RESUMO
There is no standard treatment available for recurrent high-grade gliomas. This monoinstitutional retrospective analysis evaluates the differences in overall survival and progression-free survival in patients according to the timing of re-irradiation. Patients suffering from a glioblastoma who received re-irradiation for recurrence were evaluated retrospectively. The median overall survival (OS) and the median progression-free survival were compared with different treatment options and within various time periods. From January 2007 until March 2015, 41 patients suffering from recurrent high-grade gliomas received re-irradiation [median dose of 30.6 Gy (range 20-40 Gy) in median 4 Gy fractions (range 1.8-5 Gy)] in our institution after initial postoperative irradiation or combined radiochemotherapy. The OS in this population was 34 months, and the OS after recurrence (OS-R) was 13 months. After diagnosis of recurrence, patients underwent additional surgical resection after a median of 1.2 months, received a second-line systemic therapy after 2.2 months with or without re-irradiation after 5.7 months. Growth of the tumour was assessed 4.3 months after the start of re-irradiation. The OS after the second surgical resection was 12.2 months, 11.7 months after the start of the second-line systemic therapy, and 6.7 months after the start of re-irradiation. The OS-R was not significantly correlated with the start of re-irradiation after a diagnosis of recurrence or the time period after the previous surgery. At this institution, re-irradiation was performed later compared to other treatment options. However, select patients could benefit from irradiation at an earlier time point. A precise time point should still be evaluated on an individual basis due to the patient's diverse conditions.
Assuntos
Neoplasias Encefálicas/radioterapia , Glioma/radioterapia , Recidiva Local de Neoplasia/radioterapia , Reirradiação , Neoplasias Encefálicas/mortalidade , Neoplasias Encefálicas/patologia , Progressão da Doença , Fracionamento da Dose de Radiação , Feminino , Glioma/mortalidade , Glioma/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estudos Retrospectivos , Análise de Sobrevida , Tempo para o TratamentoRESUMO
Acute pancreatitis is an often-overlooked cause of acute abdominal pain in children and adolescents. Severe hypertriglyceridaemia is an important cause of recurrent acute pancreatitis. Monogenic causes of hypertriglyceridaemia, such as familial chylomicronaemia caused by lipoprotein lipase deficiency, are more frequently encountered in children and adolescents, but remain rare. Polygenic hypertriglyceridaemia is more common, but may require a precipitant before manifesting. With the global increase in obesity and type 2 diabetes, secondary causes of hypertriglyceridaemia in children and adolescents are increasing. We report two cases of severe hypertriglyceridaemia and pancreatitis in adolescent females. Hypertriglyceridaemia improved markedly with restriction of dietary fat. An inhibitor to lipoprotein lipase was found to be the cause in one patient, while in the other limited genetic investigation excluded chylomicronaemia owing to deficiency of lipoprotein lipase, its activators and processing proteins.
Assuntos
Diabetes Mellitus Tipo 2 , Hiperlipoproteinemia Tipo I , Hipertrigliceridemia , Pancreatite , Doença Aguda , Adolescente , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Hiperlipoproteinemia Tipo I/complicações , Hiperlipoproteinemia Tipo I/diagnóstico , Hiperlipoproteinemia Tipo I/genética , Hipertrigliceridemia/complicações , Hipertrigliceridemia/genética , Lipase Lipoproteica/genética , Pancreatite/etiologia , África do SulRESUMO
Background: The second wave of coronavirus disease 2019 (COVID-19), dominated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Beta variant, has been reported to be associated with increased severity in South Africa (SA). Objectives: To describe and compare clinical characteristics, management and outcomes of COVID-19 patients admitted to an intensive care unit (ICU) in SA during the first and second waves. Methods: In a prospective, single-centre, descriptive study, we compared all patients with severe COVID-19 admitted to ICU during the first and second waves. The primary outcomes assessed were ICU mortality and ICU length of stay (LOS). Results: In 490 patients with comparable ages and comorbidities, no difference in mortality was demonstrated during the second compared with the first wave (65.9% v. 62.5%, p=0.57). ICU LOS was longer in the second wave (10 v. 6 days, p<0.001). More female admissions (67.1% v. 44.6%, p<0.001) and a greater proportion of patients were managed with invasive mechanical ventilation than with non-invasive respiratory support (39.0% v. 14%, p<0.001) in the second wave. Conclusion: While clinical characteristics were comparable between the two waves, a higher proportion of patients was invasively ventilated and ICU stay was longer in the second. ICU mortality was unchanged.
RESUMO
The coronavirus disease 2019 (COVID-19) pandemic has increased exponentially in numbers with more than 20 million people infected around the globe. It is clear that COVID-19 is not a simple viral pneumonia, but presents with unusual pathophysiological effects. Of special interest is that SARS-CoV-2 utilises the angiotensin-converting enzyme-2 (ACE2) for cell entry and therefore has a direct effect on the renin angiotensin system (RAS). The RAS is primarily responsible for blood pressure control via the classic pathway. Recently numerous other pathological processes have been described due to stimulation of this classic pathway. There is also a protective RAS pathway medicated by ACE2 which may be suppressed in COVID-19. This leads to overstimulation of the classic pathway with adverse cardiovascular and respiratory effects, hypercoagulation, endothelial dysfunction, inflammation and insulin resistance. We hypothesize that overreaction of the renin-angiotensin-aldosterone may account for the myriad of unusual biochemical and clinical abnormalities noted in patients infected with SARS-CoV-2.
Assuntos
COVID-19/metabolismo , Regulação da Expressão Gênica , Inflamação/metabolismo , Sistema Renina-Angiotensina/fisiologia , Idoso , Enzima de Conversão de Angiotensina 2/metabolismo , Pressão Sanguínea , COVID-19/complicações , COVID-19/virologia , Doenças Cardiovasculares/complicações , Estado Terminal , Citocinas/metabolismo , Feminino , Humanos , Resistência à Insulina , Unidades de Terapia Intensiva , Masculino , Modelos Teóricos , Obesidade/complicações , Pandemias , Síndrome do Desconforto Respiratório/complicações , Síndrome do Desconforto Respiratório/virologia , SARS-CoV-2 , Trombofilia/complicaçõesRESUMO
BACKGROUND: Globally, few studies have examined the effect of the COVID-19 pandemic on routine patient care and follow-up. OBJECTIVES: To evaluate the effect of the COVID-19 response on biochemical test requests received from outpatient departments (OPDs) and peripheral clinics serviced by the National Health Laboratory Service Chemical Pathology Laboratory at Tygerberg Hospital, Cape Town, South Africa (SA). Request volumes were used as a measure of the routine care of patients, as clinical information was not readily available. METHODS: A retrospective audit was conducted. The numbers of requests received from OPDs and peripheral clinics for creatinine, glycated haemoglobin (HbA1c), lipid profiles, thyroid-stimulating hormone (TSH), free thyroxine, free tri-iodothyronine (fT3), serum and urine protein electrophoresis, serum free light chains and neonatal total serum bilirubin were obtained from 1 March to 30 June for 2017, 2018, 2019 and 2020. RESULTS: The biggest impact was seen on lipids, creatinine, HbA1c, TSH and fT3. The percentage reduction between 1 March and 30 June 2019 and between 1 March and 30 June 2020 was 59% for lipids, 64% for creatinine and HbA1c, 80% for TSH and 81% for fT3. There was a noteworthy decrease in overall analyte testing from March to April 2020, coinciding with initiation of level 5 lockdown. Although an increase in testing was observed during June 2020, the number of requests was still lower than in June 2019. CONCLUSIONS: This study, focusing on the short-term consequences of the SA response to the COVID-19 pandemic, found that routine follow-up of patients with communicable and non-communicable diseases was affected. Future studies are necessary to evaluate the long-term consequences of the pandemic for these patient groups.
Assuntos
COVID-19 , Serviços de Laboratório Clínico/tendências , Técnicas de Laboratório Clínico/tendências , Atenção à Saúde , Assistência Ambulatorial , Bilirrubina/sangue , Análise Química do Sangue/tendências , Eletroforese das Proteínas Sanguíneas , Creatinina/sangue , Eletroforese/tendências , Hemoglobinas Glicadas/metabolismo , Humanos , Lipídeos/sangue , Estudos Retrospectivos , SARS-CoV-2 , Testes de Função Tireóidea/estatística & dados numéricos , Tireotropina/sangue , Tiroxina/sangue , Tri-Iodotironina/sangue , Urinálise/tendênciasRESUMO
SETTING: Pleural adenosine deaminase (ADA) levels have been found to be useful in diagnosing tuberculous pleuritis. Elevated ADA levels have been attributed to ADA2 isoenzyme, although no comprehensive studies have evaluated ADA2 as a diagnostic test. OBJECTIVE: To estimate the diagnostic accuracy of ADA and ADA2 in diagnosing tuberculous pleurisy. METHOD: A 3-year retrospective study was carried out. ADA and ADA2 were determined on patients diagnosed according to predetermined criteria. RESULTS: A total of 951 samples were received, including 387 patients with tuberculosis (TB). ADA values>or=52.4 U/l yielded a sensitivity, specificity and positive (PPV) and negative predictive value (NPV) respectively of 93.7% (95%CI 90.0-96.0), 88.7% (95%CI 85.7-91.3), 85.5% (95%CI 81.7-88.8) and 95.2% (95%CI 92.9-96.9). ADA2 values>or=40.6 U/l yielded a sensitivity, specificity and PPV and NPV of respectively 97.2% (95%CI 95.0-98.7), 94.2% (95%CI 91.8-96.0), 92.2% (95%CI 89.1-94.7) and 98.0% (95%CI 96.3-99.0). The chi2 and McNemar tests proved the superiority of ADA2 statistically. CONCLUSION: ADA2 is superior to ADA in the diagnosis of tuberculous pleuritis and should be used as a routine test in the diagnostic work-up of patients with pleural effusions in areas with high TB prevalence.
Assuntos
Adenosina Desaminase/metabolismo , Derrame Pleural/diagnóstico , Derrame Pleural/enzimologia , Tuberculose Pleural/diagnóstico , Tuberculose Pleural/enzimologia , Adulto , Feminino , Humanos , Isoenzimas/metabolismo , Masculino , Pessoa de Meia-Idade , Derrame Pleural/microbiologia , Pleurisia/diagnóstico , Pleurisia/enzimologia , Pleurisia/microbiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Tuberculose Pleural/complicaçõesRESUMO
BACKGROUND: Studies of electrophoresis testing (serum protein electrophoresis (SPE), urine protein electrophoresis (UPE), immunofixation electrophoresis (IFE)) in a South African (SA) pathology laboratory setting are limited. OBJECTIVES: To evaluate the prevalence, testing pattern and yield of electrophoresis tests performed over a 5-year period in a tertiary academic laboratory and to relate these findings to bone marrow biopsy findings in a few selected cases. METHODS: This was a retrospective audit of all SPE, UPE and IFE tests performed on new and follow-up adult patients (aged ≥18 years) from 2010 to 2015, using data from the Tygerberg Academic Hospital (Cape Town, SA) National Health Laboratory Service hospital information system database. A subgroup analysis of all patients with negative serum (SIFE) and/or urine immunofixation (UIFE) tests who had concurrent bone marrow biopsies close to the time of IFE testing was also performed. RESULTS: A total of 5 086 SPE tests were performed (44.3% were follow-up tests, and of these patients 13.8% had SIFE tests); 1 299 UPE tests were performed (23.3% were follow-up tests, and of these patients 33.6% had UIFE tests). The mean ages of patients who had SIFE and UIFE tests were 59 years (standard deviation (SD) 14.2) and 60 years (SD 15), respectively. The female-to-male ratio was 1.1:1 for both SIFE and UIFE. The negative test yields for SIFE and UIFE were 31.3% and 52.1%, respectively. Bone marrow biopsy findings for patients with negative SIFE tests identified 8 out of the 20 biopsies (40.0%) as positive for myeloma. CONCLUSION: This audit provides baseline data on the prevalence of test requests, their source and the yield of electrophoresis testing in our laboratory. An increasing trend in SIFE and UIFE was evident.
RESUMO
BACKGROUND: South Africa has the highest burden of tuberculosis (TB) in the World Health Organization (WHO) African region. Using traditional TB diagnostic tools, the diagnosis of pleural TB (PTB) is highly unrewarding. Elevated levels of pleural fluid adenosine deaminase (FADA) have been shown to be useful in the diagnosis of PTB; however, similar levels may be found in some other medical conditions leading to misdiagnosis. Following queries from clinicians concerning the likely high false-positive (FP) rate of FADA from our laboratory, we performed a retrospective audit of all high FADA results generated over a 12-month period. OBJECTIVES: To determine the positive predictive value (PPV) of FADA, the frequent causes of FPs in our laboratory and the demographic characteristics of tuberculous pleural effusions (TPEs) and non-tuberculous pleural effusions (NTPEs). METHODS: High FADA results generated in the past year were extracted with corresponding TB culture results, fluid cell count, cytology/ histology results, radiology reports and HIV results. Hospital records were reviewed for the final diagnosis in each case. Diagnosis of PTB was based on the WHO case definition of TB. RESULTS: A total of 159 results were reviewed: 133 (83.6%) were TPE, hence FADA had a PPV of 83.6%. Neoplasm was the most common cause of an FP in 13/26 (50%) NTPEs. While TPE was more common than NTPE in younger people, both groups had an equal gender distribution. CONCLUSION: FADA had a high PPV for PTB in our laboratory. We recommend its continued use as a rapid and reliable diagnostic tool for PTB.
Assuntos
Adenosina Desaminase/análise , Efeitos Psicossociais da Doença , Infecções por HIV/complicações , Derrame Pleural/enzimologia , Tuberculose Pleural/diagnóstico , Adulto , Reações Falso-Positivas , Feminino , Humanos , Renda , Masculino , Auditoria Médica , Estudos Retrospectivos , África do SulRESUMO
BACKGROUND: Monoclonal gammopathy has been noted with increased frequency in patients with HIV infection compared with the general population. The prevalence in patients on antiretroviral therapy (ART) has not been widely investigated. The present study aims to describe the prevalence and characteristics of monoclonal proteins in a population of HIV-infected patients in the Western Cape region of South Africa. METHODS: Clinical information and blood and urine samples were collected from patients with proven HIV infection attending two clinics in the Western Cape. Serum protein electrophoresis was performed on all patients using agarose gel. Those with visible mono- or oligoclonal bands or increased gamma fractions were subjected to immunofixation electrophoresis. RESULTS: Three hundred and sixty-eight patients were included in the study with a mean age of 37.7 y. Of these patients, 326 were on ART for a mean duration of 19.6 months. Monoclonal bands were found in 12 patients (3.2%) and oligoclonal bands in 14 (3.8%). These bands were associated with a shorter duration of ART, increased total protein, acute on chronic phase pattern on electrophoresis and an increased gamma fraction, but not associated with CD4 count and viral load. The majority were of low concentration and of the IgG isotype. CONCLUSION: Our study confirms that the prevalence of monoclonal and oligoclonal bands is higher in this HIV-positive cohort on ART compared with that of the general population. However, the prevalence is lower than previously reported in other studies.
Assuntos
Proteínas Sanguíneas/análise , Eletroforese/métodos , Infecções por HIV/complicações , Paraproteinemias/sangue , Paraproteinemias/complicações , Adolescente , Adulto , Idoso , Fármacos Anti-HIV/uso terapêutico , Proteínas Sanguíneas/imunologia , Feminino , Seguimentos , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , África do Sul , Adulto JovemRESUMO
Audits are part of the continuous quality improvement process and one of the key elements of clinical governance. Laboratory-based clinical audits are concerned primarily with the everyday aspects of laboratory services and are a means of providing feedback to the users of the laboratory and its staff. They involve measuring the performance of laboratory services against established standards. These standards have ideally been established using the principles of evidence-based medicine. If necessary, changes are implemented and then a re-audit is performed after a certain time period to ensure that the changes have been implemented and maintained. Areas of audit in the laboratory include the preanalytical, analytical and postanalytical phases. This review article examines the basis of clinical audits in the laboratory and then proceeds to describe in detail how a laboratory-based clinical audit should be performed and monitored, with special reference to the chemical pathology laboratory.
Assuntos
Auditoria Clínica/métodos , Laboratórios/normas , Patologia Clínica/normas , Governança Clínica , Medicina Baseada em Evidências/métodos , Pesquisa sobre Serviços de Saúde/métodos , HumanosRESUMO
AIM: The aim of this study was to determine the most common causes of hypophosphataemia (Assuntos
Hipofosfatemia/etiologia
, Pacientes Internados
, Mortalidade Hospitalar
, Humanos
, Hipofosfatemia/mortalidade
, Unidades de Terapia Intensiva
, Morbidade
, Neoplasias/complicações
, Estudos Retrospectivos
, Medição de Risco
, Sepse/complicações
, África do Sul/epidemiologia