The use of C-reactive protein to predict uncomplicated appendicitis and increase uptake of laparoscopy in low resource hospitals-A retrospective cohort study.

BACKGROUND: Acute appendicitis remains the most common surgical emergency worldwide. There has been a low uptake of laparoscopic appendicectomy in the South African public sector. Preoperative identification of cases of uncomplicated appendicitis that are amenable to a laparoscopic approach may facilitate the implementation of laparoscopic appendicectomy programs in training hospitals. With limited access to preoperative imaging, alternative strategies for this preoperative prediction are needed. METHODS: A retrospective audit of patients over the age of 12 years with a histologically confirmed diagnosis of acute appendicitis over a 5-year period was performed. Patients were categorized as uncomplicated or complicated appendicitis and C-reactive protein (CRP) and white cell count (WCC) reviewed. Receiver operating characteristics curves were constructed for these blood tests and acute appendicitis severity. Youden's J statistic was used to determine optimal cut off values for diagnosing complicated appendicitis. RESULTS: 358 patients had confirmed appendicitis and complete blood results. Of these, 189 (52.79%) had complicated appendicitis with a 40.22% perforation rate. Median CRP in uncomplicated and complicated groups were 68 mg/L (IQR 19-142) and 216 mg/L (IQR 103-313) with an area under the curve (AUC) of 0.75 (95% CI: 0.70-0.80). The median WCC in the two groups were 12.6 × 109 cells/L (IQR 9.9-15.6) and 14.4 × 109 cells/L (IQR 11.5-18.28) with an AUC of 0.61 (95% CI: 0.56-0.67). The optimal cut off value for CRP was found to be 110 mg/L with a sensitivity of 74.74% and specificity of 69.23%. CONCLUSION: A cutoff value of 110 mg/dl CRP can distinguish patients with early appendicitis from those with complicated disease and when used in conjunction with clinical assessment may help identify patients in whom laparoscopic appendicectomy is appropriate.

The effect of care interruptions on mortality in adults resuming antiretroviral therapy.

OBJECTIVE: To estimate the relative rate of all-cause mortality amongst those on antiretroviral treatment (ART) with a history of interruptions compared with those with no previous interruptions in care. DESIGN: Retrospective cohort study. METHODS: We used data from four South African cohorts participating in the International epidemiology Databases to Evaluate AIDS Southern Africa collaboration. We included adults who started ART between 2004 and 2019. We defined a care interruption as a gap in contact longer than 180 days. Observation time prior to interruption was allocated to a 'no interruption' group. Observation time after interruption was allocated to one of two groups based on whether the first interruption started before 6 months of ART ('early interruption') or later ('late interruption'). We used Cox regression to estimate hazard ratios. RESULTS: Sixty-three thousand six hundred and ninety-two participants contributed 162 916 person-years of observation. There were 3469 deaths. Most participants were female individuals (67.4%) and the median age at ART initiation was 33.3 years (interquartile range: 27.5-40.7). Seventeen thousand and eleven (26.7%) participants experienced care interruptions. Those resuming ART experienced increased mortality compared with those with no interruptions: early interrupters had a hazard ratio of 4.37 (95% confidence interval (CI) 3.87-4.95) and late interrupters had a hazard ratio of 2.74 (95% CI 2.39-3.15). In sensitivity analyses, effect sizes were found to be proportional to the length of time used to define interruptions. CONCLUSION: Our findings highlight the need to improve retention in care, regardless of treatment duration. Programmes to encourage return to care also need to be strengthened.

ART history prior to conception: trends and association with postpartum disengagement from HIV care in Khayelitsha, South Africa (2013-2019): a retrospective cohort study.

INTRODUCTION: In recent years, the expansion of HIV treatment eligibility has resulted in an increase in people with antiretroviral therapy (ART) experience prior to pregnancy but little is known about postpartum engagement in care in this population. We examined differences in disengagement from HIV care after delivery by maternal ART history before conception. METHODS: We analysed data from people living with HIV (aged 15-49) in Khayelitsha, South Africa, with ≥1 live birth between April 2013 and March 2019. We described trends over time in ART history prior to estimated conception, classifying ART history groups as: (A) on ART with no disengagement (>270 days with no evidence of HIV care); (B) returned before pregnancy following disengagement; (C) restarted ART in pregnancy after disengagement; and (D) ART new start in pregnancy. We used Kaplan-Meier curves and proportional-hazards models (adjusted for maternal age, number of pregnancy records and year of delivery) to examine the time to disengagement from delivery to 2 years postpartum. RESULTS: Among 7309 pregnancies (in 6680 individuals), the proportion on ART (A) increased from 19% in 2013 to 41% in 2019. The proportions of those who returned (B) and restarted (C) increased from 2% to 13% and from 2% to 10%, respectively. There was a corresponding decline in the proportion of new starts (D) from 77% in 2013 to 36% in 2019. In the first recorded pregnancy per person in the study period, 26% (95% CI 25-27%) had disengaged from care by 1 year and 34% (95% CI 33-36%) by 2 years postpartum. Individuals who returned (B: aHR 2.10, 95% CI 1.70-2.60), restarted (C: aHR 3.32, 95% CI 2.70-4.09) and newly started ART (D: aHR 2.41, 95% CI 2.12-2.74) had increased hazards of postpartum disengagement compared to those on ART (A). CONCLUSIONS: There is a growing population of people with ART experience prior to conception and postpartum disengagement varies substantially by ART history. Antenatal care presents an important opportunity to understand prior ART experiences and an entry into interventions for strengthened engagement in HIV care.