Inkosi Albert Luthuli Hospital Research Articles

The quality of life among children with epilepsy in resource-limited settings: A pilot study in a paediatric neurology clinic at a quaternary care teaching hospital

Background. An important part of holistic care management of children with epilepsy (CWE) is measuring their health-related quality of life (HRQOL). However, little is known about the HRQOL of CWE who live in resource-limited settings, particularly in South Africa. Objectives. To assess the HRQOL of CWE and to identify the possible factors that correlate with HRQOL including demographic variables and epilepsy health-related factors. Methods. A cross-sectional prospective quantitative study was undertaken at the paediatric neurology outpatient clinic at Inkosi Albert Luthuli Hospital (IALCH), a quaternary care teaching hospital in Durban, South Africa. Participants were recruited during the period between December 2019 and February 2020. CWE between 2 and 12 years old with no comorbid syndromic disorder or other chronic diseases accompanied by English-speaking caregivers were included in the study. We used the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) generic core parent-proxy questionnaire modified with separate sociodemographic and epilepsy data collection sheets. Results. One hundred and twenty participants were recruited. The majority of patients (54.2%) had generalised epilepsy. The aetiology of epilepsy was unknown in 40.8% of patients. The most commonly used anti-seizure medication was sodium valproate (39.2%). The mean of the total score of HRQOL (SD) (coefficient of variation %) was 66.7 (24.1 (36.1). School attendance p-value<0.001, financial aid for indigent families p 0.047, monotherapy p<0.001, absence of disability p<0.001 and absence of comorbidity p <0.001were strongly associated with good HRQOL total scores. Conclusion. CWE attending IALCH in Durban, South Africa, have compromised HRQOL scores. The variables that significantly correlate with better HRQOL scores are school attendance, receiving financial aid for indigent families, monotherapy, and absence of disabilities and comorbidities. We recommend a multicentre study that involves a larger number of epileptic children with the employment of the epilepsy-specific PedsQL 4.0 module translated into local languages.

Phenotypic Array for Identification and Screening of Antifungals against Aspergillus Isolates from Respiratory Infections in KwaZulu Natal, South Africa.

The rapid emergence of invasive fungal infections correlates with the increasing population of immunocompromised individuals, with many cases leading to death. The progressive increase in the incidence of Aspergillus isolates is even more severe due to the clinical challenges in treating invasive infections in immunocompromised patients with respiratory conditions. Rapid detection and diagnosis are needed to reduce mortality in individuals with invasive aspergillosis-related infections and thus efficient identification impacts clinical success. The phenotypic array method was compared to conventional morphology and molecular identification on thirty-six Aspergillus species isolated from patients with respiratory infections at the Inkosi Albert Luthuli Hospital in Kwa-Zulu Natal. In addition, an antimicrobial array was also carried out to screen for possible novel antimicrobial compounds for treatment. Although traditional morphological techniques are useful, genetic identification was the most reliable, assigning 26 to Aspergillus fumigatus species, 8 Aspergillus niger, and 2 Aspergillus flavus including cryptic species of A. niger, A. tubingensis and A. welwitschiae. The phenotypic array technique was only able to identify isolates up to the genus level due to a lack of adequate reference clinical species in the database. However, this technique proved crucial in assessing a wide range of possible antimicrobial options after these isolates exhibited some resistance to azoles. Antifungal profiles of the thirty-six isolates on the routine azole voriconazole showed a resistance of 6%, with 61% having moderate susceptibility. All isolates resistant to the salvage therapy drug, posaconazole pose a serious concern. Significantly, A. niger was the only species resistant (25%) to voriconazole and has recently been reported as the species isolated from patients with COVID-19-associated pulmonary aspergillosis (CAPA). Phenotypic microarray showed that 83% of the isolates were susceptible to the 24 new compounds and novel compounds were identified for potentially effective combination treatment of fungal infections. This study also reports the first TR34/98 mutation in Aspergillus clinical isolates which is located in the cyp51A gene.

Ten-year predictors of major adverse cardiovascular events in patients without angina.

Longstanding cardiovascular risk factors cause major adverse cardiovascular events (MACE). Major adverse cardiovascular events prediction may improve outcomes. The aim was to evaluate the ten-year predictors of MACE in patients without angina. Patients referred to Inkosi Albert Luthuli Hospital, Durban, South Africa, without typical angina from 2002 to 2008 were collected and followed up for MACE from 2009 to 2019. Survival time was calculated in months. Independent variables were tested with Cox proportional hazard models to predict MACE morbidity and MACE mortality. There were 525 patients; 401 (76.0%) were Indian, 167 (31.8%) had diabetes at baseline. At 10-year follow up 157/525 (29.9%) experienced MACE morbidity, of whom, 82/525 (15.6%) had MACE mortality. There were 368/525 (70.1%) patients censored, of whom 195/525 (37.1%) were lost to follow up. For MACE morbidity, mean and longest observation times were 102.2 and 201 months, respectively. Predictors for MACE morbidity were age (hazard ratio [HR] = 1.025), diabetes (HR = 1.436), Duke Risk category (HR = 1.562) and Ischaemic burden category (HR = 1.531). For MACE mortality, mean and longest observation times were 107.9 and 204 months, respectively. Predictors for MACE mortality were age (HR = 1.044), Duke Risk category (HR = 1.983), echocardiography risk category (HR = 2.537) and Ischaemic burden category (HR = 1.780). Among patients without typical angina, early ischaemia on noninvasive tests indicated microvascular disease and hyperglycaemia, predicting long-term MACE morbidity and MACE mortality.Contribution:Diabetes was a predictor for MACE morbidity but not for MACE mortality; patients lost to follow-up were possibly diabetic patients with MACE mortality at district hospitals. Early screening for ischaemia and hyperglycaemia control may improve outcomes.

Surgical Audit of Sternal Wound Infection Following Cardiac Surgery at Inkosi Albert Luthuli Hospital (IALCH), Durban, South Africa

Introduction: Sternal wound infection is a devastating complication following cardiac surgery. It is associated with sternal mal-union, mediastinitis and bacteremia with subsequent infective endocarditis and redo surgery. Although the incidence of sternal wound infections has decreased to 1% - 4% of all cardiac surgery procedures. Sternal wound infection continues to be associated with increased morbidity and mortality, and decrease long term life expectancy. New approaches to open heart surgery, deep and superficial wound infection has a significant impact on patients’ morbidity, length of stay and cost of care. This study was to identify risk factors associated with sternal wound infection and prompt treatments measures to decrease this complication. Methods: Between January 2016- December 2018, thirty-eight (38) adult patient above 14 years who underwent cardiac surgery developed sternal wound infection at IALCH, KwaZulu Natal Province. Retrospectively reviewed and analyzed patient’s records were evaluated for demographics, risk factors, management and the outcome in relation to hospital stay and cost. The following risk factors shows significant P value<0.05. Results: The study revealed that, of the 38 patients, 24 were female (63.2%) and 14 male (36.8%), while 26 patients (68.4%) below 60 years, 12 patients (31.6%) above 60 years. 13 patients (34.2%) developed deep sternal wound infection against 25 (65.8%) who developed superficial wound sternal wound infection. Surgical procedure was for valvular heart disease 24 (63.2%), CABG 13 (34.2%) and 1 (2.6%) concomitant CABG and valve replacement. Prolonged ICU stay 3.08 days SD=1.49 was associated with deep sternal wound infection compared to 1.79 days SD=0.723 for superficial, p=0.0001. Conclusion: This study showed that sternal wound infection increases overall hospital stay and is associated with increased overall treatment cost therefore, it is imperative to address known risk factors by adhering to and implementing preventative programs.

A descriptive study of trauma patients transported by helicopter emergency medical services to a level one trauma centre.

KwaZulu-Natal, the largest land mass province that is densely populated in SA has vast distances to referral centres and time to definitive treatment is key in trauma care. Helicopter Emergency Medical Service (HEMS) is still an invaluable prehospital asset for the transport of time sensitive trauma. This study reviews the impact of HEMS in the management of trauma at Inkosi Albert Luthuli hospital (IALCH) which is the only public accredited level one trauma centre in the province. A retrospective descriptive study of polytrauma patients transported by HEMS in KZN to IALCH over a three-year period from 01 January 2014 to 31 December 2016. Data was collected around patient demographics, transfer details and patient outcomes. Over the three-year period, 117 HEMS transfers were reviewed, with the majority being male (90.6%). Just 26% of HEMS transfers were direct from the scene, with the balance being interhospital transfers largely from distant regional hospitals around the province. Some 60% of injuries were caused by vehicle crashes, and 31% by intentional injury. Mortality was 30% which is reflective of the high severity of injury of the cohort. The injury severity scores (ISS) (median 26 overall) of those who died was higher (median 38) (P-= .0002), and there were more interventions before and during transfer such as thoracostomy, ventilation and immobilization. Overall, 88% required admission to ICU at IACLH. HEMS in the KwaZulu Natal province was mainly used for long-distance transfer of major trauma patients which is an appropriate use of this essential service, given the single major trauma centre in the province. The majority of patients that were transported by HEMS had severe injury, which was also associated with increased mortality outcomes. Rational use of this essential but expensive resource will require clear policy around the role of HEMS and call out criteria in each setting.

Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients

Background: The incidence of concurrent traumatic brain injury (TBI) and cervical spine injury (c-spine) is relatively high, with a variety of risk factors. Objectives: The purpose of this study was to determine the incidence and related factors associated with combined cranial and c-spine injury in TBI patients by assessing their demographics and clinical profiles. Method: A retrospective study of patients attending the Trauma Centre at the Inkosi Albert Luthuli Hospital as post head trauma emergencies and their CT brain and c-spine imaging performed between January 2018 and December 2018. Results: A total of 236 patients met the criteria for the study; 30 (12.7%) patients presented with concurrent c-spine injury. Most TBI patients were males (75%) and accounted for 70% of the c-spine injured patients. The most common mechanism of injury with a relationship to c-spine injury was motor vehicle collisions (MVCs) and/or pedestrian vehicle collisions (70%). The risk factors associated with c-spine injury in TBI patients were cerebral contusions (40%), traumatic subarachnoid haematomas (36%) and skull fractures (33.3%). The statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury ( p = 0.04). Conclusion: The results suggest that concurrent TBI and c-spine injury should be considered in patients presenting with a contusion, traumatic subarachnoid haematoma and skull fracture. The high incidence of c-spinal injury and more than 1% incidence of spinal cord injury suggests that c-spine scanning should be employed as a routine for post MVC patients with cranial injury.

Concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients.

BackgroundThe incidence of concurrent traumatic brain injury (TBI) and cervical spine injury (c-spine) is relatively high, with a variety of risk factors.ObjectivesThe purpose of this study was to determine the incidence and related factors associated with combined cranial and c-spine injury in TBI patients by assessing their demographics and clinical profiles.MethodA retrospective study of patients attending the Trauma Centre at the Inkosi Albert Luthuli Hospital as post head trauma emergencies and their CT brain and c-spine imaging performed between January 2018 and December 2018.ResultsA total of 236 patients met the criteria for the study; 30 (12.7%) patients presented with concurrent c-spine injury. Most TBI patients were males (75%) and accounted for 70% of the c-spine injured patients. The most common mechanism of injury with a relationship to c-spine injury was motor vehicle collisions (MVCs) and/or pedestrian vehicle collisions (70%). The risk factors associated with c-spine injury in TBI patients were cerebral contusions (40%), traumatic subarachnoid haematomas (36%) and skull fractures (33.3%). The statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury (p = 0.04).ConclusionThe results suggest that concurrent TBI and c-spine injury should be considered in patients presenting with a contusion, traumatic subarachnoid haematoma and skull fracture. The high incidence of c-spinal injury and more than 1% incidence of spinal cord injury suggests that c-spine scanning should be employed as a routine for post MVC patients with cranial injury.

Open abdomen in the trauma ICU patient: who? when? why? and what are the outcome results?

Temporary abdominal closure is a component of damage control surgery and may decrease mortality rates. The ultimate aim in managing an open abdomen is to achieve definitive fascial closure. The aim of this study is to assess the previously known predictors for failure to achieve definitive fascial closure and identify new predictors in order to achieve a better outcome. An 11-year retrospective chart review included open abdomen cases at Inkosi Albert Luthuli Hospital Trauma ICU in KZN (Ethics Approval BCA207-09). The evaluated outcomes were definitive fascial closure, open abdomen and mortality. Variables included age, co-morbidities, albumin levels, renal failure, multiple blood transfusions, type of blood products given, entero-atmospheric fistulas, TAC, anastomosis, intra-abdominal abscess, type of nutrition, ACS, number of re-laparotomies, deep site infections (peritonitis), systemic infections (bloodstream), ventilator acquired pneumonia, head injury, and type of fluids given. This study reviewed 188 cases, 46.8% (88) arrived from elsewhere with an open abdomen while 53.2% (100) did not; 46.8% suffered blunt trauma, 45.2% suffered gunshots, while 8.0% were stabbed. Ninety deaths (47.9%) occurred during the index admission with 57 (30.3%) within the first 30days. For both death within 30days and death as final outcome, the majority were blunt abdominal trauma, 51.1 and 52.6%, respectively. Out of 188 patients, 27.1% had definitive fascial closure and 26.6% remained with an open abdomen. The relevant variables related to failure to achieve fascial closure were hypoalbuminemia (p = 0.002, p = 0.036), anastomotic leak (p < 0.05), VAP (p = 0.007), age (p = 0.002), intra-abdominal abscesses (p = 0.006), ACS (p = 0.005), multiple re-laparotomies (p = 0,028), deep surgical site infection (p < 0.05) and multi-organ failure (p = 0.003). This study identified the predictors of failed fascial closure and mortality. While not directly modifiable, hypoalbuminaemia, anastomotic leak and sepsis, leading to multiple re-laparotomy, preclude early closure and portend high mortality.

The clinical prognostic significance of myocardial performance index (MPI) in stable placental-mediated disease

To determine whether a single elevated myocardial performance index (MPI) value in the third trimester of pregnancy is a marker for later adverse obstetric outcomes in stable placental-mediated disease, defined as well-controlled pre-eclampsia (PE) on a single agent and/or uncompensated intra-uterine growth restriction (IUGR). Fifty-five foetuses whose mothers had stable placental-mediated disease, either mild pre-eclampsia controlled on a single agent, and/or uncompensated IUGR in the third trimester, attending the Foetal Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa were prospectively recruited with 55 matched controls. Recorded data for the subjects included demographic data of maternal age and parity, sonographic data of estimated foetal weight (EFW) and amniotic fluid index (AFI), myocardial performance index (MPI), and foetal Doppler data of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). The mean gestational age in the controls, the IUGR and any PE cases was 31.4, 31.8 and 31.0 weeks, respectively. The distribution of MPI values was significantly lower in the controls compared to all other groups. The highest standardised MPI values were observed in the PE-IUGR group, where a median of 5.62 was observed. The only significant differences observed between the PE and IUGR groups was the UA resistance index (p = 0.01), where the IUGR cases tended to have higher UA values compared to the combined PE group. Borderline statistical significance was observed for the MCA resistance index values ( p = 0.05) between these groups. The overall adverse event rate in the cases was 49%. The highest rate was observed in the PE + IUGR group, where eight out of 12 (67%) experienced adverse events. MPI z-scores served as a good marker of adverse events, as evidenced by the total area under the curve (AUC) of 0.90 on the ROC curve. A cut-off value of 4.5 on the MPI z-score conferred a sensitivity of 89% and specificity of 68% for an adverse event later in pregnancy. In univariate logistic regression, MPI z-score, AFI, EFW, UA Doppler, CPR category, DV Doppler and MCA Doppler were assessed separately as potential predictors of adverse outcome. The only significant predictor of adverse outcome was MPI z-score. A single elevated value of the MPI ( z-score > 4.5) in the third trimester in stable placental-mediated disease was a strong indicator of adverse obstetric outcomes later in pregnancy. This has the potential to be incorporated in conjunction with standard monitoring models in stable placental-mediated disease to predict an adverse event later in pregnancy and thus to reduce perinatal morbidity and mortality.

PULMONARY HYDATIDOSIS- STILL UNRECOGNIZED IN ENDEMIC REGIONS: A 10 YEAR REVIEW.

Background. Echinococcus disease in still endemic in many low-middle-income countries, with 1 million people infected at any one time. Surgery, the mainstay of its treatment, is costly. Objectives. To describe the presentation, clinical features and outcomes of children referred with pulmonary hydatid disease at Inkosi Albert Luthuli Central Hospital in Durban, South Africa. Methods. A 10-year review of children with pulmonary hydatid disease at Inkosi Albert Luthuli Hospital was carried out. The data collected were demographic, clinical, laboratory and radiological. Cases were mapped geographically to analyse for clustering of cases. Spearman’s correlation was used to assess for correlations between laboratory markers. Results . A total of 24 subjects, 75% of whom were male, were included. The mean (standard deviation) age at diagnosis was 8.9 (3.4) years. The mean delay in diagnosis was 5.8 (5.7) months. Of the subjects, 15 (71.4%) were from the Eastern Cape and 9 from KwaZulu-Natal provinces. Seventy-nine percent of the patients had been exposed to dogs, while 8% reported exposure to either sheep or cattle. There was right-sided preponderance, with 11 right- and 7 left-sided cysts; 6 patients had bilateral cysts, and 4 associated extrapulmonary cysts. Indirect haemagglutination assay was positive in 70%, and blood eosinophilia was present in 45% of the subjects, with no correlation between the two markers ( p =0.22). Surgery was the only modality of treatment in 18 (75%) subjects, while 5 had had prior medical therapy for disseminated disease. The mean intensive care stay postoperatively was 2 (2) days with no mortality. Conclusion. Despite exposure to known risk factors and living in endemic regions, there is often a significant delay in diagnosis of pulmonary hydatid disease at Inkosi Albert Luthuli Hospital.

Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa.

Iatrogenic medication errors due to calculation errors are an under-reported concern in children. To determine the incidence and source of iatrogenic medication errors in a paediatric intensive care unit (PICU). A prospective study was conducted in the PICU at Inkosi Albert Luthuli Hospital, Durban, South Africa, over a 3-month period in 2014. Medication-related calculation skills of medical practitioners and nurses were assessed through the voluntary anonymous completion of a questionnaire. Medication errors were recorded either spontaneously or by review of all electronic records of admissions. Errors were classified as delays in the decision to prescribe, prescribing mistakes, dispensing errors and administration issues. Of 25 staff members sampled, only 6 (24.0%) were able to complete all medication calculations accurately, while 44.0% (n=11) were unable to answer three or more questions correctly. Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases. Of the errors, 73.8% were detected on chart review and 26.2% by spontaneous reporting. Overall, 89.2% of errors occurred during prescribing, with 10.0% having a ≥10-fold increase or decrease in dosage calculations. Only 2.7% of medication errors were reported as resulting in adverse events. Therapeutic skills of healthcare professionals working in the PICU need to be improved to decrease iatrogenic medication errors.

High prevalence of antithyroid peroxidase and antiparietal cell antibodies among patients with type 1 diabetes mellitus attending a tertiary diabetes centre in South Africa

ObjectiveData on the prevalence of autoimmune thyroid disease (AITD) and gastric autoimmunity in type 1 diabetes mellitus (T1DM) in Africa are limited. The aim of this study was to assess...

P74 – 2429: A review of a series of patients with type 1 glutaric aciduria at Inkosi Albert Luthuli Central Hospital, Durban, South Africa

Objective To describe the clinical profile, diagnosis and treatment of patients with Type 1 Glutaric Aciduria. Methods A retrospective review of children with a confirmed diagnosis at Inkosi Albert Luthuli Hospital, South Africa. Results We identified 5 children (3 females, 2 Males) during the period 2007–2014. The mean age at diagnosis was 11 months (range 7–22 months). Three patients presented in acute encephalopathic crises. Two patients had an insidious presentation-developmental delay (n=1) and hemiparesis (n=1). The clinical findings on presentation were hyptonia (n=4), hemiparesis (n=1) and macrocephaly (n=5). Two children had a history of pre-morbid developmental delay. Four children had neuro-regression on presentation. Other complications included seizures (n=3), dystonia (n=2). Urine organic acid screens showed elevated glutaric acid in all patients. Of the 4 patients tested, all were positive for the common A293 mutation on the GCDH gene. All patients had MRI brain scans. The basal ganglia were hyperintense on the T2/FLAIR sequences in all patients (enlarged n=3, atrophic n=2); those with enlarged basal ganglia showed restricted diffusion. This was seen in the 3 children who presented in crises. Delayed myelination was seen in 1 child. Other abnormalities included: abnormal signal in the cerebral peduncles/central tegmental tract n=4, enlarged temporal fossa n=5, cortical atrophy n=3. All patients were treated with L-carnitine and dietary modification. Three patients required anti-epileptics and 2 required L-dopa for dystonia. Two patients had a static clinical course, 1 has gained milestones and 2 have shown progression. Conclusion Key clinical features in our patients include a child presenting in acute encephalopathic crises follow, neuro-regression, and macrocephaly. We identified unusual imaging features – abnormal signal in the central tegmental tract/cerebral peduncles. South Africa does not have a neonatal screening programme for Glutaric Aciduria. It is crucial to have a high index of suspicion as early diagnosis/intervention improves outcome. To describe the clinical profile, diagnosis and treatment of patients with Type 1 Glutaric Aciduria. A retrospective review of children with a confirmed diagnosis at Inkosi Albert Luthuli Hospital, South Africa. We identified 5 children (3 females, 2 Males) during the period 2007–2014. The mean age at diagnosis was 11 months (range 7–22 months). Three patients presented in acute encephalopathic crises. Two patients had an insidious presentation-developmental delay (n=1) and hemiparesis (n=1). The clinical findings on presentation were hyptonia (n=4), hemiparesis (n=1) and macrocephaly (n=5). Two children had a history of pre-morbid developmental delay. Four children had neuro-regression on presentation. Other complications included seizures (n=3), dystonia (n=2). Urine organic acid screens showed elevated glutaric acid in all patients. Of the 4 patients tested, all were positive for the common A293 mutation on the GCDH gene. All patients had MRI brain scans. The basal ganglia were hyperintense on the T2/FLAIR sequences in all patients (enlarged n=3, atrophic n=2); those with enlarged basal ganglia showed restricted diffusion. This was seen in the 3 children who presented in crises. Delayed myelination was seen in 1 child. Other abnormalities included: abnormal signal in the cerebral peduncles/central tegmental tract n=4, enlarged temporal fossa n=5, cortical atrophy n=3. All patients were treated with L-carnitine and dietary modification. Three patients required anti-epileptics and 2 required L-dopa for dystonia. Two patients had a static clinical course, 1 has gained milestones and 2 have shown progression. Key clinical features in our patients include a child presenting in acute encephalopathic crises follow, neuro-regression, and macrocephaly. We identified unusual imaging features – abnormal signal in the central tegmental tract/cerebral peduncles. South Africa does not have a neonatal screening programme for Glutaric Aciduria. It is crucial to have a high index of suspicion as early diagnosis/intervention improves outcome.

An echocardiographic study of infective endocarditis, with special reference to patients with HIV.

SummaryObjectiveThe aim was to describe the echocardiographic features of patients with infective endocarditis (IE), and to compare the manifestations of IE in HIV-positive versus HIV-negative patients.MethodsThe study was prospective in nature and screened patients referred to Inkosi Albert Luthuli Hospital (IALCH) with suspected IE between 2004 and 2007. Only patients with a definite diagnosis of IE according to the modified Duke criteria were enrolled for the purpose of the study. Inkosi Albert Luthuli hospital is an 842-bed tertiary referral centre, serving a KwaZulu-Natal population of 10 million people, who are of various races.ResultsDuring this period, 91 patients were screened for IE. Seventy-seven (HIV infected, n = 17) satisfied the criteria for a definite diagnosis of IE. Blood cultures were positive in 46% of cases. The commonest organism was S aureus. Most patients had advanced valve disruption with heart failure and high peri-operative mortality. The clinical profile in the HIV-infected patients was similar to the that of the non-infected patients. The prevalence of echocardiographic complications (abscesses, aneurysms, perforations, fistulae and chordal ruptures) was 50.6% in the whole group. Except for the presence of leaflet aneurysms and root abscesses in four advanced (CD4 counts < 250 /mm3) HIV-infected cases, complications were not more frequent in the HIV-infected group.ConclusionThere was a high rate of culture-negative cases in this study, probably related to prior antibiotic usage; in this setting the modified Duke criteria have diagnostic limitations. No significant differences in the clinical presentation of infective endocarditis were noted between HIV-infected and HIV-negative patients.

Preoperative B-type natriuretic peptide risk stratification: do postoperative indices add value?

AbstractObjectives: It is unclear if there is value in measuring postoperative B-type natriuretic peptide (BNP) in patients risk-stratified using preoperative BNP.Design: Prospective observational study.Setting and subjects: Patients undergoing vascular surgery at Inkosi Albert Luthuli Hospital, Durban.Data on intraoperative risk predictors, i.e. the nature of the surgery, number of transfused red blood cell units and the duration of surgery, were collected. Preoperative and postoperative BNP, electrocardiographic and troponin I monitoring were performed. Multivariable analysis was conducted to identify independent predictors of adverse cardiac events and then tested using reclassification statistics.Outcome measures: The composite of troponin elevation within the first three postoperative days and all-cause mortality within 30 days of surgery.Results: In 149 eligible patients, the study outcome occurred in 27 patients and was independently predicted by red blood cell (RBC) transfusion [odds ratio (OR) 1....

Household energy-related morbidity and mortality surveillance at a specialised burns unit in Durban, South Africa

The Paraffin Safety Association (PASASA) of Southern Africa is a non-profit organisation established in 1996 to ensure that paraffin/kerosene use, as a domestic energy option, is safe for especially low...

Management of HIV Vasculopathy – A South African Experience

The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy. Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009. 226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4–53 years (average 36); 90% were male. The CD4 count ranged from 1–930 cells/mm 3 while serum albumin averaged 30 mMol/L. 202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease. Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications. Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia. In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%). Low CD4 count and albumen levels did not correlate with mortality or complications. Conclusion Surgical therapy for aneurysm is worthwhile in the short term. Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.