Characteristics, management and outcomes of primary hyperparathyroidism from 2009 to 2021: a single centre report from South Africa.

BACKGROUND: There has been a notable shift towards the diagnosis of less severe and asymptomatic primary hyperparathyroidism (PHPT) in developed countries. However, there is a paucity of recent data from sub-Saharan Africa (SSA), and also, no reported data from SSA on the utility of intra-operative parathyroid hormone (IO-PTH) monitoring. In an earlier study from Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa (2003-2009), majority of patients (92.9%) had symptomatic disease. The aim of this study was to evaluate the clinical profile and management outcomes of patients presenting with PHPT at IALCH. METHODS: A retrospective chart review of patients with PHPT attending the Endocrinology clinic at IALCH between July 2009 and December 2021. Clinical presentation, laboratory results, radiologic findings, surgical notes and histology were recorded. RESULTS: Analysis included 110 patients (87% female) with PHPT. Median age at presentation was 57 (44; 67.5) years. Symptomatic disease was present in 62.7% (n:69); 20.9% (n:23) had a history of nephrolithiasis and 7.3% (n:8) presented with previous fragility fractures. Mean serum calcium was 2.87 ± 0.34 mmol/l; median serum-PTH was 23.3 (15.59; 45.38) pmol/l, alkaline phosphatase 117.5 (89; 145.5) U/l and 25-hydroxyvitamin-D 42.9 (33.26; 62.92) nmol/l. Sestamibi scan (n:106 patients) identified an adenoma in 83.02%. Parathyroidectomy was performed on 84 patients with a cure rate of 95.2%. Reasons for conservative management (n:26) included: no current surgical indication (n:7), refusal (n:5) or deferral of surgery (n:5), loss to follow-up (n:5) and assessed as high anaesthetic risk (n:4). IO-PTH measurements performed on 28 patients indicated surgical success in 100%, based on Miami criteria. Histology confirmed adenoma in 88.1%, hyperplasia in 7.1% and carcinoma in 4.8%. Post-operative hypocalcaemia developed in 30 patients (35.7%), of whom, 14 developed hungry bone syndrome (HBS). In multivariate analysis, significant risk factors associated with HBS included male sex (OR 7.01; 95% CI 1.28, 38.39; p 0.025) and elevated pre-operative PTH (OR 1.01; 95% CI 1.00, 1.02; p 0.008). CONCLUSIONS: The proportion of asymptomatic PHPT has increased at this centre over the past decade but symptomatic disease remains the dominant presentation. Parathyroidectomy is curative in the majority of patients. IO-PTH monitoring is valuable in ensuring successful surgery.

High frequency of hypoglycaemia in patients with type 1 diabetes mellitus attending a tertiary diabetes clinic in Durban, South Africa.

AIM: The study aimed to assess the prevalence of hypoglycaemia in subjects with type 1 diabetes (T1D) attending a public health tertiary diabetes clinic in Durban, South Africa. METHODS: Patients with T1D were enrolled at the time of clinic attendance. Data on hypoglycaemia over the previous 12 weeks were obtained from glucose meter downloads as well as diary records. Each patient completed the Hypoglycaemia Fear Survey questionnaire as well as an in-house questionnaire on hypoglycaemic episodes in the previous 12 months. RESULTS: A total of 151 subjects (58% female, 54% black African) were enrolled. "Any" hypoglycaemia occurred in 144 (95.4%) in the 12 months prior to clinic attendance. Of these, "severe" hypoglycaemia occurred in 107 (74.3%) and 22 (20.6%) had five or more severe episodes. The most frequent behavioural change in response to hypoglycaemia was insulin dose self-adjustment and the commonest worry was the possibility of becoming emotionally upset during hypoglycaemia. CONCLUSIONS: In a tertiary diabetes clinic in Durban, South Africa, there was a high frequency of hypoglycaemia in patients with T1D and in the majority, at least one severe episode occurred in the 12 months prior to clinic attendance. The results indicate a need for further study and strategies to reduce the frequency and severity of hypoglycaemia.

Non-alcoholic fatty liver disease in Africa: a hidden danger.

There is a dearth of data on the burden and spectrum of non-alcoholic fatty liver disease (NAFLD) in African populations. The limited available information suggests that the prevalence of NAFLD in the general population is lowest for the Africa region. However, this is likely to be an underestimate and also does not take into consideration the long-term impact of rising rates of obesity, type-2 diabetes mellitus (T2DM) and high human immunodeficiency virus infection burden in Africa. A racial disparity in the prevalence of NAFLD has been observed in some studies but remains unexplained. There is an absence of data from population-based studies in Africa and this highlights the need for such studies, to reliably define the health service needs for this region. Screening for NAFLD at a population-based level using ultrasound is perhaps the ideal method for resource-poor settings because of its relative cost-effectiveness. What is required as a priority from Africa, are well-designed epidemiologic studies that screen for NAFLD in the general population as well as high-risk groups such as patients with T2DM or obesity.

Prevalence and characteristics of celiac disease in South African patients with type 1 diabetes mellitus: Results from the Durban Diabetes and Celiac Disease Study.

BACKGROUND AND AIM: The aim of this study was to assess the prevalence and characteristics of celiac disease (CD) in all patients with type 1 diabetes mellitus attending a tertiary adult diabetes clinic in Durban, South Africa. METHODS: This was a cross-sectional observational study that screened 202 patients; of these, 56.4% were African (Black), 31.7% Asian Indian, 4.5% White, and 7.4% mixed race. Demographic data, symptoms, and anthropometry were documented. Blood tests included anti-tissue transglutaminase antibody (tTG), anti-endomysial antibody (EMA), and anti-gliadin antibody (AGA). Endoscopy and duodenal biopsy were performed in patients with celiac antibodies. Diagnosis of CD was based on the modified Marsh classification. RESULTS: Mean age and mean duration of diabetes were 26.4 ± 11.4 and 10.7 ± 9.1 years, respectively. Celiac antibodies were found in 65 (32.2%) patients: EMA 7.4%, tTG immunoglobulin A (IgA) 8.4%, tTG immunoglobulin G 1.9%, AGA IgA 18.3%, and AGA immunoglobulin G 21.8%. Histological evidence of CD was found in 5.9% (n = 12/202): 2.5% were classed as definite CD (Marsh 3) and 3.4% as potential CD (Marsh 1). None of the patients with CD were symptomatic. The sensitivity of AGA IgA, EMA, and tTG IgA antibodies for detecting histologically proven CD was 66.7%, 50.0%, and 41.7%, respectively. CONCLUSION: The prevalence of CD was similar to reports from western countries. No ethnic specific differences were noted. CD was silent in all patients in this study. The sensitivity of EMA and tTG antibodies was poor and merits further evaluation as screening tools for CD in South African patients with type 1 diabetes mellitus.

The Successful Implementation of a Modified Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery in a South African Teaching Hospital.

BACKGROUND: This study assessed the impact of strict adherence to perioperative pathways incorporating an enhanced recovery after surgery protocol on the outcomes of bariatric surgery at our center. METHODS: Prospective data were collected on 62 patients undergoing bariatric surgery between January 2011 and March 2016. Outcomes were compared between those who adhered to the perioperative pathway and those who did not. RESULTS: Fifty-three patients underwent laparoscopic sleeve gastrectomy, and 9 patients underwent Laparoscopic Roux-en-Y Gastric Bypass. The majority of subjects were female individuals (n=45; 72.6%). The mean age (±SD) was 40.5±9.8 years (range, 21 to 59 y). The mean preoperative body mass index (BMI) was 54.8±11.0. The mean BMI loss from baseline was 14.8 kg/m (-15.9 kg m; P<0.001). There were no deaths, and there were only 2 postoperative complications (1 intra-abdominal bleeding postoperatively requiring reoperation and 1 patient requiring CPAP support in intensive care unit). Full adherence was achieved in 53 (85.5%) patients with a mean length of stay (LOS) of 3±0.8 days. The nonadherent group had a significantly longer LOS of 4±3.2 days (P=0.049). The time since last follow-up visit was on average 4.4±5.6 months in the fully adherent group and significantly longer in the nonadherent group at 10.6±11.3 months (P=0.013). Age, race, sex, and BMI did not significantly impact on adherence. The mean LOS among morbidly obese and super obese patients was comparable at 3 and 3.3 days, respectively (P=0.442). CONCLUSION: Adherence to enhanced recovery after surgery pathways was associated with a significantly shorter hospital stay and better follow-up in our surgical unit.

High prevalence of antithyroid peroxidase and antiparietal cell antibodies among patients with type 1 diabetes mellitus attending a tertiary diabetes centre in South Africa.

OBJECTIVE: Data on the prevalence of autoimmune thyroid disease (AITD) and gastric autoimmunity in type 1 diabetes mellitus (T1DM) in Africa are limited. The aim of this study was to assess the prevalence of antithyroid peroxidase (TPO-A) and antiparietal cell antibody (PCA) in patients with T1DM at a tertiary diabetes clinic in Durban, South Africa. RESEARCH DESIGN AND METHODS: This was a cross-sectional observational study among subjects attending the adult T1DM clinic at Inkosi Albert Luthuli Hospital. Information about history and clinical examination was collected. Blood tests included glutamic acid decarboxylase antibody (GADA), TPO-A, PCA, vitamin B12, folate, ferritin, thyroid stimulating hormone (TSH), free thyroxine, lipids and HbA1c. RESULTS: A total of 202 (M:F, 90:112) patients were recruited. The ethnic composition was African (black) (56.4%; n=114), Indian (31.7%; n=64), white (4.5%; n=9) and coloured (mixed race) (7.4%; n=15). Mean age and mean duration of diabetes were 26.4±11.4 and 10.7±9.1 years, respectively. Mean body mass index was 21.6±6.3 kg/m2. GADA was positive in 63.37% (n=128). The prevalence of TPO-A was 18.9% (n=39) and PCA 8.9% (n=17). The prevalence of overt hypothyroidism, subclinical hypothyroidism and Graves' disease was 10.9%, 2.5% and 1.5%, respectively; vitamin B12 deficiency was noted in 3.5% (n=7) and iron deficiency in 19.3% (n=39). CONCLUSIONS: Among patients with T1DM in this study, there was a high prevalence of coexistent AITD and gastric autoimmunity. Screening for hypothyroidism and thyroid autoimmunity should be undertaken in all patients at initial presentation. However, to assess the feasibility and optimal timing of subsequent testing in the African setting with limited resources, more collaborative research with longitudinal studies is required.

Characteristics, management and outcome of primary hyperparathyroidism in South Africa: a single-centre experience.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and elevated parathyroid hormone (PTH) levels. However, it remains a relatively underdiagnosed disease in the developing world primarily due to a lack of routine blood chemistry screening. The aim of this analysis was to evaluate the characteristics, management and outcome of patients with PHPT at a tertiary referral clinic in South Africa. METHODS: A retrospective analysis was undertaken on all patients with a diagnosis of PHPT attending the endocrinology clinic at a tertiary referral hospital in Durban, South Africa, between January 2003 and June 2009. Information on clinical presentation, past medical history, biochemistry, radiology, histology and surgical notes were recorded. Patients with multiple endocrine neoplasia were excluded. RESULTS: A total of 28 case records of PHPT were reviewed. The mean age at presentation was 60±14.5 years with a female preponderance (78.6%). The mode of presentation included referral for investigation of an abnormal serum calcium (n: 23), referral from urologist with nephrolithiasis (n: 3) and for investigation of bone disease (n: 2). Symptomatic disease was found in 26 patients (92.9%), including bone pain (75%), fatigue (46.4%) and abdominal pain (32.1%). Mean serum calcium was 3.0+0.39 (normal 2.08-2.65) mmol/L, serum intact PTH 34.7±41.5 (normal 1.2-8.5) pmol/L and serum alkaline phosphatase 206.3±340.2 (normal 53-141) mIU/L. Sestamibi scan was performed on 24 patients and an adenoma was identified in 83.3%. Of the 19 (68%) patients who had parathyroidectomy, an adenoma was identified as the cause in all cases where histology was available (n:18). Surgery was successful in 18 patients with only one patient requiring repeat parathyroidectomy for persistent hypercalcaemia. Postoperative hypocalcaemia developed in eight patients (42.1%) including four patients who required intravenous calcium infusion for symptomatic hypocalcaemia. CONCLUSIONS: PHPT is a treatable disorder with good surgical success. Asymptomatic disease was uncommon in this group of patients. This is compatible with the symptomatic pattern of presentation reported in other developing countries.