Clinical aspects and outcomes of patients with malaria at Chris Hani Baragwanath Academic Hospital,Johannesburg, South Africa.

BACKGROUND: South Africa (SA) is currently experiencing a significant increase in malaria cases despite having shifted focus from malaria control towards malaria elimination. The clinical features of malaria are nonspecific, but their relative frequency on presentation are not well described. HIV and malaria are both independently associated with high mortality in sub-Saharan Africa. There are important interactions between HIV and malaria. OBJECTIVES: To describe the population characteristics of patients with malaria at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, clinical and biochemical features of severity, the proportion of patients with HIV infection, management and outcomes. METHODS: A prospective observational study was conducted whereby patients with a confirmed laboratory diagnosis of malaria were identified, approached and consented for study inclusion over the time period January 2017 - January 2018. Clinical and biochemical data were collected at the time of consent and later analysed. RESULTS: The mean (standard deviation) age was 35.7 (12.98) years, and 72 (70.6%) of the 102 patients were male. Peak admissions for malaria were in January, with 58 patients (56.9%) admitted during January 2017 and 2018. All malaria cases were imported, with 74.5% associated with travel to Mozambique. The majority of the patients (61.8%) were expatriates living in SA. The most common presenting symptoms were chills (95.1%), weakness (94.1%), fever (91.2%), headache (90.2%) and lethargy (88.2%). The most common clinical signs were dehydration (31.4%), prostration (19.6%) and jaundice (13.7%). Among the 40 patients (39.2%) who had severe malaria, prostration was the most common feature of severity (19.6%), 8 (7.8%) were admitted to an intensive care unit, and 6 (5.9%) required haemodialysis. The median (interquartile range) duration of hospital stay was 5 (3 -6) (range 2 - 35) days. HIV status was known in 83 patients (81.4%), of whom 32 (38.6%) were HIV-positive. Malaria prophylaxis had been taken by only 8 patients. The all-cause mortality rate was 4.9%, and mortality attributable to malaria 3.9%. CONCLUSIONS: There was a high proportion of complicated malaria cases, particularly in January. The majority of patients were young expatriate males with a history of travel to southern Mozambique or Limpopo Province, with very few taking malaria prophylaxis. Most clinical signs and symptoms were constitutional and nonspecific. A large number of patients were found to be HIV-positive, and most were newly diagnosed. Mortality was high, at around five times the national average, and may have been an underestimate.

Surgical aspects of cardiac resynchronisation therapy.

Despite significant advances in the pharmacological treatment of heart failure, rates of mortality and morbidity from the condition remain a concern. The introduction of cardiac resynchronisation therapy (CRT) has been a welcome addition to the treatment strategy of patients who display ventricular dyssynchrony. Several control studies have shown significant benefits from this intervention in particular improved mortality and reduction in symptom burden. In this short review, we focus on several concepts of CRT and discuss the implications of surgical implantation of the left ventricular (LV) lead as compared to the standard transvenous approach.

Atrioventricular node reentrant tachycardia ablation in a patient with congenitally corrected transposition of the great vessels using the CARTO mapping system.

We present a case of a 21-year-old female with congenitally corrected transposition of the great vessels and episodes of supraventricular tachycardia. We performed an electrophysiological study and successful ablation using an electro-anatomical mapping system. A single His bundle appeared to be located at the apex of the triangle of Koch and at electrophysiological study there was evidence of triple antegrade AV nodal pathways--slow, intermediate and fast, with two types of AV nodal re-entrant tachycardias. A series of radiofrequency ablations in the right posteroseptal area eliminated both slow and intermediate pathway conduction and cured the tachycardias.

Optimisation of cardiac resynchronisation therapy: addressing the problem of "non-responders".

Cardiac resynchronisation therapy has become firmly established as a treatment for patients with symptomatic heart failure. Several randomised controlled trials and numerous observational studies have demonstrated improvements in exercise capacity and quality of life. Despite these advances it is clear that approximately 25% of patients who meet current criteria for implantation of such a device do not show objective evidence of clinical benefit. Implantation of a CRT device is expensive, time consuming and involves some risk so it is important to accurately identify patients who are likely to respond and to optimise pacing lead placement and device programming to maximise the benefit in these selected patients.

Patients undergoing coronary revascularisation: a missed opportunity for secondary prevention?

BACKGROUND: This study tested the hypothesis that the opportunity to start secondary prevention therapy before discharge after coronary revascularisation is being missed. The study assessed current prescribing practice and identified discrepancies in prescribing for patients managed by surgeons (especially) and cardiologists. METHODS: 200 consecutive patients from the Manchester Heart Centre percutaneous coronary intervention (PCI) and coronary artery bypass (CABG) registries were identified (100 from each registry) and the notes analysed. All had undergone coronary revascularisation from February 2002 to March 2002. Data were analysed using SPSS for Windows, version 10.1. RESULTS: After exclusion of two patients with contraindications, 100% (98 of 98) of PCI patients and 92% (90 of 98) CABG patients were prescribed aspirin at discharge. Eight two per cent of eligible PCI patients and 70% of eligible CABG patients were prescribed beta blockers at discharge. Ninety six per cent (96 of 100) of PCI patients and 73% (73 of 100) of CABG patients were prescribed statins of any dose at discharge, (p<0.001). Sixty five per cent of PCI but only 26% of CABG patients were discharged prescribed ACE inhibitors (eligible patients based on HOPE, heart outcomes prevention evaluation trial), (p<0.001). CONCLUSIONS: Secondary prevention prescription after coronary revascularisation remains suboptimal in all but aspirin use. Patients in the PCI group were statistically more likely to be discharged prescribed a statin or an ACE inhibitor, or both, than patients after CABG. Both interventional cardiologists and (especially) cardiac surgeons must improve their use of secondary prevention therapy.

Pulmonary artery dissection: an emerging cardiovascular complication in surviving patients with chronic pulmonary hypertension.

Pulmonary arterial dissection is an extremely rare and usually lethal complication of chronic pulmonary hypertension. The condition usually manifests as cardiogenic shock or sudden death and is therefore typically diagnosed at postmortem examination rather than during life. However, recent isolated reports have described pulmonary artery dissection in surviving patients. The first case of pulmonary artery dissection in a surviving patient with cor pulmonale caused by chronic obstructive pulmonary disease is presented. The aetiology, pathophysiology, and clinical presentation of pulmonary artery dissection are reviewed and factors that may aid diagnosis during life are discussed.

An examination of hyperconjugative and electrostatic effects in the hydride reductions of 2-substituted-4-tert-butylcyclohexanones.

To better understand electronic effects on the diastereoselectivity of nucleophilic additions to the carbonyl group, a series of 2-X-4-tert-butylcyclohexanones (X = H, CH(3), OCH(3), F, Cl, Br) were reacted with LiAlH(4). Reduction of ketones with equatorial substituents yields increasing amounts of axial alcohol in the series for X [H < CH(3) < Br < Cl < F << OCH(3)]. These data cannot be explained by steric or chelation effects or by the theories of Felkin-Anh or Cieplak. Instead, an electrostatic argument is introduced: due to repulsion between the nucleophile and the X group, axial approach becomes energetically less favorable with an increase in the component of the dipole moment anti to the hydride approach trajectory. The ab initio calculated diastereoselectivities were close to the experimental values but did not reproduce the relative selectivity ordering among substituents. For reduction of ketones with axial substituents, increasing amounts of axial alcohol are seen in the series for X [Cl < Br < CH(3) < OCH(3) < H < F]. After some minor adjustments are made, this ordering is consistent with both the electrostatic model and Felkin-Anh theory. Cieplak theory cannot account for these data regardless of adjustments. Ab initio calculated diastereoselectivities were reasonably accurate for the nonpolar substituents but were poor for the polar substituents.

Youth perceptions of comprehensive adolescent health services through the Boston HAPPENS program.

INTRODUCTION: The Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) program is a collaborative network of care made up of 8 organizations that serve youth and provide coordinated care for human immunodeficiency virus (HIV)-positive, homeless, and at-risk youth aged 12 to 24 years. Learning youth perceptions about the program is essential to determine if the program is meeting their needs. METHODS: In this qualitative evaluation, 18 youth served by the network met in 4 focus groups to provide their view of the program. Services within 5 categories were assessed: (a) medical care, (b) mental health and substance abuse care, (c) HIV prevention and care, (d) case management, and (e) allocation of finances. RESULTS: Boston HAPPENS has achieved name recognition and provides many needed services for youth from a wide variety of backgrounds. The youth were comfortable receiving care and were appreciative of the comprehensive services available. They provided suggestions for how mental health services could be offered as one-on-one counseling as part of "wellness care." Young participants also requested more recreational and support opportunities for young people living with HIV. DISCUSSION: Qualitative evaluations such as this give a voice to youth to advocate for services they need. By including youth ideas and perspectives during program development and implementation, services can be more attractive to groups of at-risk youth who historically have been less likely to seek care.

Evaluation of a targeted HIV testing program for at-risk youth.

With the advent of new therapies for HIV, case identification through HIV counseling and testing (CTS) has become critically important. Young women, youth of color, and disenfranchised youth are at significant risk of acquiring HIV. This study describes clients who access CTS at a program of comprehensive care for high-risk youth (aged 12 to 24 years), and assessed, using logistic regression analyses, whether youth at highest risk utilized CTS. Most of the 531 youth were female (72 percent) and nonwhite (60 percent). Sixty-eight percent received CTS. Logistic regression modeling revealed that white race and receiving care at the teaching hospital were the only independent predictors of testing. Data indicate that, despite targeted, youth-specific, developmentally appropriate and culturally sensitive outreach and intervention efforts, youth of color and high-risk youth are poorly accessing CTS. A greater understanding of the barriers to and cultural norms regarding CTS is needed.

Boston HAPPENS Program: a model of health care for HIV-positive, homeless, and at-risk youth. Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services.

The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12-24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV-positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

Primary care experiences and preferences of urban youth.

There are few qualitative studies that assess the experiences and preferences of urban youth with regard to use of primary care. The purpose of this pilot survey was to identify positive and negative influences and underlying issues for adolescents leading to seeking and returning for primary health care. Four focus groups totaling 20 diverse adolescents ranging in age from 13 to 21 years were conducted between April 1994 and June 1994. Participants were recruited through existing peer leadership groups that meet regularly at community health centers or afterschool programs. Urban adolescents are most concerned with being respected and treated well by primary care providers. They want to be listened to, to have their problems taken seriously, and to be treated with dignity and respect. Participants expressed strong preferences regarding sex, sexual orientation, and language of providers, but not for race or ethnicity. Qualitative methods such as focus groups give a voice to youth to advocate for access to adolescent-specific health services. Further research is needed to corroborate the results of this study, to expand our understanding of existing problems, and to investigate the predictors of health care use by vulnerable youth.

Tissue-specific regulation of sialyltransferase activities in the rat by corticosteroids in vivo.

In this study we have examined the effects of corticosteroids on both the total sialyltransferase (sialyl-T) activity and on two individual isozymes in neural, hepatic, and renal tissues using an in vivo model system. Rats were adrenalectomised to deplete their endogenous stores of steroid hormones, and some subsequently received steroid replacement with dexamethasone or aldosterone. Adrenalectomy resulted in a significant decrease in total neural sialyl-T activity when compared with sham-operated animals in the four brain regions examined, indicating that total sialyl-T activity is normally under positive corticosteroid control. The subsequent effects of exogenous corticosteroids exhibited regional specificity with the enzyme activities in the cortex, cerebellum, and brainstem being stimulated by both dexamethasone and aldosterone and enzyme activity in the hippocampus being stimulated by aldosterone alone. In general, the changes in total enzyme activity could be attributed to the alpha 2,6 sialyl-T isozyme, although the changes in the cerebellum appeared to coincide with alpha 2,3 sialyl-T activity. In the liver, adrenalectomy resulted in an increase in enzyme activity which was not altered by administration of corticosteroids. There were no changes in total renal sialyl-T activity in any of the four experimental groups although certain changes were observed at the level of individual sialyl-T isozymes. These results demonstrate that sialyl-T activity in certain tissues is under the control of corticosteroids and that this is both a tissue-specific and region-specific effect.

The first solvation shell of magnesium ion in a model protein environment with formate, water, and X-NH3, H2S, imidazole, formaldehyde, and chloride as ligands: an Ab initio study.

The first coordination shell of an Mg(II) ion in a model protein environment is studied. Complexes containing a model carboxylate, an Mg(II) ion, various ligands (NH3, H2S, imidazole, and formaldehyde) and water of hydration about the divalent metal ion were geometry optimized. We find that for complexes with the same coordination number, the unidentate carboxylate-Mg(II) ion is greater than 10 kcal mol-1 more stable than the bidentate orientation. Imidazole was found to be the most stable ligand, followed in order by NH3, formaldehyde, H2O, and H2S.

Rapid orotracheal intubation in the clenched-jaw patient: a modification of the lightwand technique.

Emergency airway management of the patient with a clenched jaw can present a special challenge to the anesthesiologist. We describe four cases in which the patients had a clenched jaw and nasotracheal intubation was either contraindicated or several attempts had failed. All patients were successfully orotracheally intubated by a modification of the lightwand technique.

Efficacy of sedation of children with chloral hydrate.

Chloral hydrate has been used extensively to sedate children, but at Brooke Army Medical Center, other drug combinations were becoming increasingly popular due to a perception that chloral hydrate had a high rate of failure, especially with younger or neurologically impaired children. Therefore, 50 children were given the drug before a diagnostic study, and patient data and a sedation score were recorded on a worksheet. Of 50 children, 43 (86%) were "successfully sedated" on the first attempt with no side effects. Children with neurologic disorders had a much greater (27% vs 4%) failure rate than "normal" children. The sedation rate did not significantly differ by age, sex, or initial drug dosage. The study suggest that chloral hydrate is a safe and effective oral sedative but that children with neurologic disorders may need alternative drugs for sedation.

Management of the difficult pediatric airway in an austere environment using the lightwand.

Increasingly, medical teams are providing sophisticated surgical treatment to pediatric patients in developing nations. Such care is often administered under relatively austere conditions using easily transported equipment. Because some of these patients may present with congenital or acquired airway abnormalities that make direct laryngoscopy difficult or impossible, alternative methods of endotracheal intubation should be available. One such technique is lightwand-guided endotracheal intubation. Use of the lightwand has a proven record of success and obviates the need for the heavier, more delicate, and more expensive flexible fiber-optic laryngoscope or pediatric bronchoscope. Two cases are reported in which pediatric patients with difficult airway anatomy due to severe burn scar contractures were successfully and easily intubated using the lightwand. This technique is useful for management of the difficult pediatric airway in the austere environment of the typical medical relief mission.