A nurse-based algorithm for earlier diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults in Lesotho

Cape Town TB Conferenc

Guidelines for antiretroviral therapy in adults

These guidelines are intended as an update to those published in the Southern African Journal of HIV Medicine in January 2008. Since the release of the previous guidelines, the scaleup of antiretroviral therapy (ART) in Southern Africa has continued to grow. Cohort studies from the region showexcellent clinical outcomes; however, ART is still being started late (in advanced disease), resulting in relatively high early mortality rates. New data on antiretroviral (ARV) tolerability in the region and several new ARV drugs have become available. Although currently few in number, some patients in the region are failing protease inhibitor (PI)-based second-line regimens. To address this, guidelines on third-line (or ‘salvage’) therapy have been expanded

Treatment of Tuberculous Meningitis and Its Complications in Adults.

PURPOSE OF REVIEW: Tuberculous meningitis (TBM) is a global health problem. In this review, we systematically evaluate the evidence for current and emerging antimicrobials, host-directed therapies and supportive managements. RECENT FINDINGS: Current antimicrobial regimes do not factor the differing ability of drugs to cross the blood-brain barrier. Rifampicin may be more effective at higher doses yet the most recent clinical trial failed to demonstrate survival benefit at 15 mg/kg/day. Dose finding studies suggest that higher doses still may be safe and more effective. Fluoroquinolones are currently listed as important second-line agents in drug-resistant TBM; however, a survival benefit as a first-line agent has yet to be shown. Linezolid may be a promising antimicrobial with good central nervous system penetrance. Dexamethasone reduces mortality in HIV-uninfected individuals yet evidence for its use in HIV co-infection is lacking. Aspirin has anti-inflammatory and anti-thrombotic properties. Small studies have demonstrated efficacy in reducing stroke but further research is required to better understand its effect on controlling the host inflammatory response. Discovery of genetic polymorphisms may direct individualized immune therapies and mediators of the innate immune response may provide targets for the development of novel therapies. There is at present no significant evidence base to guide management of hydrocephalus in HIV co-infection. Further clinical trial data is required to improve treatment outcomes in TBM in particularly in regard to the value of high-dose rifampicin, newer antimicrobials with improved central nervous system penetration and host-directed therapies. Supportive measures in particular the management of hydrocephalus in HIV co-infection should be an area for future research

On the mass transfer in AE Aquarii

The observed properties of the close binary AE Aqr indicate that the mass transfer in this system operates via the Roche lobe overflow mechanism, but the material transferred from the normal companion is neither accreted onto the surface of the white dwarf nor stored in a disk around its magnetosphere. As previously shown, such a situation can be realized if the white dwarf operates as a propeller. At the same time, the efficiency of the propeller action by the white dwarf is insufficient to explain the rapid braking of the white dwarf, which implies that the spin-down power is in excess of the bolometric luminosity of the system. To avoid this problem we have simulated the mass-transfer process in AE Aqr assuming that the observed braking of the white dwarf is governed by a pulsar-like spin-down mechanism. We show that the expected H_alpha Doppler tomogram in this case resembles the tomogram observed from the system. We find that the agreement between the simulated and the observed tomograms is rather good provided the mean value of the mass-transfer rate ~5x10^16 g/s. Three spatially separated sources of H_alpha emission can be distinguished within this approach. The structure of the tomogram depends on the relative contributions of these sources to the H_alpha emission and is expected to vary from night to night.Comment: 12 pages, 3 figures (6 eps files). Published in A&A. The paper with high resolution images can be downloaded from http://urania.it.nuigalway.ie/papers/ae_aqr.ps.g

Clinical and financial burdens of secondary level care in a public sector antiretroviral roll-out setting (G F Jooste Hospital)

Background. Antiretroviral therapy (ART) is being extended across South Africa. While efforts have been made to assess the costs of providing ART via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals.Objectives. To determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit treating and caring for antiretroviral-related conditions in a South African peri-urban setting; to identify key epidemiological cost drivers; and to examine the associated clinical and outcome data.Methods. A prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental economic costs and clinical data were collected from primary sources at G F Jooste Hospital, Cape Town, over a 1-month period (March 2005). Results. Incremental cost per outpatient was R1 280, and per inpatient R5 802. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). Infectionspredominated among diagnoses and costs – 55% and 67% respectively for inpatients, and 49% and 54% respectivelyfor outpatients. Most inpatients and outpatients were judged by attending physicians to have improved or stabilised as a result of treatment (52% and 59% respectively).Conclusions. The costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant and should be included in the government’s strategic planning: (i) so that the service can be expanded to meet current and future needs; and (ii) to avoid crowding out other secondary level health services

The risks of concurrent treatment with tenofovir and aminoglycosides in patients with HIV-associated tuberculosis

The South African public sector antiretroviral treatment (ART) guidelines have recently been changed to include tenofovir in the first-line regimen.1 Injectable drugs from the aminoglycoside class are part of the intensive phase of regimen 2 tuberculosis (TB) treatment and the multidrug-resistant (MDR) TB treatment regimen in the South African TB programme. We wish to draw the attention of clinicians managing patients with HIVassociated TB to the potential dangers of concurrent administration of these drugs. We present two illustrative cases