Inkosi Albert Luthuli Central Hospital Research Articles

Characteristics, management and outcomes of primary hyperparathyroidism from 2009 to 2021: a single centre report from South Africa

BackgroundThere has been a notable shift towards the diagnosis of less severe and asymptomatic primary hyperparathyroidism (PHPT) in developed countries. However, there is a paucity of recent data from sub-Saharan Africa (SSA), and also, no reported data from SSA on the utility of intra-operative parathyroid hormone (IO-PTH) monitoring. In an earlier study from Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa (2003–2009), majority of patients (92.9%) had symptomatic disease. The aim of this study was to evaluate the clinical profile and management outcomes of patients presenting with PHPT at IALCH.MethodsA retrospective chart review of patients with PHPT attending the Endocrinology clinic at IALCH between July 2009 and December 2021. Clinical presentation, laboratory results, radiologic findings, surgical notes and histology were recorded.ResultsAnalysis included 110 patients (87% female) with PHPT. Median age at presentation was 57 (44; 67.5) years. Symptomatic disease was present in 62.7% (n:69); 20.9% (n:23) had a history of nephrolithiasis and 7.3% (n:8) presented with previous fragility fractures. Mean serum calcium was 2.87 ± 0.34 mmol/l; median serum-PTH was 23.3 (15.59; 45.38) pmol/l, alkaline phosphatase 117.5 (89; 145.5) U/l and 25-hydroxyvitamin-D 42.9 (33.26; 62.92) nmol/l. Sestamibi scan (n:106 patients) identified an adenoma in 83.02%. Parathyroidectomy was performed on 84 patients with a cure rate of 95.2%. Reasons for conservative management (n:26) included: no current surgical indication (n:7), refusal (n:5) or deferral of surgery (n:5), loss to follow-up (n:5) and assessed as high anaesthetic risk (n:4). IO-PTH measurements performed on 28 patients indicated surgical success in 100%, based on Miami criteria. Histology confirmed adenoma in 88.1%, hyperplasia in 7.1% and carcinoma in 4.8%. Post-operative hypocalcaemia developed in 30 patients (35.7%), of whom, 14 developed hungry bone syndrome (HBS). In multivariate analysis, significant risk factors associated with HBS included male sex (OR 7.01; 95% CI 1.28, 38.39; p 0.025) and elevated pre-operative PTH (OR 1.01; 95% CI 1.00, 1.02; p 0.008).ConclusionsThe proportion of asymptomatic PHPT has increased at this centre over the past decade but symptomatic disease remains the dominant presentation. Parathyroidectomy is curative in the majority of patients. IO-PTH monitoring is valuable in ensuring successful surgery.

The Prevalence of Clinically Undiagnosed Depression in Patients With Autoimmune Bullous Diseases Seen at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.

Background Chronic autoimmune bullous diseases have been associated with major depression in previous studies. This has been attributed to inflammatory cytokines, chronic pain, and the chronicity and debilitating nature of the disease. As no similar studies have been conducted in our setting, we aimed to determine the prevalence and severity of clinically undiagnosed depression in patients with autoimmune bullous diseases. Methodology We performed a cross-sectional study among outpatients managed in a bullous disease clinic at Inkosi Albert Luthuli Central Hospital, a quaternary provincial hospital in Durban, South Africa. Results A total of 44 participants were recruited and included in this study. The majority of the participants were females (29, 65.9%). The most common autoimmune bullous diseases were pemphigus vulgaris (19, 43.2%), bullous pemphigoid (18, 40.9%), and pemphigus foliaceus (5, 11.4%). The overall prevalence of at least mild and at least moderate depression in patients with autoimmune bullous diseases in our clinic was 52.3% and 20.5%, respectively. Pemphigus vulgaris showed the highest median Patient Health Questionnaire-9 score compared to other bullous dermatoses. Statistically significant differences were observed between females and males for the duration with the bullous disease (p = 0.014) and between intraepidermal and subepidermal disease for both the mean age (p = 0.038) and age at onset (p = 0.015). Conclusions Clinically undiagnoseddepression is common in patients with autoimmune bullous disease. Its frequency and severity may differ depending on the underlying autoimmune bullous disease and possibly other factors. Dermatologists should always be alert to this fact and prompt psychiatric consultation as required to comprehensively manage these patients.

Prevalence of malnutrition and its impact on outcomes in children with cancer in a South African setting

Background. Malnutrition in children with cancer is a common problem, especially in developing countries. Determination of nutritional status on admission and during treatment is crucial to reduce morbidity and mortality. Objectives. This study reports the prevalence of malnutrition in children with cancer and its impact on outcomes. Methods. A retrospective study identified newly diagnosed children with cancer between January 2017 and June 2018 at Inkosi Albert Luthuli Central Hospital (IALCH), an academic hospital in South Africa (SA). The cohort comprised 139 patients. Demographic, anthropometric and outcome data were collected from the hospital electronic database. World Health Organization (WHO) criteria were applied to classify nutritional status. The impact of nutritional status on mortality, length of hospital stay and infection status in the first year was assessed. Results. The prevalence of malnutrition in our cohort of 139 patients was 31.7% (17.3% wasted, 7.2% stunted and 7.2% wasted and stunted). There was a higher incidence of wasting in children with solid tumours than those with haematological malignancies although this was not statistically significant (21.2% v. 7.7% respectively, p-value 0.242). No significant difference in early mortality, length of hospital stay or rate of infection was noted in malnourished patients compared with well-nourished patients. Conclusion. The prevalence of malnutrition in our cohort with cancer was high but not associated with an increased risk of mortality, hospital stay or infection. A larger sample size using a combination of arm- and weight/height-based anthropometry is recommended to confirm these findings.

Expanding Radiotherapy Access in Sub-Saharan Africa: An Analysis of Travel Burdens and Patient-Related Benefits of Hypofractionation

The purpose of this project was to examine the travel burdens for radiotherapy patients in Nigeria, Tanzania, and South Africa, and to assess the patient-related benefits of hypofractionated radiotherapy (HFRT) for breast and prostate cancer patients in these countries. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing the adoption of HFRT in Sub-Saharan Africa (SSA) to enhance radiotherapy access in the region. Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, from written records at the University of Nigeria Teaching Hospital (UNTH) Oncology Center in Enugu, Nigeria, and from phone interviews at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Google Maps was used to calculate the shortest driving distance between a patient's home address and their respective radiotherapy center. QGIS was used to map the straight-line distances to each center. Descriptive statistics were used to compare transportation costs, time expenditures, and lost wages when using HFRT versus conventionally fractionated radiotherapy (CFRT) for breast and prostate cancer. All transportation- and wage-related cost data were contextualized within each country's monthly adjusted net national income (MANNI) per capita, as reported by 2020 data from the World Bank. Patients in Nigeria (n = 390) traveled a median distance of 24.0 km (interquartile range (IQR) = 238.5 km) to NLCC and 86.7 km (IQR = 87.3 km) to UNTH, patients in Tanzania (n = 23) traveled a median distance of 537.0 km (IQR = 587.5 km) to ORCI, and patients in South Africa (n = 412) traveled a median distance of 18.0 km (IQR = 15.0 km) to IALCH. Estimated transportation cost savings for breast cancer patients in Lagos and Enugu were 12,895 Naira and 7,369 Naira (20% and 11% of MANNI per capita), respectively, and for prostate cancer patients were 25,329 and 14,276 Naira (38% and 22% of MANNI per capita), respectively. Prostate cancer patients in Tanzania saved a median of 137,765 Shillings (78% of MANNI per capita) in transportation costs. Significant time expenditures - a relevant consideration for patient convenience - were also saved for ORCI patients, including a median of 80.0 hours (includes travel, treatment, and wait times). Mean transportation cost savings for patients in South Africa were 4,777 Rand (72% of MANNI per capita) for breast cancer and 9,486 Rand (143% of MANNI per capita) for prostate cancer. Cancer patients in SSA travel considerable distances to access radiotherapy services. HFRT decreases patient-related costs and time expenditures, which may increase radiotherapy access and alleviate the growing burden of cancer in the region.

Recent trends in hereditary breast cancer incidence by race and age in KwaZulu-Natal, South Africa: An 11-year single-centre retrospective study (2011-2021).

Breast cancer incidence has increased globally in the last decade, especially in low- and middle-income countries. In Sub-Saharan Africa, breast cancer trends have been described only in a few populations owing to the scarcity of population-specific data. Using data collected between 2011 and 2021 at Inkosi Albert Luthuli Central Hospital, this retrospective study describes demographic and genetic trends for hereditary breast cancer patients in the KwaZulu-Natal province, South Africa. Six hundred and forty-five patients were included, of whom 44.3% were Black, 36.8% Indian, 15.6% White and 3.2% Coloured. The number of annual new cases increased from eight in 2011 to 145 in 2021, with a notable increase among Blacks. The mean onset age was 46 years, and Black patients were diagnosed ~10 years earlier than White and Indian patients. Triple-negative breast cancers accounted for 20.3% of hereditary cases, and 51.1% of them were Black. Bilateral and recurrent breast cancers constituted 7.4%, while pathogenic sequence variants in BRCA1/2 were reported in 10.4% of all patients, and the majority were Blacks and Indians. Overall, the KwaZulu-Natal province has seen an increase in hereditary breast cancer incidence in the past decade. Despite testing negative for pathogenic sequence variants, Black women frequently presented with breast cancers that are BRCA1-like, while Indians presented with extensive family history. This suggests that South African patients may require unique approaches to interventions, such as early detection and awareness programs among Blacks and increased genetic screening among Indians.

Seroprevalence of SARS-CoV-2 immunoglobulin G in HIV-positive and HIV-negative individuals in KwaZulu-Natal, South Africa.

KwaZulu-Natal ranked second highest among South African provinces for the number of laboratory-confirmed cases during the second wave of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The seroprevalence of SARS-CoV-2 among certain vulnerable groups, such as people living with HIV in KwaZulu-Natal, is unknown. The study aimed to determine the prevalence of SARS-CoV-2 immunoglobulin G (IgG) in HIV-positive versus HIV-negative patients. This was a retrospective analysis of residual clinical blood specimens unrelated to coronavirus disease 2019 (COVID-19) submitted for diagnostic testing at Inkosi Albert Luthuli Central Hospital, Durban, from 10 November 2020 to 09 February 2021. Specimens were tested for SARS-CoV-2 immunoglobulin G on the Abbott Architect analyser. A total of 1977/8829 (22.4%) specimens were positive for SARS-CoV-2 antibodies. Seroprevalence varied between health districts from 16.4% to 37.3%, and was 19% in HIV-positive and 35.3% in HIV-negative specimens. Seroprevalence was higher among female patients (23.6% vs 19.8%; p < 0.0001) and increased with increasing age, with a statistically significant difference between the farthest age groups (< 10 years and > 79 years; p < 0.0001). The seroprevalence increased from 17% on 10 November 2020 to 43% on 09 February 2021 during the second wave. Our results highlight that during the second COVID-19 wave in KwaZulu-Natal a large proportion of people living with HIV were still immunologically susceptible. The reduced seropositivity in people with virological failure further emphasises the importance of targeted vaccination and vaccine response monitoring in these individuals. This study contributes to data on SARS-CoV-2 seroprevalence before and during the second wave in KwaZulu-Natal, South Africa, which has the highest HIV prevalence globally. Reduced seropositivity was found among people living with HIV with virological failure, highlighting the importance of targeted booster vaccination and vaccine response monitoring.

A South African central hospital's experience with malignant colorectal obstruction.

The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting. A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded. Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32). One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

Characteristics of infants requiring mechanical reventilation in those previously ventilated during the neonatal period

Background. Factors predisposing ventilated neonates to the risk for reventilation during infancy are largely unknown.Objective. To identify factors that predispose previously mechanically ventilated neonates to reventilation.Methods. Mechanically ventilated infants at the Inkosi Albert Luthuli Central Hospital paedicatric intensive care unit (PICU), SouthAfrica, who were also ventilated during the neonatal period were compared with age-, gender-, timing-, and site-matched controls whowere not reventilated during infancy. Neonatal and postnatal records of the two cohorts and data on their clinical presentation andoutcomes of the ICU admission were collected and analysed using descriptive and comparative statistics.Results. Thirty-one reventilated index cases were identified at the PICU over a 15-month period and were matched with 31non-reventilated controls. Ex-preterm babies (n=26; 84%), males (n=19; 61.3%), chronic lung disease (CLD) of infancy (n=5; 16.7%)and prolonged neonatal length of stay (LOS) were common neonatal factors in reventilated neonates. Pneumonia (n=22; 71%), sepsis(n=11; 35.5%) and upper airway obstruction (UAO) (n=8; 25.8%) were common reasons for reventilation in neonates. There were noHIV-positive cases. Of the 31 reventilated cases, 5 (16.1%) demised and 15 (57.6%) survivors had morbidities, commonly seizures (n=8;30.8%) and short bowel syndrome (n=3; 11.5%).Conclusion. Pre-term birth, male, CLD of infancy and prolonged LOS were associated with an increased risk for mechanical reventilationin infancy. Pneumonia, sepsis, CLD of infancy and UAO were common indications for reventilation post neonatal ICU discharge.

Expanding radiotherapy access in Sub-Saharan Africa: an analysis of travel burdens and patient-related benefits of hypofractionation.

The purpose of this project was to examine the travel burdens for radiotherapy patients in Nigeria, Tanzania, and South Africa, and to assess the patient-related benefits of hypofractionated radiotherapy (HFRT) for breast and prostate cancer patients in these countries. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing the adoption of HFRT in Sub-Saharan Africa (SSA) to enhance radiotherapy access in the region. Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, from written records at the University of Nigeria Teaching Hospital (UNTH) Oncology Center in Enugu, Nigeria, and from phone interviews at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Google Maps was used to calculate the shortest driving distance between a patient's home address and their respective radiotherapy center. QGIS was used to map the straight-line distances to each center. Descriptive statistics were used to compare transportation costs, time expenditures, and lost wages when using HFRT versus conventionally fractionated radiotherapy (CFRT) for breast and prostate cancer. Patients in Nigeria (n=390) traveled a median distance of 23.1km to NLCC and 86.7km to UNTH, patients in Tanzania (n=23) traveled a median distance of 537.0km to ORCI, and patients in South Africa (n=412) traveled a median distance of 18.0km to IALCH. Estimated transportation cost savings for breast cancer patients in Lagos and Enugu were 12,895 Naira and 7,369 Naira, respectively and for prostate cancer patients were 25,329 and 14,276 Naira, respectively. Prostate cancer patients in Tanzania saved a median of 137,765 Shillings in transportation costs and 80.0 hours (includes travel, treatment, and wait times). Mean transportation cost savings for patients in South Africa were 4,777 Rand for breast cancer and 9,486 Rand for prostate cancer. Cancer patients in SSA travel considerable distances to access radiotherapy services. HFRT decreases patient-related costs and time expenditures, which may increase radiotherapy access and alleviate the growing burden of cancer in the region.

The Prevalence of Compassion Fatigue among Oncology Healthcare Professionals in Three Public Healthcare Facilities in Kwazulu-Natal, South Africa

Compassion fatigue (CF) is a serious global challenge among healthcare professionals dealing with diseases with poor health outcomes in clinical settings. Chronic exposure to the suffering of others is inevitable in the oncology setting and remains one of the main contributors to CF. Therefore, this study determined the prevalence of CF among oncology healthcare professionals (OHPs) in three public healthcare facilities in KwaZulu-Natal, South Africa. This cross-sectional descriptive study was conducted among 73 OHPs using the Professional Quality of Life Scale version 5 questionnaire, and the data were analysed using the Statistical Package for Social Sciences. More than half (56.2%) of the participants reported average scores for CF, with 43.8% of them scoring low. The participants from Inkosi Albert Luthuli Central Hospital had the highest CF mean score (26.8) compared to those from Addington Hospital (21.2) and Greys Hospital (22.9). Female OHPs had a higher mean score (24.3) for CF, compared to their male counterparts (20.6). The CF scores were positively correlated with older age and longer work experience of the OHPs. The prevalence of CF among OHPs was average, compared to those reported by other local and international studies. Nevertheless, these results cannot be taken lightly, given the straining effects of unmanaged CF on the healthcare system generally and on patient care in particular. The results of this study can potentially contribute to policy development and the planning of intervention strategies towards the effective management of CF among OHPs.

Hodgkin lymphoma in the bone marrow aspirate of a young patient with human immunodeficiency virus.

eJHaemEarly View HAEMATOLOGY IMAGESOpen Access Hodgkin lymphoma in the bone marrow aspirate of a young patient with human immunodeficiency virus Evashin Pillay, Corresponding Author Evashin Pillay evashinp@gmail.com orcid.org/0000-0003-0733-2860 University of KwaZulu-Natal & National Health Laboratory Service, Inkosi Albert Luthuli Central & King Edward VIII Hospitals, Durban, South Africa Correspondence Evashin Pillay, Department of Haematology, Inkosi Albert Luthuli Central Hospital, 4th Floor Laboratory Building, 800 Bellair Road, Durban 4091, KwaZulu-Natal, South Africa. Email: evashinp@gmail.comSearch for more papers by this authorPoobalan Naidoo, Poobalan Naidoo University of KwaZulu-Natal & KwaZulu Natal Provincial Department of Health, Inkosi Albert Luthuli Central & King Edward VIII Hospitals, Durban, South AfricaSearch for more papers by this author Evashin Pillay, Corresponding Author Evashin Pillay evashinp@gmail.com orcid.org/0000-0003-0733-2860 University of KwaZulu-Natal & National Health Laboratory Service, Inkosi Albert Luthuli Central & King Edward VIII Hospitals, Durban, South Africa Correspondence Evashin Pillay, Department of Haematology, Inkosi Albert Luthuli Central Hospital, 4th Floor Laboratory Building, 800 Bellair Road, Durban 4091, KwaZulu-Natal, South Africa. Email: evashinp@gmail.comSearch for more papers by this authorPoobalan Naidoo, Poobalan Naidoo University of KwaZulu-Natal & KwaZulu Natal Provincial Department of Health, Inkosi Albert Luthuli Central & King Edward VIII Hospitals, Durban, South AfricaSearch for more papers by this author First published: 13 March 2023 https://doi.org/10.1002/jha2.670AboutSectionsPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat A 31-year-old South African lady, HIV-positive since 2019 (medication: fixed dose combination antiretroviral therapy – tenofovir, lamivudine and dolutegravir; CD4 count: 328 cells/µL; HIV viral load: undetectable) and who completed a full course of empiric therapy for tuberculosis (TB) 2 months prior, presented to the emergency room complaining of fatigue, loss of appetite and malaise; no bleeding. During admission, her general examination was remarkable for muscle wasting, tachycardia, pallor, pyrexia (>38°C) and generalised significant lymphadenopathy (LAD), particularly evident as a left-sided axillary mass. Systemic examination revealed a distended abdomen compatible with ascites, and reduced bi-basal breath sounds; no hepatosplenomegaly. The overall clinical impression was that of a young female with stage 4 HIV and features of lymphoma, as supported by constitutional symptoms, LAD and serositis. Blood work comprising an FBC demonstrated an isolated severe anaemia (leucocytes 5.20 × 109/L – lymphocytes 7%, haemoglobin 5.1 g/dL and platelets 314 × 109/L); corrected reticulocyte count 0.45%. A staging CT (computed tomography) scan demonstrated generalised significant LAD (>1 cm; neck, supraclavicular, axillary (largest; >4 cm in short axis), mediastinal, hilar and para-aortic), bilateral pleural effusions with bi-basal atelectasis, gross ascites and hepatomegaly (±14 cm in span); no splenomegaly but multiple non-enhancing round hypodensities were noted in the spleen. Tissue biopsies were then planned, and the excision node histology confirmed a diagnosis of nodular sclerosis classic Hodgkin lymphoma (cHL), syncytial variant. A subsequent staging bone marrow (BM) biopsy was performed and remarkably, the BM aspiration smears revealed ∼5% large- and giant-sized, mono- and multi-nuclear tumour cells that morphologically resembled Hodgkin and Reed–Sternberg (HRS) cells (Figure 1). Unfortunately, several attempts to process the BM aspirate sample for flow cytometry proved unsuccessful due to repeated clogging of the sample injection tube. Nonetheless, the corresponding BM trephine biopsy sections showed focal infiltration by neoplastic cells, in addition to many pleomorphic counterparts (Figure 2). Immunohistochemical and special stains (Figure 2) revealed the HRS cells to express the following phenotype: CD45−, CD15+, CD30+, PAX5+, MUM1+, EBER+ (Epstein–Barr virus-encoded RNA), CD3−, CD20−, CD138−, ALK− and AE1/AE3−. Moreover, identifiable in close proximity to the HRS cells were a pathognomonic mixed population of inflammatory cells (Figures 1 and 2). Trilinear haematopoiesis was relatively adequately preserved. FIGURE 1Open in figure viewer Bone marrow aspirate smear (panels A–I; May–Grünwald–Giemsa; 100× objective). Morphologically heterogeneous tumour cells including Hodgkin cells (panels A–C; white arrows), forms undergoing cell division (panel D; yellow arrow), Reed–Sternberg cells (panels E–H; black arrows) and multi-nuclear counterparts (panel I; purple arrow) comprised of abundant, deeply basophilic, agranular cytoplasm with vacuolation and clasmatosis (pseudopod formation), and containing nuclei with irregular borders, reticulated chromatin, conspicuous nucleoli (panel A) and vacuolation (panels C, F and I). Inflammatory cells comprising eosinophils (panel B; pink arrow), granulocytes (panel C; green arrow), plasma cells (panel E; red arrow) and lymphocytes (panel I; cyan arrow) in close proximity to tumour cells. FIGURE 2Open in figure viewer Bone marrow trephine sections (panels A–I; 100× objective). Hodgkin cells (panels A and B; haematoxylin and eosin [H&E]; white arrows), Reed–Sternberg cells (panels B–E; H&E black arrows) and multi-nuclear tumour cell variants (panels C, E and F; H&E purple arrows). A lacunar cell (panel A; white arrow), hallmark-like cell (panel B; blue arrow) and mitotic Reed–Sternberg cell with ‘cherry-red’ nucleoli (panel D; yellow arrow). Immunostaining of tumour cells for CD15 (panel G; black arrow), CD30 (panel H; black arrow) and Epstein–Barr virus-encoded RNA (EBER) (panel I; in situ hybridisation [ISH]; black arrow). Inflammatory cells comprising eosinophils (panel A; pink arrow), plasma cells (panel A; red arrow), granulocytes (panel B; green arrow) and lymphocytes (panel B; cyan arrow) in close proximity to tumour cells. Finally, an international prognostic score of 4 was concluded (serum albumin 1.3 g/dL, haemoglobin 5.1 g/dL, stage IV disease and lymphocytes 7%). Notably, microbiological investigations for SARS-CoV-2 and TB were negative. Unfortunately, the patient succumbed to a hospital-acquired pneumonia despite exhaustive supportive therapy and empiric antibiotics, and prior to initiating chemotherapy. It is exceedingly rare to observe well preserved HRS cells in a BM aspirate film. The accompanying fibrotic milieu of the infiltrated BM probably causes tumour cell fragmentation and/or impairs their effective aspiration [1-4]. Another consideration is that of scattered focal bony lesions which may not be biopsied during the process of attempting aspiration [5, 6]. This case highlights an exceptional clinicopathologic entity by demonstrating HRS cells in the BM aspirate film of a young HIV-positive patient presenting with the syncytial variant of nodular sclerosis cHL. It has enabled careful examination of numerous HRS cells thereby contributing to appreciation of their morphological heterogeneity. Haemato-pathologists should be cognizant of such cases to prevent misdiagnosis as metastatic non-haematological neoplasms (particularly carcinoma) or other haematological neoplasms (particularly non-Hodgkin lymphoma) [7, 8]. Accordingly, timeous diagnosis may prove to be lifesaving, especially in resource-constrained settings. ACKNOWLEDGEMENTS The authors thank the hospital administrative and laboratory staff for their assistance in preparing this case. Verbal consent was duly obtained from the patient for purposes of publication. CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest. ETHICS STATEMENT Ethical approval was obtained from the Biomedical Research Ethics Committee (BREC) affiliated with the University. Open Research DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. REFERENCES 1Swart L, Shuttleworth MH, Opie JJ, van Schalkwyk W. Paediatric Hodgkin lymphoma with Reed-Sternberg and mononuclear Hodgkin cells in the bone marrow aspirate. Br J Haematol. 2012; 157: 2. 2Xu Z, Burns BF, Faught C. Reed-Sternberg cells detected in the bone marrow aspirate in a young patient with nodular sclerosis Hodgkin lymphoma. Eur J Haematol. 2013; 92: 365– 6. 3Parsons K, Leach M, Bain BJ. Hodgkin lymphoma in a bone marrow aspirate. Am J Hematol. 2020; 95: 328– 9. 4Domínguez-Muñoz MÁ, Morales-Camacho RM, Prats-Martín C, Ávila R, Vargas MT, Burillo S, et al. Unusual co-occurrence of Hodgkin lymphoma and hemophagocytic lymphohistiocytosis in a bone marrow aspirate. Ann Hematol. 2016; 95: 1019– 21. 5Lee S-G, Paik S-Y, Sohn H-J, Kim SY, Kong S-Y. Numerous Reed-Sternberg cells in bone marrow aspirate from a patient with syncytial variant of nodular sclerosis classical Hodgkin lymphoma. Int J Hematol. 2015; 101: 107– 8. 6Kini JR, Suresh PK, Sinha R, Sahu K, Kumar S, Prasad K. Value of bone marrow examination in Hodgkin lymphoma: report of three cases with review of literature. J Cancer Res Ther. 2012; 8(3): 457– 9. 7Strickler JG, Michie SA, Warnke RA, Dorfman RF. The “syncytial variant” of nodular sclerosing Hodgkin's disease. Am J Surg Pathol. 1986; 10(7): 470– 7. 8Conlin PA, Blann MM, Morgan DL. Pathologic quiz case: supraclavicular lymphadenopathy in a 30-year-old man. Arch Pathol Lab Med. 2000; 124: 1837– 8. Early ViewOnline Version of Record before inclusion in an issue FiguresReferencesRelatedInformation

Novel IRF6 variant in orofacial cleft patients from Durban, South Africa.

To date, there are over 320 variants identified in the IRF6 gene that cause Van der Woude syndrome or popliteal pterygium syndrome. We sequenced this gene in a South African orofacial cleft cohort to identify the causal IRF6 variants in our population. Saliva samples from 100 patients with syndromic and non-syndromic CL ± P were collected. Patients were recruited from the cleft clinics at two public, tertiary hospitals in Durban, South Africa (SA), namely Inkosi Albert Luthuli Central Hospital (IALCH) and KwaZulu-Natal Children's Hospital (KZNCH). We prospectively sequenced the exons of IRF6 in 100 orofacial cleft cases, and where possible, we also sequenced the parents of the individuals to determine the segregation pattern. Two variants were identified; one novel (p.Cys114Tyr) and one known (p.Arg84His) missense variant in IRF6 gene were identified. The patient with the p.Cys114Tyr variant was non-syndromic with no clinical VWS phenotype expected of individuals with IRF6 coding variants, and the patient with the p.Arg84His had phenotypic features of popliteal pterygium syndrome. The p.Arg84His variant segregated in the family, with the father also being affected. This study provides evidence that IRF6 variants are found in the South African population. Genetic counselling is essential for affected families, particularly in the absence of a known clinical phenotype since it helps with the plans for future pregnancies.

A Clinicopathological Classification Of Encephalocoeles Based On 207 Patients

Encephalocoeles are relatively rare congenital abnormalities. There have been a few classifications of encephalocoeles, but these are predominantly anatomical. A more clinical classification system would assist in planning treatment, surgical procedures and assessing outcomes. All encephalocoeles presenting at the Craniofacial Unit at Inkosi Albert Luthuli Central Hospital were reviewed. There were 207 patients with 224 encephalocoeles. The clinical presentation and CT findings were analysed and used to group these encephalocoeles. There were five distinct groups with some having subgroups.1.Cranial (n= 43). These were located on the calvarium and were subdivided into subgroups according to their anatomical location. They are occipital, parietal, frontal, temporal and acrania.2.Nasal (n= 122). These were located in the nasal region and were classified into two large subgroups (supranasal and infranasal) depending on whether the pathway and defect were above or below the nasal bones.3.Orbital (n= 21). These presented with the displacement of the globe and were subdivided into two subgroups: anterior and posterior.4.Basal (n= 11). The pathway of these encephalocoeles was through the floor of the anterior cranial fossa often with no visible deformity of the face.5.Cleft related (n= 27). The pathway of these encephalocoeles was through an existing craniofacial cleft. This classification system demonstrated good clinicopathological correlation. This allowed one to better appreciate the pathway and assess concomitant deformities. It also directed one to plan the procedure and detail the surgical corrections required to produce satisfactory outcomes.

A three-year audit of pregnancy outcomes in women with pulmonary hypertension admitted to the high-risk obstetric unit at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa.

The aim of this study was to describe the profile and outcomes of pregnancies in women with pulmonary hypertension in South Africa. A retrospective study was undertaken at a state-subsidised hospital. Data were analysed using SPSS. Descriptive statistics were used to summarise categorical variables. Central tendency and dispersion of data were measured using means and standard deviations for normally distributed variables and medians and interquartile ranges for skewed variables. A p-value less than 0.05 was considered statistically significant. Of a cohort of 185 women, 86.3% had pulmonary hypertension secondary to left heart disease. The median age of the cohort was 28 years (interquartile range 23-33) with 37.8% being HIV infected and 59% having mild pulmonary hypertension. Frequencies of deaths, intensive care unit admissions and cardiac failure events increased with increasing severity of pulmonary hypertension (p < 0.001). Women with more severe pulmonary hypertension had higher rates of preterm births (p < 0.001). Adverse pregnancy outcomes were concentrated in women with moderate-to-severe pulmonary hypertension.

A comparative analysis of the upper gastrointestinal endoscopic reporting systems within the Durban Metropolitan complex

The minimal standard terminology (MST) was developed by the World Endoscopy Organization (WEO) to standardise endoscopic reporting. This study compared current reporting within the Durban Metropolitan complex with the MST. This observational retrospective study included 130 upper gastrointestinal endoscopy reports from five different hospitals. The data were compared to the current reporting standard in the MST. The Noorbhai Maharaj (NM) score was used to assess and grade the quality of reporting. Each of the five hospitals has different endoscopic reporting systems. One hundred and thirty patients were included in the study, of which 60 were female. The indications for upper endoscopy were stated in 77 reports (59%). The commonest indications were epigastric pain (23%), dyspepsia (10%) and heartburn (10%). Sedation information per hospital was mostly seen at Inkosi Albert Luthuli Central Hospital (IALCH) (83%), followed by Prince Mshiyeni Memorial Hospital (PMMH) (67%), Addington (ADH) (13%), King Edward VIII Hospital (KEH) (13%), and RK Khan Hospital (RKKH) (0%). Consultant endoscopies per hospital were RKKH (91%), IALCH (86%), PMMH (78%), ADH (73%) and KEH (40%). All 130 reports were graded as NM Grade C. Scores of less than 20 points were seen in 106 reports (82%) and reflected across the different hospitals as follows: RKKH (100%), ADH (97%), KEH (93%), PMMH (56%) and IALCH (55%). There is no uniform structured endoscopic reporting system within the Durban Metropolitan Hospital complex. The current reporting methods do not meet the MST. The introduction of a structured standard endoscopic reporting system could improve the quality of reporting.

Oncoplastic surgery for breast carcinoma in South Africa - an audit of outcomes from a single breast unit

Oncoplastic breast surgery permits tumours traditionally requiring total mastectomy to be excised with acceptable oncological and aesthetic outcomes. The purpose of this study was to evaluate outcomes following oncoplastic breast surgery in the breast unit at Inkosi Albert Luthuli Central Hospital in Durban. This was a retrospective analysis of patient records. Patients who underwent oncoplastic breast surgery with curative intent from 2011 and 2012 were included in this study. Male patients, those with contraindications to breast conservation, and those with metastatic disease were excluded. Demographic and tumour-related data were collected and margin status, surgical site sepsis, recurrence and overall survival (OS) were recorded over a 5-year period starting from the date of presentation. Forty-five patients with 45 tumours were evaluated. The most prevalent tumour size at presentation was T2 (55.6%), and the most commonly performed procedure was a therapeutic mammoplasty. Twelve patients (27%) developed surgical site infection (SSI), eight of which were classified as deep SSI with wound breakdown. The resection margin was clear in 95.6%. Recurrence was noted in 8.9% of patients, with an OS of 91.1%. Breast-conserving surgery (BCS) using oncoplastic techniques results in favourable oncological outcomes in patients treated in a resource-constrained setting.

Factors influencing the outcomes of patients with severe traumatic brain injury following road traffic crashes

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity in South Africa. Road traffic crashes (RTCs) are among the commonest aetiology of TBI in South Africa. This study aimed to determine the factors influencing the outcomes in patients with severe TBI following RTCs. A retrospective study was conducted of patients who were admitted to the neurosurgery department at Inkosi Albert Luthuli Central Hospital between January 2013 and December 2017 with TBI following RTCs and with a Glasgow Coma Scale (GCS) < 9. Demographic, clinical, and radiological information was obtained. The outcome at discharge was categorised into favourable and unfavourable, using the Glasgow outcome score. Statistical analysis was performed to determine factors contributing to the outcome. The study population consisted of 100 patients. The mean age was 29.5 ± 14.1 years old (range 3-81 years). The majority of patients (85%) were males. Pedestrian vehicle accidents accounted for 46%, compared to motor vehicle collisions (54%). The mean hospital stay duration was 14.2 ± 8.8 days (range 1-43 days). The median postresuscitation GCS was 6 (range 3-8), (p = 0.52). Fifty-two patients had an unfavourable outcome compared to 48 who had a favourable outcome. Eleven patients presented with pupillary abnormalities (p = 0.88), which included unilateral dilated non-reactive (DNR) pupil in seven patients, whilst four patients had bilateral. Five patients developed refractory intracranial hypertension (RIC-HTN), all these patients had unfavourable outcomes, (p = 0.03). Thirty-eight patients developed systemic hypotension (SBP < 90 mmHg), 32 out of these patients had unfavourable outcomes (p < 0.001). In female patients, 80% had unfavourable outcomes compared to 47% of male patients (p = 0.02). Extracranial injuries were diagnosed in 50 patients, and 24 patients had unfavourable outcomes (p = 0.42). The outcomes in patients with severe TBI following road traffic crashes are influenced by hypotension (SBP <90 mmHg), RIC-HTN and female gender, which have a negative influence on outcomes.

Impact of rapid centrifugation on routine coagulation assays in South Africa.

The recommendation for coagulation blood samples is to centrifuge at 4000 revolutions per minute (rpm) for 15 min to produce platelet-poor plasma before analysis. Rapid centrifugation, defined as centrifuging samples at higher speeds for shorter durations, could potentially reduce turn-around times (TAT), provided sample integrity is maintained. This study assessed the impact of rapid centrifugation on routine coagulation assay results. Blood samples were collected from volunteers at Inkosi Albert Luthuli Central Hospital and King Edward VIII Hospital, Durban, KwaZulu-Natal, South Africa, from September to November 2021. Samples were centrifuged using Method A, the current standard (4000 rpm/15 min), Method B (4000 rpm/10 min), Method C (5000 rpm/10 min) and Method D (5000 rpm/5 min). Platelet count, prothrombin time, activated partial thromboplastin time, thrombin time (TT), fibrinogen and D-dimer levels were analysed and results from Methods B, C and D compared to reference Method A. Platelet-poor plasma was obtained from all samples (n = 60) using Methods A and B, and from 33/60 (55%) samples using Methods C and D. Differences between Method A and Methods C and D for normal prothrombin time, normal D-dimer and abnormal TT results were statistically significant. Prothrombin time results correlated strongly across all methods, while TT and D-dimer results correlated poorly. Activated partial thromboplastin time and fibrinogen results showed no significant differences across all methods. Rapid centrifugation at 4000 rpm/10 min (Method B) showed results consistent with the reference method. This method could potentially reduce the overall TAT for routine coagulation assays.

OP054 [Healthcare systems » Capacity building]: THE UNMET DEMAND FOR CRITICAL CARE AT A QUATERNARY PAEDIATRIC INTENSIVE CARE IN SOUTH AFRICA: A STUDY WITH HOPE

Department of Paediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa; Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa.

Surgical treatment of bronchiectasis in children: An 11-year experience at a central health facility in KwaZulu-Natal, South Africa

&#x0D; &#x0D; &#x0D; &#x0D; Background. The surgical management of children with bronchiectasis has seldom been reported.Objective. To describe the presentation, surgical management and outcomes in children with bronchiectasis presenting for surgery. Methods. We retrospectively reviewed the electronic records of 0 - 13-year-old children who underwent pulmonary resection for bronchiectasis at Inkosi Albert Luthuli Central Hospital, Durban, South Africa, between January 2004 and December 2014. Clinical, radiological and preoperative bronchoscopic findings, as well as surgical and histological outcomes, were analysed.Results. Eighty-eight patients underwent surgical resection. The female/male ratio was 3:2, with a mean age at surgery of 8.2 (range 2 - 13) years; 39 patients were HIV infected and 39 were HIV uninfected. Tuberculosis (TB) (n=68; 77.2%) was the most common cause of bronchiectasis, and recurrent chest infection (n= 45; 51.1%) was the most common clinical finding. Radiological examination confirmed isolated left-sided disease in 40 children (45.4%), isolated right-sided disease in 28 (31.8%) and bilateral disease in 20 (22.7%). Saccular disease with fibrocavitation (n=35; 39.7%) was the most common morphological disease type. Preoperative bronchoalveolar lavage samples confirmed a bacterial cause in 27 patients (30.6%). The most common operative procedures were primary pneumonectomy in 33 patients (37.0%), lobectomy in 30 (34.0%) and bilobectomy in 13 (14.7%). Seventy-five patients were asymptomatic after the operation and complications occurred in 13. Two children (2.2%), one with sepsis and the other with intraoperative hypoxia, died. Seventy patients underwent complete resection. At 1 month after surgery, 89.2% of patients were asymptomatic, while 77.7% of symptomatic patients were HIV positive.Conclusions. Complete pulmonary resection in children with advanced-stage bronchiectasis is safe, with a low morbidity and mortality. Surgery in HIV-positive patients was not associated with worse outcomes and is not contraindicated. HIV- and TB-preventive measures could reduce the burden of childhood bronchiectasis.&#x0D; &#x0D; &#x0D; &#x0D;