A Profile and Three-Year Follow-Up of Patients with Basal Cell Carcinoma in the Western Cape, South Africa.

Background: Basal cell carcinoma (BCC) is an important malignancy in sub-Saharan Africa. There is a paucity of data regarding BCC in South Africa. Aims: To describe the clinicopathological features of patients presenting with BCC in a cohort of South African patients. Methods: This retrospective descriptive study reviewed the medical records of 149 patients with BCC who attended the dermatology clinic at Tygerberg Academic Hospital from September 2015 to August 2016. Demographic and clinical data of those patients with histologically proven BCC were retrieved from clinical records. The data included the assessment for BCC recurrence after three years (September 2016-August 2019). Results: Of 390 patients, 155 (39.7%) had histologically confirmed BCCs. Complete medical records were available for 149 of these patients, and most were male (55.7%) and white (85.9%) with a median age of 70 years. Most patients had their BCC lesions for 12 months (43.1%) before diagnosis. BCCs were mostly located on the head and neck area (58.1%). In most patients (72.0%), a diagnostic punch biopsy confirmed BCC. Plastic surgeons subsequently excised the BCC lesions in 74.0% of these patients. The most common histological subtype was nodular BCC (74.0%). The National Comprehensive Cancer Network (NCCN) risk of recurrence was approximately evenly distributed between high- (54.1%) and low-risk groups (45.9%). The major high-risk feature was the location (36.6%). Histologically confirmed BCC recurrence occurred in 9 of the 149 patients (3.7%) over three years. Conclusions: BCC represents a high burden of disease in our setting. Compared to existing studies, the BCCs in this study are clinically and histologically similar to international reports.

Clinical and pathological features of acral melanoma in a South African population: A retrospective study.

BACKGROUND: Acral melanoma (AM) is a rare subtype of cutaneous melanoma (CM) that disproportionately affects skin of colour and carries a poorer prognosis than other melanoma subtypes. The poor prognosis is attributed to late diagnosis and subsequent relatively high Breslow thickness, but also to an intrinsic biological aggressiveness. Scientific data on AM from the developing world are limited and a need exists to characterise the disease further in the South African (SA) population. OBJECTIVES: To describe the clinical and pathological features of AM in an SA population. METHODOLOGY: A retrospective chart review characterised the demographics, clinical features and histological data of 66 patients diagnosed with AM between January 2010 and June 2016 at Tygerberg Academic Hospital, Cape Town, SA. RESULTS: Sixty-six patients with AM were identified from 335 patients diagnosed with CM during the set time frame. The mean age (standard deviation (SD)) was 61.5 (12.5) years. Forty-two (63.6%) of the patients were female (male/female ratio 1:1.75). The majority of patients diagnosed with AM were black (48.5%), and the proportion of AM in black patients with CM was 80.0%. Fifty-six AMs (84.8%) were located on the foot and 10 (15.2%) on the hand. The median duration of the lesion before diagnosis was 10 months (range 2 - 84) and the mean (SD) tumour size was 3.8 (2.2) cm at diagnosis. The mean Breslow thickness of all AMs at diagnosis was 5.2 mm (median 4.2  mm, range 0 - 22). Stage of disease was known in 41 patients, 23 (56.1%) of whom had at least stage III disease at diagnosis. Mean Breslow thickness for foot and hand melanomas was 4.9 mm (range 0 - 22) and 6.9 mm (range 0 - 13.3), respectively (p=0.2552). The mean Breslow thickness in the black population was 6.3 mm compared with 4.2 mm and 4.3 mm, respectively, in the white and coloured populations (p=0.178). Patients from outside the Western Cape Province (WC) presented with a mean Breslow thickness of 6.6 mm (range 0 - 14.5) and patients from the WC with a mean Breslow thickness of 4.9 mm (range 0 - 22) (p=0.3602). CONCLUSIONS: AMs accounted for a significant proportion of all CMs diagnosed. Patients presented with an advanced stage of disease at diagnosis, and further studies are needed to further investigate the reasons for delayed diagnosis.

Rib fracture fixation in a South African public trauma service.

BACKGROUND: Rib fractures and flail chests have traditionally been treated nonoperatively. Current literature suggests that it is not only safe and feasible but also desirable to perform fixation of severe rib fractures. Our unit in the Pietermaritzburg public sector adopted rib fracture fixation in 2014 and in this audit we assess its feasibility in our setting. METHODS AND RESULTS: We audited our first nine cases of rib fracture fixation performed to date, of which seven were males. The age range was 29 to 67 years. All patients had multiple rib fractures with severe displacement; one had bilateral flail segments and one had severely displaced unilateral single fractures without flail; all others had unilateral flail chests. Time from injury to operation ranged from 3 to 20 days. Of six ventilator dependent patients, all but one were liberated from the ventilator within 3 days after fixation (1-3 days). The remaining patient remained ventilator dependent for 10 days while recovering from traumatic brain injury. This patient aside, all were discharged from ICU within 5 days. Patients with no other significant injuries were discharged from hospital within five to eight days; all being mobile within five days. Procedure-related complications included accidental pleural breach during rib mobilization necessitating intercostal drain placement (2 patients) and superficial wound infection (1 patient). All patients were discharged well. CONCLUSION: Rib fracture fixation is safe and feasible in our unit and is feasible in the South African public sector.

Pyoderma gangrenosum, acne, and suppurative hidradenitis syndrome in end-stage renal disease successfully treated with adalimumab.

PASH syndrome (pyoderma gangrenosum, acne, and suppurative hidradenitis) forms part of the spectrum of autoinflammatory diseases. We report an unusual case of PASH syndrome in a patient with end-stagerenal disease (ESRD) who was successfully treated with the tumor necrosis factor inhibitor, adalimumab. The case underscores the challenges associatedwith the treatment of PASH syndrome as well as the ongoing search to establish a genetic basis for the syndrome. Renal impairment has been reported in association with pyoderma gangrenosum but has notbeen described in PASH syndrome. We believe this to be the first reported case of a patient who developed PASH syndrome in the setting of ESRD.

Effect of gender and race on the week 48 findings in treatment-naïve, HIV-1-infected patients enrolled in the randomized, phase III trials ECHO and THRIVE.

OBJECTIVES: A week 48 efficacy and safety analysis with respect to gender and race was conducted using pooled data from the phase III, double-blind, double-dummy efficacy comparison in treatment-naïve, HIV-infected subjects of TMC278 and efavirenz (ECHO) and TMC278 against HIV, in a once-daily regimen versus efavirenz (THRIVE) trials. METHODS: Treatment-naïve, HIV-1-infected adults were randomized to receive rilpivirine (RPV; TMC278) 25 mg once a day (qd), or efavirenz (EFV) 600 mg qd, plus tenofovir/emtricitabine (ECHO) or tenofovir/emtricitabine, zidovudine/lamivudine or abacavir/lamivudine (THRIVE). RESULTS: A total of 1368 participants (76% male and 61% White, of those with available race data) were randomized and treated. No gender-related differences in response rate (percentage of patients with HIV-1 viral load < 50 HIV-1 RNA copies/mL, using an intent-to-treat, time-to-loss-of-virological-response algorithm) were observed (RPV: men, 85%; women, 83%; EFV: men, 82%; women, 83%). Response rates were lower in Black compared with Asian and White participants (RPV: 75% vs. 95% and 85%, respectively; EFV: 74% vs. 93% and 83%, respectively); this finding was mostly a result of higher discontinuation and virological failure rates in Black patients. Safety findings were generally similar across race and gender subgroups. However, nausea occurred more commonly in women than in men in both treatment groups. In men, diarrhoea was more frequent in the EFV group, and abnormal dreams/nightmares were more frequent in men in both the EFV and RPV groups. CONCLUSIONS: Overall response rates were high for both RPV and EFV. No gender differences were observed. However, response rates were lower among Black patients, regardless of treatment group. Gender appeared to influence the incidence of gastrointestinal adverse events and abnormal dreams/nightmares for both treatments.

High density lipoprotein deficiency and foam cell accumulation in mice with targeted disruption of ATP-binding cassette transporter-1.

Recently, the human ATP-binding cassette transporter-1 (ABC1) gene has been demonstrated to be mutated in patients with Tangier disease. To investigate the role of the ABC1 protein in an experimental in vivo model, we used gene targeting in DBA-1J embryonic stem cells to produce an ABC1-deficient mouse. Expression of the murine Abc1 gene was ablated by using a nonisogenic targeting construct that deletes six exons coding for the first nucleotide-binding fold. Lipid profiles from Abc1 knockout (-/-) mice revealed an approximately 70% reduction in cholesterol, markedly reduced plasma phospholipids, and an almost complete lack of high density lipoproteins (HDL) when compared with wild-type littermates (+/+). Fractionation of lipoproteins by FPLC demonstrated dramatic alterations in HDL cholesterol (HDL-C), including the near absence of apolipoprotein AI. Low density lipoprotein (LDL) cholesterol (LDL-C) and apolipoprotein B were also significantly reduced in +/- and -/- compared with their littermate controls. The inactivation of the Abc1 gene led to an increase in the absorption of cholesterol in mice fed a chow or a high-fat and -cholesterol diet. Histopathologic examination of Abc1-/- mice at ages 7, 12, and 18 mo demonstrated a striking accumulation of lipid-laden macrophages and type II pneumocytes in the lungs. Taken together, these findings demonstrate that Abc1-/- mice display pathophysiologic hallmarks similar to human Tangier disease and highlight the capacity of ABC1 transporters to participate in the regulation of dietary cholesterol absorption.

Genotypic Diversity of Sphaeropsis sapinea from South Africa and Northern Sumatra.

Sphaeropsis sapinea is the most important pathogen of Pinus spp. in South Africa. The fungus, which reproduces only asexually, occurs on exotic Pinus spp. In this study, the diversity of the S. sapinea population in South Africa was compared with a population from Northern Sumatra. The populations for both countries were obtained from exotic Pinus patula plantations. The phenotypic diversity of these populations was assessed using vegetative compatibility tests. The percent maximum genotypic diversity, based on Stoddart and Taylor's index, for the South African population was 30.5% compared with 1.5% for the Northern Sumatran population. Based on the number of phenotypes, the South African S. sapinea population was significantly more diverse (P = 0.05) than that of the Northern Sumatran population. The results indicate that the population of S. sapinea in South Africa has, in all likelihood, arisen as a result of introductions of the fungus on pine seeds imported from various parts of the world during the last century.

Production and characterization of guinea pig IL-5 in baculovirus-infected insect cells.

To study the role interleukin (IL)-5 may play in altering airway function in asthma, we have produced recombinant protein for exogenous administration to guinea pigs. The guinea pig IL-5 (gpIL-5) cDNA was cloned by polymerase chain reaction (PCR) amplification of guinea pig spleen RNA and expressed as a secretion product from recombinant baculovirus-infected Sf9 insect cell cultures. The protein was purified to homogeneity by a four-step procedure that included immunoaffinity chromatography using polyclonal antipeptide antibodies against a region of the mature secreted cytokine. The cytokine was properly processed after the signal sequence by the Sf9 cells, was glycosylated with terminal mannose-containing oligosaccharide, and had proper disulfide-linked dimer structure as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The purified preparation was active in vitro and in vivo as determined by its ability to prime human basophils to release leukotriene C4 in the presence of C5a and to induce airway eosinophilia in naive guinea pigs.

Analysis of recombination rate in female and male gametogenesis in pearl millet (Pennisetum glaucum) using RFLP markers.

Sex as a factor affecting recovered recombination in plant gametes was investigated in pearl millet, Pennisetum glaucum, by using reciprocal three-way crosses [(AxB)xCvCx(A x B)]. The two populations were mapped at 42 loci pre-selected to cover the majority of the genome. No differences in recombination distances were observed at the whole-genome level and only a few individual linkage intervals were found to differ, all in favour of increased recombination through the male. Distorted segregations found in the three-way crosses provide evidence of post-gametic selection for particular gene(s) or chromosome regions. The significance of these results for the design of pearl millet breeding programmes and inheritance experiments, as well as for other experimental strategies, is discussed.

Haematological condition of the San (Bushmen) relocated from Namibia to South Africa.

A cross-sectional study was undertaken to assess the haematological condition of the San (Bushmen) relocated from Namibia to South Africa. We studied 238 subjects--145 men and 93 women; none of the women was pregnant. We performed full blood counts and estimations of serum vitamin B12, folate, ferritin and erythrocyte folate concentrations. The mean haemoglobin concentration among the men was 14.7 g/dl and 19 (13%) were anaemic; among the women it was 13.8 g/dl and 18 (19%) were anaemic. Thirteen (9%) of the men and 22 (24%) of the women had low concentrations of serum ferritin, and 38 (26%) of the men and 22 (24%) of the women had erythrocyte folate concentrations of less than 270 nmol/l. Three (2%) men and 4 (4%) women had serum vitamin B12 concentrations of less than 120 pmol/l. Eighty-one (56%) of the men and 76 (82%) of the women had eosinophilia, probably because of parasitic infections. It would appear from this and previous studies that prolonged exposure of these hunter-gatherers to a Western lifestyle has resulted in a high prevalence of anaemia, caused by low iron and folate intakes, complicated by alcohol consumption.

Cervical intra-epithelial neoplasia and invasive cervical cancer in black and white patients.

The relative incidences of cervical intra-epithelial neoplasia (CIN) and invasive cervical cancer were studied in black and white patients at the academic hospitals of the University of the Orange Free State. A statistically highly significant difference was found between black and white patients, with a higher incidence of invasive cervical cancer than stage III CIN (CIN III) in black patients and a higher incidence of CIN III than invasive cervical cancer in white patients (P = 0.000092; 95% confidence interval -0.355-(-)0.128). The time interval between the peak incidence of CIN III and that of invasive cervical cancer was found to be shorter in black than in white patients. These distressing findings emphasise the urgent need for a national cervical cytological screening programme to decrease the incidence of invasive cervical cancer. This serious yet preventable disease is still very prevalent in South Africa, especially among black women.

Erythrocyte sedimentation rate in elderly blacks.

This study investigated the erythrocyte sedimentation rate (ESR) in an elderly population with the objective of establishing reference ranges and the diagnostic value of the ESR. Elderly blacks were randomly selected from communities in the Orange Free State. ESR determinations were done according to the Westergren method. Total protein, albumin, immunoglobulin and C-reactive protein (CRP) levels were measured on serum. Results were analysed by means of non-parametric statistical methods. In the group with normal CRP' and immunoglobulin levels it was found that 99% of values were below 44 mm/h for men and 62 mm/h for women. The sensitivity and specificity for these cut-off values (CRP used as 'gold standard') were 33% and 91% respectively for men and 75% and 89% respectively for women.

[Partial ileal bypass for familial hypercholesterolemia]. / Gedeeltelike ileale omleiding vir familiële hipercholesterolemie.

The extent of reduction in cholesterol levels, the maintenance of low levels in the long-term, the morbidity and mortality as well as the acceptance of side-effects of the partial ileal bypass (PIB) is reviewed. The mean reduction in cholesterol levels following PIB was 35.2% in males and 35.8% in female patients. The reduction is significant and it is maintained over a 10-year period. The morbidity and mortality is low and side-effects are well tolerated. Our results indicate that the PIB may play an important role in the cholesterol-lowering armamentarium.

The incidence of surgical glove perforation during obstetric and gynaecological surgical procedures.

The increasing prevalence of diseases such as AIDS and hepatitis B makes safe surgical techniques more important than ever before. Intact surgical gloves act as a barrier against these infections and a study was therefore done to determine the incidence of surgical glove perforation during obstetric and gynaecological surgical procedures. Surgical gloves were collected and tested for perforations following 353 consecutive obstetric and gynaecological operations. Forty pairs of new unused surgical gloves were tested for perforations in the same way. Whereas none of the 40 control pairs of gloves was found to be perforated, 22%-24% of used gloves were perforated. The experience of the surgeon had no influence on the incidence of glove perforation (P = 0.997; chi 2-test). Left-hand gloves were more frequently perforated than right-hand gloves, but this difference was not statistically significant (P = 0.075: chi 2-test). These findings must be a source of concern to all those practising obstetrics and gynaecology and measures are therefore suggested to decrease the risk of HIV or hepatitis B transmission during operations.

Surgical glove powder and intraperitoneal adhesion formation. An appeal for the use of powder-free surgical gloves.

Intraperitoneal adhesion formation is a major cause of infertility and/or intestinal obstruction. Among the many well-known aetiological factors responsible for peritoneal inflammatory reaction is surgical glove powder; for example, cornstarch powder. A study was undertaken on 30 rats to determine whether cornstarch powder caused intraperitoneal adhesions. The rats were randomised into two groups under laboratory conditions. Laparotomies were performed on all the rats and trauma inflicted to the right uterine horn. The study group received cornstarch powder suspended in normal physiological salt solution intraperitoneally, and the control group received only normal physiological salt solution. Peritoneal adhesions were evaluated after 2 weeks and statistically analysed with a t-test and 95% confidence intervals. The study group showed a statistically significantly higher incidence of intraperitoneal adhesions (P = 0.0003). It is concluded that cornstarch, as used on surgical gloves, caused peritoneal adhesions and should therefore be removed before surgery. Powder-free gloves are more suitable for preventing adhesion formation.

The diagnosis of abdominal injuries in comatose patients.

The clinical course of 95 comatose trauma patients was prospectively evaluated. The role of clinical findings and diagnostic peritoneal lavage (DPL) combined with computed tomography (CT) were assessed in the diagnosis of abdominal injuries. Seven per cent of the patients were comatose due to hypoperfusion, and did not have a primary brain injury. Of the remaining 88 patients, 28% had an associated abdominal injury. Hypotension predicted an associated abdominal injury with an accuracy of 72%, and a haematocrit less than 30% had an accuracy of 82%. Clinical examination was 50% accurate. DPL was 93% accurate, with a false-positive rate of 10%. No abdominal injuries were present in the group in whom the lavage results were negative, while no unnecessary laparotomies were performed in the group with a 4+ or 5+ positive DPL (calorimetric method). In the group with 1+, 2+ and 3+ positive DPL, 3/15 laparotomies (12%) were done for minor abdominal injuries. Minimising unnecessary laparotomies was achieved by utilising CT to determine the nature and extent of the injury. By using DPL as a screening test, and CT to quantify the injury, unnecessary operations can be avoided, and all injuries can still be diagnosed.

Paediatric trauma care.

Paediatric trauma care varies in different countries. In South Africa injury is the leading cause of death in the 5-14-year-old age group--1.5-3.8 times higher than in the USA. In 1978 the Child Safety Centre was established and prospectively collected data on paediatric injuries. The various types of injuries are discussed. Trauma is responsible for the highest percentage of years of life lost but the least amount of money is being spent on research and prevention of injuries. The Child Accident Prevention Foundation of Southern Africa has been constituted to research, prevent and reduce the risk factors of the injuries and to improve facilities for the injured child.

Cervical cytological services in the Orange Free State. Demographic characteristics.

In the Bloemfontein academic hospitals the incidence of infiltrating cervical cancer is four times that of severe cervical intra-epithelial neoplasia (CIN III). A cross-sectional survey was therefore conducted to identify the extent of cervical cytological services in the Orange Free State. From the four major laboratories dealing with the population of the OFS all cytological reports of one randomly chosen working day per month in 1985 were analysed for three demographic variables: age, race, and locality according to census district. As a control, similar demographic variables were identified from national census figures for 1980, limited to females aged 15-65 years. The follow-up of patients with CIN III diagnosed cytologically in the academic hospitals in Bloemfontein was determined. Results showed significant differences (P less than 0.001) in age, race and locality between the census population and that submitted to cytological screening. Acceptable figures were virtually limited to Bloemfontein, predominantly in white patients, while three-quarters of the population of the OFS is black. The peak frequency in the age distribution in the screened population was 25-35 years and 15-24 years for the census population. Follow-up for patients with CIN III was 65.5%. The conclusion is that the female population of the OFS is not representatively reached by existing cytological services.