The relationship between HIV infection and acute deep vein thromboses.

Objective: HIV infection is a global pandemic with approximately 37 million adults infected worldwide.1 Numerous abnormalities predisposing to a hypercoagulable state have been described in patients with HIV infection and include deficiencies of antithrombotic proteins and the presence of procoagulants. The abnormalities have been described to correlate with the degree of HIV associated immunosuppression as well as with the presence of concomitant infections and / or neoplastic disorders. The conclusion of several studies2-3 has been that although evidence pointed towards a relationship between HIV infection and venous thrombotic disease, more studies were indicated to further elucidate this link. The majority of studies reporting on the documented prothrombotic abnormalities in HIV infection were conducted in first world cohorts. The objective of the study was to determine the prevalence of underlying HIV infection in patients presenting with acute deep vein thrombosis (DVT) without the presence of traditional risk factors for DVT. This prevalence was compared to the HIV prevalence in a sex, age and race matched control group without symptomatic DVT. In addition, the possible pathophysiological mechanisms for DVT development in this cohort are detailed. Methods: Consecutive adult patients presenting to the Charlotte Maxeke hospital casualty with lower limb acute deep vein thrombosis (DVT) were invited to participate in the study. Voluntary HIV testing of the participants were performed after counselling and consent with appropriate referral for further management if HIV result was positive. A record review was performed and information regarding the presence of commonly encountered traditional risk factors for the development of DVTs. The control group was an age, sex and race matched cohort to establish the prevalence of HIV infection in a matched population without symptomatic DVTs. A review of the literature to identify the possible underlying causative factors linking HIV and DVT was conducted. Results: The HIV prevalence in the DVT group who consented to HIV testing and who had no traditional risk factor for DVT development (22 patients) was 81% (95% CI 0.67 - 0.96). The HIV prevalence in a matched control group without symptomatic DVTs was found to be 4% (95% CI 0.039 – 0.041). All the DVT patients who consented to HIV testing were active, community integrated members of the society. The average CD4 cell count of the HIV positive patients with acute DVTs was 247 /mm3. Two of the HIV positive patients with DVTs were on ART (anti-retroviral therapy) and 4 were also diagnosed with pulmonary tuberculosis. Traditional DVT risk factors identified in the HIV infected DVT cohort other than tuberculosis were immobilisation and carcinoma. Conclusion: A prothrombotic state is present in HIV infected individuals giving rise to an increased prevalence of thrombotic complications with potentially fatal consequences. The risk of DVTs in the general population is 0.10 % a year2 but the current and other studies indicate that the prevalence in HIV positive patients is significantly increased. From this thesis it is clear that there is no available evidence evaluating thromboprophylaxis specifically in HIV-infected individuals. The available thrombosis treatment guidelines lack recommendations in this growing sub-population. Important treatment decisions are therefore left to medical attendants without clear guidelines. HIV infection in the ARV era is a chronic disease with a clearly prothrombotic tendency. Future studies and guidelines should further define the thrombotic risk in the HIV infected population and direct treatment and prophylaxis

Forensic genetic research on sudden unexpected death in an infant (SUDI) at Salt River Mortuary: experiences an perceptions of parents

The unexpected and sudden death of an infant (SUDI) is a traumatic event. SUDI is defined as all deaths occurring suddenly and unexpectedly in infants under the age of one year. Molecular autopsy is used to determine the potential genetic contribution to SUDI and may lead to screening and interventions of at-risk family members. However, the potential of this may only be realised if the family members are willing to engage in the follow-up process. Next-of-kin experiences of participating in molecular autopsy research are unknown, and not previously done in South Africa. This study explored the experiences and perceptions of bereaved next-of-kin participating in forensic genetic research on SUDI at Salt River Mortuary, Cape Town. Methods Eleven participants, including the mothers and other family members for six SUDI cases participated in the study. These participants were recruited from a larger forensic molecular autopsy study conducted at the University of Cape Town. In order to explore the experiences and perceptions of next-of-kin, a qualitative approach was used and semi structured interviews were conducted. The interviews, transcribed verbatim, were analysed through thematic analysis. The perspective from the main researcher in the larger forensic molecular autopsy study was included to holistically explore the setting in which the genetics research took place. Results Four major themes were identified, namely (i) old wounds, (ii) my booboo, (iii) the sudden death and (iv) afterthought. Their main reasons for participating in the research were to find answers and to be of value in future cases of SUDI. Grief seemed to play a significant role in their understanding and engagement with regards to their research participation. Conclusion This study found that the grief and loss of at the time of obtaining consent may play a significant role in understanding and willingness for further engagement with molecular autopsy results. Understanding has previously been implicated in the willingness to engage with genetics results, however, it has not been explored in a mortuary setting. The understanding of genetics research is critical for further engagement that may have implications for the screening of other family members and future offspring. These findings may allow researchers to better engage with participants in genetics research on sensitive topics, including SUDI

The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care : a controlled clinical trial

The original publication is available at http://ccforum.com/Publication of this article was funded by the Stellenbosch University Open Access Fund.Introduction: The physiological basis of physiotherapeutic interventions used in intensive care has been established. We must determine the optimal service approach that will result in improved patient outcome. The aim of this article is to report on the estimated effect of providing a physiotherapy service consisting of an exclusively allocated physiotherapist providing evidence-based/protocol care, compared with usual care on patient outcomes. Methods: An exploratory, controlled, pragmatic, sequential-time-block clinical trial was conducted in the surgical unit of a tertiary hospital in South Africa. Protocol care (3 weeks) and usual care (3 weeks) was provided consecutively for two 6-week intervention periods. Each intervention period was followed by a washout period. The physiotherapy care provided was based on the unit admission date. Data were analyzed with Statistica in consultation with a statistician. Where indicated, relative risks with 95% confidence intervals (CIs) are reported. Significant differences between groups or across time are reported at the alpha level of 0.05. All reported P values are two-sided. Results: Data of 193 admissions were analyzed. No difference was noted between the two patient groups at baseline. Patients admitted to the unit during protocol care were less likely to be intubated after unit admission (RR, 0.16; 95% CI, 0.07 to 0.71; RRR, 0.84; NNT, 5.02; P = 0.005) or to fail an extubation (RR, 0.23; 95% CI, 0.05 to 0.98; RRR, 0.77; NNT, 6.95; P = 0.04). The mean difference in the cumulative daily unit TISS-28 score during the two intervention periods was 1.99 (95% CI, 0.65 to 3.35) TISS-28 units (P = 0.04). Protocol-care patients were discharged from the hospital 4 days earlier than usual-care patients (P = 0.05). A tendency noted for more patients to reach independence in the transfers (P = 0.07) and mobility (P = 0.09) categories of the Barthel Index. Conclusions A physiotherapy service approach that includes an exclusively allocated physiotherapist providing evidence-based/protocol care that addresses pulmonary dysfunction and promotes early mobility improves patient outcome. This could be a more cost-effective service approach to care than is usual care. This information can now be considered by administrators in the management of scarce physiotherapy resources and by researchers in the planning of a multicenter randomized controlled trial. Trial registration PACTR201206000389290Publishers' Versio

The Use of VTE prophylaxis in relatioN to patiEnt risk profiling (TUNE-IN) Wave 2 study

Background. The TUNE-IN (The Use of VTE prophylaxis in relatioN to patiEnt risk profiling) study evaluated venous thrombo-embolism (VTE) risk assessment and prophylaxis in private medical and surgical inpatients in Gauteng Province, South Africa. The study concluded that of the 608 patients enrolled, 54.1% were clinically evaluated to be at risk for VTE. A VTE risk assessment model (RAM), the Caprini score, increased the rate to 74.6%.Objectives. TUNE-IN Wave 2, an extension of TUNE-IN, was conducted on a national level including the public sector, focusing on surgical inpatients.Methods. The study was a national, prospective, non-interventional, multisite, epidemiological disease registry enrolling 453 surgical inpatients. The perceived clinical VTE risk, VTE risk score on Caprini RAM, VTE prophylaxis and clinical details were documented during a baseline visit. A bleeding risk score was provided.Results. Of the cohort, 269 patients (59.4%) were assessed to be at risk for VTE before applying the RAM. All patients (100%), however, were at risk on the RAM score. Early mobilisation and assessment of the VTE risk as low were the most frequent reasons for non-prescription of prophylaxis. Only 15 patients in the private and 2 in the public sector were assessed as having a bleeding risk. Chemoprophylaxis differed between the healthcare sectors, with low-molecular-weight heparin predominating in the private sector and unfractionated heparin being prescribed only in the public sector.Conclusion. VTE risk assessment and prophylaxis need to improve in both the public and the private sectors. A formal RAM will improve identification of patients at risk of VTE

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients : synthesis of evidence and expert opinion and its translation into practice

The original publication is available at http://cre.sagepub.com/content/early/2011/04/15/0269215510397677Includes bibliographyObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n¼7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential.Medical Research Council of South AfricaPost-prin

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery: a pragmatic approach to interpret equivocal evidence

BACKGROUND:Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal. METHODS: The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR) < 0.5-were collated into the algorithm. RESULTS: The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential. CONCLUSION: An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population

Influence of socio-cultural factors and gender on waste behaviour of travellers: Insights from 11 touristic destinations in Europe

In the course of a global increase of tourism, the need to deal with waste generation, management and prevention caused by tourism activities requires increased attention. In this regard, tourists’ behaviour is a crucial factor for improving the efficacy and efficiency of the waste strategies in place. Tourists’ behaviour has been extensively studied in terms of environmental awareness, while less attention has been given to behaviour and attitudes of tourists in terms of waste generation and prevention. Especially, the socio-cultural and gender component have been hardly addressed in available research. There is some evidence about differences in environmental attitudes and behaviour between tourists from different countries of origin, just as there is evidence of different attitudes towards the environment between men and women, but these two sets of evidences are not integrated, and certainly not with regard to waste behaviour. The present study was developed as part of the H2020 project “URBANWASTE” that aims at understanding the influence of tourism on waste management and production and at developing eco-innovative and gender sensitive strategies for waste prevention and management in 11 European pilot cases. Particularly, this study aimed at analysing and understanding the role and effect of socio-cultural factors (e.g. place of residence, age, education) and gender on ‘waste behaviour’ of tourists; the study includes the tourists’ behaviour at home in comparison to their behaviour on holidays and accounts, hence, also for ‘behavioural gaps’ between home- vs. holiday-behaviour

The utility of thromboelastography in the monitoring of aspirin therapy

To assess the utility of the Thromboelastogram in monitoring of aspirin therapy 25 healthy volunteers were selected and given low-dose aspirin therapy. Thromboelastography and platelet aggregometry were conducted at baseline and 1 week later. After 1 week of aspirin therapy, TEG data failed to demonstrate a significant change in the clotting profile. Platelet aggregometry identified significant changes in the clotting profile in response to stimulation with arachodonic acid, adrenaline and ADP We conclude that thromboelastography may not have utility in monitoring of response to aspiri

Comments on the Sanef media audit: a new news culture is facing the media and journalism educators: the time to act is now!

This omnibus article deals with some of the comments received by the authors of the Sanef media audit (see p. 11) of the edition of Ecquid Novi). As Mark Deuze, one of the commentators puts it: The threats and challenges to contemporary journalism have caused scholars, publics, journalists, and thus journalism educators, to reconsider their approaches, definitions, roles, and function in community and society. Widely recognized as the four main changes or challenges facing education programmes in journalism are: the multicultural society; the rise and establishment of infotainment genres; the convergence of existing and new media technologies (cf. multimedia); and the internationalization or ‘glocalization’ of the media and journalism playing field. The four mentioned challenges and developments could be seen as reflected in the 2002 Sanef audit. The report particularly stresses the ‘new culture’ within which journalists are expected to do their work. This is a culture determined by fragmented audiences; a widening gap between journalists and their publics; and an increased need for quality information. It is also a culture of enhanced interactivity and media accountability; intercultural communication; recognition of cultural diversity; and dealing with ‘nonhierarchical’ management styles. Journalism education, in other words, is gearing up to face a tough challenge: keeping the best practices of the teaching context and practical skills courses on the one hand, and including cultural and critical reflective didactics on the other. This is not the traditional theory versus skills debate of old—this is definitely something ‘new’—as is clearly shown in the Sanef audit. In this respect the Sanef audit stands out for its discourse of emphasizing changes in journalism and news culture, rather than simply advocating more or less theory- or skills-based curricula

Prediction of remission and low disease activity in disease-modifying anti-rheumatic drug-refractory patients with rheumatoid arthritis treated with golimumab

OBJECTIVE: To create a tool to predict probability of remission and low disease activity (LDA) in patients with RA being considered for anti-TNF treatment in clinical practice. METHODS: We analysed data from GO-MORE, an open-label, multinational, prospective study in biologic-naïve patients with active RA (DAS28-ESR ⩾3.2) despite DMARD therapy. Patients received 50 mg s.c. golimumab (GLM) once monthly for 6 months. In secondary analyses, regression models were used to determine the best set of baseline factors to predict remission (DAS28-ESR <2.6) at month 6 and LDA (DAS28-ESR ⩽3.2) at month 1. RESULTS: In 3280 efficacy-evaluable patients, of 12 factors included in initial regression models predicting remission or LDA, six were retained in final multivariable models. Greater likelihood of LDA and remission was associated with being male; younger age; lower HAQ, ESR (or CRP) and tender joint count (or swollen joint count) scores; and absence of comorbidities. In models predicting 1-, 3- and 6-month LDA or remission, area under the receiver operating curve was 0.648-0.809 (R(2) = 0.0397-0.1078). The models also predicted 6-month HAQ and EuroQoL-5-dimension scores. A series of matrices were developed to easily show predicted rates of remission and LDA. CONCLUSION: A matrix tool was developed to show predicted GLM treatment outcomes in patients with RA, based on a combination of six baseline characteristics. The tool could help provide practical guidance in selection of candidates for anti-TNF therapy