Dr George Mukhari Academic Hospital Research Articles

Hepatitis B virus infection in patients presenting for immunosuppressive cancer therapy with and without underlying HIV infection

IntroductionReactivation of hepatitis B virus (HBV) infection induced by immunosuppressive cancer therapy is associated with fulminant liver disease and death. While national guidelines recommend HBV screening and antiviral prophylaxis for patients with cancer prior to initiating immunosuppressive therapy, compliance with these measures is unclear. This study characterized the burden of HBV infection among patients diagnosed with gynecological or dermatological cancers, with or without underlying HIV infection, before initiating immunosuppressive therapy. MethodsBetween 2016 – 2018, we recruited study patients from the Dr George Mukhari Academic Hospital in Tshwane, South Africa. Demographic (age, sex) and clinical data (HIV test results, HIV antiviral regimen, type of cancer) were recorded using a standardized data collection form. All participants were tested for HBV surface antigen (HBsAg), and antibodies to the surface (anti-HBs) and core antigens (anti-HBc). For detection of HBV DNA, a nested polymerase chain reaction was used to amplify polymerase gene fragments which were Sanger-sequenced and analyzed using bioinformatics software. All statistical analyses were performed using R version 4.1.0 (2021-05-18) and R studio version 2022.07.2. ResultsStudy participants were predominantly female (96.3%, 103/107) with a median (IQR) age of 50 (17.5) years. Cervical cancer was the most frequent cancer diagnosis (72%). Over half (52.3%; 56/107) of the participants were HIV positive and all but four (92.9%) on highly active antiretroviral therapy at the time of enrollment. The prevalence of chronic hepatitis B in the study population was 11.2% [95% CI:6.2-19.1], increasing to 14.3% [95% CI:6.8-26.8] in the HIV positive sub-population. The overall prevalence of occult HBV infection was 20% [95% CI:12.8-29.7], 57.9% [95% CI:33.97-78.9] of whom tested negative for all serological markers. Phylogenetic inference showed that all polymerase gene sequences generated in this study were sub-genotype A2. Mutational analysis did not reveal any drug resistance-associated amino acid variations in this study. ConclusionThese findings suggest that chronic and occult HBV infections are more prevalent among cancer patients with or without underlying HIV infection compared to what has previously been reported for the general South African population. This underscores the need to scale-up universal HBV serological and molecular screening with timely institution of prophylaxis prior to initiating immunosuppressive cancer therapy.

Use of granulocyte colony-stimulating factor in patients with chemotherapy-induced neutropaenia.

Febrile neutropaenia (FN) and resultant infections are the major cause of treatment-related morbidity and mortality in patients receiving chemotherapy. Clinical practice guidelines recommend the use of granulocyte colony-stimulating factors (G-CSF) to reduce the risk of FN and ensuing complications in patients receiving chemotherapy. Despite these recommendations, inappropriate usage of G-CSF has been reported. To assess prescribing patterns and adherence to international guidelines of G-CSF in adult patients with chemotherapy-induced neutropaenia (CIN) at the haematology oncology wards of the Dr George Mukhari Academic Hospital (DGMAH) and compliance to guidelines. Medical records of adult patients who received G-CSF were reviewed retrospectively between 01 January 2018 and 31 July 2018. Of the 128 patient files screened, 57 cases met the inclusion criteria. Duration of treatment with G-CSF was not in accordance with guidelines in more than 50% of the patients and in 43.86%, G-CSF dosing deviated from recommended guidelines. The study demonstrated over-prescribing of G-CSF due to either increased doses or duration of G-CSF therapy. Although prescribed for the correct indication, the dosage was often too high or the duration was too long, even once an acceptable neutrophil nadir count was reached. Interventions to optimise the use of G-CSF are required and the pharmacist may play a role in this regard. The administration of the correct doses of G-CSF can reduce both the severity and duration of neutropaenia. Over-prescribing and incorrect dosing may contribute to patient morbidity and add to the financial burden of healthcare.

Hepatitis C Virus Genotype 5 Variability in Treatment-Naïve Patients in South Africa

Introduction: Hepatitis C virus (HCV) genotype 5 was originally identified in South Africa, where it represents 35–60% of all HCV infections. There are limited data on resistance-associated variants (RAVs) in South Africa. Thus, we investigated variability within the NS3/NS4A, NS5A, and NS5B genes of treatment-naïve individuals with HCV genotype 5 infection at the Dr. George Mukhari Academic Hospital (DGMAH) in Pretoria, South Africa. Methods: Nested PCR was performed to amplify the NS3/4A, NS5A, and NS5B genes. RAVs were evaluated using the Geno2pheno tool. Results: In the NS3/4A gene, F56S and T122A were detected in one sample each. The D168E mutation was detected in 7 samples. Within the NS5A gene, the T62M mutation was detected in 2 individuals. In the NS5B gene, 8 of 12 individuals (67%) had the A421V mutation, while all 12 individuals (100%) had the S486A mutation. Discussion: RAVs were detected frequently among treatment-naïve individuals with HCV genotype 5 infection in South Africa. Thus, resistance testing may be prudent when initiating treatment of patients with genotype 5 infection. Additional population-based studies are needed to understand the prevalence of these RAVs during HCV genotype 5 infection.

The profile of patients with haemophilia managed at a haemophilia treatment centre in Pretoria, Gauteng.

Haemophilia A and B are X-linked recessive bleeding disorders resulting from a deficiency of factors VIII and IX, respectively. Early diagnosis and a comprehensive approach to management is mandatory. This study aimed to describe the profile of patients with haemophilia (PWH) managed at Dr George Mukhari Academic Hospital (DGMAH) with the view to identify potential areas to improve haemophilia care. A cross-sectional, descriptive study that retrospectively reviewed clinical and laboratory records of PWH managed at DGMAH haemophilia treatment centre from 01 January 2003 to 31 December 2017. Forty-four males were identified, with the majority being adults (~61%). Haemophilia A patients (~82%) outnumbered those with haemophilia B (~18%). Spontaneous mucocutaneous bleeding was the most frequent presenting feature followed by haemarthrosis. Disease-related complications included joint complications and life-threatening bleeds. There was a delay in diagnosis in 11% PWH. Management included episodic plasma-derived factor replacement and bypassing agents for patients with inhibitors. Only 13% of PWH were on home therapy. Prevalence of inhibitor development was 18%. There was a paucity of recorded data regarding prophylaxis, genetic counselling, psychological and physiotherapy support. The majority of PWH were adults, and haemophilia A was more prevalent than haemophilia B. A delay in haemophilia diagnosis could be addressed by increasing the awareness of haemophilia in health facilities. Expanding home therapy and introducing prophylaxis will likely improve the quality of life in PWH. Study outputs have included compilation of diagnostic and management algorithms to optimise haemophilia care at DGMAH.

Randomised controlled trial of intramuscular tramadol versus transdermal buprenorphine patch for early postoperative surgical pain.

This study assesses the efficiency of the buprenorphine patch system compared to the routine use of tramadol intramuscular injections in the context of the South African public healthcare sector. Patients were randomised into two groups, who received routine tramadol injections 100 mg every 8 hours intramuscular and buprenorphine patches 5 mcg every hour. The study assessed the first 48 hours postoperatively. A visual discrete pain scale was used to assess the level of postoperative pain as well as all complications associated with insufficient analgesic administration. The sample size included 75 patients in the tramadol group and 75 patients in the buprenorphine patch group. Nine patients (12%, p-value < 0.0001) who received the buprenorphine patch subsequently required additional analgesia. The pain score was found to be significantly less in the buprenorphine patch group on both day 1 and day 2, as were complications such as vomiting, nausea, nightmares, sweating and insomnia. The pain score in the buprenorphine group as significantly lower compared to the tramadol group. The use of the buprenorphine patch showed a slight increase in costs compared to the tramadol group (R7 800.75 vs R7 537.50; p-value 0.483) in the whole study. The study showed that the use of the buprenorphine patch is a reliable and effective method of postoperative analgesia, although it is slightly more expensive compared to the routine use of tramadol. The buprenorphine patch showed significantly better results in all assessed parameters; thus, it may be recommended for use at the Dr George Mukhari Academic Hospital (DGMAH).

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

PurposeThis was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain.MethodsPatients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019–2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the “drain” (D) and “no drain” (ND) groups.ResultsThirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the “D” group was 18% and 35% in the “ND” group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups.ConclusionFrom our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications.Trial registration numberSMUREC/M/15/2019: PG.

Investigation of Mycoplasma Species in Women With Human Papillomavirus Infection Attending the Gynaecology-Oncology Clinic at Dr George Mukhari Academic Hospital in 2017

Investigation of Mycoplasma Species in Women With Human Papillomavirus Infection Attending the Gynaecology-Oncology Clinic at Dr George Mukhari Academic Hospital in 2017

The two-year survival rate of laryngeal squamous cell carcinoma patients treated at Dr. George Mukhari academic hospital South Africa

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; The study was conducted to assess the outcome of patients diagnosed with laryngeal squamous cell carcinoma (LSCC) treated at a tertiary level hospital in South Africa. The focus was the two-year disease-specific survival (DSS) rate after diagnosis as a measuring tool for the outcomes of the disease.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective cross-sectional descriptive study was conducted at Dr. George Mukhari academic hospital (DGMAH) from 1 January 2010 to 31 December 2015. The data was collected from files of patients who were identified by clinical laryngeal symptoms, pan-endoscopy and biopsy. A total of 37 files of patients diagnosed as LSCC were included in the study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; 166 hospital records were retrieved. After application of inclusion and exclusion criteria, the study excluded 129 files because of benign lesions, malignancies other than SCC on histology report, SCC from upper aero-digestive sites other than the larynx or files with incomplete information. Therefore, 37 recordswere considered for the study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The study found the two-year DSS to be 43.2%. A significant contributing factor to the low two-year DSS was the advanced stage of the disease (III and IV) at the time of the presentation that was managed by palliative treatment. Advanced disease was likely due to delayed presentation to the hospital influenced by a low level of patient health knowledge, the negative impact of religious and cultural beliefs, low disposable household income coupled with high distance from home to the nearest hospital, and suboptimal screening at the primary health care level.&lt;/p&gt;

Failed extubation in a tertiary-level hospital intensive care unit, Pretoria, South Africa.

Background A prospective cohort study sought to measure the incidence and outcomes of failed extubation in Dr George Mukhari Academic Hospital intensive care unit (ICU), as well as to identify possible factors associated with failed extubation. Methods Data were collected over a 6-month period from 1 July 2015 to 31 December 2015. Pre-intubation parameters recorded on the data collection sheet included secretions, Glasgow Coma Scale (GCS), fluid balance, Tobin index, partial pressure of carbon dioxide (pCO2 ), partial pressure of oxygen (PaO2 ), comorbidities and weaning method. Results A total of 242 patients were enrolled over the 6-month study period. Of the 242 patients, 86 were excluded owing to pre-set exclusion criteria (death before extubation; tracheostomy before extubation; re-intubation >72 hours post extubation). An extubation failure rate of 16.7% (n=26) was observed. The incidence of ventilator-associated pneumonia in the failed extubation group was 19.23%, whereas death was recorded in 42.31% of patients who failed extubation. The average length of ICU stay in the reintubated group was 11.58 days, and 4.04 days for successfully extubated patients. Only low GCS had a statistically significant impact on failed extubation: p=0.0025; odds ratio (OR) for low v. normal 5.13 (95% confidence interval (CI) 1.78 - 14.79). Other predictor variables measured did not reach statistical significance. Weaning method: p=0.3737, OR for No T-piece v. T-piece 1.65 (95% CI 0.547 - 4.976); comorbidities: p=0.5914, OR for two or more comorbidities v. no comorbidities 2.079 (95% CI 0.246 - 17.539), no comorbidities v. single comorbidity 0.802 (95% CI 0.211 - 3.043); fluid balance: p=0.6625, OR for negative v. positive fluid balance 0.571 (95% CI 0.170 - 1.916), OR for neutral v. positive fluid balance <0.001 (95% CI <0.001 - >999.999); pCO2 : p=0.7510, OR for high v. normal pCO2 1.344 (95% CI 0.346 - 5.213), OR for low v. normal pCO2 1.515 (95% CI 0.501 - 4.576); PaO2 : p=0.4405, OR for high v. normal 1.156 (95% CI 0.382 - 3.494); OR for low v. normal PaO2 2.638 (95% CI 0.553 - 12.587); Tobin index (Fischer’s exact test): p=0.7476. Conclusion Low pre-extubation GCS is a predictor of failed extubation. Contributions of the study The study is a prospective observational study conducted in a high-volume referral hospital. It adds valuable scientific information to a growing body of data on the topic of extubation failure. It further reinforces the importance of extubation failure and the requirement for due diligence to be paid before a patient is extubated.

Low seroprevalence of hepatitis E virus in pregnant women in an urban area near Pretoria, South Africa

Hepatitis E virus (HEV) infection is a globally neglected health problem with a high burden in resource-poor communities. Pregnant women are at increased risk of complications. This pilot study sought to assess the seroprevalence of HEV infection in pregnant women at Dr George Mukhari Academic Hospital, South Africa. Stored serum samples from 384 HIV-uninfected pregnant women attending the antenatal clinic were initially screened for HEV total antibody. Positive samples were further evaluated for the presence of IgG and IgM antibody isotypes, using commercial ELISA assays. HEV RNA was assessed in antibody-positive samples utilizing qRT-PCR assay. The sample consisted of women with a median age of 31 years (interquartile range: 28-35 years). Total HEV antibody was detected in 12/384 (3.13%, 95% CI: 1.80-5.38) of these pregnant women. All 12 samples were IgG HEV antibody positive, but none tested positive for IgM antibody or for HEV RNA, demonstrating a lack of current or recent exposure. Our study revealed a low seroprevalence of HEV among pregnant women from an urban area north of Pretoria. This observation warrants further attention to the circulation of HEV in this population, and a greater understanding of the epidemiology of the infection in South Africa.

The impact of COVID-19 national lockdown on orthopaedic trauma admissions in the northern part of South Africa: A multicentre review of tertiary- and secondary-level hospital admissions.

COVID-19 national lockdown measures in South Africa (SA) have been under scrutiny since they were implemented in March 2020. Currently there are no studies showing the effect of the first lockdown on hospital admissions in the northern provinces of SA. To evaluate the impact of national lockdown restrictions on musculoskeletal injury admissions in three hospitals across three provinces (Gauteng, Limpopo and North West). In a retrospective review, we compared orthopaedic trauma admissions from 1 April 2020 to 30 June 2020 (during alert level 5 of the national lockdown) with cases admitted during the same period in 2019 (non-lockdown). We reviewed the number of admissions, demographic data and mechanisms of injury in the adult and paediatric population groups. A total of 449 patients were admitted with musculoskeletal injuries during the lockdown period compared with 664 patients in 2019, equating to a 32% reduction in total admissions. While there was an 8% increase in paediatric admissions during lockdown at Dr George Mukhari Academic Hospital, adult admissions decreased in all centres. More young males were admitted during both lockdown (mean age 39.8 years) and non-lockdown (mean age 41.2 years) periods than females (p=0.004). There were significant reductions in the number of injuries due to motor vehicle accidents (59%) and in the number of gunshot wounds (36%) during lockdown. However, we observed an 11% rise in injuries related to suicide attempts among adult admissions during the lockdown period. Lockdown restrictions resulted in a significant reduction in orthopaedic trauma admissions, and were effective in terms of allowing institutions to direct resources to the management of COVID-19 patients. In the light of the increased suicide attempts observed during lockdown, future lockdown regulations should include comprehensive measures to relieve socioeconomic stress.

The prevalence of anatomical variants of the coeliac trunk and renal arteries on contrast-enhanced abdominal computed tomography scans at Dr George Mukhari Academic Hospital.

BackgroundAnatomical variations of the coeliac trunk and renal arteries should be radiologically reported as they affect the surgical approach and subsequent outcome in patients.ObjectivesThe aim of this study was to determine the prevalence of anatomical variations of the coeliac trunk and renal arteries and whether there is a relationship between the occurrence of these variations at Dr George Mukhari Academic Hospital.MethodArterial phase abdominal computed tomography (CT) or CT abdominal angiograms performed during January and December 2017 were analysed. The variations of the coeliac trunk and renal arteries were classified according to accepted classification systems and expressed as a percentage of the study population.ResultsA normal classical coeliac trunk was present in 82.2% and a non-classical pattern was present in 9.7%. The most common variation of the coeliac trunk other than the non-classical pattern was a hepatosplenic trunk, which was present in 3% of the study population. A normal right and left renal artery was present in 88.2% and 83.7%, respectively. The most common variations of the renal arteries were bilateral hilar arteries seen in 3.4% on the right and 9.1% on the left. Renal artery variations were more prevalent on the left than on the right. Concurrent variations of both the right and the left renal arteries were present in 2.4% and variations of both the coeliac trunk and renal arteries were present in 5% of the study population.ConclusionThe most common variation of the coeliac trunk in this study is comparable to other studies in non-African populations. Concurrent vascular variations between the renal arteries and between the coeliac trunk and renal arteries may co-exist.

The Risk Factors and Associated Socio-Demographic Profile of Deep Vein Thrombosis (Dvt) Among Patients Referred For Doppler UltrasoundImaging At Dr George Mukhari Academic Hospital

Background: Venous Thromboembolism (VTE) is one of the leading causes of cardiovascular related deaths and is a significant economic burden on the healthcare system. Early identification and correct management of patients at risk of developing DVT improves their health. Objectives: The study sought to determine the risk factors and socio-demographic profiles of Deep Vein Thrombosis (DVT) of patients referred for Doppler ultrasound imaging at Dr George Mukhari Academic Hospital (DGMAH). Methods: A cross sectional descriptive study was used to determine the risk factors and associated demographic profiles of DVT among patients referred for Doppler ultrasound imaging at DGMAH. The study used quantitative methods. A total of 135 patients participated. Patients completed a structured questionnaire to assess risk factors of DVT. They were then assessed for DVT using an ultrasound scan and results were documented. The information from the questionnaires and results was coded and entered into a computer using Statistical Package for Social Science (SPSS) Version 25. Data analysis was then conducted. Results: Of the 135 patients who were referred to the radiology department for ultrasound scanning of lower limbs between January and June 2019, 42 patients (31%) were diagnosed with DVT. Prolonged bed rest (p=0.037) and history of having recently completed TB treatment (p=0.042) were associated with development of DVT. Conclusion: Prolonged immobility and recent completion of TB treatment were associated with increased risk of developing DVT. There is need to screen these patients for DVT early and institute DVT protocols.

Association of Carboxyhemoglobin Levels with Peripheral Arterial Disease in Chronic Smokers Managed at Dr George Mukhari Academic Hospital.

Chronic cigarette smokers (CCS) are known to have elevated levels of carboxyhemoglobin (COHb). However, it is not known whether increased levels of COHb are associated with endothelial dysfunction (ED), and therefore the development of peripheral arterial disease (PAD). The aim of the study was to investigate the association of blood COHb and plasma nitric oxide (NO) levels, and whether it is an independent risk factor in the development of PAD among CCS at Dr George Mukhari Academic Hospital (DGMAH). A sample of 120 CCS with PAD and a convenience sample of 100 CCS without PAD were recruited into the study. Blood COHb levels were measured using the ABL 90 FLEX CO-oximeter automated spectroscopy. Plasma nitric oxide (NO) levels were measure using ELISA. Logistic regression analysis was used to investigate the association of blood COHb and plasma NO with PAD. Blood COHb levels of CCS with PAD were significantly higher than those of CCS without PAD, and the NO levels of CCS with PAD were significantly lower than those of CCS without PAD. Although both the blood COHb and plasma NO in CCS were significantly associated with PAD in bivariate logistic analysis, only plasma NO was independently associated with PAD in multivariate logistic analysis. This finding is consistent with the hypothesis that COHb is a cause of arterial damage in PAD, leading to reduced NO, and therefore reduced arterial dilation.

Correlation between self-monitored mean blood glucose and average plasma glucose estimated from glycated haemoglobin in patients attending the diabetes clinic at Dr George Mukhari Academic Hospital, Pretoria, South Africa.

Glycated haemoglobin (HbA1c) has been used for decades as a measure of chronic glycaemia. A simple linear relationship between HbA1c values and mean blood glucose (MBG) has been identified and led to conversion of HbA1c values into estimated average glucose (eAG) levels, following the findings of the A1c-Derived Average Glucose (ADAG) Study Group. The intention was to help patients with diabetes mellitus (DM) understand their glycaemic control better, as eAG is reported in the same units as self-monitored glucose levels. However, factors other than glycaemia have been found to affect the relationship between HbA1c and MBG. To: (i) determine the relationship between self-monitored MBG levels and HbA1c values; and (ii) evaluate the correlation between MBG levels and eAG levels calculated from HbA1c values using the regression equation derived from the ADAG Study Group in black South African patients with DM. This was a prospective observational study of 96 diabetic patients. MBG levels were calculated using glucose measurements downloaded from the glucose meters for the previous 90 days (3 months). High-performance liquid chromatography was used for measurement of HbA1c values, collected at the end of 3 months. eAG was calculated using the regression equation from the ADAG Study Group, as follows: eAG (mmol/L) = 1.5944 × HbA1c (NGSP, %) - 2.594. A positive correlation was found between MBG and HbA1c in all participants (R2=0.69, p&lt;0.0001). There was a wide range of MBG levels for any given HbA1c value. Clinically significant differences between MBG and eAG were found, with a ≥10% difference in 65.6% of the participants. eAG overestimated MBG in ~71.8% of the study population, with an overestimation of ≥1.6 mmol/L (28.7 mg/dL, equivalent to a 1% change in HbA1c value) in ~50% of the total study population. Our findings showed an imperfect relationship between MBG levels and HbA1c values. eAG significantly overestimated MBG, and this disagreement may cause confusion among both patients and clinicians. The risk of hypoglycaemic episodes may also increase if HbA1c and eAG alone are used to intensify therapy. We recommend that the use of eAG should be validated prior to implementation in clinical practice. It would be ideal to evaluate the relationship between average glucose and HbA1c in each individual patient in order to provide more personalised diabetes care.

The use of three-dimensional models in tibial plateau fractures

Background: To compare three-dimensional (3D) printed models with 3D computed tomography (CT) images in terms of the reliability of the classification of tibial plateau fractures using the Hohl and Moore and the Schatzker classification systems, and whether there was any influence on surgical management. Method: The sample comprised the 20 CT scans of patients with tibial plateau fractures available in the radiology archive of Dr George Mukhari Academic Hospital (Ga-Rankuwa). Standardised illustrated guides to the Schatzker and the Hohl and Moore classification systems were used by six observers of varying orthopaedic experience. They completed questionnaires individually in three different sessions. In session one the observers had access to the 3D CT images only. On average two to five days later, in session two the observers assessed only the 3D models. In the third session, another two-to-five days later, the observers assessed the 3D CT images while handling and inspecting the corresponding 3D model. Results: The inter-observer reliability of the Schatzker system (moderate reliability) was superior to the Hohl and Moore system (fair reliability) when comparing the assessment using the images and models separately. When all observations were combined, there was no difference between the systems. For the six possible surgical management options given to the observers, there was an overall difference in agreement based on assessing only the CT images compared with assessing only the models, of 19% (23 of the possible 120 procedures). Of these 23 differing procedures, 15 were more invasive. The 3D models were considered superior to 3D CT imaging in terms of spatial awareness and the observers’ ability to assess intra-articular fracture patterns. The models were assessed as being superior to the imaging when considering the ability to estimate the quantity of bone graft required. Conclusion: Although the inter-rater reliability of classification was not significantly improved, there were several advantages to using the 3D-printed models both separately from the CT images and together with the images. The effect of 3D models on patient outcome remains untested. The clinical impact of the use of 3D models (including cost, manufacturing time and radiation exposure) should be weighed against the potential benefits. Level of evidence: Level 4

Pneumococcus nasopharyngeal carriage in children attending an academic hospital in Pretoria, South Africa, after the introduction of pneumococcal vaccine.

BackgroundIn 2009, pneumococcal conjugate vaccine was introduced in South Africa. However, there are concerns that this could lead to an increase in colonisation of non-vaccine serotypes (serotype replacement).MethodsIn a cross-sectional study, 350 children aged 1 month to 14 years were enrolled at Dr George Mukhari Academic Hospital from December 2015 to April 2016. We assessed the prevalence of nasopharyngeal colonisation with pneumococcus and characterised the serotypes found.ResultsThe median age of the cohort was 33.7 months (interquartile range 16.27–69.5 months), with 20% being < 1 year. A total of 21% of the children were diagnosed with pneumococcal-related conditions; among these, pneumonia was the most common condition. Less than half (43%) of the participants were fully immunised. Forty-six (13%) of the children were colonised with pneumococcus. Younger age was significantly associated with pneumococcal colonisation. Among those colonised with pneumococcus, 35% were fully immunised, 30% were partially immunised, 30% had an unknown immunisation status and 4% were unimmunised. Eight (17%) of the children who were colonised with pneumococcus had pneumococcal-related conditions. The commonest serotype identified was 6A/B. Overall, 2% of the cohort were colonised with vaccine-serotype pneumococcus.ConclusionAs a minority of children had evidence of nasopharyngeal colonisation with vaccine-serotype pneumococci, serotype replacement may be emerging in our population.

Ellisras Longitudinal Study 2017: elevated serum levels of carboxymethyl-lysine, an advanced glycation end-product, are associated with higher odds of developing endothelial dysfunction in black South African patients with type 2 diabetes mellitus (ELS 29).

This case-control study investigated the association between major types of serum advanced glycation end-products (AGEs) and selected serum/plasma markers of endothelial dysfunction in black patients with type 2 diabetes mellitus at Dr George Mukhari Academic Hospital. Serum AGEs were measured using either enzyme-linked immunosorbent assay (ELISA) or spectrofluoremetry. Serum markers of endothelial dysfunction were measured using either ELISA or calometry. The correlation and associations between major types of serum AGEs and markers of endothelial dysfunction were investigated using the Spearman correlation coefficient and bivariate logistic regression analysis, respectively. Although both serum total immunogenic AGEs and serum carboxymethyl-lysine (CML) were moderately and negatively associated with endothelial dysfunction, only serum CML was significantly associated with a higher odds for the development of endothelial dysfunction (low nitric oxide levels) in our diabetic subjects. It can therefore be concluded from this study that high serum levels of CML may predispose to endothelial dysfunction in black South Africans with type 2 diabetes.

Late diagnosis of multidrug-resistant tuberculosis in a child at Dr George Mukhari Academic Hospital, Ga-Rankuwa, South Africa: A case report.

IntroductionSouth Africa has one of the top ten tuberculosis burdens in the world, only lagging behind countries with significantly larger populations. Increased awareness of extrapulmonary tuberculosis, specifically spinal tuberculosis, is necessary, because of the HIV epidemic.Case presentationThis report describes the case of a 9-year-old male patient who was suspected of having multidrug-resistant (MDR) tuberculosis, based on failure to recover clinically and radiologically after 6 months on first-line anti-tuberculosis treatment. Pus samples were sent to an accredited academic laboratory for histopathology, microscopy, culture, line-probe assay (MTBDRplus assay) and phenotypic MGIT 960 drug susceptibility tests. Second-line MDR tuberculosis treatment was introduced. Clinical, radiological, physical processes and more laboratory tests were conducted to document whether or not there was improvement in the patient.Management and outcomeAfter laboratory diagnosis of MDR tuberculosis, the patient was started on MDR tuberculosis treatment. The patient started improving remarkably after the introduction of anti-tuberculosis treatment and rehabilitation, although he also required surgery to stabilise the spine. Neurological improvement was observed in the patient and he fully recovered.DiscussionAlthough the diagnosis of spinal MDR tuberculosis may not be achieved easily by culture, the well-known gold standard method of tuberculosis diagnosis, it is of great importance to rapidly initiate an effective anti-tuberculosis treatment of drug-resistant strains to reduce the deformity of the spine.

Patient Alcohol Consumption and Knowledge of Safe Alcohol Use at Dr. George Mukhari Academic Hospital, Pretoria

Background: According to the World Health Organisation (WHO), there were 3.3 million deaths globally due to alcohol use in 2012. Establishing patients’ knowledge of safe alcohol use and practices regarding alcohol consumption could reform intervention policies. Objectives: The aim of this study was to assess patients’ knowledge of safe alcohol use and practices regarding alcohol consumption among patients attending the Family Practice Clinic at Dr. George Mukhari Academic Hospital (DGMAH) in Pretoria. Methods: The sample consisted of 300 patients (150 males; 150 females). Data relating to patients’ baseline characteristics, knowledge of safe alcohol use and practice were collected by means of a researcher administered questionnaire. The SAS, Release 9.3 was used for data analysis. The statistical level of significance was set at p &lt; 0.05. Results: Majority of the respondents had lack of knowledge on safe quantities of alcohol use per day, for male and female individuals [268 (89.3%) vs 32 (10.7%); p &lt; 0.0001] and [279 (93.0%) vs 21 (7.0%); p &lt; 0.0001], respectively. Respondents mostly consumed alcohol on special occasions (152; 50.7%), and on weekends (100; 33.3%). Age groups ≥ 38 years consumed more alcohol per day (100; 33.3%). Majority of the respondents (179; 59.7%) were binge drinkers. Relatively less patients with higher levels of education were chronic harmful users of alcohol (p ≤ 0.001). Conclusion: The finding that majority of the patients lacked knowledge on safe quantities of alcohol use for males and females, and the unsafe use of alcohol, including binge drinking, warrant introduction of safe alcohol use awareness campaigns at primary health care, particularly targeting the middle aged and the elderly.