Guideline for the management of acute asthma in adults: 2013 update.

Acute asthma attacks (asthma exacerbations) are increasing episodes of shortness of breath, cough, wheezing or chest tightness associated with a decrease in airflow that can be quantified and monitored by measurement of lung function (peak expiratory flow (PEF) or forced expiratory volume in the 1st second) and requiring emergency room treatment or admission to hospital for acute asthma and/or systemic glucocorticosteroids for management. The goals of treatment are to relieve hypoxaemia and airflow obstruction as quickly as possible, restore lung function, and provide a suitable plan to avoid relapse. Severe exacerbations are potentially life-threatening and their treatment requires baseline assessment of severity, close monitoring, and frequent reassessment using objective measures of lung function (PEF) and oxygen saturation. Patients at high risk of asthma-related death require particular attention. First-line therapy consists of oxygen supplementation, repeated administration of inhaled short-acting bronchodilators (beta-2-agonists and ipratropium bromide), and early systemic glucocorticosteroids. Intravenous magnesium sulphate and aminophylline are second- and third-line treatment strategies, respectively, for poorly responding patients. Intensive care is indicated for severe asthma that is not responsive to first-line treatment. Antibiotics are only indicated when there are definite features of bacterial infection. Factors that precipitated the acute asthma episode should be identified and preventive measures implemented. Acute asthma is preventable with optimal control of chronic asthma.

Mortality in Patients Treated for Tuberculous Pericarditis in Sub-Saharan Africa

Objective: To determine the mortality rate and its predictors in patients with a presumptive diagnosis of tuberculous pericarditis in sub-Saharan Africa. Design: Between 1 March 2004 and 31 October 2004; we enrolled 185 consecutive patients with presumed tuberculous pericarditis from 15 referral hospitals in Cameroon; Nigeria; and South Africa; and observed them during the 6-month course of antituberculosis treatment for the major outcome of mortality. This was an observational study; with the diagnosis and management of each patient left at the discretion of the attending physician. Using Cox regression; we have assessed the effect of clinical and therapeutic characteristics (recorded at baseline) on mortality during follow-up. Results: We obtained the vital status of 174 (94) patients (median age 33; range 14-87 years). The overall mortality rate was 26. Mortality was higher in patients who had clinical features of HIV infection than in those who did not (40versus 17; P=0.001). Independent predictors of death during follow-up were: (1) a proven non-tuberculosis final diagnosis (hazard ratio [HR] 5.35; 95confidence interval 1.76 to 16.25); (2) the presence of clinical signs of HIV infection (HR 2.28; 1.14-4.56); (3) co-existent pulmonary tuberculosis (HR 2.33; 1.20-4.54); and (4) older age (HR 1.02; 1.01-1.05). There was also a trend towards an increase in death rate in patients with haemodynamic instability (HR 1.80; 0.90-3.58) and a decrease in those who underwent pericardiocentesis (HR 0.34; 0.10-1.19). Conclusion : A presumptive diagnosis of tuberculous pericarditis is associated with a high mortality in sub-Saharan Africans. Attention to rapid aetiological diagnosis of pericardial effusion and treatment of concomitant HIV infection may reduce the high mortality associated with the disease

The Smoking Habits; Attitudes Towards Smoking And Knowledge Regarding Anti-Smoking Legislation Of Students In Institutions Of Higher Learning In The Eastern Cape Province Of South Africa

Background: The study aimed to i) investigate the smoking habits of students attending tertiary institutions of learning in the Eastern Cape Province (ECP) and ii) determine the knowledge of the students about the health hazards of smoking and their attitude towards current government anti-smoking legislation.Methods This was a questionnaire-based study involving all seven tertiary institutions of learning in the ECP; viz. the Universities of Transkei; Fort Hare; Port Elizabeth and Rhodes University; and the Border; Eastern Cape and Port Elizabeth technikons. A total of 1 728 students were interviewed out of a student population of 30;080. Stratified random sampling was used to select the students. Two-way tables were used to test the independence of the variables and chi-square tests were applied. A `p' value of below 5was used as a test of significance.ResultsA total of 1 480 students completed the questionnaires (86). The racial classification of the respondents was 79Black; 13White; 7Coloured and 2Indian. Twenty-six per cent of the students were smokers; of which 37were male and 15were female. Forty-five per cent of the Coloured students smoked; while the figures for Whites and Blacks were 26and 25respectively. Seventy per cent of the students smoked less than 10 cigarettes a day. Fifty-two per cent of the smokers said they wanted to stop smoking. Sixty-one per cent had been influenced to start smoking by their friends and only 13were influenced by advertisements. Ninety-four percent agreed that smoking was dangerous to the smoker's health; while 73responded that there was a relationship between mothers who smoke and low birth weight. Thirteen per cent thought the legislation was too tough; while 30said it was good as it was. On measures to reduce smoking; 86favoured restricting smoking in public places.ConclusionThis study has demonstrated that smoking is prevalent in tertiary institutions of learning in the Eastern Cape Province. The demographic profile of the smokers reflects the national picture. The knowledge of the harmful effects of smoking is generally good

The Smoking Habits; Attitudes Towards Smoking and Knowledge Regarding Anti-Smoking Legislation of Students in Institutions of Higher Learning in the Eastern Cape Province of South Africa

Backgroung: Following the introduction of a new; integrated; problem-oriented undergraduate medical curriculum at the University of Pretoria (UP) in 1997; a research project was undertaken to study interpersonal skills; professional attitudes; teamwork; ethics and related topics - which have come to be known collectively as 'soft skills'. This contribution is the first of two articles on the professional socialisation of medical students and their development of 'soft skills'. It describes the particular qualitative methodology developed for; and applied to; the study of soft skills among medical students at UP.Methods: This paper describes the aim of the study; reasons for adopting a qualitative research approach to achieve this aim; the theoretical orientation underpinning the qualitative approach that we considered most suitable; the design; the sampling; the data management and analysis; and the methods that we deployed to ensure the credibility of the findings.Research Design: The aim of the study was to explore the subjective meanings that students attributed to soft skills; as they understood them. These subjective meanings involve the way students interact meaningfully with fellow students; lecturers and other individuals participating in the medical and clinical education programme; and the way they construct shared conceptualisations of soft skills and medical education in their lives and social world. A qualitative approach was considered most appropriate; as this study set out to uncover subjective and diverse meanings that do not necessarily amount to generalisable truths. The particular qualitative strategy or design used was that of an extended case study; or 'casing'; within the modernist theoretical orientation of symbolic interactionism. Elements of process evaluation were incorporated into the design to account for the process of curriculum reform within which this study was embedded. We recruited participants for this study from two cohorts of students. The first group; who completed their studies in 2001; had followed the traditional curriculum; while the second group; who completed their programme in 2002; had followed the reformed curriculum. The data collection tools were face-to-face individual interviews; focused group interviews and solicited autobiographical sketches. The utilisation of more than one method or data source enabled triangulation or cross-checking of findings. We followed an inductive reasoning approach; which means that we did not search for data to test any hypotheses that had been formulated prior to commencing the study; but focused instead on building constructs that were grounded in or reflected intimate familiarity with the students' world.Conclusion: The modernist qualitative research approach enabled us to uncover; describe and illuminate the subjective points of view on soft skills as expressed by final-year medical students before and after curriculum reform. More specifically; by carrying out an extended case study we were able to perform a process evaluation of the curriculum reform in terms of soft skills and the professional socialisation of the students. This paper outlines how qualitative research methods enabled us to capture and explore aspects of the inner life (social worlds) of these students. Whether they would be the same; similar or different in another setting are questions for further exploration or research : questions prompted by our study in a manner that illuminates the qualities that may be inherent in these subjective meanings

Concomitant sarcoidosis in a patient with tuberculosis: first report of association in Africa.

Sarcoidosis occasionally develops in patients previously treated for tuberculosis. Less commonly, tuberculosis develops as an opportunistic infection in patients following corticosteroid treatment for sarcoidosis. Rarely do you find sarcoidosis and tuberculosis coexisting in the same patient. This report in an African, documents the co-existence of both diseases in a patient, highlighting this relationship and reviews the literature on the possible aetiologic relationship between tuberculosis and sarcoidosis.

Exercise induced bronchoconstriction in Nigerian asthmatics.

This study describes the result of free-running exercise performed on 40 asthmatic subjects and 40 age and sex matched controls. A percentage fall of more than 15% in PEFR was used for the diagnosis of exercise-induced asthma (EIA). 77.5% of our asthmatic patients had exercise-induced bronchoconstriction (EIB) while none of the control subjects exhibited EIB. Twenty-seven patients gave positive history of EIA out of which 25 (92.59%) had positive exercise testing. Conversely, 13 patients with asthma did not give history of EIA but 6 of this (46.15%) were found to have EIB on exercise. History alone is therefore insufficient to diagnose patients with exercise-induced asthma.

Skin sensitivity patterns to inhalant allergens in Nigerian asthmatic patients.

The pattern of skin sensitivity response to inhalant allergens in 746 Nigerian asthmatics and 92 normal controls tested over 10 years period is reported. Significant differences in reactions were observed in 7 of the 16 allergens routinely used in the study. House dust mite--dermatophagoides pteronyssinus gave the highest incidence of positive skin reaction, 58% asthmatics, 4.3% controls (P < 0.001). Other significant allergens were house dust 51.7%, feathers 24.4%; dog hair 12.9%, cat fur 11.9%, grass pollen 6.8% and flower pollen 6.3%. More males than females reacted to most of the allergens but this was statistically significant only for feather (P < 0.02). There was good correlation between history and skin sensitivity for most allergens. 82.3% of patients with positive skin test to D. pteronyssinus gave positive history of dust induced asthmatic attacks. Similar results were obtained for pollens: grass (86.3%), flower (83%) and feathers (57.7%). The correlation was however poor in respect of normal allergens (dog 30.6%, cat 36%). From the findings of this study there may be no point in routinely testing patients with a battery of allergens most of which may have no importance in the tropics. Attempts are however underway to incorporate local substances in skin testing materials. It is hoped that the results of this study will assist doctors who may not have access to skin test reagents in management of their asthmatic patients.

Pulmonary embolism in Ibadan, Nigeria: five years autopsy report.

The autopsy findings and clinical features in 60 patients with fatal pulmonary embolism (PE) in University College Hospital, Ibadan, between 1985 and 1989 are analysed in the current study. Pulmonary embolism occurred in 3,8 pc of all autopsied patients during this period. There was a male to female ratio 1,4 to one and average age was 47 years. Malignant neoplasms, infections and cardiac failure were the leading predisposing factors to PE identified. The ante-mortem clinical features consisted largely of non-specific respiratory symptoms of dyspnoea, cough, chest pain and haemoptysis. Of these patients, 15,6 pc were diagnosed ante-mortem as having PE. Pulmonary infarction occurred in 13,3 pc of the cases and was commoner in females and in patients with underlying cardiac diseases. This study emphasises the need for a high clinical index of suspicion to improve the antemortem diagnosis of this potentially fatal condition and to advocate a greater use of prophylactic anti-coagulant therapy in high risk patients.

Clinical trial of sulbactam/ampicillin in the treatment of typhoid fever, and in-vitro sensitivity of isolates to sulbactam/ampicillin and chloramphenicol.

A trial of Sulbactam/Ampicillin in treatment of typhoid fever was carried out while in-vitro sensitivity of the drug was compared with chloramphenicol. Sulbactam/Ampicillin was found to be effective in 11 out of 12 patients who received the drug. The 1 patient who failed to respond had intestinal perforation with peritonitis. No side effects were encountered. The in-vitro study showed that 91.7% of the isolates were sensitive to sulbactam/ampicillin compared to 75% sensitivity to chloramphenicol. The difference was however not statistically significant (P < 0.05). It is concluded that sulbactam/ampicillin is effective and safe in the treatment of typhoid infection.

Neurological complication following tetanus toxoid immunization. A case report.

A 33-year-old Nigeria male developed fever, malaise, headache, muscle weakness and polyneurutis 24 hours after administration of tetanus toxoid. These manifestations however cleared within 72 hours. No other identifiable agents or predisposing factors were identified to explain this phenomenon.

Skin sensitivity patterns to inhalant allergens in Nigerian asthmatic patients.

The pattern of skin sensitivity response to inhalant allergens in 746 Nigerian asthmatics and 92 normal controls tested over 10 years period is reported. Significant differences in reactions were observed in seven of the 16 allergens routinely used in the study. House dust mite--dermatophagoides pteronyssinus--gave the highest incidence of positive skin reaction in 58 pc asthmatics and 4.3 pc controls (P = 0.002). Other significant allergens were house dust, 51.7 pc, feathers; 24.4 pc, dog hair, 12.9 pc, cat fur, 11.9 pc; grass pollen, 6.8 pc and flower pollen, 6.3 pc. More males than females reacted to most of the allergens but this was statistically significant only for feathers (p less than 0.02). There was good apparent association between history and skin sensitivity for most allergens. Eighty-two comma three percent of patients with a positive skin test to D. pteronyssinus gave a positive history of dust induced asthmatic attacks. Similar results were obtained for pollens; (grass, 86.3 pc, flower, 83 pc and feathers 57.7 pc.) The association was, however, poor in respect of animal allergens (dog, 30.6 pc; cat, 36 pc). From the findings of this study, there may be no point in routinely testing patients with a battery of allergens most of which may have no importance in the tropics. Attempts are, however, underway to incorporate local substances in skin testing materials. It is hoped that the results of this study will assist doctors who may not have access to skin test reagents in management of their asthmatic patients.

Pulmonary metastatic malignant tumours in Ibadan, Nigeria: 10 years autopsy review.

This study reports the findings of a ten year review of autopsy records at the University College Hospital, Ibadan, Nigeria of patients who died of malignant tumour metastases to the lungs and pleurae. During the study period 1977 to 1986, a total of 3,549 autopsies were performed out of which 339 cases 10.5 pc died of malignant tumours. One hundred and thirteen of these tumours (33.3 pc) metastasised to the lungs and pleurae among other sites. Further analysis of these 113 patients showed that 49 were male and 64 females giving a male:female ratio of 1:1,3. In addition, the ages of the patients ranged between 9 months and 90 years with a mean of 38.3 years. The uterus was the commonest organ from which pulmonary metastases occurred (28.3 pc), with choriocarcinoma being the predominant historical type of uterine tumour. The liver was the next most common organ 26.5 pc with male to female ration of 3:3,1. Twenty other organs were also identified, the breast, kidney and oesophagus 7 pc each; pancreas ovary and thyroid 3 pc each being the most important. Other organs are adrenals, foot, neck, cervix and rectum--2 pc each.

Left atrial myxomas--a case report.

A 49-year-old woman presented with symptoms of congestive cardiac failure. Cardiac auscultation revealed a crunching sound difficult to characterise in addition to a pansystolic murmur maximally audible in the 4th left intercostal space. The ausculatory findings varied from day to day but were unaffected by posture or exercise. A clinical impression of left atrial myxoma was confirmed by two dimensional echocardiography which revealed a well circumscribed mass almost completely filling the left atrium with a pedicle attached to the interatrial septum. The patient's cardiac failure improved with conservative management using frusemide and digoxin. The patient, however, refused cardiac surgery which is the definitive management of this disease.

Alpha-1-antitrypsin levels and prevalence of Pi variant phenotypes in adult Nigerian asthmatics.

Alpha-1-antitrypsin (A1AT) phenotypes and serum levels were determined in 99 asthmatic patients and 100 control subjects. The phenotypes encountered were PiMM 74% in asthmatics, 98% in controls; PiMZ 19% in asthmatics, 1% in controls; PiMW 3% in asthmatics, 0% in controls; and PiLM 2% in asthmatics, 1% in controls. There was one asthmatic patient with the homozygous deficient phenotype ZZ. The result revealed that there were more deficient heterozygous phenotypes in the asthmatic group than the control group. There was also a positive correlation between the number of patients with deficient phenotypes and the severity of asthma (P less than 0.02). Analysis of the serum A1AT levels revealed that as a group the asthmatic patients had significantly lower A1AT levels (1.97 +/- 0.18 g/l) than the control group (2.21 +/- 0.15 g/l) (P less than 0.01). However, there was no statistically significant difference in the A1AT serum levels of patients with P1MM phenotype and the control of the same phenotype. Statistical analysis could not be done for the other phenotypes because of the small number of subjects. Apart from the patient with PiZZ the A1AT serum levels encountered in the study were not low enough to justify replacement therapy with alpha-1-proteinase inhibitor in our asthmatic patients.

Alpha-1-antitrypsin and chronic bronchitis in adult Nigerians.

Alpha-1-antitrypsin (A1AT) serum levels and phenotypes were determined in 49 Nigerians with chronic bronchitis and 100 normal controls. The A1AT phenotypes encountered were PiMM, 69% in chronic bronchitics, 98% in controls; PiMZ, 23% in chronic bronchitics, 1% in controls; PiLM, 2% in chronic bronchitics, 1% in controls. There were three patients (6%) with the homozygous-deficient phenotype PiZZ. Spirometry confirmed obstructive ventilatory pattern in the patients with chronic bronchitis, and the difference in the values obtained between the patients and controls was statistically significant (P less than 0.01). Serum A1AT levels were within the normal range of 1.4-2.7 g/l in all except the three patients with PiZZ. There was no significant difference in the A1AT serum levels between patients with chronic bronchitis and control subjects with the PiMM phenotype; tests of significance were not possible for the other phenotypes because of the small number of subjects. The observation of PiZZ in 6% of our patients with chronic bronchitis is in support of screening of this category of patients. Replacement therapy with alpha-1-antitrypsin inhibitor is currently under investigation and may be worthwhile in these patients if detected early.

Giant lymph node hyperplasia of the lung (Castleman's disease) associated with recurrent pleural effusion.

A case of giant lymph node hyperplasia (Castleman's disease) of the lung presented with pleural effusion (which was recurrent), an unusual complication. The patient was treated with pneumonectomy and has survived for three years without relapse. This is the first report of the disease from black Africa.

Abnormal mucociliary action in asthma and bronchiectasis.

Nasal mucociliary clearance (NMCC) time was measured in four groups of patients: asthmatics with allergic rhinitis, asthmatics without rhinitis, bronchiectasis and normal subjects. The saccharin method was used for the study. The NMCC time was prolonged significantly in the asthmatic groups and group with bronchiectasis when compared with control subjects (P less than 0.001). It is likely that the impaired mucociliary clearance is due to a combination of mucus abnormality and ciliary malfunction.

The role of fiberoptic transbronchial lung biopsy in diagnosis of chronic infiltrative pulmonary disease in Nigeria.

Over a three-year period, fibreoptic transbronchial lung biopsy (FTLB) was performed in 28 adult Nigerian patients with chronic infiltrative lung disease after sputum examination, haematological, biochemical and serological tests failed to provide a definite diagnosis. Definitive histological diagnosis was obtained in 11 patients (39.3 per cent) while another seven (25 per cent) had distinct histological abnormalities but no specific diagnosis. Tuberculosis and sarcoidosis were the commonest findings. No patient had haemorrhage of more than 50mls while only one had asymptomatic mild pneumothorax. FTLB is very safe and spares a substantial proportion of patients with chronic diffuse lung infiltrates more invasive and expensive diagnostic procedures. This is especially very relevant in developing countries where there is a shortage of surgeons, theatre space and other relevant facilities.

Flexible fibre optic bronchoscopy in Ibadan: report of 6 years' experience.

This study describes 6 years' experience of flexible fibre optic bronchoscopy (FFB) at the University College Hospital, Ibadan. Ninety-three bronchoscopies were carried out in 83 patients. The study revealed 22 patients with primary lung malignancies, four with tuberculosis, three with secondary malignancies, three with sarcoidosis, and two with interstitial fibrosis. The yield from FFB was 44% and complications were encountered in only three patients, with no mortality.