No description available.

No description available.

Patients with pulmonary arterial hypertension (PAH) often require parenteral prostanoids to improve symptoms and signs of PAH. Complications of parenteral prostanoids-such as catheter-related infections and intolerable adverse effects-may develop, prompting transition to inhaled prostanoids. We report a prospective, protocol-driven transition from parenteral prostanoids to inhaled prostanoids with monitoring of exercise gas exchange and acute hemodynamics. Three PAH centers recruited patients transitioning from parenteral prostanoids to inhaled trepostinil. Rigid inclusion criteria were used, including parenteral prostanoid dose < 30 ng/kg/min, New York Heart Association functional class (FC) < 3, and pulmonary vascular resistance (PVR) < 6 Wood units. Of the 9 patients meeting initial inclusion criteria, 3 were excluded. In the remaining patients, the parenteral prostanoid was reduced and the inhaled prostanoid was increased over 24-36 hours with continuous hemodynamic monitoring. Exercise capacity and FC were measured at baseline and weeks 1, 4, and 12. All patients were successfully weaned from parenteral prostanoids. An acute PVR decrease was seen with most inhaled prostanoid doses, but PVR varied throughout the transition. Patients tolerated inhaled prostanoids for 9-12 breaths 4 times a day with no treatment-limiting adverse events. At week 12, FC was unchanged, and all patients continued to receive inhaled prostanoids without serious adverse events or additional PAH therapy. In 5 of 6 patients, 6-minute walk distance and peak VO2 were within 10% of baseline. Using a strict transition protocol and rigid patient selection criteria, the parenteral prostanoid to inhaled prostanoid transition appeared safe and well tolerated and did not result in clinical deterioration over 12 weeks. Hemodynamic variability noted acutely during transition in our study did not adversely affect successful transition.

MSc, Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Background: Chronic obstructive pulmonary disease (COPD), characterised by progressive airflow limitation which is not fully reversible and associated with pulmonary and systemic inflammatory processes, is largely associated with smoking and is classified as a disease of lifestyle. Other factors related to the incidence of COPD are passive smoking, the inhalation of gases from biomass fuels and the genetic absence of the protease alpha1-antirypsin in some people. COPD is found in all sectors of society and is not dependent on level of income or on the global location of a population. Compounding the incidence of COPD in Africa is the human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) that predisposes patients to the development of COPD. Hydrotherapy has been used since ancient times as a preventative and/or therapeutic form of treatment. Physiotherapists have used hydrotherapy alone or as a useful adjunct to other treatment options for years. Today aquatic therapy is practised in many centres where a multi-disciplinary approach to this form of treatment is offered. There are a number of methodologies of application of the therapy. Among these are Ai Chi, Halliwick, Watsu and Bad Ragaz. The treatment takes place in thermoneutral water between 29 degrees centigrade (oC) and 34oC where use is made of the buoyancy and/or resistance created by the aquatic medium. Musculoskeletal conditions, including pre-operative total hip and knee replacements; osteoarthritis and rheumatoid arthritis can be treated with this modality. Hydrotherapy affords athletes a non-weightbearing rehabilitative environment to enable a quicker recovery and also enables cardiovascular reconditioning to commence sooner than would be afforded by a land-based rehabilitation programme. Many chronic conditions, including cardiac failure, stroke and metabolic disorders have benefited from a hydrotherapy intervention. COPD has been shown to have an inflammatory component. Exercise on land has been shown to have an anti-inflammatory effect in healthy individuals but increased levels of tumour necrosis factor–alpha (TNF-alpha), known to be associated with inflammation, has resulted from moderate intensity land-based exercise in patients with COPD. Aim and objectives of the research: The aim of this study is to systematically review the evidence related to the role of hydrotherapy in the management of patients with COPD. The research objectives of this study are: to determine, from the literature, whether water temperature and depth of immersion influences cardiopulmonary function in patients with COPD; to determine, from the literature, whether hydrotherapy increases endurance, function and quality of life (QoL) in patients with COPD and to determine, from the literature, whether the anti-inflammatory effects of water-based exercise in patients with COPD have been documented. Method: The study design is a qualitative systematic review. A search was made for relevant journal articles in the PUBMED, SCOPUS, CINAHL, MEDLINE, SPORTSDiscus and Cochrane review databases. Google scholar was perused in order to find any grey literature pertaining to the population under review. The review of the literature was from 1996 until 2009. This protracted period of 13 years was needed to insure that all leading articles on the subject under review were included in the review. There were too few articles available from 2000 onwards to produce a valid review of the topic. The words and/or phrases used in the search were: hydrotherapy, Halliwick, Ai Chi, Watsu, Bad Ragaz, chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation, emphysema, chronic bronchitis and the anti-inflammatory effects of exercise. Articles in the form of systematic reviews, randomised controlled trials, clinical trials and case studies pertaining to adult patients with non-acute, non-terminal COPD and the use of hydrotherapy were included in this review. No articles based on animal studies were included. No articles on Kneipp therapy were included as hydrotherapy in this format does not include the immersion of the patient in water. The LOW (Lewis, Olds and Williams, 2007) critical appraisal tool was used to evaluate the articles included in the systematic review. Results: Thirty-seven studies were sourced and nine studies were included in the qualitative systematic review. A total of 35 outcomes measures were reported within the nine included studies. They were of a varied nature and therefore were grouped into the following categories: cardiovascular; pulmonary; muscle strength/weakness; endurance and power, QoL and activities of daily living (ADL). Beneficial results were found in relation to heart rate (HR) with a regime of upper limb exercises performed in water. Following an upper body and upper limb 15 minute land-based exercise programme and subsequent 10-15 minute rest period on land, systolic blood pressure (SBP) was decreased by 14mmHg and diastolic blood pressure (DBP) by 6 mmHg (compared to resting land values) when patients with COPD were immersed in 32 oC water. Ejection fraction (EF) improved significantly at the end of a two month breathing exercise programme in water. A water-based intervention period of 120 minutes (20 minutes, six days/week for two months) decreased left ventricular end –diastolic (LVd) and left ventricular end-systolic (LVs) dimensions (p<0.01). Exhaling into water, during an aquatic breathing exercise regimen lasting 30 minutes/day, six days/week for two months, was demonstrated to significantly increase percentage predicted forced expiratory volume in one second (FEV1%). Arterial concentration of carbon dioxide (PaCO2) levels were decreased significantly due to the breathing exercise with exhalation into water regimens and during the breathing out into water intervention for 20 minute /day for six days the arterial concentration of oxygen (PaO2) levels were increased. Peak flow (PF) was improved in all the breathing programmes where the patient exhaled into water. Improvement in respiratory rate (RR) and oxygen saturation (SaO2) were seen, in patients with COPD, who performed weight -resisted upper limb exercises in water once a week with a twice weekly pulmonary rehabilitation programme (PRP) on land as opposed to a land-based PRP three times per week. Two of the included studies recorded improvement in the incremental shuttle walk test (ISWT) following exercise in water and one noted a greater improvement in the endurance shuttle walk test (ESWT) than in the ISWT after hydrotherapy. Maximal dynamic flexion showed marked improvement after an aquatic programme. Physical and cardiopulmonary improvements, including reduced levels of dyspnoea in some instances, were reported and these were linked to increased levels of physical conditioning, better QoL and improved ability to undertake ADL in the patients with COPD. Conclusion: Breathing exercises, where the patients exhale into the water, appear to have a beneficial effect on pulmonary outcomes particularly when the programme is of a duration of120 minutes per week or more and the exercise is performed on six days / week. The physical exercise hydrotherapy programmes address some of the muscular weaknesses resulting from the systemic effects of COPD. Both the cardiopulmonary benefits and physical benefits seem to result in a general improvement in the QoL of the patients and their greater ability to perform ADL. Social interaction and psychological well-being seem to be factors related to increased compliance in hydrotherapy exercise programmes when compared to compliance in land-based programmes. No information was retrieved from the included studies relating to the anti-inflammatory effects of hydrotherapy exercise programmes. No randomised controlled trials were sourced on the subject under review. The overall evidence was of variable quality, with three studies above average, two average and four below average, according to the LOW critical appraisal tool. From the results obtained in the review it became apparent that there is an urgent need for a number of randomised controlled trials to investigate the role of breathing exercises in combination with physical exercise programmes of hydrotherapy in the management of COPD so that this form of therapy can be utilised to its full capacity.

The morbidity and mortality from tuberculosis may be influenced by the delay from the onset of symptoms until diagnosis. This study was performed to investigate patient and health services delays in the diagnosis o f pulmonary tuberculosis, and the patients’ explanations for these delays.

In spite of the extreme thinness of the avian pulmonary blood-gas barrier (PBGB), it is remarkably strong. To understand the basis of the remarkable strength of the avian PBGB, network of collagen connective tissue that form the lung’s parabronchial fibrous framework and type-IV collagen, a principal component of the basement membrane was investigated in the BGB and in the epithelial-epithelial contacts between the air capillaries in the domestic fowl, Gallus gallus variant domesticus. Techniques of discriminatory staining, selective alkali digestion, vascular casting followed by alkali digestion and immunoelectron microscopy were used. Abundant collagen fibers of the interparabronchial septa, which form part of the tunica adventitia of the interparbronchial vessels, firmly interconnect adjacent parabronchi directly and indirectly (via intraparabronchial vessels). Peripherally, the intraparabronchial artery, with its tunic of collagen fibers, enters and penetrates the exchange tissue mantle. The collagen fibers around the vessel decrease in quantity as it divides into blood capillaries. From the luminal side, the projection of the parabronchial lumen into the exchange tissue mantle as the atria, the infundibulae and the air capillaries, in this order, carry collagen covering which reduces in quantity with each division. The three-dimensional interactions between blood capillaries from the peripheral part and air capillaries from the central lumen allow contact formation between blood capillaries, air capillaries and between air- and blood capillaries. Collagen fiber continuum starting from the interparabronchial septa runs through the exchange tissue by following the three contacts sites and terminates at the parabronchial lumen. At the periphery, the collagen fibers constitute a conspicuous bundle. Within the exchange tissue mantle, the collagen forms diffuse complex interconnections of thin fibers. Towards the parabronchial lumen and within interatrial septa, the thinner collagen fibers of the exchange tissue mantle aggregate to form thick bundles which bind to the connective tissues surrounding the parabronchial muscles. Based on the structural arrangements and function of the smooth muscle, the collagen- and the elastic tissue fibers, and structures like the interparabronchial septa and their associated blood vessels, it was envisaged that: dynamic- tension and compressive forces exist in a parabronchus to form a tensegrity (tension integrity) system. The tensegrity arrangement imparts rigidity to a parabronchus while strengthening the air and the blood capillaries. Mechanical interdependence between parabronchi and between air- and blood capillaries allows efficient transmission and redistribution of tension. The tortuous course of the collagen fiber continuum that follows the three-dimensional intertwining of the gas exchange units- from septa to the lumen- ensures that tension does not travel a straight course and as such, any extrinsic or intrinsic force applied to the structure is transmitted away from the point of origin. Graded exercise intensities and perfusion at different pressures on the integrity of the BGB were used to determine the condition under which the blood-gas barrier in the avian lungs fails. Number of red blood cells and protein concentration in the harvested lung lavage fluid were estimated in the exercised chickens. For histological analysis, numbers of epithelial-epithelial (E-E) breaks and blood-gas barrier (BGB) breaks were counted in each of the four vascular regions of the lung in both the exercised and the perfused lungs. Post exercise blood lactate analysis showed a 4-fold increase between rest and maximal exercise (2.95 m/s) while the numbers of red blood cells and protein concentration increased steadily with increasing exercise intensity, however, the degree of increments appeared to decrease at higher workloads. The two kinds of breaks occurred at all levels of exercise and in the resting birds but at any exercise intensity, there were more E-E breaks than BGB breaks. The numbers of breaks increased with increasing exercise intensity and the difference between the two types of breaks decreased with increasing exercise intensity. In resting birds, there were no breaks in the area of the lung supplied by the cranial branch of the PA. In the exercised birds, differences in number of blood-gas barrier breaks among the four vascular territories only occurred at 0.66 m/s where the lowest and highest counts occurred in the cranial- and caudomedial regions respectively, whereas at all other levels of exercise, the numbers of breaks were comparable. Presence of red blood cells in the lungs of resting birds indicated that failure of the blood-gas barrier might be a common but inconsequential event in the avian lung. A positive linear relationship exists between the perfusion pressure and the numbers of both E-E and blood-gas barrier breaks. At all perfusion pressures, there are more E-E breaks than BGB breaks. The difference between the two types of breaks decreased with increasing pressure. At any perfusion pressure, more breaks occurred in the regions supplied by the accessory- and caudomedial branches of the PA than in the regions supplied by the cranial- and the caudomedial ones. This could be because the pressures in the two blood vessels may be higher since the caudomedial branch is the most direct continuation of the PA while the accessory branch is the narrowest and the first to originate from the PA. Because of the extreme thinness of the blood-gas barrier and unavoidable puncturing of air sac when the thorax is accessed to cannulate the pulmonary vessels, the exact pressure at which the BGB fails could not be ascertained since both types of failure occurred at all perfusion pressures. However, separation of the epithelial-epithelial contacts, caused by distension of the blood capillaries, started appearing at the perfusion pressure of 2.89kPa. This may represent the pressure at which the blood-gas barrier starts to fail.

Background: The D-Dimer test has a high negative predictive value used primarily to exclude clinically suspected possible thrombo-embolic disease. In Emergency Unit (EU) practice, this test is often done not only for suspected Pulmonary Emboli (PE) but also to rule out atypical PE. In South Africa, diagnostic usefulness of this test has not been evaluated in a private hospital EU. The health profile of patients presenting in public and private EUs is different and therefore, it was hypothesized that the usefulness of the DDimer test in these two settings may be different. Results of this study may inform private hospital EU best practice in the optimal utilization of this test. Objective: To evaluate the usefulness of the D-Dimer test in the diagnosis of PE at the Morningside MediClinic (MMC) private hospital EU in Johannesburg, South Africa. Patients and Methods: After approval by the University of the Witwatersrand Human Research Ethics Committee, audit of clinical records was done at the MMC EU from 1 March to 1 June 2009. Informed consent was not required from study subjects as the study was done retrospectively with data extracted from clinical records in an anonymous and delinked fashion. The study population included all patients who had a D-Dimer test done in the MMC EU as part of their diagnostic workup. Extracted data included demographic information, diagnoses and confirmatory tests done. Continuous and categorical variables of data collected were summarized using Stastistica version 9.0 statistical package. A Wells Score was calculated according to the Wells Criteria. Results: In the study period, 189 of 2948 (5%) patients seen at MMC EU had D-Dimers measured. Their population mean age was 57 years (range 38 – 84 years) and 51% were males. Positive D-Dimers were present in 40 (21%) of the total patient population sample group (189 patients). Within the diagnostic categories, the following percentages were the results found per category of the positive D-Dimers within each category: PE (5)(100%), Chest Infection (5)(56%), AMI (2)(33%), Arrhythmia (2)(33%), Hypertension (2)(25%), Chest Pain (6)(14%), Anxiety (3)(23%), Headache (1)(14%), Syncope (1)(14%) and Others (13)(32%). The mean Wells Score in PE was 3.6 (3.0-4.5.) indicating medium probability of PE. All other diagnostic groups had low probability Wells Scores. It was impossible to comment on findings in public hospitals, as there is no known literature found to date on an audit performed concerning the usefulness of the D-Dimer test in a public hospital or any of the public sector, in Johannesburg or elsewhere in South Africa, regarding the diagnosis of PE. However, data has been published by other countries regarding the D-Dimer in various hospital and EU settings (public and private). Conclusion: In the cohort, the D-Dimer was done in only a fifth of patients seen at the private MMC EU and it was positive in less than half of cases. The test yield was highest in PE and had high negative predictive value in more than half of non-PE diagnoses. Therefore, the results suggested that a positive D-Dimer is highly predictive of a diagnosis of PE in this private EU. A negative D-Dimer result appears to be largely associated with any of the non PE wide differential of diagnoses.

Background: Invasive pulmonary aspergillosis (IPA) is a common cause of mortality in haemato-oncology patients and early diagnosis is vital for improving outcomes. Since lung biopsy in this acute setting is rarely performed due to the associated risks, an empirical strategy remains the standard of care in many haematology units, but leads to overtreatment with antifungal drugs, which have significant side-effects. This project has developed novel approaches for detecting IPA, allowing early and specific treatment of genuine fungal infection. Methods: A combination marker approach involving a new Aspergillus qPCR assay, an EORTC/MSG-endorsed GM ELISA and an Aspergillus LFD, was used to establish a robust diagnosis of IPA from clinical broncho-alveolar lavage (BAL) fluid samples. The inflammatory cytokine profile associated with IPA biomarker positive BAL fluid was also evaluated. Finally, antigen and qPCR detection were combined in a proximity ligation assay (PLA), to demonstrate proof-of-principle for a diagnostic assay for the earliest possible detection of fungal infections. Results: A dual testing approach involving a novel MIQE-compliant Aspergillus qPCR assay and an Aspergillus LFD showed a sensitivity and specificity of 100% and 94%, respectively in BAL fluid, unlike in blood where this approach was not sensitive. Results confirmed previously published concerns over the repeatability of GM in serum, whereas BAL GM results appear stable. Biomarker detection results in exhaled breath condensate did not correlate well with results in BAL fluid samples. Respiratory samples did not identify a distinct inflammatory marker profile in IPA. Finally, antibodies raised against JF5 mannoprotein were used to develop a PLA test to detect active growth of Aspergillus. Conclusions: The optimised qPCR is a very sensitive and highly specific aid in IPA diagnosis. A combination biomarker approach could be incorporated into a diagnostic-driven approach to patient management to direct antifungal treatment to patients with evidence of invasive fungal disease.

No description available.

Thesis ( M Med( Family Medicine ))--University of Limpopo, 2010. / Tuberculosis (TB) is a major health problem in South Africa especially in this era of high prevalence of human immune deficiency virus (HIV) infection. South Africa is currently ranked fourth among the twenty-two high burden countries worldwide with an incidence of 940/100 000 population/year and mortality of 218/100 000 population/year. The notational tuberculosis control programme NTCP) was established in response to this growing burden. The aim of this study is to evaluate the TB programme at Matlala District hospital and to make recommendations that could improve its effectiveness. The study was a descriptive cross-sectional study. Retrospective data of all adults ≥15yrs diagnosed with pulmonary TB (PTB) were collated from the TB register and patients’ records between 01/01/2008 and 31/12/2008. Children <15years and extra-pulmonary TB were excluded because of the challenges in diagnosis. Follow-up was done until end of treatment to determine the outcome. The outcomes were cured, completed treatment, failed treatment, died, defaulted treatment, transferred out and not evaluated based on the NTCP criteria.A total of 482 patients (266 females and 216 males) were included in the study with a median age 40.91 (standard deviation (SD) 14.65; 95% CI 39.59-42.22). Women with mean age 38.35 years (SD 15.03; 95% CI 36.54-40.16) were significantly younger (P value <0.00001) than men with mean age 44.05 (SD 13.55; 95% CI 42.23-45.87). There were 399 (82.78%) new cases and 83 (17.22%) re-treatment cases. 130 (26.97%) patients were co-infected with HIV while 236 (48.96%) patients did not know their status. In all, 193 (40%) were cured, 63 (13.07%) completed treatment, 4 (0.83%) failed treatment, 43 (8.92%) died, 27 (5.60%) defaulted, 141 (29.25%) were transferred out and 11 (2.28%) were not evaluated. The treatment success rate was 53.11%. The treatment success rate in this study is well below the 85% target in the NTCP. A large number of the patients did not know their status and the outcome could not be determined in significant number of patients (not evaluated and transferred out). A systematic referral and recording process; and a collaborative effort between TB and HIV services is therefore necessary to face this challenge. It may also be important to re-open the TB ward to prevent nosocomial transmission.