South African Medical Journal - Volume 105, Issue 5, 2015
Volumes & issues
Volume 105, Issue 5, 2015
Source: South African Medical Journal 105, pp 389 –383 (2015) http://dx.doi.org/10.7196/SAMJ.8524More Less
Background. Ocular surface squamous neoplasia (OSSN) is a group of ocular tumours that has been rising in incidence among HIV-infected individuals in sub-Saharan Africa. Surgical excision is the mainstay of treatment for OSSN in this region.
Methods. This retrospective cohort study examined the clinical characteristics and treatment modalities used for 468 patients with OSSN from a large tertiary referral center in Gaborone, Botswana, over a 10-year period from 1998 to 2008.
Results. The estimated annual incidence of OSSN in Botswana reached a peak of 7.0 cases per 100 000 persons per year in 2004. The mean age of the patients in the study was 38 years (interquartile range 30 - 44), and 53.9% were women. Of the patients, 48.5% were known to be HIV-infected, 1.5% were HIV-uninfected, and 50.0% had unknown HIV status. Among HIV-infected patients with CD4 counts, the median CD4 count was 192 cells/µL. As initial OSSN treatment, 20.7% of patients received simple surgical excision, 70.9% received surgical excision with adjunctive beta radiation, 0.9% received evisceration, 1.3% received enucleation, and 6.2% underwent surgical removal of unknown type. The overall rate of known recurrence was 7.1%; however, among those with at least 6 months of follow-up, the recurrence rate was 24.2%. Rates of known recurrence after simple surgical excision and surgical excision with adjunctive beta-radiation were 10.3% and 5.4%, respectively.
Conclusion. This study confirms the high incidence of OSSN among young individuals in Botswana. Further investigation is warranted to determine the most effective treatment modalities to prevent recurrence of OSSN among patients in sub-Saharan Africa.
Validation of a severity-of-illness score in patients with tuberculosis requiring intensive care unit admission : researchSource: South African Medical Journal 105, pp 389 –392 (2015) http://dx.doi.org/10.7196/SAMJ.9148More Less
Background. There is a paucity of data on the determinants of mortality due to tuberculosis (TB) in the intensive care unit (ICU).
Objective. To develop a simple severity-of-illness score for use in patients with TB admitted to an ICU.
Methods. A scoring system was generated by retrospectively identifying the four most significant and clinically unrelated predictors of mortality from an existing prospectively collected dataset (January 2012 - May 2013), and combining these with known predictors of poor outcome.
Results. Of 83 patients admitted with TB, 38 (45.8%) died in the ICU. The four parameters identified from the retrospective analysis were: (i) HIV co-infection with a CD4 cell count < 200/µL; (ii) a raised creatinine level: (iii) a chest radiograph showing diffuse parenchymal infiltrates/miliary pattern; and (iv) absence of TB treatment on admission. These were combined with septic shock and a low arterial partial pressure of oxygen/fractional inspired oxygen (P:F) ratio to generate a six-point severity-of-illness score (one point for each parameter). The scores for survivors were significantly lower than those for non-survivors (mean (standard deviation) 2.27 (1.47) v. 3.58 (1.08); p< 0.01). A score of ≥2 was associated with significantly higher mortality than a score of < 2 (7.1% v. 46.4%; odds ratio (OR) 15.03; 95% confidence interval (CI) 1.86 - 121.32; p< 0.01), whereas a score of ≥3 was associated with a significantly higher mortality than a score of < 3 (64.6% v. 20.0%; OR 7.29; 95% CI 2.64 - 20.18; p< 0.01).
Conclusion. The proposed scoring system identified patients at increased risk of dying from TB in the ICU. Further prospective studies are indicated to validate its use.
Outcomes of TB/HIV co-infected patients presenting with antituberculosis drug-induced liver injury : researchSource: South African Medical Journal 105, pp 393 –396 (2015) http://dx.doi.org/10.7196/SAMJ.8217More Less
Background. South Africa has a significant burden of tuberculosis (TB). Anti-TB drug-induced liver injury (TB DILI) is one of the most serious adverse events that can arise from TB treatment (TBT). There are limited data on TB DILI among HIV-infected patients and those on antiretroviral therapy (ART).
Objective. To describe characteristics of HIV-infected patients presenting with TB DILI and the proportion reintroduced on standard or modified TBT after DILI.
Methods. This was a retrospective study of TB/HIV co-infected patients with DILI between 1 July 2009 and 30 September 2012. The primary focus of interest was HIV-infected patients with TB DILI on ART (ART/TB DILI) v. not on ART (TB DILI).
Results. A total of 94 patients were included, 41 with TB DILI and 53 with ART/TB DILI. Compared with patients with TB DILI, patients with ART/TB DILI were more likely to present with symptomatic DILI (71.2% v. 51.2%; p=0.03) and had a lower median alanine aminotransferase level at diagnosis (89 IU/L v. 118 IU/L; p=0.008), a lower rate of ALT decline (-23 IU/L v. -76 IU/L; p=0.047) and longer duration of TBT at DILI diagnosis (53 days v. 11 days; p< 0.001). In 71.8% of patients, standard TBT was reintroduced. More patients with ART/TB DILI than TB DILI required modified TBT (37.2% v.17.1%; p=0.05; crude odds ratio 2.17; 95% confidence interval 0.95 - 4.96). The rate of death/loss to follow-up was higher in the ART/TB DILI group (18.9% v. 14.5%).
Conclusion. A significant number of TB/HIV co-infected patients were not able to tolerate standard TBT. Furthermore, ART appears to complicate TBT, with relatively fewer patients reintroduced on standard TBT.
Author F.P.R. De VilliersSource: South African Medical Journal 105, pp 397 –399 (2015) http://dx.doi.org/10.7196/SAMJ.8496More Less
Background. Coping with diabetes control is difficult for newly diagnosed and experienced patients alike. Children with diabetes face severe challenges, as they may not yet have attained the necessary cognitive, fine motor or psychosocial skills required for performance of the tasks required from the diabetic patient. Most therefore require some adult assistance.
Objectives. To establish whether paediatric diabetic patients are adequately supported by their families in terms of giving insulin injections and doing home blood glucose monitoring (HBGM), and whether insulin and the necessary equipment are appropriately stored in their homes.
Methods. Patients attending a paediatric diabetes clinic were interviewed. The data collected included demographic variables, type of insulin, measurement of insulin doses, administration of insulin, and blood glucose monitoring tests.
Results. Twenty-five subjects were interviewed: 18 measured the insulin themselves, five mothers and one aunt did so, and in one case the mother and patient did so together. The four children aged ≤10 years had their insulin measured by their mothers, but one had to administer the injection himself. Eight of the nine children aged 11 - 15 years measured and administered the insulin themselves; in four cases the doses were checked by an adult. The mothers of four children did the fingerpricks, and eight children were helped with measuring the results. Only two children aged 11 - 15 years had their doses checked by an adult.
Conclusion. Adult assistance with regard to both insulin injections and HBGM is rarely forthcoming. The children seem not to be sufficiently supported by their families.
The success of various management techniques used in South African children with type 1 diabetes mellitus : researchSource: South African Medical Journal 105, pp 400 –404 (2015) http://dx.doi.org/10.7196/SAMJ.9334More Less
Background. Despite the availability of international guidelines for the treatment of type 1 diabetes mellitus (T1DM) in children, important aspects of treatment are not accessible to all young patients in South Africa (SA).
Objective. To investigate factors in diabetes management strategies that are associated with poor glycaemic control and decreased quality of life (QoL) in SA children with T1DM.
Methods. Eighty children (mean (standard deviation) age 12.9 (2.7) years) with T1DM were asked to answer standardised questionnaires on demographics, management techniques used and perceptions of diabetes. The height and weight of each child was recorded and glycosylated haemoglobin (HbA1c) measured. Informed consent and assent for each participant was obtained before enrolment.
Results. A total of 51.4% of the participants had poor metabolic control, with an HbA1c level >10.0% (86 mmol/mol). Factors in clinical practice found to have a significant association with decreased HbA1c and/or QoL were healthcare system (p< 0.001), insulin administration (p=0.001), correction dose (p=0.002), carbohydrate counting (p< 0.001) and number of severe hyperglycaemic events (p=0.048). Regular exercise did not show any association with HbA1c classification or QoL. Children from single-parent households were prone to unsuccessful diabetes management regardless of treatment techniques used (p=0.002).
Conclusions. The use of premixed insulin without access to rapid-acting insulin, absence of correction doses for hyperglycaemia and lack of carbohydrate counting showed significant association with poor diabetes management. Some recommendations regarding the adoption of more effective diabetes management strategies in the public healthcare system are suggested.
Self-monitoring of blood glucose measurements and glycaemic control in a managed care paediatric type 1 diabetes practice : researchSource: South African Medical Journal 105, pp 405 –407 (2015) http://dx.doi.org/10.7196/SAMJ.7686More Less
Background. Intensive diabetes management requires intensive insulin treatment and self-monitoring of blood glucose (SMBG) measurements to obtain immediate information on the status of the blood glucose level and to obtain data for pattern analysis on which meal planning, insulin and lifestyle adjustments can be made. The value and optimal frequency of SMBGs are often questioned.
Objectives. To document the relationship between SMBG frequency and glycaemic control in a managed care paediatric type 1 diabetes practice.
Methods. A retrospective analysis was performed on 141 managed care paediatric and adolescent patients over a 1-year period from 1 February 2010 to 30 January 2011. The patients were stratified according to their insulin regimen. The frequency of SMBG was analysed and glycaemic control measured by glycated haemoglobin (HbA1c).
Results. A highly significant decrease (p< 0.0001) in HbA1c was found when moving from two injections per day to three- and five-injection regimens. The average HbA1c and its variability reduced as the diabetes regimen became more intensive. A highly significant decrease (p< 0.001) in HbA1c levels was detected as the frequency of SMBG increased, with an average decrease of 0.19% in HbA1c per unit increase in the number of SMBG measurements performed per day. The modal frequency of five SMBG measurements per day was required to achieve the American Diabetes Association and International Society for Pediatric and Adolescent Diabetes guideline recommended target HbA1c of < 7.5% for a paediatric population.
Conclusion. A beneficial relationship exists between frequency of SMBG and lower HbA1c in paediatric patients with type 1 diabetes.
Role of splenectomy for immune thrombocytopenic purpura (ITP) in the era of new second-line therapies and in the setting of a high prevalence of HIV-associated ITP : researchSource: South African Medical Journal 105, pp 408 –412 (2015) http://dx.doi.org/10.7196/SAMJ.8987More Less
Background. New agents are being used as second-line treatment for immune thrombocytopenia (ITP) and have brought into question the relevance of splenectomy for steroid-resistant ITP.
Methods. We retrospectively analysed 73 patients who underwent splenectomy for ITP at our institution over an 11-year period. The median follow-up period was 25 months; patients with follow-up of < 1 month were excluded. The outcomes of splenectomy were compared in HIV-positive v. HIV-negative patients.
Results. The rate of complete response was 83%, and response was sustained for at least 1 year or until latest follow-up in 80% of patients. Twelve patients were HIV-positive. Splenectomy was laparoscopic in 43 patients (62%) with an overall 16% complication rate. The 90-day mortality rate was 1.38%. There was no statistically significant difference in response or complication rate in the HIV-positive patients. There was a statistically significant (p=0.017) poorer response to splenectomy in the patients with steroid-resistant ITP.
Conclusion. Splenectomy is effective and safe irrespective of HIV status and remains an appropriate second-line treatment for ITP. Further research is needed to corroborate our finding of lower response in patients who are steroid-resistant, as this might be a subgroup of patients who may benefit from thrombopoietin agonists as second-line therapy.
Author Marc MendelsonSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9642More Less
Since 2012, when a rallying cry was sounded in SAMJ to take the increasing threat of antibiotic resistance (ABR) seriously, a growing movement of healthcare and animal care practitioners partnered with Government to develop a national strategy framework to preserve antimicrobials for future generations and enact programmes to bring about change in prescribing. While taking into account the diverse burden of infection in South Africa (SA) (HIV, fungal infections, malaria, tuberculosis, and bacteria other than Mycobacterium tuberculosis), our national framework aligns itself squarely with the World Health Organization-led Global Action Plan (GAP) for antimicrobial resistance in focusing on the greatest threat - ABR in bacterial infections.
Role of antibiotic stewardship in extending the age of modern medicine : continuing medical education - reviewAuthor M. MendelsonSource: South African Medical Journal 105, pp 414 –418 (2015) http://dx.doi.org/10.7196/SAMJ.9635More Less
Antibiotic resistance is threatening modern medicine. Overuse and misuse of antibiotics is driving resistance to such an extent that we have entered the post-antibiotic era, where some multidrug- and pandrug-resistant bacterial infections are no longer treatable. If the situation is not reversed, 10 million people will die annually of drug-resistant infections by 2050. More than just a question of mortality, such infections are causing the closure of wards, cancellation of operations, and interference with other common medical procedures that rely on antibiotics for their success. The response to this crisis requires co-ordinated international action with increased surveillance of bacterial resistance, infection prevention, and antibiotic stewardship, i.e. access to affordable, quality-assured antibiotics prescribed appropriately. This review describes antibiotic stewardship at the individual patient and programmatic level, which must be adopted by every prescriber if we are to preserve modern medicine for future generations.
Optimising the administration of antibiotics in critically ill patients : continuing medical education - articleSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9649More Less
Optimal outcome and a reduction in the potential for resistance require that appropriate pharmacokinetic (PK) targets are achieved. Consequently, we need to target drug concentrations that are significantly higher than those conventionally presumed to be adequate. Drug exposure varies according to the molecular weight, degree of ionisation, protein binding and lipid solubility of each agent. In critically ill patients, hypoalbuminaemia increases the free fraction of hydrophilic drugs, which in turn increases the volume of distribution and clearance (CL), both of which result in reduced drug levels. Similarly, augmented renal clearance (ARC), defined as a creatinine clearance (CLcr) of >130 mL/min/1.73 m2, which occurs frequently in critically ill patients, particularly younger patients with normal or near-normal creatinine levels, may also significantly reduce drug exposure. Studies have demonstrated a greater mortality and lower cure with ARC, particularly with the additive effects of obesity, hypoalbuminaemia and increasing resistance, if conventional dosages are used. These concepts apply to antibiotics targeting Gram-negative and -positive organisms. Knowledge of PK and the resistance profiles of organisms in each environment is necessary to prescribe appropriately. This article discusses these issues and the doses that should be used.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9647More Less
Accurate diagnosis of bacterial infection is crucial to avoid unnecessary antibiotic use and to focus appropriate therapy. Bacterial infection is the combination of the presence of bacteria and inflammation or systemic dysfunction; therefore, more than one diagnostic modality is usually required for confirmation. History and examination to determine if a patient fits a clinical case definition is sometimes adequate to confirm or exclude a diagnosis. The second stage is bedside tests - some are used widely, such as urine dipstick tests, but others, such as skin scrapings of petechial rashes, are underutilised. The third stage is laboratory tests - indirect non-culture-based tests, including C-reactive protein and procalcitonin tests, when negative, can be used to prevent the unnecessary use of antibiotics. Direct non-culture-based tests detect antigens or specific antibodies, e.g. group A streptococcal antigen testing can be employed to reduce antibiotic use. Culture-based tests are often considered the reference standard in modern microbiology. Because of slow turnaround times, these tests are frequently used to focus or stop antibiotic therapy after empiric initiation. Nucleic acid amplification tests raise the possibility of detecting organisms with high sensitivity, specificity and reduced turnaround time, and novel diagnostic modalities relying on nanotechnology and mass spectrometry may dramatically alter the practice of microbiology in future.
Twitter : a tool to improve healthcare professionals' awareness of antimicrobial resistance and antimicrobial stewardship : continuing medical education - articleAuthor D.A. GoffSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9648More Less
The World Health Organization urges international collaboration for the containment of antimicrobial resistance (AMR) or 'superbugs'. If left unchecked, AMR could result in 4.1 million deaths in Africa by 2050. Furthermore, without effective antibiotics, surgical procedures would become much riskier and in many cases impossible. Antimicrobial stewardship requires a multidisciplinary approach; however, many programmes still struggle to achieve the 'reach' required to educate and engage all healthcare providers (HCPs). Twitter use among South Africans has grown by 129% in 12 months, from 2.4 million to 5.5 million. HCPs can use Twitter to network and connect with worldwide experts, obtain real-time news from medical conferences, participate in live Twitter chats conducted by experts or medical organisations, or participate in international journal clubs. Used responsibly and professionally, Twitter can spread the call to action and connect frontline healthcare professionals to help win the battle against AMR.
Role of infection control in combating antibiotic resistance : continuing medical education - articleAuthor A.C. WhitelawSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9650More Less
Infection control has been identified as one of the key interventions in controlling the threat of antibiotic resistance. Reducing the transmission of multidrug-resistant organisms (MDROs) reduces the need for broad-spectrum antibiotics in particular, while interventions that decrease the risk of infection have an impact on the use of any antibiotic. Hand hygiene remains the cornerstone of decreasing the transmission of MDROs. Alcohol-based hand rubs are a cheap, effective and convenient means of performing hand hygiene. Patients colonised or infected with MDROs should be placed on contact precautions, although implementation remains challenging in resource-limited environments. Screening for certain MDROs may play a role in curbing transmission of these organisms. If implemented, screening must be part of a comprehensive infection control strategy. In resource-limited settings, the costs and potential benefits of screening programmes need to be carefully weighed up. Care bundles have been shown to reduce the incidence of common healthcare-associated infections, including catheter-associated urinary tract infection, ventilator-associated pneumonia, central line-associated bloodstream infection and surgical site infection. These bundles are relatively inexpensive, and can play an important role in reducing antibiotic use and improving clinical outcomes.
Use of vaccines as a key antimicrobial stewardship strategy : continuing medical education - articleAuthor G.A. RichardsSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9651More Less
Vaccination may prevent bacterial infections and decrease the potential for transmission. Some effective vaccines may reduce bacterial colonisation and exposure to antimicrobials by minimising the spread of resistant strains; in this regard, a substantial indirect immunity has been demonstrated that protects unvaccinated members of society. One of the best documented examples of the crucial role of vaccination has been an adjunct to an antimicrobial stewardship programme. Pneumococcal conjugate vaccines (PCVs), for example, target the most virulent pneumococcal serotypes, which are linked to invasive disease and associated with antibiotic resistance. In this regard, recent local data highlight the remarkable impact of the sequential introduction of 7- and 13-valent PCV (PCV7/PCV13) on the incidence of penicillin-, ceftriaxone- and multidrug-resistant pneumococcal infections in South Africa in only 4 years. Equally impressive have been vaccines directed towards viruses such as influenza, which also have direct and indirect effects on antibiotic consumption.
A lady with a broken heart : apical ballooning syndrome : continuing medical education - case reportSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.960More Less
Severe chest pain after an emotional argument resulted in the admission of a healthy 72-year-old woman. She was haemodynamically compromised, with an electrocardiogram (ECG) demonstrating anterior ST-depression and T-wave inversions. Her 6-hour troponin T level was 132 ng/L. Cardiac catheterisation revealed unobstructed coronary arteries and a reduced left ventricular ejection fraction (LVEF) of < 35%, with basal hyperkinesia and apical segment ballooning (Figs 2 - 5). She was discharged home after 3 days of supportive therapy. At 3 months she was asymptomatic, with an equilibrium radionuclide angiography scan revealing a normal heart with an LVEF of 73%.