Chronic rhinitis in South Africa - more than just allergy!

Chronic rhinitis is a troublesome condition for sufferers. It is tempting to label all patients with chronic nasal symptoms as having allergic rhinitis (AR), but many such patients have other causes of chronic rhinitis that need a specific diagnosis and management strategy. Even when the patient fully fits the definition of AR, their condition will be best served by combining medication with ongoing patient education.

Diagnosis of COVID-19: Considerations, controversies and challenges.

Coronavirus disease 2019 (COVID-19) due to a novel virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global pandemic that has resulted in over 1.5 million confirmed cases and close to 100 000 deaths. In the majority of symptomatic cases, COVID-19 results in a mild disease predominantly characterised by upper respiratory tract symptoms. Reverse transcription polymerase chain reaction (RT-PCR) using a nasopharyngeal sample is the mainstay of diagnosis, but there is an ~30% false negative rate early in the disease and in patients with mild disease, and therefore repeat testing may be required. RT-PCR positivity can persist for several days after resolution of symptoms. IgM and IgG antibody responses become positive several days after the onset of symptoms, and robust antibody responses are detectable in the second week of illness. Antibody-based immunoassays have a limited role in the diagnosis of early symptomatic disease. However, their incremental benefit over RT-PCR in the first 2 weeks of illness is currently being clarified in ongoing studies. Such assays may be useful for surveillance purposes. However, their role in potentially selecting individuals who may benefit from vaccination, or as a biomarker identifying persons who could be redeployed into essential employment roles, is being investigated. Rapid antibody-based immunoassays that detect viral antigen in nasopharyngeal samples are being developed and evaluated.

Anticipated changes in sexual risk behaviour following vaccination with a low-efficacy HIV vaccine: survey results from a South African township.

We assessed the potential for anticipated changes in sexual risk-taking behaviour following hypothetical administration of a low-efficacy preventive HIV vaccine. We developed a survey and collected self-reported data from 158 HIV-negative volunteers in a cohort undergoing prescreening for Phase I/II HIV vaccine trials in Soweto. Overall, 22% reported they might use condoms less frequently; 9% reported that they might increase their frequency of sex with casual/anonymous partners; and 55% reported their sexual partners might want to use condoms less frequently knowing they were vaccinated. Multivariate analyses revealed that anticipated decrease in condom use was predicted by poor comprehension and by young age. Individuals may increase their risk-taking behaviour knowing that a vaccine would provide only incomplete protection against HIV transmission. In HIV vaccine trials and future vaccination programmes, education and risk-reduction counselling will be needed for vaccinated individuals and their partners, and mass media education campaigns may be necessary.

Allergic rhinitis in South Africa: 2012 guidelines.

BACKGROUND: Allergic rhinitis (AR) is an important disease in South Africa. The South African Allergic Rhinitis Working Group (SAARWG) has published previous guidelines for AR diagnosis and management. Areas of concern have arisen that require additional information, including the management of AR in infancy, appropriate and inappropriate allergy testing, cost of AR management, diagnosis and distinguishing the condition from sinusitis, use of over-the-counter medications, and the concept of the 'united airway'. RECOMMENDATIONS: Clinicians should consider the possibility of AR in infants with recurrent nasal symptoms. Allergy testing should be used wisely and based on local allergens. Total IgE testing is not routinely required to prove allergy. Acute and chronic sinusitis should be considered in conjunction with AR; treatment of rhinitis will improve these conditions. Over-the-counter medications should be used sparingly and with caution. Concern for long-term use of topical decongestants must be noted. Asthma should always be considered in AR diagnosis. Immunotherapy is available in SA and may be extremely useful in selected AR patients. CONCLUSION: The SAARWG proposed an algorithm for the diagnosis and management of rhinitis in South Africa. AR is common, important and troubling to patients; therefore, every effort should be made to target therapy correctly. Patient education is important in the management of AR.

A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps.

AIM: Polypectomy techniques in the removal of polyps in the 3-8 mm size range are inconsistent. The aim of our study was to compare cold (CSP) with hot snare polypectomy (HSP) in the occurrence of postpolypectomy bleeding in small colonic polyps 3-8 mm in size. METHOD: In all, 414 consecutive patients with small colorectal polyps 3-8 mm in size were prospectively randomized into the CSP group and the HSP group. RESULTS: There was no early or late postpolypectomy bleeding in either group. Intraprocedural bleeding was significantly more frequent in the CSP group than the HSP group (CSP, 19/208; HSP, 2/206; P<0.001) but resolved spontaneously without any intervention in both groups. CONCLUSION: The data show that the CSP technique is safe, effective and quicker than HSP for patients and it could be considered the ideal procedure for small polyp removal.

Deep sedation compared with moderate sedation in polyp detection during colonoscopy: a randomized controlled trial.

AIM: The detection rate of adenomas is one of the current quality indicators in high-quality colonoscopy. We compared the performance of colonoscopy for the detection of polyps in patients sedated with deep and moderate sedation. Secondary objectives included the patient's and the endoscopist's satisfaction, recovery time and the adverse events related to sedation between the two groups. METHOD: Five hundred and twenty patients submitted for colonoscopy were prospectively randomized into a deep sedation group (DS group, n = 258) and a moderate sedation (MS group, n = 262) group. In both, sedation and analgesia were performed using midazolam with pethidine. RESULTS: There were no differences between the two groups in the following three areas: (1) The overall detection of polyps (DS, 1 [0-20]; MS, 1 [0-15]; P = 0.67), (2): polyp size ≥ 10 mm (DS, 0.00 [0-7]; MS, 0.00 [0-6]; P = 0.30), and (3) polyp size < 10 mm (DS, 0.00 [0-20]; MS, 0.00 [0-13]; P = 0.83). There was no significant difference in the rate of adenoma detection (DS, 1 [0-10]; MS, 1 [0-9]; P = 0.99). CONCLUSION: The study demonstrated no difference in the detection of polyps by colonoscopy using deep or moderate sedation.

Comparison of standard vs high-definition, wide-angle colonoscopy for polyp detection: a randomized controlled trial.

AIM: We sought to compare the performance of colonoscopy using a high-definition, wide-angle endoscope vs a standard colonoscope for the detection of polyps. METHOD: A total of 390 patients were prospectively randomized into high-definition colonoscopy group (HD, n = 193) and standard colonoscopy group (SC, n = 197). RESULTS: Analysis demonstrated that there were significant differences between the two groups, as far as the overall rate of polyps (SC, 1.31 ± 1.90; HD, 1.76 ± 2.31; P = 0.03) and the rate of small hyperplastic polyps (size < 5 mm; SC, 0.10 ± 0.36; HD, 0.25 ± 0.61; P = 0.003) were concerned. No significant differences between the two groups were observed, regarding large polyps (size ≥ 10 mm; SC, 0.39 ± 0.89; HD, 0.48 ± 0.80; P = 0.10), medium polyps (10 mm > size ≥ 5 mm; SC, 0.60 ± 1.46; HD, 0.58 ± 1.25; P = 0.31) and small polyps (size < 5 mm; SC, 0.32 ± 0.86; HD, 0.71 ± 1.65; P = 0.09). Similarly, no significant differences were demonstrated in the detection rate of adenomas and hyperplastic polyps, large adenomas, medium adenomas, small adenomas and large and medium hyperplastic polyps. CONCLUSION: High-definition colonoscopy led to a significant increase in the polyp detection.

Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial.

BACKGROUND AND STUDY AIMS: We sought to determine whether bispectral index (BIS) monitoring is a useful adjunct to the administration of propofol titrated to deep sedation, as measured by reductions of doses of propofol administered during endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS: 90 consecutive patients undergoing ERCP were randomized to receive propofol titrated to deep sedation, with the BIS value either visible (BIS group, n = 46) or invisible (control group, n = 44) to the anesthesiologist. In the BIS group, the anesthesiologist was instructed to use the BIS value as the primary end point for titration of sedation, and to target BIS values between 40 and 60. For the control group, the anesthesiologist was instructed to titrate propofol according to routine practice in the unit using the modified Observer's Assessment of Alertness/Sedation (MOAA/S) Scale (MOAA/S score 0). RESULTS: The mean (SD) propofol doses (mg/min per kg weight) were 0.139 (0.02) and 0.193 (0.02) for the BIS and control groups, respectively (P < 0.001). Mean (SD) BIS values throughout the procedure were 61.68 (7.5) and 56.93 (4.77) for the BIS and control groups, respectively (P = 0.001). During the maintenance phase of sedation (MOAA/S score 0), the mean (SD) BIS values were 53.73 (8.67) and 45.65 (4.39) for the BIS and control groups, respectively (P < 0.001). CONCLUSIONS: Our data suggest that BIS monitoring led to a reduction in the mean propofol dose when the BIS value was used as the primary target for sedation in ERCP procedures.

Endoscopic sedation in Greece: results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition.

BACKGROUND AND STUDY AIMS: Recent surveys regarding practices in sedation during endoscopic procedures are limited, particularly in Greece where they are nonexistent. This survey was designed to provide national data on sedation practices in Greece. METHODS: A 27-item survey regarding practices of endoscopy and sedation was mailed nationwide to 502 members of the Hellenic Society of Gastroenterology. RESULTS: A total of 201 questionnaires were returned (40%). Survey respondents performed an average of 48 oesophagogastroduodenoscopies (EGD) and 35 colonoscopies per month. 50 of the respondents, who perform endoscopic retrograde cholangiopancreatography (ERCP), conducted an average of 10 ERCP per month. 15 of the respondents, who perform endoscopic ultrasound (EUS), conducted an average of 6 EUS per month. Respondents administered sedation intravenously in 64% of EGD, 78% of colonoscopies, 100% of ERCP and 100% of EUS. 125 of the respondents (62.1%) reported the use of synergistic sedation (benzodiazepines plus opioids), 71 of the respondents (35.3%) reported the use of benzodiazepines alone and 68 of the respondents (33.8%) reported the use of propofol based sedation in selected cases (more than one response was permitted). In most cases, propofol administration was directed by an anaesthesiologist. The majority of the respondents monitored vital signs and pulse oximetry (90% and 96%, respectively). CONCLUSION: The use of sedation and physiologic monitoring in Greece is now standard practice during endoscopy. Benzodiazepines, either alone or combined with an opioid, are used by the majority of endoscopists, while propofol is used in selected cases, mainly in the presence of an anaesthesiologist.

Sexual risk behaviour of the first cohort undergoing screening for enrollment into Phase I/II HIV vaccine trials in South Africa.

We assessed risk behaviour in a heterosexual cohort undergoing prescreening for the first Phase I/II HIV vaccine trials in Soweto. We developed a survey and collected self-reported data from HIV-negative potential volunteers. Of 488 participants, most were single and approximately half were from households with incomes below the poverty level. Males reported higher rates of heavy alcohol use (P < 0.001), marijuana use (P < 0.001) and other recreational drug use (P < 0.01). Males reported more sex partners than females in the previous six months (P < 0.001), as well as more casual/anonymous partners (P < 0.001) and one-night stands (P < 0.001). Multivariate analyses revealed substance use and male gender predicted higher risk behaviours, including <100% condom use with known/suspected HIV-positive partners, having casual/anonymous partners and having more than two partners. For this population, male volunteers may need increased risk-reduction counselling during Phase I/II trials and additional recruitment methods may be necessary to identify high-risk female volunteers for Phase III efficacy trials.

Complications of colonoscopy in a large public county hospital in Greece. A 10-year study.

BACKGROUND AND STUDY AIMS: Information about the complications of colonoscopy in Southern Europe is limited, particularly in Greece where it is non-existent. Our study sought to determine the complications of colonoscopy in a large public county hospital in Greece over a 10-year period. PATIENTS AND METHODS: All colonoscopy procedures from 1996 to 2006 were entered into a database. Data were analysed by both univariate and multivariate methods. RESULTS: Nine thousand six hundred forty-eight colonoscopies were entered into a database. The procedures were diagnostic in 79% and therapeutic in 21%. Overall bleeding complications occurred in 83 out of the 9648 patients (0.8%: 95% confidence interval [0.7%, 0.9%]). Perforation occurred in four female patients (0.04%: 95% confidence interval [0.01%, 0.07%]) in the sigmoid colon. Multivariate stepwise logistic regression analysis in the therapeutic colonoscopies revealed that presence of significant polyps (odds ratio 4.7, confidence interval [2.9-7.6]), the male sex (odds ratio 2, 95% confidence interval [1.2-3.3]) and the time period of the procedure (the first 5 years) (odds ratio 1.7, 95% confidence interval [1.01-3]), are significant predictors of a post-colonoscopy bleeding episode. CONCLUSION: This historical cohort study, the first in Greece on this subject, shows that colonoscopy is a rather safe procedure and that the rate of complications in this study was low.

Deep sedation for endoscopic retrograde cholangiopancreatography: intravenous propofol alone versus intravenous propofol with oral midazolam premedication.

BACKGROUND AND STUDY AIMS: The primary objective of the present study was to compare the dosage of intravenous propofol required in patients being sedated with propofol alone (group P) with the dosage of propofol required in patients who also received an oral dose of midazolam (group M + P) for endoscopic retrograde cholangiopancreatography (ERCP) procedures. The secondary objectives were to compare the two groups with regard to patient anxiety levels before the procedure, patient satisfaction, the recovery time, and the adverse events related to sedation. PATIENTS AND METHODS: A total of 91 consecutive patients undergoing ERCP were randomly assigned to one of the two medication regimens. Patients in group P (n = 45) received only intravenous propofol, titrated to achieve deep sedation. Patients in group M + P (n = 46) received 7.5 mg of midazolam orally 30 minutes before being given intravenous propofol, which was similarly titrated to achieve deep sedation. RESULTS: Patients receiving propofol alone required higher doses of propofol compared with those receiving synergistic sedation (512 +/- 238 mg vs. 330 +/- 223 mg respectively, P < 0.001). The patients' anxiety levels before the procedure were lower in group M + P patients than in group P patients (P < 0.001). The mean percentage decline in oxygen saturation during the procedure was significantly greater in group P patients than it was in group M + P patients. A significant drop in the oxygen saturation (to < 90 %) occurred in 11 group P patients and in three group M + P patients (P = 0.02). CONCLUSIONS: Our data suggest that synergistic sedation with an oral dose of midazolam combined with intravenous propofol can provide a significant benefit, with a reduction in the dosage of propofol required and in patient anxiety levels before ERCP.

Bipolar electrocoagulation vs conventional monopolar hot biopsy forceps in the endoscopic treatment of diminutive rectal adenomas.

OBJECTIVE: To assess whether a cold biopsy from a diminutive rectal adenoma followed by destruction with bipolar (gold probe) electrocoagulation using large probes and high power setting would be a safe and efficient alternative to conventional monopolar hot biopsy forceps (MHBF). PATIENTS AND METHODS: Eligible patients were those undergoing colonoscopy, fulfilling the criteria of additional clearing colonoscopy and having at least one suspected rectal adenoma < or = 5 mm. At the time of endoscopy patients were randomized to receive treatment for their diminutive rectal adenomas either with cold biopsy followed by repeated gold probe electrocoagulation (Group A) using a 10 Fr catheter with setting 8 (40 W) for 1 second or with MHBF (Group B). These patients were followed up with a colonoscopy at 2-4 months. RESULTS: A total number of 24 (15 males, 9 females; mean age 56 years) patients were included in group A and 26 (14 males, 12 females; mean age 58 years) in group B. A total number of 38 and 37 diminutive rectal adenomas was detected in patients of Group A and Group B, respectively. At follow up colonoscopy residual adenoma tissue was found in 2 (5.2%) adenomas of 38 in Group A and in 4 (10.8%) of 37 in Group B (P > 0.3). No complications related to colonoscopy or endoscopic treatments in both groups occurred. CONCLUSIONS: Our data suggest that the use of cold biopsy followed by bipolar electrocoagulation using large probes and high power setting for destroying diminutive rectal adenoma seems to be equally effective and safe as MHBF.

Serum laminin and collagen IV in inflammatory bowel disease.

BACKGROUND: / AIMS: Laminin and collagen IV have been proposed as extracellular matrix serum markers. Because fibrosis is a major complication of inflammatory bowel disease, serum concentrations of laminin and collagen IV were measured in patients with ulcerative colitis (UC) and Crohn's disease (CD) and compared with inflammatory and healthy controls. METHODS: Laminin and collagen IV serum concentrations were measured in 170 patients with inflammatory bowel disease (86 UC and 84 CD), in 23 patients with other causes of intestinal inflammation, and in 80 matched healthy controls using commercially available enzyme linked immunosorbent assays. Laminin and collagen IV concentrations were correlated with disease activity, type, localisation, and treatment. RESULTS: Mean (SD) serum laminin concentrations were 281.0 (110.1) ng/ml in patients with UC, 275.6 (106.7) ng/ml in patients with CD, 192.0 (17.8) ng/ml in healthy controls, and 198.5 (32.5) ng/ml in inflammatory controls. Mean (SD) serum collagen IV concentrations were 72.8 (22.9) ng/ml in patients with UC, 71.0 (18.2) in patients with CD, 79.8 (12.2) ng/ml in healthy controls, and 88.9 (24.6) ng/ml in inflammatory controls. There was a significant difference among the four groups (p < 0.0001) for both markers. There was a strong correlation between serum laminin, but not collagen IV, and disease activity in both diseases. No significant association was found between these markers and disease localisation or disease type. CONCLUSIONS: Serum concentrations of laminin are increased, whereas serum concentrations of collagen IV are decreased, in patients with inflammatory bowel disease. They may be useful surrogate markers for sustained inflammation and tissue remodelling.

Incidence of penetration of a blood vessel during inferior alveolar nerve block.

Aspiration of the syringe after the needle had been placed in position for an inferior alveolar nerve block (but before the anaesthetic solution was injected) in 250 patients showed that the tip of the needle was in a blood vessel in 49 (20%). Aspiration of blood was significantly more common in patients aged 9-19 years than in all others (P=0.04).