Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs). METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards. RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94–98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3–5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0–3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6–11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12–18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS. The following standards (14–18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual’s lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available. CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings

Infective endocarditis in chronic hemodialysis: A transition from left heart to right heart

Infective endocarditis (IE) of the left heart is the most frequent type of IE in chronic hemodialysis (CHD) (in 90% of cases) whereas involvement of the right heart is rare. The aim of this study was to determine the clinical, biological, and echocardiographic characteristics, as well as the prognosis of IE in CHD. This is a retrospective study conducted at the Center of Nephrology and Hemodialysis in Oujda, Morocco. Over a period of 56 months, we compiled data on a series of 11 CHD patients with IE. Their mean age was 40.5 ± 14 years, 72% were male and 27.3% had diabetes. All patients had native valve. All patients had bacteremia preceding the episode of IE. The tricuspid valve was the site of IE in 45% of the cases. Cardiac complications were observed in 72% of the patients and mortality was observed in 72% of cases. The period from IE diagnosis to death was 9 ± 6 days. In our study, the tricuspid valve was the most affected valve of IE in CHD

Kyste hydatique du muscle psoas r&#233v&233l&#233 par une mass abdominale f&#233brile: A propos d'un cas

No Abstract

The exploitation of marine resources at Saruq al‐Hadid: Insights into the movement of people and resources in Bronze and Iron Age south‐eastern Arabia

Marine resources were an integral and consistent component of subsistence strategies employed in south-eastern Arabia throughout late prehistory. Of particular interest is the movement of these resources from the coast to interior sites and the implications of this movement for transhumance and trade in the region during this period. Marine species were frequently identified in the faunal assemblage from the inland site of Saruq al-Hadid, dating from the Bronze Age to Early Iron Age (c.2000–c.800 BCE). This included marine fish species, along with two cormorant species (Phalacrocorax sp.) and several fragments of dugong (Dugong dugon). Twenty-seven families of marine shell were also identified in the remains recovered from the site. The presence of these remains at this inland site demonstrates that resources were frequently moved from the coast to the interior throughout Saruq al-Hadid’s occupation, indicative of their enduring significance in subsistence strategies employed at the site. This paper presents the results of zooarchaeological analysis of these remains and discusses the significance of their presence at Saruq al-Hadid, with reference to subsistence, craft production and intra-regional exchange during the Bronze and Iron Ages

A critical role of sodium flux via the plasma membrane na+/h+ exchanger sos1 in the salt tolerance of rice

Rice (Oryza sativa) stands among the world's most important crop species. Rice is salt sensitive, and the undue accumulation of sodium ions (Na+) in shoots has the strongest negative correlation with rice productivity under long-term salinity. The plasma membrane Na+/H+ exchanger protein Salt Overly Sensitive 1 (SOS1) is the sole Na+ efflux transporter that has been genetically characterized to date. Here, the importance of SOS1-facilitated Na+ flux in the salt tolerance of rice was analyzed in a reversegenetics approach. A sos1 loss-of-function mutant displayed exceptional salt sensitivity that was correlated with excessive Na+ intake and impaired Na+ loading into the xylem, thus indicating that SOS1 controls net root Na+ uptake and long-distance Na+ transport to shoots. The acute Na+ sensitivity of sos1 plants at low NaCl concentrations allowed analysis of the transcriptional response to sodicity stress without effects of the osmotic stress intrinsic to high-salinity treatments. In contrast with that in the wild type, sos1 mutant roots displayed preferential down-regulation of stress-related genes in response to salt treatment, despite the greater intensity of stress experienced by the mutant. These results suggest there is impaired stress detection or an inability to mount a comprehensive response to salinity in sos1. In summary, the plasma membrane Na+/H+ exchanger SOS1 plays a major role in the salt tolerance of rice by controlling Na+ homeostasis and possibly contributing to the sensing of sodicity stress