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Sabet N, Omar T, Milovanovic M, Magajane T, Mosala M, Moloantoa T, Kato-Kalule N, Semedo LV, Swanepoel F, Wallis C, Abraham P, Lebina L, Variava E, Martinson N. Undiagnosed Pulmonary Tuberculosis (TB) and Coronavirus Disease 2019 (COVID-19) in Adults Dying at Home in a High-TB-Burden Setting, Before and During Pandemic COVID-19: An Autopsy Study. Clin Infect Dis 2023; 77:453-459. [PMID: 37041678 DOI: 10.1093/cid/ciad212] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Missing or undiagnosed patients with tuberculosis (TB) or coronavirus disease 2019 (COVID-19) are of concern. Identifying both infections in patients with no diagnosis prior to death contributes to understanding the burden of disease. To confirm reports of global reduction in TB incidence, a 2012 autopsy study of adults dying at home of natural causes in a high-TB-burden setting was repeated, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) assessments after the first COVID-19 surge in South Africa. METHODS Adult decedents who died at home with insufficient information to determine cause of death, no recent hospitalization, and no current antemortem TB or COVID-19 diagnosis were identified between March 2019 and October 2020 with a 4-month halt during lockdown. A standardized verbal autopsy followed by minimally invasive needle autopsy (MIA) was performed. Biopsies were taken for histopathology from liver, bilateral brain and lung; bronchoalveolar lavage fluid was collected for Xpert (MTB/RIF) and mycobacterial culture, and blood for human immunodeficiency virus (HIV) polymerase chain reaction (PCR) testing. After the start of the COVID-19 pandemic, a nasopharyngeal swab and lung tissue were subjected to SARS-CoV-2 PCR testing. RESULTS Sixty-six MIAs were completed in 25 men and 41 women (median age, 60 years); 68.2% had antemortem respiratory symptoms and 30.3% were people with HIV. Overall, TB was diagnosed in 11 of 66 (16.7%) decedents, and 14 of 41 (34.1%) in the COVID-19 pandemic were SARS-CoV-2 positive. CONCLUSIONS Undiagnosed TB in adults dying at home has decreased but remains unacceptably high. Forty percent of decedents had undiagnosed COVID-19, suggesting that estimates of excess deaths may underestimate the impact of SARS-CoV-2 on mortality.
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Affiliation(s)
- Nadia Sabet
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Minja Milovanovic
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Tebogo Magajane
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Modiehi Mosala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Tumelo Moloantoa
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Nalukenge Kato-Kalule
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Lenise Varela Semedo
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Floris Swanepoel
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Carole Wallis
- Bio Analytical Research Corporation, Johannesburg, South Africa
| | - Pattamukkil Abraham
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Limakatso Lebina
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
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Karakayali M, Artac I, Omar T, Rencuzogullari I, Karabag Y, Hamideyin S. The importance of frontal QRS-T angle for predicting reverse dipper status in newly diagnosed hypertensive patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
| | - I Artac
- Kafkas University, Cardiology , Kars , Turkey
| | - T Omar
- Kafkas University, Cardiology , Kars , Turkey
| | | | - Y Karabag
- Kafkas University, Cardiology , Kars , Turkey
| | - S Hamideyin
- Kafkas University, Cardiology , Kars , Turkey
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Vogt SL, Maloma L, Xian RR, Ambinder RF, Philip V, Patel M, Martinson NA, Omar T. Significance of lymph node fine needle aspiration for the diagnosis of HIV-associated lymphoma in a low-resource setting. AIDS 2022; 36:1393-1398. [PMID: 35466960 PMCID: PMC9329253 DOI: 10.1097/qad.0000000000003261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Fine needle aspiration (FNA) is an early step in the work-up of lymphadenopathy in people with HIV (PWH). We set out to characterize the FNA cytology in PWH and report on the time to lymphoma diagnosis through the FNA clinics in the public healthcare system in Johannesburg, South Africa. DESIGN Retrospective review of laboratory database. METHODS A retrospective chart review of patients undergoing FNA through the department of cytopathology at the National Health Laboratory Service (NHLS) was undertaken. Results of FNAs performed between March and May 2018 were reviewed. Medical record chart abstraction included general demographics, HIV status, site and results of FNA, prior history of malignancy and other laboratory data. RESULTS Five hundred and thirty-nine lymph node FNAs were performed on PWH. Pathological findings included tuberculosis 47% (252), inadequate sampling 14% (75), reactive adenopathy 13% (71), benign disease 12% (63), suspicious for lymphoproliferative neoplasm 8% (45), other malignancy 4% (21) and inflammation 2% ( n = 12). Only 53% (24) of lymphomas were confirmed by biopsy. Those not confirmed had a high mortality (57%) and loss to follow-up rate (29%) over the following year. The median diagnostic interval exceeded 8 weeks from time of FNA to lymphoma diagnosis. CONCLUSION FNA is an important screening modality in this high HIV and tuberculosis (TB) burden region. Patients with cytology suggestive for lymphoma, but without biopsy confirmation, have a high mortality rate suggesting undiagnosed lymphoma. A better understanding of the barriers to appropriate diagnostic triage for lymphoma is needed.
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Affiliation(s)
- Samantha L Vogt
- Department of Medicine
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Lucia Maloma
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Rena R Xian
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Richard F Ambinder
- Department of Medicine
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vinitha Philip
- Clinical Haematology Unit, Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences
| | - Moosa Patel
- Clinical Haematology Unit, Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences
| | - Neil A Martinson
- Department of Medicine
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Division of Anatomical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Vogt SL, Patel M, Lakha A, Philip V, Omar T, Ashmore P, Pather S, Haley LM, Zheng G, Stone J, Mayne E, Stevens W, Wagner-Johnston N, Gocke CD, Martinson NA, Ambinder RF, Xian RR. Feasibility of Cell-Free DNA Collection and Clonal Immunoglobulin Sequencing in South African Patients With HIV-Associated Lymphoma. JCO Glob Oncol 2021; 7:611-621. [PMID: 33909482 PMCID: PMC8162966 DOI: 10.1200/go.20.00651] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Diagnosis of AIDS lymphoma in low-resource settings, like South Africa, is often delayed, leaving patients with limited treatment options. In tuberculosis (TB) endemic regions, overlapping signs and symptoms often lead to diagnostic delays. Assessment of plasma cell-free DNA (cfDNA) by next-generation sequencing (NGS) may expedite the diagnosis of lymphoma but requires high-quality cfDNA. METHODS People living with HIV with newly diagnosed aggressive B-cell lymphoma and those with newly diagnosed TB seeking care at Chris Hani Baragwanath Academic Hospital and its surrounding clinics, in Soweto, South Africa, were enrolled in this study. Each participant provided a whole blood specimen collected in cell-stabilizing tubes. Quantity and quality of plasma cfDNA were assessed. NGS of the immunoglobulin heavy chain was performed. RESULTS Nine HIV+ patients with untreated lymphoma and eight HIV+ patients with TB, but without lymphoma, were enrolled. All cfDNA quantity and quality metrics were similar between the two groups, except that cfDNA accounted for a larger fraction of recovered plasma DNA in patients with lymphoma. The concentration of cfDNA in plasma also trended higher in patients with lymphoma. NGS of immunoglobulin heavy chain showed robust amplification of DNA, with large amplicons (> 250 bp) being more readily detected in patients with lymphoma. Clonal sequences were detected in five of nine patients with lymphoma, and none of the patients with TB. CONCLUSION This proof-of-principle study demonstrates that whole blood collected for cfDNA in a low-resource setting is suitable for sophisticated sequencing analyses, including clonal immunoglobulin NGS. The detection of clonal sequences in more than half of patients with lymphoma shows promise as a diagnostic marker that may be explored in future studies.
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Affiliation(s)
- Samantha L Vogt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Moosa Patel
- Clinical Haematology Unit, Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Atul Lakha
- Clinical Haematology Unit, Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vinitha Philip
- Clinical Haematology Unit, Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Division of Anatomical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Philippa Ashmore
- Clinical Haematology, Netcare Olivedale Hospital, Johannesburg, South Africa
| | - Sugeshnee Pather
- Division of Anatomical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa M Haley
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Gang Zheng
- Department of Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer Stone
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Mayne
- Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- Department of Immunology, Faculty of Health Sciences, University of Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Nina Wagner-Johnston
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Christopher D Gocke
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Neil A Martinson
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.,Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Richard F Ambinder
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rena R Xian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
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Kennedy DA, Mujčin M, Omar T, Tezel FH. Synthesis and preliminary gas permeation properties of vitreous composite clinoptilolite membranes. CHEM ENG COMMUN 2021. [DOI: 10.1080/00986445.2021.1903448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- D. A. Kennedy
- Department of Chemical and Biological Engineering, University of Ottawa, Ottawa, ON, Canada
| | - M. Mujčin
- Department of Chemical and Biological Engineering, University of Ottawa, Ottawa, ON, Canada
| | - T. Omar
- Department of Chemical and Biological Engineering, University of Ottawa, Ottawa, ON, Canada
| | - F. H. Tezel
- Department of Chemical and Biological Engineering, University of Ottawa, Ottawa, ON, Canada
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6
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Kelly HA, Chikandiwa A, Sawadogo B, Gilham C, Michelow P, Lompo OG, Omar T, Zan S, Magooa P, Segondy M, Nagot N, Meda N, Delany-Moretlwe S, Mayaud P. Diagnostic accuracy of cervical cancer screening and screening-triage strategies among women living with HIV-1 in Burkina Faso and South Africa: A cohort study. PLoS Med 2021; 18:e1003528. [PMID: 33661957 PMCID: PMC7971880 DOI: 10.1371/journal.pmed.1003528] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 03/18/2021] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cervical cancer screening strategies using visual inspection or cytology may have suboptimal diagnostic accuracy for detection of precancer in women living with HIV (WLHIV). The optimal screen and screen-triage strategy, age to initiate, and frequency of screening for WLHIV remain unclear. This study evaluated the sensitivity, specificity, and positive predictive value of different cervical cancer strategies in WLHIV in Africa. METHODS AND FINDINGS WLHIV aged 25-50 years attending HIV treatment centres in Burkina Faso (BF) and South Africa (SA) from 5 December 2011 to 30 October 2012 were enrolled in a prospective evaluation study of visual inspection using acetic acid (VIA) or visual inspection using Lugol's iodine (VILI), high-risk human papillomavirus DNA test (Hybrid Capture 2 [HC2] or careHPV), and cytology for histology-verified high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) at baseline and endline, a median 16 months later. Among 1,238 women (BF: 615; SA: 623), median age was 36 and 34 years (p < 0.001), 28.6% and 49.6% ever had prior cervical cancer screening (p < 0.001), and 69.9% and 64.2% were taking ART at enrolment (p = 0.045) in BF and SA, respectively. CIN2+ prevalence was 5.8% and 22.4% in BF and SA (p < 0.001), respectively. VIA had low sensitivity for CIN2+ (44.7%, 95% confidence interval [CI] 36.9%-52.7%) and CIN3+ (56.1%, 95% CI 43.3%-68.3%) in both countries, with specificity for ≤CIN1 of 78.7% (95% CI 76.0%-81.3%). HC2 had sensitivity of 88.8% (95% CI 82.9%-93.2%) for CIN2+ and 86.4% (95% CI 75.7%-93.6%) for CIN3+. Specificity for ≤CIN1 was 55.4% (95% CI 52.2%-58.6%), and screen positivity was 51.3%. Specificity was higher with a restricted genotype (HPV16/18/31/33/35/45/52/58) approach (73.5%, 95% CI 70.6%-76.2%), with lower screen positivity (33.7%), although there was lower sensitivity for CIN3+ (77.3%, 95% CI 65.3%-86.7%). In BF, HC2 was more sensitive for CIN2+/CIN3+ compared to VIA/VILI (relative sensitivity for CIN2+ = 1.72, 95% CI 1.28-2.32; CIN3+: 1.18, 95% CI 0.94-1.49). Triage of HC2-positive women with VIA/VILI reduced the number of colposcopy referrals, but with loss in sensitivity for CIN2+ (58.1%) but not for CIN3+ (84.6%). In SA, cytology high-grade squamous intraepithelial lesion or greater (HSIL+) had best combination of sensitivity (CIN2+: 70.1%, 95% CI 61.3%-77.9%; CIN3+: 80.8%, 95% CI 67.5%-90.4%) and specificity (81.6%, 95% CI 77.6%-85.1%). HC2 had similar sensitivity for CIN3+ (83.0%, 95% CI 70.2%-91.9%) but lower specificity compared to HSIL+ (42.7%, 95% CI 38.4%-47.1%; relative specificity = 0.57, 95% CI 0.52-0.63), resulting in almost twice as many referrals. Compared to HC2, triage of HC2-positive women with HSIL+ resulted in a 40% reduction in colposcopy referrals but was associated with some loss in sensitivity. CIN2+ incidence over a median 16 months was highest among VIA baseline screen-negative women (2.2%, 95% CI 1.3%-3.7%) and women who were baseline double-negative with HC2 and VIA (2.1%, 95% CI 1.3%-3.5%) and lowest among HC2 baseline screen-negative women (0.5%, 95% CI 0.1%-1.8%). Limitations of our study are that WLHIV included in the study may not reflect a contemporary cohort of WLHIV initiating ART in the universal ART era and that we did not evaluate HPV tests available in study settings today. CONCLUSIONS In this cohort study among WLHIV in Africa, a human papillomavirus (HPV) test targeting 14 high-risk (HR) types had higher sensitivity to detect CIN2+ compared to visual inspection but had low specificity, although a restricted genotype approach targeting 8 HR types decreased the number of unnecessary colposcopy referrals. Cytology HSIL+ had optimal performance for CIN2+/CIN3+ detection in SA. Triage of HPV-positive women with HSIL+ maintained high specificity but with some loss in sensitivity compared to HC2 alone.
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Affiliation(s)
- Helen A. Kelly
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernard Sawadogo
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Clare Gilham
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pamela Michelow
- Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Olga Goumbri Lompo
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Tanvier Omar
- Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Souleymane Zan
- Department of Gynaecology, Centre Hospitalier Universitaire Yalgado, Ouagadougou, Burkina Faso
| | - Precious Magooa
- Sexually Transmitted Infections Reference Centre, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | | | - Nicolas Nagot
- UMR1058, Montpellier University, Montpellier, France
| | - Nicolas Meda
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Philippe Mayaud
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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7
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Wake RM, Govender NP, Omar T, Nel C, Mazanderani AH, Karat AS, Ismail NA, Tiemessen CT, Jarvis JN, Harrison TS. Cryptococcal-related Mortality Despite Fluconazole Preemptive Treatment in a Cryptococcal Antigen Screen-and-Treat Program. Clin Infect Dis 2020; 70:1683-1690. [PMID: 31179488 PMCID: PMC7346756 DOI: 10.1093/cid/ciz485] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 01/22/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cryptococcal antigen (CrAg) screening and treatment with preemptive fluconazole reduces the incidence of clinically evident cryptococcal meningitis in individuals living with advanced human immunodeficiency virus (HIV) disease. However, mortality remains higher in CrAg-positive than in CrAg-negative patients with similar CD4+ T-lymphocyte counts. METHODS We conducted a cohort study to investigate causes of morbidity and mortality during 6 months of follow-up among asymptomatic CrAg-positive and CrAg-negative (ratio of 1:2) patients living with HIV with CD4 counts <100 cells/µL attending 2 hospitals in Johannesburg, South Africa. When possible, minimally invasive autopsy (MIA) was performed on participants who died. RESULTS Sixty-seven CrAg-positive and 134 CrAg-negative patients were enrolled. Death occurred in 17/67 (25%) CrAg-positive and 12/134 (9%) CrAg-negative participants (hazard ratio for death, adjusted for CD4 count, 3.0; 95% confidence interval, 1.4-6.7; P = .006). Cryptococcal disease was an immediate or contributing cause of death in 12/17 (71%) CrAg-positive participants. Postmortem cryptococcal meningitis and pulmonary cryptococcosis were identified at MIA in all 4 CrAg-positive participants, 3 of whom had negative cerebrospinal fluid CrAg tests from lumbar punctures (LPs) at the time of CrAg screening. CONCLUSIONS Cryptococcal disease was an important cause of mortality among asymptomatic CrAg-positive participants despite LPs to identify and treat those with subclinical cryptococcal meningitis and preemptive fluconazole for those without meningitis. Thorough investigation for cryptococcal disease with LPs and blood cultures, prompt ART initiation, and more intensive antifungals may reduce mortality among asymptomatic CrAg-positive patients identified through screening.
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Affiliation(s)
- Rachel M Wake
- Centre for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- Institute of Infection & Immunity, St George’s University of London, United Kingdom
| | - Nelesh P Govender
- Centre for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, University of the Witwatersrand, South Africa
- Department of Pathology, National Health Laboratory Services, South Africa
| | - Carolina Nel
- Department of Anatomical Pathology, University of the Witwatersrand, South Africa
- Department of Pathology, National Health Laboratory Services, South Africa
| | - Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Medical Virology, University of Pretoria, South Africa
| | - Aaron S Karat
- Tuberculosis Centre, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Nazir A Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Caroline T Tiemessen
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
- Botswana-UPenn Partnership, Gaborone
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas S Harrison
- Institute of Infection & Immunity, St George’s University of London, United Kingdom
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8
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Karat AS, Omar T, Tlali M, Charalambous S, Chihota VN, Churchyard GJ, Fielding KL, Martinson NA, McCarthy KM, Grant AD. Lessons learnt conducting minimally invasive autopsies in private mortuaries as part of HIV and tuberculosis research in South Africa. Public Health Action 2019; 9:186-190. [PMID: 32042614 DOI: 10.5588/pha.19.0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 05/17/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- A S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - T Omar
- Division of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - M Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - V N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, and South African Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa.,Johns Hopkins University Center for TB Research, Baltimore, MD, USA.,Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - K M McCarthy
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Milovanovic M, Ringane A, Maphakula D, Makete F, Nkuta M, Omar T, Martinson N, Lebina L. Brief report: Challenges of conducting research within the funeral services sector in South Africa. Death Stud 2019; 44:379-383. [PMID: 30663945 DOI: 10.1080/07481187.2018.1561555] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Funeral services sector personnel are at risk of contracting infectious diseases and have poor adherence to universal safety precautions. More work needs to be done to understand this industry; however, there is limited information on conducting research within this sector. This manuscript draws on experiences and observations of funeral services study describing lessons learned in the field, particularly emphasizing attempts to engage funeral homes in research and the impact of this work on the research team. Factors to be considered before researching in this sector: obtaining approvals, identification as researchers, and in-house emotional support for the research team.
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Affiliation(s)
- Minja Milovanovic
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley Ringane
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daphney Maphakula
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Floyd Makete
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbali Nkuta
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University, Baltimore, MD, USA
| | - Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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10
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Wake RM, Britz E, Sriruttan C, Rukasha I, Omar T, Spencer DC, Nel JS, Mashamaite S, Adelekan A, Chiller TM, Jarvis JN, Harrison TS, Govender NP. High Cryptococcal Antigen Titers in Blood Are Predictive of Subclinical Cryptococcal Meningitis Among Human Immunodeficiency Virus-Infected Patients. Clin Infect Dis 2018; 66:686-692. [PMID: 29028998 PMCID: PMC6220350 DOI: 10.1093/cid/cix872] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [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: 06/28/2017] [Accepted: 10/03/2017] [Indexed: 01/30/2023] Open
Abstract
Background High mortality rates among asymptomatic cryptococcal antigen (CrAg)-positive patients identified through CrAg screening, despite preemptive fluconazole treatment, may be due to undiagnosed cryptococcal meningitis. Methods Symptoms were reviewed in CrAg-positive patients identified by screening 19233 individuals with human immunodeficiency virus infection and CD4 cell counts <100/µL at 17 clinics and 3 hospitals in Johannesburg from September 2012 until September 2015, and at 2 hospitals until June 2016. Cerebrospinal fluid samples from 90 of 254 asymptomatic patients (35%) and 78 of 173 (45%) with headache only were analyzed for cryptococcal meningitis, considered present if Cryptococcus was identified by means of India ink microscopy, culture, or CrAg test. CrAg titers were determined with stored blood samples from 62 of these patients. The associations between blood CrAg titer, concurrent cryptococcal meningitis, and mortality rate were assessed. Results Cryptococcal meningitis was confirmed in 34% (95% confidence interval, 25%-43%; 31 of 90) of asymptomatic CrAg-positive patients and 90% (81%-96%; 70 of 78) with headache only. Blood CrAg titer was significantly associated with concurrent cryptococcal meningitis in asymptomatic patients (P < .001) and patients with headache only (P = .003). The optimal titer for predicting cryptococcal meningitis was >160 (sensitivity, 88.2%; specificity, 82.1%); the odds ratio for concurrent cryptococcal meningitis was 34.5 (95% confidence interval, 8.3-143.1; P < .001). Conclusions About a third of asymptomatic CrAg-positive patients have concurrent cryptococcal meningitis. More effective clinical assessment strategies and antifungal regimens are required for CrAg-positive patients, including investigation for cryptococcal meningitis irrespective of symptoms. Where it is not possible to perform lumbar punctures in all CrAg-positive patients, blood CrAg titers should be used to target those most at risk of cryptococcal meningitis.
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Affiliation(s)
- Rachel M Wake
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- Institute for Infection and Immunity, St George’s University of London
| | - Erika Britz
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Charlotte Sriruttan
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
| | - Ivy Rukasha
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Tanvier Omar
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
| | - David C Spencer
- Helen Joseph Hospital, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | - Jeremy S Nel
- Helen Joseph Hospital, Johannesburg, South Africa
| | | | | | - Tom M Chiller
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George’s University of London
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, South Africa
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11
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Segondy M, Ngou J, Kelly H, Omar T, Goumbri-Lompo O, Doutre S, Mayaud P, Didelot MN. Diagnostic value of human papillomavirus (HPV) 16 and HPV18 viral loads for the detection of high-grade cervical intraepithelial neoplasia (CIN2+) in a cohort of African women living with HIV. J Clin Virol 2018; 99-100:79-83. [PMID: 29353074 DOI: 10.1016/j.jcv.2018.01.006] [Citation(s) in RCA: 8] [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: 10/20/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND African women living with HIV (WLHIV) are at high risk of cervical cancer but rarely adequately screened. Better strategies enabling identification of WLHIV with high-grade cervical intraepithelial lesions (CIN2+) are required. OBJECTIVES To investigate the diagnostic value of HPV16 and HPV18 viral loads in a cohort of African WLHIV. DESIGN HPV16 and HPV18 viral loads were determined by quantitation of the E6 gene DNA by real-time PCR in cervical specimens collected at baseline and endline (16 months) from 245 African WLHIV positive for HPV16 or/and HPV18. Cervical biopsies were graded using the histopathological CIN classification. RESULTS Women with CIN2+ had higher viral load for HPV16 (p < 0.0001) or HPV18 (p = 0.03) than those without CIN2+. HPV16 viral load ≥3.59 log copies/1000 cells detected CIN2+ with sensitivity and specificity of 93.5% (95%CI: 81.7-98.3%) and 74.1% (95%CI: 66.3-80.6%), respectively, whereas HPV18 viral load ≥1.63 log copies/1000 cells detected CIN2+ with sensitivity and specificity of 59.1% (95%CI: 38.7-76.7%) and 66.9% (95%CI: 58.8-74.1%), respectively. A high baseline HPV16 viral load was significantly associated with persistence of, or progression to CIN2+ at endline; these findings were not observed for HPV18. CONCLUSIONS HPV16 viral load is a powerful marker of CIN2+ in African WLHIV. HPV18 viral load is of lower diagnostic value in this population.
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Affiliation(s)
- Michel Segondy
- INSERM, EFS, University of Montpellier, Montpellier, France; Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France.
| | - Jean Ngou
- INSERM, EFS, University of Montpellier, Montpellier, France
| | - Helen Kelly
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanvier Omar
- Department of Pathology, National Health Laboratory Services, Johannesburg, South Africa
| | - Olga Goumbri-Lompo
- Department of Pathology, University Teaching Hospital Yalgado, Ouagadougou, Burkina Faso
| | - Sylviane Doutre
- Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Marie-Noelle Didelot
- INSERM, EFS, University of Montpellier, Montpellier, France; Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France
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12
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Vogt SL, Patel M, Omar T, Pather S, Martinson N, Ambinder R. Molecular Diagnostics for AIDS Lymphoma Diagnosis in South Africa and the Potential for Other Low- and Middle-Income Countries. J Glob Oncol 2017; 4:1-6. [PMID: 30241211 PMCID: PMC6180762 DOI: 10.1200/jgo.17.00043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Samantha L Vogt
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
| | - Moosa Patel
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
| | - Tanvier Omar
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
| | - Sugeshnee Pather
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
| | - Neil Martinson
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
| | - Richard Ambinder
- Samantha L. Vogt and Richard Ambinder, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Moosa Patel, Tanvier Omar, and Sugeshnee Pather, University of the Witwatersrand, Johannesburg; and Neil Martinson, Perinatal HIV Research Unit, Soweto, South Africa
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13
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Smith JS, Sanusi B, Swarts A, Faesen M, Levin S, Goeieman B, Ramotshela S, Rakhombe N, Williamson AL, Michelow P, Omar T, Hudgens MG, Firnhaber C. A randomized clinical trial comparing cervical dysplasia treatment with cryotherapy vs loop electrosurgical excision procedure in HIV-seropositive women from Johannesburg, South Africa. Am J Obstet Gynecol 2017; 217:183.e1-183.e11. [PMID: 28366730 DOI: 10.1016/j.ajog.2017.03.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/19/2017] [Accepted: 03/23/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mortality associated with cervical cancer is a public health concern for women, particularly in HIV-seropositive women in resource-limited countries. HIV-seropositive women are at a higher risk of high-grade cervical precancer, which can eventually progress to invasive carcinoma as compared to HIV-seronegative women. It is imperative to identify effective treatment methods for high-grade cervical precursors among HIV-seropositive women. OBJECTIVE Randomized controlled trial data are needed comparing cryotherapy vs loop electrosurgical excision procedure treatment efficacy in HIV-seropositive women. Our primary aim was to compare the difference in the efficacy of loop electrosurgical excision procedure vs cryotherapy for the treatment of high-grade cervical intraepithelial neoplasia (grade ≥2) among HIV-seropositive women by conducting a randomized clinical trial. STUDY DESIGN HIV-seropositive women (n = 166) aged 18-65 years with histology-proven cervical intraepithelial neoplasia grade ≥2 were randomized (1:1) to cryotherapy or loop electrosurgical excision procedure treatment at a government hospital in Johannesburg. Treatment efficacy was compared using 6- and 12-month cumulative incidence posttreatment of: (1) cervical intraepithelial neoplasia grade ≥2; (2) secondary endpoints of histologic cervical intraepithelial neoplasia grade ≥3 and grade ≥1; and (3) high-grade and low-grade cervical cytology. The study was registered (ClinicalTrials.govNCT01723956). RESULTS From January 2010 through August 2014, 166 participants were randomized (86 loop electrosurgical excision procedure; 80 cryotherapy). Cumulative cervical intraepithelial neoplasia grade ≥2 incidence was higher for cryotherapy (24.3%; 95% confidence interval, 16.1-35.8) than loop electrosurgical excision procedure at 6 months (10.8%; 95% confidence interval, 5.7-19.8) (P = .02), although by 12 months, the difference was not significant (27.2%; 95% confidence interval, 18.5-38.9 vs 18.5%; 95% confidence interval, 11.6-28.8, P = .21). Cumulative cervical intraepithelial neoplasia grade ≥1 incidence for cryotherapy (89.2%; 95% confidence interval, 80.9-94.9) did not differ from loop electrosurgical excision procedure (78.3%; 95% confidence interval, 68.9-86.4) at 6 months (P = .06); cumulative cervical intraepithelial neoplasia grade ≥1 incidence by 12 months was higher for cryotherapy (98.5%; 95% confidence interval, 92.7-99.8) than loop electrosurgical excision procedure (89.8%; 95% confidence interval, 82.1-95.2) (P = .02). Cumulative high-grade cytology incidence was higher for cryotherapy (41.9%) than loop electrosurgical excision procedure at 6 months (18.1%, P < .01) and 12 months (44.8% vs 19.4%, P < .001). Cumulative incidence of low-grade cytology or greater in cryotherapy (90.5%) did not differ from loop electrosurgical excision procedure at 6 months (80.7%, P = .08); by 12 months, cumulative incidence of low-grade cytology or greater was higher in cryotherapy (100%) than loop electrosurgical excision procedure (94.8%, P = .03). No serious adverse effects were recorded. CONCLUSION Although rates of cumulative cervical intraepithelial neoplasia grade ≥2 were lower after loop electrosurgical excision procedure than cryotherapy treatment at 6 months, both treatments appeared effective in reducing cervical intraepithelial neoplasia grade ≥2 by >70% by 12 months. The difference in cumulative cervical intraepithelial neoplasia grade ≥2 incidence between the 2 treatment methods by 12 months was not statistically significant. Relatively high cervical intraepithelial neoplasia grade ≥2 recurrence rates, indicating treatment failure, were observed in both treatment arms by 12 months. A different treatment protocol should be considered to optimally treat cervical intraepithelial neoplasia grade ≥2 in HIV-seropositive women.
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Doutre S, Omar T, Goumbri-Lompo O, Kelly H, Clavero O, Zan S, Chikandiwa A, Sawadogo B, Delany-Moretlwe S, Costes V, Mayaud P, Segondy M. Cervical intraepithelial neoplasia (CIN) in African women living with HIV: role and effect of rigorous histopathological review by a panel of pathologists in the HARP study endpoint determination. J Clin Pathol 2017; 71:40-45. [PMID: 28600294 DOI: 10.1136/jclinpath-2017-204512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 04/12/2017] [Revised: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 11/04/2022]
Abstract
AIMS To analyse the effect of the expert end-point committee (EPC) review on histological endpoint classification of cervical intraepithelial neoplasia (CIN). METHODS A cohort of women living with HIV were recruited in Burkina Faso (BF) and South Africa (SA) and followed over 18 months. Four-quadrant cervical biopsies were obtained in women with abnormalities detected by at least one screening test. A central review by a panel of five pathologists was organised at baseline and at endline. RESULTS At baseline the prevalence of high-grade CIN (CIN2+) was 5.1% (28/554) in BF and 23.3% (134/574) in SA by local diagnosis, and 5.8% (32/554) in BF and 22.5% (129/574) in SA by the EPC. At endline the prevalence of CIN2+ was 2.3% (11/483) in BF and 9.4% (47/501) in SA by local diagnosis, and 1.4% (7/483) in BF and 10.2% (51/501) in SA by EPC. The prevalence of borderline CIN1/2 cases was 2.8% (32/1128) and 0.8% (8/984) at baseline and endline. Overall agreement between local diagnosis and final diagnosis for distinguishing CIN2+ from ≤CIN1 was 91.2% (κ=0.82) and 88.9% (κ=0.71) for BF at baseline and endline, and 92.7% (κ=0.79) and 98.7% (κ=0.97) for SA at baseline and endline. Among the CIN1/2 cases, 12 (37.5%) were graded up to CIN2 and 20 (62.5%) were graded down to CIN1 at baseline, and 3 (37.5%) were graded up to CIN2 and 5 (62.5%) were graded down to CIN1 at endline. CONCLUSIONS This study highlights the importance of a centralised rigorous re-reading with exchange of experiences among pathologists from different settings.
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Affiliation(s)
- Sylviane Doutre
- Department of Biology and Pathology, University Hospital (CHU), Montpellier, France
| | - Tanvier Omar
- Department of Pathology, National Health Laboratory Services Johannesburg, South Africa
| | - Olga Goumbri-Lompo
- Department of Pathology, University Teaching Hospital Yalgado, Ouagadougou, Burkina Faso
| | - Helen Kelly
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Omar Clavero
- Department of Pathology, Catalan Institute of Oncology, Barcelona, Spain
| | - Souleymane Zan
- Department of Gynaecology, University Teaching Hospital Yalgado, Ouagadougou, Burkina Faso
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernard Sawadogo
- Centre de Recherches Internationales en Santé (CRIS), University of Ouagadougou, Burkina Faso
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Valérie Costes
- Department of Biology and Pathology, University Hospital (CHU), Montpellier, France.,Pathogenesis and Control of Chronic Infections, University of Montpellier, INSERM, EFS, Montpellier, France
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Michel Segondy
- Department of Biology and Pathology, University Hospital (CHU), Montpellier, France.,Pathogenesis and Control of Chronic Infections, University of Montpellier, INSERM, EFS, Montpellier, France
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15
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Kelly HA, Ngou J, Chikandiwa A, Sawadogo B, Gilham C, Omar T, Lompo O, Doutre S, Meda N, Weiss HA, Delany-Moretlwe S, Segondy M, Mayaud P. Associations of Human Papillomavirus (HPV) genotypes with high-grade cervical neoplasia (CIN2+) in a cohort of women living with HIV in Burkina Faso and South Africa. PLoS One 2017; 12:e0174117. [PMID: 28333966 PMCID: PMC5363860 DOI: 10.1371/journal.pone.0174117] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 06/28/2016] [Accepted: 03/04/2017] [Indexed: 12/29/2022] Open
Abstract
Objective To describe associations of high-risk human papillomavirus (HR-HPV) with high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA). Methods Prospective cohort of WLHIV attending HIV outpatient clinics and treatment centres. Recruitment was stratified by ART status. Cervical HPV genotyping using INNO-LiPA and histological assessment of 4-quadrant cervical biopsies at enrolment and 16 months later. Results Among women with CIN2+ at baseline, the prevalence of any HR-HPV genotypes included in the bi/quadrivalent (HPV16/18) or nonavalent (HPV16/18/31/35/45/52/58) HPV vaccines ranged from 37% to 90%. HPV58 was most strongly associated with CIN2+ (aOR = 5.40, 95%CI: 2.77–10.53). At 16-months follow-up, persistence of any HR-HPV was strongly associated with incident CIN2+ (aOR = 7.90, 95%CI: 3.11–20.07), as was persistence of HPV16/18 (aOR = 5.25, 95%CI: 2.14–12.91) and the additional HR types in the nonavalent vaccine (aOR = 3.23, 95%CI: 1.23–8.54). Conclusion HR-HPV persistence is very common among African WLHIV and is linked to incident CIN2+. HPV vaccines could prevent between 37–90% of CIN2+ among African WLHIV.
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Affiliation(s)
- Helen A Kelly
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jean Ngou
- INSERM U1058 and University Hospital (CHRU), Montpellier, France
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernard Sawadogo
- Centre de Recherches Internationales en Santé, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Clare Gilham
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tanvier Omar
- National Health Laboratory Services, Johannesburg, South Africa
| | - Olga Lompo
- Centre de Recherches Internationales en Santé, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Sylviane Doutre
- INSERM U1058 and University Hospital (CHRU), Montpellier, France
| | - Nicolas Meda
- Centre de Recherches Internationales en Santé, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Helen A Weiss
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Michel Segondy
- INSERM U1058 and University Hospital (CHRU), Montpellier, France
| | - Philippe Mayaud
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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Karat AS, Tlali M, Fielding KL, Charalambous S, Chihota VN, Churchyard GJ, Hanifa Y, Johnson S, McCarthy K, Martinson NA, Omar T, Kahn K, Chandramohan D, Grant AD. Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data. PLoS One 2017; 12:e0174097. [PMID: 28334030 PMCID: PMC5363862 DOI: 10.1371/journal.pone.0174097] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 11/04/2016] [Accepted: 03/04/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA). METHODS AND FINDINGS Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/μL. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively). CONCLUSIONS Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.
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Affiliation(s)
- Aaron S. Karat
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Katherine L. Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmeen Hanifa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, United States of America
- Department of Science and Technology / National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison D. Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Karat AS, Omar T, von Gottberg A, Tlali M, Chihota VN, Churchyard GJ, Fielding KL, Johnson S, Martinson NA, McCarthy K, Wolter N, Wong EB, Charalambous S, Grant AD. Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa. PLoS One 2016; 11:e0166158. [PMID: 27829072 PMCID: PMC5102350 DOI: 10.1371/journal.pone.0166158] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 05/06/2016] [Accepted: 10/23/2016] [Indexed: 11/19/2022] Open
Abstract
Background Early mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”). Methods and Findings Adults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease. Conclusions TB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.
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Affiliation(s)
- Aaron S. Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J. Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katherine L. Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, United States of America
- Department of Science and Technology / National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Nicole Wolter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily B. Wong
- Africa Health Research Institute, Durban, South Africa
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Durban, South Africa
- University of KwaZulu-Natal, Durban, South Africa
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Omar T, Variava E, Moroe E, Billioux A, Chaisson RE, Lebina L, Martinson N. Undiagnosed TB in adults dying at home from natural causes in a high TB burden setting: a post-mortem study. Int J Tuberc Lung Dis 2016; 19:1320-5. [PMID: 26467584 DOI: 10.5588/ijtld.15.0222] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- T Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - E Variava
- Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex and University of the Witwatersrand, Johannesburg, South Africa
| | - E Moroe
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - A Billioux
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA
| | - R E Chaisson
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA
| | - L Lebina
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - N Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA; Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
Mycobacterial infection, tuberculosis (TB) in particular, remains one of the world's deadliest communicable diseases in adults and particularly in children, in low and middle income countries. The combination of human immunodeficiency virus (HIV) and TB is often lethal with TB accounting for 25% of deaths in the HIV population. One of the cornerstones for reducing the TB epidemic is early case detection using high quality diagnostic techniques. Cytology, especially fine needle aspiration biopsy (FNAB) is able to diagnose mycobacterial infection in a rapid and cost-effective manner without requiring surgery, thus allowing appropriate management to be quickly instituted. Confirmatory ancillary tests can effectively be performed on cytologic material. In this review, the pertinent cytomorphology of mycobacterial infection in various exfoliative and FNAB specimens is presented, in both immunocompetent and immunosuppressed patients. In the immunosuppressed, the typical cytomorphology of caseating granulomatous inflammation may not be seen but suppurative necrotic inflammation, mycobacterial spindle pseudotumour or a specimen comprised entirely of necrosis may be seen instead. This review includes discussion of currently available ancillary tests that can be performed on cytologic specimens.
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Affiliation(s)
- Pamela Michelow
- Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Andrew Field
- Department of Anatomical Pathology, St Vincent's Hospital, and Notre Dame University Medical School, Sydney, Australia
| | - Colleen Wright
- Division of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town and National Health Laboratory Service, Port Elizabeth, South Africa
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Papasavvas E, Surrey LF, Glencross DK, Azzoni L, Joseph J, Omar T, Feldman MD, Williamson AL, Siminya M, Swarts A, Yin X, Liu Q, Firnhaber C, Montaner LJ. High-risk oncogenic HPV genotype infection associates with increased immune activation and T cell exhaustion in ART-suppressed HIV-1-infected women. Oncoimmunology 2016; 5:e1128612. [PMID: 27467943 DOI: 10.1080/2162402x.2015.1128612] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 10/14/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022] Open
Abstract
Persistence of human papillomavirus (HPV) and cervical disease in the context of HIV co-infection can be influenced by introduction of antiretroviral therapy (ART) and sustained immune activation despite ART. We conducted a cross-sectional study in order to evaluate immune activation/exhaustion in ART-suppressed HIV(+) women with or without high-risk (HR) HPV-related cervical intraepithelial neoplasia (CIN). 55 South African women were recruited in three groups: HR (-) (n = 16) and HR (+) (n = 15) HPV with negative cervical histopathology, and HR (+) HPV with CIN grade 1/2/3 (n = 24). Sampling included endocervical brushing (HPV DNA genotyping), Pap smear (cytology), colposcopic punch biopsy (histopathology, histochemical evaluation of immune cells), and peripheral blood (clinical assessment, flow cytometry-based immune subset characterization). Statistics were done using R2.5.1. Irrespective of the presence of CIN, HR (+) HPV women had higher circulating levels of T cells expressing markers of activation/exhaustion (CD38, PD1, CTLA-4, BTLA, CD160), Tregs, and myeloid subsets expressing corresponding ligands (PDL1, PDL2, CD86, CD40, HVEM) than HR (-) HPV women. A decrease in circulating NK cells was associated with CIN grade. CD4(+) T cell count associated negatively with T cell exhaustion and expression of negative regulators on myeloid cells. Women with CIN when compared to HR (-) HPV women, had higher cervical cell density in stroma and epithelium for CD4(+), CD68(+), and CD11c(+) cells, and only in stroma for CD8(+) cells. We conclude that in ART-suppressed HIV-infected women with HPV co-infection the levels of T and myeloid cell activation/exhaustion are associated with the presence of HR HPV genotypes.
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Affiliation(s)
| | - Lea F Surrey
- Division of Molecular Pathology, Hospital of the University of Pennsylvania , Philadelphia, PA, USA
| | - Deborah K Glencross
- Faculty of Health Science Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa; National Health Laboratory Service, Johannesburg, South Africa
| | | | | | - Tanvier Omar
- National Health Laboratory Service, Johannesburg, South Africa; Faculty of Health Science Department of Anatomical Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Michael D Feldman
- Division of Surgical Pathology, Hospital of the University of Pennsylvania , Philadelphia, PA, USA
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Molecular Medicine and Department of Pathology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Service, Cape Town, South Africa
| | - Maureen Siminya
- Faculty of Health Science Department of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa; Right to Care, Johannesburg, South Africa
| | - Avril Swarts
- Faculty of Health Science Department of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa; Right to Care, Johannesburg, South Africa
| | | | - Qin Liu
- The Wistar Institute , Philadelphia, PA, USA
| | - Cynthia Firnhaber
- Faculty of Health Science Department of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa; Right to Care, Johannesburg, South Africa
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Firnhaber C, Goeieman B, Faesen M, Levin S, Williams S, Rameotshela S, Swarts A, Michelow P, Omar T, Williamson AL, Allan B, Schnippel K, Smith JS. Prospective One Year Follow Up of HIV Infected Women Screened for Cervical Cancer Using Visual Inspection with Acetic Acid, Cytology and Human Papillomavirus Testing in Johannesburg South Africa. PLoS One 2016; 11:e0144905. [PMID: 26730710 PMCID: PMC4701358 DOI: 10.1371/journal.pone.0144905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 08/31/2015] [Accepted: 11/26/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cervical cancer is the most common cancer in Sub-Saharan Africa. There are little of HIV-infected women one-year after screening using visual inspection with acetic acid (VIA), HPV or cytology in sub-Saharan Africa. METHODS HIV-infected women in Johannesburg South Africa were screened one year later by Pap smear, VIA and human papillomavirus (HPV) testing. Women qualified for the 12 month follow-up visit if they had a negative or cervical intra-epithelial neoplasia (CIN) 1 results at the baseline visit. Modified Poisson regression was used to analyse associations between patient baseline characteristics and progression. RESULTS A total of 688 of 1,202 enrolled at baseline study who were CIN-2+ negative and qualified for a 12 month follow-up visit. Progression to CIN-2+ was higher in women with positive VIA results (12.6%; 24/191) than those VIA-negative (4.4%; 19/432). HPV-positive women at baseline were more likely to progress to CIN-2+ (12.3%; 36/293) than those HPV-negative (2.1%; 7/329). Cytology-positive women at baseline were more likely to progress to CIN-2+ (9.6%; 37/384) than cytology-negative women (2.5%; 6/237). Approximately 10% (10.4%; 39/376) of women with CIN 1 at baseline progressed to CIN 2+. Women who were VIA or HPV positive at baseline were more likely to progress aIRR 1.85, CI 95% (1.46 to 2.36), aIRR 1.41 CI 95% (1.14 to 1.75) respectively. CONCLUSION Progression to CIN-2+ in HIV-infected women is significant when measured by baseline positive VIA, HPV or Pap and yearly screening by any method should be considered in this population if possible.
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Affiliation(s)
- Cynthia Firnhaber
- Clinical HIV Research Unit, Faculty of Health Sciences, Department of Internal Medicine, University Witwatersrand, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | | | | | - Simon Levin
- Right to Care, Johannesburg, South Africa
- Department of OB/GYN, Coronation Hospital, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Avril Swarts
- Clinical HIV Research Unit, Faculty of Health Sciences, Department of Internal Medicine, University Witwatersrand, Johannesburg, South Africa
| | - Pam Michelow
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Science, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Tanvier Omar
- National Health Laboratory Service, Johannesburg, South Africa
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Division of Medical Virology, Department of Clinical Laboratory Sciences, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Bruce Allan
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | | | - Jennifer S. Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Hoffmann CJ, Hoffmann JD, Kensler C, van der Watt M, Omar T, Chaisson RE, Martinson NA, Variava E. Tuberculosis and hepatic steatosis are prevalent liver pathology findings among HIV-infected patients in South Africa. PLoS One 2015; 10:e0117813. [PMID: 25668620 PMCID: PMC4323253 DOI: 10.1371/journal.pone.0117813] [Citation(s) in RCA: 13] [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: 09/07/2014] [Accepted: 01/02/2015] [Indexed: 01/04/2023] Open
Abstract
Liver disease epidemiology in sub-Saharan Africa has shifted as a result of HIV and the increased use of antiretroviral therapy leading to a need for updated data on common causes of liver disease. We retrospectively reviewed records from all hospitalized patients who had liver biopsy at a single hospital in South Africa from 2001 to 2009 and compared diagnosis by HIV status. During the period of study 262 patients had liver biopsy, 108 (41%) were HIV-infected, 25 (10%) were HIV-sero-negative, and 129 (49%) had unknown or unrecorded HIV status. Overall 81% of biopsies provided additional diagnostic data. Malignancy was the most common finding reported on 56 (21%) biopsies followed by granuloma or TB, hepatic steatosis, and fibrosis or cirrhosis. HIV-infected patients were more likely to have granulomas and steatosis. Half of patients with granulomas were already on TB treatment, suggesting paradoxical reactions or drug induced liver injury may have been important causes of liver inflammation among these patients. We note that TB, paradoxical reactions during TB treatment, possible drug induced liver injury, and hepatic steatosis are important causes of liver pathology among HIV-infected hospitalized patients with unclear etiology of liver disease after initial assessment. Among HIV sero-negative patients, malignancy was the major cause of liver disease. Our findings re-enforce the importance of TB as a diagnosis among HIV-infected individuals.
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Affiliation(s)
- Christopher J. Hoffmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
- * E-mail:
| | - Jennifer D. Hoffmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Caroline Kensler
- University of Pittsburgh School of Medicine, Pittsburgh, United States of America
| | - Martin van der Watt
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Richard E. Chaisson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Neil A. Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ebrahim Variava
- Department of Medicine, Klerksdorp Tshepong Hospital Complex and University of the Witwatersrand, Klerksdorp, South Africa
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Patel M, Philip V, Omar T, Turton D, Candy G, Lakha A, Pather S. The Impact of Human Immunodeficiency Virus Infection (HIV) on Lymphoma in South Africa. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/jct.2015.66057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Amer Y, Elzalabany M, Omar T, Ibrahim A. P002 A Summary of the Methods That the Alexandria Centre for Evidence-Based Clinical Practice Guidelines (CEBCPGs) uses to produce Clinical Practice Guidelines for the Healthcare Quality Directorate of Alexandria University Hospitals and Healthcare Sectors in Alexandria. BMJ Qual Saf 2013. [DOI: 10.1136/bmjqs-2013-002293.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Delany S, Weiss HA, Lompo O, Doutre S, Omar T, Kelly H, Zan S, Michelow P, Costes V, Mayaud P. P5.009 Performance of Cervical Cancer Screening Tests in HIV Positive Women in Africa: Influence of CD4 Counts: Abstract P5.009 Table 1. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.1056] [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] [Indexed: 11/03/2022]
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Van Rie A, Page-Shipp L, Mellet K, Scott L, Mkhwnazi M, Jong E, Omar T, Beylis N, Stevens W, Sanne I, Menezes CN. Diagnostic accuracy and effectiveness of the Xpert MTB/RIF assay for the diagnosis of HIV-associated lymph node tuberculosis. Eur J Clin Microbiol Infect Dis 2013; 32:1409-15. [PMID: 23660698 DOI: 10.1007/s10096-013-1890-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 04/25/2013] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- A Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, 2104F McGavran Greenberg Hall, Chapel Hill, NC, 27514-7435, USA,
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Firnhaber C, Mayisela N, Mao L, Williams S, Swarts A, Faesen M, Levin S, Michelow P, Omar T, Hudgens MG, Williamson AL, Allan B, Lewis DA, Smith JS. Validation of cervical cancer screening methods in HIV positive women from Johannesburg South Africa. PLoS One 2013; 8:e53494. [PMID: 23326441 PMCID: PMC3543403 DOI: 10.1371/journal.pone.0053494] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [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: 08/10/2012] [Accepted: 11/29/2012] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND HIV-infected women are at increased risk for developing cervical cancer. Women living in resource-limited countries are especially at risk due to poor access to cervical cancer screening and treatment. We evaluated three cervical cancer screening methods to detect cervical intraepithelial neoplasia grade 2 and above (CIN 2+) in HIV-infected women in South Africa; Pap smear, visual inspection with 5% acetic acid (VIA) and human papillomavirus detection (HPV). METHODS HIV-infected women aged 18-65 were recruited in Johannesburg. A cross-sectional study evaluating three screening methods for the detection of the histologically-defined gold standard CIN-2 + was performed. Women were screened for cervical abnormalities with the Digene HC2 assay (HPV), Pap smear and VIA. VIA was performed by clinic nurses, digital photographs taken and then later reviewed by specialist physicians. The sensitivity, specificity and predictive valves for CIN-2 + were calculated using maximum likelihood estimators. RESULTS 1,202 HIV-infected women participated, with a median age of 38 years and CD4 counts of 394 cells/mm(3). One third of women had a high grade lesion on cytology. VIA and HPV were positive in 45% and 61% of women respectively. Estimated sensitivity/specificity for HPV, Pap smear and VIA for CIN 2+ was 92%/51.4%, 75.8%/83.4% and 65.4/68.5% (nurse reading), respectively. Sensitivities were similar, and specificities appeared significantly lower for the HPV test, cytology and VIA among women with CD4 counts ≤200 cells/mm(3) as compared to CD4 counts >350 cells/mm(3). CONCLUSIONS Although HPV was the most sensitive screening method for detecting CIN 2+, it was less specific than conventional cytology and VIA with digital imaging review. Screening programs may need to be individualized in context of the resources and capacity in each area.
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Affiliation(s)
- Cynthia Firnhaber
- Faculty of Health Science Centre, Department of Medicine, University of Witwatersrand, Johannesburg, South Africa.
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Abstract
Background: One of the constraints of the conventional FNA smear is the limited material available for adjuvant diagnostic investigations including immunocytochemistry. The cell block technique employs the retrieval of small tissue fragments from a FNA specimen which are processed to form a paraffin block. It is widely accepted that cell block technique increases the cellular yield and improves diagnostic accuracy. The ability to obtain numerous tissue sections allows for multiple immunostains and other studies to be performed akin to paraffin sections produced in histopathology. Aims: To determine the effectiveness of the cell block technique by comparing cytomorphological preservation and immunocytochemistry (ICC) stains on paired cell block and conventional fine needle aspiration (FNA) samples. Materials and Methods: In this prospective study, material for both glass slides and cell blocks were collected simultaneously during fine needle aspirates from 47 samples comprising lung and liver masses. Grading of cellularity, morphological preservation, architectural preservation, immunocytochemical staining intensity and presence of background staining on paired FNA smears and cell block samples were compared. Each arm of the paired analysis was performed blindly without knowledge of the grading outcome of the other. The Kappa statistic (κ) was used to measure inter-rater agreement. Results: The 47 samples evaluated included FNAs from the lung, 24/47 (51%) and liver, 23/47 (49%). The immunocytochemistry stains consisted of 44/47 (94%) CK7; 44/47 (94%) CK20; 18/47 (38%) TTF1; 10/47 (21%) synaptophysin; 10/47 (21%) Hepar-1 and 7/47 (15%) AE1/3. There was no overall agreement in preservation of cytomorphological detail and ICC staining between the two methods. The Papanicolaou-stained conventional FNA smears fared better than the cell block for the evaluation of nuclear and morphologic characteristics. The ICC stains worked better on the cell block samples due to lack of background and aberrant staining. Conclusion: Direct FNA smears and cell blocks complement each other and our results indicate that both are needed in the diagnostic work-up of patients. The cost implications of performing both techniques on all FNA material warrants further evaluation.
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Affiliation(s)
- Shehnaz Khan
- Department of Anatomical Pathology, Division of Cytopathology, National Health Laboratory Service, Johannesburg, South Africa
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Wong EB, Omar T, Setlhako GJ, Osih R, Feldman C, Murdoch DM, Martinson NA, Bangsberg DR, Venter WDF. Causes of death on antiretroviral therapy: a post-mortem study from South Africa. PLoS One 2012; 7:e47542. [PMID: 23094059 PMCID: PMC3472995 DOI: 10.1371/journal.pone.0047542] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [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: 06/18/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022] Open
Abstract
Background Mortality in the first months of antiretroviral therapy (ART) is a significant clinical problem in sub-Saharan Africa. To date, no post-mortem study has investigated the causes of mortality in these patients. Methods HIV-positive adults who died as in-patients at a Johannesburg academic hospital underwent chart-review and ultrasound-guided needle autopsy for histological and microbiological examination of lung, liver, spleen, kidney, bone marrow, lymph node, skin and cerebrospinal fluid. A clinico-pathologic committee considered all available data and adjudicated immediate and contributing causes of death. Results Thirty-nine adults were enrolled: 14 pre-ART, 15 early-ART (7–90 days), and 10 late-ART (>90 days). Needle sampling yielded adequate specimen in 100% of kidney, skin, heart and cerebrospinal fluid samples, 97% of livers and lungs, 92% of bone marrows, 87% of spleens and 68% of lymph nodes. Mycobacterial infections were implicated in 69% of deaths (26 of 27 of these due to M. tuberculosis), bacterial infections in 33%, fungal infections in 21%, neoplasm in 26%, and non-infectious organ failure in 26%. Immune reconstitution inflammatory syndrome (IRIS) was implicated in 73% of early-ART deaths. Post-mortem investigations revealed previously undiagnosed causes of death in 49% of cases. Multiple pathologies were common with 62% of subjects with mycobacterial infection also having at least one other infectious or neoplastic cause of death. Conclusions Needle biopsy was efficient and yielded excellent pathology. The large majority of deaths in all three groups were caused by M. tuberculosis suggesting an urgent need for improved diagnosis and expedited treatment prior to and throughout the course of antiretroviral therapy. Complex, unrecognized co-morbidities pose an additional challenge.
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Affiliation(s)
- Emily B Wong
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
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Martinson NA, Karstaedt A, Venter WDF, Omar T, King P, Mbengo T, Marais E, McIntyre J, Chaisson RE, Hale M. Causes of death in hospitalized adults with a premortem diagnosis of tuberculosis: an autopsy study. AIDS 2007; 21:2043-50. [PMID: 17885294 DOI: 10.1097/qad.0b013e3282eea47f] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To ascertain the immediate and underlying causes of death in adults who died in hospital with a premortem diagnosis of tuberculosis. DESIGN Causes of death were assessed independently by internists and pathologists in 50 adults admitted to two Soweto hospitals who died 24 h or more after admission. Detailed record reviews and complete autopsies, including HIV tests when not performed premortem, were performed. In addition, a variety of postmortem microbiological tests were performed. RESULTS Forty-seven patients had HIV infection; all were antiretroviral naive. Their median age was 34.5 years, median CD4 cell count was 48 cells/microl and median length of hospitalization before death was 6 days. Autopsy confirmed the premortem diagnosis of tuberculosis in 37 HIV-infected patients (79%), whereas 10 (21%) did not demonstrate tuberculosis. Bronchopneumonia and cytomegalovirus pneumonitis were the leading pathologies in these 10 patients. In 47 HIV-infected cadavers immediate or contributory causes of death were: extensive pulmonary tuberculosis, 32 (68%); disseminated tuberculosis, 28 (60%); bacterial pneumonia, 13 (26%); cytomegalovirus pneumonitis in seven (15%); cytomegalovirus DNA was found in 31 (66%) and Pneumocystis pneumonia was found in five cadavers (11%). The lung, followed by lymph nodes, liver and kidney, were the commonest sites of tuberculosis. Mycobacterium tuberculosis was cultured from 19 spleens, one of which was multidrug resistant, and Salmonella spp. was cultured from 11 splenic specimens. CONCLUSION We demonstrated disseminated, extensive tuberculosis associated with advanced HIV disease. Severe bacterial infections, including salmonellosis, were the leading co-morbidity, suggesting that hospitalized HIV-infected adults in whom tuberculosis is suspected may benefit from broad-spectrum antibiotic therapy.
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Affiliation(s)
- Neil A Martinson
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA.
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Abstract
Pediatric human immunodeficiency virus (HIV) infection is a major and increasing burden worldwide, but particularly in sub-Saharan Africa. Coinfection with other pathogens increases the likelihood of progression of HIV/acquired immunodeficiency syndrome (AIDS), and the immunosuppressive consequences of the disease predispose to opportunistic infections that can run a fulminant course. Despite high prevalence, amebiasis has not appeared as a major source of morbidity during the HIV/AIDS pandemic. Information from recent sources, however, appears to suggest that amebiasis may indeed be a risk for individuals living with HIV/AIDS.
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Affiliation(s)
- Douglas M Bowley
- Division of Paediatric Surgery, University of Witwatersrand, Johannesburg, South Africa.
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Martinson NA, Omar T, Gray GE, Vermaak JS, Badicel M, Degiannis E, Steyn J, McIntyre JA, Smith M. High rates of HIV in surgical patients in Soweto, South Africa: impact on resource utilisation and recommendations for HIV testing. Trans R Soc Trop Med Hyg 2006; 101:176-82. [PMID: 16814822 DOI: 10.1016/j.trstmh.2006.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [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: 01/06/2006] [Revised: 04/05/2006] [Accepted: 04/05/2006] [Indexed: 11/26/2022] Open
Abstract
Interactions between HIV and surgical diseases are relatively poorly described in high HIV prevalence settings. We report HIV prevalence and its associations in a prospective study of adults admitted to surgical units in Soweto, South Africa. Voluntary counselling and testing (VCT) for HIV was offered to surgical inpatients. Research nurses interviewed participants at enrolment and doctors reviewed records after discharge. In HIV-infected participants, CD4 counts and viral loads were ascertained. Of 1000 participants, 537 consented to VCT, of whom 176 (32.8%, 95% CI 28.8-36.9%) tested HIV positive. A history of tuberculosis (adjusted odds ratio (AOR) 3.0, 95% CI 1.5-6.2) or sexually transmitted infection (AOR 2.7, 95% CI 1.8-4.2) was associated with HIV infection. Diagnoses of cutaneous abscesses (OR 3.4, 95% CI 1.4-8.1) and anorectal sepsis (OR 3.1, 95% CI 1.1-9.0) were associated with HIV and indicated advanced disease. There were no differences in rates of operative procedures, wound sepsis, investigations or length of stay by HIV status. Hospital-acquired pneumonia was more common in HIV-infected participants (P=0.028). In conclusion, in this high HIV prevalence setting, resource utilisation is similar between HIV-infected and uninfected patients in surgical wards where high rates of HIV in young adults support routine HIV testing. WHO clinical staging of HIV should include anal sepsis as an indicator of advanced HIV disease.
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Affiliation(s)
- Neil A Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa.
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Abstract
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.
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Affiliation(s)
- A S Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.
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Abstract
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.
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Affiliation(s)
- L Pantanowitz
- Department of Medicine, Chris Hani Baragwanath Hospital and South African Institute for Medical Research, University of Witwatersrand, Johannesburg, South Africa
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Bassili A, Zaki A, Zaher SR, El-Sawy IH, Ahmed MH, Omar M, Omar T, Bedwani RN, Davies C, Tognoni G. 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. Pediatrics 2000; 106:E12. [PMID: 10878181 DOI: 10.1542/peds.106.1.e12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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
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Affiliation(s)
- A Bassili
- Department of Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt.
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Affiliation(s)
- S J Nayler
- Department of Anatomical Pathology, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
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.
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Affiliation(s)
- T Omar
- Department of Anatomical Pathology, School of Pathology, South African Institute for Medical Research, Johannesburg
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