The importance of frontal QRS-T angle for predicting reverse dipper status in newly diagnosed hypertensive patients

Background

The frontal QRS-T angle (fQRS-T angle) in electrocardiography is a new measure of myocardial repolarization, in which a higher fQRS-T angle is linked with worse cardiac outcomes. Reverse dipper hypertension is also linked to poor cardiac outcomes. The purpose of this study was to investigate the association between the fQRS-T angle and reverse dipper status in individuals newly diagnosed with hypertension who did not have left ventricular hypertrophy (LVH).

Methods

The investigation recruited 171 hypertensive individuals without LVH who underwent 24h ambulatory blood pressure monitoring (ABPM). Based on the findings of 24h ABPM, the study population was categorized into the following three groups: patients with dipper hypertension, with non-dipper hypertension, and with reverse dipper hypertension. The frontal QRS-T angle was measured using 12-lead electrocardiography (ECG).

Results

The fQRS-T angle in individuals with reverse dipper hypertension was substantially greater than in patients with and without dipper hypertension (510±280 vs. 280±220 vs. 390±250 respectively, p<0.001). The fQRS-T angle (OR: 1.040, 95% CI: 1.016–1.066; p=0.001) was independently associated with reverse dipper hypertension according to multivariate analysis. In receiver operating characteristic curve analysis, the fQRS-T angle to predict reverse dipper hypertension was 33.5° with 76% sensitivity and 71% specificity.

Conclusion

This study showed that an increased fQRS-T angle was a predictor of reverse hypertension in newly diagnosed hypertensive patients without LVH.

Funding Acknowledgement

Type of funding sources: None.

Lessons learnt conducting minimally invasive autopsies in private mortuaries as part of HIV and tuberculosis research in South Africa

Current estimates of the burden of tuberculosis (TB) disease and cause-specific mortality in human immunodeficiency virus (HIV) positive people rely heavily on indirect methods that are less reliable for ascertaining individual-level causes of death and on mathematical models. Minimally invasive autopsy (MIA) is useful for diagnosing infectious diseases, provides a reasonable proxy for the gold standard in cause of death ascertainment (complete diagnostic autopsy) and, used routinely, could improve cause-specific mortality estimates. From our experience in performing MIAs in HIV-positive adults in private mortuaries in South Africa (during the Lesedi Kamoso Study), we describe the challenges we faced and make recommendations for the conduct of MIA in future studies or surveillance programmes, including strategies for effective communication, approaches to obtaining informed consent, risk management for staff and efficient preparation for the procedure.

Undiagnosed TB in adults dying at home from natural causes in a high TB burden setting: a post-mortem study

BACKGROUND

A high proportion of deaths in Africa occur at home, where cause of death (CoD) is often unknown. We ascertained undiagnosed pulmonary tuberculosis (TB) by performing limited autopsies in adults dying at home in whom there was no apparent CoD.

METHODS

Mortuaries in Matlosana, South Africa, identified potentially eligible adults with no ante-mortem diagnosis and/or no recent hospital admission. A questionnaire was administered to family members. Bilateral lung core biopsies and modified bronchoalveolar lavage (BAL) were performed. The biopsies were examined histologically and submitted with BAL aspirates for mycobacterial culture (MGIT(TM)) and Xpert(®) MTB/RIF testing. Human immunodeficiency virus (HIV) testing was not performed.

RESULTS

Of 162 families approached, 28 refused and 29 of the deceased were on or had recently stopped anti-tuberculosis treatment; 85 were included. All were Black and 53% were men. The median age was 57 years (interquartile range [IQR] 44-66) and median symptom duration (mainly cough) was 63 days (IQR 14-112). Laboratory evidence of TB was found in 27 (31.8%); 21 were Xpert-positive, 23 were MGIT-positive and 14 had histological evidence consistent with active TB.

CONCLUSION

In this high HIV prevalence setting, a quarter of the home deaths had evidence of undiagnosed, likely infectious TB, suggesting that TB-related mortality is under-ascertained and under-reported, with serious implications for TB control in high TB burden settings.

Diagnostic accuracy and effectiveness of the Xpert MTB/RIF assay for the diagnosis of HIV-associated lymph node tuberculosis

Xpert MTB/RIF (Xpert) is recommended for human immunodeficiency virus (HIV)-associated pulmonary tuberculosis but not extrapulmonary tuberculosis. We assessed the performance of Xpert for HIV-associated lymph node tuberculosis (LNTB), the most common type of extrapulmonary tuberculosis. Among HIV-infected adults suspected of LNTB presenting for fine needle aspirate (FNA) at a South African hospital, we assessed the diagnostic accuracy of Xpert using either FNA culture or a composite of microscopy, culture, and cytology as the reference standard, and evaluated the impact of different diagnostics on patient management. Among 344 adults with valid FNA culture and Xpert results, 84 (24 %) were positive on microscopy, 149 (43 %) on culture, 152 (53 %) on Xpert, and 181 (57 %) had a cytology result suggestive of tuberculosis. Using liquid culture as the reference standard, the specificity of a single Xpert was suboptimal (88.2 %) but the sensitivity was high [93.3 %, 95 % confidence interval (CI) 87.6-96.6] and increased with decreasing CD4 count (from 87.0 % for CD4 >250 to 98.6 % for CD4 <100 cells/mm(3)). Using a composite reference standard reduced the sensitivity to 79.2 % but increased the specificity to 98.6 %. All Xpert-positive patients initiated treatment within one day, compared to 70 % of culture-positive but Xpert-negative and 13 % of culture- and Xpert-negative but cytology-positive patients. Xpert is accurate and effective and could be endorsed as the initial diagnostic for HIV-associated LNTB.

The utility of bone-marrow examination in HIV-infected adults in South Africa

We retrospectively reviewed a consecutive case series of 257 adults with HIV infection who had undergone a bone-marrow examination with trephine bone biopsy, to assess the diagnostic usefulness of bone-marrow examination and evaluate possible predictors of a diagnostic examination. Bone-marrow examination was positive in 97 (38%) patients and gave a unique diagnosis in 61 (24%). The diseases were tuberculosis (83 patients), Mycobacterium avium complex infection and cryptococcosis (four patients each), and haematological malignancies (eight patients). The yield of the examination was significantly increased, by univariate analysis, in patients with wasting, oral thrush, leukopenia, CD4< or =100/mm3, and granuloma formation on histopathology. Granulomata were present in 113 (44%) patients, of whom 28 (25%) had no specific cause identified. Granulomata occurred in 22 (25%) of 89 patients with CD4 >100/mm3 compared to 36 (51%) of 70 patients with CD4< or =100/mm3 (OR 0.3; 95%CI 0.15-0.62). Of 48 patients with CD4 <50/mm3, 25 had granulomata, including 15 with caseation necrosis. The yield of bone-marrow examination was considerable in our setting. Expanding access to modern blood culture techniques for mycobacteria to primary care level could limit the number of bone-marrow examinations required.

Bone marrow cryptococcal infection in the acquired immunodeficiency syndrome

OBJECTIVES

To describe the bone marrow lesions in eight cases of Cryptococcus neoformans infection involving the bone marrow in HIV-infected patients.

METHODS

Archival bone marrow biopsies from patients with HIV-related cryptococcosis of the bone marrow were retrospectively reviewed. Cryptocococcal organisms were identified on haematoxylin- and eosin-stained slides and confirmed using mucicarmine staining.

RESULTS

Yeast cells stimulated a granulomatous response in all cases despite immunosuppression. The number of cryptococcal organisms appeared to be inversely proportional to the adequacy of the granulomatous response. All patients had a cytopenia.

CONCLUSIONS

The ability to mount a tissue response in order to localize organisms is retained in patients with AIDS. Infection of the bone marrow with cryptococci may act in synergy with HIV to cause cytopenia.

Quality of care of children with chronic diseases in Alexandria, Egypt: the models of asthma, type I diabetes, epilepsy, and rheumatic heart disease. Egyptian-Italian Collaborative Group on Pediatric Chronic Diseases

OBJECTIVES

To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children.

DESIGN

Over a 9-month period, guidelines for optimal care were formulated. A specific questionnaire for every studied chronic disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and 34% adult specialists). The clinicians were asked to write the details of daily practice, ie, how these children were managed on a routine basis as well as in an emergency situation. A cross-sectional study was conducted over a 4-month period and included 953 children suffering from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random sample of children was selected from children visiting the ambulatory settings of all children's hospitals. Every fourth child was selected on 2 randomly chosen days each week, while all diseased children admitted in the hospital settings of the children's hospitals during the study were included. A general form describing the impact of the diseases on the child was prepared. A network of clinicians was created in all children's hospitals; seminars were held during which the content validity of the questionnaire was tested. Items were evaluated for their internal consistency using the Cronbach alpha. According to the degree of adherence to the recent therapeutic guidelines concerning selected indicators of the quality of care specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of inhaled bronchodilators in acute asthmatic attacks in mild asthma and the use of the prophylactic drugs (inhaled sodium cromoglycate or inhaled beclomethasone) in moderate to severe chronic BA in between acute asthmatic attacks; compliance with antiepileptic drugs in epileptic children; regular performance of self-monitoring of blood glucose and/or urine testing in diabetic children; and compliance with prophylactic antibiotics in children suffering from RHD. The records of the outpatient clinics for ambulatory and hospitalized cases were reviewed to assess the degree of compliance with the prescribed management before the index visit. Sociodemographic characteristics and health care system-related predictors of SQC were analyzed via stepwise logistic regression analysis. The impact of illness on the child was assessed by 7 items which were: dependence on parents in domestic activities, level of activity compared with peers, mood compared with peers, level of socializing, degree of discomfort attributable to illness, level of physical disadvantage, and urinary incontinence. Factor analysis with Varimax rotation was performed on items related to the impact of illness. Parental satisfaction with care was rated as excellent, very good, fair, or poor. Information on school outcome was obtained by asking the caretakers whether the child was able to attend school regularly despite his sickness. Scholastic achievement was also rated as excellent, very good, good, and acceptable. Parents were asked whether the child had ever repeated a grade because of his sickness.

SETTING

Ambulatory and hospital settings of all children's hospitals in Alexandria, Egypt.

RESULTS

Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two

Botryomycosis of the liver

A case of visceral botryomycosis of the liver in a 50-year-old man is reported. The clinical diagnosis was hepatocellular carcinoma. Pathological examination of the surgically resected specimen demonstrated microabscesses containing gram- positive microorganisms with surrounding fibrosis replacing liver parenchyma. An immune deficiency state was not demonstrated. Recognition of this condition is important because of its clinical confusion with malignancy and its histological similarity to actinomycosis, nocardia, and eumycotic infections.