Scintigraphic assessment of cardiovascular diseases in asymptomatic diabetic black patients

The association between diabetes and coronary artery disease (CAD) has been recognized as a major public health problem in the developed world. While there is an increased prevalence of silent myocardial ischaemia among asymptomatic individuals with diabetes, diabetic individuals with CAD in their larger number are usually asymptomatic, and when they present with signs of disease, there is extensive and severe CAD. It should be noted that amongst black South African, ischemic heart disease (IHD) remains rare, and there is little data linking diabetes mellitus with IHD. However, contrary to early reports that have suggested a low prevalence of CAD in black population in Africa, many studies have indicated a rapid change on the spectrum of CAD in numerous parts of the African continent. Despite the emerging report of high prevalence of risk factors there are only limited data investigating prevalence of CAD in black African with diabetes. The purpose of this thesis was to use myocardial perfusion imaging (MPI) at rest and after stress testing to detect CAD in a group of asymptomatic black patients suffering from diabetes and therefore assess the prevalence of CAD; to assess the changes in myocardial perfusion in asymptomatic diabetic black individuals and compare the differences seen in myocardial perfusion changes between the asymptomatic diabetic black and, the asymptomatic diabetic white and Indian individuals; to include data from symptomatic diabetic patients who were referred for MPI as part of their routine clinical management for possible comparison Consecutive 94 asymptomatic diabetic black patients and 50 asymptomatic diabetic white and Indian patients were recruited from the outpatient diabetic clinic of the Johannesburg hospital. Data from 90 subjects forming a group of symptomatic diabetic patients, 45 blacks and 45 whites and Indians referred for MPI as part of their clinical management were also analyzed. A two-day protocol for SPECT MPI was used in all participants: on the first day the stress testing MPI while the rest MPI was consistently done on the second day. Both exercise and pharmacologic stress testing were used. Technetium-99m methoxy-isobutylisonitrile (MIBI) was used as the myocardial perfusion radiopharmaceutical. Myocardial perfusion was assessed by means of semi-quantitative scoring system to measure the extent and severity of perfusion abnormality. Visual inspection of the reconstructed SPECT MPI images was carried out to assess perfusion deficit where there was a doubt on the extent and severity of perfusion abnormality. The QPS/QGS software allows obtaining resting and post stress left ventricular ejection fraction (LVEF). The means and percentages on study variables were obtained. The Spearmen correlation coefficient was used to calculate correlations between variables. The Kruskal-Wallis test was used to assess differences between black diabetic and white or Indian diabetic patients and Wilcoxon scores (rank sum) two-sided were used to measure differences within these racial groups. There were 123 females (52.6%) and 111 males (47.4%) in total. From the recruited participants, 53 (56.4%) asymptomatic females and 41 (43.6%) asymptomatic males were blacks whereas 24 (48%) asymptomatic females and 26 (52%) asymptomatic males were whites or Indians. The symptomatic group was comprised of 26 (57.8%) female and 19 (42.2%) male black patients and 20 (44.5%) female and 25 (55.5%) male white or Indian patients. Asymptomatic diabetic black participants were younger than the participants from the asymptomatic diabetic white and Indian group with a mean age of 60 (SD±7.2) years Vs 64 (SD±7.7) [p=0.003]. Fourteen percent of asymptomatic black participants had evidence of ischaemia by showing improvement of perfusion on stress testing versus twenty eight percent of white and Indian asymptomatic participants (p=0.62). Perfusion defects that did not change from rest to post stress testing MPI (fixed defects) were also noted in 20% of asymptomatic black and 26% of asymptomatic white and Indian diabetic participants. These fixed perfusion defects are indicative of previous myocardial infarctions and therefore suggestive of CAD. No significant difference was noted on the changes of perfusion that could account either for ischaemia or infract between asymptomatic diabetic black participants and their white and Indian counterparts (p=0.47). The difference on the improvement of perfusion from rest to post-stress MPIs or reversibility of perfusion to suggest only the presence of ischaemia did not also show a significant difference between these two racial groups (p=0.62). Our data demonstrated a high prevalence of CAD in asymptomatic diabetic black participants similar to other racial groups. Our study has demonstrated evidence to recommend screening of asymptomatic diabetic black individuals in equal manner than other races for the detection of CAD. More importantly, stress MPI should be routinely used as a noninvasive investigation in our environment and be utilized more actively in the management of all asymptomatic diabetic patients

Lithium-enhanced radioactive iodine ablation of hyperthyroid patients

Objective: The objective of this study was to compare the effect of adjuvant lithium therapy on the efficacy of radioactive iodine therapy in hyperthyroidism.Methods: This was a prospective simple randomised comparative, experimental cohort study of hyperthyroid patients for radioactive iodine (RAI) ablation therapy. A total of 163 of the 185 hyperthyroid patients recruited completed the study. Cure was defined by achievement of euthyroidism or hypothyroidism.Results: From of total of 163 patients, 75 received RAI alone and 88 received RAI with lithium. Those who received RAI with adjuvant lithium showed a higher cure rate (78.4%) compared with those who received RAI only (68.1%) (p = 0.002). At one month post RAI therapy, 27.4% of patients who received RAI with adjuvant therapy were cured. This finding showed a trend of being significant compared with just 14.5% cure rate in the group of patients who received RAI alone (p = 0.08). This is an indication of a faster cure rate for patients receiving RAI with lithium. Difference in mean T4 concentration at three months between RAI only (17.67 pmol/l) and RAI with lithium (11.55 pmol/l) was significant with a small size effect (U = 2328.5, Z = –2.700, p = 0.007, r = 0.01). A significant drop in T4 concentrations was observed between the baseline and one-month visit with small effect size (p = 0.001, r = 0.287) in patients who received both RAI and lithium.Conclusion: Adjuvant lithium therapy increases the efficacy of radioactive iodine treatment in hyperthyroidism by increasing overall cure rate and also shortening the time to cure.Keywords: hyperthyroidism, lithium, radioactive iodine ablation, thyroid stimulating hormone, thyroxin

Patients seen at the university hospital in Johannesburg: their views on truth-telling

Truth telling forms part of the contemporary debate in clinical bioethics and centers around the right of the patient to know honest information concerning his or her medical condition / illness and the duty of the doctor to inform the patient of such. Anecdotal evidence seems to imply that patients have concerns with the practice of truthtelling. Many often complain that they are not being informed and sometimes simply being ignored in matters that primarily concerns their health. On the other hand, there may be patients who do not to want a truthful answer to their health problems-they would in fact rather not know. The aim of this study was to explore my intuition that patients who attend the Johannesburg General Hospital are not given full information about their condition(s) and / or treatment(s) although they would like to know. The study explored the preferences of patients regarding the practice of truth telling and their attitudes toward truth telling in four out patient clinics of the Johannesburg General Hospital. Four hundred and sixty five participants completed and retuned the questionnaire from four different out patient clinics, namely oncology, surgical (general surgery and orthopedics), medical (gastro, renal and general internal medicine) and the nuclear medicine unit that represented the mixed out patient clinic. The majority of participants stated that the doctor had disclosed information about their condition (92.90%). Almost all participants were of the opinion that patients have the right to know about their condition (98.28%) and also that the doctor has the duty to inform them of their condition (98.02%). If they were suffering from a serious condition, a higher percentage of participants (86.28%) would prefer to know about their condition while a small but significant percentage (13.72%) would prefer not to know. The vast majority of participants (96.64%) also preferred to know about information relating to their treatment in detail while a high percentage (87.83%) supported disclosure to relatives. Variables such as gender, age and level of education did not seem to impact on the participants’ opinions of the truth telling process with significance with the exception of iv gender in relation with knowledge of one’s condition (p=0.0176) and education with regard to opinions on the right of patients to disclosure (p=0.0430). From the above results it can then be concluded that: 1. Participants in our study supported the right of patients to disclosure and the vast majority also felt that doctors have the duty to inform patients of their condition. 2. A significant percentage of participants felt that the level of information given to them was not satisfactory even when they have requested for more. This should be looked at and means for improvement should be sought. 3. A small but significant group did not support disclosure and must be respected as autonomous beings. 4. Gender seems to influence opinions of patients concerning their condition and education impacts on opinions relating to right of patients to disclosure of information. 5. To our appeasement, we found that patients attending the Johannesburg hospital are in fact given information about their condition. It is rather the quality and the quantity of information given that should be subject to scrutiny if we would like to move towards full disclosure in the process of truth telling in our institution. 6. Future studies should be considered to assess the attitudes of doctors towards disclosing, as well as further assess conflicting opinions in small group of patients by means of direct interviews

Potentiation of the abscopal effect by modulated electro-hyperthermia in locally advanced cervical cancer patients

Background: A Phase III randomized controlled trial investigating the addition of modulated electro-hyperthermia (mEHT) to chemoradiotherapy for locally advanced cervical cancer patients is being conducted in South Africa (Human Research Ethics Committee approval: M1704133; ID: NCT03332069). Two hundred and ten participants were randomized and 202 participants were eligible for six month local disease control evaluation. Screening F-18-FDG PET/CT scans were conducted and repeated at six months post-treatment. Significant improvement in local control was reported in the mEHT group and complete metabolic resolution (CMR) of extra-pelvic disease was noted in some participants. We report on an analysis of the participants with CMR of disease inside and outside the radiation field. Method: Participants were included in this analysis if nodes outside the treatment field (FDG-uptake SUV>2.5) were visualized on pre-treatment scans and if participants were evaluated by F-18-FDG PET/CT scans at six months post-treatment. Results: One hundred and eight participants (mEHT: HIV-positive n = 25, HIV-negative n = 29; Control Group: HIV-positive n = 26, HIV-negative n = 28) were eligible for analysis. There was a higher CMR of all disease inside and outside the radiation field in the mEHT Group: n = 13 [24.1%] than the control group: n = 3 [5.6%] (Chi squared, Fisher's exact: p = 0.013) with no significant difference in the extra-pelvic response to treatment between the HIV-positive and -negative participants of each group. Conclusion: The CMR of disease outside the radiation field at six months post-treatment provides evidence of an abscopal effect which was significantly associated with the addition of mEHT to treatment protocols. This finding is important as the combined synergistic use of radiotherapy with mEHT could broaden the scope of radiotherapy to include systemic disease

Defining characteristics of nodal disease on PET/CT scans in patients with HIV-positive and -negative locally advanced cervical cancer in South Africa

Literature reports increased FDG nodal uptake in HIV-positive patients. Our aim is to identify differences in presentation and characteristics of FDG-avid lymph nodes between HIV-positive and HIV-negative locally advanced cervical cancer (LACC) patients in our clinical setting. We evaluated 250 pre-treatment F-18-FDG PET/CT imaging studies from women screened for a phase III randomised controlled trial investigating modulated electro-hyperthermia as a radiosensitiser (Ethics approval: M120477). The number of nodes; size; maximum standardised uptake value (SUVmax); symmetry; and relationship between nodal size and SUVmax uptake, were assessed by region and by HIV status. In total, 1314 nodes with a SUVmax >= 2.5 were visualised. Of 128(51%) HIV-positive participants, 82% were on antiretroviral therapy (ART) and 10 had a CD4 count four nodes visualised in the neck, symmetrical inguinal lymph nodes, increased rates of supraclavicular node visualisation; FDG-avid axillary nodes were more common, but not exclusive, in HIV-positive participants. F-18-FDG PET/CT is a reliable staging method for LACC in HIV-positive patients who are not in acute stages of HIV infection, have a CD4 count >200 cells/mL, and/or are on ART and there is a potential risk of underestimating metastatic spread by attributing increased nodal metabolic activity to HIV infection in these patients

The effect of modulated electro-hyperthermia on local disease control in HIV-positive and -negative cervical cancer women in South Africa : early results from a phase III randomised controlled trial

Background : The global burden of cervical cancer remains high with the highest morbidity and mortality rates reported in developing countries. Hyperthermia as a chemo- and radiosensitiser has shown to improve treatment outcomes. This is an analysis of the local control results at six months post-treatment of patients enrolled in an ongoing study investigating the effects of the addition of modulated electro-hyperthermia (mEHT) to chemoradiotherapy for the treatment of HIV-positive and -negative cervical cancer patients in a low-resource setting. Methods : This ongoing Phase III randomised controlled trial, conducted at a state hospital in Johannesburg, South Africa, was registered with the appropriate ethics committee. After signing an informed consent, participants with FIGO stages IIB to IIIB squamous cell carcinoma of the cervix were randomised to receive chemoradiotherapy with/without mEHT using a secure online random-sampling tool (stratum: HIV status) accounting for age and stage. Reporting physicians were blind to treatment allocation. HIV-positive participants on antiretroviral treatment, or with a CD4 count >200cell/mu L were included. mEHT was administered 2/weekly immediately before external beam radiation. The primary end point is local disease control (LDC) and secondary endpoints are toxicity; quality of life analysis; and two year survival. We report on six month LDC, including nodes visualised in the radiation field on F-18-FDG PET/CT (censored for six month survival), and six month local disease free survival (LDFS) (based on intention to treat). Trial status: Recruitment closed (ClinicalTrials. gov: NCT03332069). Results : 271 participants were recruited between January 2014 and November 2017, of which 210 were randomised for trial and 202 were available for analysis at six months post-treatment (mEHT: n = 101; Control: n = 101). Six month LDFS was higher in the mEHT Group (n = 39 [38.6%]), than in the Control Group (n = 20[19.8%]); p = 0.003). LDC was also higher in the mEHT Group (n = 40[45.5%]) than the Control Group (n = 20[24.1%]); (p = 0.003). Conclusion : Our results show that mEHT is effective as a chemo-radiosensitiser for cervical cancer, even in high risk a patients and resource-constrained settings

Declines in Lung Function After Antiretroviral Therapy Initiation in Adults With Human Immunodeficiency Virus and Tuberculosis: A Potential Manifestation of Respiratory Immune Reconstitution Inflammatory Syndrome

End-organ impairment has received relatively little research attention as a possible manifestation of tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS). In this prospective cohort study, one-half of adults with human immunodeficiency virus and pulmonary tuberculosis experienced meaningful declines in lung function on antiretroviral therapy, suggesting a role for lung function in TB-IRIS definitions

Spect scintigraphic TC-99m HMPAO appearance in pre- and post electroconvusive therapy (ECT) in patients with major depression

The attention recently gained by functional brain imaging research in affective disorders is considerable. Decreases in regional cerebral blood flow in depressed patients have been reported in the limbic and paralimbic areas by tomographic imaging techniques (Ito et al, 1996; Mayberg et al, 1994). Studies examining the long term effects of electroconvulsive therapy (ECT) on the cerebral perfusion demonstrate contrasting results in both the responders and non responders (Silfverskiold et al, 1986; Nobler et al, 1994). The aim ofthis study was to observe regional cerebral blood flow (rCBF) changes in patients with major depression while using brain SPECT imaging before and after a course of ECT. 15 patients with major depression diagnosed according to DSM-IV criteria were investigated in this study., They were 11 females and 4 males who did not respond to pharmaceutical treatment. Their mean age was 36.9 + 11.9 and except for two who refused ECT after the pretreatment imaging, all the others scored at least 17 on the Hamilton Rating Scale for Depression (HAM-D), mean 25.8 ± 4.7. The data analysis consisted of visual assessment and semiquantitetive evaluation of 99mTc-HMPAO uptake ratios measured between cerebral regions of interest and the cerebellum. The results in the group of responders showed obvious improvement on visual assessment and unchanged patterns in non responders. Two of the 15 patients showed signs of post traumatic stress disorder (PTSD) after ECT and demonstrated peculiar patterns regarding their response to therapy. When patients were considered as a whole, significant changes on the semiquantitative evaluation were noted in the anterior cingulate gyrus and the left frontal area, in keeping with available literature. When patients were separated in groups of responders versus non responders however, no significant change was noted between the pre and post ECT studies

Radioiodine therapy in skeletal metastases from well-differentiated thyroid cancer: a Johannesburg experience

Aim.The purpose of this study was to examine the outcome of patients with skeletal metastases from well-differentiated thyroid carcinoma and analyse the effect of variables that influence the prognosis of this disease. Method. We retrospectively reviewed 352 patients treated and followed-up at the Charlotte Maxeke Johannesburg Academic Hospital’s thyroid cancer clinic from 1982 - 1999. Findings. Skeletal metastases were diagnosed in 24 (6.8%), 17 at presentation to the thyroid clinic, and 7 at follow-up. Patients’ ages ranged from 30 - 77 years (mean 53.9 years) and the female:male ratio was 3.8:1. Based on the original pathology reports from resected tumours, 9 were papillary and 15 were follicular cancers. Twenty-three of the 24 patients underwent thyroid surgery as the initial management – total thyroidectomy in 18, subtotal thyroidectomy in 3, and lobectomy plus neck dissection in one. The diagnosis of thyroid cancer was based on lobectomy in a single subject. Radioactive iodine (RAI) was used as part of the original treatment; external radiation therapy (XRT) was mainly used to alleviate severe symptoms. Twenty-one patients (87.5%) were treated with RAI; 11 (45.8%) received radiotherapy. Seven patients died – 4 from neurological disease directly associated with bone metastases. Of the 17 surviving patients, 2 appeared to be disease-free, 8 were asymptomatic despite overt bony disease, and 7 had persistent symptoms which much improved in 5. Bone metastases were uncommon, and follicular cancer predominated in this survey. Conclusion. RAI therapy improves quality of life in most patients. There is a place for XRT

Chilaiditi's syndrome demonstrated by SPECT/CT

Purpose: Chilaiditi’s syndrome is a rare condition commonly diagnosed as an incidental radiological finding. The aim of this report is to show the role of SPECT-CT in this syndrome and state the functional and anatomical role of this hybrid imaging modality. Materials and Methods: A case report. Results: A 49-year-old female patient was referred for gallium-67 citrate for a possible granulomatous myositis and underwent SPECT-CT of the abdomen to assess the area of decreased gallium uptake on planar images of the liver. The combined SPECT and CT modality demonstrated findings consistent with the clinical evidence of Chilaiditi’s syndrome. The anatomical part of this hybrid modality made it easier to evaluate the area of gallium lack of uptake which was due to air in the colon. Conclusion: This case does not only show the role of SPECT-CT in this syndrome but also suggest that the use of such modality should be considered whenever available in the evaluation of patients in whom the localization of active disease becomes imperative