and had a normal chestradiograph. Steroids alone had been given to the other five,and three of these remained dyspnoeic with cardiomegaly. The Clinical features distinguishing chronic pericardial diseasefrom other causes of right heart failure in rheumatoid arthritispatients are subtle. As management is fundamentally different,serious consideration should be given to the diagnosis of chronicpericardial disease in any patient with rheumatoid arthritiswho presents with right-sided heart failure.     

Active tuberculosis in the medical intensive care unit: a 15-year retrospective analysis

Of approximately 6000 admissions to the Henry Ford Hospital medical ICU between October 1969 and September 1984, 61 (1%) had active tuberculosis (TB). Forty-three (70%) of these 61 had acute respiratory failure (ARF). TB was considered to be the sole cause of ARF in 12 and contributory in 31. Eighteen patients with TB but without ARF were admitted for treatment of other critical illnesses. Alcoholism was present in 31 (51%) of the TB patients. Only one of 12 whose ARF was caused primarily by TB had a history of known TB at the time of admission. Important factors contributing to ARF in TB patients included Gram-negative pneumonia and/or sepsis, chronic obstructive pulmonary disease, prior TB with anti-TB medication noncompliance, and malignancy. Six patients were not suspected of having TB when admitted to the medical ICU; three patients who had not been treated for TB were found to have TB on autopsy. The inhospital mortality rate for all patients with TB requiring intensive care was 67%, but was 81% in those with ARF.     

The natural history of asymptomatic extracranial arterial disease

The natural history of a group of 76 patients without neurological symptoms, but with untreated extracranial arterial disease demonstrated by angiography 10 years ago, was studied. During this period 46 patients died, and coronary artery disease was the most common cause of death (n = 25). Six patients suffered a lethal stroke, five patients had a stroke before they died from other causes and five of the six surviving patients, who became symptomatic developed TIAs, followed by a stroke in two cases, leaving only one who suffered a sudden stroke without premonitory warning symptoms. Although the overall cumulative stroke rate (18 per cent) was three times higher than normal, the cerebrovascular territories affected corresponded only twice with the original extracranial carotid lesion. Therefore, early carotid endarterectomy is inadvisable for the majority of asymptomatic patients and repetitive non-invasive prospective study of these patients is favoured for selection of more appropriate timing for individual treatment.     

Acromegalic Heart Disease: Influence of Treatment of the Acromegaly on the Heart

In a series of 256 patients with acromegaly, 10 had evidenceof heart disease for which no explanation apart from the acromegalycould be found. Heart disease presented with effort dyspnoea,cardiac failure, palpitation, ECG changes or cardiomegaly. Initialchest radiographs showed cardiac enlargement in seven patients.Electrocardiograms were abnormal in nine patients with repolarisationdisorders or intraventricular conduction defects. Rhythm disturbanceswere found in six. Echocardiograms were performed on six patients;all were abnormal showing left ventricular hypertrophy or impairedfunction. In five patients radionuclide ventriculography wasalso performed. Cardiac catheterisation was undertaken on sevenpatients; all showed either hypertrophy or dilatation of theleft ventricle. Coronary arteries were widely dilated in twopatients and in another there was dilation of the proximal segmentonly. In six of the 10 patients, acromegaly was cured by transsphenoidalsurgery. This resulted in limited improvement of cardiac functionin two patients only. Of the four patients who were not cured,three died and one was lost to the study. Four patients in totaldied and autopsies were obtained in two: one showed changessuggesting myocarditis and the other diffuse fibrosis. It isconcluded that acromegaly may infrequently lead to héartdisease, and that if recognised at an early stage progressionmay, in a proportion of patients, be arrested by successfultreatment.     

The effect of automated telephone appointment reminders on HIV primary care no-shows by veterans

Appointment attendance for follow-up care and laboratory monitoring are central components of HIV treatment. In general, appointment reminders are an effective method of reducing outpatient no-shows; however, no single strategy has proven superior. This study tested the effectiveness of adding an automated telephone reminder for laboratory monitoring to the standard set of three appointment reminders to reduce subsequent HIV primary care no-shows. We conducted a quasi-experimental design study in three geographically and administratively affiliated Veterans Administration HIV clinics with one clinic serving as the intervention facility and two others as control facilities. The intervention lasted 6 months. The data show that patients who were not homeless, who were not diagnosed with depression, and who had five or more appointments scheduled in 6 months had significantly fewer no-shows after intervention. The intervention was not effective in reducing no-shows among homeless patients, racial/ethnic minorities, and patients with mental health disorders.     

Testing for HIV among patients with tuberculosis in Montreal.

OBJECTIVE: To determine the rate of HIV testing among patients with tuberculosis (TB) in Montreal, and to identify patient characteristics associated with physician screening patterns. Knowledge of local patterns of HIV testing among patients with TB could be used to facilitate the development of strategies to improve compliance with recommendations that all patients with TB be screened for HIV. DESIGN: Retrospective chart review. PATIENTS: All patients with TB reported to the Montreal Public Health Unit from 1992 to 1994 (ages 19 to 50) and from 1992 to 1995 (ages 18 and under) and for whom a chart could be reviewed. OUTCOME MEASURES: Patients with TB screened versus not screened for HIV infection, analyzed to determine which variables independently predict the likelihood of screening for HIV infection. RESULTS: Of the 376 patients with TB for whom data were available, 192 (51%) were screened for HIV. Of those, 33 (17%) had been tested before having received the diagnosis of TB. Multivariate analysis revealed that patients with TB who were male, aged 30 to 39, had a positive sputum smear, displayed at least 1 clinical symptom, received the TB diagnosis from a microbiologist or infectious disease specialist, or reported 1 or more HIV risk factors were more likely to be screened for HIV. CONCLUSIONS: HIV screening of patients with TB is selective, depending on both patient and physician characteristics. Physicians' awareness of recommendations needs to be increased to improve the diagnosis and treatment of TB/HIV co-infection.     

Feasibility of an Emergency Department-based Tuberculosis Counseling and Screening Program

OBJECTIVE: To assess the feasibility and effectiveness of an ED-based tuberculosis (TB) screening program. METHODS: A TB screening program of adult ED patients was conducted at a university hospital ED with 46,000 annual visits that serves a poor urban community. Patients were screened on weekdays during business hours. ED patients were counseled about the disease and the screening procedure and, after consent, purified protein derivative (PPD) tests were placed. Patients returned in 48-72 hours for reaction reading and post-test counseling. PPD-positive patients received a physical examination, chest x-ray, and HIV testing and were referred to a city TB clinic for possible treatment. RESULTS: Overall, 873 patients were counseled, 630 were eligible for screening, and 374 (59.4%) consented to PPD testing. Of the 203 (54.1%) who returned, 32 (15.8%) were PPD-positive. No active case was detected, but 26 patients were referred to the health department. Eighteen kept their appointments and all 13 who were started on therapy completed treatment. Targeted screening of groups aged 55 years or more, nonwhite groups, and those with other high-risk factors would detect 84% of PPD-positive cases while testing only 48% of eligible patients. CONCLUSION: An ED-based TB screening program is feasible and can identify many patients requiring treatment. Targeted screening of high-risk groups could reduce the program cost, but would miss some cases.     

青海省结核病患者治疗结局影响因素分析及贝叶斯网络模型研究

  目的  分析2011 — 2019年青海省登记报告的结核病患者治疗结局的影响因素,并通过构建贝叶斯网络模型进行因果效应推断和条件概率分析。  方法  通过全国结核病管理系统导出2011 — 2019年青海省登记报告的结核病例信息,描述其治疗结局现状,并利用多因素logistic回归分析结核病患者治疗结局的影响因素,将具有统计学意义的影响因素纳入贝叶斯网络模型中进行因果关联和条件概率推断。  结果  2011 — 2019年青海省结核病患者治疗成功率为88.86%。 多因素logistic回归分析结果显示,患者来源中的因症就诊、转诊和追踪以及诊断分型是影响结核病患者治疗结局的保护因素,而高年龄组（≥55岁）、农牧民、患者来源中的健康检查及其他接触者检查、重症、复治和非全程管理督导是危险因素。 通过构建贝叶斯网络模型可以得出,患者来源、是否重症和管理方式与治疗结局存在因果关联,当因症就诊的非重症结核病患者被全程管理督导时,其治疗成功率最高（95.63%）,出现不良结局概率最低（4.37%）。  结论  年龄、职业、患者来源、诊断分型、重症、治疗分类和管理方式是结核病患者治疗结局的影响因素,因症就诊的非重症结核病患者被全程管理督导时治疗成功率最高。     

Fate of Explanted ICD Patients

Of 56 consecutive patients who underwent an initial AICD implantation at our center, we analyzed eight patients who subsequently had their units explanted and not replaced by other antitachycardia devices. The mean age was 57.8 years, mean ejection fraction was 28.4%; six patients had coronary disease and two had cardiomyopathy. The presenting arrhythmia was sudden death in four patients and sustained ventricular tachycardia in four others. Mean follow-up from implant to explant was 25 ± 22 months, and 22 ± 10 months from explant to end of follow-up. Reasons for explantation were: infection in five patients, lead fracture in one patient, battery depletion in one patient, and one patient underwent cardiac transplantation. Devices were not reimplanted because of: patient refusal in three patients, physician discretion in two patients (one recurrent infection, one received no shocks over 24 months), cardiac transplantation in one patient, ablation of VT focus in one patient, and one patient died while being treated for infection. Three patients died 2, 21, and 26 months after device explantation of nonsudden cardiac, sudden cardiac and noncardiac causes, respectively. Conclusions: Preoperative clinical parameters were not indicative of a lower risk of arrhythmic events in these patients as compared to the general population of AICD implantees. Of eight patients, two received alternate nonmedical therapy, one died while receiving treatment for a device-related infection; of the five remaining patients none died of cardiac causes. Termination of AICD therapy for malignant ventricular arrhythmias does not imply imminent sudden cardiac death for most patients treated by alternate modes of therapy.     

Abdominal lymphadenopathy in sarcoidosis

Medical records of 370 patients with sarcoidosis were reviewed. Of these, 32 had a computerized tomographic (CT) and/or ultrasound (US) examination of the abdomen. Two patients had extensive abdominal adenopathy: one was diagnosed by CT and the other by US. Both patients had conventional chest radiographic findings characteristic of sarcoidosis. In addition, five patients had hepatosplenomegaly; three had only hepatomegaly; three had only splenomegaly. There exists a small and previously unsuspected incidence of patients with extensive abdominal adenopathy in sarcoidosis. Although lymphoma and metastatic disease are far more common causes of extensive abdominal lymphadenopathy, sarcoidosis should be considered in the appropriate clinical setting. In many cases, correlation with conventional chest radiographs may be confirmatory.     

Early antiviral treatment of hepatitis C virus recurrence after liver transplantation in HIV-infected patients

OBJECTIVE: To investigate the efficacy of early antiviral treatment for hepatitis C virus (HCV) recurrence in HIV/HCV-coinfected patients undergoing liver transplantation for end-stage liver disease. METHODS: Open prospective trial of early treatment of HCV recurrence in consecutive HIV/HCV-coinfected patients transplanted at a tertiary hospital in Barcelona between 2002 and 2004. All patients had indication for liver transplantation, no previous CDC class C HIV-associated opportunistic events, a CD4+ T-cell count >100cells/microl, and undetectable plasma HIV RNA on highly active antiretroviral therapy. Treatment with pegylated interferon-alpha2b (1.5 microg/kg/week) and ribavirin (800-1000 mg/day) was given for 24 to 48 weeks, as soon as HCV recurrence was histologically documented. RESULTS: Of six patients who underwent transplant, five patients surviving the early post-transplantation period developed HCV recurrence, presenting as severe cholestatic hepatitis in three, and were started on antiviral treatment a median of 12 weeks (range: 5-31) after transplantation. After a median follow-up of 24 months all treated patients were alive. Biochemical response was achieved in all patients, although only one achieved a sustained virological response. Mild rejection before HCV recurrence occurred in two cases. Treatment was well tolerated with no episodes of rejection or mitochondrial toxicity. No patient required modification of the antiretroviral regimen. Liver biopsies performed in patients without virological response, 12-34 months after transplantation, showed cirrhosis in two and moderate chronic active hepatitis in the remainder. CONCLUSIONS: Despite early antiviral treatment, severe HCV recurrence after liver transplantation may compromise long-term survival in HIV-infected patients. Improved treatment strategies for these patients are urgently required.     

Clinical characteristics of IRIS syndrome in patients with HIV and tuberculosis

BACKGROUND: Some patients with HIV/tuberculosis (TB) coinfection who are on anti-TB treatment and highly active antiretroviral therapy (HAART) will develop an exacerbation of symptoms, signs or radiological manifestations of TB that are not due to relapse or recurrence of their TB. The aetiology of these immune reconstitution inflammatory syndrome (IRIS) reactions is unknown but it is presumed that they occur, at least in part, as a consequence of HAART-related reconstitution of immunity. METHODS: Patients who were diagnosed with their first episode of definitive or presumed TB between January 2001 and July 2003 were identified from the Chelsea and Westminster TB/HIV database. The patients were classified into those who developed IRIS and those who did not using a set definition of the syndrome. Demographic, clinical and laboratory data relating to both HIV and TB were compared between the two groups. RESULTS: A total of 55 cases of TB were identified, of which 45 cases were confirmed on culture or gene probe and 10 were presumed cases. Fourteen cases (25.5%) developed IRIS with a median (range) duration of 2.53 (0.53-14.97) months. The median baseline CD4 [interquartile range (IQR)] for the IRIS group was significantly lower at 80 (33-117) cells/mm3 (P = 0.05) than the non-IRIS group at 139 (77-284) cells/mm3. A significantly greater proportion of patients in the IRIS group [11/14 (78.60%), P = 0.011] had baseline CD4 < 100cells/mm3 compared with the non-IRIS group [16/41 (39.0%)]. There was no significant difference between the two groups when comparing the log10 baseline viral load (VL). Eight (57.0%) patients in the IRIS group had disseminated TB at baseline compared with seven (17.0%) in the non-IRIS group (P = 0.006). In those who had a detectable VL at baseline, the median fold change (IQR) in CD4 from baseline to 3 months was significantly higher in the IRIS group patients, 1.5 (0.6-5.6), compared with 0.7 (-0.2 to 1.0) for those in the non-IRIS group (P = 0.046). CONCLUSIONS: Patients who develop IRIS are more likely to present with disseminated TB, have a CD4 count < 100 cells/mm3 and have a prompt rise in CD4 count in the initial 3 months of HAART.     

Lymphocyte sensitization to Aspergillus fumigatus antigens in pulmonary diseases in man.

In vitro studies of T-lymphocyte responses using five different batches of Aspergillus fumigatus antigens, were undertaken in twelve patients with A. fumigatus related lung disease and in three normal controls. Using a leucocyte migration method, five of the twelve patients showed significant inhibition of leucocyte migration with a migration index of 0-80 or less to A. fumigatus, but in only three was this demonstrated with more than one batch of antigen (one patient with aspergilloma and two with bronchopulmonary aspergillosis). The same antigens were used in lymphocyte transformation tests. Only two patients, one with aspergilloma and one with bronchopulmonary aspergillosis, showed clearly significant transformation although there were several borderline results. Only three patients had evidence of delayed skin responses to A. fumigatus antigens in vivo, one with aspergilloma, one with bronchopulmonary aspergillosis and one with atypical bronchopulmonary aspergillosis. Two of these three patients also had one or more positive in vitro test results. Thus T-lymphocyte sensitization to A. fumigatus as demonstrated by these in vitro methods, although present in occasional patients, was not clearly related to any one particular clinical syndrome in this small group of patients with aspergillus related pulmonary disease. There was, however, one of the three aspergilloma patients with positive lymphocyte transformation to all five batches of antigens and having higher transformation indices than in any other patient. This suggest that lymphocyte studies should be extended in this group. In contrast to the frequent negative results using A. fumigatus antigens, evidence of T-lymphocyte sensitization to either Candida albicans or Mycobacterium tuberculosis or both, was shown by positive delayed hypersensitivity skin responses and in vitro inhibition of leucocyte migration in the majority of the patients, despite which lymphocyte transformation was often negative. The possibility of impaired capacity to transform is supported by the finding of an impaired response to phytohaemagglutinin (PHA) in four of the twelve cases. This information, together with other data discussed, helps to complete the contrasting immunological profiles seen in different Aspergillus fumigatus related lung diseases.     

Tuberculosis hepatitis: a clinical review of 96 cases

Hepatic tuberculosis was confirmed in 96 patients presenting with the features of liver disease, only 14 of whom had other concomitant hepatic pathology. Although respiratory symptoms occurred in 74 per cent of cases, these were overshadowed by the abdominal manifestations. The latter most frequently included right hypochondrial pain, abdominal distension, firm tender hepatomegaly, splenomegaly and ascites. Icterus was observed in 11 cases (only one of whom had concurrent hepatic pathology) and liver failure was found in 10 patients. A surgical presentation occurred in three patients. Four of 15 patients with pancytopenia were noted to have hypersplenism. Abnormalities in coagulation were noted in 26 patients (24 with low prothrombin index and two with moderately raised fibrinogen degradation products). The characteristic serum profile included hyponatraemia (64 per cent of cases), raised alkaline phosphatase (83 per cent) and gamma glutamyl transferase (77 per cent), hypoalbuminaemia (63 per cent) and hypergammaglobulinaemia (83 per cent). Transaminase levels were moderately elevated in 78 per cent of cases. Hepatic imaging techniques were frequently misleading. Chest radiographs aided the diagnosis but were normal in 25 per cent of cases. Histologically, acid fast bacilli, caseation and granulomas were seen in 9, 83 and 96 per cent of cases respectively. Adverse prognostic features included age (below 20 years), miliary TB, coagulation defects and the presence of predisposing factors; these were of value in selecting appropriate therapy. The overall mortality was 42 per cent. Liver biopsy was the most useful aid to correct diagnosis which was suspected clinically in only 47 per cent of cases.     

Crohn's Disease: Course, Treatment and Long Term Prognosis

The course, treatment and outcome of Crohn's disease affecting174 patients diagnosed more than 20 years ago and followed for20 to 45 years are reported. Fifty patients died, 23 relatedto Crohn's disease, against an expected 33, giving an increasedmortality risk of 1.5 for the series. Flstulae of varying typeoccurring in 38 per cent of patients were successfully treatedusually by excision and had no significant adverse effect uponthe long term prognosis. The incidence of suicide and dementiaappeared to be increased. Amyloid disease, obstructive uropathyand osteomalacia were other important complications. Definitivesurgical operations averaged 2.5 per patient and after the firstfive years following diagnosis varied between 5 and 7 per centof those at risk each year for the next 20 years. Recurrencerates were similar after any of the first five operations ona patient for the first 10 years after any operation. Therewas no evidence that the chance of operation was increased ormade to recur more frequently by the performance of such anoperation. All but two of the 121 living patients (three lost to follow-up)with a mean duration since diagnosis of 28 years were leadinga normal life free from physical restrictions from Crohn's diseasethough three were mentally handicapped, 21 had radiologicalabnormality (recurrence), mostly longstanding, and 16 had lessthan 200 cm small intestine remaining. Specific therapy (corticosterolds 58 patients, sulphasalazine11 patients and azathioprine four patients) was used at sometime in only one third of the series so that such treatmentdid not appear necessary to produce good results in the majority.It is concluded that the indications for corticosteroid therapyare limited and that at present the joint efforts of physicianand surgeon with adequate supportive therapy and well timedsurgical resection produce the best results. An optimistic attitudeto the eventual outcome is justified.