Echocardiographic features of infective endocarditis in South Africa: A prospective cohort study.

BACKGROUND: Historically, infective endocarditis (IE) in South Africa (SA) was associated with the viridans group of streptococci affecting patients with underlying rheumatic heart disease (RHD). A changing IE bacteriological profile raises the question of whether the profile of underlying valvular abnormality has changed. OBJECTIVES: To investigate the prevalence of underlying structural valve abnormalities and their aetiologies associated with IE in SA, and describe the typical imaging findings. METHODS: The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and April 2021. Patients underwent detailed transthoracic and transoesophageal echocardiography to assess their underlying cardiac and valvular structure. RESULTS: Among 71 patients included, a predisposing endocardial abnormality was detected in 49.3%, with RHD the most common single identifiable aetiology (16.9%). The in-hospital mortality rate was similar in patients with and without a predisposing endocardial abnormality (20% v. 16.7%; p=0.72), as was the rate of embolic events (20% v. 27.2%; p=0.58). Significantly more patients with a predisposing endocardial abnormality had an indication for surgery (94.3% v. 69.4%; p<0.01). The viridans group of streptococci was more prevalent in patients with a predisposing endocardial abnormality (25.7% v. 2.7%; p<0.01). Left-sided linear vegetation size >10 mm was associated with an increased risk of in-hospital mortality (24% v. 5%; p=0.05). CONCLUSION: We observed a marked decrease in the prevalence of RHD in this cohort of patients with IE. The viridans group of streptococci was an uncommon cause of IE in patients with no predisposing endocardial abnormality detected. The presence of a predisposing endocardial abnormality was not associated with an increased risk of in-hospital mortality or embolic events. Linear vegetation length >10 mm was associated with an increased risk of in-hospital mortality in patients with left-sided IE.

New ecosystems in the deep subsurface follow the flow of water driven by geological activity.

Eukarya have been discovered in the deep subsurface at several locations in South Africa, but how organisms reach the subsurface remains unknown. We studied river-subsurface fissure water systems and identified Eukarya from a river that are genetically identical for 18S rDNA. To further confirm that these are identical species one metazoan species recovered from the overlying river interbred successfully with specimen recovered from an underlying mine at -1.4 km. In situ seismic simulation experiments were carried out and show seismic activity to be a major force increasing the hydraulic conductivity in faults allowing organisms to create ecosystems in the deep subsurface. As seismic activity is a non-selective force we recovered specimen of algae and Insecta that defy any obvious other explanation at a depth of -3.4 km. Our results show there is a steady flow of surface organisms to the deep subsurface where some survive and adapt and others perish. As seismic activity is also present on other planets and moons in our solar system the mechanism elucidated here may be relevant for future search and selection of landing sites in planetary exploration.

Data Centre Profile: The Provincial Health Data Centre of the Western Cape Province, South Africa.

INTRODUCTION: The Western Cape Provincial Health Data Centre (PHDC) consolidates person-level clinical data across government services, leveraging sustained investments in patient registration systems, a unique identifier, and maturation of administrative and clinical digital health systems. OBJECTIVES: The PHDC supports clinical care directly through tools for clinicians which integrate patient data or identify patients in need of interventions, and indirectly through supporting operational and epidemiological analyses. METHODS: The PHDC is housed entirely within government. Data are processed from a range of source systems, usually daily, through distinct harmonisation and curation, beneficiation, and reporting processes. Linkage is predominantly through the unique identifier which doubles as a pervasive folder number, augmented by other identifiers. Further data processing includes triangulation of multiple data sources for enumerating health conditions, with assignment of certainty levels for each enumeration. Outputs include patient-specific email alerts, a web-based consolidated patient clinical viewing platform, filterable line-listings of patients with specific conditions and associated characteristics and outcomes, management reports and dashboards, and data releases in response to operational and research data requests. Strict architectural, administrative and governance processes ensure privacy protection. RESULTS: In the past decade 8 million unique people are recorded as having sought healthcare in the provincial public sector health services, with current utilisation at 15 million attendances or admissions a year. Cross-sectional enumeration of health conditions includes over 430 000 people with HIV, 500 000 with hypertension, 235 000 with diabetes. Annually 110 000 pregnancies and 54 000 patients with tuberculosis are enumerated. Over 50 data requests are processed each year for internal and external requesters in accordance with data request and release governance processes. CONCLUSIONS: The single consolidated environment for person-level health data in the Western Cape has created new opportunities for supporting patient care, while improving the governance around access to and release of sensitive patient data.

Eukaryotic opportunists dominate the deep-subsurface biosphere in South Africa.

Following the discovery of the first Eukarya in the deep subsurface, intense interest has developed to understand the diversity of eukaryotes living in these extreme environments. We identified that Platyhelminthes, Rotifera, Annelida and Arthropoda are thriving at 1.4 km depths in palaeometeoric fissure water up to 12,300 yr old in South African mines. Protozoa and Fungi have also been identified; however, they are present in low numbers. Characterization of the different species reveals that many are opportunistic organisms with an origin due to recharge from surface waters rather than soil leaching. This is the first known study to demonstrate the in situ distribution of biofilms on fissure rock faces using video documentation. Calculations suggest that food, not dissolved oxygen is the limiting factor for eukaryal population growth. The discovery of a group of Eukarya underground has important implications for the search for life on other planets in our solar system.

Regional anaesthesia for cleft lip surgery in a developing world setting.

BACKGROUND: The role of regional anaesthesia in cleft lip surgery in the developing world is not well documented. METHOD: A retrospective chart review of 100 patients aged >14 years who had cleft lip surgery during an Operation Smile South Africa (OSSA) volunteer surgical programme in Madagascar during 2007 and 2008. The nerve blocks used included a bilateral infraorbital nerve block, a dorsalnasal nerve block and a septal block supplemented with peri-incisional local in_ltration. Appropriateness of the regional anaesthesia alone for cleft lip surgery was determined by absence of any intraoperative complications, postoperative complications or conversions to general anaesthesia. RESULTS: Seventy-four patients commenced their operation under regional anaesthesia. There were no intraoperative or postoperative complications documented, and no patient required conversion to general anaesthesia. Two patients required additional analgesia in the immediate postoperative period. CONCLUSION: Regional anaesthesia for cleft lip surgery in patients >14 years of age was well tolerated and associated with few complications. It is a safe and effective option when used as the sole anaesthetic modality for cheiloplasty in the developing world.

Clinical experience with end-to-side nerve transfer.

A retrospective study was undertaken to determine the effectiveness of end-to-side nerve transfer. Twenty patients with peripheral nerve lesions of varying aetiology underwent 23 end-to-side nerve transfers over a 15-month period. The mean patient age was 30 years and 18 were male. The mean delay in presentation was 2.4 months. All underwent end-to-side nerve repairs and were reviewed in outpatients at regular intervals. Ten patients were lost to follow-up before 12 months and were therefore excluded from the study. The remaining ten patients, who had undergone 13 end-to-side procedures, had a mean follow-up period of 16 months. None demonstrated objective evidence of motor recovery at the end of the study period. Four patients had modest recovery of deep protective sensation, and two patients suffered a subtle degree of "donor" nerve morbidity. We have abandoned this technique in our centre in preference for standard nerve grafting techniques.

Anaerobiospirillum succiniciproducens bacteraemia.

This report describes a case of bacteraemia caused by Anaerobiospirillum succiniciproducens. Anaerobiospirillum succiniciproducens is a rare cause of bacteraemia in humans, and when encountered usually occurs in immunocompromised patients. The organism is an anaerobic, spiral shaped, Gram negative bacillus with bipolar tufts of flagella. In this report, the morphology, with special reference to electron microscopic features, culture characteristics, and antimicrobial susceptibility are described.

Duplex Doppler investigation of suspected vascular lesions at the carotid bifurcation.

This prospective study was undertaken to evaluate the role of duplex Doppler (DD) scanning in the diagnosis of masses of suspected vascular origin at the carotid bifurcation. We also assessed the different DD signs of carotid body tumors, especially the difference in resistance index (RI) in the external carotid artery on the side of the tumor. Over a 3-year period (1987-1991) all patients (n = 50) with masses of suspected vascular origin at the angle of the mandible underwent DD investigation. The clinical diagnoses included carotid body tumors and carotid bifurcation area aneurysms. Arteriography was also performed in all patients. DD examination diagnosed carotid body tumors in 11 patients, aneurysms in 5, nonvascular lesions in 11, carotid artery kinks in 10, and a prominent carotid bifurcation in 13 patients. In 23 of 50 patients (46%) no pathology (kinks and prominent vessels) was present. DD imaging proved to be 100% accurate in diagnosing these lesions as determined by arteriography. The DD findings in carotid body tumors demonstrated a "wineglass" bifurcation containing a lesion with echoes as well as pronounced and turbulent multidirectional flow ("hypervascular tumor flow"). Low-resistance flow was present in the external carotid artery in 80% of patients, indicating the blood supply of the tumor. Patients with lumps of suspected vascular origin at the carotid bifurcation should be initially investigated by DD examination, which can accurately exclude the diagnosis of carotid body tumors and carotid aneurysms and clearly eliminate arteriography in these patients.

Changes in penile skin blood flow following intracavernosal injection of papaverine.

Marked changes in penile skin blood flow following intracavernosal injection of papaverine were observed in 14 subjects. Increased flow was more pronounced in those patients who failed to achieve erection or had poor erection than in those who responded with adequate erection. This observation may explain in part why papaverine fails in subjects responding to prostaglandin E1. It raises the suspicion of a corporal cutaneous shunt, which may influence the choice between the use of an external vacuum device and venous surgery in certain cases of venogenic impotence.

Gonadotropin and estradiol secretion during the week of placebo therapy in oral contraceptive pill users.

The changes in the hypothalamic-pituitary-ovarian axis during the placebo week in oral contraceptive pill users were assessed. Fifteen women using the combined oral contraceptive pill were studied for eight hours at the start and at the end of the placebo week and gonadotropin secretion and estradiol concentrations were compared with those in control women in the follicular phase of an unmedicated menstrual cycle. Both gonadotropin and estradiol concentrations were suppressed at the start of the placebo week. By day 7 of placebo, gonadotropin concentrations and pulse patterns were indistinguishable from those of the control subjects although estradiol concentrations were still significantly lower.

PIP: The changes in the hypothalamic-pituitary-ovarian axis during the placebo week in oral contraceptive (OC) users were assessed. 15 women who used a combined OC were studied for 8 hours at the start and at the end of the placebo week; gonadotropin secretion and estradiol concentrations were compared with those in control women during the follicular phase of an unmedicated menstrual cycle. Both hormone concentrations were suppressed at the start of the placebo week. By day 7 of placebo, gonadotropin concentrations and pulse patterns were indistinguishable from those of the controls although estradiol concentrations were still significantly lower.

Accuracy of B-mode ultrasonography in detecting carotid plaque hemorrhage and ulceration.

A prospective study comparing the accuracy of B-mode ultrasound with evaluation of gross appearance in detecting plaque hemorrhage and ulceration is reported. Ultrasonography was performed on 78 vessels in 66 patients undergoing carotid endarterectomy. Carotid bifurcation atheroma were classified ultrasonographically as smooth, irregular, or ulcerated. Sonolucent areas were considered to be plaque hemorrhage. Analysis of carotid plaques removed at operation included macroscopic and microscopic findings. Duplex Doppler was only 44% sensitive but 78% specific for plaque hemorrhage. If all irregular atheroma were considered ulcerated, the sensitivity of Duplex Doppler was 81% with specificity only 33%. If only lesions with a clearly visualized crater were considered ulcerated, B-mode ultrasound was 85% specific but only 17% sensitive. False B-mode ultrasound diagnoses of ulceration were mainly due to culs-de-sac or pits in fibrotic plaque that looked like ulcers. Ulceration was not noticed on B-mode when there was a two-dimensional problem or calcification with shadowing. False B-mode diagnoses of plaque hemorrhage were due to atheromatous debris, ulcerated plaque hemorrhage, or calcification. Problems still exist in the B-mode ultrasound diagnosis of carotid plaque hemorrhage and ulceration.

Atherosclerosis--multi-organ involvement the rule rather than the exception.

Atherosclerosis is a systemic disorder and significant lesions often occur in organ systems other than the symptomatic area. Three groups of patients, those admitted to hospital with either coronary artery disease, carotid artery stenosis or peripheral vascular disease, were examined for concomitant atherosclerotic lesions. Non-invasive tests, namely duplex scanning of the carotid arteries, arm ergometer exercise testing, and segmental pressure of the limbs, were used during evaluation. A clear association between ischaemic heart disease, carotid artery stenosis and femoropopliteal disease was found. Women appear to be more prone to multi-organ involvement than men; their higher average age on admission to hospital is a possible explanation for this in some cases, but not all.

The short-term use of luteinising hormone-releasing hormone analogues in uterine fibroids.

Twelve patients with uterine fibroids, who were due to undergo myomectomy, were treated preoperatively with the luteinising hormone-releasing hormone analogue, Zoladex. This resulted in a marked reduction in uterine and fibroid volume and surgery was facilitated.