Human papillomavirus vaccination in Africa: An airway perspective.

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a chronic condition caused by Human papillomavirus six (HPV-6) and HPV-11 that involves the respiratory tract. Disease severity ranges from mild (hoarseness), through to severe (stridor, respiratory distress and airway emergencies). Africa has the fastest growing and youngest population of all the continents. It also has the greatest burden of cervical cancer. There is an association with infection of the oncogenic HPV strains and the strains responsible for RRP. It is reasonable to conclude that although RRP may be underestimated in low-to-middle-income countries, it poses a considerable health risk to Africa. The primary aim of this project was to assess the suitability of HPV vaccination coverage on the African continent. METHODS: A prospective study was designed to consist of an online survey. It was distributed to 135 African otolaryngologists. Questions focussed on HPV vaccination programmes; whether they were government directed; and their rollout. Information from countries that had multiple otolaryngologists respond to the survey were compared. Additionally, data review and corroboration were performed. RESULTS: There were 58 (43%) participants from 19 countries. Nine countries reported a national vaccination programme (NVP), five used Cervarix; four used quadrivalent Gardasil. Collateral data revealed 18 of 54 countries had NVP in Africa and 26 countries had completed HPV vaccine pilot or demonstration projects. CONCLUSIONS: HPV vaccination in Africa should be urgently re-evaluated to include the HPV-6 and HPV-11 strains that cause JORRP, which have not been recognised during national vaccination programme planning.

Does thyroid-sparing total laryngectomy decrease the risk of hypothyroidism?

BACKGROUND: Thyroid lobectomy is recommended with total laryngectomy for laryngeal cancer in the National Comprehensive Cancer Network ('NCCN') guidelines. However, it is associated with a 32-89 per cent risk of hypothyroidism, with or without adjuvant radiotherapy. OBJECTIVE: The study aimed to determine whether preserving the whole thyroid, compared to a single lobe, does indeed significantly lower the incidence of hypothyroidism in the setting of total laryngectomy. METHOD: A retrospective study was conducted at Groote Schuur Hospital in Cape Town, South Africa. RESULTS: Eighty-four patients met the inclusion criteria. The overall incidence of hypothyroidism was 45.2 per cent. The incidence of hypothyroidism was significantly reduced in patients who underwent thyroid-sparing total laryngectomy compared to hemithyroidectomy (p = 0.037). Adjuvant radiotherapy was associated with a higher incidence of hypothyroidism (p = 0.001). CONCLUSION: Thyroid-preserving laryngectomy should be advocated in carefully selected patients with advanced laryngeal carcinoma, as it reduces the incidence of hypothyroidism.

Reintroduction of elective paediatric otolaryngology procedures in South Africa during the COVID-19 pandemic.

Cancelling elective clinical consultations and surgical procedures was instrumental in assisting hospitals prepare for the COVID-19 crisis. Essential bed space was made available, and it allowed mobilisation of health workers and enforced social distancing. A shift in patient-centred ethics to public health ethics was required to provide a utilitarian approach to the crisis. However, at some point, clinicians need to start becoming patient centred again, and this needs to happen within the utilitarian framework. Children only account for 1 - 5% of confirmed COVID-19 cases, and they present with a much milder disease spectrum than adults. Consequently, paediatric units may be at the forefront of implementing reintroduction of patient-centred elective clinical and surgical procedures. The following recommendations provide a framework to do this in a way that minimises risk to patients and clinicians. They are the first paediatric guidelines in the literature to propose a strategy to reintroduce elective surgical procedures.

Reintroduction of elective paediatric otolaryngology procedures in South Africa during the COVID-19 pandemic

Cancelling elective clinical consultations and surgical procedures was instrumental in assisting hospitals prepare for the COVID-19 crisis. Essential bed space was made available, and it allowed mobilisation of health workers and enforced social distancing. A shift in patient-centred ethics to public health ethics was required to provide a utilitarian approach to the crisis. However, at some point, clinicians need to start becoming patient centred again, and this needs to happen within the utilitarian framework. Children only account for 1 - 5% of confirmed COVID-19 cases, and they present with a much milder disease spectrum than adults. Consequently, paediatric units may be at the forefront of implementing reintroduction of patient-centred elective clinical and surgical procedures. The following recommendations provide a framework to do this in a way that minimises risk to patients and clinicians. They are the first paediatric guidelines in the literature to propose a strategy to reintroduce elective surgical procedures

Quality of life after total laryngectomy: evaluating the effect of socioeconomic status.

OBJECTIVE: Total laryngectomy is considered the primary treatment modality for advanced laryngeal carcinoma. This study assessed the quality of life in patients after total laryngectomy, and ascertained whether quality of life is affected by socioeconomic status. METHOD: Forty-seven patients (20 state- and 27 private-sector) who underwent total laryngectomy between 1998 and 2014 responded to the University of Washington Quality of Life Questionnaire, the Voice-Related Quality of Life Questionnaire and the Brief Illness Perception Questionnaire. RESULTS: Significant differences were found in socioeconomic status between state- and private-sector patients (p < 0.001). There was no significant difference in overall quality of life between groups (p = 0.210). State-sector patients scored significantly higher Voice-Related Quality of Life Questionnaire scores (p = 0.043). Perception of illness did not differ significantly between groups. CONCLUSION: Overall quality of life after total laryngectomy appears to be similar in patients from different socioeconomic backgrounds. However, patients from lower socioeconomic circumstances have better voice-related quality of life. The results illustrate the importance of including socioeconomic status when reporting voice outcomes in total laryngectomy patients.

Radiological differences between HIV-positive and HIV-negative children with cholesteatoma.

INTRODUCTION: HIV-positive children are possibly more prone to developing cholesteatoma. Chronic inflammation of the middle ear cleft may be more common in patients with HIV and this may predispose HIV-positive children to developing cholesteatoma. There are no studies that describe the radiological morphology of the middle ear cleft in HIV-positive compared to HIV-negative children with cholesteatoma. OBJECTIVES: Compare the radiological differences of the middle ear cleft in HIV-positive and HIV-negative children with cholesteatoma. METHODS: A retrospective, cross-sectional, observational analytical review of patients with cholesteatoma at our institute over a 6 year period. RESULTS: Forty patients were included in the study, 11 of whom had bilateral cholesteatoma and therefore 51 ears were eligible for our evaluation. HIV-positive patients had smaller (p=0.02) mastoid air cell systems (MACS). Forty percent of HIV-positive patients had sclerotic mastoids, whereas the rate was 3% in HIV-negative ears (p<0.02). Eighty-two percent of the HIV-positive patients had bilateral cholesteatoma compared to 7% of the control group (p<0.02). There was no difference between the 2 groups with regards to opacification of the middle ear cleft, bony erosion of middle ear structures, Eustachian tube obstruction or soft tissue occlusion of the post-nasal space. CONCLUSION: HIV-positive paediatric patients with cholesteatoma are more likely to have smaller, sclerotic mastoids compared to HIV-negative patients. They are significantly more likely to have bilateral cholesteatoma. This may have implications in terms of surveillance of HIV-positive children, as well as, an approach to management, recurrence and follow-up. HIV infection should be flagged as a risk factor for developing cholesteatoma.

Management of pediatric cholesteatoma based on presentations, complications, and outcomes.

OBJECTIVES: To highlight important aspects and paradigms in the management of paediatric cholesteatoma in a developing world setting. METHODS: A retrospective audit was conducted of paediatric cholesteatomas that underwent tympanomastoid surgery between 2008 and 2012 at the Red Cross War Memorial Children's Hospital in Cape Town. The following was audited: initial presentation; cholesteatoma complications; types of surgery, intraoperative findings and outcomes of surgery in terms of hearing, otorrhoea and recidivism; and the reliability of follow-up and how this might influence the type of surgery. RESULTS: Fifty-seven children aged 2-13 years with 61 cholesteatomas (4 bilateral) were reviewed. Fifty-five mastoidectomies were done; 11% presented with complicated cholesteatoma. Referrals from primary care were significantly delayed (>6 months) in 76%. Canal wall down surgery was done in 71%. Forty-five percent had improved hearing (within 15dB of better hearing ear) and a further 15% had no or only mild hearing loss. Ossicular chain involvement and ossicles encased in inflammatory tissue were associated with poorer hearing outcomes. Sixty-four percent of ears remained dry. Forty-five percent of the canal wall up, and 23% of canal wall down mastoidectomies had recidivism. Twenty-six percent of patients were lost to follow-up. CONCLUSIONS: Children are likely to present with advanced cholesteatoma with ossicular chain involvement. The children present with high rates of complications, poor pre-operative hearing and have high recurrence rates post-surgery. Referral from primary health care is delayed. Canal wall down procedures may be appropriate in a setting where patient follow-up is unreliable and access to operating theatre is limited.

A risk assessment scoring system predicts survival following the Norwood procedure.

No one set of characteristics has been consistently predictive of perioperative mortality and morbidity associated with the Norwood procedure. The purpose of the current study is to further validate a scoring system shown to be predictive of mortality following the Norwood procedure. We performed a retrospective review of all infants with the diagnosis of hypoplastic left heart syndrome (HLHS) who underwent the Norwood procedure at St. Louis Children's Hospital from July 1, 1994, to December 31, 2002. A weighted score for each of six factors comprised the scoring system. The factors included ventricular function, tricuspid regurgitation, ascending aortic diameter, atrial septal defect blood flow characteristics, blood type, and age. A score of > or = 7 points indicated lower reconstructive mortality risk, and a total score of < 7 points indicated a higher mortality risk. A total of 57 patients were analyzed. Twenty-five infants (44%) had a low risk score. These infants had a significantly greater survival at 48 hours compared to infants with a score of < 7 (92 vs 75%, p < 0.05). Infants with a high risk score had a significantly greater relative risk of mortality at 48 hours [OR = 2.04; confidence interval (CI) 1.04-4.00; p = 0.036]. The area under the receiver operating characteristic (ROC) curve is 0.8534 (95% CI, 0.78-0.922). This suggests that the scoring system has a very good degree of discriminatory power in selecting children who did not survive. Based on the results of the ROC, a cutoff score of >7 gives the best sensitivity and specificity for survival. When applied retrospectively, the survival outcomes predicted by our scoring system significantly correlated with actual outcomes. This supports the conclusion that a specific population of HLHS patients may have a higher mortality risk independent of surgical technique and postoperative care based on factors that can be assessed preoperatively.

Fatal hypermagnesemia in a child treated with megavitamin/megamineral therapy.

We report a case of fatal hypermagnesemia resulting from the unsupervised use of high doses of magnesium oxide administered as part of a regimen of megavitamin and megamineral therapy to a child with mental retardation, spastic quadriplegia, and seizures. The treatment regimen was given at the recommendation of a dietician working as a private nutritional consultant without the involvement or notification of the child's pediatrician. Hypermagnesemia is an uncommon but serious side effect of the use of magnesium containing compounds. These compounds are widely used as laxatives and dietary supplements, and serious side effects are uncommon when used in appropriate dosages and with adequate supervision. The use of alternative medical therapies, including megavitamin/megamineral therapy, is widespread. Many patients use alternative medicine or seek care from alternative medicine practitioners without the recommendation or knowledge of their primary physicians. Despite unproved benefit, many alternative therapies may be safe. However, unsupervised use of generally safe treatments can result in serious side effects. This case report serves to illustrate the characteristic pathophysiologic changes of severe hypermagnesemia, an entity rarely seen in pediatric practice, and more importantly, it alerts primary care and subspecialty pediatricians to be aware of and monitor the use of alternative medical therapies in their patients.

New experimental approaches to the isoelectric fractionation of cells.

Several parameters that could affect the survival rate and the resolution of cells in continuous-flow isoelectric focusing have been investigated. Cell survival at progressively lower pHs was found to be a function of the osmolarity of the medium: at pH 4 there was an absolute requirement for a 300 mOsm environment. A pH-dependent interaction of the carrier ampholytes with the cell surface has been demonstrated. The binding was very strong at pH 4, weak at pH 5 and totally abolished above pH 5. The same interaction was obtained with pentaethylenehexamine, the polyamino backbone of carrier ampholytes, stripped of carboxyl groups. A model was derived showing how at pH 4 the oligocationic carrier ampholytes, via their nitrogen groups, would bind to the polyanionic cell surface. The Hannig apparatus was adapted for cell separation in a continuously flowing curtain of isoelectric ampholytes. The medium osmolarity was maintained with glycine (delta pK 7.2), taurine (delta pK 8.5) and trimethylaminopropionyl sulphonate (TMAPS, delta pK 11). With increasing delta pK, the pH range that can be created in the presence of these compounds progressively widens, from a pH 4.3-7.5 range with glycine, to pH 3.5-7.5 with taurine up to pH 3.5-9.5 with TMAPS. The 48 fractions collected were routinely assayed for conductivity, osmolarity and pH.