South African Medical Journal - Volume 106, Issue 6, 2016
Volumes & issues
Volume 106, Issue 6, 2016
Case report - a case of biventricular endomyocardial fibrosis complicated by right ventricular outflow tract aneurysms : in practiceSource: South African Medical Journal 106, pp 582 –584 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.9056More Less
Endomyocardial fibrosis remains a major public health problem worldwide. It is a restrictive cardiomyopathy, of uncertain aetiology, which may lead to right, left or biventricular heart failure. Progress continues to be made in understanding the prevalence and natural history of this disease. Specific treatment, apart from surgery, remains suboptimal. We report a case of advanced, biventricular EMF complicated by right ventricular outflow tract aneurysms.
Case report - thrombotic thrombocytopenic purpura in the presence of connective tissue disease and HIV infection : a diagnostic and therapeutic challenge in a resource constrainedsetting : in practiceSource: South African Medical Journal 106, pp 585 –588 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10274More Less
Thrombotic thrombocytopenic purpura (TTP) may occur in the presence of other confounding diseases. We present a case of TTP in a patient with connective tissue disease and HIV infection, in whom the diagnosis and management of TTP was challenging. It is important to understand the various underlying mechanisms that drive TTP in the presence of these comorbid diseases, so that an appropriate treatment strategy can be initiated. Our patient failed an initial trial of plasma infusion alone, but responded well to plasma exchange.
Source: South African Medical Journal 106, pp 589 –591 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10379More Less
Background. The low number of firearm assaults and overall assault-related deaths in Statistics South Africa's death notification reports is incongruous with other recently released data, including police crime statistics.
Methods. We conducted a review of all gunshot injuries recorded in death notifications from 1997 to 2013, including all cases in which the underlying cause of death was ascribed to cause-specific codes in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) that referred to a gunshot injury.
Results. We identified 105 694 gunshot-related injury deaths over the 17-year period, an average of 6 217 per annum. The total annual number of gunshot injuries increased from 1997 to 2000, at which point firearm-related deaths peaked at 9 540 recorded cases. Thereafter there was a steadily decreasing trend (interrupted only in 2006 and 2008) until 2011, when 3 793 deaths were attributed to gunshot-related injuries as the underlying cause - a decrease of >60% from the peak in 2000.
Conclusion. The cause-specific profile for gunshot injury deaths in this study indicated extensive misclassification, which explained the near-absence of these injuries among assault cases. However, the trend in gunshot-related injury deaths irrespective of intent provides further support for the hypothesis that stricter gun control, coinciding with the implementation of the Firearms Control Act of 2000, accounts for this decrease.
A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes : researchSource: South African Medical Journal 106, pp 592 –597 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.9863More Less
Background. Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications.
Objective. To determine the efficacy of the SSC using data from randomised controlled trials (RCTs).
Methods. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine.
Results. Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital, with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection, attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64, 95% CI 0.57 - 0.71; p<0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59, 95% CI 0.21 - 1.70; p=0.33, cardiac complications RR 0.74, 95% CI 0.28 - 1.95; p=0.54, infectious complications RR 0.61, 95% CI 0.29 - 1.27; p=0.18, and perioperative bleeding RR 0.36, 95% CI 0.23 - 0.56; p<0.00001.
Conclusions. There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However, randomised evidence of the efficacy of the SSC at rural hospital level is absent.
Screening for retinopathy of prematurity in a provincial hospital in Port Elizabeth, South Africa : researchSource: South African Medical Journal 106, pp 598 –601 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10663More Less
Background. Retinopathy of prematurity (ROP) is an emerging public health problem in many middle-income countries where improved neonatal survival rates coupled with inadequate health resources have created a new epidemic. There are limited available data on the magnitude of the problem, and screening in South African (SA) hospitals has not been uniformly practised.
Objective. To describe the results of various interventions implemented over a 6-year period while developing a new ROP screening service in a provincial hospital in Port Elizabeth, SA. Method. A retrospective case folder review of ROP screening at Dora Nginza Hospital, Port Elizabeth, SA, over the 6-year period 2009 - 2014 was conducted.
Results. A total of 919 new cases were seen. Fifteen patients received treatment for type 1 ROP (T1ROP), 223 had type 2 (T2) or earlier ROP, 1 had stage 4 ROP and 6 had stage 5 ROP. The combination of healthcare worker education, improved equipment and human resources and the introduction of dual responsibility for case referrals resulted in an increase in the number of new infants screened from 33 in year 1 to 292 in year 6. The number of infants who were screened late decreased from 33/33 (100%) in year 1, prior to the interventions, to 23/292 in the final year (7.9%). Improved oxygen delivery and adequate oxygen saturation monitoring contributed to a decrease in the incidence of T1ROP from 1.5% to 1% over 1 year and in the incidence of T2 or earlier ROP from 30.3% to 24%.
Conclusions. Better management of ROP can be achieved through adequate provision of healthcare professionals and material resources coupled with education and a well-supported referral system. A close working relationship between paediatricians and ophthalmologists results in a more efficient screening programme.
Retinopathy of prematurity screening criteria and workload implications at Tygerberg Children's Hospital, South Africa : a cross-sectional study : researchSource: South African Medical Journal 106, pp 602 –606 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10358More Less
Background. Screening guidelines for retinopathy of prematurity (ROP) used in high-income countries are not appropriate for middleincome countries, and screening requirements may vary even between units within one city.
Objective. To determine optimal ROP screening criteria, and its workload implications, for Tygerberg Children's Hospital (TCH), Cape Town, South Africa.
Methods. This cross-sectional study included premature infants screened for ROP at TCH from 1 January 2009 to 31 December 2014. Logistic regression analysis for prediction and classification was performed. Predictors were birth weight (BW) and gestational age (GA). Endpoints were clinically significant ROP (CSROP) and type 1 ROP (T1ROP).
Results. Of 1 104 eligible infants, 33.4% had ROP (CSROP 9.1%, T1ROP 2.5%). All T1ROP infants received laser therapy. The number of screening examinations was inversely correlated with GA and BW. The number needed to screen to identify one infant requiring treatment was 41 (entailing 83 examinations, 4 screening hours, one technician and three doctors). Screening infants with a GA of ≤28 weeks or a BW of <1 000 g would have detected all infants with T1ROP but missed two outliers with CSROP. These outliers would only have been detected with a GA of ≤32 weeks or a BW <1 500 g.
Conclusions. Detection of infants with T1ROP is resource intensive. Larger infants require screening to include a few outliers, but they require fewer examinations than smaller infants. Making local screening criteria narrower on the basis of a limited evidence base may be dangerous. Risk factors for CSROP in larger infants need to be researched.
An overview of cancer research in South African academic and research institutions, 2013 - 2014 : researchSource: South African Medical Journal 106, pp 607 –610 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10314More Less
Background and objectives. Cancer is emerging as a critical public health problem in South Africa (SA). Recognising the importance of research in addressing the cancer burden, the Ministerial Advisory Committee on the Prevention and Control of Cancer (MACC) research working group undertook a review of the current cancer research landscape in SA and related this to the cancer burden.
Methods. Academic and research institutions in SA were contacted to provide information on the titles of all current and recently completed (2013/2014) cancer research projects. Three MACC research working group members used the project titles to independently classify the projects by type of research (basic, clinical and public health - projects could be classified in more than one category) and disease site. A more detailed classification of projects addressing the five most common cancers diagnosed in males and females in SA was conducted using an adapted Common Scientific Outline (CSO) categorisation.
Results. Information was available on 556 cancer research projects. Overall, 301 projects were classified as clinical, 254 as basic science and71 as public health research. The most common cancers being researched were cancers of the breast (n=95 projects) and cervix (n=43), leukaemia (n=36), non-Hodgkin's lymphoma (n=35) and lung cancer (n=23). Classification of the five most common cancers in males and females in SA, using the adapted CSO categories, showed that the majority of projects related to treatment, with relatively few projects on prevention, survivorship and patient perspectives.
Conclusion. Our findings established that there is a dearth of public health cancer research in SA.
HAART in hand : the change in Kaposi's sarcoma presentation in KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 106, pp 611 –616 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10333More Less
Background. HIV/AIDS-related Kaposi's sarcoma (HIV-KS) is a public health problem in South Africa (SA). It is AIDS defining. There have been no studies evaluating its prevalence since the national roll-out of highly active antiretroviral therapy (HAART).
Objective. To evaluate the effect of HAART on the disease profile of HIV-KS in KwaZulu-Natal Province (KZN), SA.
Methods. Charts of patients with histologically confirmed HIV-KS were reviewed at an oncology clinic in KZN. The significance of associations of HAART with age, gender, CD4 count, urban/rural residence, fungating lesions, ulceration and lymphoedema, and treatment delay, was determined by t-tests for normally distributed continuous variables and X2 tests for categorical variables. Logistic regression models were used to analyse the association of HAART with CD4 count.
Results. Of 198 patients, 194 were documented as HIV-positive; 168 (86.6%) were on HAART at the time of their KS diagnosis. The mean CD4 count of 266 cells/µL was higher than that in previous studies at this site. The mean age at presentation was 36.6 (standard deviation 10.1) years. Females presented at a younger mean age than males (p<0.001). The mean age of females on HAART was 34.7 years and that of males 39.0 years (p=0.003). HAART-naive patients were three times more likely than those receiving HAART (15.4% v. 4.8%) to have visceral involvement (p=0.03).
Conclusions. HAART use has resulted in outcome improvement. Mean age at presentation has increased in the group as a whole and for females in particular. The trend in mean CD4 counts has shown positive growth. Females no longer shoulder a disproportionate burden of disease.
Oncogenic and incidental HPV types associated with histologically confirmed cervical intraepithelial neoplasia in HIV-positive and HIV-negative South African women : researchSource: South African Medical Journal 106, pp 617 –622 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10335More Less
Background. In Africa, data on the relationship between oncogenic human papillomavirus (HPV) types, immune status and cervical preinvasive lesions are lacking.
Methods. We investigated low-risk (lrHPV) and high-risk (hrHPV) HPV types in a cohort of women with cervical intraepithelial neoplasia (CIN) II/III confirmed on histological examination, in an urban setting with a high prevalence of HIV infection.
Results. Of 270 women with confirmed CIN II/III, 45 were HIV-negative and 225 HIV-positive. HIV-infected women had significantly more HPV type infections, including all HPV (p<0.001) and hrHPV (p=0.014) types. The prevalences of one or more hrHPV type/s were 93.3% and 92.9% in HIV-negative and positive patients, respectively. The most prevalent hrHPV type among HIV-negative women was HPV 16, followed by HPV 52, 31, 35 and 58. Among HIV-positive women, HPV 16 was followed by HPV 58, 35, 51 and 52. Not yet qualifying for highly active antiretroviral therapy (HAART) (CD4 count >350 cells/µL) or having received HAART for ≥12 months were negatively associated with HPV 18, 33, 45, 51, 52, 59 and 82.
Conclusions. In South Africa, burdened by the HIV pandemic, high numbers of high- and low-risk HPV type infections are present in women with cervical preneoplasia. HPV type distribution differs among varying levels of HIV-induced immune depletion.
Clinical findings and genetic screening for copy number variation mutations in a cohort of South African patients with Parkinson's disease : researchSource: South African Medical Journal 106, pp 623 –625 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10340More Less
Background. Parkinson's disease (PD), with a prevalence of up to 4% in Western countries, appears to be less common in Africa, possibly in part because of genetic factors. African studies investigating the genetic causation of PD are limited.
Objective. To describe the clinical and genetic findings in a group of black South African patients with PD.
Methods. All black African patients with PD from a tertiary hospital neurology clinic were examined. Symptoms were scored according to the Unified Parkinson's Disease Rating Scale (UPDRS), and patients were classified according to motor features. Genomic DNA was extracted and multiplex ligation-dependent probe amplification was used for detection of copy number variation (CNV) mutations in the known PD-causing genes.
Results. Sixteen patients were identified (ages 56 - 82 years). Three had a family history of PD. Classification into motor subtypes showed 44% mixed, 31% akinetic-rigid, and 25% tremor-dominant subtypes. UPDRS scores ranged from 7 to 88, with dementia in 20%. No patient had G2019S LRRK2 and A30P SNCA mutations, and all except one had no CNV mutations in the known PD-causing genes. A female patient (age of onset 50 years, no family history) had a parkin gene heterozygous deletion of exon 4. She had hyperreflexia, bilateral Hoffmann's reflexes, normal plantar responses and no dystonia.
Conclusion. This group of black African patients showed similar characteristics to patients in Western studies, possibly with a higher proportion having tremor-dominant disease. Genetic analysis showed one parkin gene mutation. The limited knowledge on PD-causing genes and mutations in black populations warrants further studies involving next-generation sequencing approaches.
Delay and poor diagnosis of Down syndrome in KwaZulu-Natal, South Africa : a retrospective review of postnatal cytogenetic testing : researchSource: South African Medical Journal 106, pp 626 –629 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10105More Less
Background. Down syndrome (DS) is the most common chromosomal disorder in newborns. Until 20 years ago DS was considered rare in black African children in South Africa (SA). Lack of awareness of DS on the part of medical staff in SA, and difficulty in diagnosing it, appear to persist.
Objectives. To establish an epidemiological profile of DS and investigate the ability of clinicians in KwaZulu-Natal Province (KZN), SA, to make accurate clinical diagnoses of DS.
Methods. Records at the South African National Blood Service cytogenetic laboratory in Pinetown, KZN, were examined for all tests for clinically suspected DS undertaken during January 2009 - December 2013 and all cytogenetically proven DS test results. Age at diagnosis, the hospital from where the test was sent and type of chromosomal pattern for each confirmed DS test result were recorded.
Results. Of a total of 1 578 tests requested, 875 confirmed DS, indicating that clinicians correctly clinically diagnosed DS 55.4% of the time.The average age of cytogenetic diagnosis of DS was 1 year and 20 days. The minimum population prevalence of DS was 0.8/1 000.
Conclusions. The diagnosis of DS is a challenge in KZN, potentiating missed opportunities for early intervention. The relatively low population prevalence of DS may be attributable to a lack of confirmatory cytogenetic tests or missed clinical diagnoses. It may also be attributable to a high mortality rate for children with DS in the province.
Psoriatic arthritis : an assessment of clinical, biochemical and radiological features in a single-centre South African cohort : researchSource: South African Medical Journal 106, pp 630 –633 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10347More Less
Background. Although psoriatic arthritis (PsA) is a well-documented clinical entity, epidemiological, clinical and radiological studies of South African (SA) patients are scarce.
Objectives. To assess clinical, biochemical and radiological features in a single-centre SA cohort.
Methods. We conducted a prospective assessment of the clinical, biochemical and radiological features of 384 consecutive patients with PsA seen at the rheumatology clinic at Prince Mshiyeni Memorial Hospital, Durban, SA, between January 2007 and December 2013. Patients were assessed at enrolment and 6 months after enrolment. They were classified into five groups as described by Moll and Wright, being entered into the group that best described the clinical manifestations. Clinicopathological characteristics recorded at enrolment were age at the time of examination, racial background, personal and family medical history, age and symptoms at the onset of PsA, pattern of joint involvement, joint pain, and the relationship between joint pain and the onset of PsA.
Results. Of the patients, 59.1% had a polyarticular presentation indistinguishable from rheumatoid arthritis, 19.0% had distal interphalangeal involvement, 9.1% had spondyloarthropathy, 11.9% had oligoarthritis and 0.9% had arthritis mutilans. The epidemiological trends (male/female ratio 1.45:1, mean age at onset of arthritis 50.2 (standard deviation 11.8) years, female preponderance in the polyarticular group and male preponderance in the spondyloarthropathy and oligoarticular groups) were similar to trends published elsewhere. A notable characteristic of our cohort was the complete absence of black South Africans with PsA.
Conclusions. The complete absence of black South Africans with PsA is interesting. We anticipate that our findings will prompt genetic studies to isolate both protective and susceptibility genes for further elucidating PsA.
Hepatitis B infection in HIV-1-infected patients receiving highly active antiretroviral therapy in Lomé, Togo : prevalence and molecular consequences : researchSource: South African Medical Journal 106, pp 634 –639 (2016) http://dx.doi.org/http://dx.doi.org.10.7196/SAMJ.2016.v106i6.10312More Less
Background. No data are available on HIV/hepatitis B virus (HBV) or hepatitis C virus coinfection in Togo, and patients are not routinelytested for HBV infection.
Objectives. To determine the prevalence of HBV and the risk of HBV drug resistance during antiretroviral treatment in HIV-coinfected patients in Togo.
Method. This cross-sectional study was carried out in Lomé, Togo, from January 2010 to December 2011 among HIV-infected patients who had been on antiretroviral therapy (ART) for at least 6 months.
Results. In total, 1 212 patients (74.9% female) living with HIV/AIDS and treated with ART were included in the study. The seroprevalence of hepatitis B surface antigen (HBsAg) was 9.7% (117/1 212; 95% confidence interval (CI) 8.04 - 11.45). Of these 117 HBsAg-positive patients, 16 (13.7%) were hepatitis B e-antigen (HBeAg)-positive, and 115 (98.3%) were on lamivudine. The HBV DNA load was <10 IU/mL in 33/117 patients overall (38%), and in 87.5% of 16 HBeAg-positive patients (p<0.0001). In multivariate analysis, factors associated with HBV DNA load >10 IU/mL were HBeAg positivity (adjusted odds ratio (aOR) 6.4; p=0.001) and a higher level of education (aOR 6.5;p=0.026). The prevalence of HBV resistance to lamivudine was 13.0% (15/115; 95% CI 7.0 - 19.0). The detected resistance mutations werertL180M (14/15 patients) and rtM204V/I (15/15).
Conclusion. The seroprevalence of HBV among ART-treated HIV-infected patients in Togo was 9.7%. The prevalence of HBV lamivudine resistance mutations after 2 years of ART was 13.0%. These results suggest that HBV screening before ART initiation can be based on HBsAg testing.