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OBJECTIVE - To assess the practicality and effectiveness of an Ultra-Short zidovudine regimen for prevention of perinatal HIV transmission in rural Zimbabwe.
DESIGN - Double-blinded placebo-controlled randomized clinical trial.
SETTING - The Salvation Army Howard Hospital, a district hospital in rural Zimbabwe.
SUBJECTS - 222 HIV positive pregnant women presenting for antenatal care prior to 36 weeks were randomized. Twenty nine women were lost to follow up.
INTERVENTION - In the Thai regimen, mothers received zidovudine (300 mg po bid) from 36 weeks gestation until labour, and zidovudine (300 mg po q3h) during labour, and the neonates received a placebo. In the Ultra-Short regimen, the mothers received a placebo from 36 weeks to labour, then zidovudine (300 mg po q3h) in labour. The neonates received zidovudine (2 mg/kg po qid) for the first three days of life.
MAIN OUTCOME MEASURE - Infant HIV RNA status at six weeks of life.
RESULTS - Results were available for 90 infants from the Thai group and 89 infants from the Ultra-Short group. Infant HIV seroconversion rates at six weeks of life were 18.9% (95%CI 10.8 to 27.0) with the Thai regimen, and 15.7% [95% Confidence Interval (CI) 8.1 to 23.4] with the Ultra-Short regimen. The upper bound of seroconversion in the Ultra-Short group was lower than the 25% seroconversion boundary that was specified to show equivalence.
CONCLUSIONS - Although the Ultra-Short regimen has equivalent efficacy to the Thai regimen, it also has many practical advantages. Ultra-Short is thus a preferable protocol.
OBJECTIVE - To document the clinical and immunogenetic features of arthritis associated with heterosexually acquired human immunodeficiency virus (HIV) infection.
METHODS - All patients were assessed by a rheumatologist and standard laboratory tests were performed.
RESULTS - There were 3 common clinical presentations. (1) Oligo/polyarticular arthritis (22 men, 4 women). HIV infection had not previously been diagnosed in 24 of these patients but persistent generalized lymphadenopathy (85%) and weight loss (42%) were present. Joints commonly involved were ankles (65%) and knees (54%), often with associated enthesitis (31%) and dactylitis (23%). Followup data in 18 patients showed that arthritis resolved completely in 9 patients (one subsequently recurred), improved by >50% in 5 patients, was unremitting in 3 patients, and recurred frequently in one patient. None of 7 patients tested were HLA-B27 or B7 positive. (2) Reiter's syndrome (RS) (21 men, 3 women; incomplete RS 18 patients,complete RS 6 patients). Lymphadenopathy was present in 19 patients (79%) and 4 patients were previously known to have HIV infection. Involvement of knees (80%) and ankles (58%) was common, as were enthesitis (29%) and dactylitis (13%). Followup data in 21 patients showed that 14 resolved (5 with recurrences), 2 improved by >50%, and 5 had continued arthritis. HLA-B27 was not found in 13 patients tested but a cross reacting antigen was found in 6 patients. (3) Symmetrical polyarthritis (4 men, 4 women). Symmetrical arthritis of the wrists (8 patients) and peripheral interphalangeal (PIP) and metacarpophalangeal (MCP) joints (7), as well as lymphadenopathy (5), nodules (4), rheumatoid factor (3), and erosive radiographic changes (one patient) were seen. (4) Miscellaneous. Other types of arthritis included 3 patients with psoriasis and arthritis and one patient each with Behcet's disease, Salmonella septic arthritis, and secondary syphilis.
CONCLUSION - Arthritis associated with HIV in this population is most commonly characterized by oligoarticular, asymmetrical, large joint arthritis, with or without features of Reiter's syndrome, and is not associated with HLA-B27.
Seventy-two patients with rheumatoid arthritis (RA) and 82 controls have been typed with the XI Histocompatibility Workshop DRB1 and DQB1 sequence-specific oligonucleotide probes. The increase of DRB1*04 corresponds to an increase of the serologically defined DR4, previously found in a small group of Zimbabwean RA patients and we now show that this increase is due to the subtype DRB1*0405 in association with DQB1*0302. In addition there is a clearcut increase of DRB1*1001 equivalent to the serologically defined DR10. There was no increase amongst RA patients of DRB1*0102 which was the predominant DR1 sub-type amongst controls. In the course of our investigation, we observed a DRB1*04 variant which corresponds to DRB1*0412, newly defined in the XIth Histocompatibility Workshop.
OBJECTIVE - To compare the clinical, serologic and radiologic expression of rheumatoid arthritis (RA) in UK Caucasian and ethnic black patients from Zimbabwe.
METHODS - Standardized protocols and assessment criteria were used to study 84 black patients with no non-Bantu antecedents and 84 UK Caucasian patients with RA (matched for disease duration, sex and age).
RESULTS - Articular manifestations of RA were less severe in the black patients with RA from Zimbabwe as shown by less early morning stiffness (p = 0.001), fewer patients with > or = 3 active joints (p = 0.01), fewer joint deformities (p = 0.004) and better grip strength (p = 0.001) in comparison to the white patients with RA from the UK. Caucasian patients had a higher frequency of extraarticular manifestations (p = 1 x 10(-6)) including rheumatoid nodules (p = 0.0001), Raynaud's (p = 0.01) and Sicca syndrome (p = 0.001). Toxic effects from disease modifying antirheumatic drugs occurred less frequently in black patients (p = 0.0002). More white patients had Ro and La antibodies. The radiologic changes in the black patients were less severe than those in the white patients. The distribution of erosions in hands and feet were different in the 2 groups of patients studied. There were no differences between the urban and rural black patients but a more detailed study involving a large number of patients is required to confirm this observation.
CONCLUSION - Black patients with RA from Zimbabwe have a disease that is clinically and radiologically less severe with fewer extraarticular features when compared to UK white patients.
A survey of antibiotic prescribing by nurses in primary care clinics was carried out in Harare, Zimbabwe. Of 1000 patients surveyed 543 were treated with antibiotics. Respiratory and soft tissue infections were the commonest reasons for prescribing an antibiotic. Procaine penicillin was the commonest antibiotic used. Because of the design of the survey audit of antibiotic use was difficult but antibiotic use was deemed inappropriate in 12.3% of patients. Viral upper respiratory tract infections accounted for the largest single source of error. The large (23.1%) assessor disagreement illustrates the difficulties encountered when applying accepted guidelines for antibiotic use to developing countries. The disagreements were consistent and highlight areas for local research and debate. The overall standard of antibiotic prescribing by ancillary medical staff is good. Clearly outlined policies, continuing education and permanent staff contribute to this.