Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort

OBJECTIVES: To determine the long-term incidence of tuberculosis (TB) and associated risk factors among individuals receiving HAART in South Africa. DESIGN: Prospective cohort study. METHODS: Microbiologically or histologically confirmed incident TB was identified in a hospital-based cohort of 346 patients receiving HAART between 1996 and 2005 in Cape Town. RESULTS: The TB incidence density rate was 3.5/100 person-years in the first year and significantly decreased during follow-up, reaching 1.01/100 person-years in the fifth year (P = 0.002 for trend). TB incidence during the study was highest among patients with baseline CD4 cell counts < 100 cells/microl and those with World Health Organization (WHO) clinical stage 3 or 4 disease (5.71 and 3.88/100 person-years, respectively). Risk of TB was independently associated with CD4 cell count < 100 cells/microl (adjusted risk ratio [ARR], 2.38; 95% confidence interval (CI), 1.01-5.60; P = 0.04), WHO stage 3 or 4 disease (ARR, 3.60; 95% CI, 1.32-9.80; P = 0.01) and age < 33 years (ARR, 2.86; 95% CI, 1.29-6.34; P = 0.01). Risk of TB was not independently associated with plasma viral load, previous history of TB, low socioeconomic status or sex. Despite similar virological responses to HAART, blood CD4 cell count increases were much smaller among patients who developed TB than among those who remained free of TB. CONCLUSIONS: Incidence of TB continues to decrease during the first 5 years of HAART and so HAART may contribute more to TB control in low-income countries than was previously estimated from short-term follow-up. Patients with advanced pretreatment immunodeficiency had persistently increased risk of TB during HAART; this may reflect limited capacity for immune restoration among such patients.     

Genital primary herpetic infection in an infant: clinical features, diagnosis and management

Genital herpes is a rare disease in infants and is mainly associated with herpes simplex virus (HSV) type 1. Asymptomatic carriers are frequently implicated as transmitters of the disease. Clinical manifestations are the main criteria for diagnosis, However, type-specific serologies and PCR are the most sensitive techniques for detecting HSV. Genital herpes is treated with local or systemic antiviral therapy depending on the severity of the infection. Reducing transmission relies on counseling patients. The disease prognosis is correlated with the underlying immunological status. We report a case of genital primary herpetic infection in an infant.     

Preferred Models of Integrative Care

Introduction and Objectives

The opinions of healthcare providers play a crucial role in the debate around integrating complementary and alternative medicine (CAM) into the current healthcare system. The aim of this study is to explore the issue of CAM integration from the provider viewpoint by determining (a) what working relationship CAM practitioners and general practitioners (GPs) prefer or find acceptable, (b) whether there is agreement in the responses of CAM practitioners and GPs and (c) whether expressed opinions differ by CAM modalities.

Methods

A cross-sectional random sample of CAM practitioners (acupuncturists, chiropractors, massage therapists, naturopaths, homeopaths and herbalists; n = 1112) and GPs (n = 413) from Alberta and British Columbia, Canada, were mailed a questionnaire at three timepoints in 2003. In total, 457 questionnaires were returned from CAM practitioners (41% response rate) and 85 from GPs (21% response rate). Participants were asked to rate four models of integration (independent model, collaborative model, supervised model, assimilation model) for six CAM therapies (acupuncture, chiropractic, massage therapy, naturopathy, homeopathy and herbology).

Results

The collaborative model was rated as the most acceptable by all CAM practitioners and GPs, across all therapies. The least acceptable model, for both CAM practitioners and GPs, was the assimilation model. CAM practitioners and GPs disagreed on the acceptability of the independent model and the supervised model, and these differences were statistically significant.

Conclusion

A collaborative working relationship is preferred by both CAM practitioners and GPs. An integrative healthcare system would need to faciliate such working relations.     

Towards Integration

Background

This qualitative study describes what the integration of complementary and alternative medicine (CAM) means to healthcare policy makers in Canada and examines their recommendations and concerns with regard to the increased integration of CAM in the conventional healthcare system.

Method

The study employed face-to-face interviews with ten provincial government policy makers from Alberta and British Columbia, Canada. The interviews consisted of open-ended questions that focused on the barriers and solutions to the integration of CAM.

Results

Content analysis of the transcribed interviews revealed seven major themes. Participants highlighted the issues that need to be addressed for CAM integration to proceed: the prevention focus in CAM; economic issues; the need for scientific evidence; accreditation and education of CAM practitioners; professional boundary issues; the role of advocacy and strategic planning; and a suggested mechanism for CAM service delivery.

Discussion and Conclusion

The findings indicate policy makers hold a positive view for the integration of CAM at the clinical and primary care level of practice. Policy makers support movement towards integrative health services, but emphasise that the issues of evidence-based CAM research, standards of accreditation and training for CAM practitioners, as well as the issue of who pays for these services, need to be addressed to ensure the improved health and well-being of Canadians.     

Value of Fentanyl in Flexible Sigmoidoscopy

Studies have recorded significant patient discomfort during flexible sigmoidoscopy when it is performed without sedation/analgesia. This study observed whether a single dose of 50 mcg intravenous fentanyl reduces pain, improving compliance, acceptability, and completion rates. In a prospective study, 109 consecutive patients were offered the option of 50 mcg intravenous fentanyl or no analgesia. Patients pre-procedure expectations, objective pain scores, and willingness to undergo a subsequent procedure using the same technique were recorded. Endoscopist recorded the success, complications, and objective pain scores for each patient. Of the 46 patients (42%) choosing fentanyl, 9 (20%) experienced moderate/severe pain as against 26(41%) of the 63 patients (58%) opting for no analgesia (p < 0.05). Further, 52% receiving fentanyl had a significantly better experience compared to their pre-procedure expectations as against 33% who received no analgesia (p < 0.05). No patient receiving fentanyl expressed unwillingness to undergo the procedure again using the same technique, whereas 16 (25%) of those receiving no analgesia indicated they would not (p < 0.01). Endoscopists recorded moderate/severe pain in 13 patients (12%), whereas 35 patients (32%) recorded moderate/severe pain (p < 0.001). Analgesia for endoscopy should involve patient choice. However, a single dose of 50 mcg fentanyl reduced patient discomfort and improved satisfaction. It appeared safe and likely to improve patient compliance and acceptability for flexible sigmoidoscopy.     

National strategy in the battle against scorpion stings and envenomations. Application and evaluation

Scorpion stings represent the first cause of poisoning with an incidence of 30 to 50% of all declared cases in the Centre Anti Poison of Morocco (CAPM). Aware of this increasing problem, the CAPM paid special attention to this pathology. Thanks to its retrospective and prospective studies, the scorpion species mapping has been determined as well as the demographic features of stung patients, the nature and the chronology of clinical events in scorpion envenimation, and the epidemiological, clinical and therapeutical factors of severity. On this basis, the CAPM worked out a national strategy to struggle against scorpion stings whose aim was to decrease the morbidity and mortality caused by stings of scorpion as well as to rationalise economic expenses. The components of this strategy were based on the training of the medical and paramedical staff, on information, education, communication involving different sectors, on identification of needs and on follow-up and assessment. A nationwide campaign was implemented to change the population and health-care staff's behaviour regarding this pathology. Its evaluation permitted to improve the compilation of cases with census of 14104 cases, to reduce lethality rate and to rationalise expenses while banishing some medicines and avoiding useless hospitalization.     

Oculosporidiosis in eastern Nepal: a report of five cases

Rhinosporidiosis is endemic in India, Sri Lanka, and parts of East Africa and South America; sporadic cases are reported in other countries. We report on five patients from eastern Nepal with oculosporidiosis. The conjunctiva was involved in two patients and the lacrimal sac was involved in three patients; treatment was by simple total excision of the conjunctivalgrowth (patients with conjunctival involvement) and by dacryocystectomy (patients with lacrimal sac involvement). This is the second case report from Nepal.     

Biochemical characterization of desloratadine,a potent antagonist of the human histamine H(1) receptor

We have characterized desloratadine (5H-benzo[5,6]cyclohepta[1,2-b]pyridine, 8-chloro-6,11-dihydro-11-(4-piperidinylidene), CAS 100643-71-8) as a potent antagonist of the human histamine H(1) receptor. [3H]Desloratadine bound to membranes expressing the recombinant human histamine H(1) receptor in Chinese hamster ovary cells (CHO-H(1)) in a specific and saturable manner with a K(d) of 1.1+/-0.2 nM, a B(max) of 7.9+/-2.0 pmol/mg protein, and an association rate constant of 0.011 nM(-1) x min(-1). The K(d) calculated from the kinetic measurements was 1.5 nM. Dissociation of [3H]desloratadine from the human histamine H(1) receptor was slow, with only 37% of the binding reversed at 6 h in the presence of 5 microM unlabeled desloratadine. Seventeen histamine H(1)-receptor antagonists were evaluated in competition-binding studies. Desloratadine had a K(i) of 0.9+/-0.1 nM in these competition studies. In CHO-H(1) cells, histamine stimulation resulted in a concentration-dependent increase in [Ca(2+)](i) with an EC(50) of 170+/-30 nM. After a 90-min preincubation with desloratadine, the histamine-stimulated increase in [Ca(2+)](i) was shifted to the right, with a depression of the maximal response at higher concentrations of antagonist. The apparent K(b) value was 0.2+/-0.14 nM with a slope of 1.6+/-0.1. The slow dissociation from the receptor and noncompetitive antagonism suggests that desloratadine may be a pseudoirreversible antagonist of the human histamine H(1) receptor. The mechanism of desloratadine antagonism of the human histamine H(1) receptor may help to explain the high potency and 24-h duration of action observed in clinical studies.     

Isolation and characterization of a novel antihyperglycemic protein from the fruits of Momordica cymbalaria

Aim of the study

A new antihyperglycemic protein was identified in the aqueous extract of fruits of Momordica cymbalaria by bioassay-guided fractionation. The study was aimed at isolation and characterization of this protein.

Materials and methods

The active principle was purified to homogeneity by ammonium sulphate precipitation, gel filtration column chromatography on Sephadex G-50 followed by reverse phase HPLC. Its N-terminal amino acid sequence was identified and compared in the protein data bank. Optimum dose and route of administration of the active principle was determined in STZ induced diabetic rats.

Results

A 17 kDa protein with an isoelectric point of 5.0 was identified as the active principle of antidiabetic action present in the aqueous extract of fruits of MC. It is named as M.Cy protein and found to be a novel protein by comparing its N-terminal amino acid sequence with those in the protein data bank. It did not produce any hypoglycemia in either normal or diabetic rats.

Conclusions

The results suggest that ‘M.Cy protein’, present in the fruits of Momordica cymbalaria is an effective antihyperglycemic active principle in STZ induced diabetic rats at a dose of 2.5 mg/kg b.w.