R e v is ta d a S o c ie d a d e B r a s ile ira d e M e d ic in a T r o p ic a l 1 9 (4 ): 2 0 9 - 2 1 2 , O u t- D e z , 1 9 8 6 .
ARTIGOS
ABSENCE OF CLINICAL ABNORMALITIES SUGGESTING RENAL
INVOLVEMENT DUR IN G THE LONG-TERM COURSE OF VISCERAL
LEISHMANIASIS
R e in a ld o M a rt in e lli, R ose m a r ie Lo r e n ço e H e on ir Roch a
Abnormalities o f renalfunction have been demonstrated inpatients with visceral leishmaniasis; although there was a trend toward normalization following anti-parasitic therapy, some abnormalities persisted. With thepurpose o f studying the long-term clinicai course o f renal involvement in visceral leishmaniasis, 32 patients with a diagnosis o f this parasitic disease were evaluated in the endemic area and at least 6 months after the clinicai cure o f the disease and compared with a control group o f 28 individuais. N o patient had a history or clinicai findings suggestive o f renal disease and ali were normotensive. Laboratory evaluation was normal in ali except 3 patients with abnormal urinalysis. M ildproteinuria and microscopic hematuria were seen in a single urinalysis in one patient (although three other urinalysis were normal), and leucocyturia in two fem ale patients. It was concluded that the renal involvement in visceral leishmaniasis is m ild and transient, with normal renal function observed on long-term follow-up after cure o f the parasitic infection.
Key words: V isceral leishm aniasis. N e p h ro p a th y . R eversib ility . C linic ai C ourse. P a ra sitic disease.
R e n a l involv em en t h as b e e n well d o cu m en ted in p atien ts w ith v isceral leishm ania sis 2 7 8 9 25 A lth o u g h m o st o f th e rep o rts h av e b e e n co n c e m e d w ith the patholo gical c h an g es 2 7 8 25, in a prospective clin icai stu dy 9 it w as d e m o n stra te d th a t som e im p a irm e n t o f renal fu nction w as p re se n t in 6 0 % o f ho sp italized p atients. T h is c o n sisted o f ab n o rm alities o f u rin aly sis (5 1 % ), in creased u rin ary p ro te in e x cretio n (5 7 % ), creatinin e c le a ra n c e b elo w 80 m l/m in (3 7 % ) and ab n o rm al acid lo ad te st (6 6 % ). A fte r th e ra p y o f the p arasitic d ise a se , alth o u g h th ere w as a tre n d to w ard n o rm alizatio n o f th e ren al function, a b o u t 2 5 % o f the p atien ts co n tin u ed to h av e ab n o rm alities in urin aly sis, 2 4 h r u rin ary p ro te in ex cretio n a n d /o r c re atin in e c le a rance. Q u e stio n s a b o u t rev ersib ility o f such ab n o r m alities an d th e role o f th e p a ra sitic d isease a s a cau se o f p rogressiv e ren al d isease a re still u n an sw ered . T h e purpose o f th e p re se n t stu d y w as to determ ine the
long-D e p a r tm e n t o f M e d ic in e , F e d e r a l U n iv e r s ity o f B a h ia , S a lv a d o r - B a h ia - B ra zil.
T h is w o rk w a s s u p p o r te d b y g ra n ts n ° 4 0 .3 6 8 4 /8 2 ( C o n s e lh o N a c io n a l d e D e s e n v o lv im e n to C ie n tífic o e T e c n o ló g ic o ) a n d A I - 1 6 2 8 2 o f N a tio n a l In s titu te o f H e a lth .
E n d e r e ç o p a r a c o r re s p o n d ê n c ia : D r. R e in a ld o M a rtin e lli, M . D . - H o s p ita l P ro f. E d g a r d S a n to s , L a b o r a tó r io 1 1 1 7 — N e fro lo g ia - R u a J o ã o d a s B o ta s , s /n - C a n e la - 4 0 0 0 0 S a lv a d o r - B a h ia - B ra sil.
R e c e b id o p a r a p u b lic a ç ã o e m 2 6 / 6 /1 9 8 6 .
term clinicai co u rse o f clinicai signs o f renal involve m en t in v isceral leishm ania sis.
M A T E R IA L A N D M E T H O D S
A to tal o f 32 p atien ts o f both sexes with a pro- ven diagnosis o f visceral leishm aniasis in the past. W ere studied ali the patients had the diagnosis documen ted by the dem onstration o f leishm ania on bone-marrow
sm ear and w ere treated with in travenous N -m eth yl- glucam in e. C u re was d efined as d isap p earan ce of p a ra site s from th e b o ne-m arrow an d subsidence o f clinicai signs o f th e d isease. T h e patien ts w ere re- ev alu ated in th e endem ic a re a a t le a st 6 m onths follow ing the cu re o f the p arasitic disease. Besides h isto ry an d p h ysic al ex am in atio n , u rinalysis and se rum d eterm in atio n o f B U N a n d creatinin e were also perform ed. A s a control group, 28 su bjects with the sam e age range an d living in the sam e endem ic area, with n o previous o r p re se n t d o cu m en tatio n o f leish- m ania l infection w ere sim iiarly evalu ated.
R E S U L T S
A m o n g the patien ts w ith p a s t diagnosis o f visceral leishm ania sis th ere w ere 15 m ale and 17 fem ale, w ith a m e a n age o f 9.7 y ears, ranging from 1 to 19 y e a rs (T ab le 1). T w en ty four w ere y o u n g e rth a n 12 years o f age. T w o p atien ts w ere re-evalu ate d betw een 6 an d 12 m o n th s after in itial diagnosis, 7 b etw een 13 and 21 m onth s, 6 b etw een 25 an d 36 m onth s, 17
M a rtin e lli R , L o r e n ç o R , R o c h a H . A b s e n c e o f c lin ic a i a b n o rm a litie s su g g e stin g re n a l in v o lv e m e n td u r in g th e lo n g -te rm c o u rs e o f v isc e ra l le is h m a n ia s is . R e v is ta d a S o c ie d a d e B r a s ile ira d e M e d ic in a T r o p ic a l 19: 2 0 9 - 2 1 2 , O u t- D e z , 1 9 8 6 .
T able 1 - Renal involvement in visceral leishmaniasis:
demographic data
Sex M ale F em ale
T o ta l n ° o f cases
Visceral leishmaniasis
15 17 32
Control
15 13 28
Age Year
M e a n 9.7 ± 44 9.8 ± 4 . 9
(R ange) (1 to 19) (2 to 19)
Reevaluation Months
6 - 1 2 2
1 3 - 2 4 7
2 5 - 3 6 6
3 7 - 4 8 5
4 9 - 6 0 1
> 6 0 11
betw een 36 a n d 6 0 m o nth s a n d 11 p a tie n ts w ere re- ev alu ated m o re th a n 6 0 m on th s afte r th e th e ra p y . T h e co n tro l group w as co m p o sed o f 15 m ales an d 13 fem ales w ith a m e a n age o f 9.8 y e a rs, ranging from 2 to
19 years; 16 were younger th an 12 years old.
N o h isto ry o r clin icai findings suggestive o f ren al d isease c o u ld be d e te c te d in e ith er group stu died. T h e m e a n blo o d p ressu re w as 1 0 2 /6 0 m m H g for the p atien ts w ith h isto ry o f v isceral leish m an iasis an d 1 0 0 /6 0 0 m m H g in the co n tro l group (T a b le 2). In one
T ab le 2 -R e n a l involvement in visceral leishmaniasis: clinicai evaluation
Visceral Control
leishmaniasis
B lood p ressu re, m m H g 1 0 2 /6 0 1 0 0 /6 0
(m ean)
U rin aly sis
P ro te in u ria /h e m a tu ria 1 0
L eucocyturia 2 1
M e a n serum creatinin e, 0.9 3 ± 0 . 2 0 .9 7 ± 0 .3 m g/dl.
M e a n blo o d u re a nitrogen, 11.0 ± 3.4 10.2 ± 2 . 7 m g/dl.
p a tien t, seen 3 y ears after th e in itial d ia gnosis o f the p ara sitic d ise a se , m ild p ro tein u ria an d m icro sco p ic h e m atu ria w ere in itially d e te c te d , alth o u g h 3 o th e r u rin aly sis, d o n e a t different in terv als, w ere n o rm al.
L e u co cy tu ria (m ore th an 5 le u co cy tes p e r high pow er field) w ere d o cu m en ted in 2 p a tie n ts (fem ales) a n d in one o f the co n tro l group (m ale). T h e leveis o f B U N and serum creatin in e w ere n o rm a l in a li p a tie n ts b u t one in th e co n tro l gro u p , w ho h a d a slight elev atio n o f serum creatin in e (1 .5 m g /d l). T h e m e a n serum creatin in e was 0 .9 3 m g /d l a n d B U N 11 .0 ± 3 .4 m g /d l fo r the gro u p o f p a tie n ts w ith p a s t d ia gnosis o f v isceral leish m an iasis a n d 0 .9 7 m g/d l an d 10.2 ± 2.7 m g/d l, respectively, for th e co n tro l group.
D I S C U S S I O N
R e n a l in vo lv em en t h a s b een d e m o n stra te d in asso c ia tio n w ith so m e p a ra sitic in fections 3 17 21. E ven th ough p a ra site antigen h a s b e e n d e m o n stra te d in the k id ney in o n ly a few o f such c a se s 13 19, th ere is enough clinicai an d ex p erim en tal d a ta to su p p o rt th is a sso c ia t i o n 6 14. In v isceral leish m an iasis, alth o u g h L. dono-vani re lated antigenic m a terial h as n o t b e e n d e m o n s trated in th e glom eruli o f th e p a tie n ts, th e high prev alen ce o f ren al a b n o rm alities am ong infected p a tie n ts a n d th e findings o f in terstitial neph ritis an d m ild form s o f g lo m erulo nephritis, as well as, glom eru- lar d ep o sitio n o f im m unoglobulins a n d c o m p lem en t in th ese p a tie n ts, strongly su p p o rts a n im m unolo gical b asis fo r the ren al in v o lv e m e n t21 8 9 25.
I n a previo us re p o rt D u tra e t a l9 d e m o n stra te d im p ro v em en t o f ren al fu n ctio n in som e p a tie n ts after tre a tm e n t o f th e p a ra sitic d iseases, how ever, a sig nificant n u m b e r h ad p e rsiste n t renal d ysfunction. I t sh ould b e stressed th a t th is ev alu atio n w as d o n e soon afte r th e ra p y , w hen several serologic an d im m unolo gic ab n o rm alities w ere still p re se n t. In th e p re se n t study, do ne in a n endem ic sm all village (w here m ore sensitiv e tech n iq u es c o u ld n o t be u sed ), ren al d y sfu n ctio n , as e v a lu a te d b y clin icai an d la b o ra to ry p a ra m e te rs , could n o t be d e m o n stra te d in a n y o f the p a tie n ts m o re th a n 6 m on th s afte r th e d ia gnosis an d cu re o f v isceral leishm aniasis.
In two patients with past diagnosis o f leishmaniasis, an d in one o f th e control group, m o re th a n 5 leu co cy tes p e r high p o w er field were d o cu m en ted . In th e ab sen ce o f clin icai sy m pto m s, b a c te riu ria a n d positiv e urine c u ltu re, th e diag n o sis o f u rin a ry tra c t in fectio n c a n n o t be e n te rtain ed . A n o th e r fem ale p a tie n t h a d p ro tein u ria a n d m icro sco p ic h e m atu ria in o n e u rin a ly sis, even though th ree o th e r u rin alysis, a n d th e leveis o f serum creatin in e a n d B U N w ere p e rsiste n tly no rm al. In view o f th e ab n o rm al u rin aly sis, ren al d ise a se c a n n o t be ru led o u t in th is p a tie n t since tra n sie n t, slight abnorm alities in the urinalysis m ay in dicate early stages o f som e n ep h ro p ath y . A lso , ren al d ise a se c a n n o t be ex clu d ed in a child, in th e co n tro l g ro u p , w ith slight e le vation o f seru m c re atin in e, d esp ite a norm al u rin aly sis.
M a rtin e lli R , L o r e n ç o R , R o c h a H . A b s e n c e o f c lin ic a i a b n o rm a litie s su g g e stin g re n a l in v o lv e m e n t d u rin g th e lo n g -te rm c o u rse o f v isc e ra l le is h m a n ia s is . R e v is ta d a S o c ie d a d e B r a s ile ira d e M e d ic in a T r o p ic a l 19: 2 0 9 - 2 1 2 , O u t- D e z , 1 9 8 6 .
T h e b o rd erlin e evid en ce o f ren al d isease in ju s t one o f 32 p a tie n ts a fte r dia g n o sis o f visceral leishm ania sis, an d a sim ilar finding in o n e p a tie n t o f the co n tro l group, argues ag ain st a p rim a ry role o f the leishm ania sis in the p ath o g en esis o f chro nic ren al disease. T h e rev ersib ility o f th e disease afte r cure o f the visceral le ish m an iasis, as a lso re p o rte d in a b stra c t form in on e c a s e 5, w as n o t surprising. T h e in cid ence o f renal disease in a leish m an iasis endem ic a re a d oes n o t seem to be higher th an in oth er areas. Second, d isap p earan ce o f th e ren al d ise a se a sso c ia te d w ith cure of a n in fectious pro cess h a s b e e n d e m o n strated in o th er co n d itio n s su ch as b a c te ria l en d o c a rd itis24, po st- streptococcal and post-staphylococcal infections1016 23, typhoid fev er24, chro n ic septicem ic salm o n e llo sis11, syphilis1215 20 a n d infectious m o n o n u c le o sis18. Since the p ath o g en esis o f th e g lo m eru lar d ise a se in such in sta nce is th o u g h t to b e im m unolo gically m e d ia te d , it is co n ceiv ab le th a t cu re o f th e in fectio n leads, con seq u en tly , to th e d isa p p e a ra n c e o f the antigenic source. In the ab sen ce o f a p e rsiste n t antig enic so urce, hypertension, vascular o r extensive glom erular lesio ns1 4 reversibility o f the renal involvem ent in leishm aniasis should, in fact, be expected.
R E S U M O
Anormalidades das funções renais têm sido demonstradas em pacientes portadores de leishmaniose visceral; embora haja tendência à normalização logo após o tratamento antiparasitário, algumas dessas anormalidades persistem. Com o propósito de es tudar o curso clínico a longo prazo do envolvimento renal na leishmaniose visceral, 32 pacientes foram estudados na área endêmica, pelo menos 6 meses após a cura clínica da doença, e comparado a um grupo-controle de 28 indivíduos. E m nenhum p a ciente se documentou história ou dados clínicos sugestivos de doença renal. A avaliação laboratorial fo i normal em todos os pacientes, exceto 3 com sumários de urina anormais em um, proteinúria leve e hematúria microscópica num único sumário de urina (três outros foram normais) e leucocitúria em dois outros pacientes. Concluiu-se que na leishmaniose visceral o envolvimento renal é discreto e transitório, havendo desaparecimento das alterações sugestivas de disfunção após a cura da doença parasitária.
P a la v ra s chaves: Leishmaniose visceral.
Nefropatia. Reversibilidade. Curso Clínico.
R E F E R E N C E S
1. A d le r S G , K o p p le J D . F a c to r s in flu en cin g th e p ro g ressio n o f r e n a l in su ffic ie n c y . S e m in a rs o f N e p h ro lo g y 3: 3 3 5 - 3 4 3 , 1 9 8 3 .
2 . A n d r a d e Z A , I a b u k i K . A n e fro p a tia d o c a la z a r . R e v is ta d o In s titu to d e M e d ic in a T r o p ic a l d e S ã o P a u lo 14: 3 1 - 5 4 , 1 9 7 2 .
3. A n d r a d e Z A , R o c h a H . S c h is to s o m a l g lo m e ru lo p a th y . K id n e y I n te r n a tio n a l 16: 2 3 - 2 9 , 1 9 7 9 .
4 . B ald w in D S . C h ro n ic glom erulonephritis: no n-im m unologic m e c h a n ism s o f p ro g ressio n o f g lo m e ru lar d a m a g e. K id n e y In te r n a tio n a l 2 1 : 1 0 9 -1 2 0 , 1 9 8 2 .
5 . B e n M a iz H , B e n M o u s s e F , K h e d e r M A , A y e d K L , B e n A y e d H . G lo m e r u la r in v o lv e m e n t in a h u m a n k a la -a z a r: a clin icai a n d h isto lo g ical stu d y o f o n e case. In: A b s tra c t I X * I n te r n a tio n a l C o n g re s s o f N e p h r o lo g y , L o s A n g e le s , p. 1 0 7 A , 1 9 8 4 .
6 . C a r v a lh o E M , A n d re w s B S , M a rtin e lli R , D u t r a M , R o c h a H . C irc u la tin g im m u n e c o m p le x e s a n d rh e u m a to id f a c to r in v is c e ra l le is h m a n ia s is a n d s c h is to s o m ia s is . T h e A m e r ic a n J o u r n a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 3 2 : 6 1 - 6 8 , 1 9 8 3 .
7 . D e B rito T , H o s h in o -S h im iz u S , A m a to N e to V, D u a rte IS , P e n n a D O . G lo m e r u la r in v o lv e m e n t in h u m a n k a la - a z a r: a lig h t im m u n o flu o re s e e n t a n d e le c tr o n m ic ro s c o p ic stu d y b a s e d o n k id n e y b io p s ie s . T h e A m e r ic a n J o u r n a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 24 : 9 - 1 8 , 1 9 7 5 . 8. D u a r te M I S , S ilv a M R R , G o t o H ,N i c o d e m o E L , A m a to
N e t o V . I n te r s titia l n e p h ritis in h u m a n k a la - a z a r. T h e T r a n s a c tio n s o f th e R o y a l S o c ie ty o f T r o p ic a l M e d ic in e a n d H y g ie n e 77 : 5 3 1 - 5 3 7 , 1 9 8 3 .
9 . D u tr a M , M a r tin e lli R , C a r v a lh o E M , R o d rig u e s L E , B rito E , R o c h a H . R e n a l in v o lv e m e n t in v isc e ra l le is h m a n ia s is . A m e r ic a n J o u r n a l o f K id n e y D is e a s e 6 : 2 2 - 2 7 , 1 9 8 5 .
10. G a r c i a R , R u b io L , R o d r ig u e z -Itu rb e B . L o n g -te rm p rognosis o f ep id em ic p o st-stre p to c o cc a l g lom erulonephritis in M a r a c a ib o : F o llo w -u p s tu d ie s 1 1 -1 2 y e a r s a f te r th e a c u te e p is o d e . C lin ic a i N e p h ro lo g y 1 5 :2 9 1 -2 9 8 , 19 8 1 . 11. H ig o s h i G I , F a r i d Z , B a s s ily S , M ir o n W F . N e p h ro tic
sy n d ro m e in s c h is to s o m ia s is m a n s o n i c o m p lic a te d b y c h ro n ic s a lm o n e llo s is . T h e A m e r ic a n J o u m a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 2 4 : 7 1 3 - 7 1 4 , 1 9 7 5 .
12. H illie r M D , W e b s te r A D B , E is in g e r A J M F . N e p h r o tic s y n d ro m e : a c o m p lic a tio n o f s e c o n d a ry sy p h ilis . B ritis h M e d ic a i J o u r n a l 4: 4 0 4 , 1 9 7 1 .
13 . H o s h in o - S h im iz u S , B rito T , K a n a m u r a H Y , C o u to A L , S ilv a A D , C a m p o s A R , P e n n a D O , S ilv a L C . H u m a n sc h is to s o m ia s is : s c h is to s o m a a n tig e n d e te c tio n in re n a l g lo m e ru li. T h e T r a n s a c tio n s o f th e R o y a l S o c ie ty o f T r o p ic a l M e d ic in e a n d H y g ie n e 70 : 4 9 2 - 4 9 6 , 1 9 7 7 . 14. K a g e r P A H o c k C E , H a n n e m a A J , R e is P H , v o n d e m
B o m e A E G R . H ig h C i q le v e is, lo w C / C i q ra tio a n d h ig h lev e is o f c irc u la tin g im m u n e c o m p le x e s in k a la -a z a r. C lin ic a i Im m u n o lo g y a n d I m m u n o p a th o lo g y 2 3 : 8 6 -9 3 , 1 9 8 2 .
1 5 . K a p l a n B S , W ig le sw irtii F W , M a r k s M I . T h e g lo m e ru lo p ath y o f co n g en ital sy philis - an im m une c o m p le x d e p o s it d is e a s e . J o u r n a l o f P e d ia tr ic s 8 1 : 1 1 5 9 , 1 9 7 2 .
16. K im Y , M ic h a e l A F . C h r o n ic b a c te r iu r ia a n d n e p h ritis A n n u a l R e v ie w o f M e d ic in e 29 : 3 1 9 - 3 2 5 , 1 9 7 8 .
M a rtin e lli R , L o r e n ç o R , R o c h a H . A b s e n c e o f c lin ic a i a b n o r m a litie s s u g g e s tin g re n a l in v o lv e m e n t d u rin g th e lo n g -te rm c o u rs e o f v isc e ra l le is h m a n ia s is . R e v is ta d a S o c ie d a d e B r a s ile ira d e M e d ic in a T r o p ic a l 19: 2 0 9 - 2 1 2 , O u t- D e z , 1 9 8 6 .
1 7 .K l e i T R , C r o w e ll W R , T h o m p s o n P E . U l tr a s tr u c tu r a l g lo m e ru la r c h a n g e s a s s o c ia te d w ith fila ria s is . T h e A m e ric a n J o u r n a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 23 : 6 0 8 - 6 1 8 , 1 9 7 4 .
18. L e e S , K jlls tr a n d C M . R e n a l d is e a s e in in fe c tio u s m o n o n u c le o s is . C lin ic a i N e p h r o lo g y 9: 2 3 6 - 2 4 0 , 1 9 7 8 . 19 . L o p e s J D , M o r e ir a A A B , C a m p o s R , K a n a m u r a H Y ,
H o sh in o -S h im izu S, G a y o tto L C C , Silva L C . C ircu la tin g a n tig e n s , a n tib o d ie s a n d g lo m e ru la r im m u n e c o m p le x e s in m ic e w ith u n is e x u a l S. m a n so n i in fe c tio n . R e v is ta d o In s titu to d e M e d ic in a T r o p ic a l d e S ã o P a u lo 2 3 : 1 5 5 - 1 6 0 , 1 9 8 1 .
2 0 . L o s ito A , B u c c o re lli E , N a s i- B e m a d e tti F , L a to M . M e m b r a n o u s g lo m e ru lo n e p h ritis in c o n g e n ita l sy p h ilis. C lin ic a i N e p h r o lo g y 12: 3 2 - 3 7 , 1 9 7 9 .
2 1 . N a g le R B , W a r d P A , L in d s ly H B . E x p e rim e n ta l in fectio n w ith A f r ic a n tr y p a n o s o m e s . V I. G lo m e r u lo n e p h r itis
involv ing th e a lte m a te p a th w a y o f c o m p le m e n t activ atio n . T h e A m e r ic a n J o u r n a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 2 3 : 1 5 -2 6 , 1 9 7 4 .
2 2 . N e u g a rte n J , G a llo G R , B a ld w in D S . G lo m e ru lo n e p h ritis in b a c te r ia l e n d o c a r d itis . A m e r ic a n J o u r n a l o f K id n e y D is e a s e 3: 3 7 1 - 3 7 9 , 1 9 8 4 .
2 3 . P o t t e r E V , L ip s c h u ltz S A , A b id h S , P o n n -k in g T , E a r le D P . T w e lv e to s e v e n te e n y e a r fo llo w -u p o f p a tie n ts w ith p o s ts tr e p to c o c c a l g lo m e ru lo n e p h ritis . N e w E n g la n d J o u r n a l o f M e d ic in e 3 0 7 : 7 2 5 - 7 2 9 , 1 9 8 2 .
2 4 . S itp rija V , P ip a ta n a g u l V , B o o n p u c k n a v in g V , B o o n p u c k n a v ig S. G lo m e r u litis in ty p h o id fe v er. A n n a ls o f I n te r n a i M e d ic in e 8 1 : 2 1 0 - 2 1 3 , 1 9 7 4 .
2 5 . W e is in g e r J R , P in to A , V e la z q u e z G A , B r o n s te in I, D e s s im J J , D u q u e J F , M o n te n e g r o J , T a p a m s F , R o u s s e A R . C lin ic a i a n d h is to lo g ic a l k id n e y in v o lv e m e n t in h u m a n k a la - a z a r . T h e A m e r ic a n J o u r n a l o f T r o p ic a l M e d ic in e a n d H y g ie n e 2 7 : 3 5 7 - 3 5 9 , 1 9 7 8 .
