Yoshan Moodley

Procalcitonin, C-reactive protein and prognosis in septic patients

Sepsis is of major importance worldwide, placing economic burden on healthcare systems and often resulting in morbidity and mortality in affected patients. The use of rapid, effective prognostic laboratory tests will no doubt improve decision-making on the part of the physician. We describe prospective observational studies of two commonly used biomarkers when monitoring the clinical course of sepsis, procalcitonin and C-reactive protein, herein. Keywords: Procalcitonin, C-reactive protein, sepsis

Preoperative serum sodium measurements and postoperative inpatient mortality: A case-control analysis of data from the South African Surgical Outcomes Study

BACKGROUND Abnormal preoperative serum sodium measurements have been shown to be associated with increased postoperative mortality in US and European surgical populations. It is possible that such measurements are also associated with increased postoperative mortality in a South African (SA) setting, but this is yet to be confirmed. Establishing whether preoperative serum sodium measurements are associated with postoperative mortality could have implications for perioperative risk stratification in SA settings. OBJECTIVES To determine whether preoperative serum sodium measurements are associated with postoperative mortality in SA surgical patients. METHODS This was an unmatched case-control study of patient data (demographics, comorbidities, procedure-related variables, and preoperative serum sodium measurements) collected during the South African Surgical Outcomes Study. Data were analysed using recommended statistical methods for unmatched case-control studies. RESULTS The study population comprised 103 patients and 410 controls. Cases were defined as patients who suffered postoperative inpatient mortality, while controls were defined as patients who did not suffer postoperative inpatient mortality. Preoperative hypernatraemia (i.e. a preoperative serum sodium measurement >144 mEq/L) was independently associated with a four-fold higher risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement of 135 - 144 mEq/L (odds ratio (OR) 4.21, 95% confidence interval (CI) 1.19 - 14.83, p=0.025). Preoperative hyponatraemia (i.e. a preoperative serum sodium measurement <135 mEq/L) was not independently associated with a higher or lower risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement (OR 1.39, 95% CI 0.70 - 2.76, p=0.346). CONCLUSIONS Preoperative hypernatraemia, but not preoperative hyponatraemia, is a risk factor for postoperative inpatient mortality in SA surgical patients.

Fibroadenoma of the breast in a South African population -a pilot study of the diagnostic accuracy of fine needle aspirate cytology and breast ultrasonography

Background The triple assessment of clinical breast exam (CBE), fine needle aspirate cytology (FNAC) and breast ultrasonography (US) is used in many settings for the diagnosis of fibroadenoma (FA). The diagnostic accuracy of FNAC and US for FA in South African (SA) women with palpable breast masses (PBM) is unknown. Objective To report the diagnostic accuracy of FNAC/US for FA in SA women with PBM. Methods We conducted a retrospective pilot diagnostic study of 91 women who presented with PBM to a SA regional academic hospital. Data for CBE, US, unguided FNAC, and open biopsies was collected from study participant medical records and analyzed using diagnostic accuracy tables. Results A total of 57/91 (62.6%) study participants had uninterpretable FNAC results. No study participants had uninterpretable US results. The overall diagnostic accuracy of FNAC for FA was 36.3% (95% Confidence Interval - CI: 27.1–46.5%). The overall diagnostic accuracy of US for FA was 83.5% (95% CI: 74.6–89.8%). Conclusion The yield of interpretable test results for FNAC was poor in our study. The diagnostic accuracy of US for FA appears to be superior to that of FNAC. Omission of FNAC from the triple assessment in our setting should be considered.

The impact of an unknown HIV serostatus on inpatient mortality

Introduction Determining HIV serostatus is crucial for linking HIV-infected patients to appropriate care, which might reduce their risk of subsequent morbidity and mortality. A recent South African study demonstrated a potentially harmful association between an unknown HIV serostatus and rehospitalisation. The impact of an unknown HIV status on inpatient mortality has not yet been established in that setting, which formed the impetus for the current study. Methods This was an unmatched case-control analysis of adult patient data collected as part of a demographic survey at the Hlabisa Hospital, South Africa between October 2009 and February 2014. Cases were defined as patients who suffered inpatient mortality, while controls were patients who did not suffer inpatient mortality. A sample size of 92 cases and 276 controls was used in this study. Patient data related to age, gender, distance between referral clinic and the hospital, HIV serostatus (HIV-negative, HIV-positive or an unknown HIV serostatus) and comorbidity were analysed using recommended methods for unmatched case-control studies. Results When potential confounders were accounted for, we found an unknown HIV serostatus to be associated with an almost 8-fold increase in the odds of inpatient mortality when compared with patients who were known HIV-negative (Odds Ratio: 7.64, 95% Confidence Interval: 1.11-52.33, p = 0.038). Conclusion An unknown HIV serostatus was independently associated with a higher odds of inpatient mortality. This finding highlights the potential benefit of adopting an “opt-out” approach to HIV counseling and testing. Further research on this topic is required.

An HIV-positive status and short term perioperative mortality – a systematic review

Background: A contemporary summary describing the impact of an HIV-positive status on short term perioperative mortality is lacking.Objective: To collate and summarise published data related to short term perioperative mortality from studies comparing HIV-positive and HIV-negative patient groups.Method: We conducted a systematic review of the published literature by performing structured searches of two medical literature databases. Pre-defined inclusion/exclusion criteria were used to identify potentially relevant manuscripts. Further screening of the reference lists of eligible manuscripts, as well as a prior systematic review was also performed to identify any additional manuscripts that may have been relevant. Data retrieved from eligible manuscripts included, amongst other variables: study and population descriptions, surgical category (cardiac or noncardiac surgery), as well the incidence of short term perioperative mortality. Crude odds ratios were calculated for each eligible manuscript to describ...

Relationship between HIV serostatus, CD4 count and rehospitalisation: Potential implications for health systems strengthening in South Africa

BACKGROUND Despite three decades of scientific response to HIV/AIDS, the generalised HIV epidemic continues to persist in South Africa. There is growing acknowledgement that health system strengthening will be critical in tackling HIV/AIDS. Patient rehospitalisation is an important quality benchmark of health service delivery, but there is currently limited data on rehospitalisation of patients with HIV/AIDS in South Africa, a setting with a high burden of HIV disease. OBJECTIVES To determine the relationship between combined HIV serostatus and CD4 count, and rehospitalisation in South Africa. METHODS This study was a retrospective analysis of data from 11,362 non-surgical adult patients who attended the Hlabisa Hospital in South Africa. Data related to patient age, gender, HIV serostatus, CD4 count (for HIV-positive patients) and comorbidity were analysed through univariate (Fishers Exact or χ2 tests) and multivariate (Cox regression) statistical methods to determine associations with rehospitalisation within 1 month (acute rehospitalisation) or 12 months (long term rehospitalisation). RESULTS An HIV-positive serostatus with CD4 count < 350 cells/mm3 or an HIV-positive serostatus with an unknown CD4 count were independently associated with a higher risk of acute (p = 0.010 and p = 0.003) and long term rehospitalisation (p < 0.001 for both categories) when compared with an HIV-negative serostatus group. CONCLUSIONS HIV-positive individuals with immune deficiency, or lacking a CD4 count measurement are at risk of rehospitalisation. Strengthening primary healthcare service delivery of these key affected inpatient populations should be a priority.

A systematic review of published literature describing factors associated with tuberculosis recurrence in people living with HIV in Africa.

BACKGROUND A summary of factors associated with recurrent tuberculosis (TB) in the African HIV-infected population is lacking. We performed a systematic review to address this. METHODS We performed a literature search within PubMed and The WHO Global Library with specific inclusion and exclusion criteria to identify manuscripts emanating from the African continent which potentially described factors associated with recurrent TB in persons living with HIV. RESULTS The literature search yielded 52 unique manuscripts, of which only 4 manuscripts were included in the final systematic review following application of the inclusion and exclusion criteria. Baseline CD4 count, baseline HIV viral load, a positive tuberculin skin test, prior active TB disease, cutaneous hypersensitivity reaction to treatment, having < 3 lung zones affected by prior TB disease, and anaemia were associated with recurrent TB in HIV-infected individuals, whilst age and antiretroviral status were not. CONCLUSION The lack of studies describing recurrent TB in Africa which stratify results by HIV-status is a hindrance to understanding risk factors for recurrent TB in this population. This might be overcome by implementing guidelines related to the publishing of data from observational studies in peer-reviewed medical journals reporting recurrent TB in populations with a high-burden of HIV infection.

Predictors of in-hospital mortality following non-cardiac surgery: Findings from an analysis of a South African hospital administrative database

BACKGROUND Predictors of in-hospital mortality (IHM) following non-cardiac surgery in South African (SA) patients are not well described. OBJECTIVE To determine the association between patient comorbidity and IHM in a cohort of SA non-cardiac surgery patients. METHODS Data related to comorbidity and IHM for 3,727 patients aged ≥45 years were obtained from a large administrative database at a tertiary SA hospital. Logistic regression analysis was used to determine independent predictors of IHM. In addition, population-attributable fractions (PAFs) were calculated for all clinical factors identified as independent predictors of IHM. RESULTS Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were independently associated with IHM (odds ratios (95% confidence intervals) 7.585 (5.480-10.50); 2.604 (1.119-6.060); 2.645 (1.414-4.950); 1.433 (1.107-1.853); and 1.646 (1.213-2.233), respectively). Ischaemic heart disease, diabetes and hypertension were not identified as independent predictors of IHM in SA non-cardiac surgery patients. Renal dysfunction had the largest contribution to IHM in this study (PAF 0.34), followed by high-risk surgical specialties (PAF 0.15), male gender (PAF 0.08), cerebrovascular disease (PAF 0.03) and congestive heart failure (PAF 0.03). CONCLUSION Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were major contributors to increased IHM in SA non-cardiac surgery patients. Prospectively designed research is required to determine whether ischaemic heart disease, diabetes and hypertension contribute to IHM in these patients.

The impact of acute preoperative beta- blockade on perioperative cardiac morbidity and all-cause mortality in hypertensive South African vascular surgery patients.

BACKGROUND Acute β-blockade has been associated with poor perioperative outcomes in non-cardiac surgery patients, probably as a result of P-blocker-induced haemodynamic instability during the perioperative period, which has been shown to be more severe in hypertensive patients. OBJECTIVE To determine the impact of acute preoperative β-blockade on the incidence of perioperative cardiovascular morbidity and all-cause mortality in hypertensive South African (SA) patients who underwent vascular surgery at a tertiary hospital. METHODS We conducted two separate case-control analyses to determine the impact of acute preoperative β-blockade on the incidence of major adverse cardiovascular events (MACEs, a composite outcome of a perioperative troponin-I leak or all-cause mortality) and perioperative troponin-I leak alone. Case and control groups were compared using χ2, Fishers exact, McNemars or Students t-tests, where applicable. Binary logistic regression was used to determine whether acute preoperative -blocker use was an independent predictor of perioperative MACEs/troponin-I leak in hypertensive SA vascular surgery patients. RESULTS We found acute preoperative β-blockade to be an independent predictor of perioperative MACEs (odds ratio (OR) 3.496; 95% confidence interval (CI) 1.948 - 6.273; p<0.001) and troponin-I leak (OR 5.962; 95% CI 3.085 - 11.52; p<0.001) in hypertensive SA vascular surgery patients. CONCLUSIONS Our findings suggest that acute preoperative β-blockade is associated with an increased risk of perioperative cardiac morbidity and all-cause mortality in hypertensive SA vascular surgery patients.

Post-operative acute kidney injury in non-suprainguinal vascular surgery patients with a pre-operative history of hypertension

Hypertension is an independent predictor of acute kidney injury (AKI) in non-cardiac surgery patients. There are a few published studies which report AKI following non-suprainguinal vascular procedures, but these studies have not investigated predictors of AKI, including anti-hypertensive medications and other comorbidities, in the hypertensive population alone. We sought to identify independent predictors of post-operative AKI in non-suprainguinal vascular surgery patients with a pre-operative history of hypertension. We performed univariate (chi-squared, or Fishers exact testing) and multivariate (binary logistic regression) statistical analysis of prospectively collected data from 243 adult hypertensive patients who underwent non-suprainguinal vascular surgery (lower limb amputation or peripheral artery bypass surgery) at a tertiary hospital between 2008 and 2011 in an attempt to identify possible associations between comorbidity, acute pre-operative antihypertensive medication administration, and post-operative AKI (a post-operative increase in serum creatinine of ≥ 25 % above the pre-operative measurement) in these patients. The incidence of post-operative AKI in this study was 5.3 % (95 % Confidence Interval: 3.2-8.9 %). Acute pre-operative β-blocker administration was independently associated with post-operative AKI in non-suprainguinal vascular surgery patients with a pre-operative history of hypertension (Odds Ratio: 3.24; 95 % Confidence Interval: 1.03-10.25). The acute pre-operative administration of β-blockers should be carefully considered in non-suprainguinal vascular surgery patients with a pre-operative history of hypertension, in lieu of an increased risk of potentially poor post-operative renal outcomes.