Gestational gigantomastia complicated by pseudo-angiomatous stromal hyperplasia - a multidisciplinary management approach

SUMMARY

Gestational gigantomastia is a rare condition typified by disproportionate bilateral breast enlargement in pregnant women, resulting in skin thinning, ulceration, and bleeding. Less than sixty cases have been documented worldwide, and only one other in South Africa. Pseudo-angiomatous stromal hyperplasia (PASH) is a rare benign proliferation of stromal tissue in a tumorous or diffuse pattern. This, to the best of our knowledge, is the first published case, a 27-year-old human immunodeficiency virus (HIV) positive woman, to present with both conditions concurrently. Medical management with cabergoline was initiated and, seven months post-delivery, a novel Goldilocks mastectomy was performed with acceptable outcomes.

Retroperitoneoscopic adrenalectomy - introducing a new surgical technique in South Africa

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy (PRA) is purported to be superior to the laparoscopic transperitoneal approach (LA) in patients with a select spectrum of benign adrenal pathologies. Advantages attributed to the technique include minimal blood loss, shortened operative times, and decreased postoperative pain, explained anatomically by the direct access to the adrenal gland. Reduced workspace is a limitation.

METHODS

A retrospective review of 22 consecutive PRAs performed in a single centre between 1 September 2016 and 30 October 2020 is presented. Two experienced laparoscopic surgeons operated on all patients after acquiring the technique at international centres. Suitable candidates were carefully pre-selected. Non-benign pathology, high vascularity, body mass index (BMI) ≥ 45 kg/m2 and anatomical concerns on prior computed tomography (CT) imaging were exclusion criteria.

RESULTS

Twenty-two PRAs were performed for a spectrum of benign adrenal pathologies. Twenty-one surgeries (95%) were completed. A single case of pheochromocytoma required conversion. The procedure was safe, a minor postoperative complication (pneumaturia) occurred in one case, and the mortality rate was 0%. Median operative time (80 minutes) is comparable to other reported series in the literature, with a modest linear descending tendency noted over the study period. Underlying pathology influenced operative times. Pheochromocytomas proved to be most challenging and required careful preoperative evaluation.

CONCLUSION

The PRA procedures performed at Tygerberg Academic Hospital were safe and reproducible in a select group of cases with benign adrenal pathology. Endocrine surgeons proficient with laparoscopic techniques should be encouraged to use the PRA approach when encountering adrenal neoplasms that fit the criteria.

Premenopausal osteoporosis

In premenopausal women, bone mineral density measurement by dual-energy X-ray absorptiometry should not be used as the sole guide for diagnosis or treatment of osteoporosis, universal screening with bone mineral density is not advised and the World Health Organization classification of bone status should not be applied. A diagnosis of premenopausal osteoporosis is reserved for those with evidence of fragility and may also be considered in women with low bone mass and an ongoing secondary cause of osteoporosis. Idiopathic osteoporosis in young women is rare. A thorough evaluation of secondary causes is indicated in all patients, with glucocorticoid treatment a common secondary cause of low bone mass and osteoporosis. Hypoestrogenism may be the primary cause of low bone mass and contribute to excessive bone loss in many conditions associated with premenopausal osteoporosis, and should be treated unless contra-indicated. The mainstay of treatment in premenopausal females with low bone mass includes risk factor reduction, advocating a healthy, active lifestyle and optimal treatment of secondary causes of bone loss. The safety of bone-specific therapy, especially long term and during pregnancy, remains uncertain. Bisphosphonates, teriparatide, denosumab and estrogen treatment increase bone density in premenopausal women with osteoporosis, but there are no study data confirming short-term fracture prevention with use of these agents.

Diabetes mellitus and COVID-19: A review and management guidance for South Africa

This article reviews the association between diabetes mellitus (DM) and COVID-19. We report on the convergence of infectious diseases such as coronavirus infections and non-communicable diseases including DM. The mechanisms for the interaction between COVID-19 and DM are explored, and suggestions for the management of DM in patients with COVID-19 in South Africa are offered.

Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study

BACKGROUND

Limited data exist on the incidence of hip fractures in South Africa (SA). We report gender and ethnic specific incidence rates of hip fractures in SA.

METHODS

In a multicentre prospective study, conducted in geographically defined municipalities of three provinces in SA, a structured questionnaire was administered to all subjects aged 40 years and over, presenting with a new atraumatic hip fracture, from 1 April 2017 to 31 March 2018. Gender and ethnic specific incidence rates (IR) of hip fractures were calculated using population statistics from Statistics SA.

FINDINGS

Of the 2767 subjects enrolled, 1914 (69·2%) were women and 853 (30·8%) were men. The majority of subjects were from the White population (40·9%) followed by those from the African (26·4%), Coloured (18·7%) and Indian (13·9%) populations. Men with hip fractures were significantly younger than women in the total group (69 [IQR 59-79] versus 77 years [IQR 68-84], p < 0·001) and in each ethnic group. White subjects were significantly older (p < 0·0001) and Africans significantly younger (p < 0·0001) than the other ethnic groups. In women, the highest IR was noted in the White population (176·0 per 100,000), followed by that in the Indian (147·7 per 100,000), Coloured (73·2 per 100,000) and African populations (43·6 per 100,000). A similar pattern was seen in men albeit at lower rates, with the highest rate in White men at 76·5 per 100,000. In the total study population and the African population, the IR was higher in men compared to women in subjects under 60 years. In the White population, the IR was higher in men compared to women in the 40-44 years age group. While in the Coloured and Indian populations the IR was higher in men compared to women in the 40-49 years and 45-54 years age groups, respectively. There was an increase in the relative risk ratios with age in the total study population, and in all ethnic groups in both women and men.

INTERPRETATION

Hip fractures occur in all ethnic groups in South Africa with higher IRs in the White and Indian populations compared to the Coloured and African populations. Consistent with the published literature, the overall hip fracture IR was higher in women than in men, except in the younger age groups, and increased with age.

FUNDING

South African Medical Research Council and the University of KwaZulu-Natal Competitive Research Grant.

Pharmacogenetics of Aromatase Inhibitors in Endocrine Responsive Breast Cancer: Lessons Learnt from Tamoxifen and CYP2D6 Genotyping

BACKGROUND

Genetics play a significant role in drug metabolism of endocrine therapy of breast cancer. These aspects have been studied extensively in patients on tamoxifen, but the pharmacogenetics of aromatase inhibitors are less established. In contrast to the protective effect of tamoxifen, aromatase inhibitors are linked with an increased risk for bone loss and fractures.

OBJECTIVE

This review outlines key issues in the implementation of pharmacogenetics of cytochrome P450 and tamoxifen as a model for optimal use of aromatase inhibitors in postmenopausal women with estrogen receptor positive breast cancer.

METHODS

Lessons learnt from the association between tamoxifen and CYP2D6 genotyping were applied to identify polymorphisms with the potential to change clinical decision-making in patients on aromatase inhibitors. The ability of next generation sequencing to supersede single-gene analysis was furthermore evaluated in a subset of breast cancer patients on aromatase inhibitors selected from a central genomics database.

RESULTS

Methodological flaws in major randomised controlled trials and continued referral to incorrect results in expert consensus statements are important factors delaying the implementation of CYP2D6 pharmacogenetics in tamoxifen treatment. This highlighted the importance of a clinical pipeline including comprehensive genotyping, to define the target population most likely to benefit from aromatase inhibitor pharmacogenetics.

CONCLUSION

The clinical utility of CYP2D6 genotyping is well-established in patients at increased risk of tamoxifen resistance due to cumulative risk. The pharmacogenetics of CYP19A1 requires further clarification in terms of bone risk assessment for appropriate use in the treatment algorithm of high-risk patients at the onset of aromatase inhibitors.

A comparison between point-of-care testing and venous glucose determination for the diagnosis of diabetes mellitus 6-12 weeks after gestational diabetes

AIM

To evaluate point-of-care-testing (POCT) for the diagnosis of Type 2 diabetes mellitus 6-12 weeks post-partum in women with gestational diabetes (GDM).

METHODS

Post-partum glucose assessment (75-mg oral glucose tolerance test, OGTT) was performed prospectively in 122 women with GDM (1 November 2015 to 1 November 2017) at Tygerberg Hospital, Cape Town, South Africa. Individuals with known pre-existing diabetes were excluded. The accuracy and clinical utility of POCT (capillary finger-prick) were compared with laboratory plasma glucose (hexokinase and glucokinase methods). The OGTT consisted of two time points (fasting and 2 h) during which concurrent glucose samples (POCT and laboratory) were obtained. Bland-Altman plots and paired analysis were used to assess the analytical accuracy of POCT, whereas its diagnostic performance was determined using positive and negative predictive values to calculate specificity and sensitivity.

RESULTS

Spearman's ranked correlation analysis indicated a strong association between POCT and laboratory glucose values at both OGTT time points (fasting, r = 0.95, P < 0.0001; 2 h, r = 0.88, P < 0.0001). Thirty-six women were diagnosed with Type 2 diabetes based on gold standard laboratory glucose levels (fasting > 7 mmol/l; 2 h > 11.1 mmol/l). POCT correctly identified Type 2 diabetes in 78% of women (28 of 36) with a positive predictive value of 89.3% and a negative predictive value of 96.7% at the fasting time point. The sensitivity and specificity of POCT to diagnose Type 2 diabetes were 89% (fasting), 85.7% (2 h) and 96.7% (fasting), 98.5% (2 h) respectively. POCT proved less sensitive to diagnose pre-diabetes (69%) but displayed satisfactory specificity (92%) at both time points assessed.

CONCLUSION

POCT accurately identifies women with Type 2 diabetes 6-12 weeks after GDM.

A Direct Comparison of the Effects of the Antiretroviral Drugs Stavudine, Tenofovir and the Combination Lopinavir/Ritonavir on Bone Metabolism in a Rat Model

Antiretroviral (ARV) treatment may induce metabolic complications in HIV patients on long-term therapy that can affect bone health. In this study, the effects of the ARVs Stavudine (d4T), Tenofovir (TDF) and Lopinavir/ritonavir (LPV/r) on bone metabolism and lipodystrophy were directly compared in rats to negate the consequences of HIV-associated confounding factors. Healthy 12-14-week-old male Wistar rats (n = 40) were divided into four treatment groups and received an oral animal equivalent dose of either Stavudine (6.2 mg/kg/day), TDF (26.6 mg/kg/day), LPV/r (70.8 mg/kg/day) or water (Control 1.5 mL water/day) for a period of 9 weeks. Whole-body DXA measurements, a biomechanical three-point breaking test and histomorphometric analysis were performed on the femurs and tibias at the end of the treatment period. Stavudine monotherapy was found to be associated with decreased femoral bone mineral density that translated into reduced bone strength, whereas histomorphometric analysis demonstrated that Stavudine induces an imbalance in bone metabolism at tissue level, evident in higher resorption (eroded surfaces, osteoclast surfaces and osteoclast number) and lower formation parameters (osteoblast surfaces and osteoid surfaces). This was less clear in the rats treated with either TDF or LPV/r. Furthermore, both Stavudine and TDF treatment resulted in significant bone marrow adiposity, although no significant redistribution of body fat was noted in the treated rats compared to controls. The data from this study suggest that in the absence of HIV-associated factors, LPV/r is less detrimental to bone metabolism compared to Stavudine and TDF.

Association between low serum free testosterone and adverse prognostic factors in men diagnosed with prostate cancer in KwaZulu-Natal

BACKGROUND

The association of serum free testosterone (FT) with prostate cancer is not fully understood. Studies on the results of the relationship between serum testosterone level and prostate cancer are conflicting. However, there is a reported association between lower serum testosterone levels and high-grade prostate cancer.

OBJECTIVE

To investigate the relationship between serum FT and the clinico-pathological characteristics of prostate cancer in South African patients.

MATERIALS AND METHODS

The clinical data of 109 consecutive patients diagnosed with prostate cancer on biopsy were evaluated prospectively. The variables were age, ethnic group, prostate specific antigen (PSA), digital rectal examination (DRE) findings, clinical tumour, nodes and metastases (TNM) stage, and Gleason score. Low serum FT was defined as <250ng/dl. Statistical analysis was performed using Stata V10 software (p<0.05 considered significant).

RESULTS

There was a statistically significant association between low serum FT and high serum PSA, high Gleason score and clinically advanced stage prostate cancer.

CONCLUSIONS

In this cohort of men with histologically diagnosed prostate cancer, low serum FT was associated with higher PSA, higher grade, and locally advanced or metastatic prostate cancer.

Do clinical features and MRI suggest the same nerve root in acute cervical radiculopathy

Different proposed pathophysiological mechanisms can result in variable clinical presentations of cervical radiculopathy (CR), often making it difficult to detect minor nerve root (NR) conditions. This descriptive study determined (1) the level(s) of  NR involvement suggested by the distribution patterns of clinical features and detected by magnetic resonance imaging (MRI) and (2) the most common associations between the different variables in patients diagnosed with acute CR by a neurosurgeon. A physiotherapist blinded to the level(s) of NR involvement performed a standardized interview on 21 subjects to determine the distribution patterns of pain and paraesthesia, and a neurological examination. The Fisher exact test was used to determine associations between the different variables. Only seven subjects presented clinically and radiologically with the same single-level NR involvement. Multiple- level presentations occurred which might be due to dermatomal overlapping, central sensitization or the possible involvement of two adjacent NR levels. Distribution patterns of motor weakness, pain and paraesthesia, and to a lesser extent sensory and reflex changes, have value in identifying the compressed NR level. For this sample the distri-bution patterns of radicular features identified C6 and C8 with more certainty than C7.

Psychosocial factors associated with acute cervical radiculopathy

Pain is an individual multi-dimensional experience, depending on contributions from the sensory, affective and cognitive dimensions. Only a few studies investigated the psychosocial factors associated with cervical radiculopathy (CR). These studies suggested that chronic CR affects functional abilities, emotional and cognitive states. This descriptive study determined (1) whether psychological factors were present, (2) the impact of pain on the ability to perform activities of daily living, and (3) the correlation between pain intensity, emotional state and functional abilities. The researcher, a physiotherapist, interviewed 21 subjects whose clinical diagnosis of acute CR made by a neurosurgeon [and confirmed with magnetic resonance imaging (MRI)], to determine the cognitive dimension. Three  standardized questionnaires, namely the Neck Disability Index (NDI), the Hospital Anxiety and Depression (HAD) Scale and the McGill Pain Questionnaire (MPQ long form) were administrated to assess the pain intensity, emotional state, total pain experience and functional abilities. Central tendencies were determined by calculating the mean andmedian. The Spearman rank order correlation coefficient test was performed to establish correlations between variables.Results suggested that radicular pain is not only a sensory experience since altered emotional and cognitive stateswere present, which frequently influenced functional abilities. Correlations existed between functional abilities, emotional state and total pain experience, as well as anxiety and depression levels. Higher anxiety than depression levels were found. Thoughts on beliefs and coping strategies were affected. We concluded that clinicians should also address the psychosocial factors and consider the functional impact of the disease, during the assessment and management of acute CR.

Do experienced physiotherapists apply equal magnitude of force during a grade I central pa on the cervical spine?

Background and purpose: Physiotherapists frequently use central posterior-anterior (PA) joint mobilization techniques for assessing and managing spinal disorders. Manual examination findings provide the basis for the selection of treatment techniques. From the literature it is evident that the level of reliability varies when physiotherapists perform different mobilization techniques. Repeatability of mobilization techniques is important for better physiotherapy management. The aim of the study was to determine whether experienced physiotherapists apply equal magnitude of force during a grade I central PA mobilisation technique on the cervical spine. Another aim was to determine the variation in the magnitude of forceapplied by each individual physiotherapist. Subjects: Sample of convenience, consisting of sixteen (n=16) selected qualified physiotherapists with experience inOrthopaedic Manual Therapy.Methods: A grade I central PA was performed on the Flexiforce TM sensors positioned on C6 of the same asymptomatic model to measure the applied magnitude of force. Two separate measurements, each lasting 30-seconds, were obtained.Results: The average maximum peak force applied by the majority of physiotherapists (87.5%) was between 10.95gand 72g. The difference in the forces applied for the two measurements ranged between 0.64g and 24.4g. The BlandAltman scatterplot determined the mean of the difference between measurement one and two, calculated for the group, was zero. When comparing the two measurements, little variation was noted in the forces applied, as well as the coefficient of variation for each physiotherapist.Conclusion and Discussion: Current results demonstrated good intra-therapist and moderate to good inter-therapist repeatability. Further research is required to generalize results.

Leiomyoma of the bladder in a patient with von Recklinghausen's neurofibromatosis

Leiomyomas are an uncommon manifestation of neurofibromatosis type 1 (NF-1) and occur most often in the gastrointestinal tract. Here, they have a proclivity for the proximal small bowel and tend to be multiple. Urinary tract involvement by NF-1 is usually in the form of neurofibromas, and leiomyomas are exceptionally rare. This report describes a case of solitary leiomyoma occurring in a 49 year old woman with NF-1. The patient had symptoms related to a lower urinary tract infection and on examination was found to have a distended bladder. Imaging of the bladder showed a mass involving the posterior wall, neck, and trigone causing bilateral hydronephrosis. The mass was excised with part of the bladder. Microscopic examination revealed typical features of a leiomyoma and there was strong immunoreactivity for desmin and smooth muscle actin. Leiomyoma must be considered in the differential diagnosis of spindle cell neoplasms in patients with NF-1.

Measurement of the magnitude of force applied by students when learning a mobilisation technique

Passive accessory intervertebral movements (PAIVM’s) are frequently used by physiotherapists in the  assessment and management of patients. Studies investigating the reliability of passive mobilisation techniques have shown conflicting results. Therefore, standardisation of PAIVM’s is essential for research and teaching purposes, which could result in better clinical management. In order to standardise graded passive mobilisation techniques, a reliable, easy-to-use, objective measurement tool must be used. The aim of this  study was to determine whether it is necessary to quantify the magnitude of force applied when teaching a grade I central  posteroanterior (PA) mobilisation technique (according to Maitland) on the cervical spine. An objective measurement tool (FlexiForceTM) was used to determine the consistency of force applied by third and fourth year physiotherapy students while performing this technique. Twenty third- and 20 fourth year physiotherapy students (n=40) were randomly selected. Each subject performed a grade I central PA on sensors placed on C6 for 25 seconds. The average maximum grade 1 force applied by the third year students was  significantly higher than the force applied by the fourth year students (p=0.034). There was a significantly larger variation in applied force among third years (p=0.00043). The results indicate that the current teaching method is insufficient to ensure inter-therapist reliability amongst students, emphasising the need for an objective measurement tool to be used for teaching students. The measurement tool used in this study is economical, easily applied and is an efficient method of measuring the magnitude of force. Further research is needed to demonstrate the reliability and validity of the tool to assist teaching and research in a clinical setting.

Nutritional status of renal transplant patients

OBJECTIVE

To assess the effect of renal transplantation on the nutritional status of patients.

DESIGN

Prospective descriptive study.

SETTING

Renal Transplant Clinic at Tygerberg Hospital, Western Cape.

SUBJECTS

Fifty-eight renal transplant patients from Tygerberg Hospital were enrolled in the study. The sample was divided into two groups of 29 patients each: group 1, less than 28 months post-transplant; and group 2, more than 28 months post-transplant.

OUTCOME MEASURES

Nutritional status assessment comprised biochemical evaluation, a dietary history, anthropometric measurements and a clinical examination.

RESULTS

Serum vitamin B6 levels were below normal in 56% of patients from group 1 and 59% from group 2. Vitamin B6 intake, however, was insufficient in only 14% of patients from group 1 and 10% from group 2. Serum vitamin C levels were below normal in 7% of patients from group 1 and 24% from group 2, while vitamin C intake was insufficient in 21% and 14% of patients from groups 1 and 2 respectively. Serum magnesium levels were below normal in 55% of patients from group 1, and in 28% from group 2. Serum albumin and cholesterol levels increased significantly during the post-transplant period in the total sample (P = 0.0001). There was also a significant increase in body mass index (P = 0.0001) during the post-transplant period.

CONCLUSIONS

Several nutritional abnormalities were observed, which primarily reflect the side-effects of immunosuppressive therapy. The causes, consequences and treatment of the vitamin B6 and vitamin C deficiencies in renal transplant recipients need further investigation.

Ureteral access for upper urinary tract disease: the access sheath

Ureteral access with the flexible ureteroscope remains a challenge for the urologist. The routine use of a newly developed, site-specific ureteral access sheath facilitates entry into the ureter for fragmentation and basket extraction of ureteral and renal calculi. The step-by-step technique of ureteral access with the Access Sheath is described.