Tygerberg Hospital Research Articles

Paediatric cerebral palsy in South Africa: Prevention and care gaps at hospital level.

Population-based data show high proportions of severe cases of cerebral palsy (CP) in resource-poor regions such as sub-Saharan Africa, where most children have potentially preventable risk factors (factors that may increase the likelihood of CP occurrence but can be mitigated through medical interventions). This study aimed to describe the demographic and clinical profile of children living with CP accessing services at Tygerberg Hospital over a period of 10 years (2010-2020), identify the potential gaps in care (proportion of individuals in a country requiring but not receiving suboptimal or inadequate care), and comparison with a similar study at the same centre two decades ago. This 10-year retrospective study investigated causes and morbidities in children with CP, attending a central hospital in the Western Cape, South Africa. A total of 613 children with CP were identified. Perinatal causes were predominant, especially in 57.7% (n = 354) of the cohort: perinatal asphyxia (41.1%) and preterm birth (16.6%). Postnatal causes constituted 15.2% (n = 93), which included tuberculous meningitis (3.6%) and bacterial meningitis (3.6%). The most common complications were intellectual impairment (61.8%; n = 379); epilepsy (30.8%; n = 189) and visual impairment (54.7%; n = 234). A third of the cohort had severe CP, classified as Gross Motor Function Classification System IV and V (38%). Most of the previously documented main drivers of CP are still present and the implementation of healthcare prevention strategies remains inadequate. This study provides longitudinal evidence to confirm that CP in a South African setting is associated with a high burden of potentially preventable causes.

Cerebral infarcts, edema, hypoperfusion and vasospasm in preeclampsia and eclampsia

Eclampsia, a serious pregnancy complication, is associated with cerebral edema and infarctions but the underlying pathophysiology remains largely unexplored. To assess the pathophysiology of eclampsia using specialized magnetic resonance imaging that measures diffusion, perfusion, and vasospasm. This was a cross-sectional study recruiting consecutive pregnant women between April 2018 to November 2021 at Tygerberg Hospital, Cape Town, South Africa. We recruited women with eclampsia, preeclampsia, and normotensive pregnancies who underwent magnetic resonance imaging after birth. Main outcome measures were cerebral infarcts, edema, and perfusion using intravoxel incoherent motion imaging and vasospasm using magnetic resonance imaging angiography. The imaging protocol was established before inclusion. Forty-nine women with eclampsia, 20 with preeclampsia and 10 normotensive women were included. Cerebral infarcts were identified in 34% of eclamptic, 5% of preeclamptic (risk difference (RD) 0.29; 95% confidence interval (CI) 0.06 to 0.52, p=0.012) and in no normotensive controls. Eclamptic women were more likely to have vasogenic cerebral edema compared to preeclamptic (80% vs 20%, RD 0.60; CI 0.34 to 0.85, p<.001) and normotensive women (RD 0.80; CI 0.47 to 1.00, p<.001). Diffusion was increased in eclampsia in the parietooccipital white matter (mean difference (MD) 0.02 x10-3 mm2/s, CI 0.00 to 0.05, p=0.045) and the caudate nucleus (MD 0.02 x10-3 mm2/s, CI 0.00 to 0.04, p=0.033) when compared to preeclamptic women. Diffusion was also increased in eclamptic women in the frontal (MD 0.07 x10-3 mm2/s, CI 0.02 to 0.12, p=0.012) and parietooccipital white matter (MD 0.05 x10-3 mm2/s, CI 0.02 to 0.07, p=0.03) and the caudate nucleus (MD 0.04 x10-3 mm2/s, CI 0.00 to 0.07, p=0.028) when compared to normotensive women. Perfusion was decreased in edematous regions. Hypoperfusion was present in the caudate nucleus in eclampsia (MD -0.17 x10-3 mm2/s, CI -0.27 to -0.06, p=0.003) when compared to preeclampsia. There were no signs of hyperperfusion. Vasospasm was present in 18% of eclamptic, 6% of preeclamptic and none of the controls. Eclampsia is associated with cerebral infarcts, vasogenic cerebral edema, vasospasm and decreased perfusion, all not usually evident on standard clinical imaging. This may explain why some have cerebral symptoms and signs despite having normal conventional imaging.

Antipsychotics and chronic dystonia at a Botulinum Toxin clinic.

Chronic dystonia, characterised by sustained muscle contractions and abnormal postures, poses clinical challenges, especially when associated with antipsychotic medication use. To delineate the demographic and clinical profiles of adults with dystonia and examine the association with antipsychotic medication. Botulinum Toxin Clinic at Tygerberg Hospital, Cape Town, South Africa. We conducted a retrospective cohort study of adult patients seen at the Botulinum Toxin Clinic between January 2018 and June 2022. Of the 119 patients studied, those assessed with antipsychotic-induced dystonia (32.69%) presented at a younger age (p < 0.001), were more likely female (p = 0.04), received higher average dose of Botulinum toxin (p < 0.001), and incurred a higher estimated Botulinum toxin treatment cost (p = 0.01) compared to those with primary dystonia. Logistic regression identified age and Botulinum toxin dose as factors associated with psychotropic-related dystonia (p = 0.005 and p = 0.012, respectively). Clinical and demographic factors are associated with dystonia in adults taking antipsychotic medication. These patients generally manifested symptoms at an earlier age, had a higher male prevalence, and required prolonged treatment with Botulinum toxin, leading to increased costs. In those assessed with antipsychotic-induced dystonia, a comorbid diagnosis of a mood disorder was more common than that of a psychotic disorder. By identifying the demographic and clinical profile of individuals with dystonia because of antipsychotic medication, this study provides a basis for preventative strategies and enhanced patient care.

The Surgical Outcome of Infective Endocarditis in South Africa over 10 Years: A Retrospective Review.

Objectives: There is a paucity of data on the outcome of left-sided cardiac valve surgery for infective endocarditis in South Africa. It is hypothesized that outcomes may be poorer compared to international standards due to differences in disease burden, timing of surgery, organism prevalence, and co-morbidities. Method: This is a retrospective study of 160 patients with left heart valve endocarditis who underwent cardiac surgery from January 2010 to December 2019. Demographic, operative, and admission-related parameters were assessed to determine their association with all-cause mortality during the early post-operative (<30 days) and late post-operative (>30 days) periods. Results: Early post-operative mortality (<30 days) was 8.8% and late post-operative mortality (>30 days) was 13.1%. Late survival showed 77.5% of the patients were alive with a mean follow-up period of 41 months. Increased age (p = 0.04), critical illness (p < 0.001), and higher urgency of intervention (p < 0.001) were associated with higher early post-operative mortality. Peri-operative organ failure, including cardiac (p = 0.025), renal (p = 0.016), and respiratory failure (p < 0.001), contributed significantly to both early and late mortality. Pre-operative antibiotics for fewer days (p = 0.024), ongoing sepsis (p = 0.022), and para-valvular extension (p = 0.046) were associated with higher early mortality. Conclusions: Infective endocarditis is a common indication for cardiac valve surgery in South Africa. Goal-directed medical management and clinical optimization prior to surgery were crucial to achieving better outcomes. Salvage procedures and critical illness with organ failure prior to surgery were associated with poorer outcomes. Despite unique challenges, cardiac surgery for infective endocarditis at Tygerberg Hospital compares favorably to international standards.

The iliac and femoral arteries: Dimensions and tortuosity in a South African radiological sample

BackgroundArterial morphology varies and changes with increasing age. This may challenge the success of endovascular procedures and influence candidate selection. The study aimed to determine the mean dimensions, tortuosity severity, and tortuosity phenotype of the iliofemoral pathway of adult males and females from a South African sample. Furthermore, the relationship between increased age and changes in vessel morphology was investigated. DesignA retrospective cross-sectional study was conducted using a sample of 224 (117 males and 107 females) computed tomography angiograms of patients hospitalized due to traumatic injuries (aged 18–80 years), accessed from Tygerberg Hospital, Cape Town, South Africa. MethodsThe arterial lengths and lumen diameters of the common iliac (CIA), external iliac (EIA), and femoral arteries (FA) were measured. Tortuosity severity was described by visual estimation and quantified using the tortuosity index (TI) and inflection count metric (ICM). The data were compared between right and left sides of the body, the sexes, and age categories. ResultsOn average, the common iliac artery was the widest (9.50 ± 1.53 mm), while the external iliac artery was the longest (110.89 ± 16.04 mm). Bilateral asymmetries were observed. Arterial diameters were larger in males. Regression analysis revealed a strong positive relationship between arterial tortuosity and increasing age, particularly in females. Tortuosity was most frequently observed in the external iliac artery. However, the c-shaped curving tortuosity phenotype was observed in all three arteries investigated. ConclusionThe morphology of the iliofemoral arterial pathway varied bilaterally, between the sexes, and with increased age. These findings align with previous studies, noting the variable morphology of the iliofemoral pathway, in countries outside of Sub-Saharan Africa. Sex- and age-specific descriptions of arterial anatomy may enhance the safety of endovascular procedures and interventions. These descriptions contribute towards the development of a reference database of typical arterial anatomy in South Africa, ultimately assisting with patient selection and the identification of vascular pathologies.

SARS-CoV-2 coinfection in children with severe airway obstruction due to pulmonary tuberculosis.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on tuberculosis (TB) control globally, with the number of new TB diagnoses decreasing. Coinfection with some viruses, especially measles, could aggravate TB in children. This is presumably a result of depressed cellular immunity. Reports on children with TB and SARS-CoV-2 coinfection are limited. A retrospective analysis of children up to 13 years old admitted to Tygerberg Hospital, Cape Town, South Africa, from March 2020 to December 2022 with suspected TB-induced airway compression requiring bronchoscopy. Children were included if they presented with severe intrathoracic airway obstruction and/or radiographic evidence of complicated TB. The patients were divided into two groups based on SARS-CoV-2 respiratory polymerase chain reaction results. Demographics, TB exposure, microbiology, SARS-CoV-2 laboratory data, imaging, inflammatory cytokine levels, and bronchoscopy data were collected. Statistical analyses compared SARS-CoV-2 positive and negative groups. Of the 50 children undergoing bronchoscopy for TB airway obstruction, 7 (14%) were SARS-CoV-2 positive. Cough was more prevalent in the SARS-CoV-2 positive group (p = 0.04). There was no difference in TB culture yield between groups. However, SARS-CoV-2 positive children showed slower radiological improvement at 1 month (p = 0.01), pleural effusions (p < 0.001), and a higher need for endoscopic enucleation (p < 0.001). FDG PET/CT scans indicated an ongoing inflammation in the SARS-CoV-2 positive group. Coinfection with SARS-CoV-2 in children with TB airway obstruction appears to complicate the disease course, necessitating more medical interventions and demonstrating a longer duration of the TB inflammatory process. Further research is needed to understand the impact of viral infections on TB progression and outcomes in pediatric patients.

Assessment Criteria to Diagnose Malnutrition (Undernutrition and Overnutrition) in Hemodialysis Patients

This study aimed to determine if adapted Global Leadership Initiative on Malnutrition (GLIM) criteria can diagnose overnutrition, in addition to undernutrition, in hemodialysis patients. Additionally, it compared the adapted GLIM criteria with the Subjective Global Assessment (SGA) for diagnosing undernutrition. A cross-sectional, descriptive study design with an analytical component was utilized. An interviewer-administered questionnaire (IAQ) was completed with 116 adult participants from two public renal units in Cape Town. Data collection included demographic, medical, and anthropometric information, incorporating the established SGA tool and the adapted GLIM criteria. Of the participants, 58% were female, with a mean age of 41.04 years (SD 10.6). The primary causes of renal failure were hypertension (38%) and glomerular disease (33%). The median weight was 64.74 kg (IQR 16.4) and the mean BMI was 25.44 kg/m2 (SD 4.66). The prevalence of obesity was 20%, and undernutrition was 4% by BMI. Participants from Groote Schuur Hospital (GSH) had a higher mean BMI (26.40, SD 4.9) than those from Tygerberg Hospital (TBH) (p=0.0033). Abdominal obesity prevalence was 51%, with a mean waist circumference of 87.06 cm (SD 11.37). Using SGA parameters, undernutrition prevalence was 26%, all classified as SGA-B, compared to 22% by adapted GLIM. Adapted GLIM classified 69.83% as malnourished (overnutrition 47%, undernutrition 22%). For undernutrition, the adapted GLIM had a sensitivity of 75% (CI 64.04, 85.96), specificity of 77.78% (CI 67.26, 88.3), positive predictive value of 69.23% (CI 57.55, 80.91), and negative predictive value of 82.35% (CI 72.71, 92.00). Among those diagnosed with overnutrition by adapted GLIM, 89% were classified as well-nourished by SGA. The adapted GLIM criteria effectively assessed overnutrition as well as undernutrition in hemodialysis patients. It identified a significant proportion of patients misclassified as well-nourished by SGA who were actually overnourished. The adapted GLIM showed good sensitivity and specificity for diagnosing undernutrition in this population.

Performance comparison of three commercial multiplex molecular panels for respiratory viruses at a South African academic hospital.

Respiratory infections are a major contributor to hospital admissions. Identification of respiratory pathogens by means of conventional culture and serology methods remains challenging. Multiplex molecular assays are an appealing alternative that endeavours to be rapid, more accurate and less arduous. The study aimed to compare the clinical performance of three commercial multiplex molecular assays for respiratory viruses. Forty-eight respiratory specimens obtained from patients at Tygerberg Hospital in the Western Cape province of South Africa were studied. These specimens were collected between May 2020 and August 2020. The results of the Seegene Anyplex™ II RV16, FilmArray® Respiratory 2.1 plus Panel (FARP), and QIAstat-Dx® Respiratory SARS-CoV-2 Panel (QRP) were analysed based on the overlapping targets. A composite reference standard was applied to provide a standard reference for comparison. The overall sensitivity of the Seegene Anyplex™ II RV16 was 96.6% (57/59), the FARP 98.2% (56/57) and the QRP 80.7% (46/57). The overall specificities were 99.8% (660/661), 99.0% (704/711) and 99.7% (709/711), respectively. The QRP failed to detect coronaviruses and parainfluenza viruses in 41.7% (5/12) and 28.6% (4/14) of positive specimens, respectively, while the FARP produced the lowest target specificity of 88.4% (38/43) for rhinovirus/enterovirus. The overall specificity of all three platforms was comparable; however, the sensitivity of the QRP was inferior to that of the ARV and FARP. This study adds to the body of performance characteristics described for respiratory multiplex panels, especially in the African context where molecular diagnostics for infectious diseases are gaining momentum.

The prevalence of human papillomavirus in ocular surface squamous neoplasia in HIV positive and negative patients in a South African population.

To assess the prevalence and subtypes of Human Papillomavirus (HPV) in Ocular Surface Squamous Neoplasia (OSSN) in Human Immunodeficiency Virus (HIV) positive and negative patients in South Africa. This study was a single center retrospective cross-sectional study, conducted at Tygerberg Hospital, Western Cape, South Africa. We assessed 63 histopathologically confirmed OSSN formalin-fixed paraffin-embedded (FFPE) tissue blocks from 2015-2023. The presence of HPV was determined using the Hybrispot Direct Flow Chip Kit. Corresponding clinical data was retrieved from the National Health Laboratory Service (NHLS) central data warehouse. Of the confirmed OSSN samples, 66.7% tested positive for HPV (95% confidence interval [CI] 54-77.3%). Of the 42 HPV positive samples, 38 (90.5%) had one or more known genotypes detected and 4 had unknown genotypes. The most prevalent subtypes were HPV 11, 16 and 18 (found in 61.9%, 52.4% and 33.3% of HPV positive samples respectively). 88.9% of the lesions biopsied were from HIV positive patients, of whom 56.4% had a CD4 + count of < 200 cells/µL. A lower median CD4 + count was detected among HIV positive patients with invasive squamous cell carcinoma compared to those with moderate dysplasia (p < 0.0198). There is a high prevalence of HPV in OSSN in South Africa. Certain subtypes namely, 11, 16, 18, 31, 33 and 35 may be more carcinogenic. HIV with HPV co-infection may be linked as a causative factor in the development of OSSN.

Towards improved theatre efficiency: a study of procedural times for common elective surgical procedures at Tygerberg Hospital

Towards improved theatre efficiency: a study of procedural times for common elective surgical procedures at Tygerberg Hospital

Urinary metabolic characterization of advanced tuberculous meningitis cases in a South African paediatric population.

Tuberculous meningitis (TBM) is a severe form of tuberculosis with high neuro-morbidity and mortality, especially among the paediatric population (aged ≤12years). Little is known of the associated metabolic changes. This study aimed to identify characteristic metabolic markers that differentiate severe cases of paediatric TBM from controls, through non-invasive urine collection. Urine samples selected for this study were from two paediatric groups. Group 1: controls (n = 44): children without meningitis, no neurological symptoms and from the same geographical region as group 2. Group 2: TBM cases (n = 13): collected from paediatric patients that were admitted to Tygerberg Hospital in South Africa on the suspicion of TBM, mostly severely ill; with a later confirmation of TBM. Untargeted 1H NMR-based metabolomics data of urine were generated, followed by statistical analyses via MetaboAnalyst (v5.0), and the identification of important metabolites. Twenty nine urinary metabolites were identified as characteristic of advanced TBM and categorized in terms of six dysregulated metabolic pathways: 1) upregulated tryptophan catabolism linked to an altered vitamin B metabolism; 2) perturbation of amino acid metabolism; 3) increased energy production-metabolic burst; 4) disrupted gut microbiota metabolism; 5) ketoacidosis; 6) increased nitrogen excretion. We also provide original biological insights into this biosignature of urinary metabolites that can be used to characterize paediatric TBM patients in a South African cohort.

Bullous pemphigoid and its association with neurological diseases

Background: Bullous Pemphigoid (BP) is the most common immunobullous skin disease.Methods: This was a descriptive cross-sectional study of electronic health records data at a specialist dermatology clinic at Tygerberg Hospital in the Western Cape. Patients presenting during a predefined 5-year period with a clinicopathologic diagnosis of BP were included.Results: The final sample comprised 54 cases of BP. The median age at diagnosis was 71.0 years, and 64.8% were female. Eighty per cent had at least one chronic medical condition at the time of BP diagnosis. The most common comorbidities were hypertension (63.0%), diabetes mellitus (33.3%) and strokes (24.1%). Twenty-eight per cent had been diagnosed with at least one neurological comorbidity at the time of BP diagnosis. Patients experienced a median delay of 45 days (interquartile range: 21.0-90.0 days) between onset of symptoms and presentation to dermatology.Conclusion: This is the first study reporting co-morbidities in patients with BP in sub-Saharan Africa. Despite the high burden of disease due to physical injury in the study setting, no patients with BP had a history of traumatic brain injury. This suggests the possibility that the association between BP and neurologic disorders is limited to stroke, epilepsy, and neurodegenerative diseases. Future prospective cohort studies are indicated to further investigate the results of this study.Contribution: To describe neurologic and other comorbidities in patients presenting with BP at a tertiary hospital in South Africa. This research in South Africa, a lower-middle-income country, seeks to address knowledge gaps, utilize data, and advance the field of dermatology.

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

IntroductionPulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. MethodThis study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. ResultsOf the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. ConclusionEarly identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Evaluation of Gallium-68 prostate-specific membrane antigen, positron emission tomography/computed tomography (GA-68 PSMA PET/CT) in recurrent prostate cancer: a retrospective review of initial clinical experience at Tygerberg Hospital.

prostate cancer recurrence after definitive therapy for organ-confined disease often manifests as rising prostate-specific antigen (PSA) levels without clinically overt disease. 68Gallium prostate-specific membrane antigen, positron emission tomography/computed tomography (68GaPSMA PET/CT) imaging plays a major role in the management of recurrent prostate cancer. The purpose of this study was to assess the positivity rate of 68Ga PSMA PET/CT scans in cases of prostate cancer recurrence, and to compare the results with existing international literature. a retrospective analysis of 177 68Ga PSMA PET/CT scans of patients with biochemically proven disease recurrence was performed. The possible association of a positive PSMA PET/CT with the PSA level and Gleason score were analyzed. a total of 177 68Ga PSMA PET/CT scans were performed in 163 patients (median age 66 years). Of these, 117 (66%) scans detected the site of disease recurrence. Among patients with PSA 0.2-0.99 ng/ml, 23/49 (47%, p<0.0001) were positive, and 20/35 (57%, p<0.0005) were positive in the group of patients with PSA 1.00-1.99. When PSA values were further categorized into PSA <2 ng/ml and PSA ≥2 ng/ml, detection rates were 49% and 86% respectively (p <0.0001). The scans were positive in 65% of patients with Gleason score of <7, 62% with Gleason score of =7 and 68% with Gleason score >7 (p=0.745). there was an increase in the detection rate with an increase in the PSA. Gleason score was not a predictor of a positive 68Ga PSMA PET/CT scan. 68Ga-PSMA PET/CT should be prioritized in patients with biochemical recurrence with PSA levels >0.2 ng/ml.

The impact of the COVID-19 pandemic on lung cancer presentation at a high-volume tertiary referral centre in South Africa.

The COVID-19 pandemic had a significant impact on health services globally. Cancer diagnosis and treatment was one of the services most frequently reported to be disrupted. Several international studies showed a marked reduction in the number of new lung cancer cases. To assess the impact of the COVID-19 pandemic on lung cancer diagnosis at a high-volume tertiary referral centre in South Africa. A retrospective audit was conducted of all patients with primary lung cancer who were presented at the multidisciplinary oncology meeting at Tygerberg Hospital, Cape Town, from January 2018 to December 2021, and the incidence of lung cancer was compared between two cohorts: one prior to and one during the COVID-19 pandemic. We collected data on patient demographics, as well as performance status. A combined panel staged all patients. During the COVID-19 pandemic there was a relative reduction of 46% in the frequency of lung cancer, from a mean of 25.6 cases per month to 13.9. Patients referred during the COVID-19 pandemic had statistically better performance status (75.0% v. 25.0% with performance status 0 - 2; p=0.01) and were more likely to have adenocarcinoma (49.7% v. 41.1%; p=0.02) than those referred before the pandemic. The proportion of potentially curable lung cancer at presentation (i.e. stages I - IIIA) did not differ between the two cohorts. The COVID-19 pandemic resulted in a substantial decrease in the number of new lung cancers diagnosed. Patients who were diagnosed with lung cancer during the pandemic had better performance status and were more likely to have adenocarcinoma. No impact on the proportion of potential curable disease was noted. What the study adds. Health services globally were substantially impacted by the COVID-19 pandemic. Cancer diagnosis and treatment was one of the services most frequently reported to be disrupted. This study highlights the significant impact of the COVID-19 pandemic on lung cancer presentation in a high-volume tertiary hospital in South Africa.Implications of the findings. Lung cancer is known to have high mortality. The reduction in lung cancer presentation during the COVID-19 pandemic is likely to result in an increase in lung cancer-related morbidity and mortality over the next few years.

Evaluation of Noninvasive Tools for Predicting Esophageal Varices in Patients With Cirrhosis at Tygerberg Hospital, Cape Town.

Background: In patients with cirrhosis, esophageal variceal hemorrhage (EVH) is a devastating consequence of portal hypertension (PH). Upper endoscopy is considered the gold standard for the detection and diagnosis of esophageal varices (EVs), despite being invasive and costly. This study was aimed at identifying and evaluating the diagnostic accuracy of noninvasive tools in predicting EVs in patients with compensated cirrhosis. Methods: This cross-sectional study included 50 patients with compensated cirrhosis at the Tygerberg Hospital Gastroenterology Clinic in Cape Town between November 2022 and May 2023. We collected clinical, anthropometric, and laboratory data from patients' physical and electronic charts. All patients underwent an abdominal ultrasound, vibration-controlled transient elastography (VCTE) to assess liver and splenic stiffness, and upper endoscopy. In this comparative study, we evaluated the diagnostic accuracy of different noninvasive tools in detecting EVs in patients with compensated cirrhosis. Results: Of the 50 patients included in the study, 30 (60%) were female and 20 (40%) were male. The patients' age ranged from 18 to 83, with a mean age of 46.6 years. Cirrhosis was mainly due to alcohol use (n = 11, 22%), hepatitis B virus (HBV) infection (n = 11, 22%), and autoimmune hepatitis (n = 10, 20%). The patients included in the study were divided into two subgroups: with (n = 34, 68%) or without (n = 16, 32%) EVs. Statistically significant differences were detected between groups in platelet count (PC), liver stiffness measurement (LSM), spleen stiffness measurement (SSM), portal vein diameter (PVD), bipolar spleen diameter (SBD), aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), platelet/bipolar spleen diameter ratio (PSR), liver stiffness-spleen size-platelet ratio (LSPS), liver stiffness-spleen stiffness-platelet ratio score (LS3PS), and spleen stiffness-spleen size-platelet ratio score (SSPS) (p < 0.001). The highest diagnostic precision was observed with SSM (96%), SSPS (96%), LS3PS (94%), LSPS (94%), PSR (94%), and PC (92%). SBD (88%), LSM (86%), APRI (82%), and FIB-4 (82%) had the lowest diagnostic accuracy. Conclusion: SSM and SSPS have the highest diagnostic accuracy for predicting the presence of EVs in patients with compensated cirrhosis. LSPS, LS3PS, and PSR come second at 94%. We recommend SSM and SSPS in institutions with transient elastography equipped with the software necessary to measure splenic stiffness. We introduce and propose LS3PS as a novel composite score for predicting the presence of EVs in patients with compensated cirrhosis. Large-sample-size studies are needed to validate these prediction scores and to allow direct comparison with Baveno VII. These prediction tools can help clinicians avoid unnecessary endoscopic procedures in patients with compensated cirrhosis, especially in developing countries with limited resources such as South Africa.

Clinical spectrum of disease and outcomes in children with Omicron SARS-COV-2 infection in Cape Town, South Africa.

Children with underlying comorbidities and infants are most severely affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, including in low- and middle-income countries with a high prevalence of HIV and TB. We describe the clinical presentation of SARS-CoV-2 infection in children during the Omicron wave, in Cape Town, South Africa. We analysed routine care data from a prospective cohort of children aged 0-13 years, with a positive SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) or SARS-CoV-2 antigen test, admitted to Tygerberg Hospital between 1 November 2021 until 1 March 2022. Risk factors for severity of disease were assessed. Ninety-five children tested positive for SARS-CoV-2, of whom 87 (91.6%) were symptomatic. Clinical data were available for 86 children. The median age was 11 months (IQR 3.0-60.0), 37 (43.0%) were females, 21 (24.7%) were HIV-exposed and 7 (8.1%) were living with HIV (CLHIV). In total, 44 (51.2%) children had at least one underlying comorbidity. TB co-infection was seen in 11 children, 6 children were newly diagnosed and 5 children were already on TB treatment at the time of admission. There was no evidence of more severe disease in children living with HIV or TB.

Genetic basis of osteogenesis imperfecta from a single tertiary centre in South Africa

Osteogenesis imperfecta (OI) is a clinically heterogeneous disorder characterised by skeletal fragility and an increased fracture incidence. It occurs in approximately one in every 15–20,000 births and is known to vary considerably in its severity. This report aimed to use next-generation sequencing (NGS) technology to identify disease genes and causal variants in South African patients with clinical-radiological features of OI. A total of 50 affected individuals were recruited at Tygerberg Hospital’s Medical Genetics clinic. Patients were selected for a gene panel test (n = 39), a single variant test (n = 1) or exome sequencing (ES) (n = 12, 7 singletons, 1 affected duo, and 1 trio), depending on funding eligibility. An in-house genomic bioinformatics pipeline was developed for the ES samples using open-source software and tools. This study’s 100% diagnostic yield was largely attributable to an accurate clinical diagnosis. A causal variant in COL1A1 or COL1A2 was identified in 94% of this patient cohort, which is in line with previous studies. Interestingly, this study was the first to identify the common South African pathogenic FKBP10 variant in a patient of mixed ancestry, adding to what was previously known about this variant in our population. Additionally, a recurrent variant in COL1A2: c.1892G>T was discovered in 27 individuals (25 from three large unrelated families and two further individuals), facilitating the establishment of local testing for this variant in South African patients.

Outcomes of complex burn injury patients managed at two primary and one tertiary level burns facilities in the Western Cape province of South Africa - a retrospective review.

This study aimed to compare factors contributing to a positive outcome of adult burn injury patients managed at two primary and one tertiary level Western Cape hospitals. These patients from the primary hospitals (PLHs) met the referral criteria for specialised care at the Tygerberg Hospital burns unit (TBU) but were not accepted or were accepted late. A total of 1034 adult burn injury patients seen at two primary level ("A" and "B") hospitals and the TBU between 2016 and 2019 were retrospectively analysed. One hundred and eleven (111) primary level patients ("A" 71, "B" 40) met the criteria for referral to the TBU. The outcomes and factors contributing to positive outcome of these patients were compared with the 859 patients treated at the TBU during the same period. Patients treated at the TBU showed longer theatre waiting times, more operations, and higher complication and death rates than their primary level counterparts. The PLHs showed no factors significantly contributing to hospital discharge. At TBU, pregnancy status, younger age, hot water burns, lower abbreviated burns severity index (ABSI) score, and longer time to theatre were associated with hospital discharge. A shortage of beds was the main reason for denial of admission to the TBU. The PLHs showed good outcomes in managing severe burn injuries, although no significant contributors to a positive outcome were identified. Patient- and facility-related factors contributed to positive outcomes at the TBU. Upgrading both the Western Cape's primary level capabilities and the TBU's accessibility and efficiency are necessary to improve burns services.

Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity.

Diabetic ketoacidosis (DKA) during pregnancy poses significant risks to both the mother and fetus, with an increased risk of fetal demise. Although more prevalent in women with Type I diabetes (T1D); those with Type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) can also develop DKA. A lack of information about DKA during pregnancy exists worldwide, including in South Africa. This study examined the characteristics and outcomes associated with DKA during pregnancy. The study took place between 1 April 2020 and 1 October 2022. Pregnant women with DKA, admitted to Tygerberg Hospital's Obstetric Critical Care Unit (OCCU) were included. Maternal characteristics, precipitants of DKA, adverse events during treatment, and maternal-fetal outcomes were examined. There were 54 episodes of DKA among 47 women. Most DKA's were mild and occurred in the third trimester. Pregestational diabetes dominated (31/47; 60%), with 47% having T1D and 94% requiring insulin. Seven women (7/47, 15%; T2D:6, T1D:1) had two episodes of DKA during the same pregnancy. Most women (32/47; 68%) were either overweight or obese. Yet, despite the T2D phenotype, biomarkers indicated that auto-immune diabetes was prevalent among women without any prior history of T1D (6/21; 29%). Twelve women (26%) developed gestational hypertension during pregnancy, and 17 (36%) pre-eclampsia. Precipitating causes of DKA included infection (14/54; 26%), insulin disruption (14/54; 26%) and betamethasone administration (10/54; 19%). More than half of the episodes of DKA involved hypokalemia (35/54, 65%) that was associated with fetal death (P=0.042) and hypoglycemia (28/54, 52%). Preterm birth (<37 weeks' gestation) occurred in 85% of women. No maternal deaths were recorded. A high fetal mortality rate (13/47; 28%) that included 11 spontaneous intrauterine deaths and two medical terminations, was observed. Women with DKA have a high risk of fetal mortality as well as undiagnosed auto-immune diabetes. There is a strong link between maternal hypokalemia and fetal loss, suggesting an opportunity to address management gaps in pregnant women with DKA.