Risk factors for Coronavirus disease 2019 (Covid-19) death in a population cohort study from the Western Cape province, South Africa

Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector “active patients” (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates.Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70–2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81–4.04] and 1.51 [95% CI, 1.18–1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96–2.86); population attributable fraction 8.5% (95% CI, 6.1–11.1)

A retrospective review of computed tomography pulmonary angiography image quality and the impact on diagnostic outcome at a tertiary South African hospital

Background: Computed Tomography Pulmonary Angiography (CTPA) is a key diagnostic imaging modality for pulmonary embolism. These studies are technically challenging to perform. Degraded image quality may result from inadequate pulmonary artery contrast opacification, motion- or streak artefact as well as patient factors. Literature suggests that poor quality scans could lead to indeterminate outcomes and suboptimal clinical decisions with risk of increased mortality. Objective: The study aimed to benchmark the image quality and diagnostic outcomes of CTPA studies in the setting of a tertiary Southern African hospital. The relationships between CTPA image quality and diagnostic and clinical outcomes, as well as related variables such as health risk factors and effective dose, were also explored. Methods: A retrospective cross-sectional study evaluated consecutive CTPA studies performed at Groote Schuur hospital, Cape Town, South Africa, over a six-month period from 1 July 2018 to 31 December 2018. All studies performed for suspected acute or chronic pulmonary embolism (PE) in patients 18 years and older were included. Records were reviewed regarding image quality and diagnostic and clinical outcomes. Correlation tests were performed between continuous variables and chisquare tests among categorical variables. Results: During the study period, 231 CTPA studies were performed, of which 226 were included. The sample comprised 69 % females and 31 % males, with median age of 45 years (range 19-84 years). In 204 (90.3 %) of studies, adequate contrast opacification ≥ 211 HU was obtained. Inadequate contrast opacification was present in 9.7% of cases, in line with previous research. Motion and/ or streak artefacts were present in 45.6%. PE was confirmed in 22% and excluded in 65 % of cases. The number of scans with indeterminate diagnostic results only comprised 30 out of the 226 scans reviewed, however, the percentage was higher than previously reported (13.3% vs mean of 6.4 % in published literature). Amongst these, inadequate contrast opacification occurred in 15 (50 %) of studies and artefacts degraded image quality in 24 (80 %). Patients with a diagnosis of PE had higher mortality, compared to patients with negative and indeterminate scans. Clinicians interpreted indeterminate scans as negative, however, this did not impact adversely on mortality. Conclusions It was encouraging that the percentage of studies with adequate contrast opacification met published bench-marks. Although the higher-than-expected percentage of indeterminate studies may partially be explained by the prevalence of artefacts, it requires further investigation. This did not, however, translate into adverse mortality outcomes

Urticaria and Angioedema – More than just Skin Deep!

Urticaria and angioedema are characterized by pruritic hives and sometimes swelling of deeper mucocutaneous layers. Urticaria is caused by release of histamine and other mediators from mast cells. A cut-off of six weeks distinguishes acute and chronic forms, as these seem to differ regarding etiological and response patterns. Angioedema may be histaminergic or due to factors involving the bradykinin pathway. Medications such as ACE-Inhibitors or conditions affecting the C1-esterase inhibitor enzyme are potential causes. Acute urticaria may be related to triggers such as infections, medications or food allergy. When occurring with systemic symptoms and a temporal relationship to food or drug ingestion, IgE mediated allergy could be considered. Chronic Inducible Urticaria (CInd) is suspected on history and may be confirmed by provocation testing where physical and other specific trigger factors elicit the wheals. The term Chronic Spontaneous Urticaria (CSU) is used when symptoms persist for more than six weeks in the absence of inducible factors. A single cause is seldom found but a thorough history and clinical evaluation may elicit trigger factors and associated medical conditions such as auto-immune or thyroid disorders. Indiscriminate food allergy testing is unhelpful, but additive intolerance may be implicated in some cases. Modern non-sedating antihistamines are the mainstay of treatment, and omalizumab or immunosuppressives may be considered for refractory cases. Emotional support is needed as the condition is associated with psychological distress. If there are unusual features, vasculitis, auto-inflammatory or haematological conditions should be considered and skin biopsy or detailed immunological work-up may be indicated