Ventriculoperitoneal shunt in cryptococcal meningitis with hydrocephalus

Fourteen patients with cryptococcal meningitis were reviewed. All patients had a ventriculoperitoneal shunt for hydrocephalus. Early recognitions and prompt relief of hydrocephalus were useful for eight patients who showed rapid deterioration of consciousness or signs of cerebral herniation. There was no surgical response in four patients who had had weeks of confusion or mental change. It seems, therefore, that the duration of disturbance of consciousness or change of mentality before shunting is critical in determination of the outcome of the treatment. Ventricular shunting was effective in relieving papilledema in five patients. However, the surgery did not prevent the development of papilledema to optic atrophy and subsequent blindness in two patients. Hence, in addition to hydrocephalus with increased intracranial pressure, conditions such as direct invasion of the optic pathways by Cryptococcus neoformans or optochiasmatic arachnoiditis may be responsible for the visual failure. Ventricular shunting was also helpful in restoring paraparesis in one patient. Of the cerebrospinal fluid determinations, low protein concentration was a favorable indicator for surgery. Of the seven patients who received the surgical procedure before the start of antifungal therapy, four showed a significant improvement despite active infection of the central nervous system. None of the seven patients deteriorated because of the surgical operation. Thus, active stage of cryptococcal meningitis does not contraindicate the necessity of shunting, and premedication with antifungal drugs is unnecessary. Also, no shunt-related morbidity and mortality was seen in this study.     

原发性小血管炎合并隐球菌脑膜炎一例的治疗

男，49岁，因肾功能异常1年．发热5d，意识不清3h人院。1年前出现恶心呕吐，化验Scr为248．6μmol／L，Hb84g／L，c-ANCA阳性，24h尿蛋白定量2．43g．肾病理为Ⅲ型新月体性肾炎，诊断为原发性小血管炎、急性肾衰竭。曾接受甲基泼尼松龙1．0g静点3d，2个疗程后改为泼尼松40mg／d口服，症状减轻出院。随访期间，     

An evaluation of the District Health Information System in rural South Africa

BACKGROUND: Since reliable health information is essential for the planning and management of health services, we investigated the functioning of the District Health Information System (DHIS) in 10 rural clinics. DESIGN AND SUBJECTS: Semi-structured key informant interviews were conducted with clinic managers, supervisors and district information staff. Data collected over a 12-month period for each clinic were assessed for missing data, data out of minimum and maximum ranges, and validation rule violations. SETTING: Our investigation was part of a larger study on improving information systems for primary care in rural KwaZulu-Natal. OUTCOMES: We assessed data quality, the utilisation for facility management, perceptions of work burden, and usefulness of the system to clinic staff. RESULTS: A high perceived work burden associated with data collection and collation was found. Some data collation tools were not used as intended. There was good understanding of the data collection and collation process but little analysis, interpretation or utilisation of data. Feedback to clinics occurred rarely. In the 10 clinics, 2.5% of data values were missing, and 25% of data were outside expected ranges without an explanation provided. CONCLUSIONS: The culture of information use essential to an information system having an impact at the local level is weak in these clinics or at the sub-district level. Further training and support is required for the DHIS to function as intended.     

Blood lead levels in a remote, unpolluted rural area in South Africa

The whole-blood lead levels of 14-16-year-olds in a remote, unpolluted rural area (Wupperthal, north-western Cape Province) were determined. Graphite-furnace atomic absorption spectrometry was used to analyse lead levels. The mean whole-blood lead level was found to be 3,4 micrograms/dl. This value should also be considered to be representative of the natural 'background' whole-blood lead level of South Africans.     

Sensitivity and specificity of a latex agglutination test for detection of cryptococcal antigen in meningitis

A cryptococcal latex agglutination test (Crypto-La; International Biological Laboratories, Canbury, New Jersey, USA) was evaluated for its ability to detect cryptococcal antigen in cerebrospinal fluid (CSF) specimens obtained from black patients with a clinical diagnosis of meningitis. Of the 445 Gram-stained and bacterial culture-negative CSF specimens routinely tested for cryptococcal antigen, 34 (7,6%) were positive. With the exception of 1 false-positive result, the remaining 33 specimens were obtained from 12 patients in whom the diagnosis of cryptococcal meningitis was confirmed by the isolation of Cryptococcus neoformans. The Crypto-La test gave false-positive results on 1% (4/384) of control CSF specimens tested. Nonspecific agglutination reactions were observed with 1,6% (13/829) of all CSF specimens and 22% (10) of sera tested. The ethylenediaminetetra-acetic heat-extraction method proved reliable in eliminating false-positives and nonspecific agglutination reactions in CSF and serum specimens.     

Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers

Objective—To evaluate the adherence to current guidelines for surgery in patients with aortic valve stenosis.

Design—From 1 January 1997 to 31 May 1999, 99 patients were accepted for aortic valve surgery with preserved left ventricular function and normal coronary angiogram. On admission for operation, 20 patients were evaluated regarding symptoms, exercise capacity, and left ventricular morphology and function.

Results—There were 14 men and 6 women, mean age 64.3 years. Years from symptom onset varied from 2.1 to 3.2. Dyspnoea was the most common limiting symptom. Thirty per cent of the patients were classified as NYHA IIIB. Physical capacity was reduced to 79% of the expected. Left ventricular hypertrophy was present in 14/20 patients. Left ventricular systolic function was reduced with mean ejection fraction of 0.46. Diastolic dysfunction (E/A ratio <1) was present in 12 patients.

Conclusion—Many patients accepted for aortic valve replacement due to aortic stenosis show advanced disease and are referred for surgery later in the disease process than is recommended in the current guidelines.     

获得性免疫缺陷综合征合并隐球菌性脑膜炎患者的眼部护理

目的总结获得性免疫缺陷综合征（AIDS）合并隐球菌性脑膜炎患者的眼部并发症及眼部护理方法。 方法回顾性分析42例AIDS合并隐球菌性脑膜炎患者的眼部并发症,总结其护理方案。 结果19例患者（37只眼）出现视乳头水肿,6例患者（12只眼）出现视神经萎缩,2例患者（4只眼）出现脉络膜病灶,3例患者（6只眼）出现复视,1例患者单眼合并巨细胞病毒性视网膜炎（CMVR）。11例患者眼底正常。42例患者（84只眼）中17只眼视力为光感～0.1,12只眼视力为0.12～0.3,视力≤ 0.3的患眼占总数的34.5%,55只眼视力为0.4～1.0。 结论临床护理工作中应密切观察患者的颅内压、视力及眼底变化,对低视力患者加强生活技能及视力的训练,有利于控制病情,提高患者的生活质量。