CEPHEUS SA: a South African survey on the undertreatment of hypercholesterolaemia

AIM

The aim of the CEntralised Pan-South African survey on tHE Under-treatment of hypercholeSterolaemia (CEPHEUS SA) was to evaluate the current use and efficacy of lipidlowering drugs (LLDs), and to identify possible patient and physician characteristics associated with failure, if any, to achieve low-density lipoprotein cholesterol (LDL-C) targets.

METHODS

The survey was conducted in 69 study centres in South Africa and recruited consecutive consenting patients who had been prescribed LLDs for at least three months. One visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Physicians and patients completed questionnaires regarding their knowledge, awareness and perceptions of hypercholesterolaemia and the treatment thereof.

RESULTS

Of the 3 001 patients recruited, 2 996 were included in the final analyses. The mean age was 59.4 years, and 47.5% were female. Only 60.5 and 52.3% of patients on LLDs for at least three months achieved the LDL-C target recommended by the NCEP ATP III/2004 updated NCEP ATP III and the Fourth JETF/South African guidelines, respectively. Being male, older than 40 years, falling into the lower-risk categories, compliance with the medication regimen, and patient knowledge that the LDL-C goal had been reached, were associated with the highest probability of attaining LDL-C goals.

CONCLUSION

The results of this survey highlight the sub-optimal lipid control achieved in many South African patients taking lipid-lowering therapy.

Pulsed radiofrequency modulation for lingual neuralgia

Pulsed radiofrequency modulation (PRM) is a minimally invasive procedure that has been used successfully to treat neuropathic pain. Its use to treat lingual neuralgia has not to our knowledge been described previously, and we report a case.

The impact of mucosal infections on acquisition and progression of tuberculosis

More than one-third of the world's population, or over 2 billion people, are infected with Mycobacterium tuberculosis, the causative pathogen of tuberculosis in humans. Why only 10% of those infected develop active disease while the remainder harbor latent infection remains one of the greatest scientific and public health mysteries. Bacterial persistence is characterized by a dynamic state of immunological tolerance between pathogen and host. The critical role of CD4(+) T cells in defense against intracellular pathogens became evident during epidemiological studies of HIV-1 infection, which showed a clear inverse relationship between CD4(+) T-cell count in peripheral blood and increased risk of infection with M. tuberculosis, pneumocystis and Toxoplasma gondii. There is also growing evidence of a common mucosal immune system, whereby immune cells activated at one mucosal site may disseminate to remote effector sites. In this commentary, we review emerging evidence from human studies that the outcome of M. tuberculosis infection is influenced by concurrent mucosal infections, using Helicobacter pylori and geohelminths as examples. Understanding how the complexity of microbial exposures influences host immunity may have important implications for vaccine development and therapeutic interventions.

Measurement error for ultrasound fetal biometry performed by paramedics in rural Bangladesh

OBJECTIVES

To document the accuracy and precision of sonographic fetal biometry performed by nine paramedics from rural Bangladesh.

METHODS

Paramedics underwent intensive training (6 weeks) including hands-on practice then underwent a series of standardization exercises. Measurements of each fetus were taken by a highly-trained medical doctor (study supervisor) and the nine paramedics. Crown-rump length (CRL) in fetuses of less than 10 weeks' gestation, and biparietal diameter (BPD), occipitofrontal diameter, head and abdominal circumference (AC) and femur diaphysis length (FL) were measured twice using standard procedures by each paramedic and the medical doctor for each fetus, with at least 20 min between them. Precision was quantified using variance components analysis; the intraobserver error for each of the paramedics was calculated by comparing repeat measurements taken on the same participant, and the measurements obtained by each individual paramedic were also compared with those taken by the others (interobserver error). Accuracy was estimated by comparing the mean of the two measures taken by each paramedic to those taken by the study supervisor using paired t-tests. Bland-Altman plots were used to visually assess the relationship between precision of repeat measurements (intraobserver error) and fetal size.

RESULTS

A total of 180 women, at 7 to 31 weeks' gestation, participated in the study. Intraobserver error of the measurements obtained by the paramedics, expressed as the mean SD, ranged from 0.97 mm for BPD in the first trimester to 7.25 mm for AC in the third trimester, and was larger than the interobserver error (i.e. accounting for a greater proportion of total variance) for most measurements. Interobserver error ranged from 0.00 mm for FL to 3.36 mm for AC, both in the third trimester. For all measurements except CRL, intraobserver error increased with increasing fetal size. The measurements obtained by the paramedics did show some statistically significant differences from those obtained by the study supervisor, but these were relatively small in magnitude.

CONCLUSIONS

Both inter- and intraobserver measurement errors were within the range reported in the literature for studies conducted by technical staff and medical doctors. With intense training, paramedics with no prior exposure to ultrasonography can provide accurate and precise measures of fetal biometry.

The effect of religious, cultural and social identity on population genetic structure among Muslims in Pakistan

Knowledge of historical demography and contemporary social stratification can be valuable in understanding disease patterns, including genetic disorders, especially in communities that have a high prevalence of endogamous and/or consanguineous marriages. This paper provides a background to the religious, historical and socio-cultural factors that have helped define the bounds of endogamy for Muslims in undivided India and more specifically since the creation of Pakistan. The preference for endogamous marriage is based on the clan-oriented nature of the society, which values and actively seeks similarities in social group identity based on several factors, including religious, sectarian, ethnic, and tribal/clan affiliation. Religious affiliation is itself multi-layered and includes religious considerations other than being Muslim, such as sectarian identity (e.g. Shia or Sunni, etc.) and religious orientation within the sect (Isnashari, Ismaili, Ahmedi, etc.). Both ethnic affiliation (e.g. Sindhi, Baloch, Punjabi, etc.) and membership of specific biraderis or zat/quoms are additional integral components of social identity. Within the bounds of endogamy defined by the above parameters, close consanguineous unions are preferential due to a congruence of key features of group- and individual-level background factors.

Dynamic changes in biomarker profiles associated with clinical and subclinical tuberculosis in a high transmission setting: a four-year follow-up study

Mycobacterium tuberculosis (MTB) is a slow growing bacterium. Therefore, the immune responses associated with resolution of infection or development of disease post-exposure may take several months to evolve. We have carried out a prospective longitudinal study in a high TB transmission setting to determine the evolution of biomarkers in a recently exposed household contact (HC = 77) and their respective sputum positive index cases (TB = 17). Mycobacterium-induced cytokines [interferon-gamma (IFN-gamma), tumour necrosis factor-alpha, interleukin-6 (IL-6) and IL-10)] were assessed in whole blood cultures and immunoglobulin G (IgG1) antibodies in plasma. When compared with non-exposed community controls (endemic controls = 59) the HC group at intake showed changes in biomarkers commensurate with recent exposure. The HC group showed significant increases in IFN-gamma between 0 and 6 months (paired t-test; P = 0.001) and IL-0 between 6 and 12 months (P = 0.001), most likely reflecting the role of these cytokines in resolution and immune recovery from infection as this HC cohort remained symptom-free for 4 years without prophylactic treatment. When the TB group post-treatment was compared with the HC group, the best discriminators (ANOVA; repeated measures) were IL-10 responses at 0 (P = 0.004) and 6 months (P = 0.001) and IgG1 at 6 (P = 0.004) and 12 months (P = 0.014) with a 3-4 fold higher responses in the TB group. Therefore, within each group, biomarkers show unique profile of responses. These studies highlighted the importance of assessing multiple biomarkers in longitudinal studies for providing better understanding of protective biomarker profiles associated with resolution of clinical and subclinical infections in TB.

Function preservation with multimodality treatment in locally advanced oral tongue cancer

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Background: Total or near total glossectomy with postoperative radiation is a standard treatment option for locally advanced squamous cell carcinoma oral tongue (LASCCOT). However, the procedure is controversial due to dismal cure rates and major functional deficits that impact on speech, deglutition and quality of life. We evaluated function preservation and survival outcome in LASCCOT treated with induction chemotherapy, limited surgery, and postoperative radiation/chemoradiation. Methods: We retrospectively identified 15 patients with LASCCOT treated with induction chemotherapy, limited surgery and postoperative radiation/chemoradiation at our institution between 04/07 - 04–08. M67%:F33% median age 50 years. Pretreatment AJCC stage as assessed on MRI was T2N+ (tumour crossing midline) 13%, T3N0 20%, T3N+ 47%, and T4N+ 20%. Prior to surgery induction chemotherapy, consisting of cisplatin 75 mg/m2 day 1 and gemcitabine 1 mg/m2 day 1 and 8 every three weeks for 2 cycles was given. Four to six weeks following second cycle of chemotherapy local excision of residual primary tumor with ipsilateral modified neck dissection was performed. Postoperative radiation dose was 60Gy/30 fractions. Post therapy pathological stage was ypT0N0 20%, ypT1N0 20%, ypT1N+ 40%, ypT2N+ 13%, and ypT3N+ 7%. Patients with ypN+ disease received concomitant 3 weekly cisplatin 75 mg/m2 with radiation. Results: Overall and disease free survival at 20 months was 60%. Twelve patients (80%) are alive and 3 patients (20%) have died of disease at 9, 14 and 14 months (locoregional failure 1 and distant metastasis 2 patients). In patients alive without disease assessment of deglutition and speech at the time of last follow up showed all patients on full oral diet with spontaneous intelligible speech. Conclusions: Multimodality treatment with induction chemotherapy, limited surgery and post operative radiation/chemoradiation may allow selected LASCCOT patients to avoid morbid surgery and preserve tongue function without compromising survival. This approach merits further investigation in clinical trials.

No significant financial relationships to disclose.

Neoadjuvant chemotherapy followed by radiotherapy or chemoradiation for locally advanced nasal and paranasal sinus tumors

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Background: The treatment of locally advanced nasal and paranasal sinus tumors is controversial. The disease is chemosensitive and there is increasing interest in the use of chemotherapy with radiation in this group of patients. Our aim was to determine survival in patients with locally advanced nasal and paranasal sinus tumors treated with neoadjuvant chemotherapy followed by radiotherapy or chemoradiation (RT/CRT). Methods: Between August 2005 and August 2008, 21 patients with AJCC stage III or IV nasal and paranasal sinus tumors were treated with neoadjuvant chemotherapy followed by RT/CRT in our institution. There were 15 males and 6 females (M 71%:F 29%) with a median age of 49 years (range 19 - 70 years). Site of disease was nasal cavity 33% (7), ethamoid sinus 43% (9), maxillary antrum 19% (4), and frontal sinus in 5% (1) of patients. Histopathological diagnosis was squamous cell carcinoma 43% (9), undifferentiated carcinoma 29% (6), adenocarcinoma 19% (4), esthesioneuroblastoma in 9% (2) of patients. Induction chemotherapy consisted of cisplatin 75 mg / metre2 day 1 and gemcitabine 1 gm / metre2 day 1 and 8 every three weeks. Eighty-five percent (18/21) received 2 cycles of neoadjuvant chemotherapy (range 1–4 cycles) prior to radiotherapy. Radiotherapy dose was 54 Gy - 70 Gy (median radiation dose 66 Gy). Fifty-seven percent (12/21) received concomitant cisplatin with radiotherapy. Results: Response to neoadjuvant chemotherapy; complete in 19% (4), partial in 67% (14), no response/progression 14% (3). Following RT/CRT 86% (18/21) had complete regression of disease. Thirty-three percent (7/21) have failed treatment (local 3, regional 2, and distant metastasis in 2 patients). Among treatment failures 2 patients were successfully salvaged; surgery for local recurrence in one patient and in the other case radiation was given for regional recurrence. Disease free and overall survival at 40 months was 52% and 63%, respectively. Conclusions: Gemcitabine cisplatin chemotherapy has good activity in nasal and paranasal sinus tumors. In combination with RT/CRT survival rates are encouraging and the approach merits further investigations in clinical trials.

No significant financial relationships to disclose.

Primary squamous cell carcinoma of the oral cavity at presentation in Pakistan

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Background: Squamous cell carcinoma of oral cavity (SCCOC) is characterized by marked geographical differences in frequency and site distribution. Pakistan is situated within the high risk zone on the global oral cancer map. However, no reliable data exists on oral cancer in this area. Our aim was to determine clinicopathological features and patterns at presentation of primary SCCOC in a comprehensive cancer centre in Pakistan. Methods: Demographic, risk factors, pathological and AJCC staging data for SCCOC treated at Shaukat Khanum Memorial Hospital for the period November 2003-October 2008 were obtained from the head and neck unit database. Results: The database identified 666 patients with biopsy proven primary SCCOC. Mean age was 53 years (range 12 - 90 years). Male (428): Female (238) ratio was M64%:F36%. The occurrence of major risk factors for oral cancer specifically smoking, betel quid chewing, naswar (smokeless tobacco) and alcohol use in males (428) was 45% (193), 28% (118), 29% (126), 3% (13), and in females (238) was 8% (20), 29% (68), 13% (30), 0% (0), respectively. Thirty-eight percent (411/666) had no association with tobacco, betel quid or alcohol use. Subsite within oral cavity; anterior tongue 41.1% (274), buccal mucosa 26.6% (177), lower gingival and alveolus 19.5% (130), upper gingival and alveolus 4.1% (27), lips 3.6% (24), retromolar trigone 2.9% (19), hard palate 1.7% (11), and floor mouth 0.6 (4). Broder's/World Health Organization histological grade; grade I 52% (334), grade II 34% (226), grade III 7% (49), and unknown 5% (36). According to AJCC 2002 system 0.2% (1), 10.8% (72), 12.2% (81), 13.2% (88), and 63.7% (420) had stage 0, I, II, III, and IV, respectively. Conclusions: Approximately 80% of patients with primary SCCOC present with stage III or IV disease with anterior tongue as the most common subsite in our hospital. While tobacco and betel quid chewing can be attributed to development of SCCOC in a significant proportion of patients, nearly 38% are unlinked to typical risks factors suggesting other environmental and genetic agents as etiological factors in this region.

No significant financial relationships to disclose.

Relationship between circulating levels of IFN-gamma, IL-10, CXCL9 and CCL2 in pulmonary and extrapulmonary tuberculosis is dependent on disease severity

Protection against Mycobacterium tuberculosis infection is dependent on T cell and macrophage activation regulated by cytokines. Cytokines and chemokines produced at disease sites may be released into circulation. Data available on circulating cytokines in tuberculosis (TB) is mostly on pulmonary TB (PTB) with limited information on extrapulmonary disease (EPul-TB). We measured interferon-gamma (IFN-gamma), interkeukin-10 (IL-10), CXCL9 and CCL2 in sera of patients (n = 80) including; PTB (n = 42), EPul-TB (n = 38) and BCG vaccinated healthy endemic controls (EC, n = 42). EPul-TB patients comprised those with less severe (LNTB) or severe (SevTB) disease. Serum IFN-gamma, IL-10 and CXCL9 levels were significantly greater while CCL2 was reduced in TB patients as compared with EC. IFN-gamma was significantly greater in PTB as compared with LNTB (P = 0.002) and SevTB (P = 0.029). CXCL9 was greater in PTB as compared with LNTB (P = 0.009). In contrast, CCL2 levels were reduced in PTB as compared with LNTB (P = 0.021) and SevTB (P = 0.024). A Spearman's rank correlation analysis determined a positive association between IFN-gamma and IL-10 (rho = 0.473, P = 0.002) and IFN-gamma and CXCL9 (rho = 0.403, P = 0.008) in the PTB group. However, in SevTB, only IFN-gamma and CXCL9 were positively associated (rho = 0.529, P = 0.016). Systemic levels of cytokines are reflective of local responses at disease sites. Therefore, our data suggests that in PTB increased IFN-gamma and CXCL9 balanced by IL-10 may result in a more effective cell mediated response in the host. However, elevated inflammatory chemokines CXCL9 and CCL2 in severe EPul-TB without concomitant down modulatory cytokines may exacerbate disease related pathology and hamper restriction of M. tuberculosis infection.

Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections

BACKGROUND

Primary care providers are well placed to control the spread of sexually transmitted infections (STI); however, care is likely to be influenced by their attitudes and beliefs. The present study investigates the relationship between general practitioner's (GP) self-reported level of comfort in dealing with patients with STI and the care they deliver.

METHODS

A postal survey was conducted using a stratified random sample of 15% of GPs practising in New South Wales, Australia, to assess practitioners' management of STI. A total of 409 GPs participated in the study yielding a response rate of 45.4%.

RESULTS

Although over two-thirds (69-72%) of GPs were comfortable in managing STI in heterosexual or young patients, fewer than half (40-46%) felt comfortable caring for patients who were sex workers, indigenous, people who inject drugs, gay or lesbian. Practitioners who were comfortable were more likely to offer sexual risk assessment, safe-sex counselling, and were less likely to report limited ability to influence patients' risk behaviours. Practitioner discomfort was positively associated with reporting constraints in sexual history-taking and the need for training in sexual health.

CONCLUSIONS

Practitioners' care and support for patients with STI are influenced by their inexperience, lack of skills and/or attitudes. The reasons for GP discomfort in managing STI patients need further exploration as does its impact on patient care.

Cisplatin plus gemcitabine (GC) as induction chemotherapy in locally advanced head and neck cancer (HANC)

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Background: Cisplatin/infusional 5-fluorouracil chemotherapy is routinely administered as standard induction chemotherapy in advanced HANC. However, the optimum treatment remains to be defined. Gemcitabine is an active agent in HANC and few studies have evaluated induction GC in HANC. We have explored the activity and toxicity of GC as induction treatment in HANC and report the results. Methods: From August 2005 to September 2006, 55 patients with locally advanced HANC had induction chemotherapy with GC at Shaukat Khanum Memorial Cancer Hospital and Research Centre. We reviewed the medical records and prospectively collected data to determine activity and toxicity of induction GC. M:F ratio was 64%:36% with a median age of 50 years (range 19–80). All patients had histologically confirmed squamous cell carcinoma. The site of disease was nasopharynx, paranasal sinuses, oral cavity, oropharynx, larynx and hyopharynx in 4% (2), 11% (6), 51% (21), 2% (1), 11% (6) and 22% (11) respectively. According to AJCC staging 7% (4) had stage III and 93% (51) had stage IVa/IVb disease (T3N0 7%, T3N+ 2%, T4N0 38% and T4N+ 53%). Induction chemotherapy consisted of 2 cycles of cisplatin 75 mg/m2 day 1 and gemcitabine 1000 mg/m2 day 1 and 8 with treatment repeated three weekly. Fifty-three (94%) patients received 2 cycles as planned. Toxicity was scored after each cycle according to the NCI.CTC criteria. Response was assessed following completion of induction chemotherapy by clinical examination/MRI scan. Results: All patients were available for assessment of toxicity and response. A total of 111 cycles were delivered. The response rates are: complete 24% (13), partial 62% (34), no response 7% (4) and progression 7% (4). The overall response rate was 86% (complete 24%, partial 62%). No treatment related deaths occurred. Haematological G3/G4 toxicity included neutropenia (13%/7%) and thrombocytopenia (5%/0%). The non-haematological toxicity observed (nausea, vomiting and diarrhoea) was only G1/G2. Conclusions: GC is well tolerated with low toxicity and high anti tumour activity as neoadjuvant chemotherapy treatment in squamous cell head and neck cancer. Combination GC arm should be included in future trials.

No significant financial relationships to disclose.

Comparative features and outcomes of malaria at a tertiary care hospital in Karachi, Pakistan

OBJECTIVES

A comparison of clinical and laboratory features, diagnostic methods, drug treatment, and outcomes for patients hospitalized with malaria by Plasmodium species.

METHODS

Records of 521 patients hospitalized during the four and half-year study period were analyzed.

RESULTS

Infections were caused by Plasmodium vivax (51.8%), Plasmodium falciparum (46.5%), P. vivax plus P. falciparum (1.3%), and Plasmodium malariae (0.4%). Vomiting (odds ratio (OR)=1.86, p=0.001) and abdominal pain (OR=1.60, p=0.024) occurred more frequently in patients infected with P. falciparum compared to P. vivax; this was also the case for hepatomegaly, splenomegaly and jaundice. Low hemoglobin levels were common but were significantly lower with P. falciparum, and creatinine levels were significantly higher with P. falciparum. Treatment regimens consisted of single drug therapy (61.5%), appropriate combination therapy (15.8%), and inappropriate combination therapy (22.7%). Antimalarials given alone included chloroquine (38.7%), quinine (19%) and doxycycline (1.5%). The overall mortality was 1.7% (n=9) and nearly 56% of patients developed disease complications, most commonly thrombocytopenia (36.4%), anemia (23.4%), and thrombocytopenia plus anemia (32.7%).

CONCLUSIONS

Despite resistance, chloroquine was prescribed in patients with malaria requiring hospitalization. We found a high proportion of single antimalarial drug use as well as inappropriate combination therapy (22.7%), and inadequate use of primaquine terminal prophylaxis. Physicians need to be acquainted with malaria treatment guidelines in an endemic zone.

Phytoestrogens levels determination in the cord blood from Malaysia rural and urban populations

This study is a result of an analysis of free and conjugated phytoestrogens daidzein, genistein, daidzin, genistin and coumesterol in human cord blood plasma using LCMS. Cord blood was collected from urban and rural populations of Malaysia (n=300) to establish a simple preliminary database on the levels of the analyzed compounds in the collected samples. The study also aimed to look at the levels of phytoestrogens in babies during birth as this may have a profound effect on the developmental process. The sample clean up was carried out by solid-phase extraction using C18 column and passed through DEAE sephadex gel before analysis by LCMS. The mean concentrations of total phytoestrogens were daidzein (1.4+/-2.9 ng/ml), genistein (3.7+/-2.8 ng/ml), daidzin (3.5+/-3.1 ng/ml), genistin (19.5+/-4.2 ng/ml) and coumesterol (3.3+/-3.3 ng/ml). Distribution of phytoestrogen was found to be higher in samples collected from rural areas compared to that of urban areas.

The profile and incidence of cancer in Down syndrome

BACKGROUND

Down syndrome is one of the commonest causes of intellectual disability. As life expectancy improves with early and more intensive surgical and medical treatments, people with the disorder are more likely to exhibit classic morbidity and mortality patterns and be diagnosed with diseases such as cancer.

METHODS

A profile of cancer cases among people with Down syndrome has been compiled, based on the analysis of a linked data set that included information from the Disability Services Commission of Western Australian and the State Cancer Registry.

RESULTS AND CONCLUSIONS

Although the total age- and sex-standardized incidence ratios (SIRs) for people with Down syndrome were similar to that for the general population, SIRs for leukaemia were significantly higher while the incidence of certain other types of cancers was reduced. Overall, there was a lower incidence of solid tumours in Down syndrome, possibly reflecting the age profile of the study cohort.