Biomedical subjects
Publications and source records attributed to S R Benatar.
Attacks of asthma can be precipitated in susceptible individuals by a variety of stimuli acting through immunological or non-immunological pathways. The pathological changes in the lung which characterize asthma include bronchoconstriction, mucosal oedema and tenacious secretions. A logical approach to therapy is outlined, based on intervention at successive sites along the trigger-to-target organ response pathway.
A questionnaire was used to assess the prevalence of smoking and chronic respiratory symptoms in 315 White and 290 Coloured children in the 11--15-year old group. The quantity and duration of smoking, reasons for starting the habit, and social influences were examined. Simple tests of ventilatory function were also done. This study highlights the early age of onset of smoking in South African children, as in other countries, and provides a data base on which anti-smoking programmes can be structured.
Histoplasmosis is a rare disease in the Cape Province. The diagnosis of acute disseminated histoplasmosis in a patient who presented at Groote Schuur Hospital 3 weeks after a caving expedition, led to the identification of acute benign pulmonary histoplasmosis in 9 other people who had explored the same cave. Possible explanations for this outbreak are discussed.
Two cases of phlegmasia caerulea dolens with peripheral venous gangrene treated with streptokinase are presented. Both patients had excellent results, beyond expectation. The literature is reviewed and the symptomatology, aetiology, pathogenesis and current thoughts on treatment are discussed.
A controlled, prospective study comparing streptokinase and heparin treatment has been completed in 51 patients presenting with acute proximal venous thrombosis of less than 8 days' clinical duration. Patients were studied by means of pre-treatment, post-treatment, 3- and 12-monthly phlebography and pulmonary perfusion scanning and were followed up at 3-monthly intervals. Of the 26 patients randomized to receive streptokinase, therapy was stopped in 3 because of complications. Phlebography 5 days after starting treatment showed 80--100 per cent lysis in 17 of the 23 patients who completed the course of streptokinase. Two patients later developed partial rethrombosis. One patient developed an asymptomatic pulmonary embolus during treatment. During follow-up (mean 19 months) only 1 of the 17 patients with 80--100 per cent lysis developed postphlebitic symptoms, 3 patients died of unrelated causes and 1 patient was lost to follow-up. In patients randomized to heparin therapy no significant lysis was achieved in any of the 25 patients and only 2 of these patients were found to have asymptomatic legs on follow-up. Two patients in this group died and autopsy confirmed massive pulmonary embolus during treatment. These data suggest that streptokinase is superior to heparin in the treatment of acute proximal venous thrombosis of less than 1 week's clinical duration especially if the thrombus is largely non-occlusive. It must be stressed that in order to avoid the bleeding complications of thrombolytic therapy, streptokinase must not be used within 10 days of major surgery, or even longer after vascular, neurosurgical or eye operations.
Thirty-nine asthmatic patients required mechanical ventilation (IPPV) for status asthamticus over a seven and a half year period. We reviewed their clinical records with particular emphasis on the events leading to intermittent positive pressure ventilation (IPPV) and the long-term courses of those patients who survived IPPV. Long delays by patients before seeking medical attention, incomplete assessment of acute attacks, underuse of corticosteroids prior to admission and overuse of sedation were important factors often influencing the necessity for IPPV. Four patients died during IPPV. Of the 35 who survived, 32 were regularly followed in our Respiratory Clinic. Nine patients subsequently died, eight undoubtedly from asthma. Serial measurements of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were retrospectively analyzed to determine patterns of asthma. Of the 23 patients still alive, 14 have well controlled asthma, five have a pattern of persistent airflow obstruction, two have markedly labile asthma, and two have gradually deteriorating airflow obstruction. By contrast, seven patients who died sufficiently long after IPPV to enable categorization of their patterns showed either markedly labile asthma or gradually deteriorating airflow obstruction. None had relatively constant ventilatory function at either normal or suboptimal levels. We suggest that patterns of asthma are useful guides in detecting patients at high-risk. Patterns characterized by markedly labile asthma or gradually deteriorating airflow obstruction appear to be associated with an increased risk of sudden death from asthma.
A rare but potentially lethal complication of coumarin and its congeners is skin necrosis. A case of skin necrosis due to warfarin is reported and the literature is reviewed. It is suggested that if necrosis develops, the coumarin therapy should be terminated, and the patient should immediately be heparinized. Heparin, which never causes necrosis, can be used freely if further anticoagulation therapy is required, and may well prevent necrosis due to the thrombotic process.
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The magnitude of the asthma problem in Cape Town, as reflected by cases presenting to a large hospital, is described. The need for better facilities to treat acute asthma and to provide supervised interval therapy is discussed. A plea is made for the more widespread use of well-established simple beside aids in the assessment of the severity of asthma and the response to therapy.
Prediction equations is forced vital capacity (FVC), forced expiratory volume in 1 second (FEVi), maximum mid-expiratory flow rate (MMFR) and peak expiratory flow rate (PFR) have been derived from a study of 367 asymptomatic Caucasian and Coloured (mixed race) children, aged 11--15 years, who did not smoke. Significant ethnic differences were found in FEVi, FVC, FEVi/FVC, and MMFR/FVC, but not in MMRF or PFR. The practical and epidemiological value of these observations is discussed.
Two asthmatic patients with life-threatening allergy to intravenous hydrocortisone are described. A 21-year-old woman with chronic atopic asthma developed severe bronchospasm on 3 occasions after treatment with hydrocortisone. Allergy to hydrocortisone was only established on the third occasion. Skin prick tests with hydrocortisone (Solu-Cortef) gave a 5-mm wheal reaction and confirmed the allergy. Skin prick tests with methylprednisolone and dexamethasone elicited no allergic response. Allergy to hydrocortisone was also seen on 2 occasions in a 41-year-old man with asthma, although it was not proved by challenging him with intravenous hydrocortisone.
The results of 140 percutaneous lung biopsies by 3 different methods and 37 transbronchial biopsies through the fibre-optic bronchoscope are presented. The indications for each procedure, their diagnostic accuracy and ensuing complications are discussed. We conclude that each method has its place and that skill with several techniques permits the selection of the most appropriate method in each individual case.
A patient with Goodpasture's syndrome who presented with severe pulmonary haemorrhage and minimal renal involvement is described. The diagnosis was substantiated by immunofluorescence studies on a renal biopsy specimen and by the detection of circulating antiglomerular basement membrane antibody. The patient was treated with corticosteroids and cyclophosphamide. He remains in good health 20 months after diagnosis, although there is a persisting abnormality in single-breath gas transfer for carbon monoxide. Recovery from Goodpasture's syndrome is reviewed in the light of recent advances.
A diagnostic approach to pulmonary complications in the immunocompromised patient is outlined. The importance of early lung biopsy in selected patients is emphasized and the various techniques available are discussed. Successful early diagnosis and management of opportunistic infections ia a challenge for the clinician, bacteriologist and pathologist, and requires these close collaboration.
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One hundred and ten cases of sarcoidosis seen in Cape Town over a 7-year period (1969-1975) are reported. Seventy-one patients were Coloured, 25 Black and 14 White. The calculated minimum incidence of sarcoidosis in the Cape Peninsula is 23,2/100 000 population in Blacks, 11,6/100 000 in Coloureds and 3,7/100 000 in Whites. Differences in the incidence, presentation, clinical and laboratory features in the three groups of patients are presented and discussed. The differences between Whites and Blacks are similar to those reported from the USA, and the Coloured patients resemble the Blacks. The study clarifies some of the misconceptions about the incidence of sarcoidosis in South Africa, and documents the similarity of sarcoidosis in American and African Blacks.