Overnight oximetry as a screening tool for moderate to severe obstructive sleep apnoea in South African children

Background. Obstructive sleep apnoea (OSA) is common in children yet  often overlooked, as symptom-based screening is unreliable. Polysomnography is regarded as the gold standard for the diagnosis of OSA, but is not widely available in South Africa (SA). Overnight oximetry is a validated screening tool for OSA.Objectives. To describe the impact and utility of overnight oximetry at a tertiary children’s hospital in SA.Methods. A retrospective descriptive study was conducted of patients screened for OSA by overnight oximetry at a paediatric referral hospital from December 2012 to December 2014. Clinical data were retrieved from the oximetry database and medical records. Recordings of ≥6 hours were considered adequate and included in the study. OSA severity was  determined using the McGill score. Details on management and outcome were documented.Results. Oximetry studies in 137 of 153 patients were suitable for analysis (88 males (64.2%), median age 31.4 months (interquartile range (IQR) 15.8 - 65.8). Adenotonsillar hypertrophy was common (n=97, 70.8%), and 65 children (47.4%) had two or more underlying OSA risk factors. McGill’s score classified patients as follows: no/mild OSA n=55 (40.1%), moderate OSA n=23 (16.8%), severe OSA n=23 (16.8%) and very severe OSA n=36 (26.3%). Male gender, adenotonsillar hypertrophy and a lower weight-for-age z-score (–1.3 v. –0.7; p=0.038) were associated with severe to very severe OSA. Seventy-eight children (56.9%) were referred for surgery, 33 (24.1%) receiving urgent surgery within a median of 6 days (IQR 4 - 12). In contrast, 59 children (43.1%) with suspected OSA did not require surgical intervention.Conclusions. Overnight oximetry is a simple low-cost tool to assess severity of OSA and prioritise appropriate OSA management in resource-constrained settings such as SA

The use of the full blood count and differential parameters to assess immune activation levels in asymptomatic, untreated HIV infection

  Background. A feature of HIV/AIDS is chronic immune activation, which results in a number of complications including inflammation-related disorders and blood cytopaenias. Immune activation status is not routinely tested in HIV infection. However, the full blood count (FBC) is a commonly performed test. Objective. We hypothesised that FBC parameters would be significantly different in HIV-infected v. -uninfected individuals, and that some of these parameters would correlate with markers of immune activation (i.e. percentage CD38 expression on CD8+ T cells (%CD38onCD8)) and disease progression (i.e. CD4+ counts) in HIV infection. Methods. This was a cross-sectional study with 83 HIV-infected adults who were antiretroviral therapy-naive and clinically well, and 51 HIV-uninfected adults. The %CD38onCD8 and CD4+ counts were determined by flow cytometry and the FBC was performed on a Siemens ADVIA 2120 system. FBC parameters investigated were total white cell count (WCC), haemoglobin (Hb) concentration, platelet count, absolute neutrophil count, absolute lymphocyte count, and percentage of large unstained cells (%LUCs). Results. Significant differences were found between the HIV-infected and -uninfected groups for total WCC, Hb, neutrophil count, lymphocyte count and %LUCs. The mean ± standard deviation (SD) for the total WCC (5.3±1.3 v. 6.9±2.2; p≤0.001) and the %LUCs (2.5±0.9 v. 2.0±0.9; p=0.001) both showed correlations with CD4+ counts and %CD38onCD8. Conclusion. The total WCC and %LUCs showed significant differences in HIV-infected individuals and correlated with markers of immune activation and disease progression. This suggests the potential use of these parameters as markers of immune activation in HIV infection.

Coronary artery dominance dependent collateral development in the human heart

Background: In obstructive coronary artery disease, coronary collateral arteries serve as alternative conduits for blood flow to the myocardial tissue supplied by the obstructed vessel(s). Therefore, they are a “natural coronary arterial bypass” to the region supplied by the obstructed vessels. This study aims to determine the influence of demographic and morphologic coronary arterial factors on coronary collateral development in coronary arterial obstruction. Materials and methods: The study group was selected from the coronary angiographic records of 2029 consecutive patients (mean age: 59 ± 12 years). Coronary collaterals were graded from 0 to 3 based on the collateral connection between the donor and recipient arteries. The angiograms of the patients (n = 286) with total obstruction of the coronary arteries were selected for analysis. Results: There were no significant association between patients’ age and sex and the formation of excellent collaterals. However, the location of atherosclerotic lesion affected collateral development in the right coronary artery. In addition, the right coronary arterial dominant pattern significantly influenced the formation of excellent coronary collaterals. Conclusions: Coronary collateral arteries are better developed in right dominant pattern. It may be concluded that coronary arterial morphological pattern influences coronary collateral artery development

The use of the full blood count and differential parameters to assess immune activation levels in asymptomatic, untreated HIV infection

CITATION: Vanker, N. & Ipp, H. 2014. The use of the full blood count and differential parameters to assess immune activation levels in asymptomatic, untreated HIV infection. South African Medical Journal, 104(1), doi::10.7916/SAMJ.6983.The original publication is available at http://www.samj.org.zaBackground. A feature of HIV/AIDS is chronic immune activation, which results in a number of complications including inflammation-related disorders and blood cytopaenias. Immune activation status is not routinely tested in HIV infection. However, the full blood count (FBC) is a commonly performed test. Objective. We hypothesised that FBC parameters would be significantly different in HIV-infected v. -uninfected individuals, and that some of these parameters would correlate with markers of immune activation (i.e. percentage CD38 expression on CD8+ T cells (%CD38onCD8)) and disease progression (i.e. CD4+ counts) in HIV infection. Methods. This was a cross-sectional study with 83 HIV-infected adults who were antiretroviral therapy-naive and clinically well, and 51 HIV-uninfected adults. The %CD38onCD8 and CD4+ counts were determined by flow cytometry and the FBC was performed on a Siemens ADVIA 2120 system. FBC parameters investigated were total white cell count (WCC), haemoglobin (Hb) concentration, platelet count, absolute neutrophil count, absolute lymphocyte count, and percentage of large unstained cells (%LUCs). Results. Significant differences were found between the HIV-infected and -uninfected groups for total WCC, Hb, neutrophil count, lymphocyte count and %LUCs. The mean ± standard deviation (SD) for the total WCC (5.3±1.3 v. 6.9±2.2; p≤0.001) and the %LUCs (2.5±0.9 v. 2.0±0.9; p=0.001) both showed correlations with CD4+ counts and %CD38onCD8. Conclusion. The total WCC and %LUCs showed significant differences in HIV-infected individuals and correlated with markers of immune activation and disease progression. This suggests the potential use of these parameters as markers of immune activation in HIV infection.http://www.samj.org.za/index.php/samj/article/view/12355Publisher's versio

The prevalence and clinical importance of an “additional” terminal branch of the left coronary artery

The left coronary artery (LCA) usually divides into two (anterior interventricular artery [AIA] and left circumflex [LCx] artery) or less frequently into the AIA, LCx, and one or more “additional” terminal branch/es (ATBs). These ATBs of the LCA have no unanimity regarding their anatomical nomenclature. There is a lack of common consensus on the criteria used for their definition, and they are also absent from the current Terminologia Anatomica (1998). This study, therefore, aimed to document the prevalence of the ATBs of the LCA, discuss their clinical importance, and propose an anatomical nomenclature. This study was conducted by reviewing 367 coronary angiograms. The termination patterns of the LCA were classified into 3 categories based on the number of their branches, viz. (a) bifurcation 78.2%, (b) trifurcation 20.4%, and (c) quadrifurcation 1.4%, respectively. The presence of an ATB was recorded in 21.8% of the angiograms. The identification of this vessel may be of clinical importance because the extent of its supply may decrease the effect of occlusion of the LCx artery and AIA on the myocardium. The term “left ramus medianus artery” is proposed as the nomenclature for the ATB of the LCA

Overnight oximetry as a screening tool for moderate to severe obstructive sleep apnoea in South African children

Background. Obstructive sleep apnoea (OSA) is common in children yet often overlooked, as symptom-based screening is unreliable. Polysomnography is regarded as the gold standard for the diagnosis of OSA, but is not widely available in South Africa (SA). Overnight oximetry is a validated screening tool for OSA.Objectives. To describe the impact and utility of overnight oximetry at a tertiary children’s hospital in SA.Methods. A retrospective descriptive study was conducted of patients screened for OSA by overnight oximetry at a paediatric referral hospital from December 2012 to December 2014. Clinical data were retrieved from the oximetry database and medical records. Recordings of ≥6 hours were considered adequate and included in the study. OSA severity was determined using the McGill score. Details on management and outcome were documented.Results. Oximetry studies in 137 of 153 patients were suitable for analysis (88 males (64.2%), median age 31.4 months (interquartile range (IQR) 15.8 - 65.8). Adenotonsillar hypertrophy was common (n=97, 70.8%), and 65 children (47.4%) had two or more underlying OSA risk factors. McGill’s score classified patients as follows: no/mild OSA n=55 (40.1%), moderate OSA n=23 (16.8%), severe OSA n=23 (16.8%) and very severe OSA n=36 (26.3%). Male gender, adenotonsillar hypertrophy and a lower weight-for-age z-score (–1.3 v. –0.7; p=0.038) were associated with severe to very severe OSA. Seventy-eight children (56.9%) were referred for surgery, 33 (24.1%) receiving urgent surgery within a median of 6 days (IQR 4 - 12). In contrast, 59 children (43.1%) with suspected OSA did not require surgical intervention.Conclusions. Overnight oximetry is a simple low-cost tool to assess severity of OSA and prioritise appropriate OSA management in resource-constrained settings such as SA.

Neonatal, infant and child health in South Africa : reflecting on the past towards a better future

CITATION: Goga, A. et al. 2019. Neonatal, infant and child health in South Africa : reflecting on the past towards a better future. South African Medical Journal, 109(11b):83-88, doi:10.7196/SAMJ.2019.v109i11b.14301.The original publication is available at http://www.samj.org.zaAlthough the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the ‘Survive, thrive and transform’ global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.http://www.samj.org.za/index.php/samj/article/view/12807Publisher's versio

Neonatal, infant and child health in South Africa : reflecting on the past towards a better future

Although the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the ‘Survive, thrive and transform’ global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.http://www.samj.org.zapm2020Geography, Geoinformatics and MeteorologyPaediatrics and Child HealthSchool of Health Systems and Public Health (SHSPH

Autoantibodies against type I IFNs in patients with critical influenza pneumonia

In an international cohort of 279 patients with hypoxemic influenza pneumonia, we identified 13 patients (4.6%) with autoantibodies neutralizing IFN-alpha and/or -omega, which were previously reported to underlie 15% cases of life-threatening COVID-19 pneumonia and one third of severe adverse reactions to live-attenuated yellow fever vaccine. Autoantibodies neutralizing type I interferons (IFNs) can underlie critical COVID-19 pneumonia and yellow fever vaccine disease. We report here on 13 patients harboring autoantibodies neutralizing IFN-alpha 2 alone (five patients) or with IFN-omega (eight patients) from a cohort of 279 patients (4.7%) aged 6-73 yr with critical influenza pneumonia. Nine and four patients had antibodies neutralizing high and low concentrations, respectively, of IFN-alpha 2, and six and two patients had antibodies neutralizing high and low concentrations, respectively, of IFN-omega. The patients' autoantibodies increased influenza A virus replication in both A549 cells and reconstituted human airway epithelia. The prevalence of these antibodies was significantly higher than that in the general population for patients 70 yr of age (3.1 vs. 4.4%, P = 0.68). The risk of critical influenza was highest in patients with antibodies neutralizing high concentrations of both IFN-alpha 2 and IFN-omega (OR = 11.7, P = 1.3 x 10(-5)), especially those <70 yr old (OR = 139.9, P = 3.1 x 10(-10)). We also identified 10 patients in additional influenza patient cohorts. Autoantibodies neutralizing type I IFNs account for similar to 5% of cases of life-threatening influenza pneumonia in patients <70 yr old