L. du Plessis

The molecular basis and diagnosis of familial hypercholesterolaemia in South African Afrikaners

Three different point mutations were recently identified in South African familial hypercholesterolaemics. These mutations result in the modification of recognition sites of specific restriction endonucleases. This study describes rapid methods for presymptomatic detection of these defects based on restriction enzyme analysis or allele‐specific hybridization of enzymatically amplified genomic DNA. These methods were used to determine the frequencies of the three known low‐density lipoprotein (LDL) receptor gene mutations in 138 chromosomes of Afrikaner FH patients. It has been shown that a common mutation at the 3′ end of exon 4 (base 681) of the LDL receptor gene is present in about 70% of alleles, while the mutations in exons 9 (base 1285) and 4 (base 523) of the gene are present in about 20 and 10% respectively of the genes studied. These mutations were found in approximately 95% of Afrikaner familial hypercholesterolaemic patients studied, indicating at least three founder members for the disease in this population of South Arica.

Mutational and genetic origin of LDL receptor gene mutations detected in both Belgian and Dutch familial hypercholesterolemics

Abstract DNA samples from 100 unrelated Belgian patients with familial hypercholesterolemia (FH) were screened for the presence of specific low-density lipoprotein receptor (LDLR) gene mutations, previously shown to be prevalent in related populations. Two point mutations, viz., P664L and a G to A splicing defect at position 1359–1, were detected in single Flemish-speaking families. A long-distance polymerase chain reaction (PCR) assay, used to screen for the 4-kb and 2.5-kb deletions previously identified by Southern blot analyses in different parts of The Netherlands, revealed a 3-kb deletion in two Belgian patients. Comparison of PCR product length showed that both Dutch deletions of exons 7–8 are identical to that found in Belgians, but different from the 2.5-kb deletion previously described in South Africans of mixed ancestry. The Belgian patients probably share a common ancestor, for each mutation identified, with FH patients from The Netherlands, since all three mutations were associated with the same LDLR gene haplotype as described for the Dutch population. Analysis of the deletion junctions demonstrated the role of a 31-bp repetitive sequence in the generation of large rearrangements involving exons 7 and 8 of the LDLR gene. The finding that only 4 out of 100 analyzed Belgian hypercholesterolemics carry a known LDLR mutation that is prevalent in related populations suggests that the Belgian FH population has its own spectrum of mutations.

Significance of novel endothelin-B receptor gene polymorphisms in Hirschsprung's disease: predominance of a novel variant (561C/T) in patients with co-existing Down's syndrome.

Several genes have been implicated in the pathogenesis of Hirschsprungs disease (HSCR). In a previous study performed, five novel (V202M, E480K, IVS10-2A/G, D771N, IVS19-9C/T) mutations and one previously described mutation (P937L) have been identified in the RET proto-oncogene in 20% of the study population. To further investigate the involvement of other genes, mutation analysis of the endothelin-B receptor (EDNRB) gene was performed in 52 unrelated sporadic HSCR patients, including 38 non-syndromic and 14 patients with HSCR and Downs syndrome. Six novel (178G/A, 552C/T, 561C/T, 702C/T, IVS3-6C/T and IVS4 + 3A/G) sequence variants and one previously described (831G/A) polymorphism were identified. Statistically significant differences were achieved for six (178G/A, 552C/T, 561C/T, 702C/T, IVS3-6C/T and 831G/A) of these variants. The T-allele of the 561C/T polymorphism was over represented in the HSCR/Downs syndrome patient group (36% representing 5 of 14) compared to normal controls (6% representing 5 of 84) (p < 0.002, chi(2) with Yates correction = 12.14), suggesting that the 561C/T variant is associated with a low penetrance effect in patients with this complex phenotype. Detection of the 178G/A polymorphism in only non-syndromic HSCR patients, provide further support for an important role of specific sequence variants in the EDNRB gene in the HSCR/Downs syndrome phenotype.

Clinical features and outcome of lupus myocarditis in the Western Cape, South Africa

Background African American ethnicity is independently associated with lupus myocarditis compared with other ethnic groups. In the mixed racial population of the Western Cape, South Africa, no data exists on the clinical features/outcome of lupus myocarditis. Objectives The objective of this study was to give a comprehensive description of the clinical features and outcome of acute lupus myocarditis in a mixed racial population. Methods Clinical records (between 2008 and 2014) of adult systemic lupus erythematosus (SLE) patients at a tertiary referral centre were retrospectively screened for a clinical and echocardiographic diagnosis of lupus myocarditis. Clinical features, laboratory results, management and outcome were described. Echocardiographic images stored in a digital archive were reanalysed including global and regional left ventricular function. A poor outcome was defined as lupus myocarditis related mortality or final left ventricular ejection fraction (LVEF) <40%. Results Twenty-eight of 457 lupus patients (6.1%) met inclusion criteria: 92.9% were female and 89.3% were of mixed racial origin. Fifty-three per cent of patients presented within three months after being diagnosed with SLE. Seventy-five per cent had severely active disease (SLE disease activity index ≥ 12) and 67.9% of patients had concomitant lupus nephritis. Laboratory results included: lymphopenia (69%) and an increased aRNP (61.5%). Treatment included corticosteroids (96%) and cyclophosphamide (75%); 14% of patients required additional immunosuppression including rituximab. Diastolic dysfunction and regional wall motion abnormalities occurred in > 90% of patients. LVEF improved from 35% to 47% (p = 0.023) and wall motion score from 1.88 to 1.5 (p = 0.017) following treatment. Overall mortality was high (12/28): five patients (17.9%) died due to lupus myocarditis (bimodal pattern). Patients who died of lupus myocarditis had a longer duration of SLE (p = 0.045) and a lower absolute lymphocyte count (p = 0.041) at diagnosis. LVEF at diagnosis was lower in patients who died of lupus myocarditis (p = 0.099) and in those with a persistent LVEF < 40% (n = 5; p = 0.046). Conclusions This is the largest reported series on lupus myocarditis. The mixed racial population had a similar prevalence, but higher mortality compared with other ethnic groups (internationally published literature). Patients typically presented with high SLE disease activity and the majority had concomitant lupus nephritis. Lymphopenia and low LVEF at presentation were of prognostic significance, associated with lupus myocarditis related mortality or a persistent LVEF < 40%.

Evaluation of the implementation of the vitamin A supplementation programme in the Boland/Overberg region of the Western Cape Province

Objective: To assess the implementation of the vitamin A supplementation programme in primary health care (PHC) clinics in a rural area of the Western Cape Province. Material and methods: A study was conducted at 14 randomly selected PHC clinics. All children aged 6 - 60 months attending on the day of surveying with their mothers/caregivers were selected by purposive sampling, after they had been seen by a PHC nurse in the clinic. A structured exit interview was conducted with the mother/caregiver of each child. The information from 56 such interviews could be utilised for data analysis. The manager of each clinic was also interviewed. Results: Seventy-seven per cent of the study population (N=40) was eligible for high-dose vitamin A supplementation on the day of the study, based on the criteria of the vitamin A supplementation protocol. However, 25% of these children (N=10) did not receive vitamin A, even though there was an indication to administer it. Only 39% of mothers (N=22) reported that they were aware of the supplementation programme. All the health facility managers of the clinics had received training in the programme. Staffing problems and stock shortages appeared to play a role in inadequate implementation of the programme at some clinics. In addition, health facility managers reported that many children failed to receive their vitamin A dose because parents did not bring them regularly to clinics. Conclusions: The vitamin A supplementation programme appears to be reasonably successfully implemented in the Boland/Overberg region. Informing mothers about the importance of vitamin A supplementation and regular clinic attendance, as well as improving the availability of human and material resources and logistic support at PHC facilities, may further enhance the implementation and success of the programme.

Comparison of infant-feeding practices in two health subdistricts with different baby-friendly status in Mpumalanga province

Abstract Objectives: The objective of the study was to compare the infant-feeding practices of two subdistricts with different baby-friendly status in Mpumalanga province, South Africa. Design: This was a cross-sectional, descriptive, observational study with an analytical component. Eighteen fieldworkers assisted with the data collection, utilising two sets of interviewer-administered questionnaires – one on socio-demographic information and the other on infant-feeding practices. Subjects: Mothers with infants from birth to six months old, attending postnatal care at public sector primary health care facilities in Emalahleni and Mbombela health subdistricts on the days of data collection were included. A total of 435 mother and infant pairs were included in the study. Outcome measures: Five infant-feeding indicators were used, namely the early initiation of breastfeeding, exclusive breastfeeding, exclusive replacement feeding and mixed feeding rates, as well as the age at which complementary food was introduced. Results: There was a significantly higher early initiation of breastfeeding (57% vs. 43%), exclusive breastfeeding rates (60% vs 48%), and a lower exclusive replacement feeding rate (18% vs. 33%) in Emalahleni subdistrict, where all the public sector maternity facilities are accredited as being baby friendly, compared to that in Mbombela subdistrict, where none of the public sector maternity facilities are baby friendly. The mixed feeding rate (19% vs. 15%) and the mean age of the introduction of complementary foods (50 days versus 35 days) did not differ significantly between the two subdistricts. Conclusion: Implementation of the Baby-Friendly Hospital Initiative (BFHI) in a health subdistrict was associated with more optimal infant-feeding practices in mothers with infants aged six months and younger. It is concluded that strengthening practices prescribed within the BFHI would improve infant-feeding practices at community level.AbstractObjectives: The objective of the study was to compare the infant-feeding practices of two subdistricts with different baby-friendly status in Mpumalanga province, South Africa.Design: This was a cross-sectional, descriptive, observational study with an analytical component. Eighteen fieldworkers assisted with the data collection, utilising two sets of interviewer-administered questionnaires – one on socio-demographic information and the other on infant-feeding practices.Subjects: Mothers with infants from birth to six months old, attending postnatal care at public sector primary health care facilities in Emalahleni and Mbombela health subdistricts on the days of data collection were included. A total of 435 mother and infant pairs were included in the study.Outcome measures: Five infant-feeding indicators were used, namely the early initiation of breastfeeding, exclusive breastfeeding, exclusive replacement feeding and mixed feeding rates, as well as the age at which complementary food was introdu...

Allelic variation in the promoter region of the LDL receptor gene: analysis of an African-specific variant in the FP2 cis-acting regulatory element

DNA samples of 2303 individuals from nine different population groups were screened for variant -175g-->t in the promoter region of the low-density lipoprotein receptor (LDLR) gene. The -175g-->t variant detected at carrier frequencies of 3-10% in different African population groups was absent in the Caucasian and Asian (Chinese) individuals studied. In contrast to previous findings in Black South Africans where this polymorphism predominated in patients with familial hypercholesterolaemia (FH), it occurred at a significantly lower frequency in hypercholesterolaemics from the recently admixed Coloured population of South Africa compared with population-matched controls (P<0.0001). Haplotype and mutation analysis excluded the likelihood that this finding is due to association with a specific disease-related mutation in FH patients, although reversal of the positive association with FH observed in the Black population may, at least in part, be due to admixture linkage disequilibrium. Transient transfection studies in HepG2 cells demonstrated that the -175t allele is associated with a non-significant decrease ( approximately 7%) of LDLR transcription in the absence of sterols. The data presented in this study raise the possibility that the -175g-->t polymorphism may have subtle effects that become clinically important within certain genetic and/or environmental contexts.

Burden, spectrum and outcomes of children with tuberculosis diagnosed at a district-level hospital in South Africa

SETTING The Khayelitsha subdistrict has the highest burden of reported tuberculosis (TB) cases in Cape Town, Western Cape Province, South Africa. OBJECTIVES To characterise the TB burden, spectrum and treatment outcomes among children managed at a district-level hospital, the Khayelitsha District Hospital. DESIGN Retrospective medical record review of all children (age <13 years) diagnosed with TB in January-July 2014. A lay health care worker completed daily surveillance and supported linkage to TB care. Symptoms and investigations at presentation, TB disease spectrum, referral pathways and outcomes were reported. RESULTS Most children were aged 2 years (84/99, 85%), 18/96 (19%) were infected with the human immunodeficiency virus, 31/91 (34%) were malnourished and 80/99 (81%) had pulmonary TB only. The majority of the children (63/80, 79%) presented with cough of acute onset (<2 weeks). Only 5/36 (14%) eligible child contacts had documentation of receiving isoniazid preventive therapy. Twelve (13%) children had bacteriologically confirmed pulmonary TB. Overall, 93/97 (96%) children successfully continued TB care after hospital discharge. Favourable TB treatment outcomes were recorded in only 77 (78%) children. CONCLUSIONS Children with TB managed at this district-level hospital were young, and frequently had acute symptoms and substantial comorbidities. Missed opportunities for TB prevention were identified. Linkage to care support resulted in excellent continuation of TB care; however, treatment outcomes could be further improved.

Operational implementation and impact of The Union's online childhood TB training course in South Africa

Novel, effective tuberculosis (TB) training strategies are needed in developing settings to scale up training and improve TB management at facility level. This study evaluated the feasibility of implementing an online childhood TB training course for community-based health-care workers in the Eastern Cape Province, South Africa, and measured its impact on knowledge. Training sessions were convened and participants completed the course independently. A total of 220 primary care participants completed pre- and post-training tests. The mean knowledge increase was 8% (95% confidence interval 7.0-8.8, P < 0.001). The course proved an acceptable, versatile option for decentralised training in childhood TB, provided that the technology requirements can be met.

AB0606 Lupus Myocarditis in the Western Cape, South Africa: Analysis of Clinical and Echocardiographic Features

Background Lupus myocarditis (LM) is a serious manifestation of systemic lupus erythematosus (SLE). LM in patients of African American ethnicity has an increased prevalence and higher mortality compared to other ethnic groups. In the mixed racial population of the Western Cape, South Africa, no data exists on the clinical features and outcome of LM. Echocardiography is frequently used to support the diagnosis of LM. Speckle tracking (ST) is more sensitive than standard imaging in the detection of left ventricular (LV) dysfunction. Literature on the use of ST in patients with clinically evident LM is limited. Objectives To give a comprehensive description of the clinical and echocardiographic features of acute LM in a mixed racial population. Methods Clinical records (over 6 years) of adult SLE patients at a tertiary referral centre were retrospectively screened for a clinical and echocardiographic diagnosis of LM. Clinical features, laboratory results, management and outcome were described. Echocardiographic images stored in a digital archive were reanalysed (where views allowed), including LV regional wall motion abnormalities (RWMA) and longitudinal strain through ST. Results 28 patients (6.1%) met inclusion criteria: 92.9% were female and 89% were of mixed racial origin. 54% of patients presented with LM within 3 months after being diagnosed with SLE. Median SLE disease activity index was 17.5 (IQR:12.3-24) and 50% of patients had concomitant lupus nephritis. Laboratory results included: low complement (92.3%); urinary protein >0.5g/day (83%); increased aRNP (62%). Initial (at time of diagnosis) and most recent echocardiographic data are summarised in table 1. Treatment included corticosteroids (96%) and cyclophosphamide (75%); 14% of patients required additional immunosuppression. Clinical improvement occurred in 67% of patients (563 days, median); 2 patients relapsed. Though the median LV ejection fraction (LVEF) improved from 35 to 47%, reduced longitudinal strain and RWMA persisted in most patients (Table 1). Overall mortality was high (12/28): 5/28 (17.9%) died due to LM compared to 2/24 (8.3%) in another case series. Mortality due to LM and/or treatment related complications were 35.7% (10/28).Table 1 Initial echocardiogram (n=28) Most recent echocardiogram (n=19) Median Ratio of test done Median Ratio of test done (IQR) (%) (IQR) (%) Time (days) 0 390 (93–799) Increased LVIDa (cm) 5.2 (4.4–5.6) 11/28 (39) 4.8 (4–5.6) 5/19 (26) LVEFb 35% (26–46) 47% (37–50) RWMA present 24/24 (100) 16/18 (89) Decreased longitudinal strain 13/13 (100) 8/8 (100) IQR: interquartile range; LVID: left ventricular internal diameter; LVEF: left ventricular ejection fraction; RWMA: regional wall motion abnormalities.a Increased LVID >5.3cm;b LVEF: Mild impairment: 45–54%; moderate: 36–44%; severe: ≤35%. Conclusions This is the largest reported case series on LM. The mixed racial population had a similar prevalence, but higher mortality compared to other ethnic groups (published literature). An increased awareness towards an early diagnosis is essential, especially in recently diagnosed SLE patients with concomitant lupus nephritis. ST (not previously described in acute LM) and RWMA showed persistent LV dysfunction despite an improved LVEF and could be utilised as a sensitive diagnostic tool in LM. Disclosure of Interest None declared