Guidance for the gastrointestinal evaluation and management of iron deficiency in Sub-Saharan Africa.

BACKGROUND: Over 30% of the world's population is anaemic, with a significant proportion of these being iron deficient. As iron deficiency (ID) anaemia in men and post-menopausal women is mostly caused by gastrointestinal blood loss or malabsorption, the initial evaluation of a patient with ID anaemia involves referral to a gastroenterologist. The current drive towards patient blood management in sub-Saharan Africa (SSA)prescribes that we regulate not only the use of blood transfusion but also the management of patients in whom the cause of iron loss or inadequate iron absorption is sought. Recommendations have been developed to: (i) aid clinicians in the evaluation of suspected gastrointestinal iron loss and iron malabsorption, and often a combination of these; (ii) improve clinical outcomes for patients with gastrointestinal causes of ID; (iii) provide current, evidence-based, context-specific recommendations for use in the management of ID; and (iv) conserve resources by ensuring rational utilisation of blood and blood products. METHOD: Development of the guidance document was facilitated by the Gastroenterology Foundation of Sub-Saharan Africa and the South African Gastroenterology Society. The consensus recommendations are based on a rigorous process involving 21 experts in gastroenterology and haematology in SSA. Following discussion of the scope and purpose of the guidance document among the experts, an initial review of the literature and existing guidelines was undertaken. Thereafter, draft recommendation statements were produced to fulfil the outlined purpose of the guidance document. These were reviewed in a round-table discussion and were subjected to two rounds of anonymised consensus voting by the full committee in an electronic Delphi exercise during 2022 using the online platform, Research Electronic Data Capture. Recommendations were modified by considering feedback from the previous round, and those reaching a consensus of over 80% were incorporated into the final document. Finally, 44 statements in the document were read and approved by all members of the working group. CONCLUSION: The recommendations incorporate six areas, namely: general recommendations and practice, Helicobacter pylori, coeliac disease, suspected small bowel bleeding, inflammatory bowel disease, and preoperative care. Implementation of the recommendations is aimed at various levels from individual practitioners to healthcare institutions, departments and regional, district, provincial and national platforms. It is intended that the recommendations spur the development of centre-specific guidelines and that they are integrated with the relevant patient blood management protocols. Integration of the recommendations is intended to promote optimal evaluation and management of patients with ID, regardless of the presence of anaemia.

Heparin-induced thrombocytopenia: An update for the COVID-19 era.

The increased use of heparin during the current COVID-19 pandemic has highlighted the risk of a rare but potentially serious complication of heparin therapy, viz. heparin-induced thrombocytopenia (HIT). This is a short review on the pharmacology of heparin and its derivatives, and the pathophysiology of HIT. Guidance on laboratory testing for and clinical management of HIT is presented in accordance with international guidelines. There are important similarities and differences between HIT and the new entity of vaccine-induced immune thrombotic thrombocytopenia, also known as thrombosis with thrombocytopenia syndrome, which clinicians need to be aware of.

Patient blood management: A solution for South Africa.

For more than 70 years the default therapy for anaemia and blood loss was mostly transfusion. Accumulating evidence demonstrates a significant dose-dependent relationship between transfusion and adverse outcomes. This and other transfusion-related challenges led the way to a new paradigm. Patient blood management (PBM) is the application of evidence-based practices to optimise patient outcomes by managing and preserving the patient's own blood. 'Real-world' studies have shown that PBM improves patient outcomes and saves money. The prevalence of anaemia in adult South Africans is 31% in females and 17% in males. Improving the management of anaemia will firstly improve public health, secondly relieve the pressure on the blood supply, and thirdly improve the productivity of the nation's workforce. While high-income countries are increasingly implementing PBM, many middle- and low-income countries are still trying to upscale their transfusion services. The implementation of PBM will improve South Africa's health status while saving costs.

Concomitant HIV infection in newly diagnosed multiple myeloma patients is hard to recognise and should be tested for routinely in areas of high endemicity.

BACKGROUND: Over the past three decades much has changed in the treatment and outcomes of patients suffering concurrently from both multiple myeloma (MM) and HIV. While the prevalence of MM appears to be higher in HIV-positive individuals than in those who are uninfected, early recognition of patients suffering from both diseases is difficult and little information is available on their demographics and clinical presentation. OBJECTIVE: To compare the presenting features of HIV-positive patients diagnosed with MM with those of HIV-negative patients. METHODS: A single-centre, retrospective cohort study included 16 HIV-positive and 73 HIV-negative patients diagnosed with MM, in order to compare variables related to the clinical presentation of both conditions. RESULTS: HIV-positive patients presented with MM at a significantly younger age, and had fewer osteolytic lesions, less renal impairment and lower neutrophil counts. Disease stage, gender, pathological fractures, bone marrow plasmacytosis, plasmacytomas and lymphocyte counts were comparable, emphasising the difficulty of identifying these patients. The HIV-positive patients had relatively high CD4 counts and a low prevalence of abnormal Freelite kappa/lambda ratios. All HIV-positive patients presented with paraproteins of the immunoglobulin G (IgG) type, implying a possible relationship between MM and an IgG response to HIV antigens. CONCLUSIONS: On the basis of our findings and literature on the treatment of both diseases, we suggest that HIV be tested for routinely in younger MM patients, especially in areas with a high prevalence of HIV. The integration of our results into the sparse knowledge on the role of HIV infection-related MM provides possible new insights into the interaction between these diseases.

Pica Practices among Apparently Healthy Women and Their Young Children in Ghana.

BACKGROUND: Pica is an increased appetite/craving for food or non-food substances like clay, and chalk, and is strongly associated with iron deficiency (ID) anemia. This study assessed pica practices among non-pregnant mothers and their children, 12-to-59 months, in an anaemia endemic population in Ghana. SUBJECTS AND METHODS: A cross-sectional quantitative survey was conducted in two randomly selected districts in Northern Ghana. The researchers developed semi-structured questionnaires with components on pica practice, history and experiences and administered via structured face-to-face interviews with mothers (N=161) and all their children 6-59 months. Of this population, 132 mothers had children 12-to-59 months (N=139) in April 2012. Pica practice among children was reported by their mothers. Data was analysed using SPSS version 23.0. RESULTS: Few mothers (3%) spontaneously reported pica (for uncommon food and/or non-food substances) at the time of the interview, however, 16 (12.1%) mothers with pica were confirmed after further probing. Twelve (8.6%) children were reported to have ingested/craved clay/soil/dust (11 / 91.7 %), paper (1 / 7.1%) and chalk (1/7.1%) prior to the interview. One child had poly-pica (pica for two substance). Pica was reported to have been practised by expecting mothers during 37 (26.6%) of the pregnancies of the children involved in the study, and was mostly for clay/soil (33 / 89.1%), kola nut (5 / 3.6%), uncooked rice and bambara beans. Children's pica practices were significantly associated (χ2=6.33; p=0.011) with their mothers' pica practices during pregnancy as well as with mothers' pica practices at the time of the study (χ2=5.98; p=0.035). A logistic regression analysis seemed to show that pica of the mother during pregnancy was more strongly associated with the child's pica than later pica behaviour of the mother. Many myths and misconceptions associated with the practice of pica were also reported in these communities. CONCLUSIONS: The reported pica practice among mothers and their children was lower than what has been observed in other studies. Knowledge and perceptions regarding pica were mostly inaccurate. Education on pica and associated dangers of its practices should be included in nutrition interventions in communities with known high anemia prevalence.

Concomitant HIV infection in newly diagnosed multiple myeloma patients is hard to recognise and should be tested for routinely in areas of high endemicity

Background. Over the past three decades much has changed in the treatment and outcomes of patients suffering concurrently from both multiple myeloma (MM) and HIV. While the prevalence of MM appears to be higher in HIV-positive individuals than in those who are uninfected, early recognition of patients suffering from both diseases is difficult and little information is available on their demographics and clinical presentation.Objective. To compare the presenting features of HIV-positive patients diagnosed with MM with those of HIV-negative patients.Methods. A single-centre, retrospective cohort study included 16 HIV-positive and 73 HIV-negative patients diagnosed with MM, in order to compare variables related to the clinical presentation of both conditions.Results. HIV-positive patients presented with MM at a significantly younger age, and had fewer osteolytic lesions, less renal impairment and lower neutrophil counts. Disease stage, gender, pathological fractures, bone marrow plasmacytosis, plasmacytomas and lymphocyte counts were comparable, emphasising the difficulty of identifying these patients. The HIV-positive patients had relatively high CD4 counts and a low prevalence of abnormal Freelite kappa/lambda ratios. All HIV-positive patients presented with paraproteins of the immunoglobulin G (IgG) type, implying a possible relationship between MM and an IgG response to HIV antigens.Conclusions. On the basis of our findings and literature on the treatment of both diseases, we suggest that HIV be tested for routinely in younger MM patients, especially in areas with a high prevalence of HIV. The integration of our results into the sparse knowledge on the role of HIV infection-related MM provides possible new insights into the interaction between these diseases

Concomitant HIV infection in newly diagnosed multiple myeloma patients is hard to recognise and should be tested for routinely in areas of high endemicity

Background. Over the past three decades much has changed in the treatment and outcomes of patients suffering concurrently from both multiple myeloma (MM) and HIV. While the prevalence of MM appears to be higher in HIV-positive individuals than in those who are uninfected, early recognition of patients suffering from both diseases is difficult and little information is available on their demographics and clinical presentation.Objective. To compare the presenting features of HIV-positive patients diagnosed with MM with those of HIV-negative patients.Methods. A single-centre, retrospective cohort study included 16 HIV-positive and 73 HIV-negative patients diagnosed with MM, in order to compare variables related to the clinical presentation of both conditions.Results. HIV-positive patients presented with MM at a significantly younger age, and had fewer osteolytic lesions, less renal impairment and lower neutrophil counts. Disease stage, gender, pathological fractures, bone marrow plasmacytosis, plasmacytomas and lymphocyte counts were comparable, emphasising the difficulty of identifying these patients. The HIV-positive patients had relatively high CD4 counts and a low prevalence of abnormal Freelite kappa/lambda ratios. All HIV-positive patients presented with paraproteins of the immunoglobulin G (IgG) type, implying a possible relationship between MM and an IgG response to HIV antigens.Conclusions. On the basis of our findings and literature on the treatment of both diseases, we suggest that HIV be tested for routinely in younger MM patients, especially in areas with a high prevalence of HIV. The integration of our results into the sparse knowledge on the role of HIV infection-related MM provides possible new insights into the interaction between these diseases

An audit of the use of platelet transfusions at Universitas Academic Hospital, Bloemfontein, South Africa.

An audit was performed at a tertiary hospital in Bloemfontein, South Africa, to establish whether clinicians adhered to local platelet transfusion guidelines. The audit showed poor compliance with local guidelines, with 34% of platelet transfusions not aligned with guidelines and 29.9% of transfusions administered to patients with platelet counts of ≥ 150 × 10(9)/L. When compared to medical disciplines, surgical disciplines tended significantly more to transfuse platelets inappropriately (17.1% and 53.7%, respectively; p < 0.0001). Documentation was poor and in 48.4% of orders for platelets, the indication for the platelet transfusion was not clearly stated. Considerable cost could be avoided with improved adherence to guidelines. This study emphasises the need for improving education in transfusion medicine amongst medical doctors. It is hoped that the information gleaned from this study would assist in the design of educational programmes in transfusion medicine as we attempt to close the existing gaps in knowledge and skills in the field, while ensuring that blood is transfused in a cost-effective and appropriate manner.

Patients' recall and perceptions regarding consent to blood transfusion at Universitas Academic Hospital, Bloemfontein, South Africa.

We studied the recall and perceptions of transfused patients at a single centre. Fifty-three patients were included. In 11 (20.8%) cases, no written informed consent document could be traced. Four patients who had informed consent documents in their records had no recollection of the consent process. Approximately 11% of patients stated that the consent process was performed using unfamiliar terms. When compared to Caucasian and mixed race respondents, more African respondents (83%) would have preferred the presence of a family member (p < 0.01). Although not all the patients experienced the informed consent positively, it did not impact on their perception of the blood transfusion itself.

Recommendations for the management of sickle cell disease in South Africa.

The spectrum of sickle cell disease (SCD) encompasses a heterogeneous group of disorders that include: (I) homozygous SCD (HbSS), also referred to as sickle cell anaemia; (ii) heterozygous SCD (HbAS), also referred to as sickle cell trait; and (iii) compound heterozygous states such as HbSC disease, HbSß thalassaemia, etc. Homozygous or compound heterozygous SCD patients manifest with clinical disease of varying severity that is influenced by biological and environmental factors, whereas subject with sickle cell trait are largely asymptomatic. SCD is characterized by vaso-occlusive episodes that result in tissue ischaemia and pain in the affected region. Repeated infarctive episodes cause organ damage and may eventually lead to organ failure. For effective management, regular follow-up with support from a multidisciplinary healthcare team is necessary. The chronic nature of the disease, the steady increase in patient numbers, and relapsing acute episodes have cost implications that are likely to impact on provincial and national health budgets. Limited resources mandate local management protocols for the purposes of consistency and standardisation, which could also facilitate sharing of resources between centres for maximal utility. These recommendations have been developed for the South African setting, and it is intended to update them regularly to meet new demands and challenges.

The utilization of red cell concentrates at Kimberley Hospital Complex, Northern Cape Province, South Africa.

This prospective clinical audit of the utilization of red cell concentrates assesses 55 consecutive transfusion episodes in chronically anaemic adult patients. It examines the appropriateness and outcome of the transfusion episodes; over-transfusion and wastage rates, assessment of anaemia, the informed consent process, and if teaching influenced these parameters when compared to an earlier retrospective audit. The audit revealed several strengths and weaknesses relating to our institution's transfusion practices. Training sessions led to clinically and economically important improvements in transfusion decisions, the investigation of anaemia and the obtainment of informed consent prior to transfusions.

Recommendations for the management of adult chronic myeloid leukaemia in South Africa.

INTRODUCTION: Chronic myeloid leukaemia (CML) is a chronic myeloproliferative disorder characterised by a chromosomal translocation between the long arms of chromosomes 9 and 22 [corrected] resulting in the formation of the BCR-ABL fusion gene. The management of CML has undergone major changes over the past decade. Novel treatment approaches have had a dramatic impact on patient outcomes and survival. Nevertheless, these outcomes can only be achieved in the context of expert management, careful monitoring of disease response, appropriate management of adverse events and timeous adjustments to therapy when responses are not achieved within stated time-frames. AIM: With the advent of novel treatments providing molecular responses, both the monitoring and management of CML have become more complicated. The aim of these recommendations was to provide a pragmatic yet comprehensive roadmap to negotiate these complexities. METHODS: Recommendations were developed based on local expert opinion from both the academic and private medical care arenas after careful review of the relevant literature and taking into account the most widely used international guidelines. About five meetings were held at which these recommendations were discussed and debated in detail. RESULTS: A comprehensive set of recommendations was compiled with an emphasis on diagnosis, investigation, treatment and monitoring of disease. Careful attention was given to circumstances unique to South Africa, funding constraints, availability and access to laboratory resources, as well as the effects of concurrent HIV infection. CONCLUSION: Most patients with CML can live a reasonably normal life if their disease is appropriately managed. These recommendations should be of value to all specialists involved in the treatment of haematological disorders.

Guidelines for the treatment of myelodysplastic syndromes (MDS) in South Africa.

INTRODUCTION: Myelodysplastic syndromes (MDS) encompass a heterogeneous group of clonal haematopoietic disorders characterised by chronic and progressive cytopenias resulting from ineffective haematopoiesis. Treatment is complicated by differences in disease mechanisms in different subgroups, variable clinical phenotypes and risk of progression to acute myeloid leukaemia. RATIONALE: Changes in disease classification, prognostic scoring systems, the availability of novel treatment options and the absence of South African guidelines for the diagnosis and management of these complex disorders underpinned the need for the development of these recommendations. METHODS: These recommendations are based on the opinion of a number of experts in the field from the laboratory as well as clinical settings and came from both the private and institutional academic environments. The most recent literature as well as available guidelines from other countries were discussed and debated at a number of different meetings held over a 2-year period. RESULTS: A comprehensive set of recommendations was developed focusing on risk stratification, supportive management and specific treatment. Novel agents and their indications are discussed and recommendations are made based on best available evidence and taking into account the availability of treatments in South Africa. CONCLUSION: Correct diagnosis, risk stratification and appropriate therapeutic choices are the cornerstones of success in the management of patients with myelodysplastic syndromes.

Myocardial injury in HIV-associated thrombotic thrombocytopenic purpura (TTP).

Thrombotic thrombocytopenic purpura (TTP) has been associated with human immunodeficiency virus (HIV) infection. With the high prevalence of HIV in sub-Saharan Africa, HIV-associated TTP is the most common form of this disease seen in the South African population. Several case reports describe myocardial infarction in HIV-negative TTP patients. The case of the first HIV-positive patient who presented with clinical signs and symptoms of TTP and myocardial injury is reported in this study. A patient with fragmentation haemolysis and thrombocytopenia presented with angina. Risk factors for ischaemic heart disease were absent. An electrocardiogram (EKG) revealed ST-segment elevation and a significantly raised Troponin T level. The patient's HIV test was positive and a diagnosis of myocardial injury with HIV-associated TTP was made. The patient was treated with plasma infusion and steroid therapy. Due to poor response, the therapy was changed to plasma exchange. The patient recovered fully and subsequent coronary angiography revealed normal coronary vessels. Treatment of myocardial infarction in TTP is controversial, but the treatment cornerstone should remain plasma infusion or plasma exchange. As patients are often young and do not have the classical risk factors of ischaemic heart disease, a high level of suspicion and routine exclusion of myocardial ischaemia in these patients are advised.

The Antibiotic Susceptibility of Bacteria Isolated from Blood Cultures during Episodes of Neutropenic Fever in Patients with Acute Myeloid Leukaemia

Neutropenic fever (NF) is a common and life-threatening complication of high-dose chemotherapy in patients with acute myeloid leukaemia (AML). Induction chemotherapy may result in complete remission in approximately 50-70of AML patients but is associated with an increased risk of infection due to immune suppression by the disease itself or as a result of treatment. Chemotherapy causes neutropenia as well as defective chemotaxis and phagocytosis. Chemotherapy-induced mucositis often occurs throughout the gastrointestinal tract; facilitating spread of endogenous flora to the blood circulation; leading to NF. The aim of this study was to determine the spectrum of bacteraemic microorganisms isolated during episodes of NF (NFEs) in AML patients in the Haematology Unit of the Universitas Academic Complex (UAC); as well as antibiotic susceptibility profiles of these organisms. Duration of NF; the time-span between chemotherapy and onset of NF; and the efficacy of antibiotics administered to patients; were also investigated

Percutaneous Injuries in Doctors in the School of Medicine; University of the Free State: Prevalence; Reporting and Adherence to Precautionary and Management Procedures

"Background: Despite the official precautionary measures against percutaneous injuries; incidents still occur. Consequently; it is possible that healthcare workers could contract infections like HBV; HCV; HGV (hepatitis B; C and G viruses) and HIV (human immune deficiency virus). The most serious problem lies in the fact that percutaneous injuries are often underestimated; resulting in non-reporting of the incident. The aim of this study was to determine the incidence of percutaneous injuries in doctors in the School of Medicine at the University of the Free State (UFS); whether the incidents were reported; and the reasons for non-reporting. The use of gloves during procedures was also evaluated. Methods: A mainly descriptive study design was used. Questionnaires were administered from October 2006 through January 2007 to collect information. Participants were selected randomly; and the respondents were divided into surgical and non-surgical groups. Results: The respondents fulfilled the following roles and/or functions in their respective departments of employment: 35 (67.3) were registrars; 12 (23.1) were specialists/consultants; four (7.7) were medical officers; and one (1.9) was exclusively involved in student training. Two of the respondents did not indicate their roles and functions in their respective departments. A total of 82 incidents of percutaneous injuries occurred. Although the surgical groups handled sharp objects more frequently per week than the non-surgical groups (p-value = 0.04); more incidents occurred in the non- surgical groups (p-value = 0.02). Only 39 (47.6) of the incidents were reported; while 44.4of the respondents were aware of the correct reporting procedures. The reasons given for the non-reporting of these incidents were ""too busy"" (58.1); ""did not think it was serious"" (48.8); and ""was not aware of the reporting procedures"" (7). Only 13.7of the respondents indicated that they always used gloves when drawing blood; 17.4used them when injections were administered; and 22.4used gloves during intravenous cannulation. However; 86.8of the respondents wore gloves when they used a scalpel or any other incision object. The respondents (n = 51) suggested that the three most important precautionary measures to take into consideration when working with sharp objects were (i) the use of gloves (23/51; 45.1); (ii) never recapping a needle (9/51; 17.6); and (iii) keeping the container for disposing of sharp objects close at hand (6/51; 11.8). Conclusions: Despite the risk of percutaneous injuries; non-reporting still occurs. Although the rate of reporting these incidents could be compared with international findings published in the literature; it remains too low. Drastic measures should be taken to ensure that physicians are informed of the hazards of percutaneous injuries; as well as of the appropriate mechanisms of reporting these incidents."

Successful treatment of Chromobacterium violaceum sepsis in South Africa.

Chromobacterium violaceum sepsis is extremely rare and usually fatal. A very few cases of C. violaceum infection have been reported from Africa, but never from South Africa. As far as could be ascertained, this infection has never been reported in a patient with leukaemia. We describe what we believe to be the first such case of C. violaceum sepsis, in a 16-year-old female patient with acute biphenotypic leukaemia, which developed during the neutropenic phase after intensive chemotherapy. The infection was due to a non-pigmented strain of C. violaceum and was associated with a co-infection with Candida parapsilosis; both were successfully treated using broad-spectrum antibiotics, antifungals and removal of a Hickman line.