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Iddrisu AK, Iddrisu WA, Azomyan ASG, Gumedze F. Joint modeling of longitudinal CD4 count data and time to first occurrence of composite outcome. J Clin Tuberc Other Mycobact Dis 2024; 35:100434. [PMID: 38584976 PMCID: PMC10995979 DOI: 10.1016/j.jctube.2024.100434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
In this study, we jointly modeled longitudinal CD4 count data and survival outcome (time-to-first occurrence of composite outcome of death, cardiac tamponade or constriction) in other to investigate the effects of Mycobacterium indicus pranii immunotherapy and the CD4 count measurements on the hazard of the composite outcome among patients with HIV and tuberculous (TB) pericarditis. In this joint modeling framework, the models for longitudinal and the survival data are linked by an association structure. The association structure represents the hazard of the event for 1-unit increase in the longitudinal measurement. Models fitting and parameter estimation were carried out using R version 4.2.3. The association structure that represents the strength of the association between the hazard for an event at time point j and the area under the longitudinal trajectory up to the same time j provides the best fit. We found that 1-unit increase in CD4 count results in 2 % significant reduction in the hazard of the composite outcome. Among HIV and TB pericarditis individuals, the hazard of the composite outcome does not differ between of M.indicus pranii versus placebo. Application of joint models to investigate the effect of M.indicus pranii on the hazard of the composite outcome is limited. Hence, this study provides information on the effect of M.indicus pranii on the hazard of the composite outcome among HIV and TB pericarditis patients.
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Affiliation(s)
- Abdul-Karim Iddrisu
- Department of Mathematics and Statistics, University of Energy and Natural Resources, Ghana
| | | | | | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, South Africa
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Hahnle L, Mennen M, Gumedze F, Mutithu D, Adriaanse M, Egan D, Mazondwa S, Walters R, Appiah LT, Inofomoh F, Ogah O, Adekanmbi O, Goma F, Ogola E, Mwazo K, Suliman A, Singh K, Raspail L, Prabhakaran D, Perel P, Sliwa K, Ntusi NAB. Greater Disease Severity and Worse Clinical Outcomes in Patients Hospitalised with COVID-19 in Africa. Glob Heart 2024; 19:34. [PMID: 38638124 PMCID: PMC11025574 DOI: 10.5334/gh.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/27/2024] [Indexed: 04/20/2024] Open
Abstract
Background COVID-19 cardiovascular research from Africa is limited. This study describes cardiovascular risk factors, manifestations, and outcomes of patients hospitalised with COVID-19 in the African region, with an overarching goal to investigate whether important differences exist between African and other populations, which may inform health policies. Methods A multinational prospective cohort study was conducted on adults hospitalised with confirmed COVID-19, consecutively admitted to 40 hospitals across 23 countries, 6 of which were African countries. Of the 5,313 participants enrolled globally, 948 were from African sites (n = 9). Data on demographics, pre-existing conditions, clinical outcomes in hospital (major adverse cardiovascular events (MACE), renal failure, neurological events, pulmonary outcomes, and death), 30-day vitality status and re-hospitalization were assessed, comparing African to non-African participants. Results Access to specialist care at African sites was significantly lower than the global average (71% vs. 95%), as were ICU admissions (19.4% vs. 34.0%) and COVID-19 vaccination rates (0.6% vs. 7.4%). The African cohort was slightly younger than the non-African cohort (55.0 vs. 57.5 years), with higher rates of hypertension (48.8% vs. 46.9%), HIV (5.9% vs. 0.3%), and Tuberculosis (3.6% vs. 0.3%). In African sites, a higher proportion of patients suffered cardiac arrest (7.5% vs. 5.1%) and acute kidney injury (12.7% vs. 7.2%), with acute kidney injury (AKI) appearing to be one of the strongest predictors of MACE and death in African populations compared to other populations. The overall mortality rate was significantly higher among African participants (18.2% vs. 14.2%). Conclusions Overall, hospitalised African patients with COVID-19 had a higher mortality despite a lower mean age, contradicting literature that had previously reported a lower mortality attributed to COVID-19 in Africa. African sites had lower COVID-19 vaccination rates and higher AKI rates, which were positively associated with increased mortality. In conclusion, African patients were hospitalized with more severe COVID-19 cases and had poorer outcomes.
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Affiliation(s)
- Lina Hahnle
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Mathilda Mennen
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, South Africa
| | - Daniel Mutithu
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
- Cape Heart Institute, University of Cape Town, South Africa
| | - Marguerite Adriaanse
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Daniel Egan
- Department of Medicine, University of Cape Town, South Africa
| | | | - Rochelle Walters
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Lambert Tetteh Appiah
- Department of Medicine, Kwame Nkrumah University of Science & Technology (KNUST) and Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Francisca Inofomoh
- Internal Medicine Department, Olabisi Onabanjo University Teaching Hospital, Nigeria
| | - Okechukwu Ogah
- Department of Medicine, College of Medicine, University of Ibadan, and University College Hospital Ibadan, Nigeria
| | | | - Fastone Goma
- Centre for Primary Care Research, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | | | - Kieran Mwazo
- Department of Medicine, Coast General Teaching and Referral Hospital, Mombasa, Kenya
| | | | - Kavita Singh
- Public Health Foundation of India, Gurugram, Haryana and Centre for Chronic Disease Control, New Delhi, IN
- Heidelberg Institute of Global Health, University of Heidelberg, Germany
| | | | - Dorairaj Prabhakaran
- Public Health Foundation India, Centre for Chronic Disease Control, IN
- World Heart Federation, CH
- London School of Hygiene & Tropical Medicine, GB
| | - Pablo Perel
- World Heart Federation, CH
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, GB
| | - Karen Sliwa
- World Heart Federation, CH
- Cape Heart Institute, Department of Medicine & Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Ntobeko A. B. Ntusi
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- World Heart Federation, CH
- J46 (J floor) Old Main Building, Groote Schuur Hospital Observatory, 7925, Cape Town, South Africa
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Iddrisu A, Otoo D, Kwasi A, Gumedze F. Assessing the hazard of death, cardiac tamponade, and pericardial constriction among HIV and tuberculosis pericarditis patients using the extended Cox-hazard model: Intervention study. Health Sci Rep 2024; 7:e1892. [PMID: 38361809 PMCID: PMC10867395 DOI: 10.1002/hsr2.1892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/02/2024] [Accepted: 01/23/2024] [Indexed: 02/17/2024] Open
Abstract
Background and Aims Tuberculous (TB) pericarditis (TBP), a TB of the heart, is linked to significant morbidity and mortality rates. Administering glucocorticoid therapy to individuals with TBP might enhance overall results and lower the likelihood of fatality. However, the actual clinical effectiveness of supplementary glucocorticoids remains uncertain. This study specifically evaluated the effects of prednisolone, prednisolone-antiretroviral therapy (ART) interaction, and other potential risk factors in reducing the hazard of the composite outcome, death, cardiac tamponade, and constriction, among TBP and human immunodeficiency virus (HIV) patients. Methods The data used in this study were obtained from the investigation of the Management of Pericarditis trial, a multicentre international randomized double-blind placebo-controlled 2 × 2 factorial study that investigated the effects of two TB treatments, prednisolone and Mycobacterium indicus pranii immunotherapy in patients with TBP in Africa. This study used a sample size of 587 TBP and HIV-positive patients randomized into prednisolone and its corresponding placebo arm. We used the extended Cox-proportional hazard model to evaluate the effects of the covariates on the hazard of the survival outcomes. Models fitting and parameter estimation were carried out using R version 4.3.1. Results Prednisolone reduces the hazard of composite outcome (hazrad ratio [HR] = 0.32, 95% confidence interval [CI] = 0.19 , 0.54 , p < 0.001), cardiac tamponade (HR = 0.14, 95% CI = 0.05, 0.42, p < 0.001) and constriction (HR = 0.81, 95% CI = 0.41, 1.61, p = 0.55). However, prednisolone increases the hazard of death (HR = 1.58, 95% CI = 1.11, 2.24, p = 0.01). Consistent usage of ART reduces the hazard of composite outcome, death, and constriction but insignificantly increased the hazard of cardiac tamponade. Conclusion The study offers valuable insights into how prednisolone impact the hazard of different outcomes in patients with TBP and HIV. The findings hold potential clinical significance, particularly in guiding treatment decisions and devising strategies to enhance outcomes in this specific patient group. However, there are concerns about prednisolone potentially increasing the risk of death due to HIV-related death.
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Affiliation(s)
- Abdul‐Karim Iddrisu
- Department of Mathematics and StatisticsUniversity of Energy and Natural ResourcesSunyaniGhana
| | - Dominic Otoo
- Department of Mathematics and StatisticsUniversity of Energy and Natural ResourcesSunyaniGhana
| | - Afa Kwasi
- Department of Mathematics and StatisticsUniversity of Energy and Natural ResourcesSunyaniGhana
| | - Freedom Gumedze
- Department of Statistical SciencesUniversity of Cape TownRondeboschSouth Africa
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Snyman JR, Gumedze F, Jones ESW, Alaba OA, Tsabedze N, Vira A, Ntusi NAB. Comparing Cardiovascular Outcomes and Costs of Perindopril-, Enalapril- or Losartan-Based Antihypertensive Regimens in South Africa: Real-World Medical Claims Database Analysis. Adv Ther 2023; 40:5076-5089. [PMID: 37730949 PMCID: PMC10567948 DOI: 10.1007/s12325-023-02641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Differences in class or molecule-specific effects between renin-angiotensin-aldosterone system (RAAS) inhibitors have not been conclusively demonstrated. This study used South African data to assess clinical and cost outcomes of antihypertensive therapy with the three most common RAAS inhibitors: perindopril, losartan and enalapril. METHODS Using a large, South African private health insurance claims database, we identified patients with a hypertension diagnosis in January 2015 receiving standard doses of perindopril, enalapril or losartan, alone or in combination with other agents. From claims over the subsequent 5 years, we calculated the risk-adjusted rate of the composite primary outcome of myocardial infarction, ischaemic heart disease, heart failure or stroke; rate of all-cause mortality; and costs per life per month (PLPM), with adjustments based on demographic characteristics, healthcare plan and comorbidity. RESULTS Overall, 32,857 individuals received perindopril, 16,693 losartan and 13,939 enalapril. Perindopril-based regimens were associated with a significantly lower primary outcome rate (205 per 1000 patients over 5 years) versus losartan (221; P < 0.0001) or enalapril (223; P < 0.0001). The risk-adjusted all-cause mortality rate was lower with perindopril than enalapril (100 vs. 139 deaths per 1000 patients over 5 years; P = 0.007), but not losartan (100 vs. 94; P = 0.650). Mean (95% confidence interval) overall risk-adjusted cost PLPM was Rands (ZAR) 1342 (87-8973) for perindopril, ZAR 1466 (104-9365) for losartan (P = 0.0044) and ZAR 1540 (77-10,546) for enalapril (P = 0.0003). CONCLUSION In South African individuals with private health insurance, a perindopril-based antihypertensive regimen provided better clinical and cost outcomes compared with other regimens.
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Affiliation(s)
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Erika S W Jones
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Olufunke A Alaba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand and The Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Alykhan Vira
- Quantium Health South Africa, Johannesburg, South Africa
| | - Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, J46.53, Old Main Building, Main Road, Observatory, Cape Town, 7925, South Africa.
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Kraus SM, Shaboodien G, Francis V, Laing N, Cirota J, Chin A, Pandie S, Lawrenson J, Comitis GAM, Fourie B, Zühlke L, Wonkam A, Wainwright H, Damasceno A, Mocumbi AO, Pepeta L, Moeketsi K, Thomas BM, Thomas K, Makotoko M, Brown S, Ntsekhe M, Sliwa K, Badri M, Gumedze F, Cordell HJ, Keavney B, Ferreira V, Mahmod M, Cooper LT, Yacoub M, Neubauer S, Watkins H, Mayosi BM, Ntusi NAB. Rationale and design of the African Cardiomyopathy and Myocarditis Registry Program: The IMHOTEP study. Int J Cardiol 2021; 333:119-126. [PMID: 33607192 DOI: 10.1016/j.ijcard.2021.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/27/2021] [Accepted: 02/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF), the dominant form of cardiovascular disease in Africans, is mainly due to hypertension, rheumatic heart disease and cardiomyopathy. Cardiomyopathies pose a great challenge because of poor prognosis and high prevalence in low- and middle-income countries (LMICs). Little is known about the etiology and outcome of cardiomyopathy in Africa. Specifically, the role of myocarditis and the genetic causes of cardiomyopathy are largely unidentified in Africans. METHOD The African Cardiomyopathy and Myocarditis Registry Program (the IMHOTEP study) is a pan-African multi-centre, hospital-based cohort study, designed with the primary aim of describing the clinical characteristics, genetic causes, prevalence, management and outcome of cardiomyopathy and myocarditis in children and adults. The secondary aim is to identify barriers to the implementation of evidence-based care and provide a platform for trials and other intervention studies to reduce morbidity and mortality in cardiomyopathy. The registry consists of a prospective cohort of newly diagnosed (i.e., incident) cases and a retrospective (i.e., prevalent) cohort of existing cases from participating centres. Patients with cardiomyopathy and myocarditis will be subjected to a standardized 3-stage diagnostic process. To date, 750 patients have been recruited into the multi-centre pilot phase of the study. CONCLUSION The IMHOTEP study will provide comprehensive and novel data on clinical features, genetic causes, prevalence and outcome of African children and adults with all forms of cardiomyopathy and myocarditis in Africa. Based on these findings, appropriate strategies for management and prevention of the cardiomyopathies in LMICs are likely to emerge.
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Affiliation(s)
- Sarah M Kraus
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Gasnat Shaboodien
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Veronica Francis
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Nakita Laing
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa; Division of Human Genetics, Department of Medicine, UCT, Cape Town, South Africa
| | - Jacqui Cirota
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Ashley Chin
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Shahiemah Pandie
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - John Lawrenson
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, UCT and Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - George A M Comitis
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, UCT and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Barend Fourie
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Liesl Zühlke
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, UCT and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Ambroise Wonkam
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa; Division of Human Genetics, Department of Medicine, UCT, Cape Town, South Africa
| | - Helen Wainwright
- Department of Pathology, National Health Laboratory Service and UCT, Cape Town, South Africa
| | | | - Ana Olga Mocumbi
- Instituto Nacional de Saúde and Eduardo Mondlane University, Maputo, Mozambique
| | - Lungile Pepeta
- Department of Paediatrics, Port Elizabeth Hospital Complex and Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
| | - Khulile Moeketsi
- Division of Cardiology, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Baby M Thomas
- Division of Cardiology, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Kandathil Thomas
- Division of Cardiology, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Makoali Makotoko
- Division of Cardiology, Universitas Hospital and University of the Free State, Bloemfontein, South Africa
| | - Stephen Brown
- Division of Cardiology, Universitas Hospital and University of the Free State, Bloemfontein, South Africa
| | - Mpiko Ntsekhe
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Karen Sliwa
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Motasim Badri
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa; College of Medicine, King Saudi Bin Abdulaziz University for Medical Sciences, Riyadh, Saudi Arabia
| | | | - Heather J Cordell
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Bernard Keavney
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Vanessa Ferreira
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Masliza Mahmod
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, USA
| | | | - Stefan Neubauer
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Hugh Watkins
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Bongani M Mayosi
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa
| | - Ntobeko A B Ntusi
- The Cardiac Clinic and Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town (UCT) and Groote Schuur Hospital, Cape Town, South Africa.
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Ngwanya RM, Adeola HA, Beach RA, Gantsho N, Walker CL, Pillay K, Prokopetz R, Gumedze F, Khumalo NP. Reliability of Histopathology for the Early Recognition of Fibrosis in Traction Alopecia: Correlation with Clinical Severity. Dermatopathology (Basel) 2019; 6:170-181. [PMID: 31700859 PMCID: PMC6827454 DOI: 10.1159/000500509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/18/2019] [Indexed: 11/30/2022] Open
Abstract
Traction alopecia (TA) is hair loss caused by prolonged pulling or repetitive tension on scalp hair; it belongs to the biphasic group of primary alopecia. It is non-scarring, typically with preservation of follicular stem cells and the potential for regrowth of early lesions especially if traction hairstyles are stopped. However, the alopecia may become permanent (scarring) and fail to respond to treatment if the traction is excessive and prolonged. Hence, the ability to detect fibrosis early in these lesions could predict patients who respond to treatment. Histopathological diagnosis based on scalp biopsies has been used as a gold standard to delineate various forms of non-scarring alopecia and to differentiate them from scarring ones. However, due to potential discrepant reporting as a result of the type of biopsy, method of sectioning, and site of biopsy, histopathology often tends to be unreliable for the early recognition of fibrosis in TA. In this study, 45 patients were assessed using the marginal TA severity scoring system, and their biopsies (both longitudinal and transverse sections) were systematically assessed by three dermatopathologists, the aim being to correlate histopathological findings with clinical staging. Intraclass correlation coefficients were used to determine the level of agreement between the assessors. We found poor agreement of the identification and grading of perifollicular and interfollicular fibrosis (0.55 [0.23–0.75] and 0.01 [2.20–0.41], respectively), and no correlation could be drawn with the clinical severity score. Better methods of diagnosis are needed for grading and for recognition of early fibrosis in TA.
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Affiliation(s)
| | - Henry Ademola Adeola
- Division of Dermatology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Renée A Beach
- Division of Dermatology and Pathology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nomphelo Gantsho
- Division of Dermatology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Christopher L Walker
- Department of Anatomical Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Komala Pillay
- Department of Anatomical Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert Prokopetz
- Division of Dermatology and Pathology, University of Ottawa, Ottawa, Ontario, Canada
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Nonhlanhla P Khumalo
- Division of Dermatology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Abstract
In this paper, we assess the effect of tuberculosis pericarditis treatment (prednisolone) on CD4 count changes over time and draw inferences in the presence of missing data. We accounted for the missing data and performed sensitivity analyses to assess robustness of inferences, from a model that assumes that the data are missing at random, to models that assume that the data are not missing at random. Our sensitivity approaches are within the shared-parameter model framework. We implemented the approach by Creemers and colleagues to the CD4 count data and performed simulation studies to evaluate the performance of this approach. We also assessed the influence of potentially influential subjects, on parameter estimates, via the global influence approach. Our results revealed that inferences from missing at random analysis model are robust to not missing at random models and influential subjects did not overturn the study conclusions about prednisolone effect and missing data mechanism. Prednisolone was found to have no significant effect on CD4 count changes over time and also did not interact with anti-retroviral therapy. The simulation studies produced unbiased estimates of prednisolone effect with lower mean square errors and coverage probabilities approximately equal the nominal coverage probability.
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Affiliation(s)
- Abdul-Karim Iddrisu
- Department of Statistical Sciences, University of Cape Town, Rondebosch South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Rondebosch South Africa
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Iddrisu AK, Gumedze F. An application of a pattern-mixture model with multiple imputation for the analysis of longitudinal trials with protocol deviations. BMC Med Res Methodol 2019; 19:10. [PMID: 30626328 PMCID: PMC6327569 DOI: 10.1186/s12874-018-0639-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 12/06/2018] [Indexed: 11/18/2022] Open
Abstract
Background The benefit of a given treatment can be evaluated via a randomized clinical trial design. However, protocol deviations may severely compromise treatment effect since such deviations often lead to missing values. The assumption that methods of analysis can account for the missing data cannot be justified and hence methods of analysis based on plausible assumptions should be used. An alternative analysis to the simple imputation methods requires unverifiable assumptions about the missing data. Therefore sensitivity analysis should be performed to investigate the robustness of statistical inferences to alternative assumptions about the missing data. Aims In this paper, we investigate the effect of tuberculosis pericarditis treatment (prednisolone) on CD4 count changes over time and draw inferences in the presence of missing data. The data come from a multicentre clinical trial (the IMPI trial). Methods We investigate the effect of prednisolone on CD4 count changes by adjusting for baseline and time-dependent covariates in the fitted model. To draw inferences in the presence of missing data, we investigate sensitivity of statistical inferences to missing data assumptions using the pattern-mixture model with multiple imputation (PM-MI) approach. We also performed simulation experiment to evaluate the performance of the imputation approaches. Results Our results showed that the prednisolone treatment has no significant effect on CD4 count changes over time and that the prednisolone treatment does not interact with time and anti-retroviral therapy (ART). Also, patients’ CD4 count levels significantly increase over the study period and patients on ART treatment have higher CD4 count levels compared with those not on ART. The results also showed that older patients had lower CD4 count levels compared with younger patients, and parameter estimates under the MAR assumption are robust to NMAR assumptions. Conclusions Since the parameter estimates under the MAR analysis are robust to NMAR analyses, the process that generated the missing data in the CD4 count measurements is missing at random (MAR). The implication is that valid inferences can be obtained using either the likelihood-based methods or multiple imputation approaches.
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Affiliation(s)
- Abdul-Karim Iddrisu
- Department of Statistical Sciences, University of Cape Town, Cape Town, Rondebosch7701, South Africa.
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, Rondebosch7701, South Africa
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Ntusi NA, Francis JM, Gumedze F, Karvounis H, Matthews PM, Wordsworth PB, Neubauer S, Karamitsos TD. Cardiovascular magnetic resonance characterization of myocardial and vascular function in rheumatoid arthritis patients. Hellenic J Cardiol 2019; 60:28-35. [DOI: 10.1016/j.hjc.2018.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/04/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
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10
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Affiliation(s)
- Abdul-Karim Iddrisu
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
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11
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Abstract
BACKGROUND Tuberculous pericarditis can impair the heart's function and cause death; long term, it can cause the membrane to fibrose and constrict causing heart failure. In addition to antituberculous chemotherapy, treatments include corticosteroids, drainage, and surgery. OBJECTIVES To assess the effects of treatments for tuberculous pericarditis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register (27 March 2017); the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library (2017, Issue 2); MEDLINE (1966 to 27 March 2017); Embase (1974 to 27 March 2017); and LILACS (1982 to 27 March 2017). In addition we searched the metaRegister of Controlled Trials (mRCT) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal using 'tuberculosis' and 'pericard*' as search terms on 27 March 2017. We searched ClinicalTrials.gov and contacted researchers in the field of tuberculous pericarditis. This is a new version of the original 2002 review. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs. DATA COLLECTION AND ANALYSIS Two review authors independently screened search outputs, evaluated study eligibility, assessed risk of bias, and extracted data; and we resolved any discrepancies by discussion and consensus. One trial assessed the effects of both corticosteroid and Mycobacterium indicus pranii treatment in a two-by-two factorial design; we excluded data from the group that received both interventions. We conducted fixed-effect meta-analysis and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Seven trials met the inclusion criteria; all were from sub-Saharan Africa and included 1959 participants, with 1051/1959 (54%) HIV-positive. All trials evaluated corticosteroids and one each evaluated colchicine, M. indicus pranii immunotherapy, and open surgical drainage. Four trials (1841 participants) were at low risk of bias, and three trials (118 participants) were at high risk of bias.In people who are not infected with HIV, corticosteroids may reduce deaths from all causes (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.09; 660 participants, 4 trials, low certainty evidence) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04; 492 participants, 2 trials, low certainty evidence). Corticosteroids probably reduce deaths from pericarditis (RR 0.39, 95% CI 0.19 to 0.80; 660 participants, 4 trials, moderate certainty evidence). However, we do not know whether or not corticosteroids have an effect on constriction or cancer among HIV-negative people (very low certainty evidence).In people living with HIV, only 19.9% (203/1959) were on antiretroviral drugs. Corticosteroids may reduce constriction (RR 0.55, 0.26 to 1.16; 575 participants, 3 trials, low certainty evidence). It is uncertain whether corticosteroids have an effect on all-cause death or cancer (very low certainty evidence); and may have little or no effect on repeat pericardiocentesis (RR 1.02, 0.89 to 1.18; 517 participants, 2 trials, low certainty evidence).For colchicine among people living with HIV, we found one small trial (33 participants) which had insufficient data to make any conclusions about any effects on death or constrictive pericarditis.Irrespective of HIV status, due to very low certainty evidence from one trial, it is uncertain whether adding M. indicus pranii immunotherapy to antituberculous drugs has an effect on any outcome.Open surgical drainage for effusion may reduce repeat pericardiocentesis In HIV-negative people (RR 0.23, 95% CI 0.07 to 0.76; 122 participants, 1 trial, low certainty evidence) but may make little or no difference to other outcomes. We did not find an eligible trial that assessed the effects of open surgical drainage in people living with HIV.The review authors found no eligible trials that examined the length of antituberculous treatment needed nor the effects of other adjunctive treatments for tuberculous pericarditis. AUTHORS' CONCLUSIONS For HIV-negative patients, corticosteroids may reduce death. For HIV-positive patients not on antiretroviral drugs, corticosteroids may reduce constriction. For HIV-positive patients with good antiretroviral drug viral suppression, clinicians may consider the results from HIV-negative patients more relevant.Further research may help evaluate percutaneous drainage of the pericardium under local anaesthesia, the timing of pericardiectomy in tuberculous constrictive pericarditis, and new antibiotic regimens.
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Affiliation(s)
- Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Mpiko Ntsekhe
- Groote Schuur HospitalDivision of CardiologyObservatory 7925Cape TownSouth Africa
| | - Lehana Thabane
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics50 Charlton Ave ERoom H325, St. Joseph's HealthcareHamiltonONCanadaL8N 4A6
| | - Jimmy Volmink
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Dumisani Majombozi
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Freedom Gumedze
- University of Cape TownDepartment of Statistical SciencesCape TownSouth Africa
| | - Shaheen Pandie
- University of Cape TownDepartment of MedicineCape TownSouth Africa
| | - Bongani M Mayosi
- University of Cape TownDepartment of MedicineCape TownSouth Africa
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Ngwanya MR, Gray NA, Gumedze F, Ndyenga A, Khumalo NP. Higher concentrations of dithranol appear to induce hair growth even in severe alopecia areata. Dermatol Ther 2017; 30. [PMID: 28598005 DOI: 10.1111/dth.12500] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
Abstract
Alopecia areata (AA) is the commonest autoimmune cause of non-scarring alopecia. Topical treatments including corticosteroids and irritants maybe beneficial. Studies report variable hair regrowth with dithranol (anthralin) but all used low concentrations (0.1-1.25%) and inconsistent measurements of AA severity. We report retrospective data (2005-2014) of 102 patients who had failed ultra-potent topical steroids and were referred to a specialist hair clinic for treatment with dithranol up to 3%. The severity of alopecia areata tool was used and participants graded as mild (<25%), moderate (>25 to 75%), and severe (>75%) hair loss. Compared with baseline any and at-least 50% hair regrowth [72%, 68%, 50% and 61.5%, 48.4%, 37.5%, in mild, moderate and severe AA respectively] occurred in all groups (median treatment duration 12 months). Twenty-nine patients (28.4%) were discharged with complete regrowth; with no difference in proportions in severity groups (33.3%, 29%, and 21.9%) but in the period to discharge [7.9, 6.3, and 29.4 months (p-values <.05)] for mild, moderate, and severe AA. Treatment trials of 12 months with dithranol at higher concentrations may be an option in patients who failed potent topical or intra-lesional steroids) regardless of AA severity. Randomized trials (of less staining formulations) of dithranol are warranted.
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Affiliation(s)
- M R Ngwanya
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - N A Gray
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - F Gumedze
- Department of Statistical Sciences, University of Cape Town, South Africa
| | - A Ndyenga
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - N P Khumalo
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, South Africa
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Mkentane K, Van Wyk JC, Sishi N, Gumedze F, Ngoepe M, Davids LM, Khumalo NP. Geometric classification of scalp hair for valid drug testing, 6 more reliable than 8 hair curl groups. PLoS One 2017; 12:e0172834. [PMID: 28570555 PMCID: PMC5453415 DOI: 10.1371/journal.pone.0172834] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 02/09/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Curly hair is reported to contain higher lipid content than straight hair, which may influence incorporation of lipid soluble drugs. The use of race to describe hair curl variation (Asian, Caucasian and African) is unscientific yet common in medical literature (including reports of drug levels in hair). This study investigated the reliability of a geometric classification of hair (based on 3 measurements: the curve diameter, curl index and number of waves). MATERIALS AND METHODS After ethical approval and informed consent, proximal virgin (6cm) hair sampled from the vertex of scalp in 48 healthy volunteers were evaluated. Three raters each scored hairs from 48 volunteers at two occasions each for the 8 and 6-group classifications. One rater applied the 6-group classification to 80 additional volunteers in order to further confirm the reliability of this system. The Kappa statistic was used to assess intra and inter rater agreement. RESULTS Each rater classified 480 hairs on each occasion. No rater classified any volunteer's 10 hairs into the same group; the most frequently occurring group was used for analysis. The inter-rater agreement was poor for the 8-groups (k = 0.418) but improved for the 6-groups (k = 0.671). The intra-rater agreement also improved (k = 0.444 to 0.648 versus 0.599 to 0.836) for 6-groups; that for the one evaluator for all volunteers was good (k = 0.754). CONCLUSIONS Although small, this is the first study to test the reliability of a geometric classification. The 6-group method is more reliable. However, a digital classification system is likely to reduce operator error. A reliable objective classification of human hair curl is long overdue, particularly with the increasing use of hair as a testing substrate for treatment compliance in Medicine.
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Affiliation(s)
- K. Mkentane
- Hair and Skin Research Lab, Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J. C. Van Wyk
- Hair and Skin Research Lab, Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
| | - N. Sishi
- Hair and Skin Research Lab, Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
| | - F. Gumedze
- Statistical Sciences, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - M. Ngoepe
- Engineering, University of Cape Town, Cape Town, South Africa
| | - L. M. Davids
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - N. P. Khumalo
- Hair and Skin Research Lab, Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
- * E-mail:
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Ntusi NA, Shaboodien G, Badri M, Gumedze F, Mayosi BM. Clinical features, spectrum of causal genetic mutations and outcome of hypertrophic cardiomyopathy in South Africans. Cardiovasc J Afr 2017; 27:152-158. [PMID: 27841901 PMCID: PMC5101433 DOI: 10.5830/cvja-2015-075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/15/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is known about the clinical characteristics, spectrum of causal genetic mutations and outcome of hypertrophic cardiomyopathy (HCM) in Africans. The objective of this study was to delineate the clinical and genetic features and outcome of HCM in African patients. METHODS Information on clinical presentation, electrocardiographic and echocardiographic findings, and outcome of cases with HCM was collected from the Cardiac Clinic at Groote Schuur Hospital over a mean duration of follow up of 9.1 ± 3.4 years. Genomic DNA was screened for mutations in 15 genes that cause HCM, i.e. cardiac myosin-binding protein C (MYBPC3), cardiac β-myosin heavy chain (MYH7), cardiac troponin T2 (TNNT2), cardiac troponin I (TNNI3), regulatory light chain of myosin (MYL2), essential light chain of myosin (MYL3), tropomyosin 1 (TPM1), phospholamban (PLN), α-actin (ACTC1), cysteine and glycine-rich protein 3 (CSRP3), AMP-activated protein kinase (PRKAG2), α-galactosidase (GLA), four-and-a-half LIM domains 1 (FHL1), lamin A/C (LMNA) and lysosome-associated membrane protein 2 (LAMP2). Survival and its predictors were analysed using the Kaplan-Meier and Cox proportional hazards regression methods, respectively. RESULTS Forty-three consecutive patients [mean age 38.5 ± 14.3 years; 25 (58.1%) male; and 13 (30.2%) black African] were prospectively enrolled in the study from January 1996 to December 2012. Clinical presentation was similar to that reported in other studies. The South African founder mutations that cause HCM were not found in the 42 probands. Ten of 35 index cases (28.6%) tested for mutations in 15 genes had disease-causing mutations in MYH7 (six cases or 60%) and MYBPC3 (four cases or 40%). No disease-causing mutation was found in the other 13 genes screened. The annual mortality rate was 2.9% per annum and overall survival was 74% at 10 years, which was similar to the general South African population. Cox's proportional hazards regression showed that survival was predicted by New York Heart Association (NYHA) functional class at last visit (p equals; 0.026), but not by the presence of a disease-causing mutation (p = 0.474). CONCLUSIONS Comprehensive genetic screening was associated with a 29% yield of causal genetic mutations in South African HCM cases, all in MYH7 and MBPC3 genes. A quarter of the patients had died after a decade of follow up, with NYHA functional class serving as a predictor of survival.
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Affiliation(s)
- Ntobeko A Ntusi
- Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular Research in Africa and The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa. ntobeko.ntusi@ gmail.com
| | - Gasnat Shaboodien
- Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular Research in Africa and The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Motasim Badri
- Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular Research in Africa and The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa; King Saud Bin Abdulaziz University for Medical Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Bongani M Mayosi
- Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular Research in Africa and The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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15
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Dhana A, Gumedze F, Khumalo N. Regarding ‘Frontal fibrosing alopecia: possible association with leave-on facial skincare products and sunscreens; a questionnaire study’. Br J Dermatol 2017; 176:836-837. [DOI: 10.1111/bjd.15197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A. Dhana
- Division of Dermatology; Groote Schuur Hospital and University of Cape Town; Cape Town South Africa
| | - F. Gumedze
- Department of Statistical Sciences; University of Cape Town; Cape Town South Africa
| | - N.P. Khumalo
- Division of Dermatology; Groote Schuur Hospital and University of Cape Town; Cape Town South Africa
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16
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Abstract
There is a sense that many patients seen at referral centers could be managed at a primary health care level. The objective of the current study was to examine the range of diagnoses among consultations at the Red Cross Children's Hospital in Cape Town, South Africa, to help develop a strategy for targeted education of primary health care personnel. This was a retrospective review of data for children seen at a pediatric dermatology clinic from 2005 to 2010, recorded according to International Classification of Diseases coding and compared with published data from similar clinical settings. There were 13,253 clinic visits, with 4,789 patients seen (median age 4.8 yrs, range 2 days to 18.6 yrs). The top 10 diagnoses accounted for 88.5% of consultations (59.5% atopic eczema [AE], 7.1% seborrheic dermatitis [SD], 4.2% superficial mycoses, 3.1% molluscum contagiosum, 2.8% vitiligo, 2.7% viral warts, 2.4% prurigo or scabies, 2.3% psoriasis, 2.3% hemangioma, 2.1% impetigo). Disease prevalence was somewhat different during the first year of life (AE 43.7%, SD 18.6%, hemangiomas 13.4%). Inflammatory dermatoses (76.6%) were more prevalent than infections and infestations (14.5%). The disease spectrum was similar to that in developed countries, although AE prevalence was higher in this study (followed by London 36%, Greece 35%, and Hong Kong 33%) than in 19 published studies. The top 10 diagnoses accounted for more than 70% of diagnoses in 12 studies. The retrospective nature and setting at a specialist clinic increased bias and limited generalizability. Focused education on the optimal care of common diseases, especially AE, could reduce referrals, improve access, and allow specialists at tertiary centers more time to manage complex and uncommon dermatoses.
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Affiliation(s)
- Betty Kakande
- Division of Dermatology, Red Cross Children's Hospital, Cape Town, South Africa.,Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Carol Hlela
- Division of Dermatology, Red Cross Children's Hospital, Cape Town, South Africa.,Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
| | - Nonhlanhla P Khumalo
- Division of Dermatology, Red Cross Children's Hospital, Cape Town, South Africa.,Division of Dermatology, Groote Schuur Hospital, Cape Town, South Africa
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17
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Pasipanodya JG, Mubanga M, Ntsekhe M, Pandie S, Magazi BT, Gumedze F, Myer L, Gumbo T, Mayosi BM. Tuberculous Pericarditis is Multibacillary and Bacterial Burden Drives High Mortality. EBioMedicine 2015; 2:1634-9. [PMID: 26870789 PMCID: PMC4740299 DOI: 10.1016/j.ebiom.2015.09.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
Background Tuberculous pericarditis is considered to be a paucibacillary process; the large pericardial fluid accumulation is attributed to an inflammatory response to tuberculoproteins. Mortality rates are high. We investigated the role of clinical and microbial factors predictive of tuberculous pericarditis mortality using the artificial intelligence algorithm termed classification and regression tree (CART) analysis. Methods Patients were prospectively enrolled and followed in the Investigation of the Management of Pericarditis (IMPI) registry. Clinical and laboratory data of 70 patients with confirmed tuberculous pericarditis, including time-to-positive (TTP) cultures from pericardial fluid, were extracted and analyzed for mortality outcomes using CART. TTP was translated to log10 colony forming units (CFUs) per mL, and compared to that obtained from sputum in some of our patients. Findings Seventy patients with proven tuberculous pericarditis were enrolled. The median patient age was 35 (range: 20–71) years. The median, follow up was for 11.97 (range: 0·03–74.73) months. The median TTP for pericardial fluid cultures was 22 (range: 4–58) days or 3.91(range: 0·5–8·96) log10CFU/mL, which overlapped with the range of 3.24–7.42 log10CFU/mL encountered in sputum, a multi-bacillary disease. The overall mortality rate was 1.43 per 100 person-months. CART identified follow-up duration of 5·23 months on directly observed therapy, a CD4 + count of ≤ 199.5/mL, and TTP ≤ 14 days (bacillary load ≥ 5.53 log10 CFU/mL) as predictive of mortality. TTP interacted with follow-up duration in a non-linear fashion. Interpretation Patients with culture confirmed tuberculous pericarditis have a high bacillary burden, and this bacterial burden drives mortality. Thus proven tuberculosis pericarditis is not a paucibacillary disease. Moreover, the severe immunosuppression suggests limited inflammation. There is a need for the design of a highly bactericidal regimen for this condition. The antibiotic concentrations achieved in TB pericarditis fluid have up to now been unknown The pH in pericardial fluid was alkaline, which would mean that pyrazinamide effect would be compromised. The protein content in pericardial fluid was high, which would lead to low non-protein bound drug concentrations The concentrations of rifampicin, ethambutol and pyrazinamide in pericardial were dramatically low and below their MICs
Tuberculous pericarditis kills many patients, even those receiving appropriate antibiotic treatment which consists of a cocktail of rifampicin, isoniazid, ethambutol and pyrazinamide. It is unknown if curative concentrations of these drugs are achieved at the site of tuberculous pericarditis. Therefore, we measured the concentrations of each of these antibiotics in pericardial fluid of patients with tuberculous pericarditis. There were dramatically low rifampicin, ethambutol, and pyrazinamide concentrations in pericardial fluid, compared to susceptibility of the infecting bacterium, Mycobacterium tuberculosis. Only isoniazid entered pericardial fluid at effective concentrations. This could explain the high rates of mortality and morbidity of current therapy. There might be a need to identify new drugs that can penetrate into pericardial fluid for treatment of tuberculosis pericarditis.
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Affiliation(s)
- Jotam G. Pasipanodya
- Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Mwenya Mubanga
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mpiko Ntsekhe
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Shaheen Pandie
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Beki T. Magazi
- National Health Laboratory Services (Tshwane Academic Division), Department of Medical Microbiology, University of Pretoria, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tawanda Gumbo
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
- Corresponding author at: Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, 3434 Live Oak Street, Dallas, TX 75204, USA.Center for Infectious Diseases Research and Experimental TherapeuticsBaylor Research InstituteBaylor University Medical Center3434 Live Oak StreetDallasTX75204USA
| | - Bongani M. Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Ntusi NBA, Badri M, Gumedze F, Sliwa K, Mayosi BM. Pregnancy-Associated Heart Failure: A Comparison of Clinical Presentation and Outcome between Hypertensive Heart Failure of Pregnancy and Idiopathic Peripartum Cardiomyopathy. PLoS One 2015; 10:e0133466. [PMID: 26252951 PMCID: PMC4529210 DOI: 10.1371/journal.pone.0133466] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/28/2015] [Indexed: 01/26/2023] Open
Abstract
Aims There is controversy regarding the inclusion of patients with hypertension among cases of peripartum cardiomyopathy (PPCM), as the practice has contributed significantly to the discrepancy in reported characteristics of PPCM. We sought to determine whether hypertensive heart failure of pregnancy (HHFP) (i.e., peripartum cardiac failure associated with any form of hypertension) and PPCM have similar or different clinical features and outcome. Methods and Results We compared the time of onset of symptoms, clinical profile (including electrocardiographic [ECG] and echocardiographic features) and outcome of patients with HHFP (n = 53; age 29.6 ± 6.6 years) and PPCM (n = 30; age 31.5 ± 7.5 years). The onset of symptoms was postpartum in all PPCM patients, whereas it was antepartum in 85% of HHFP cases (p<0.001). PPCM was more significantly associated with the following features than HHFP (p<0.05): twin pregnancy, smoking, cardiomegaly with lower left ventricular ejection fraction on echocardiography, and longer QRS duration, QRS abnormalities, left atrial hypertrophy, left bundle branch block, T wave inversion and atrial fibrillation on ECG. By contrast, HHFP patients were significantly more likely (p<0.05) to have a family history of hypertension, hypertension and pre-eclampsia in a previous pregnancy, tachycardia at presentation on ECG, and left ventricular hypertrophy on echocardiography. Chronic heart failure, intra-cardiac thrombus and pulmonary hypertension were found significantly more commonly in PPCM than in HHFP (p<0.05). There were 5 deaths in the PPCM group compared to none among HHFP cases (p = 0.005) during follow-up. Conclusion There are significant differences in the time of onset of heart failure, clinical, ECG and echocardiographic features, and outcome of HHFP compared to PPCM, indicating that the presence of hypertension in pregnancy-associated heart failure may not fit the case definition of idiopathic PPCM.
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Affiliation(s)
- Ntobeko B. A. Ntusi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Motasim Badri
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Bongani M. Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- * E-mail:
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Van Wyk JC, Mkentane K, Gumedze F, Khumalo NP. No-lye not better than lye relaxers. J Cosmet Sci 2014; 65:403-405. [PMID: 25898766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Mayosi BM, Ntsekhe M, Bosch J, Pandie S, Jung H, Gumedze F, Pogue J, Thabane L, Smieja M, Francis V, Joldersma L, Thomas KM, Thomas B, Awotedu AA, Magula NP, Naidoo DP, Damasceno A, Chitsa Banda A, Brown B, Manga P, Kirenga B, Mondo C, Mntla P, Tsitsi JM, Peters F, Essop MR, Russell JBW, Hakim J, Matenga J, Barasa AF, Sani MU, Olunuga T, Ogah O, Ansa V, Aje A, Danbauchi S, Ojji D, Yusuf S. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis. N Engl J Med 2014; 371:1121-30. [PMID: 25178809 PMCID: PMC4912834 DOI: 10.1056/nejmoa1407380] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis. METHODS Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. RESULTS There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer. CONCLUSIONS In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).
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Mayosi BM, Ntsekhe M, Bosch J, Pogue J, Gumedze F, Badri M, Jung H, Pandie S, Smieja M, Thabane L, Francis V, Thomas KM, Thomas B, Awotedu AA, Magula NP, Naidoo DP, Damasceno A, Banda AC, Mutyaba A, Brown B, Ntuli P, Mntla P, Ntyintyane L, Ramjee R, Manga P, Kirenga B, Mondo C, Russell JBW, Tsitsi JM, Peters F, Essop MR, Barasa AF, Mijinyawa MS, Sani MU, Olunuga T, Ogah O, Adebiyi A, Aje A, Ansa V, Ojji D, Danbauchi S, Hakim J, Matenga J, Yusuf S. Rationale and design of the Investigation of the Management of Pericarditis (IMPI) trial: a 2 × 2 factorial randomized double-blind multicenter trial of adjunctive prednisolone and Mycobacterium w immunotherapy in tuberculous pericarditis. Am Heart J 2013; 165:109-15.e3. [PMID: 23351812 DOI: 10.1016/j.ahj.2012.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 08/22/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND In spite of antituberculosis chemotherapy, tuberculous (TB) pericarditis causes death or disability in nearly half of those affected. Attenuation of the inflammatory response in TB pericarditis may improve outcome by reducing cardiac tamponade and pericardial constriction, but there is uncertainty as to whether adjunctive immunomodulation with corticosteroids and Mycobacterium w (M. w) can safely reduce mortality and morbidity. OBJECTIVES The primary objective of the IMPI Trial is to assess the effectiveness and safety of prednisolone and M. w immunotherapy in reducing the composite outcome of death, constriction, or cardiac tamponade requiring pericardial drainage in 1,400 patients with TB pericardial effusion. DESIGN The IMPI trial is a multicenter international randomized double-blind placebo-controlled 2 × 2 factorial study. Eligible patients are randomly assigned to receive oral prednisolone or placebo for 6 weeks and M. w injection or placebo for 3 months. Patients are followed up at weeks 2, 4, and 6 and months 3 and 6 during the intervention period and 6-monthly thereafter for up to 4 years. The primary outcome is the first occurrence of death, pericardial constriction, or cardiac tamponade requiring pericardiocentesis. The secondary outcome is safety of immunomodulatory treatment measured by effect on opportunistic infections (eg, herpes zoster) and malignancy (eg, Kaposi sarcoma) and impact on measures of immunosuppression and the incidence of immune reconstitution disease. CONCLUSIONS IMPI is the largest trial yet conducted comparing adjunctive immunotherapy in pericarditis. Its results will define the role of adjunctive corticosteroids and M. w immunotherapy in patients with TB pericardial effusion.
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Affiliation(s)
- Bongani M Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.
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Khumalo NP, Gumedze F. The adapted classification of male pattern hair loss improves reliability. Dermatology 2012; 225:110-4. [PMID: 23038020 DOI: 10.1159/000341542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 06/29/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Hamilton-Norwood classification (HNC) is used to assess the severity of pattern hair loss (PHL). Conflicting associations between PHL and cardiovascular disease (CVD) have been reported from studies that used different methods to assess alopecia severity. No classification including the HNC has been validated for population studies. We aimed to simplify the HNC, produce the adapted HNC and test its reliability for use in population studies. METHODS Identifying vertex alopecia as distinct allowed for a simpler alignment of alopecia figures where scores 4V and 5V in the adapted HNC replace IV and V in the original HNC. The two classifications were to be used by twelve of our staff (secretaries, nurses, dermatology trainees and dermatologists) to evaluate 16 men with PHL. Observer agreement was estimated using intraclass correlation coefficient (ICC) and a percentage method duplicated from the recent basic and specific (BASP) classification. RESULTS The ICC improved with the adapted HNC when assessed by both the nurses/secretaries (from 0.47 to 0.61) and dermatology residents/consultants (from 0.68 to 0.76). Agreement using the BASP percentage method for dermatologists was 62-69% for the original and 93-100% for the adapted HNC. CONCLUSIONS The adapted HNC increased reliability at various staff levels, making it suitable for epidemiological studies; its use in future studies could help elucidate the association between PHL and CVD.
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Affiliation(s)
- N P Khumalo
- Division of Dermatology, Groote Schuur and Red Cross Children's Hospitals, Cape Town, South Africa.
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Beach RA, Wilkinson KA, Gumedze F, Khumalo NP. Baseline sebum IL-1α is higher than expected in afro-textured hair: a risk factor for hair loss?*. J Cosmet Dermatol 2012; 11:9-16. [DOI: 10.1111/j.1473-2165.2011.00603.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ntusi NBA, Badri M, Gumedze F, Wonkam A, Mayosi BM. Clinical characteristics and outcomes of familial and idiopathic dilated cardiomyopathy in Cape Town: a comparative study of 120 cases followed up over 14 years. S Afr Med J 2011; 101:399-404. [PMID: 21920074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Accepted: 03/21/2011] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND It is not known whether there are differences in clinical characteristics and outcomes of patients with familial and idiopathic dilated cardiomyopathy (DCM) in an African setting. PURPOSE To compare the clinical characteristics and outcomes of familial and idiopathic DCM. METHODS We performed a retrospective study of familial and idiopathic DCM at Groote Schuur Hospital, Cape Town, between 1 February 1996 and 31 December 2009. Clinical, electrocardiographic (ECG) and imaging characteristics were compared, in addition to treatment and survival. RESULTS Eighty patients with idiopathic DCM and 40 familial cases were studied. ECG T-wave inversion was significantly more frequent in familial DCM (87.5%) than in idiopathic cases (68.8%) (p=0.014), whereas idiopathic patients had a higher prevalence of pathological Q waves (32.5%) than familial cases (12.5%) (p=0.028). Cardiac chambers were significantly more dilated with poorer systolic function in idiopathic than familial cases. A mortality rate of 40% after a median follow-up of 5 years was, however, similar in both groups. The presence of New York Heart Association functional class III and IV symptoms was an independent predictor of mortality (odds ratio (OR) 3.85, 95% confidence interval (CI) 1.30 - 48.47, p<0.001), while heart transplantation was an independent predictor of survival (OR 4.72, 95% CI 1.31 - 72.60, p=0.026) in both groups. Digoxin use without serum monitoring was a significant predictor of mortality in idiopathic DCM (OR 1.62, 95% CI 1.04 - 3.98, p=0.037). CONCLUSION Patients with idiopathic DCM have greater cardiac dysfunction than those with familiar disease, but mortality is similarly high in both groups. Digoxin use without drug level monitoring may be associated with increased mortality in idiopathic DCM.
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Affiliation(s)
- Ntobeko B A Ntusi
- Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town
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Khumalo NP, Stone J, Gumedze F, McGrath E, Ngwanya MR, de Berker D. 'Relaxers' damage hair: evidence from amino acid analysis. J Am Acad Dermatol 2010; 62:402-8. [PMID: 20159306 DOI: 10.1016/j.jaad.2009.04.061] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 04/13/2009] [Accepted: 04/14/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND 'Relaxers' are used by more than two thirds of African females to straighten hair, with easy grooming and increased length often cited as reasons. A recent study reported relaxed hair lengths much shorter than expected, suggesting increased fragility; the potential for scalp inflammation and scarring alopecia remains unclear. OBJECTIVE To investigate the biochemical effects of 'relaxers' on hair. METHODS With informed consent, included participants represented 3 groups: natural hair, asymptomatic relaxed hair, and symptomatic (brittle) relaxed hair. Biochemical analysis was performed by using a Biochrom 30 amino acid analyzer. Differences in amino acid levels were assessed using either Wilcoxon rank sum test or matched-pairs signed-rank test. RESULTS There was a decrease in cystine, citrulline, and arginine; however, an increase in glutamine was found in all relaxed compared to natural hair. Cystine levels (milligram per gram amino acid nitrogen) were similar in natural proximal and distal hair: 14 mg/g (range, 4-15 mg/g) versus 14 mg/g (range, 12-15 mg/g); P = .139. In asymptomatic relaxed hair, cystine levels were higher in less frequently relaxed samples proximal to scalp: 7.5 mg/g (5.6-12) versus 3.3 mg/g (1.3-9.2); P = .005. Cystine levels in distal asymptomatic relaxed and symptomatic relaxed hair were similar to each other and to those in the genetic hair fragility disease trichothiodystrophy. LIMITATIONS It was not possible to analyze lye and no-lye 'relaxers' separately. CONCLUSIONS 'Relaxers' are associated with reduced cystine consistent with fragile damaged hair. A decrease in citrulline and glutamine has been associated with inflammation; prospective studies are needed to investigate whether or how 'relaxers' induce inflammation.
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Affiliation(s)
- Nonhlanhla P Khumalo
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol 2008; 59:432-8. [DOI: 10.1016/j.jaad.2008.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Revised: 05/14/2008] [Accepted: 05/18/2008] [Indexed: 10/21/2022]
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Ntsekhe M, Wiysonge CS, Gumedze F, Maartens G, Commerford PJ, Volmink JA, Mayosi BM. HIV infection is associated with a lower incidence of constriction in presumed tuberculous pericarditis: a prospective observational study. PLoS One 2008; 3:e2253. [PMID: 18523576 PMCID: PMC2386966 DOI: 10.1371/journal.pone.0002253] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 04/17/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pericardial constriction is a serious complication of tuberculous pericardial effusion that occurs in up to a quarter of patients despite anti-tuberculosis chemotherapy. The impact of human immunodeficiency virus (HIV) infection on the incidence of constrictive pericarditis following tuberculous pericardial effusion is unknown. METHODS AND RESULTS We conducted a prospective observational study to determine the association between HIV infection and the incidence of constrictive pericarditis among 185 patients (median age 33 years) with suspected tuberculous pericardial effusion. These patients were recruited consecutively between March and October 2004 on commencement of anti-tuberculosis treatment, from 15 hospitals in Cameroon, Nigeria and South Africa. Surviving patients (N = 119) were assessed for clinical evidence of constrictive pericarditis at 3 and 6 months of follow-up. Clinical features of HIV infection were present in 42 (35.2%) of the 119 patients at enrolment into the study. 66 of the 119 (56.9%) patients consented to HIV testing at enrolment. During the 6 months of follow-up, a clinical diagnosis of constrictive pericarditis was made in 13 of the 119 patients (10.9 %, 95% confidence interval [CI] 5.9-18%). Patients with clinical features of HIV infection appear less likely to develop constriction than those without (4.8% versus 14.3%; P = 0.08). None of the 33 HIV seropositive patients developed constriction, but 8 (24.2%, 95%CI 11.1-42.3%) of the 33 HIV seronegative patients did (P = 0.005). In a multivariate logistic regression model adjusting simultaneously for several baseline characteristics, only clinical signs of HIV infection were significantly associated with a lower risk of constriction (odd ratio 0.14, 95% CI 0.02-0.87, P = 0.035). CONCLUSIONS These data suggest that HIV infection is associated with a lower incidence of pericardial constriction in patients with presumed tuberculous pericarditis.
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Affiliation(s)
- Mpiko Ntsekhe
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles S. Wiysonge
- South African Cochrane Centre, Medical Research Council, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Jimmy A. Volmink
- South African Cochrane Centre, Medical Research Council, Cape Town, South Africa
- Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Bongani M. Mayosi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Abstract
BACKGROUND Anecdotal data suggest that combed natural African hair reaches a length steady state. Easier grooming and anticipated long hair have made relaxers popular. OBJECTIVES These hypotheses were tested in a cross-sectional survey of 1042 school children using a piloted questionnaire and hair length measurements done on four scalp regions. RESULTS Participants included 45% boys and 55% girls. Girls consider length important for hairstyle choice (P < 0.0001). There was no difference in mean length at 2 to 5 vs. > 5 years (P = 0.3) and at 1 to < 2 vs. 2 to 5 years (P = 0.99), suggesting that a steady state is reached within 1 year after a hair cut for combed natural hair [mean, 5.1 cm (4.3)]. Relaxed hair reached length steady state > 2 years after a haircut [mean, 10.9 cm (3.6)], was longer than natural hair (P < 0.0001), shorter than expected, and significantly shorter on the occiput than the rest of the scalp (P < 0.0001). CONCLUSIONS Persistently short combed natural hair years after a hair cut suggests that breakage eventually equals new growth (i.e., steady state), which is likely to be variable. Relaxed hair, irrespective of last haircut, is also short; chemical damage as a limit to potential lengths needs confirmation. Relatively short occipital relaxed hair could be a clue to disease pathogenesis.
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Affiliation(s)
- N P Khumalo
- Division of Dermatology, Groote Schuur Hospital, South Africa.
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Wiysonge CS, Ntsekhe M, Gumedze F, Sliwa K, Blackett KN, Commerford PJ, Volmink JA, Mayosi BM. Contemporary use of adjunctive corticosteroids in tuberculous pericarditis. Int J Cardiol 2008; 124:388-90. [PMID: 17445921 DOI: 10.1016/j.ijcard.2006.12.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2006] [Accepted: 12/31/2006] [Indexed: 11/22/2022]
Abstract
There is controversy concerning the effectiveness of adjunctive corticosteroids in reducing mortality in tuberculous pericarditis. To assess the impact of this controversy on contemporary clinical practice, we studied the use of adjunctive corticosteroid in 185 consecutive patients with suspected pericardial tuberculosis from 15 hospitals in Cameroon, Nigeria, and South Africa. 109 (58.9%) patients received steroids with significant variation in corticosteroid use ranging from 0% to 93.5% per centre (P<0.0001). The presence of clinical features of HIV infection was the independent predictor of the non-use of adjunctive corticosteroids (OR 0.39, 95% CI 0.20-0.75, P=0.005). We have demonstrated marked variation in the use of corticosteroids by practitioners, with nearly half of all patients not receiving this intervention. Taken together with the statistical uncertainty regarding the effectiveness of adjunctive steroids in tuberculous pericarditis, these observations probably reflect a state of genuine uncertainty or clinical equipoise among practitioners who care for patients with tuberculous pericarditis in sub-Saharan Africa. These data provide a justification for the establishment of adequately powered randomised clinical trials to assess the effectiveness of adjunctive corticosteroids in patients with tuberculous pericarditis.
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Mayosi BM, Wiysonge CS, Ntsekhe M, Gumedze F, Volmink JA, Maartens G, Aje A, Thomas BM, Thomas KM, Awotedu AA, Thembela B, Mntla P, Maritz F, Blackett KN, Nkouonlack DC, Burch VC, Rebe K, Parrish A, Sliwa K, Vezi BZ, Alam N, Brown BG, Gould T, Visser T, Magula NP, Commerford PJ. Mortality in patients treated for tuberculous pericarditis in sub-Saharan Africa. S Afr Med J 2008; 98:36-40. [PMID: 18270639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVE To determine the mortality rate and its predictors in patients with a presumptive diagnosis of tuberculous pericarditis in sub-Saharan Africa. DESIGN Between 1 March 2004 and 31 October 2004, we enrolled 185 consecutive patients with presumed tuberculous pericarditis from 15 referral hospitals in Cameroon, Nigeria and South Africa, and observed them during the 6-month course of antituberculosis treatment for the major outcome of mortality. This was an observational study, with the diagnosis and management of each patient left at the discretion of the attending physician. Using Cox regression, we have assessed the effect of clinical and therapeutic characteristics (recorded at baseline) on mortality during follow-up. RESULTS We obtained the vital status of 174 (94%) patients (median age 33; range 14 - 87 years). The overall mortality rate was 26%. Mortality was higher in patients who had clinical features of HIV infection than in those who did not (40% v. 17%, p=0.001). Independent predictors of death during followup were: (i) a proven non-tuberculosis final diagnosis (hazard ratio (HR) 5.35, 95% confidence interval (CI) 1.76 - 16.25), (ii) the presence of clinical signs of HIV infection (HR 2.28, CI 1.14 - 4.56), (iii) coexistent pulmonary tuberculosis (HR 2.33, CI 1.20 - 4.54), and (iv) older age (HR 1.02, CI 1.01 - 1.05). There was also a trend towards an increase in death rate in patients with haemodynamic instability (HR 1.80, CI 0.90 - 3.58) and a decrease in those who underwent pericardiocentesis (HR 0.34, CI 0.10 - 1.19). CONCLUSION A presumptive diagnosis of tuberculous pericarditis is associated with a high mortality in sub-Saharan Africa. Attention to rapid aetiological diagnosis of pericardial effusion and treatment of concomitant HIV infection may reduce the high mortality associated with the disease.
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Khumalo NP, Ngwanya RM, Jessop S, Gumedze F, Ehrlich R. Marginal traction alopecia severity score: development and test of reliability. J Cosmet Dermatol 2007; 6:262-9. [DOI: 10.1111/j.1473-2165.2007.00345.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Anecdotal reports suggest that certain scalp disorders are common in Africans and may be associated with hairstyles. OBJECTIVES This study of 874 African adults in Cape Town was performed to test this hypothesis. METHODS A questionnaire was administered and scalp examinations performed, after ethics approval. RESULTS Participants included 30.9% men and 69.1% women (median age 36.1 years, range 18-99). Most men had natural hair: 91.7% vs. 24.3% women. The majority of men had recent haircuts (< 4 weeks): 74.8% vs. 9.9% women. The overall prevalence of acne (folliculitis) keloidalis nuchae (AKN) was 3.5%: higher in men than women (10.5% vs. 0.3%). AKN prevalence was not associated with whether clippers or blades were used. However, it was associated with haircut symptoms. Haircut-associated symptoms, i.e. at least one episode of transient pimples (or crusts) and bleeding (however small) were reported in 37% and 18.9% of men, respectively. The latter may have implications for disease transmission. Most women (58.7%) had chemically treated hair (49.2% relaxed and 9.6% permed hair) vs. 2.3% men. The prevalences of traction alopecia (TA) and central centrifugal cicatricial alopecia (CCCA) were 22.6% and 1.9%: higher in women (31.7% vs. 2.2% and 2.7% vs. 0%, respectively). CCCA was highest in women > 50 years (6.7% vs. 1.2%). TA prevalence was highest if the usual hairstyle was extensions attached to relaxed hair (48%). CONCLUSION We found associations between specific scalp diseases, hairstyles, gender, and age. These associations need further study, better to elucidate determinants and to improve disease prevention and treatment.
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Affiliation(s)
- N P Khumalo
- Division of Dermatology, Groote Schuur Hospital and the University of Cape Town, Observatory 7925, South Africa.
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Abstract
BACKGROUND Anecdotal reports suggest that certain disorders are common in African hair and may be associated with hairstyles. OBJECTIVES A cross-sectional study of 1042 schoolchildren was performed to test this hypothesis. METHODS A questionnaire was administered and scalp examinations performed, after ethics approval. RESULTS Participants included 45% boys and 55% girls. The majority of boys, 72.8%, kept natural hair with frequent haircuts (within 4 weeks). The prevalence of acne (folliculitis) keloidalis nuchae (AKN) was 0.67% in the whole group and highest (4.7%) in boys in the final year of high school, all of whom had frequent haircuts. The majority of girls (78.4%) had chemically relaxed hair, which was usually combed back or tied in ponytails, vs. 8.6% of boys. Traction alopecia (TA) was significantly more common with relaxed than natural hair, with an overall prevalence of 9.4% (98 of 1042) and of 17.1% in girls, in whom it increased with age from 8.6% in the first year of school to 21.7% in the last year of high school. The proportion with TA in participants with a history of braids on natural hair was lower (22.9%), but not significantly, than among those with a history of braids on relaxed hair (32.1%). No cases of central centrifugal cicatricial alopecia were identified. CONCLUSIONS We found associations between hairstyle and disease in our population of schoolchildren. AKN appears to be associated with frequently cut natural hair and TA with relaxed hair. These associations need further study for purposes of disease prevention.
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Affiliation(s)
- N P Khumalo
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa.
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Abstract
Background and Purpose—
To determine the relationship between chronic
Chlamydia pneumoniae
infection and stroke in Cameroon.
Methods—
Sixty-four consecutive stroke patients 26 to 80 years of age were enrolled at 2 tertiary hospitals in Yaoundé, Cameroon, between March 2000 and December 2001 and matched for age and sex to 64 controls. We measured IgG (1/64) and IgA (1/16) titers against
C pneumoniae
in both patients and controls using a validated microimmunofluorescence technique.
Results—
There was no significant difference between cases and controls with respect to hypertension (
P
=0.2), smoking (
P
=0.53), alcohol intake (
P
=0.8), body mass index (
P
=0.49), waist-to-hip ratio (
P
=0.14), and diabetes (
P
=0.76). IgA antibodies were detected in 50 (78.1%) patients and 27 (42.2%) controls (odds ratio [OR] 4.29; 95% CI, 1.84 to 11.56;
P
=0.0002), and IgG antibodies in 41 (64.1%) patients and 35 (54.7%) controls (OR, 1.46; 95% CI, 0.68 to 3.22;
P
=0.29). For confirmed thrombotic stroke, the association with IgA antibodies became stronger (OR, 21.0; 95% CI, 3.38 to 868.45;
P
<0.0001), but there was still no association with IgG antibodies (OR, 1.86; 95% CI, 0.69 to 5.50;
P
=0.18).
Conclusions—
Our study shows a strong statistical association between (IgA, and not IgG, as a serological marker of) chronic
C pneumoniae
infection and stroke for the first time in a resident indigenous African population. These findings, if confirmed, may have important policy implications (in terms of antibiotic use in stroke prevention) in sub-Saharan Africa.
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Affiliation(s)
- Alfred K Njamnshi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon
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Mayosi BM, Wiysonge CS, Ntsekhe M, Volmink JA, Gumedze F, Maartens G, Aje A, Thomas BM, Thomas KM, Awotedu AA, Thembela B, Mntla P, Maritz F, Blackett KN, Nkouonlack DC, Burch VC, Rebe K, Parish A, Sliwa K, Vezi BZ, Alam N, Brown BG, Gould T, Visser T, Shey MS, Magula NP, Commerford PJ. Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry. BMC Infect Dis 2006; 6:2. [PMID: 16396690 PMCID: PMC1352368 DOI: 10.1186/1471-2334-6-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Accepted: 01/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa. METHODS Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status. RESULTS A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs. CONCLUSION Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.
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Affiliation(s)
- Bongani M Mayosi
- The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa
| | - Charles Shey Wiysonge
- The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa
| | - Mpiko Ntsekhe
- The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa
| | - Jimmy A Volmink
- Primary Health Care Directorate, University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Akinyemi Aje
- Department of Cardiology, University College Hospital, Ibadan, Nigeria
| | - Baby M Thomas
- Department of Medicine, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Kandathil M Thomas
- Department of Medicine, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Abolade A Awotedu
- Department of Medicine, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa
| | - Bongani Thembela
- Department of Medicine, Prince Mshiyeni Hospital, Durban, South Africa
| | - Phindile Mntla
- Department of Cardiology, MEDUNSA, Pretoria, South Africa
| | - Frans Maritz
- Department of Internal Medicine, Karl Bremer Hospital, Bellville, South Africa
| | - Kathleen Ngu Blackett
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I and Centre Hospitalier et Universitaire, Yaoundé, Cameroon
| | - Duquesne C Nkouonlack
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I and Centre Hospitalier et Universitaire, Yaoundé, Cameroon
| | - Vanessa C Burch
- Department of Medicine, GF Jooste Hospital, Cape Town, South Africa
| | - Kevin Rebe
- Department of Medicine, GF Jooste Hospital, Cape Town, South Africa
| | - Andy Parish
- Cecilia Makiwane Hospital, East London, South Africa
| | - Karen Sliwa
- Department of Cardiology, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Soweto, South Africa
| | - Brian Z Vezi
- Subdepartment of Cardiology, Inkosi Albert Luthuli Central Hospital and University of KwaZulu Natal, Durban, South Africa
| | - Nowshad Alam
- Livingstone's Hospital, Port Elizabeth, South Africa
| | | | - Trevor Gould
- Department of Medicine, George Hospital, George, South Africa
| | - Tim Visser
- Eersterivier Hospital, Cape Town, South Africa
| | - Muki S Shey
- Mycobacterial Immunology Group, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nombulelo P Magula
- Subdepartment of Infectious Diseases, Department of Medicine, King Edward VIII Hospital and University of KwaZulu Natal, Durban, South Africa
| | - Patrick J Commerford
- The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa
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Mayosi BM, Kardos A, Davies CH, Gumedze F, Hovnanian A, Burge S, Watkins H. Heterozygous disruption of SERCA2a is not associated with impairment of cardiac performance in humans: implications for SERCA2a as a therapeutic target in heart failure. Heart 2005; 92:105-9. [PMID: 15845614 PMCID: PMC1861003 DOI: 10.1136/hrt.2004.051037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To verify whether a deficiency in the cardiac sarcoplasmic reticulum pump SERCA2a causes cardiac dysfunction in humans. DESIGN Cardiac performance was measured in a serendipitous human model of primary SERCA2a deficiency, Darier's disease, an autosomal dominant skin disorder caused by mutations inactivating one copy of the ATP2A2 gene, which encodes SERCA2a. METHODS Systolic and diastolic function and contractility were assessed by echocardiography at rest and during exercise in patients with Darier's disease with known mutations. Fourteen patients with Darier's disease were compared with 14 normal controls and six patients with dilated cardiomyopathy with stable heart failure. RESULTS Resting systolic and diastolic function was normal in patients with Darier's disease and in controls. The increase in systolic function during exercise was not different between patients with Darier's disease and normal controls; neither was there a difference in contractility. As expected, patients with dilated cardiomyopathy had impaired diastolic and systolic function with depressed contractility at rest and during exercise. CONCLUSION Contrary to expectations, heterozygous disruption of SERCA2a is not associated with the impairment of cardiac performance in humans. Attempts to increase SERCA2a levels in heart failure, although showing promise in rodent studies, may not be addressing a critical causal pathway in humans.
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Affiliation(s)
- B M Mayosi
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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