The impact of obesity on vaginal hysterectomy and laparoscopically-assisted vaginal hysterectomy outcomes: A randomised control trial

OBJECTIVES

This prospective randomised control trial aimed to compare outcome measures of vaginal hysterectomy (VH) and laparoscopically-assisted vaginal hysterectomy (LAVH) in obese vs. non-obese women undergoing hysterectomy for benign uterine conditions with a non-prolapsed uterus. The primary objective of the study was to estimate operation time, uterine weight and blood loss amongst obese and non-obese patients undergoing VH and LAVH. The secondary objective was to determine any difference in hospital stay, the need for post-operative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy for obese vs. non-obese patients undergoing VH and LAVH.

STUDY DESIGN

A prospective randomised control study was undertaken in the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria set by the unit (vaginally accessible uterus, uterine size ≤ 12 weeks of gestation or ≤ 280gr on ultrasound examination, pathology confined to the uterus) were included in the study. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. All the LAVHs were performed by one surgeon (AC). In addition to the patient characteristics and surgical approach to hysterectomy, operative time, estimated blood loss, uterine weight, length of hospital stay, intra-operative and immediate post-operative complications were also recorded in obese and non-obese patient groups and comparatively analysed.

RESULTS

A total of 227 women were included in the study. 151 patients underwent VH and 76 LAVH, upon randomisation on a 2:1 basis, reflecting the habitual proportion of hysterectomy cases in the Urogynaecology and Endoscopy Unit at CMJAH. No significant differences were found in mean shift of pre-operative to post-operative serum haemoglobin, uterine weight, intra- and immediate post-operative complications, and convalescence period when comparing obese and non-obese patients in both the VH and LAVH groups. There was a statistically significant difference in operating time between the two procedures. The LAVHs took longer compared to the VHs to be performed (62.8 ± 9.3 vs. 29.9 ± 6.6 min in non-obese patients, and 62.7 ± 9.8 vs 30.0 ± 6,9 min for obese patients). All VHs and LAVHs were successfully accomplished without major complications.

CONCLUSION

VH and LAVH for the non-prolapsed uterus is a feasible and safe alternative for obese patients demonstrating similar perioperative outcome measures as non-obese women undergoing VH and LAVH. Where possible, VH should be preferred to LAVH as it is a safe route of hysterectomy, with operation time being significantly shorter.

A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE

BACKGROUND

The efficacy and safety of thromboprophylaxis in pregnancy at intermediate to high risk of venous thrombo-embolism (VTE) is an area of ongoing research.

AIM

This study aimed to assess thrombosis and bleeding outcomes associated with thromboprophylaxis in women at risk of VTE.

METHODS

A cohort of 129 pregnancies, who received thromboprophylaxis for the prevention of VTE, were identified from a specialist obstetric clinic in Johannesburg, South Africa. Intermediate-risk pregnancies, with medical comorbidities or multiple low risks, were managed with fixed low-dose enoxaparin antepartum and for a median (interquartile range) of 4 (4) weeks postpartum. High-risk pregnancies, with a history of previous VTE, were managed with anti-Xa adjusted enoxaparin antepartum and for a median of 6 (0) weeks postpartum. Pregnancy-related VTE was objectively confirmed. Major bleeding, clinically relevant nonmajor bleeding (CRNMB) and minor bleeding were defined according to the International Society on Thrombosis and Hemostasis Scientific Subcommittee.

RESULTS

Venous thrombo-embolism occurred antepartum in 1.4% (95% CI: 0.04-7.7) of intermediate and 3.4% (95% CI: 0.4-11.7) of high-risk pregnancies. Bleeding events occurred in 7.1% (95% CI: 2.4-15.9) of intermediate and 8.5% (95% CI: 2.8-18.7) of high-risk pregnancies. Of these bleeding events, 3.1% (95% CI: 1.0-8.0) were classified as major bleeding. On univariate analysis, no independent predictors of bleeding were identified.

CONCLUSION

The rates of thrombosis and bleeding in this predominantly African population were consistent with similar studies and can be used to inform pregnant women of the benefits of anticoagulation and the risks of potential bleeding.

The role of conventional echocardiographic parameters on detecting subclinical anthracycline therapy related cardiac dysfunction

Background

Subclinical anthracycline therapy related cardiac dysfunction (ATRCD) can be detected with speckle tracking echocardiographic image (STE), which is not widely available in Uganda. We aimed to investigate the accuracy, sensitivity and specificity of the two conventional echocardiographic parameters (reduction of mitral annular plane systolic exertion (MAPSE) and reduction of mitral annular peak systolic tissue Doppler velocity (s')) on diagnosing subclinical ATRCD.

Method and results

207 cancer patients who underwent anthracycline based chemo therapy were recruited at baseline and followed up until 6 months after ending anthracycline therapy. Comprehensive echocardiographic data were collected at each visits. Global longitudinal strain (GLS) by STE was used as the gold standard diagnostic test to define the case of subclinical ATRCD. Data of the 200 patients who had no evidence of clinical ATRCD were analyzed. 172 (86.0%) were female, with a median age of 42 years and cumulative incidence of ATRCD at the end of anthracycline therapy was 23.5% by GLS criteria. The AUC, cutpoint, sensitivity, specificity, PPV and NPV of reduction of MAPSE were 0.6736 (95% CI: 0.5885, 0.7587), ≥2 mm, 74.47% (95% CI: 59.65%, 86.06%), 54.90% (95% CI: 46.66%, 62.95%), 33.70% (95% CI: 24.68%, 43.58%) and 87.50%% (95% CI: 79.18%, 93.37%). The AUC, cutpoint, sensitivity, specificity, PPV and NPV of reduction of S' were 0.6018 (95% CI: 0.5084, 0.6953), ≥0.5 mm/s, 61.70% (95% CI: 46.38%, 75.49%), 52.67% (95% CI: 44.36%, 60.87%), 29.00% (95% CI: 20.36%, 38.93%) and 76.14%% (95% CI: 72.27%, 88.62%).

Conclusion

The reduction of MAPSE and S' demonstrated fairly good accuracy, sensitivity and negative predictive value to detect subclinical ATRCD in Ugandan cancer patients. These conventional echocardiographic parameters may serve as screening tools for detecting subclinical ATRCD in resource limited settings.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NURTURE Research Training and Mentoring Program for Career Development of Faculty at MakerereUniversity College of Health Sciences, Uganda supported by the Office Of The Director, National Institutes of Health, National Institute of Dental and Craniofacial Research, National Institute Of Neurological.

Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease developing towards the end of pregnancy or in the months following delivery in previously healthy women in terms of cardiac disease. Enhanced oxidative stress and the subsequent cleavage of the nursing hormone Prolactin into an anti-angiogenic 16 kDa subfragment emerged as a potential causal factor of the disease. We established a prospective registry with confirmed PPCM present in 115 patients (mean baseline left ventricular ejection fraction, LVEF: 27 ± 9 %). Follow-up data (6 ± 3 months) showed LVEF improvement in 85 % and full recovery in 47 % while 15 % failed to recover with death in 2 % of patients. A positive family history of cardiomyopathy was present in 16.5 %. Pregnancy-associated hypertension was associated with a better outcome while a baseline LVEF ≤ 25 % was associated with a worse outcome. A high recovery rate (96 %) was observed in patients obtaining combination therapy with beta-blocker, angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor-blockers (ARBs) and bromocriptine. Increased serum levels of Cathepsin D, the enzyme that generates 16 kDa Prolactin, miR-146a, a direct target of 16 kDa Prolactin, N-terminal-pro-brain-natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) emerged as biomarkers for PPCM. In conclusion, low baseline LVEF is a predictor for poor outcome while pregnancy-induced hypertensive disorders are associated with a better outcome in this European PPCM cohort. The high recovery rate in this collective is associated with a treatment concept using beta-blockers, ACE inhibitors/ARBs and bromocriptine. Increased levels of Cathepsin D activity, miR-146a and ADMA in serum of PPCM patients support the pathophysiological role of 16 kDa Prolactin for PPCM and may be used as a specific diagnostic marker profile.

Personality, depressive symptoms and prior trauma exposure of new recruits at two Metropolitan Police Service academies in South Africa

<p><strong>Background.</strong> Police officers are predisposed to trauma exposure. The development of depression and post-traumatic stress disorder (PTSD) may be influenced by personality style, prior exposure to traumatic events and prior depression.</p><p><strong> Objectives.</strong> To describe the personality profiles of new Metropolitan Police Service (MPS) officers, and to determine the association between personality profiles, trauma exposure and depressive symptoms.</p><p><strong> Methods.</strong> We performed a cross-sectional analysis of 139 new recruits at two MPS academies in South Africa. A questionnaire elucidating traumatic life events and personality profiles was developed using the Millon Clinical Multiaxial Inventory-III (MCMI-III). Depressive symptoms were measured using the Hamilton Depression Rating Scale (HAMD).</p><p><strong>Results.</strong> Almost all subjects (99.3%) had previous trauma exposure, most commonly the unexpected death of a loved one and motor vehicle accidents. Prevalence of clinical depression was low (mean HAMD 3.57; standard deviation ±3.37). Personality characteristics revealed a high prevalence of anxiety (64.7%; 95% CI 56.8 - 72.6), depressive clinical patterns (34.5%; 95% CI 26.6 - 42.2), paranoia (33.1 %; 95% CI 26.6 - 42.2) and major depression (10.3%; 95% CI 5.1 - 15.1). There were no significant associations between any of the traumatic events and depressive symptoms, nor were there any significant associations between any of the personality variables and HAMD score (p&gt;0.05).</p><p><strong>Conclusion.</strong> The presence of depressive symptoms among MPS officers was low, with no significant associations between traumatic events, personality variables and depressive symptoms.</p>

The thrombotic profile of treatment-naive HIV-positive Black South Africans with acute coronary syndromes

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection on protease inhibitors (PIs) have a heightened risk of arterial thrombosis but little is known about treatment-naive patients.

METHODS/RESULTS

Prospective study from South Africa comparing thrombotic profiles of HIV-positive and -negative patients with acute coronary syndrome (ACS). A total of 30 treatment-naive HIV-positive patients with ACS were compared to 30 HIV-negative patients with ACS. Patients with HIV were younger; and besides smoking (73% vs 33%) and low high-density lipoprotein (HDL; 0.8 ± 0.3 vs 1.1 ± 0.4), they had fewer risk factors. Thrombophilia was more common in HIV-positive patients with lower protein C (PC; 82 ± 22 vs 108 ± 20) and higher factor VIII levels (201 ± 87 vs 136 ± 45). Patients with HIV had higher frequencies of anticardiolipin (aCL; 47% vs 10%) and antiprothrombin antibodies (87% vs 21%).

CONCLUSION

Treatment-naive HIV-positive patients with ACS are younger, with fewer traditional risk factors but a greater degree of thrombophilia compared with HIV-negative patients.

Acute coronary syndromes in treatment-naïve black South africans with human immunodeficiency virus infection

BACKGROUND

HIV patients on protease inhibitors have greater risk of acute coronary syndromes (ACS) but little is known about treatment-naïve patients.

METHODS AND RESULTS

Authors conducted a prospective single-center study from Soweto, South Africa, comparing the clinical and angiographic features of treatment-naïve HIV positive and negative patients with ACS. Between March 2004 and February 2008, 30 consecutive treatment-naïve HIV patients with ACS were compared to the next HIV-negative patient as a 1:1 control. HIV patients were younger (43 +/- 7 vs. 54 +/- 13, P = 0.004) and, besides smoking (73% vs. 33%, P = 0.002), had fewer risk factors than the control group with less hypertension (23% vs. 77%, P = 0.0001), diabetes (3% vs. 23%, P = 0.05), LDL hyperlipidemia (2.2 +/- 0.9 vs. 3.0 +/- 1.2, P = 0.006), and other coronary risk factors (7% vs. 53%, P = 0.0001). HDL was lower in the HIV group (0.8 +/- 0.3 vs. 1.1 +/- 0.4, P = 0.001). Atherosclerotic burden was lower in the HIV group with more normal infarct-related arteries (47% vs. 13%, P = 0.005) but a higher degree of large thrombus burden (43% vs. 17%, P = 0.02). Stents were used to a similar degree in HIV and control patients (30% vs. 37%, P = 0.78) with more target lesion revascularization in the HIV group (56% vs. 0%, P = 0.008).

CONCLUSION

Treatment-naïve HIV patients with ACS are younger and have fewer traditional risk factors than HIV-negative patients. HIV patients have less atherosclerotic but higher thrombotic burden which may imply a prothrombotic state in the pathogenesis of ACS in these patients.

Obesity promotes left ventricular concentric rather than eccentric geometric remodeling and hypertrophy independent of blood pressure

BACKGROUND

As it is uncertain whether excess adiposity promotes primarily concentric or eccentric left ventricular hypertrophy (LVH), we aimed to determine at a population level, the independent relationship between waist circumference (WC) and LV geometric changes and the potential hemodynamic mechanisms thereof.

METHODS

We assessed the relations between WC and LV end-diastolic diameter (EDD), LV mean wall thickness (MWT = posterior + septal wall thickness/2), LV relative wall thickness (RWT = MWT/EDD), LV mass index (LVMI), concentric LVH (LVMI > 51 g/m2.7 and RWT > 0.45), eccentric LVH (LVMI > 51 g/m2.7 and RWT < 0.45), or concentric LV remodeling (normal LVMI and RWT > 0.45), in 309 never treated for hypertension, randomly recruited adult participants with a high prevalence of excess adiposity ( approximately 25% overweight; 38% obese). Pulse-wave analysis was performed to determine central artery blood pressures (BPs). Two hundred and thirty-one participants had high-quality ambulatory BP monitoring.

RESULTS

Approximately 7% of participants had concentric LVH, approximately 16% concentric LV remodeling, and approximately 15% eccentric LVH. After adjustments for potential confounders including conventional systolic BP (SBP), WC was related to MWT (partial r = 0.23, P = 0.0001), RWT (partial r = 0.13, P = 0.03), concentric LVH (P < 0.04), concentric LV remodeling (P = 0.02), but not with EDD or eccentric LVH (P = 0.91). Similar outcomes were noted after adjustments for central or 24-h SBP, and for conventional, central, or 24-h pulse pressure. Separate analysis in normotensive subjects revealed similar outcomes.

CONCLUSIONS

In a population sample with a high prevalence of obesity, excess adiposity promotes concentric, rather than eccentric LV geometric changes, effects which are independent of conventional, central artery or 24-h BP measured on a single occasion.

Accuracy of cervical assessment in the active phase of labour

OBJECTIVE

To determine accuracy of clinicians in estimating cervical dilatation during the active phase of labour and how this is affected by clinician experience and obstetric factors.

DESIGN

Prospective, cross-sectional, comparative study.

SETTING

Chris Hani Baragwanath Hospital labour ward, Johannesburg, South Africa.

POPULATION

Women at term in the active phase of labour, with vertex presentations and live fetuses.

METHODS

The researcher performed cervical assessment immediately after the clinician on duty. The researcher and clinician were unaware of each other's findings. The researcher, used as the standard, was an experienced obstetric consultant, and the clinicians were hospital consultants and registrars at various levels of training. Accuracy was defined as agreement of the clinician's cervical dilatation estimate with that of the researcher. Multivariate logistic regression analysis was carried out to determine independent predictors of inaccuracy.

MAIN OUTCOME MEASURE

Agreement in estimation of cervical dilatation between the researcher and the clinicians.

RESULTS

Examinations were performed on 508 women. The researcher and clinicians agreed on the dilatation in 250 instances (49.2%) and differed by 2 cm or more in 56 (11.0%) (kappa = 0.40, 95% CI 0.34-0.45). Accuracy was greater at low (3-4 cm) and high (8-10 cm) dilatations. Reduced accuracy was associated with decreasing clinician experience and with lower stations of fetal head.

CONCLUSION

This is the first study to investigate accuracy of cervical assessment in parturient women. Results were similar to those found in studies that used models, with about 90% of estimations accurate to within 1 cm.

Efficacy of different drug classes used to initiate antihypertensive treatment in black subjects: results of a randomized trial in Johannesburg, South Africa

BACKGROUND

Thiazides are recommended to initiate antihypertensive drug treatment in black subjects.

OBJECTIVE

To test the efficacy of this recommendation in a South African black cohort.

METHODS

Men and women (N = 409), aged 18 to 70 years, with a mean ambulatory daytime diastolic blood pressure between 90 and 114 mm Hg, were randomized to 13 months of open-label treatment starting with the nifedipine gastrointestinal therapeutic system (30 mg/d, n = 233), sustained-release verapamil hydrochloride (240 mg/d, n = 58), hydrochlorothiazide (12.5 mg/d, n = 58), or enalapril maleate (10 mg/d, n = 60). If the target of reducing daytime diastolic blood pressure below 90 mm Hg was not attained, the first-line drugs were titrated up and after 2 months other medications were added to the regimen.

RESULTS

While receiving monotherapy (2 months, n = 366), the patients' systolic and diastolic decreases in daytime blood pressure averaged 22/14 mm Hg for nifedipine, 17/11 mm Hg for verapamil, 12/8 mm Hg for hydrochlorothiazide, and 5/3 mm Hg for enalapril. At 2 months the blood pressure of more patients treated with nifedipine was controlled: 133 (63.3%, P</=.03) vs 20 (39.9%) receiving verapamil, 21 (40.4%) receiving hydrochlorothiazide, and 11 (20.8%) receiving enalapril. At 13 months (n = 257), more patients (P<.001) continued receiving monotherapy with nifedipine (94/154 [61.0%]) or verapamil (22/35 [62.9%]) than hydrochlorothiazide (10/39 [25.6%]) or enalapril (1/29 [3.4%]). A sustained decrease of left ventricular mass (P<.001) with no between-group differences was achieved at 4 and 13 months.

CONCLUSIONS

In contrast to current recommendations, calcium channel blockers are more effective than thiazides as initial treatment in black subjects with hypertension. If treatment is started with thiazides or converting-enzyme inhibitors, combination therapy is more likely to be required to control blood pressure and reduce left ventricular mass.