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Johannesburg, South Africa

Jacobson B.F.,University of Witwatersrand | Louw S.,University of Witwatersrand | Mer M.,University of Witwatersrand | de Jong P.R.,University of Cape Town | And 7 more authors.
South African Medical Journal

Background. Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed. This has resulted in unacceptable rates of morbidity and mortality. Method. The Southern African Society of Thrombosis and Haemostasis held a meeting to update the previous guideline and review new literature including guidelines from other societies. The following specialties were represented on the committees: anaesthetics, cardiology, clinical haematology, critical care, obstetrics and gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery and pulmonology. A draft document was presented at the meeting, which was then revised by consensus agreement. To avoid local bias, the guideline was adjudicated by recognised international external experts. Results and conclusion. A concise, practical updated guideline for thromboprophylaxis and treatment in medical and surgical patients has been produced for South African conditions. It is hoped that this guideline will continue to improve anticoagulation practice in this country, which we believe will directly benefit patient outcomes. Source

Levin M.E.,University of Cape Town | Gray C.L.,Vincent Pallotti Hospital | Goddard E.,Vincent Pallotti Hospital | Karabus S.,University of Cape Town | And 3 more authors.
South African Medical Journal

The prevalence of food allergy is increasing worldwide and is an important cause of anaphylaxis. There are no local South African food allergy guidelines. This document was devised by the Allergy Society of South Africa (ALLSA), the South African Gastroenterology Society (SAGES) and the Association for Dietetics in South Africa (ADSA).Subjects may have reactions to more than one food, and different types and severity of reactions to different foods may coexist in one individual. A detailed history directed at identifying the type and severity of possible reactions is essential for every food allergen under consideration. Skin-prick tests and specific immunoglobulin E (IgE) (ImmunoCAP) tests prove IgE sensitisation rather than clinical reactivity. The magnitude of sensitisation combined with the history may be sufficient to ascribe causality, but where this is not possible an incremental oral food challenge may be required to assess tolerance or clinical allergy. For milder non-IgE-mediated conditions a diagnostic elimination diet may be followed with food re-introduction at home to assess causality.The primary therapy for food allergy is strict avoidance of the offending food/s, taking into account nutritional status and provision of alternative sources of nutrients. Acute management of severe reactions requires prompt intramuscular administration of adrenaline 0.01 mg/kg and basic resuscitation. Adjunctive therapy includes antihistamines, bronchodilators and corticosteroids. Subjects with food allergy require risk assessment and those at increased risk for future severe reactions require the implementation of risk-reduction strategies, including education of the patient, families and all caregivers (including teachers), the provision of a written emergency action plan, a MedicAlert necklace or bracelet and injectable adrenaline (preferably via auto-injector) where necessary. © 2014, South African Medical Association. All rights reserved. Source

Lowman W.,Molecular Partners | Lowman W.,Wits Donald Gordon Medical Center | Marais M.,Molecular Partners | Ahmed K.,Molecular Partners | Marcus L.,Molecular Partners
Journal of Hospital Infection

Background: Screening for carriage of carbapenemase-producing Enterobacteriaceae (CPE) is considered an important infection prevention and control strategy. To date, screening has relied primarily on culture although polymerase chain reaction (PCR)-based screening is gaining momentum. Currently there is no gold standard screening method and consequently it is important to consider the implications of different diagnostic strategies used in active surveillance. Aim: To assess the utility of a multiplex PCR screening strategy, as a component of active surveillance, for detection of CPE in patients admitted to various hospitals. Methods: A single rectal swab was collected from patients at various hospitals, considered to be at risk of colonization with CPE. Comparison of a modified US Centers for Disease Control and Prevention culture protocol with a PCR-based assay for the detection of the blaNDM, blaKPC, blaOxA-48-like, blaVIM, blaIMP, and blaGES genes was performed. Findings: Of the 251 consecutive rectal swabs collected, 30 were PCR positive for one or more carbapenemase genes. Fifteen (50%) were culture positive and CPE only accounted for six isolates. PCR demonstrated excellent sensitivity (100%), specificity (89.8%), and negative predictive value (100%) for detection of CPE, but a positive predictive value of only 46.6% and 16.6% for detection of carbapenemase-producing Gram-negatives and CPE, respectively. Conclusion: The apparent excellent performance characteristics of PCR for detection of CPE from rectal swabs must be tempered by knowledge of CPE prevalence and be interpreted within a defined epidemiological context. Further comparative research with culture, evaluating the clinical utility of PCR-based assays as a screening tool, is needed. © 2014 The Healthcare Infection Society. Source

Lang A.C.,Wits Donald Gordon Medical Center | Terblanche A.J.,University of Pretoria | Risenga S.M.,University of Limpopo | Gray C.L.,Vincent Pallotti Hospital | And 4 more authors.
South African Medical Journal

Instituting an exclusion diet for 2-6 weeks, and following it up with a planned and intentional re-introduction of the diet, is important for the diagnosis of a food allergy when a cause-and-effect relationship between ingestion of food and symptoms is unclear.Food may be re-introduced after (short-term) exclusion diets for mild-to-moderate non-immunoglobulin E (IgE)-mediated conditions in a safe clinical environment or cautiously at home. However, patients who have had an IgE-mediated immediate reaction to food, a previous severe non-IgE-mediated reaction or a long period of food exclusion should not have a home challenge, but rather a formal incremental food challenge protocol in a controlled setting.An incremental oral food challenge (OFC) test is the gold standard to diagnose clinical food allergy or demonstrate tolerance. It consists of gradual feeding of the suspected food under close observation. It should be done by trained practitioners in centres that have experience in performing the procedure in an appropriate setting.An OFC must be performed in a setting where resuscitation equipment is available in the event of a severe anaphylactic reaction. OFCs are terminated when a reaction becomes apparent. Standardised and pre-set criteria are available on when to discontinue challenges. Patients who tolerate the full dose ‘pass’ the challenge and are advised to eat a full portion of the food at least twice a week to maintain tolerance. Those who have reactions have ‘failed’ the challenge, should avoid the food, receive education and implement risk-reduction strategies where appropriate. Patients should be observed for a minimum of 2 hours following a negative challenge and for 4 hours after a positive one. © 2014, South African Medical Association. All rights reserved. Source

Faller G.,Wits Donald Gordon Medical Center
Current Allergy and Clinical Immunology

Juvenile dermatomyositis (JDM) is a rare autoimmune vasculopathy of childhood. The presenting features are protean but primary features are skin rash and muscle weakness, accompanied by laboratory evidence of inflammation and antibodies to cellular components. Magnetic resonance imaging (MRI) has been shown to be sensitive in the diagnosis, and new diagnostic criteria are being established. Recent advances in immunogenetics have begun to identify genetic and autoimmune profiles and the underlying immune mechanisms responsible for the inflammation causing muscle damage. This understanding has helped the development of treatment protocols for early and aggressive therapy which offers hope of improved outcomes and less morbidity. Source

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