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CITATION: Abdool-Gaffar, M. S. et al. 2019. Management of chronic obstructive pulmonary disease - A position statement of the South African Thoracic Society: 2019 update. Journal of thoracic disease, 11(11):4408–4427. doi:10.21037/jtd.2019.10.65

A 31-year- old male with no comorbidities presented with chest discomfort and shortness of breath following SARS-CoV-2 infection. Primary viral myocarditis was confirmed with the aid of cardiac biomarkers and cardiac magnetic resonance (CMR) imaging. Herein, we detail his clinical presentation, management and highlight the role of CMR in viral myocarditis.

Summary: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles

Background Lung cancer is the highest incident cancer globally and is associated with significant morbidity and mortality particularly if identified at a late stage. Poor patient outcomes in low- and middle-income countries (LMIC’s) might reflect contextual patient and health system constraints at multiple levels, that act as barriers to prevention, disease recognition, diagnosis, and treatment. Lung cancer screening, even for high-risk patients, is not available in the public health sector in South Africa (SA), where the current HIV and tuberculosis (TB) epidemics often take precedence. Yet, there has been no formal assessment of the individual and health-system related barriers that may delay patients with lung cancer from seeking and accessing help within the public health care system and receiving the appropriate and effective diagnosis and treatment. This study aimed to derive consensus from health-system stakeholders in the urban Gauteng Province of SA on the most important challenges faced by the health services and patients in achieving optimum lung cancer management and to identify potential solutions. Methods The study was undertaken among 27 participant stakeholders representing clinical managers, clinicians, opinion leaders from the public health sector and non-governmental organisation (NGO) representatives. The study compromised two components: consensus and engagement. For the consensus component, the Delphi Technique was employed with open-ended questions and item ranking from five rounds of consensus-seeking, to achieve collective agreement on the most important challenges faced by patients and the health services in achieving optimal lung cancer management. For the engagement component, the Nominal Group Technique was used to articulate ideas and reach an agreement on the group’s recommendations for solution strategies and approaches. Results Public health sector stakeholders suggested that a lack of knowledge and awareness of lung cancer, and the apparent stigma associated with the disease and its risk factors, as well as symptoms and signs, are critical to treatment delay. Furthermore, delays in up-referral of patients with suspected lung cancer from district health care level were attributed to inadequate knowledge arising from a lack of in-service training of nurses and doctors regarding oncologic symptoms, risk factors, need for further investigation, interpretation of x-rays and available treatments. At a tertiary level, participants suggested that insufficient availability of specialised diagnostic resources (imaging, cytological and pathological services including biomolecular assessment of lung cancer), theatres, cardiothoracic surgeons, and appropriate therapeutic modalities (chemotherapeutic agents and radiation oncology) are the main barriers to the provision of optimal care. It was suggested that a primary prevention programme initiated by the government that involves private-public partnerships may improve lung cancer management nationally. Conclusions Considerable barriers to the early identification and treatment of lung cancer exist. Finding solutions to overcome both individual and health-system level obstacles to lung cancer screening and management are vital to facilitate early identification and treatment, and to improve survival. Furthermore, research on inexpensive biomarkers for asymptomatic disease detection, the introduction of diagnostic imaging tools that utilise artificial intelligence to compensate for inadequate human resources and improving clinical integration across all levels of the healthcare system are essential.

Hydatid disease (HD) is prevalent in South Africa, with cardiac HD being a rare but important manifestation to recognise and diagnose. An incidental finding on computed tomography (CT) of the chest in a patient with pulmonary HD prompted further multimodality imaging, which confirmed the presence of cardiac HD involving the interventricular septum. This case report focuses on imaging findings related to cardiac HD, as demonstrated by the CT of the chest and two- and three-dimensional transoesophageal echocardiography. Multimodality imaging is essential to assist in making a diagnosis and providing a detailed assessment of patients with cardiac HD.

Context In sub-Saharan Africa, late diagnosis with cancer is common. Many dying patients rely on family members for care; little is known about the challenges African informal caregivers face. Objectives To better understand the challenges of informal caregivers at the end of life in South Africa, both at home and in inpatient facilities. Methods We included advanced cancer patients and caregivers from a public hospital in Johannesburg, South Africa. Study nurses interviewed patients and caregivers about their experiences. Using univariate and multivariate analyses, we determined the factors associated with greater caregiver difficulty, focusing on patients dying at home vs. in inpatient facilities. Results Among 174 informal caregivers, 62 (36%) reported "a lot" of challenges. These caregivers struggled most with keeping the patient clean (16%) and with patient interactions (34%). Symptoms associated with greater difficulty included pain (odds ratio [OR] 2.4 [95% CI 1.2–4.7]), urinary incontinence (OR 2.3 [95% CI 1.1–4.9]), fecal incontinence (OR 2.4 [95% CI 1.0–5.7]), insomnia (OR 2.9 [95% CI 1.3–6.9]), fatigue (OR 6.3 [95% CI 1.8–21.6]), extremity weakness (OR 2.9 [95% CI 1.3–6.9]), shame (OR 4.2 [95% CI 1.5–12.0]), and sadness (OR 2.3 [95% CI 1.1–4.8]). Caregivers of patients dying at home reported the greatest difficulty with patients' physical symptoms; caregivers of those dying in facilities reported the greatest difficulty with emotional symptoms. Conclusion Informal caregivers of patients dying at home reported challenges with practical functional care; this effect was reduced in the inpatient setting. Skills training for these caregivers could relieve some of this burden.

Context When religious and spiritual (R/S) care needs of patients with advanced disease are met, their quality of life (QoL) improves. We studied the association between R/S support and QoL of patients with cancer at the end of life in Soweto, South Africa. Objectives To identify R/S needs among patients with advanced cancer receiving palliative care services and to assess associations of receipt of R/S care with patient QoL and place of death. Methods A prospective cohort study conducted from May 1, 2016 to April 30, 2018 at a tertiary hospital in Soweto, South Africa. Nurses enrolled patients with advanced cancer and referred them to the palliative care multidisciplinary team. Spiritual counselors assessed and provided spiritual care to patients. We compared sociodemographic, clinical, and R/S factors and QoL of R/S care recipients and others. Results Of 233 deceased participants, 92 (39.5%) had received R/S care. Patients who received R/S care reported less pain (2.82 ± 1.23 vs. 1.93 ± 1.69), used less morphine, and were more likely to die at home than patients who did not (57.5% compared with 33.7%). On multivariate logistic regression analysis, adjusting for significant confounding influences and baseline African Palliative Care Association Palliative care Outcome Scale scores, receipt of spiritual care was associated with reduced pain and family worry (odds ratio 0.33; 95% CI 0.11–0.95 and odds ratio 3.43; 95% CI 1.10–10.70, respectively). Conclusion Patients with cancer have R/S needs. R/S care among our patients appeared to improve their end-of-life experience. More research is needed to determine the mechanisms by which R/S care may have improved the observed patient outcomes.

Background. Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis. Objectives. To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups. Methods. This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients’ VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity. Results. Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18 cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. Secondary outcomes. Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this. Conclusions. Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients’ VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.

Purpose The understanding of patients with cancer of their condition and their wishes regarding care as they approach end of life (EoL) have been studied more in high-income countries than in low- and middle-income countries (LMICs). Patients and Methods Data were analyzed from a cohort study (N = 221) of patients with advanced cancer who were recruited from a palliative care center in Soweto, South Africa (LMIC), between May 2016 and June 2017. Patients were asked about their understanding of their illness, estimated life expectancy, EoL care communication, and EoL care preferences. Results Only 13 patients (5.9%) acknowledged that they were terminally ill; nine patients (4.1%) estimated accurately that they had months, not years, left to live. A total of 216 patients (97.7%) reported that they had not had an EoL care discussion with their physician, and 170 patients (76.9%) did not want to know their prognosis even if the doctor knew it. Most patients preferred comfort care (72.9%; n = 161) to life-extending care (14.0%; n = 31), and did not want to be kept alive using extreme measures (80.5%; n = 178) or have their doctors do everything possible to extend their lives (78.3%; n = 173). Finally, 127 patients (57.5%) preferred to die at home, and 51 (23.1%) preferred to die in the hospital. Most patients (81.0%; n = 179) had funeral plans. Conclusion South African patients demonstrated less awareness of the fact that they were terminally ill, were less likely to have discussed their prognosis with their doctor, and more strongly preferred comfort care to life-extending EoL care than US and other LMIC patients in prior research. These differences highlight the need for culturally appropriate, patient-centered EoL care for South African patients with advanced cancer as well as to determine individual preferences and needs in all EoL settings.

To investigate the frequency, severity and predictors of interstitial lung disease (ILD) in a cohort of South Africans with systemic sclerosis (SSc). Retrospective record review of SSc patients attending a tertiary Connective Tissue Diseases Clinic. Patients with ILD, defined by a combination of clinical findings, imaging, and lung function tests were compared to patients without ILD in terms of demographics, clinical features and autoantibodies. The majority (86.8%) of the 151 patients included were of Black ethnicity, 40% had ILD, of whom 39% had moderate-severe lung disease. Univariate predictors of ILD included: disease duration (OR 1.08, 95% CI 1.01-1.15); cough (OR 2.93, 95% CI 1.37-6.29); dyspnoea (OR 2.44, 95% CI 1.23-4.87); bibasal crackles (OR 7.58, 95% CI 3.31-17.37); diffuse cutaneous SSc (dcSSc) (OR 4.55, 95% CI 2.10-9.86) and a speckled anti-nuclear antibody (ANA) pattern (OR 2.47, 95% CI 1.25-4.90). Conversely, limited cutaneous disease (OR 0.22, 95% CI 0.09-0.50) and anti-centromere antibody (ACA) (OR 0.12, 95% CI 0.02-0.97) were protective. Independent predictors of ILD on multivariate analysis were bibasal crackles (OR 9.43, 95% CI 3.25-27.39), disease duration (OR 1.19, 95% CI 1.09-1.30) and speckled ANA (OR 2.95, 95% CI 1.22-7.15). Almost all (86.4%) patients received immunosuppressive treatment and the leading cause of death was related to ILD itself (44.4%). In this cohort of predominantly Black South Africans, SSc ILD was common and carried a poor prognosis. ILD occurred mainly, but not exclusively, in patients with dcSSc, especially those with a speckled ANA pattern. Conversely, the presence of ACA was protective against ILD.

Idiopathic pulmonary fibrosis (IPF) is a very specific form of a chronic, progressive fibroproliferative interstitial pneumonia of unknown aetiology. The disease is generally associated with a poor prognosis. Several international evidence-based guidelines on the diagnosis and management of IPF and other interstitial lung diseases (ILDs) have been published and updated in the last decade, and while the body of evidence for the use of some treatment modalities has grown, others have been shown to be futile and even harmful to patients. In a patient who presents with the classic clinical features, restrictive ventilatory impairment with impaired diffusion and a high resolution computed tomography (HRCT) scan of the lungs showing a usual interstitial pneumonia (UIP) pattern, a definitive diagnosis of IPF can be made, provided all other causes of a radiological UIP pattern are excluded. Patients who present with atypical clinical features or an HRCT pattern classified as "possible" UIP, should be referred for a surgical lung biopsy. Once the diagnosis of IPF is confirmed, a patient-centred approached should be followed, as the stage of the disease, degree of impairment, rate of disease progression, comorbid illnesses and patient preferences all impact on long-term management. The South African Thoracic Society (SATS) suggests that anti-fibrotic treatment should be offered to appropriate candidates [confirmed IPF with a forced vital capacity (FVC) of 50-80%], but discontinued should there be evidence of disease progression (a decline in FVC of ≥10% within any 12-month period). The routine use of high dose oral steroids, immunosuppressive drugs and anticoagulants is not recommended whilst anti-acid therapy may be considered in patients without advanced disease.

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive, inflammatory disease affecting the airways and lung parenchyma. It is characterised by persistent airflow obstruction which may be partially reversible, and is caused by exposure of the lung to noxious particles or gases. 1 Although preventable and treatable, once established, the disease course is punctuated by exacerbations. The consequences of COPD result in not just a disease of the respiratory system, but rather a systemic illness which affects multiple organs. COPD is a common disease, yet frequently unrecognised and underdiagnosed. The WHO predicts it will become the 3rd leading cause of death worldwide by 2030. 2 There has been a trend away from classifying COPD patients as having either emphysema (“pink puffers”) or chronic bronchitis (“blue bloaters”). However, there is now mounting evidence that this may become clinically useful in stratifying patients with regard to prognosis and making treatment decisions. More topically, there is an enhanced appreciation that some patients with COPD manifest with features of coexistent asthma. This entity has been labelled the asthma-COPD overlap syndrome (ACOS).

Cystic echinococcosis is regarded as endemic in sub-Saharan Africa; however, for most countries only scarce data, if any, exist. For most of the continent, information about burden of disease is not available; neither are data for the animal hosts involved in the lifecycle of the parasite, thus making introduction of preventive measures difficult. Available evidence suggests that several species or strains within the Echinococcus granulosus complex are prevalent in sub-Saharan Africa and that these strains might be associated with varying virulence and host preference. Treatment strategies (chemotherapy, percutaneous radiological techniques, but mainly surgery) predominantly target active disease. Prevention strategies encompass anthelmintic treatment of dogs, slaughter hygiene, surveillance, and health-educational measures. Existing data are suggestive of unusual clinical presentations of cystic echinococcosis in some parts of the continent, for which the causes are speculative.

Cystic echinococcosis is recognised as causing considerable morbidity and even mortality in South Africa, but the epidemiology of the disease is to date unknown. From current evidence there are also concerns that co-infections with HIV and tuberculosis (TB) considerably increase CE-associated morbidity. The aim of this analysis was to characterise clinical features and disease burden of CE in South Africa in preparation for a prospective study. Retrospective case note analysis of patients presenting to two large academic hospitals in Johannesburg, South Africa, for clinical and demographic data was performed. In addition, data of the National Health Laboratory Service were accessed for requested serological and microscopic investigations for CE and the numbers of positive results evaluated. According to a recently published definition, 14 cases of confirmed CE and 9 cases of probable CE were identified at both hospitals. When accessing the national database it became apparent that even with the most conservative estimate at least 137 patients per year present with CE in South Africa. However, numbers are likely to be much higher for a variety of reasons. Further prospective analysis is necessary to shed more light on the epidemiology, clinical presentation and risk factors for CE, which is currently underway.

Background. Pleural effusions are a common reason for presentation to healthcare facilities. Blind closed pleural biopsy can be a useful tool to diagnose their cause, especially in resource-limited settings. Objectives. To determine the aetiology, frequency and change in profile of histopathological diagnoses made at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa, over the period 1 January 2001 - 31 December 2015. Methods. Pleural biopsies performed at CHBAH and analysed by histopathologists from the National Health Laboratory Service at the hospital over the study period were retrospectively reviewed by accessing reports from two databases (DISA and TrakCare). The subjects’ ages, genders, HIV status and histopathological diagnoses as well as adenosine deaminase and Ziehl-Neelsen results were recorded. Results. A total of 1 013 samples were included in the study, with 780 considered adequate for assessment. The most common diagnosis was granulomatous inflammation (48.1%, n =375), with the most common type being necrotising granulomatous inflammation (73.6%, n =276). Ten percent of biopsies ( n =78) showed malignancy, most commonly adenocarcinoma, with 46.2% ( n =36) metastatic and 23.1% ( n =18) primary lung adenocarcinoma. The odds of being diagnosed with malignancy showed increasing statistical significance above the age of 40 years: 40 - 49 years odds ratio (OR) 8.7, 95% confidence interval (CI) 1.1 - 66.9 ( p =0.038); 50 - 59 years OR 12.4, 95% CI 1.6 - 95.0 ( p =0.015); ≥60 years OR 23.0, 95% CI 3.1 - 171.3 ( p =0.002). HIV seropositivity was associated with lower odds of being diagnosed with malignancy compared with HIV-negative patients (OR 0.5, 95% CI 0.2 - 0.9; p =0.040), with greater odds of a ‘non-cancer’ diagnosis in HIV-positive patients (including granulomatous inflammation and pleuritis (OR 2.16, 95% CI 1.03 - 4.51; p =0.040)). Conclusions. Blind closed pleural biopsy has a role to play in the diagnosis of exudative pleural effusions in resource-limited settings, particularly for patients suspected to have tuberculosis (TB) or malignancy. TB remains a common cause of exudative pleural effusions. Patients aged >40 years presenting with an exudative pleural effusion should routinely have pleural biopsy performed. However, this study showed a high frequency of inadequate specimens from closed pleural biopsy. Training in the performance of this procedure to increase diagnostic rates is recommended.

To assess HIV/sexually transmitted infection (STI) prevalence and associated risk factors among miners in Yunnan, China.A cross-sectional study was conducted among 1798 miners in 2 townships of Gejiu City, Yunnan, from March to May 2006. Standardized interviewer-administered questionnaires were completed and specimens collected for HIV/STI testing.The prevalence of HIV, Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, herpes simplex virus-2, and any STIs among all miners was 0.7%, 4.8%, 0.8%, 1.8%, 9.6%, and 14.9%, respectively. One fifth of miners reported patronizing female sex workers (FSWs) at least once, and of these, 72% never used a condom with a FSW. Miners who visited FSWs had a higher prevalence of HIV (1.8% vs. 0.5%) and any STI (23.2% vs. 4.3%), including C. trachomatis (6.9% vs. 4.3%), N. gonorrhoeae (2.1% vs. 0.5%), and herpes simplex virus-2 (14.9% vs. 8.4%), and higher rates of illegal drug use compared with miners who visited no FSWs.High prevalence of HIV/STIs among miners in Gejiu warrants special attention to this population, and vigorous interventions should address both sexual and drug use-related risk.

Effective tuberculosis (TB) control in HIV-prevalent settings is hindered by absence of accurate, rapid TB diagnostic tests. We evaluated the accuracy of a urine lipoarabinomannan (LAM) test for TB diagnosis in South Africa.Hospitalized adults with signs and/or symptoms of active TB were enrolled. Sputum smear microscopy and mycobacterial culture, mycobacterial blood culture, and HIV testing were performed. A spot urine specimen was tested for LAM.Four hundred ninety nine participants were enrolled; 422 (84.6%) were HIV infected. In microbiologically confirmed TB patients, the LAM test was positive in 114 of 193 [sensitivity 59%, (95% confidence interval: 52 to 66)], including 112 of 167 [67% (59 to 74)] who were HIV infected. Among individuals classified as "not TB", the LAM test was negative in 117 of 122 [specificity 96% (91 to 99)], including 83 of 88 [94% (87 to 98)] who were HIV infected. In confirmed TB patients, the LAM test was more sensitive than sputum smear microscopy (42%, 82 of 193, P0.001) and detected 56% (62 of 111) of those who were sputum smear negative. HIV infection [adjusted odds ratio (AOR 13.4)], mycobacteremia (AOR 3.21), and positive sputum smear (AOR 2.42) were risk factors for a positive LAM test.The urine LAM test detected a subset of HIV-infected patients with severe TB in whom sputum smear microscopy had suboptimal sensitivity. The combination of urine LAM testing and sputum smear microscopy is attractive for use in settings with high HIV burden.

Asthma prevalence is increasing worldwide and surveys indicate that the majority of patients in developed and developing countries do not receive optimal care and are therefore not well controlled. The aim of these guidelines is to promote a better standard of treatment based on advances in the understanding of the pathophysiology and pharmacotherapy of asthma and to encourage uniformity in the management of asthma.

Study objectives The management of life-threatening hemoptysis frequently poses a therapeutic dilemma because such patients are often poor surgical risks. Less often, patients refuse surgical intervention. The value of percutaneous embolotherapy, a useful alternative in these situations, was assessed. Design, setting, patients, interventions Sixteen consecutive patients who underwent percutaneous embolotherapy for life-threatening hemoptysis in a tertiary-care hospital were evaluated retrospectively. The bronchial arteries, as well as other intrathoracic arteries, were evaluated and selectively embolized if they were considered to supply the pathologic area from which the hemoptysis arose. Results The most common cause for hemoptysis was posttuberculous bronchiectasis (n = 12) with or without mycetomas. Ten patients required blood transfusions before embolotherapy. Pleural disease was noted on the chest radiograph in 13 patients and was generally associated with the presence of nonbronchial systemic collateral vessels. In three patients, arteries other than the bronchial arteries were the only source of hemoptysis. Percutaneous embolotherapy was successful in controlling the hemoptysis in all patients. The only complication documented was a transient paraparesis in one patient. Six patients did not return for follow-up. Of the remaining 10 patients, 3 patients had minor episodes of hemoptysis that were treated conservatively with success. One patient had significant recurrent hemoptysis that was managed with radiotherapy. One patient subsequently underwent a lobectomy. Conclusion Percutaneous embolotherapy is a useful therapeutic modality in the management of life-threatening hemoptysis. The contribution of nonbronchial systemic collateral vessels, particularly where there is evidence of coexistent pleural disease, should always be suspected. In experienced hands, this is a safe and potentially life-saving procedure.

A 32-year-old man previously was diagnosed with sarcoidosis on the basis of bilateral lung infiltrates, hypercalcaemia, multiple renal calculi and an elevated serum angiotensin-converting enzyme level, all of which improved on corticosteroids. Nine months later he developed symptomatic, sputum-positive pulmonary tuberculosis and tuberculous lymphadenitis, which were successfully treated. At his initial presentation, …

Cystic echinococcosis is a serious and neglected parasitic zoonosis that is regarded as an emerging disease world-wide. Effective control of the disease is based on understanding the variability of Echinococcus granulosus (sensu lato), as genotypic characteristics may influence lifecycle patterns, development rate, and transmission. No molecular epidemiological research has previously been conducted to shed light on genotypes responsible for the disease in South Africa. To identify strains circulating in the country, parasite material was collected from patients between August 2010 and September 2012 and analyzed by PCR/RFLP methods. A total of 32 samples was characterized as E. granulosus sensu stricto (G1-G3) (81%), E. canadensis (G6/7) (16%) and E. ortleppi (G5) (3%). Furthermore, two co-amplifying G6/7 genotypes were confirmed as G7 by sequencing. This is the first report on genotyping of Echinococcus species in South Africa, and, to the best of our knowledge, the first report of the G5 and G7 genotypes from humans in Africa.

Background. ere is a sense among respiratory physicians that asthma is poorly controlled in public sector hospitals, possibly due to pooradherence and lack of knowledge regarding inhaler technique.Objective. To describe the status of asthma control in patients attending the Respiratory Outpatient Department at Chris Hani BaragwanathAcademic Hospital.Methods. A retrospective record review was conducted on outpatient les of asthmatics known to the Respiratory Department. Dataobtained included demographics, level of control and number of admissions and exacerbations.Results. A total of 519 patient les were reviewed, 74.2% of whom were female. e mean (standard deviation) age was 47 (16.5) years.We found 47.2% of patients were controlled, 30.4% partially controlled and 22.4% uncontrolled. Most patients (88%) had no admissions inthe previous year. About 60% had not experienced exacerbations in the previous year. ere were signicant dierences between the threegroups for number of exacerbations, both per year and per lifetime, and type of steroid prescribed. For a number of signicant areas, suchas forced expiratory volume in one second (FEV1%) predicted and competency of inhaler technique, a large proportion of the data (>30%)had not been documented by the attending doctor in the patient les.Conclusion. In this population of mostly middle-aged female asthmatics, less than half the patients were well-controlled despite very fewadmissions or exacerbations in the previous year. Documentation by clinicians of aspects indicative of asthma control was generally poor, andbetter documentation should be encouraged in order to improve knowledge and highlight awareness of best practice in the management of asthma.

Hypereosinophilia is a rare paraneoplastic nding in malignant disease, particularly lung cancer. When it occurs, it is usually indicative ofmetastatic disease. We describe a 52-year-old male patient with paraneoplastic hypereosinophilia associated with primary adenocarcinomaof the right lower lobe and extensive metastatic disease.

To investigate the role of BCL6 in the pathogenesis of gastric lymphoma, we analyzed the BCL6 promoter region for BCL6 translocations, somatic hypermutations, and deregulating mutations in 43 gastric lymphomas, including 4 extranodal marginal-zone B-cell lymphomas of mucosa-associated lymphoid tissues (MALT lymphomas), 33 diffuse large B-cell lymphomas (DLBCLs), and 6 composite DLBCLs with residual MALT lymphoma (DLCLMLs). BCL6 promoter substitutions by immunoglobulin (Ig) and non-Ig translocation partners, resulting in its deregulation, were frequently involved in DLBCL (36.4%) and DLCLML (50%). Two novel BCL6 translocation partner genes, 28S rRNA and DMRT1, and a new BCL6 translocation breakpoint in intron 2 were also identified. Deregulating mutations were found only in DLBCL (24.2%), which correlated significantly with high BCL6 protein expression. Significantly, high BCL6 expression correlated strongly with longer overall survival (OS), independent of mechanism in gastric DLBCL and DLCLML. Gastric DLBCLs were further subclassified into germinal center B-cell–like (GCB) and non-GCB subgroups immunohistochemically. High BCL6 expression was detected in all GCB cases, irrespective of BCL6 genetic alterations. In the non-GCB subgroup, BCL6-deregulating mutations correlated significantly with high BCL6 expression level. No significant correlation was found between the BCL6 expression level and OS in the non-GCB subgroup, which had significantly poorer prognosis than the GCB subgroup.

Objective. To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations. Key points. 1. Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. 2. Spirometry is essential for the diagnosis and staging of COPD. 3. COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. 4. Oral corticosteroids are no longer recommended for maintenance treatment of COPD. 5. A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. 6. Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. 7. Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. 8. Acute exacerbations of COPD significantly affect morbidity, health care units and mortality. 9. Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. 10. COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes. Options. Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease initiative (GOLD), that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost. Outcome. Holistic management utilising pharmacological and non-pharmacological options are put in perspective. Evidence. Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. Benefits, harms and costs. The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction. Recommendations. These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery. Validation. The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. Guideline sponsor. The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith-Kline.

The association of paraneoplastic hypoglycemia [Doege-Potter syndrome] and finger clubbing [Pierre-Marie-Bamberg syndrome] with pleural solitary fibrous tumour is rare. We present a previously unpublished but typical example of this rare occurrence together with a detailed updated literature review of previously published cases of pleural SFT discussing the histopathology of SFT; pathophysiology of the hypoglycemia and finger clubbing; treatment and outcome of pleural SFT. The patient, a 57-year-old African male was admitted at our hospital with recurrent episodes of hypoglycemia. He was found to have digital clubbing and decreased breath sounds in the right lower chest but no other significant clinical findings. His insulin level measured during an episode of hypoglycemia was undetectable. Chest radiograph and CT-scan revealed a lobulated mass in the right chest which was diagnosed to be SFT on histology. Surgical excision of the mass resulted in cure of the hypoglycemic episodes and rapid regression of the clubbing. Less than 65 cases of pleural SFT manifesting with hypoglycemia with or without finger-clubbing have been published in the English literature. The mean diameter of these tumours manifesting with hypoglycemia is 20 cm, 54% being benign while 42% were malignant. They predominantly present in the 6th-8th decade, average age of 64 years and a slight male preponderance at 58%. Complete surgical resection remains the most important predictor of clinical outcome in terms of recurrence and metastases, while providing instant cure for the hypoglycemia and rapid resolution of the finger clubbing.