62 research outputs found
Post-exposure prophylaxis for rape survivors
CITATION: Pluddemann, A., Reuter, H. & Johnson, C. 2007. Post-exposure prophylaxis for rape survivors. South African Medical Journal, 97(1):12-13The original publication is available at http://www.samj.org.za[No abstract available]Publisher’s versio
The management of tuberculous pericardial effusion : experience in 233 consecutive patients
The original publication is available at http://www.cvja.co.za/Aim: We report on the 30-day and one-year outcome of
consecutive effusive pericarditis patients, including those
with tuberculous pericarditis, over a six-year-period.
Methods and Results: Patients with large pericardial
effusions requiring pericardiocentesis were included in
the study after having given written informed consent.
Clinical and radiological evaluations were followed by
echo-guided pericardiocentesis, and extended daily intermittent
drainage via an indwelling pigtail catheter. A
standard short-course anti-tuberculous regimen was
initiated. A total of 233 patients was included. One
hundred and sixty-two patients had pericardial tuberculosis
(TB), including 118 (73%) with microbiological and/
or histological evidence of TB and 44 (27%) diagnosed on
clinical and supportive laboratory data. Over the six-year
period, two patients developed fibrous constrictive pericarditis
after receiving adjuvant corticosteroid therapy.
The 30-day mortality (8.0%) was statistically higher for
HIV-positive patients (corresponding mortality 9.9%)
than for HIV-negative patients (6.2%; p=0.04). The oneyear
all-cause mortality was 17.3%. It was also higher
for HIV-positive (22.2%) than for HIV-negative patients
(12.3%; p=0.03). Cardiac mortality was equal for HIVpositive
and -negative patients.
Conclusion: Tuberculous pericardial effusions responded
well to closed pericardiocentesis and a six-month treatment
of antituberculous chemotherapy. The former was
effective and safe irrespective of HIV status.Publishers' versio
An unusual case of an unusual bug
The original publication is available at http://www.cmej.org.za/index.php/cmejMany doctors dislike patients presenting with psychiatric
symptoms. This may lead to less careful examination and less
precise laboratory testing. When routine examinations and
tests are declared normal, the patients are medically cleared,
and many diseases are missed. The patient is rapidly referred
to a psychiatrist who may inappropriately treat for a non-existent
psychiatric disorder. To avoid diagnostic disasters, it is
essential to remember that psychiatric and behavioural symptoms
are nonspecific. Other causes must be excluded before
any psychiatric treatment begins.Publishers’ versio
Tuberculous pericarditis and HIV infection in Africa
The original publication is available at http://www.samj.org.za[No abstract available]Publishers' versio
The immunopathogenesis and treatment of tuberculous pericardial effusions in a population with a high prevalence of infection with the human immunodeficiency virus
Thesis (DMed (Medicine. Internal Medicine))-University of Stellenbosch, 2005.Mycobacterium tuberculosis (M. tuberculosis) accounts for more adult deaths than
any other infectious agents. The present study included 162 patients with tuberculous
pericarditis; 50% of the tuberculous pericarditis patients studied were human
immunodeficiency virus (HIV) positive, compared to only 4.2% of patients who
presented with non-tuberculous pericardial effusions. A steady year-to-year rise in
HIV prevalence was observed in this 6-year study. Although the prognosis of
pericardial tuberculosis (TB) is excellent with appropriate medical treatment,
untreated pericardial TB has a mortality of 80-85%. It is thus important to diagnose
tuberculous pericarditis efficiently. Traditionally, the diagnosis of pericardial TB is
established by positive mycobacterial culture and/or histological evidence of
necrotising granulomatous inflammation of the pericardium. Our study confirmed the
insensitivity of pericardial fluid culture and pericardial biopsy in the diagnosis of
pericardial TB, and at the time of clinical decision-making, results were usually not
available. To overcome these difficulties, we explored various alternative strategies
and this resulted in two diagnostic tools, namely a diagnostic rule and a diagnostic
algorithm or classification tree.
By means of classification and regression tree analysis, we allocated a weighted
diagnostic index to each of five independently predictive features (fever, night sweats,
weight loss, serum globulin >40 g/L and peripheral blood leukocyte count
<10x109/L). A total diagnostic index of 6 or more corresponded to 82-86% sensitivity
and 76-87% specificity for a diagnosis of tuberculous pericarditis. When possible, pericardial fluid should be aspirated to determine adenosine
deaminase (ADA) levels and pericardial differential leukocyte counts. Fluid should
also be sent for Gram stain and culture. The proposed diagnostic classification tree
utilises the independently predictive attributes of pericardial adenosine deaminase
levels, pericardial fluid lymphocyte/neutrophil ratios, peripheral leukocyte counts and
the HIV status. Applying this prediction model to our entire data set of 233 patients
resulted in 96% sensitivity and 97% specificity for the correct diagnosis of
tuberculous pericarditis.
Generally, patients were critically ill at the time of enrolment; 90% of tuberculous
pericarditis presented with echocardiographic features of cardiac tamponade. Echoguided
percutaneous pericardiocentesis with an indwelling catheter and intermittent
daily aspiration was highly effective and safe. It is likely that the combination of this
drainage technique and the early initiation of anti-tuberculous chemotherapy
contributed to the almost complete absence of constriction in the patients studied, and
our data do not support the routine use of adjunctive corticosteroids in patients with
tuberculous pericarditis.
Tuberculous exudates result from a Th1 mediated immune response characterised by
lymphocyte dominance, significantly elevated levels of gamma-interferon (IFN-γ) and
undetectable levels of interleukin-4 (IL-4). IFN-γ levels were not influenced by HIV
status in spite of the severely diminished pericardial CD4+ lymphocyte counts
observed in this study. It is thus likely that in HIV positive patients IFN-γ production
is partly maintained by activated CD8+ T cells, which were significantly elevated in
HIV positive patients compared to HIV negative tuberculous pericarditis patients. This finding underlines the importance of IFN-γ in the human immune response
against M. tuberculosis. We also demonstrated that the presence of ADA in
pericardial fluids reflects the activity of the cellular immune response. Both IFN-γ and
ADA can be utilised as sensitive and specific diagnostic tools for pericardial TB
The role of chest radiography in diagnosing patients with tuberculous pericarditis
The original publication is available at http://www.cvja.co.za/Aim: To describe the abnormalities on chest X-ray
(CXR) in patients presenting with tuberculous pericardial
effusions.
Methods: One hundred and seventy patients presented
to Tygerberg Hospital with large pericardial effusions
(epi-pericardial separation > 10 mm). All patients had
a diagnostic work-up, which included CXR, ECG,
two-dimensional echocardiography and HIV serology.
Echocardiography was followed by pericardiocentesis
and drainage. Pericardial fluid was analysed for adenosine
deaminase (ADA), Ziehl Neelsen (ZN) stain, bacterial
and mycobacterial cultures. Sputum was sent for
ZN stain and mycobacterial cultures. Tuberculous pericardial
effusions were diagnosed according to predetermined
criteria.
Results: The diagnosis of tuberculous pericarditis was
made in 53% (n = 90) of patients with pericardial
effusions. Forty-one of the subjects (45.5%) were HIV
positive. All patients had an enlarged cardiac silhouette
and in the majority of cases, the cardiac shadow was
globular with distinct margins. The cardiothoracic ratio
(CTR) exceeded 0.55 in all patients. The amount of
fluid drained correlated with the radiographic finding
of cardiac enlargement.
Conclusion: In developing countries where TB is very
prevalent, CXR plays an important role in the identification
of large pericardial effusions. Although sonography
will still be required for a definite diagnosis, the results
of this study show that CXR is a useful screening tool.Publishers' versio
An overview of the biological disease modifying drugs available for arthritic conditions in South Africa
The past decade has seen a major change in the treatment options and strategies for rheumatoid arthritis (RA) and the other immune-mediated arthritic diseases. The disease modifying antirheumatic drugs (DMARDs) are now used in early stages of the disease in order to preserve joint architecture. There are two groups of DMARDs, the small molecules, like methotrexate, and the biological DMARDs, which are frequently referred to as “magic bullets” since they target specific cytokines and immune cells associated with arthritic conditions. They are monoclonal antibodies or fusion proteins designed to bind and inactivate immune targets.Tumour necrosis factor-alpha (TNF-α) plays an important role in the pathogenesis of rheumatoid disorders and is the target of four biological DMARDs, etanercept, infliximab, golimumab and adalimumab. The other biological DMARDs include abatacept, rituximab and tocilizumab and these prevent T-cell costimulation, cause the depletion of mature CD20 positive B cells or prevent the activation of the interleukin-6 receptor molecule, respectively. Ustekinumab, a monoclonal antibody against IL12/IL23 is effective in psoriatic arthritis.Biological agents are indicated when patients do not respond adequately to the traditional DMARDs. Numerous clinical trials have shown that the biological agents reduce joint inflammation and erosive damage, especially when used in combination with methotrexate.Apart from their prohibitive cost, the biological agents are not without potentially serious adverse effects with infections being the main concern. The TNF-α inhibitors increase the risk for tuberculosis and other opportunistic infections, whereas the non-TNF-α immune inhibitors increase the risk for opportunistic viral, fungal and bacterial infections. This review provides an overview of the biological agents currently available in South Africa
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