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Simba K, Mohamed Z, Opie JJ, Andera LF, Brown K, Oosthuizen J, Antel K, Dawood T, der Vyfer LV, Toit CD, Louw VJ, Verburgh E. The International Prognostic Score and HIV status predict red cell concentrate transfusion needs in Hodgkin lymphoma. Leuk Lymphoma 2023; 64:613-620. [PMID: 36562564 PMCID: PMC10200008 DOI: 10.1080/10428194.2022.2157214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Despite the burden of anemia among Hodgkin lymphoma (HL) patients, data evaluating red cell concentrate transfusion are limited. We retrospectively studied 285 newly diagnosed HL patients who received first-line adriamycin, bleomycin sulfate, vinblastine sulfate, and dacarbazine (ABVD) treatment at Groote Schuur Hospital, Cape Town. HIV prevalence in the cohort was 39.5% and 74.2% of patients had advanced stage HL. Patient prognosis was scored using the HL International Prognostic Score (IPS-7) and HL IPS-3. Seventy (24.6%) patients were transfused with a median of 2 (IQR 1-5) units per patient. Compared to HIV-negative patients, more HIV-positive patients were transfused (14.1% vs. 40.4%, p < .001) and received more units, median 2 (IQR 1-3) vs. 3 (IQR 2-5), p = .035. HL IPS-7 (OR 2.1, p < .001) and HL IPS-3 (OR 2.6, p < .001) were independently associated with transfusion. HL IPS-7, HL IPS-3, and HIV positivity remained associated with transfusion after adjusting for covariates. For patients with newly diagnosed HL, HL IPS-7, HL IPS-3, and HIV status predicted transfusion.
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Affiliation(s)
- Kudakwashe Simba
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Zainab Mohamed
- Department of Radiation Oncology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jessica J. Opie
- Department of Pathology, Division of Haematology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Lillian F. Andera
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Karryn Brown
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jenna Oosthuizen
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Katherine Antel
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Tareen Dawood
- Department of Human Biology, Division of Biomedical Engineering, University of Cape Town, Cape Town South Africa
| | - Lydia Van der Vyfer
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Cecile Du Toit
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Vernon J. Louw
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Estelle Verburgh
- Department of Medicine, Division of Clinical Haematology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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O’Mahony D, Mabunda SA, Mntonintshi M, Iruedo J, Kaswa R, Blanco-Blanco E, Ogunsanwo B, Namugenyi KAF, Vasaikar S, Yogeswaran P. Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3584. [PMID: 36834279 PMCID: PMC9966846 DOI: 10.3390/ijerph20043584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting. METHODS A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests. RESULTS Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively. CONCLUSIONS HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.
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Affiliation(s)
- Don O’Mahony
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Sikhumbuzo A. Mabunda
- School of Population Health, University of New South Wales, Sydney 2052, Australia
- George Institute for Global Health, University of New South Wales, Sydney 2042, Australia
- Department of Public Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Mbulelo Mntonintshi
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Joshua Iruedo
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Ramprakash Kaswa
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Ernesto Blanco-Blanco
- Department of Laboratory Medicine and Pathology, Walter Sisulu University, Mthatha 5100, South Africa
| | - Basil Ogunsanwo
- Department of Surgery, Walter Sisulu University, Mthatha 5117, South Africa
| | | | - Sandeep Vasaikar
- Department of Microbiology, Walter Sisulu University, Mthatha 5117, South Africa
| | - Parimalaranie Yogeswaran
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
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Wang X, Chen M, Ma S, Ding Y, Zhou C, Yuan Y. HIV-1 Tat Protein-Mediated Inflammatory Response Inhibits the Erythroid Hematopoietic Support Function of Bone Marrow Mesenchymal Stem Cells. AIDS Res Hum Retroviruses 2022; 38:753-763. [PMID: 35972747 DOI: 10.1089/aid.2022.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Although combination antiretroviral therapy is widely used to treat HIV-1 infection, anemia affects the health and quality of life in a large number of these patients. The proliferation and differentiation of bone marrow mesenchymal stem cells (BMSCs), as important support cells in the hematopoietic microenvironment, can be affected by HIV-1 Tat protein. In this study, we explored the mechanism underlying the effect of Tat protein on the hematopoietic support function of BMSCs in erythroid commitment. BMSCs were treated with Tat protein or transfected with Tat mRNA and cocultured with hematopoietic stem cells (HSCs) to detect the number of erythroid colony-forming units (CFUs) and the proportion of mature red blood cells from HSCs. Subsequently, the expression level of a series of erythroid hematopoietic support factors and inflammatory factors in BMSCs after Tat treatment were analyzed. Then, the activation effect of Tat on the mitogen-activated protein kinase/nuclear factor kappa-B (MAPK/NF-κB) pathway, which is an important inflammatory response signaling pathway, was evaluated. The results showed that the number of erythroid CFUs and the production of mature red blood cells supported by BMSCs treated with Tat protein were significantly reduced and the expression of a series of erythroid supporting factors of BMSCs were significantly decreased by Tat protein. Tat-treated BMSCs highly express a variety of inflammatory mediators. Moreover, the expression of P38, p-p38, ERK1/2, p-ERK1/2, JNK1/2, p-JNK1/2, NF-κB, and p-NF-κB was significantly upregulated by Tat protein. In conclusion, Tat protein induces the inflammatory response of BMSCs by activating the MAPK/NF-κB pathway to inhibit the erythroid hematopoietic support function of BMSCs.
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Affiliation(s)
- Xiaoli Wang
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Meijuan Chen
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Shinan Ma
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yan Ding
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chunfang Zhou
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Department of Gastroenterology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Yahong Yuan
- Department of Neurosurgery, Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Izco S, Murias‐Closas A, Jordan AM, Greene G, Catorze N, Chiconela H, Garcia JI, Blanco‐Arevalo A, Febrer A, Casellas A, Saavedra B, Chiller T, Nhampossa T, Garcia‐Basteiro A, Letang E. Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique. J Int AIDS Soc 2021; 24:e25775. [PMID: 34347366 PMCID: PMC8336616 DOI: 10.1002/jia2.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population. METHODS All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months. RESULTS A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts. CONCLUSIONS A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
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Affiliation(s)
- Santiago Izco
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Alexander M Jordan
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Gregory Greene
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Nteruma Catorze
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Juan Ignacio Garcia
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
- PhD Program in Methodology of Biomedical ResearchFaculty of MedicineUniversity of BarcelonaBarcelonaSpain
| | | | - Anna Febrer
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Aina Casellas
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Belén Saavedra
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Tom Chiller
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Alberto Garcia‐Basteiro
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Emilio Letang
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Department of Infectious Diseases Hospital del MarHospital del Mar Research Institute (IMIM)BarcelonaSpain
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5
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Gupta-Wright A, Fielding K, Wilson D, van Oosterhout JJ, Grint D, Mwandumba HC, Alufandika-Moyo M, Peters JA, Chiume L, Lawn SD, Corbett EL. Tuberculosis in Hospitalized Patients With Human Immunodeficiency Virus: Clinical Characteristics, Mortality, and Implications From the Rapid Urine-based Screening for Tuberculosis to Reduce AIDS Related Mortality in Hospitalized Patients in Africa. Clin Infect Dis 2020; 71:2618-2626. [PMID: 31781758 PMCID: PMC7744971 DOI: 10.1093/cid/ciz1133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates. METHODS A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days). RESULTS Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729). CONCLUSIONS Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.
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Affiliation(s)
- Ankur Gupta-Wright
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Katherine Fielding
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Daniel Grint
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Jurgens A Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen D Lawn
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth L Corbett
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
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Glatt N, Schapkaitz E, Vaughan J. The multifactorial pathogenesis of severe central anemia in a cohort of HIV-positive patients. Int J Lab Hematol 2019; 41:e92-e94. [PMID: 30806480 DOI: 10.1111/ijlh.12986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/17/2019] [Accepted: 01/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Nadia Glatt
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Haematology, National Health Laboratory Services, Johannesburg, South Africa
| | - Elise Schapkaitz
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Haematology, National Health Laboratory Services, Johannesburg, South Africa
| | - Jenifer Vaughan
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Haematology, National Health Laboratory Services, Johannesburg, South Africa
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Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study. PLoS Med 2019; 16:e1002776. [PMID: 30951533 PMCID: PMC6450614 DOI: 10.1371/journal.pmed.1002776] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/06/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The prevalence of and mortality from HIV-associated tuberculosis (HIV/TB) in hospital inpatients in Africa remains unacceptably high. Currently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. We therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings. METHODS AND FINDINGS A cohort of HIV-positive adults with laboratory-confirmed TB from the STAMP TB screening trial (Malawi and South Africa) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [LAM] detection) thought to be associated with 2-month mortality. Performance was evaluated internally and then externally validated using independent cohorts from 2 other studies (LAM-RCT and a Médecins Sans Frontières [MSF] cohort) from South Africa, Zambia, Zimbabwe, Tanzania, and Kenya. The derivation cohort included 315 patients enrolled from October 2015 and September 2017. Their median age was 36 years (IQR 30-43), 45.4% were female, median CD4 cell count at admission was 76 cells/μl (IQR 23-206), and 80.2% (210/262) of those who knew they were HIV-positive at hospital admission were taking antiretroviral therapy (ART). Two-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being ART experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary Determine TB LAM Ag test (Alere). The score identified patients with a 46.4% (95% CI 37.8%-55.2%) mortality risk in the high-risk group compared to 12.5% (95% CI 5.7%-25.4%) in the low-risk group (p < 0.001). The odds ratio (OR) for mortality was 6.1 (95% CI 2.4-15.2) in high-risk patients compared to low-risk patients (p < 0.001). Discrimination (c-statistic 0.70, 95% CI 0.63-0.76) and calibration (Hosmer-Lemeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% CI 0.61-0.74]). The validation cohort included 644 patients between January 2013 and August 2015. Median age was 36 years, 48.9% were female, and median CD4 count at admission was 61 (IQR 21-145). OR for mortality was 5.3 (95% CI 2.2-9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). The score also predicted patients at higher risk of death both pre- and post-discharge. A simplified score (any 3 or more of the predictors) performed equally well. The main limitations of the scores were their imperfect accuracy, the need for access to urine LAM testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance). CONCLUSIONS This risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. Given the scale of HIV/TB morbidity and mortality in African hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.
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Mauka WI, Mtuy TB, Mahande MJ, Msuya SE, Mboya IB, Juma A, Philemon RN. Risk factors for inappropriate blood requisition among hospitals in Tanzania. PLoS One 2018; 13:e0196453. [PMID: 29771998 PMCID: PMC5957429 DOI: 10.1371/journal.pone.0196453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/15/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Blood is a critical aspect of treatment in life saving situations, increasing demand. Blood requisition practices greatly effect sufficient supply in blood banks. This study aimed to determine the risk factors for inappropriate blood requisition in Tanzania. METHODS This was a cross sectional study using secondary data of 14,460 patients' blood requests from 42 transfusion hospitals. Primary data were obtained by using cluster-sampling design. Data were analysed using a two-level mixed-effects Poisson regression to determine fixed-effects of individual-level factors and hospital level factors associated with inappropriate blood requests. P-value <0.05 (2-tails) was considered statistically significant. RESULTS Inappropriate requisition was 28.8%. Factors significantly associated with inappropriate requisition were; reporting pulse rate and capillary refill decrease the risk (RR 0.74; 95% CI 0.64, 0.84) and (RR 0.73; 95% CI 0.63, 0.85) respectively and the following increased the risk; having surgery during hospital stay (RR 1.22; 95% CI 1.06, 1.4); being in general surgical ward (RR 3.3; 95% CI 2.7, 4.2), paediatric ward (RR 1.8; 95% CI 1.2, 2.7), obstetric ward (RR 2.5; 95% CI 2.0, 3.1), gynaecological ward (RR 2.1; 95% CI 1.5, 2.9), orthopaedics ward (RR 3.8; 95% CI 2.2, 6.7). Age of the patient, pallor and confirmation of pre-transfusion haemoglobin level were also significantly associated with inappropriate requisition. Majority of appropriate requisitions within the wards were marked in internal medicine (91.7%) and gynaecological wards (77.8%). CONCLUSIONS The proportion of inappropriate blood requests was high. Blood requisition was determined by clinical and laboratory findings and the ward patients were admitted to. Adherence to transfusion guidelines is recommended to assure the best use of limited blood supply.
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Affiliation(s)
- Wilhellmuss I. Mauka
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- * E-mail:
| | - Tara B. Mtuy
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael J. Mahande
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sia E. Msuya
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Innocent B. Mboya
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Abdul Juma
- National Blood Transfusion Services, Dar es Salaam, Tanzania
| | - Rune N. Philemon
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Kerkhoff AD, Barr DA, Schutz C, Burton R, Nicol MP, Lawn SD, Meintjes G. Disseminated tuberculosis among hospitalised HIV patients in South Africa: a common condition that can be rapidly diagnosed using urine-based assays. Sci Rep 2017; 7:10931. [PMID: 28883510 PMCID: PMC5589905 DOI: 10.1038/s41598-017-09895-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/31/2017] [Indexed: 01/04/2023] Open
Abstract
HIV-associated disseminated TB (tuberculosis) has been under-recognised and poorly characterised. Blood culture is the gold-standard diagnostic test, but is expensive, slow, and may under-diagnose TB dissemination. In a cohort of hospitalised HIV patients, we aimed to report the prevalence of TB-blood-culture positivity, performance of rapid diagnostics as diagnostic surrogates, and better characterise the clinical phenotype of disseminated TB. HIV-inpatients were systematically investigated using sputum, urine and blood testing. Overall, 132/410 (32.2%) patients had confirmed TB; 41/132 (31.1%) had a positive TB blood culture, of these 9/41 (22.0%) died within 90-days. In contrast to sputum diagnostics, urine Xpert and urine-lipoarabinomannan (LAM) combined identified 88% of TB blood-culture-positive patients, including 9/9 who died within 90-days. For confirmed-TB patients, half the variation in major clinical variables was captured on two principle components (PCs). Urine Xpert, urine LAM and TB-blood-culture positive patients clustered similarly on these axes, distinctly from patients with localised disease. Total number of positive tests from urine Xpert, urine LAM and MTB-blood-culture correlated with PCs (p < 0.001 for both). PC1&PC2 independently predicted 90-day mortality (ORs 2.6, 95%CI = 1.3-6.4; and 2.4, 95%CI = 1.3-4.5, respectively). Rather than being a non-specific diagnosis, disseminated TB is a distinct, life-threatening condition, which can be diagnosed using rapid urine-based tests, and warrants specific interventional trials.
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Affiliation(s)
- Andrew D Kerkhoff
- Division of Infectious Disease, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA.
| | - David A Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Wellcome Trust Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Wellcome Trust Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa.,Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Meintjes
- Wellcome Trust Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Mntonintshi M, O'Mahony D, Mabunda S, Namugenyi KAF. Undiagnosed tuberculosis in patients with HIV infection who present with severe anaemia at a district hospital. Afr J Prim Health Care Fam Med 2017; 9:e1-e6. [PMID: 28697621 PMCID: PMC5506498 DOI: 10.4102/phcfm.v9i1.1406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/09/2017] [Indexed: 01/26/2023] Open
Abstract
Background Tuberculosis (TB) is a major cause of severe anaemia in patients with human immunodeficiency virus (HIV) infection in South Africa. However, TB can be difficult to diagnose as it may be extra pulmonary and paucibacillary. Aim The aim of this study was to investigate undiagnosed TB in patients with HIV infection and severe anaemia and to identify the optimal investigations for diagnosing TB. Setting Mthatha General Hospital, a district hospital. Methods The study was a case series. Results Haemoglobin levels ranged from 3.6 g/dL to 7.9 g/dL, the mean CD4 count was 176 cells/μL and 80% of patients had a positive TB symptom screen. Forty-three (86%) patients had either clinical or bacteriologically proven TB of whom 33 had pulmonary TB, 34 had extra pulmonary TB and 24 had both types. The diagnostic yield for TB was: chest X-ray (CXR) 91%; ultrasound (US) abdomen pericardium and lower chest 62%; sputum Xpert MTB/RIF 35%; TB blood culture 21% and TB urine culture 15%. Blood and urine cultures did not identify any additional cases over those identified by CXR and US. The laboratory turnaround times were as follows: sputum Xpert, 1.6 days; blood culture, 20 days and urine culture, 28 days. CXR and US were done within one day of initial patient assessment. Conclusions The majority of HIV patients with severe anaemia had TB disease, and extra pulmonary TB was as prevalent as pulmonary TB. CXR, US and sputum Xpert were the optimum tests for rapid diagnosis of TB. South African national TB/HIV guidelines should incorporate these specific tests to diagnose TB in patients with HIV and severe anaemia.
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Affiliation(s)
| | - Don O'Mahony
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University.
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Meiring S, Fortuin-de Smidt M, Kularatne R, Dawood H, Govender NP. Prevalence and Hospital Management of Amphotericin B Deoxycholate-Related Toxicities during Treatment of HIV-Associated Cryptococcal Meningitis in South Africa. PLoS Negl Trop Dis 2016; 10:e0004865. [PMID: 27467556 PMCID: PMC4965057 DOI: 10.1371/journal.pntd.0004865] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/29/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND We aimed to establish the prevalence of amphotericin B deoxycholate (AmBd)-related toxicities among South African patients with cryptococcosis and determine adherence to international recommendations to prevent, monitor and manage AmBd-related toxicities. METHODS Clinical data were collected from cases of laboratory-confirmed cryptococcosis at 25 hospitals, October 2012 -February 2013. Anemia was defined as hemoglobin (Hb) concentration <10 g/dl, hypokalemia as serum potassium (K) <3.4 mEq/L and nephrotoxicity as an increase in serum creatinine (Cr) to >1.1 times the upper limit of normal. To determine adherence to toxicity prevention recommendations, we documented whether baseline Hb, K and Cr tests were performed, whether pre-emptive hydration and IV potassium chloride (KCl) was administered prior to 80% and 60% of AmBd doses and whether daily oral KCl supplementation was given ≥60% of the time. To determine adherence to monitoring recommendations, we ascertained whether a daily fluid chart was completed, Hb was monitored weekly and K or Cr were monitored bi-weekly. RESULTS Of 846 patients, clinical data were available for 76% (642/846), 82% (524/642) of whom received AmBd. Sixty-four per cent (n = 333) had documented baseline laboratory tests, 40% (n = 211) were given pre-emptive hydration and 14% (n = 72) and 19% (n = 101) received intravenous and oral KCl. While on AmBd, 88% (n = 452) had fluid monitoring; 27% (n = 142), 45% (n = 235) and 44% (n = 232) had Hb, K and Cr levels monitored. Toxicities developed frequently during treatment: anemia, 16% (86/524); hypokalemia, 43% (226/524) and nephrotoxicity, 32% (169/524). CONCLUSION AmBd-related toxicities occurred frequently but were potentially preventable with adequate monitoring, supplemental fluid and electrolyte therapies.
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Affiliation(s)
- Susan Meiring
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Melony Fortuin-de Smidt
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ranmini Kularatne
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Halima Dawood
- Pietermaritzburg Hospital Complex, Pietermaritzburg and University of KwaZulu-Natal, Durban, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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