Erratum: Southern African HIV Clinicians Society 2022 guideline for the management of sexually transmitted infections: Moving towards best practice.

[This corrects the article DOI: 10.4102/sajhivmed.v23i1.1450.].

Prescribing patterns of long-acting injectable antipsychotics in a community setting in South Africa.

Background: Long-acting injectable antipsychotics (LAI - APs) improve adherence to antipsychotics and decrease functional decline in schizophrenia. Yet they are prescribed late, in patients with established functional decline. Although LAI - APs are widely prescribed in South Africa, there is a paucity of research regarding the prescription profile for LAI - APs. Aim: This study aimed to describe prescribing practices for LAI - APs at psychiatric clinics. Setting: Community psychiatric clinics in South Africa. Methods: A retrospective review of the psychiatric files of all patients on LAI - APs attending the clinics over the study period was conducted. Sociodemographic, clinical and pharmacological information regarding the LAI - AP prescribed was extracted from the files. Results: A total of 206 charts were examined. The mean age of the study population was 46 (SD ± 12) years. Significantly more patients were male (n = 154; 74.8%), single (n = 184, 89.3%) and unemployed (n = 115; 55.8%) (p < 0.001). Approximately half had a comorbid substance use disorder (47.6%). The most common indication for the prescription of a LAI - AP was non-adherence (66%). Only 9.7% of the patients were prescribed a LAI - AP alone. No significant socio-demographic or clinical characteristic was associated with this prescribing habit. A LAI - AP was prescribed in combination with an oral antipsychotic, mood stabiliser or antidepressant in 53.9%, 44.7% and 7.8% of patients, respectively. Conclusion: Long-acting injectable antipsychotics were prescribed mainly following noncompliance with oral antipsychotics and may represent a missed opportunity to prevent functional decline. The high prevalence of LAI - AP polypharmacy has been highlighted.

Clinical use of neuro-imaging in psychiatric patients at the Charlotte Maxeke Johannesburg Academic Hospital.

BACKGROUND: Neuro-imaging is relatively new in psychiatry. Although the actual role of neuro-imaging in psychiatry remains unclear, it is used to strengthen clinical evidence in making psychiatric diagnoses. AIM: To analyse the records of inpatients referred for neuro-imaging (computerised tomography [CT] and/or magnetic resonance imaging [MRI] scans) to determine the proportion of abnormal neuro-imaging results and, if any, factors associated with abnormal neuro-imaging results. SETTING: This study was conducted at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) situated in Johannesburg, South Africa. METHODS: This was a quantitative retrospective record review. All adult psychiatric inpatients who had undergone a CT and/or MRI scan during 01 January 2014 to 31 December 2015 were included. Out-patients or patients admitted in the medical wards were excluded from the study. All neuro-imaging referrals were identified from hospital records and their demographics, scan characteristics and diagnoses were subsequently captured. RESULTS: A total of 1040 patients were admitted to the CMJAH psychiatric unit, of which 213 (20.5%) underwent neuro-imaging tests. Of the 213 scans performed, 74 were abnormal, representing a yield of 34.7%. The most common reported pathology was atrophy (n = 22, 29.7%). There was no statistically significant association between age group (χ 2 = 3.9, p = 0.8), gender (χ 2 = 1.3; p = 0.5), psychiatric diagnoses and abnormal scans. However, there were trends towards an association with comorbid HIV infection (χ 2 = 3.476, p = 0.062) and comorbid substance abuse (χ 2 = 2.286, p = 0.091). CONCLUSION: This study supports the need for clear clinical indications to justify the cost-effective use of neuro-imaging in psychiatry. This study's high yield of abnormal CT scans, although similar to other studies, advocates that HIV positive testing and the presence of focal neurological signs will improve the yield further.

Mental illness attitudes and knowledge in non-specialist medical doctors working in state and private sectors.

BACKGROUND: An increasing number of South Africans utilise primary healthcare services (either in the state or private sector) for mental health concerns; hence, there is a need to objectively assess these doctors' attitudes and knowledge of mental illness. AIM: To investigate aspects of knowledge and attitudes towards mental illness of a group of private and state-employed non-specialist medical doctors. METHOD: Doctors in the state sector who were working at a primary healthcare level and who were not working towards, or did not hold, a specialist qualification were considered eligible for the study. Doctors in the private sector who were working as general practitioners and who did not hold a specialist qualification were considered eligible for the study. Data were collected by means of a self-administered questionnaire. A link to the study questionnaire, information about the study, details of the researcher and matters pertaining to informed consent were emailed to potential participants. RESULTS: Of the 140 practitioners who responded to the survey, 51.4% (n = 72) worked in the state sector, 41.4% (n = 58) worked in the private sector and 7.1% (n = 10) worked in both the state and private sectors (χ2 1 = 45.31, p < 0.010). The majority (> 50%) of participants in all three groups had a positive attitude towards mental illness (χ2 2 = 1.52, p = 0.468). Although there were no significant associations between attitude and socio-demographic characteristics (p > 0.05), male SS doctors reported feeling less comfortable when dealing with mentally ill patients (p = 0.015); SS doctors who did not have family contact with mental illness were less likely to feel that mentally ill patients did not pose a risk to others (p = 0.007), and PS doctors under the age of 35 years were more likely to feel adequately trained to treat mental illness (p = 0.026). The majority (> 50%) of participants in all three groups had an adequate level of knowledge of mental illness (modal scores = 10). There were no significant associations between knowledge and socio-demographic characteristics (p > 0.05). CONCLUSION: Despite the findings of a positive attitude and adequate knowledge of mental illness amongst the participants of this study, it is recommended that more targeted interventions are established to further improve mental health awareness and knowledge of doctors at both undergraduate and postgraduate levels of study.

Toxic epidermal necrolysis and fluoxetine: a case report.

Toxic epidermal necrolysis (TEN) is a distinct clinical entity within a spectrum of adverse cutaneous drug reactions. It is characterized by >30% of the body surface area of skin detachment with an average reported mortality of 25-35%. Drug induced TEN is associated with various antibiotics, anticonvulsants and other drugs. While adverse cutaneous drug reactions are common with antidepressants, the majority eruptions are benign and easily treated. TEN is rarely reported in association with selective serotonin reuptake inhibitors (SSRI's). We describe TEN in a 34-year-old patient from Mozambique associated with the addition of fluoxetine for a major depressive episode with psychotic features.

African women with depression: the effect of imipramine and fluoxetine on body mass index and leptin secretion.

Treatment of depression is often accompanied by weight changes. Previous studies indicate that leptin plays no role in this change despite showing a strong correlation with body mass index (BMI) in healthy people. The aim of this study was to evaluate the effect of imipramine and fluoxetine on BMI and its correlation with leptin. Eighteen depressed female patients randomly received either drug for 3 months. BMI was calculated and fasting blood samples were assayed for glucose, leptin, insulin, free fatty acids (FFA), and lipids. The difference between the changes in BMI (imipramine + 1.0 kg/m2, fluoxetine -0.5 kg/m2) was statistically significant (P < 0.05, t = 2.106). There was a significant positive correlation between overall BMI and leptin (r = 0.784, P < 0.001) but not between BMI and insulin or FFA. However, fasting insulin levels and calculated insulin resistance levels dropped substantially in the imipramine group. We conclude that the use of tricyclic antidepressants (TCAs) in depressed patients at risk for developing type 2 diabetes remains unresolved at this stage.

Left internal mammary artery graft perforation due to high-pressure stent deployment.

Perforation of newly placed left internal mammary artery (LIMA) grafts due to stent deployment is an infrequent but potentially dangerous complication of coronary interventions. It may lead to brisk hemorrhage and massive cardiac tamponade requiring emergent pericardiocentesis and surgery. We report a case of a LIMA graft perforation following stent deployment with a high-pressure balloon 12 days after surgery. The patient was treated with emergent pericardiocentesis, rapid autotransfusion of the pericardial aspirate into the systemic circulation, and surgical repair of the ruptured vessel.

Establishment of a clinically correlated human pericardial fluid bank: evaluation of intrapericardial diagnostic potential.

The development of a clinically correlated human pericardial fluid bank and database is described. A unique feature of this registry is the availability of a large number of pericardial fluid samples for testing with respect to multiple factors and for correlation with angiographic findings and clinical syndromes expressed by the patients. The collection of data at the present time comprises frozen pericardial fluid samples obtained from patients who have undergone cardiac surgery; and historical, clinical, and laboratory data obtained from the patient records. Nearly 400 samples have been stored and analyzed thus far, with sample entry continuing. This registry is designed to evaluate the local factors that play a role in mediating or reflecting myocardial or coronary responses. Pathophysiologic processes of particular interest include restenosis, plaque ruptures, and angiogenesis. Study of the pericardial fluid bank should lead to enhanced understanding of molecular mechanisms, as well as to the explanation for the reasons underlying interpatient variability in these processes. It is further anticipated that this information might provide a foundation for the diagnostic use of pericardial fluid to individualize therapies targeting angiogenesis or plaque physiology.

The use of adjunctive GPIIb/IIIa inhibitors in patients with unstable angina/non-Q-wave MI undergoing percutaneous coronary intervention.

Glycoprotein IIb/IIIa receptor inhibitors represent a relatively new therapeutic approach in the field of antiplatelet therapy. Following the development of abciximab a number of small molecule GPIIb/IIIa inhibitors have been introduced such as tirofiban and eptifibatide. In this fast-moving field the interventional cardiologist needs a framework to guide decision-making for the individual patient. This review covers the efficacy and safety data from the clinical trials of GPIIb/IIIa inhibitors in the context of patients undergoing percutaneous coronary intervention for unstable angina/non-Q-wave myocardial infarction. There is an increasing body of evidence to support the efficacy of GPIIb/IIIa inhibitors in reducing the risk of adverse ischemic events in high and low risk patients undergoing percutaneous coronary intervention. A number of unresolved efficacy and safety issues remain, including the duration of treatment before and after intervention; whether a reduction in the heparin dose would further decrease the risk of hemorrhage without affecting the periprocedural thrombotic rate in patients undergoing PTCA with adjunctive GPIIb/IIIa inhibitors; and the cost-effectiveness of this therapy. When a thorough analysis of cost-effectiveness has been made, it will be easier to advocate the widespread use of these agents in all patients undergoing coronary intervention.

Heart transplantation in patients with Marfan's syndrome: a survey of attitudes and results.

Our institution performed an orthotopic heart transplantation in a patient with Marfan's syndrome. The immediate postoperative course was complicated with ultimate discharge; however, this patient died within 1 year as a result of an aortic dissection. On the basis of our experience, we surveyed all heart transplant centers listed with the North American Transplant Coordinator Organization for other patients with Marfan's syndrome who had been referred for transplantation. Nearly one third of responding centers evaluated a total of 30 patients with Marfan's syndrome. Of these, only 13 were formally listed for a donor organ and 11 underwent heart transplantation with an operative mortality of 9.1% (n = 1). Posttransplantation morbidity was significant and includes a 40% (n = 4) incidence of thoracic aorta dissection (one fatal) in operative survivors. There were three other non-dissection-related late deaths for an overall survival of 54.4% after a mean follow-up of 33.0 months. In this shared experience, it appears that the known vascular complications of Marfan's syndrome may diminish the anticipated results after heart transplantation. The reluctance to place these patients on heart transplant donor waiting lists can be justified.

Cardiac transplantation in infants and children.

Cardiac transplantation has become a more frequently used therapeutic modality for select cardiac pathology in infants and children. Since June 1986, 30 pediatric patients (19 male and 11 female) ranging in age from 4 days to 15 years (11 < or = 1 month old) have undergone orthotopic cardiac transplantation at our institution. Indications included idiopathic cardiomyopathy (n = 8), hypoplastic left heart syndrome (n = 13), and other forms of complex congenital heart disease (n = 9). There have been four operative and three late deaths only in the groups with hypoplastic left heart syndrome and other forms of complex congenital heart disease. Cumulative survival is 77% after a mean follow-up of 30 months (range, 6 to 77 months). Three operative deaths were attributable to pulmonary hypertension, and the other was due to pulmonary hemorrhage. Two late deaths were secondary to allograft rejection, and the third was due to infection. There has been uniform survival in the group with idiopathic cardiomyopathy, and intermediate-term survival rates are 78% and 62% in the groups with complex congenital heart diseases and hypoplastic left heart syndrome, respectively (p = 0.15). Although longer-term results are necessary, orthotopic cardiac transplantation appears to be an acceptable mode of therapy for endstage heart disease in the pediatric age group and technically can be performed despite complex malformations of the great arteries or atria.

Characteristics of Ca(2+)-activated K+ channels isolated from the left ventricle of a patient with idiopathic long QT syndrome.

Early afterdepolarizations (EADs), possibly caused by reduced K+ conductance, have been hypothesized to cause the long QTU interval and ventricular tachyarrhythmias (VT) in patients with the long QT syndrome (LQTS). In a 26-year-old woman with aborted sudden death as a consequence of the idiopathic LQTS, we recorded with a contact electrode left ventricular endocardial EADs that were enhanced by epinephrine and phenylephrine. Because of uncertain efficacy and side effects achieved with beta-adrenoceptor blockade, the patient underwent left-sided cardiac sympathectomy, at which time we obtained left ventricular biopsy tissue. Crude membrane vesicles were prepared from this tissue and single-channel activity was studied after incorporation of the vesicles in an artificial lipid bilayer (phosphatidylserine, phosphatidylethanolamine, 4:5 weight ratio in decane) in the tip of a patch clamp pipette. Bath and pipette contained 100 mmol/L KCI and 25 mmol/L N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid (HEPES) at pH 7.4. We recorded K+ conducting channels with a mean slope conductance of 49.9 +/- 4.7 picosiemens (pS) (n = 5). Channel open probability was increased by the addition of 1 to 10 mumol/L Ca2+ to the experimental chamber. Addition of charybdotoxin (1-3 nmol/L), a known specific inhibitor of Ca(2+)-activated K+ channels, blocked channel activity. These results are the first to demonstrate Ca(2+)-activated K+ channels from a patient with idiopathic LQTS. These channels appear to show normal characteristics when studied in an artificial planar lipid bilayer.

Triple-drug immunosuppression for heart transplantation in infants and children.

Triple-drug immunosuppression with OKT3 induction is effective rejection prophylaxis in pediatric cardiac allograft recipients. The concerns regarding prevalent lymphoproliferative disease, growth retardation, cytomegalovirus, and other opportunistic infections have not been realized. Since June 1986, 34 pediatric patients, 23 males and 11 females, (age 4 days to 15 years) have undergone orthotopic heart transplantation at our institution. Fifteen patients were less than 6 months old and 13 had type I or II hypoplastic left heart syndrome. There have been four (12%) operative and four (12%) late deaths and a survival rate of 76% after a mean follow-up of 33 months (range, 1 to 82 months). The only deaths attributed to allograft rejection occurred in two newborn recipients (2 and 10 months after surgery) who neither received maintenance steroids nor underwent routine biopsy. The only death from infection (pneumococcus) occurred 6 months after surgery in a 4-year-old patient who was not known to be asplenic. Of the 27 long-term (> 1 year) survivors, 17 (68%) had an average of two rejection episodes during the follow-up period, 10 patients (32%) have been free of graft rejection, and 26 patients (96%) have not experienced a cytomegalovirus infection despite OKT3 induction therapy. Two patients developed lymphoproliferative disease, one of whom was successfully treated by transient reduction of immunosuppression. The other patient died 13 months after transplantation of a lymphoma of the central nervous system. All survivors have demonstrated satisfactory increases in mean height and weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for atrioventricular node reentry tachycardia. Results with surgical skeletonization of the atrioventricular node and discrete perinodal cryosurgery.

Surgical treatment options for interruption of atrioventricular node reentrant tachycardia include (1) skeletonization of the atrioventricular node by dissecting it from most of its atrial inputs and (2) discrete cryosurgery of the perinodal tissues by applying a series of sequential cryolesions to the atrial tissues immediately adjacent to the atrioventricular node. Both these techniques attempt to interrupt one of the dual atrioventricular node conduction pathways while preserving the other. This report describes 17 consecutive patients who underwent surgical treatment, 10 patients with skeletonization of the atrioventricular node and seven patients with discrete perinodal cryosurgery. There were 10 female and seven male patients and their ages ranged from 28 to 56 years (mean 38). Two of the 17 patients had Wolff-Parkinson-White syndrome and their accessory pathways were interrupted before the atrioventricular nodal reentrant tachycardia was ablated. All the procedures were performed in a normothermic beating heart while atrioventricular conduction was monitored closely. In the skeletonization technique, the right atrial septum was mobilized and the atrioventricular node exposed anterior to the tendon of the Todaro. The perinodal cryosurgical procedure was also performed through a right atriotomy and a series of sequential 3 mm cryolesions were placed around the borders of the triangle of Koch on the inferior right atrial septum. There were no operative deaths. Two patients who underwent the skeletonization operation had heart block necessitating pacemaker therapy. At postoperative electrophysiologic study, no echoes or atrioventricular nodal reentrant tachycardia were inducible in any of the 17 patients. All patients have remained free of arrhythmia recurrence and have required no antiarrhythmic therapy after a follow-up of 5 to 28 months (mean 14). In conclusion, both atrioventricular node skeletonization and perinodal cryosurgery successfully ablate atrioventricular nodal reentrant tachycardia; however, perinodal cryosurgery appears to be safer in avoiding heart block, is more easily performed, and is our procedure of choice for the management of medically refractory atrioventricular nodal reentrant tachycardia.

Anterior wall left ventricular aneurysm repair. A comparison of linear versus circular closure.

To determine the efficacy of ventricular closure techniques, we reviewed our experience with 62 patients who survived the repair of aneurysms of the anterior wall of the left ventricular from 1984 through 1989. Forty of these patients underwent aneurysm repair by standard linear closure and 22 by a circular closure technique. After a mean follow-up interval of 3 years, there were no demonstrable differences in angina class, New York Heart Association functional classification, or survival. In 41 surviving patients, postoperative left ventricular dimensions and function were satisfactorily evaluated by standard echocardiographic measurements. No significant differences were found in postoperative long-axis left ventricular systolic diameter or in short-axis systolic or diastolic areas. There was a significantly larger long-axis diastolic diameter in the circular closure group; however, there was no difference in this parameter when the ratios of postoperative to preoperative lengths were compared. Further intragroup comparisons demonstrated an increase in short-axis areas postoperatively within the circular closure group in contrast to a decrease in patients in the linear closure group; these changes were not statistically significant. There was no significant difference in postoperative ejection fraction between the two closure groups, although minor reductions were found in the circular closure group. These data demonstrate no significant difference between the linear and circular closure techniques with respect to standard echocardiographic parameters, functional classification, and survival.

Anterior pericardial tracheoplasty for congenital tracheal stenosis.

Congenital tracheal stenosis may be a life-threatening anomaly not relieved by airway intubation. Over the past 7 years, anterior pericardial tracheoplasty has been used at our institution for treatment of congenital long-segment tracheal stenosis in infants with impeding airway obstruction. Case histories of eight patients undergoing nine anterior pericardial tracheoplasties have been reviewed to assess this technique. Of these patients, six have required preoperative tracheal intubation before repair to maintain ventilation. The surgical technique of anterior pericardial tracheoplasty includes a median sternotomy approach with partial normothermic cardiopulmonary bypass. An anterior tracheotomy through all hypoplastic rings allows enlargement with autologous pericardium to 1.5 times the predicted normal diameter. After insertion, the pericardium and hypoplastic tracheal cartilages are suspended to surrounding mediastinal structures, which prevents airway collapse. Seven of eight infants have survived without tracheoplasty dehiscence or wound infections. Five were ultimately extubated and are currently free of symptoms from 6 months to 5 years after anterior pericardial tracheoplasty. The other two survivors had residual stenosis as a result of complications of prior tracheostomy. One of these patients has undergone a successful second anterior pericardial tracheoplasty and is currently extubated and well. The other is palliated at 6 months with a tracheostomy awaiting a second anterior pericardial tracheoplasty. Our review of anterior pericardial tracheoplasty has demonstrated the safety, utility, and at least medium-term benefit of this procedure in infants of any age and weight.

Surgical myocardial revascularization for the 1990s.

After two decades, coronary artery surgery remains a reliable mainstay in the treatment of select patients suffering from ischemic heart disease. However, surgical myocardial revascularization has undergone continuous evolution. Several trends have emerged, including increased use of autogenous artery for bypass conduit, extending indications to include patients with poor ventricular function or following recent myocardial infarction and new techniques, such as surgical angioplasty of the left main coronary artery.