Ventilating my thoughts on severe asthma exacerbations

-

A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

SUMMARY

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death.

RECOMMENDATIONS

Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

Parental perspectives towards sugar-sweetened beverages and polices: a qualitative study

PURPOSE

This qualitative study aimed to understand parental perception of (1) sugar-sweetened beverages (SSB) and implications of SSB on health; (2) their role in shaping their children's consumption of SSB; (3) the influences on SSB consumption of their children; and (4) potential government policies targeted at controlling SSB consumption.

METHODS

English-speaking parents of pre-schoolers aged 2-6 years were recruited. Semi-structured interviews based on the knowledge, attitude, practice framework were conducted, and transcripts were subjected to thematic analysis based on inductive approaches. Recruitment continued until data saturation was reached.

RESULTS

Twenty parents participated in the study and themes addressing the objectives identified. (1) There were misconceptions regarding the healthfulness of certain non-packaged SSB such as traditional remedies and juices. Some were unaware about the association between SSB and dental caries. (2) The need to reduce and restrict sugar consumption for overall and oral health reasons was well-recognised, but the extent of control varied. (3) Multiple stakeholders including pre-schools, grandparents and domestic helpers were involved in shaping children's diet. Children's sugar intake was also influenced by environmental factors, such as the ubiquitously available SSB, targeted marketing and high cost of healthy alternatives. (4) Participants were less accepting towards SSB taxation than the ban of SSB sales.

CONCLUSION

Despite the awareness of the types of SSBs and the general/oral health implications of sugar consumption, misconceptions exist. Although most parents possessed the knowledge and attitude, this did not translate into the practice of reducing sugar consumption in their children. There was no SSB reduction policy that had overwhelming acceptability.

Subgingival Microbiota during Healthy Pregnancy and Pregnancy Gingivitis

INTRODUCTION

Previous studies have largely explored the microbial composition and pathogenesis of pregnancy gingivitis. However, the patterns of microbial colonization during pregnancy in the absence of pregnancy gingivitis have rarely been studied. Characterization of the oral microbiome in pregnant women with healthy gingiva is an important initial step in understanding the role of the microbiome in progression to pregnancy gingivitis.

OBJECTIVES

In this study, we compared the oral microbiome of pregnant women without gingivitis (healthy pregnancy) with pregnant women having gingivitis and nonpregnant healthy women to understand how pregnancy modifies the oral microbiome and induces progression to pregnancy gingivitis.

METHODS

Subgingival plaque samples were collected from Chinese pregnant women with gingivitis (n = 10), healthy pregnant women (n = 10), and nonpregnant healthy women (n = 10). The Illumina MiSeq platform was used to perform 16S rRNA gene sequencing targeting the V4 region.

RESULTS

The alpha and beta diversity was significantly different between pregnant and nonpregnant women, but minimal differences were observed between pregnant women with and without gingivitis. Interestingly, the oral bacterial community showed higher abundance of pathogenic taxa during healthy pregnancy as compared with nonpregnant women despite similar gingival and plaque index scores. However, when compared with overt pregnancy gingivitis, pathogenic taxa were less abundant during healthy pregnancy. PICRUSt analysis (phylogenetic investigation of communities by reconstruction of unobserved states) also suggested no difference in the functional capabilities of the microbiome during pregnancy, irrespective of gingival disease status. However, metabolic pathways related to amino acid metabolism were significantly increased in healthy pregnant women as compared with nonpregnant women.

CONCLUSION

The presence of pathogenic taxa in healthy pregnancy and pregnancy gingivitis suggests that bacteria may be necessary for initiating disease development but progression to gingivitis may be influenced by the host environmental factors. More efforts are required to plan interventions aimed at sustaining health before the appearance of overt gingivitis.

KNOWLEDGE TRANSFER STATEMENT

The results of this study draw attention to the importance of oral health maintenance during pregnancy, as women without any prenatal oral conditions are predisposed to the risk of developing pregnancy gingivitis. Hence, it is important to incorporate comprehensive assessment of oral health in the prenatal health care schedules. Pregnant woman should be screened for oral risks, counseled on proper oral hygiene and expected oral changes, and referred for dental treatment, when necessary.

Examining the influence of specificity ligands and ATP-competitive ligands on the overall effectiveness of bivalent kinase inhibitors

Background

Identifying selective kinase inhibitors remains a major challenge. The design of bivalent inhibitors provides a rational strategy for accessing potent and selective inhibitors. While bivalent kinase inhibitors have been successfully designed, no comprehensive assessment of affinity and selectivity for a series of bivalent inhibitors has been performed. Here, we present an evaluation of the structure activity relationship for bivalent kinase inhibitors targeting ABL1.

Methods

Various SNAPtag constructs bearing different specificity ligands were expressed in vitro. Bivalent inhibitor formation was accomplished by synthesizing individual ATP-competitive kinase inhibitors containing a SNAPtag targeting moiety, enabling the spontaneous self-assembly of the bivalent inhibitor. Assembled bivalent inhibitors were incubated with K562 lysates, and then subjected to affinity enrichment using various ATP-competitive inhibitors immobilized to sepharose beads. Resulting eluents were analyzed using Tandem Mass Tag (TMT) labeling and two-dimensional liquid chromatography-tandem mass spectrometry (2D–LC-MS/MS). Relative binding affinity of the bivalent inhibitor was determined by calculating the concentration at which 50% of a given kinase remained bound to the affinity matrix.

Results

The profiling of three parental ATP-competitive inhibitors and nine SNAPtag conjugates led to the identification of 349 kinase proteins. In all cases, the bivalent inhibitors exhibited enhanced binding affinity and selectivity for ABL1 when compared to the parental compound conjugated to SNAPtag alone. While the rank order of binding affinity could be predicted by considering the binding affinities of the individual specificity ligands, the resulting affinity of the assembled bivalent inhibitor was not predictable. The results from this study suggest that as the potency of the ATP-competitive ligand increases, the contribution of the specificity ligand towards the overall binding affinity of the bivalent inhibitor decreases. However, the affinity of the specificity components in its interaction with the target is essential for achieving selectivity.

Conclusion

Through comprehensive chemical proteomic profiling, this work provides the first insight into the influence of ATP-competitive and specificity ligands binding to their intended target on a proteome-wide scale. The resulting data suggest a subtle interplay between the ATP-competitive and specificity ligands that cannot be accounted for by considering the specificity or affinity of the individual components alone.

Electronic supplementary material

The online version of this article (doi:10.1186/s12953-017-0125-1) contains supplementary material, which is available to authorized users.

APOE*E2 allele delays age of onset in PSEN1 E280A Alzheimer's disease

Alzheimer's disease (AD) age of onset (ADAOO) varies greatly between individuals, with unique causal mutations suggesting the role of modifying genetic and environmental interactions. We analyzed ~50 000 common and rare functional genomic variants from 71 individuals of the 'Paisa' pedigree, the world's largest pedigree segregating a severe form of early-onset AD, who were affected carriers of the fully penetrant E280A mutation in the presenilin-1 (PSEN1) gene. Affected carriers with ages at the extremes of the ADAOO distribution (30s-70s age range), and linear mixed-effects models were used to build single-locus regression models outlining the ADAOO. We identified the rs7412 (APOE*E2 allele) as a whole exome-wide ADAOO modifier that delays ADAOO by ~12 years (β=11.74, 95% confidence interval (CI): 8.07-15.41, P=6.31 × 10(-8), PFDR=2.48 × 10(-3)). Subsequently, to evaluate comprehensively the APOE (apolipoprotein E) haplotype variants (E1/E2/E3/E4), the markers rs7412 and rs429358 were genotyped in 93 AD affected carriers of the E280A mutation. We found that the APOE*E2 allele, and not APOE*E4, modifies ADAOO in carriers of the E280A mutation (β=8.24, 95% CI: 4.45-12.01, P=3.84 × 10(-5)). Exploratory linear mixed-effects multilocus analysis suggested that other functional variants harbored in genes involved in cell proliferation, protein degradation, apoptotic and immune dysregulation processes (i.e., GPR20, TRIM22, FCRL5, AOAH, PINLYP, IFI16, RC3H1 and DFNA5) might interact with the APOE*E2 allele. Interestingly, suggestive evidence as an ADAOO modifier was found for one of these variants (GPR20) in a set of patients with sporadic AD from the Paisa genetic isolate. This is the first study demonstrating that the APOE*E2 allele modifies the natural history of AD typified by the age of onset in E280A mutation carriers. To the best of our knowledge, this is the largest analyzed sample of patients with a unique mutation sharing uniform environment. Formal replication of our results in other populations and in other forms of AD will be crucial for prediction, follow-up and presumably developing new therapeutic strategies for patients either at risk or affected by AD.

New insights into bacterial chemoreceptor array structure and assembly from electron cryotomography

Bacterial chemoreceptors cluster in highly ordered, cooperative, extended arrays with a conserved architecture, but the principles that govern array assembly remain unclear. Here we show images of cellular arrays as well as selected chemoreceptor complexes reconstituted in vitro that reveal new principles of array structure and assembly. First, in every case, receptors clustered in a trimers-of-dimers configuration, suggesting this is a highly favored fundamental building block. Second, these trimers-of-receptor dimers exhibited great versatility in the kinds of contacts they formed with each other and with other components of the signaling pathway, although only one architectural type occurred in native arrays. Third, the membrane, while it likely accelerates the formation of arrays, was neither necessary nor sufficient for lattice formation. Molecular crowding substituted for the stabilizing effect of the membrane and allowed cytoplasmic receptor fragments to form sandwiched lattices that strongly resemble the cytoplasmic chemoreceptor arrays found in some bacterial species. Finally, the effective determinant of array structure seemed to be CheA and CheW, which formed a "superlattice" of alternating CheA-filled and CheA-empty rings that linked receptor trimers-of-dimer units into their native hexagonal lattice. While concomitant overexpression of receptors, CheA, and CheW yielded arrays with native spacing, the CheA occupancy was lower and less ordered, suggesting that temporal and spatial coordination of gene expression driven by a single transcription factor may be vital for full order, or that array overgrowth may trigger a disassembly process. The results described here provide new insights into the assembly intermediates and assembly mechanism of this massive macromolecular complex.

Can MRI replace CT in evaluating semicircular canal dehiscence?

BACKGROUND AND PURPOSE

Patients with symptoms of semicircular canal dehiscence often undergo both CT and MR imaging. We assessed whether FIESTA can replace temporal bone CT in evaluating patients for SC dehiscence.

MATERIALS AND METHODS

We retrospectively reviewed 112 consecutive patients (224 ears) with vestibulocochlear symptoms who underwent concurrent MR imaging and CT of the temporal bones between 2007 and 2009. MR imaging protocol included a FIESTA sequence covering the temporal bone (axial 0.8-mm section thickness, 0.4-mm spacing, coronal/oblique reformations; 41 patients at 1.5T, 71 patients at 3T). CT was performed on a 64-row multidetector row scanner (0.625-mm axial acquisition, with coronal/oblique reformations). Both ears of each patient were evaluated for dehiscence of the superior and posterior semicircular canals in consensual fashion by 2 neuroradiologists. Analysis of the FIESTA sequence and reformations was performed first for the MR imaging evaluation. CT evaluation was performed at least 2 weeks after the MR imaging review, resulting in a blinded comparison of CT with MR imaging. CT was used as the reference standard to evaluate the MR imaging results.

RESULTS

For SSC dehiscence, MR imaging sensitivity was 100%, specificity was 96.5%, positive predictive value was 61.1%, and negative predictive value was 100% in comparison with CT. For PSC dehiscence, MR imaging sensitivity was 100%, specificity was 99.1%, positive predictive value was 33.3%, and negative predictive value was 100% in comparison with CT.

CONCLUSIONS

MR imaging, with a sensitivity and negative predictive value of 100%, conclusively excludes SSC or PSC dehiscence. Negative findings on MR imaging preclude the need for CT to detect SC dehiscence. Only patients with positive findings on MR imaging should undergo CT evaluation.

Theory and action for effective condom promotion: illustrations from a behavior intervention project for sex workers in singapore

Acquired immunodeficiency virus (AIDS) and sexually transmitted diseases (STD) control programs targeted at sex workers have focused on condom use. Reasons for non-condom use among female brothel-based sex workers in Singapore were found to be low self-efficacy, lack of condom negotiation skills, and barriers such as fear of annoying clients. Green's PRECEDE framework and Bandura's self-efficacy theory were applied to develop a project aimed at equipping sex workers with negotiation skills, overcoming barriers to condom use, and gathering support from brothel keepers and peers. The experimental group showed significant improvements in negotiation skills and outcome behavior of always refusing sex without a condom, that were supported by a decline in gonorrhea incidence. This article describes the application of behavior change and health education theories to achieve reduction in gonorrhea risk.

An asymmetric synthesis of L-pyrrolysine

An efficient asymmetric synthesis of the 22nd amino acid L-pyrrolysine has been accomplished. The key stereogenic centers were installed by an asymmetric conjugate addition reaction. A Staudinger/aza-Wittig cyclization was used to form the acid-sensitive pyrroline ring. Pyrrolysine was synthesized in 13 steps in 20% overall yield.

Small-molecule-modified surfaces engage cells through the αvβ3 integrin

Integrins play myriad and vital roles in development and disease. They connect a cell with its surroundings and transmit chemical and mechanical signals across the plasma membrane to the cell's interior. Dissecting their roles in cell behavior is complicated by their overlapping ligand specificity and shared downstream signaling components. In principle, immobilized synthetic peptides can mimic extracellular matrix proteins by supporting integrin-mediated adhesion, but most short peptide sequences lack selectivity for one integrin over others. In contrast, synthetic integrin antagonists can be highly selective. We hypothesized that this selectivity could be exploited if antagonists, when immobilized, could support cellular adhesion and activate signaling by engaging specific cell-surface integrins. To investigate this possibility, we designed a bifunctional (RGD)-based peptidomimetic for surface presentation. Our conjugate combines a high affinity integrin ligand with a biotin moiety; the former engages the α(v)β(3) integrin, and the latter allows for presentation on streptavidin-coated surfaces. Surfaces decorated with this ligand promote both cellular adhesion and integrin activation. Moreover, the selectivity of these surfaces for the α(v)β(3) integrin can be exploited to capture a subset of cells from a mixed population. We anticipate that surfaces displaying highly selective small molecule ligands can reveal the contributions of specific integrin heterodimers to cell adhesion and signaling.

Enzyme replacement therapy for mucopolysaccharidosis VI (Maroteaux-Lamy syndrome): experience in Hong Kong

Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome) is a very rare inherited lysosomal storage disease. We evaluated the efficacy and safety of weekly infusions of recombinant human arylsulfatase B as enzyme replacement therapy for two patients in whom this condition was advanced. The primary outcome variables were the distance walked in a 6-minute walk test, forced vital capacity, and ejection fraction. The secondary outcome variables were the number of stairs climbed in a 3-minute stair climbing test, joint mobility, urinary glycosaminoglycan excretion, auto-continuous positive airway pressure study and liver size. After 24 weeks of treatment, patient A walked 40 m (36%) and patient B walked 66 m (58%) more in the walk test than at baseline. After 48 weeks, in patient A the corresponding improvements were 142 m (129%) in the walk test and 33 stairs (60%) in the 3-minute stair climbing test, and in patient B the respective improvements were 198 m (174%) and 77 stairs (140%). There was a significant decline in urinary glycosaminoglycan excretion and improvement in range of motion of joints in both patients. The auto-continuous positive airway pressure study revealed improvements in patient A, while other efficacy variables remained static. There were no drug-related adverse events or allergic reactions reported during and after the infusions of recombinant human arylsulfatase B. Recombinant human arylsulfatase B significantly improves endurance and reduces urinary glycosaminoglycan excretion. The drug is generally safe and well tolerated.

A qualitative study on HPV vaccination from a nursing perspective in Hong Kong

OBJECTIVE

To identify the perception on human papillomavirus (HPV) vaccination among female nursing students in Hong Kong.

DATA SOURCES

Data were collected through focus group discussions and semi-structured in-depth interviews. All participants (n=28) were female nursing students of a university in Hong Kong. Tape recordings of individual interviews and focus group discussions were transcribed verbatim in Chinese, translated into English, and analyzed according to Colaizzi's phenomenological analysis.

STUDY DESIGN

Four major themes emerged from the data: nursing students' understanding about HPV vaccine, nursing students' attitude on HPV vaccine, nursing students' perspective on HPV vaccination promotion, and nursing role on HPV vaccination.

CONCLUSIONS

Government should take initiative in promotion with vaccine suppliers. The awareness and knowledge of HPV and HPV vaccination among women should be increased in order to raise the positive attitude of women towards HPV vaccination and prevention of cervical cancer. Health professionals should work together on HPV promotion among women and increase the HPV vaccination rates. Moreover, further studies regarding attitude and awareness of HPV vaccination among women in different age groups are needed in order to identify more associated factors affecting their perceptions towards HPV vaccination.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

Is the worldwide epidemic of obesity a communicable feature of globalization?

Globalization has a major impact on both economic and social determinants in public health. The current worldwide epidemic in obesity needs to be considered in the context of globalization as a communicable rather than non-communicable process. There is increasing evidence that global trends in lifestyle, eating behavior and cultural adaptation contribute to the rapid increase in obesity around the world. Thus, obesity may be defined as a "socially-contagious" feature of globalization. Furthermore, infectious agents are being identified that may cause obesity by central mechanisms or by modulating adipocyte function or at least by contributing to the chronic inflammatory milieu of the metabolic syndrome. Therefore, globalization may indeed form a critical platform for these pathogens to fuel the obesity epidemic. Understanding obesity in the light of globalization as a communicable disorder will allow outlining better avenues of prevention and treatment.

Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions

SETTING

Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa.

OBJECTIVES

To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment.

DESIGN

Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits.

RESULTS

Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced.

CONCLUSIONS

Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Framingham Risk Scores and Anthropometric Measurements in Predicting Cardiovascular Risks among Malay Men

Framingham Risk Scores is an established method to predict an individual's 10-year risk for coronary heart disease (CHD). It provides a more precise delineation of risk which might lead to appropriate selection of therapy and opportunities for patient education and motivation. A Healthy Lifestyle Project was initiated to decrease the modifiable risk factors for CHD in a worksite in Kuala Lumpur. The participants were Malay men (n=186) working as security guards in a public university. Their mean age was 46.6 + 6.6 years. The majority had secondary education and were married. The participants' 10-year risks based on the Framingham Risk Scores were 55.4%, 39.8% and 4.8% respectively for categories of low (< 10%), intermediate (10 to 20%) and high (>20%) risk. Their Framingham Risk Scores were then correlated with anthropometric measurements such as the Body Mass Index (BMI), waist circumference and waist-hip-ratio (WHR). All the anthropometric measurements had weak but significant correlation with the Framingham Risk Scores (WHR: r=0.26; waist circumference: r=0.23; BMI: r=0.16). In conclusion, 44.6% of our participants had more than 10% risk in developing CHD in the coming ten years. Hence, they are suitable target candidates for the promotion of a healthy lifestyle such as smoking cessation, weight control, healthy dietary patterns and increased physical activities. Indicators of abdominal obesity like WHR or waist circumference may be used to complement the Framingham Risk Scores for the prediction of CHD risk in this population.

Cryptococcal pneumonia in African miners at autopsy

SETTING

Deceased miners from South Africa whose cardiorespiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000.

OBJECTIVES

To 1) calculate the prevalence of cryptococcal pneumonia in 8421 autopsied miners, a population with a high prevalence of human immunodeficiency virus (HIV) infection; 2) document the association of cryptococcal pneumonia with other pulmonary infection; 3) document the association of cryptococcal pneumonia with a clinical diagnosis of cryptococcal meningitis; and 4) determine the accuracy of the clinical diagnosis of cryptococcal pneumonia.

DESIGN

Case series of 589 black miners with histological evidence of cryptococcal pneumonia at autopsy, defined as the presence of cryptococcal organisms in the lung parenchyma, identified by staining of the mucinous capsule.

RESULTS

The incidence of cryptococcal pneumonia at autopsy was 7%. Ninety-seven of the 589 cases (16.5%) had a concomitant respiratory infection, most commonly Pneumocystis jirovecii pneumonia (51.5%), followed by mycobacterial infection (42.3%). In life, cryptococcal meningitis was diagnosed in 46.9% and cryptococcal pneumonia in only 2.7%.

CONCLUSION

Although tuberculosis remains the most common HIV-associated respiratory disease in Africa, it is important to consider the diagnosis of cryptococcal pneumonia in acquired immune-deficiency syndrome (AIDS) patients, and to bear in mind the possibility of dual pathology.

Fetal myocardial performance in pregnancies complicated by gestational impaired glucose tolerance

OBJECTIVE

To determine fetal myocardial performance in pregnancies complicated by mild gestational impaired glucose tolerance (GIGT).

METHODS

Ultrasound examinations were performed in 37 pregnant women with mild GIGT (36 did not require insulin) and in 44 controls at 18-24, 26-30 and 34-37 weeks of gestation. The thickness of the fetal ventricular walls and interventricular septum were measured by M-mode echocardiography. Using conventional Doppler echocardiography, the mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular myocardial performance index (MPI) were determined.

RESULTS

The fetuses of women with GIGT had a greater abdominal circumference (P = 0.02), a larger amniotic fluid index (P = 0.03), and a tendency to be heavier (P = 0.058) at the third scan. There were no significant differences in myocardial thickness, mitral and tricuspid E and A velocities, and E/A ratios between study and control groups. The left and right ventricular MPIs, while similar between the two groups in the first and second scans, had decreased significantly by late gestation in the GIGT fetuses (P for trend = 0.018 and 0.014, respectively) and were significantly lower than those of the control group (P = 0.002 and 0.0008, respectively).

CONCLUSIONS

Fetuses of women with mild GIGT lack the ventricular hypertrophy and diastolic dysfunction that is common in fetuses of diabetic mothers, and they have a decreased MPI late in gestation. Published by John Wiley & Sons, Ltd.

An epidemiological and knowledge, attitudes, beliefs and practices study of sexually transmitted infections in older men

INTRODUCTION

This study was conducted to determine the disease patterns of sexually transmitted infections (STI) in older men, as well as to gather information on their knowledge, attitudes, beliefs and sexual practices.

METHODS

A prospective study was carried out from January to June 2005 in men aged 50 years or older who attended the Department of STI Control clinic.

RESULTS

There were 104 men enrolled. The majority (92.3 percent) were Chinese, and 62.5 percent were aged between 50 and 59 years, 25.9 percent between 60 and 69 years, and 11.5 percent aged 70 years or older. The patients were predominantly heterosexual, and had fairly low levels of education--85.6 percent of the patients had received primary or secondary school level of education. Majority (79.8 percent) of the men had been sexually active in the preceding six months, and 37.3 percent had paid sex during that time. 29.8 percent of men reported having taken drugs such as sildenafil (Viagra, Pfizer, New York, NY, USA) or similar drugs such as vardenafil (Levitra, Bayer, Wuppertal, Germany) or tadalafil (Cialis, Eli Lilly, Indianapolis, IN, USA). 56.7 percent of the men had active infections, with non-gonococcal urethritis (15.4 percent), genital warts (12.5 percent) and gonorrhoea (10.6 percent) being the commonest. Generally, condom usage was accepted as an effective way to prevent transmission of STI. However, many of the men surveyed felt that condom usage reduced their sexual pleasure, and 38.5 percent felt that condoms were inconvenient. There were also areas of human immunodeficiency virus (HIV) knowledge that were lacking. Most patients listed the media as their main source of knowledge about STI and HIV.

CONCLUSION

Older males attending the clinic remain at significant risk of STI and targeted educational efforts are warranted.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics

SETTING

A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems.

OBJECTIVES

To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005.

METHODS

The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described.

RESULTS

In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients.

CONCLUSIONS

Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.