Diagnostik der pulmonalen Tuberkulose beim Erwachsenen

Zusammenfassung: Die Inzidenz der pulmonalen Tuberkulose (TB) in Westeuropa nimmt ab. Dennoch ist sie vor allem bei Migranten und Immunsupprimierten (z.B. HIV) keine seltene Erkrankung. Bei Immunsupprimierten ist die Präsentation oft atypisch; generell unterschätzt die Klinik das Ausmaß der Erkrankung. Eine radiologische Abklärung und eine Untersuchung von 3sequenziell gewonnenen Sputa inklusive Mikroskopie, Kultur und Resistenztestung auf die Erstlinienmedikamente sind nötig zur Diagnosestellung. Der Tuberkulintest kommt vor allem bei der Diagnose der latenten TB und bei Umgebungsabklärungen zum Einsatz. Neuere Bluttests, basierend auf einem Nachweis von Interferon-g, welches durch antigenspezifische T-Zellen gebildet wird, haben gewisse Vorteile gegenüber dem Tuberkulintes

Diagnostik bei ambulant erworbener Pneumonie

Zusammenfassung: Pneumonien gehören zu den häufigeren Diagnosen in der Hausarztpraxis und im Spital. Bei der ambulant erworbenen Pneumonie weisen die vertiefte Anamnese bei einem Patienten mit akutem Husten und zusätzlichem fokalen klinischen Lungenbefund, Fieber über mehr als 4Tage sowie Dys- und Tachypnoe auf diese Diagnose hin. Ein wichtiger Entscheid ist, ob ein Patient hospitalisiert werden soll oder nicht. Hierzu erfolgt die Risikoeinschätzung gemäß verschiedener Scores, die den Schweregrad einer Pneumonie einstufen. Im ambulanten Bereich muss a priori keine Erregerdiagnostik durchgeführt werden, wobei bei einem purulenten Sputum die Wertigkeit der Gramfärbung für verschiedene Erreger, vor allem S. pneumoniae, hoch ist. In speziellen Situationen kann der Urinantigentest für Pneumokokken eine zusätzliche diagnostische Hilfe bieten. Wichtig für eine meist empirische Therapie ist die Berücksichtigung des Alters des Patienten, die Epidemiologie hinsichtlich Resistenzmuster sowie das Wissen über die häufigsten Errege

Pregnancy after liver transplantation with tacrolimus immunosuppression: A single center's experience update at 13 years

Background. Chronic liver disease often leads to amenorrhea in women of childbearing age. There are several reports of successful pregnancy after liver transplantation (LTx) with cyclosporine A immunosuppression. Tacrolimus has been increasingly used in solid-organ transplantation, and the effect of the drug on pregnancy is still of interest to clinicians. This study updates our single-center experience. Methods. All pregnancies after LTx with tacrolimus immunosuppression were followed prospectively. Patients' clinical courses during pregnancy and labor along with gestational period and birth weight were catalogued. Changes in liver function, renal function, and immunosuppression also were recorded. The birth weight percentile was calculated on the basis of the gestational period using a standard chart. Results. Thirty-seven mothers delivered 49 babies. Three mothers delivered three times, and six mothers delivered two times. Thirty-six mothers (97%) survived the pregnancy, and 36 allografts (97%) survived. The one death and graft loss was in a patient who demonstrated infra-aortic arterial graft, which clotted by the gravid uterus during labor. The patient developed a gangrenous liver and died before she could undergo retransplantation. The mean gestational period was 36.4±3. 2 weeks, excluding two premature deliveries at 23 and 24 weeks gestation. Twenty-two babies (46.9%) were delivered by cesarean section, and the other babies were delivered vaginally. In addition to the two premature babies, one baby, who was born to a mother with Alagille syndrome, died from congenital birth defects. The rest of the newborns survived. The mean birth weight was 2,797±775 g, with 38 babies (78%) weighing more than 2,000 g. The mean birth weight percentile to gestational period was 54±23. Four babies (8.5%) had a birth weight percentile of less than 25, and 28 babies (59.6%) had a birth weight percentile greater than 50. Twelve patients demonstrated an increase in hepatic enzymes without jaundice during the pregnancy. All of them responded to augmentation of immunosuppression. Conclusion. The present report reconfirms the safety of tacrolimus during pregnancy after LTx. Preterm delivery and low birth weight seem to be a persistent problem in all solid-organ transplantation under any form of immunosuppression. However, toxemia of pregnancy and new onset of hypertension seem to be have a low occurrence with the use of tacrolimus

Making soft power work: theory and practice in Australia’s international education policy

Policy makers around the world are increasingly concerned with the challenge of cultivating and capitalising on soft power. Yet government efforts to increase others’ feelings of attraction toward their countries face conceptual and practical challenges. This article examines Australia’s attempt to operationalize soft power in Asia through its international education strategy. Drawing on interviews with key officials, we show how the design of Australia’s international education policy was consciously informed by multiple dimensions of soft power. Yet the nature of soft power means that whether the policy will achieve its soft power objectives is up to Asia, not Australia

Psychological and Physical Intimate Partner Aggression Are Associated with Broad and Specific Internalizing Symptoms during Pregnancy

Background: Intimate partner violence (IPV) has serious consequences, particularly during high-risk periods such as pregnancy, which poses a significant risk to maternal mental health. However, it is unclear whether IPV presents a broad risk for psychopathology or is specific to distinct diagnoses or symptom dimensions (e.g., panic, social anxiety). Further, the relative impact of physical versus psychological aggression remains unclear. Methods: One hundred and fifty-nine pregnant couples completed surveys assessing psychological and physical intimate partner aggression unfolding in the couple relationship, as well as a range of internalizing symptoms. Results: Psychological and physical aggression were each associated with broad negative affectivity, which underlies mood and anxiety disorders; however, only psychological aggression demonstrated a unique association. Further, for pregnant women, aggression was uniquely associated with several symptom dimensions characteristic of PTSD. In contrast, men demonstrated a relatively heterogeneous symptom presentation in relation to aggression. Conclusion: The present study identifies unique symptom manifestations associated with IPV for couples navigating pregnancy and suggests psychological aggression can be more detrimental to mental health than physical aggression. To promote maternal perinatal mental health, clinicians should screen for covert forms of psychological aggression during pregnancy (e.g., raised voices, insults), trauma-related distress, and symptom elevations in women and their partners

Self‑Objectification During the Perinatal Period: The Role of Body Surveillance in Maternal and Infant Wellbeing

Pregnancy represents a unique time during which women’s bodies undergo significant physical changes (e.g., expanding belly, larger breasts, weight gain) that can elicit increased objectification. Experiences of objectification set the stage for women to view themselves as sexual objects (i.e., self-objectification) and are associated with adverse mental health outcomes. Although women may experience heightened self-objectification and behavioral consequences (such as body surveillance) due to the objectification of pregnant bodies in Western cultures, there are remarkably few studies examining objectification theory among women during the perinatal period. The present study investigated the impact of body surveillance, a consequence of self-objectification, on maternal mental health, mother-infant bonding, and infant socioemotional outcomes in a sample of 159 women navigating pregnancy and postpartum. Utilizing a serial mediation model, we found that mothers who endorsed higher levels of body surveillance during pregnancy reported more depressive symptoms and body dissatisfaction, which were associated with greater impairments in mother-infant bonding following childbirth and more infant socioemotional dysfunction at 1-year postpartum. Maternal prenatal depressive symptoms emerged as a unique mechanism through which body surveillance predicted bonding impairments and subsequent infant outcomes. Results highlight the critical need for early intervention efforts that not only target general depression, but also promote body functionality and acceptance over the Western “thin ideal” of attractiveness among expecting mothers

Contrast-enhanced sonography as a novel tool for assessment of vascular malformations

Vascular malformations with arteriovenous shunt components can cause significant disability, chronic pain, and functional impairment. Effective treatment may require serial procedures, yet an imaging modality optimized to control cost and reduce radiation exposure in this predominantly pediatric population has not yet been identified. We describe the use of contrast-enhanced sonography as a novel tool to define vascular anatomy and localize arteriovenous shunting in a young patient with a symptomatic vascular malformation. This method may effectively reduce radiation exposure and cost, and additionally provide unique information about arteriovenous shunting, offering a novel imaging application for patients with these conditions

Pregnancy after liver transplantation under tacrolimus

Background. The maternal and fetal risk of pregnancy after organ transplantation under tacrolimus has not been reported. This was prospectively studied in 27 pregnancies by 21 female liver recipients who were treated with tacrolimus before and throughout gestation. Method. Twenty- seven babies were born between October 1990 and April 1996. In 15 cases, samples were obtained at or after delivery and stored (-40°C) for comparison of tacrolimus concentration in the maternal blood with different combinations of cord and infant venous blood, breast milk, or a section of the placenta. Results. The 21 mothers had surprisingly few serious complications of pregnancy and no mortality. Two infants with 23 and 24 weeks gestation died shortly after birth. The mean birth weight of the other 25 was 2638±781 g after a gestational period of 36.0±3.3 weeks. Mean birth weight percentile for gestational age was 50.2±26.2 (median 40). On the day of delivery, the mean tacrolimus concentrations (ng/ml) were 4.3 in placenta versus 1.5, 0.7, and 0.5 in maternal, cord, and child plasma, and 0.6 in the first breast milk specimens. The infants had a 36% incidence of transient perinatal hyperkalemia (K+>7.0 meq/L) and a mild reversible renal impairment, which were thought to reflect in part maternal homeostasis. One newborn had unilateral polycystic renal disease (the only anomaly). All 25 babies have had satisfactory postnatal growth and development with a current mean weight percentile of 62±37 (median 80). Conclusions. Pregnancy by postliver transplant mothers under tacrolimus was possible with a surprisingly low incidence of the hypertension, preeclampsia, and other maternal complications historically associated with such gestations. As in previous experience with other immunosuppressive regimens, preterm deliveries were common. However, prenatal growth for gestational age and postnatal infant growth for post- partum age were normal