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Browsing by Author "Bhigjee, Ahmed Iqbal."

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    Cervical spondylotic myelopathy : a prospective study of outcome after surgery.
    (2014) Harrichandparsad, Rohen.; Bhigjee, Ahmed Iqbal.
    Background: The natural history of cervical spondylotic myelopathy (CSM) is mixed. Surgical decompression is offered to patients with the aim of improving functional outcome. In some patients with chronic myelopathy, the aim is to prevent further deterioration. Despite surgical decompression, the functional status of some patients may deteriorate. CSM thus has a variable prognosis and it is difficult to predict neurological recovery after surgical decompression. There is a lack of consistency in the currently available literature regarding post-operative outcomes. Objectives: 1. To prospectively assess and compare the pre and post-operative clinical and functional status of patients with CSM using the modified Japanese Orthopaedic Association (mJOA) scores and the modified Myelopathy Disability Index (mMDI) scores at baseline, 3, 6 and 12 months post surgery. 2. To prospectively assess the natural history of patients with CSM who did not undergo surgery using the mJOA and mMDI scores at baseline, 3, 6 and 12 months. 3. To identify factors which influence outcome. Materials and Methods: All eligible patients in whom a diagnosis of CSM was made from 01 January 2011 to 31 December 2012 were evaluated. A neurologist (independent of the surgical team) performed baseline mJOA and mMDI scores. This was repeated at 3, 6, 12 and in some patients 24 months after surgery. Patients who refused or were not fit for surgery were also evaluated with mJOA and mMDI scores at baseline, 3, 6, 12 and in some, 24 months later by a 8 of 113 neurologist. These patients formed the natural history group. A minimum of 12 months follow up was obtained in all patients with a total of 540 months of follow up. The following factors were evaluated: age at presentation; gender; cigarette smoking; duration of symptoms; HIV status; presence of T2WI cord signal cord abnormality on MRI; number of cervical disc levels operated upon / affected; surgical approach used and post-operative complications. We also assessed recovery / progression of individual aspects of the mJOA: upper limb; lower limb; sensation and sphincters in both groups. Severity of CSM was assessed as mild if baseline mJOA score was ≥ 12 and moderate-severe if baseline mJOA score was < 12. Results: Surgery was associated with significant improvement in clinical recovery as assessed by mJOA scores at 3, 6 and 12 months post-operatively with p-values of 0.0002, 0.0001 and 0.0067 respectively. Upper limb function improved after surgery as assessed by the upper limb component of the mJOA score at 3, 6 and 12 months with p-values of 0.0096, 0.0030 and 0.0459 respectively. Lower limb function also improved significantly as assessed by the lower limb recovery scores at 3, 6 and 12 months with p-values of 0.0256, 0.0011 and 0.0107 respectively. Sensation and sphincter function did not improve after surgery. There was significant functional recovery as assessed by mMDI scores at 3, 6 and 12 months after surgery with p values of 0.0001, 0.0001 and 0.0023 respectively. There was no significant clinical or functional improvement in the non-surgical group when looking at overall mJOA and mMDI scores at 3, 6 and 12 months. Furthermore, there was no improvement in upper limb, lower limb, sensation or sphincter function in the non-surgical group as assessed by individual components of the mJOA score at 3, 6 and 12 months. 9 of 113 When assessing factors that could predict outcome we found that the patients’ age, gender, smoking status and duration of symptoms had no effect on outcome. The presence of T2WI cord signal abnormality on baseline MRI was associated with more severe CSM at presentation (p=0.036), but this did not affect outcome. Those with moderate-severe CSM at baseline had a better recovery at 12 months (p=0.025). The occurrence of intra-operative complications resulted in a worse outcome with both clinical and functional recovery rates worse at 3 months. Clinical recovery as assessed by mJOA score normalised at 12 months (p=0.235), but these patients were still functionally impaired as assessed by mMDI at 12 months (p=0.005). Conclusions: Patients with CSM benefit from surgical decompression regardless of baseline severity, with significant clinical and functional improvement noted at least 12 months post-operatively. Upper and lower limb function improves significantly, but sensation and sphincter function do not recover. The occurrence of intra-operative complications results in a worse outcome and this negative effect is still seen 12 months post-operatively. Patients who are managed non-operatively do not show significant improvement and 42% have some clinical deterioration at 12 months. Identification of patients with mild CSM (mJOA score ≥ 12) who can be safely managed non-operatively remains a challenge, however it appears that this is a reasonable option in patients with mild CSM and no T2WI cord signal abnormality on MRI.
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    Molecular diagnosis and typing of HTLV-I in KwaZulu-Natal.
    (1998) Tarin, Michelle Lucille.; York, Denis Francis.; Bhigjee, Ahmed Iqbal.
    Two areas of the HTLV-I genome were targeted for an in-house molecular diagnostic test, namely the pol and env regions. The pol primers proved the most sensitive (100%)and specific (100%). Amplification using the env primer pair was not reproducible, and was not pursued further. The AmpliSensor assay (Acugen Systems, Lowell, MA) was also tested. The assay was very specific, but not as sensitive as our in-house PCR. To investigate the predominant HTLV-I subtype in the region, a 1535 by env gene was isolated from peripheral blood obtained from five local HTLV-I seropositive patients. Four of the patients presented with HAM/TSP, and the fifth presented with a skin disease. Nucleotide sequencing of the amplified products revealed the local strains to be very conserved, differing by 0.1% to 0.9% among themselves. No apparent difference was noted for the two clinical manifestations. Phylogenetic analysis was performed using repesentative strains from around the world. The local strains clearly fell within the cosmopolitan subtype. The local strains were most closely related to the North American strains suggesting an unexpected link between the two countries.
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    Multidrug-resistant Tuberculous Meningitis in KwaZulu-Natal, South Africa.
    (The Infectious Diseases Society of America., 2003) Patel, Vinod B.; Padayatchi, Nesri.; Bhigjee, Ahmed Iqbal.; Allen, J.; Bhagwan, B.; Moodley, A. A.; Mthiyane, T.
    Multidrug-resistant (MDR) pulmonary tuberculosis (TB) is well described in the literature. Reports of MDR TB meningitis (MDR-TBM), however, are limited to case reports and a single case series. During the period of 1999-2002, 350 patients with TBM were identified by cerebrospinal fluid culture for TB. Thirty patients (8.6%) had TB that was resistant to at least isoniazid and rifampicin. All 30 patients were included in this study. We reviewed hospital charts of the patients with MDR-TBM and describe our experience. Seventeen patients with MDR-TBM died, and, of those who were known to be alive, many experienced significant morbidity. Eighteen patients were HIV positive. Twenty-two patients had been treated for TB in the past, 3 patients had received no previous treatment for TB, and the history of TB treatment was unknown for 5 patients. The study highlights the prevalence of MDR-TBM and identifies new challenges in the management of affected patients.
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    A qualitative and quantitative magnetic resonance diffusion study investigating the pathogenesis of cryptococcal-induced visual loss.
    (2013) Moodley, Anandan A.; Rae, William Ian Duncombe.; Bhigjee, Ahmed Iqbal.
    Background: Cryptococcal induced visual loss is common and increasingly becoming a debilitating consequence in survivors of cryptococcal meningitis (CM). Conflicting reports of the optic neuritis and papilloedema models of visual loss have delayed the introduction of effective interventional strategies for prevention and treatment of visual loss in CM. Qualitative and quantitative diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) of the optic nerves have proven useful in the examination of the microstructure of the optic nerve especially in optic neuritis. Its application has been extrapolated to other optic nerve disorders such as ischaemic optic neuropathy and glaucoma. The aim of this study is to elucidate the pathogenesis of cryptococcal-induced visual loss using diffusion imaging of the optic nerve as an investigational tool. Method: Full ethical approval was obtained from the Greys Hospital, Department of Health and University of KwaZulu Natal Ethics Committees. Reliable and reproducible optic nerve diffusion techniques were first developed and optimized on 29 healthy volunteers at Greys Hospital, Neurology and Radiology departments using a Philips 1.5 Tesla Gyroscan. Informed consent was also obtained from 95 patients suffering from CM (≥18 yrs. of age), 14 patients with papilloedema and 14 patients with optic neuritis from other causes, recruited from Greys and Edendale Hospitals. Patients underwent full neuro-ophthalmological assessments, CSF examination, haematological workup, CD4 count, (viral load for some), electrophysiological assessment of vision [Visual evoked potential (VEP) and Humphreys visual fields (HVF)], Magnetic Resonance Imaging (MRI) scan of the brain and orbits and DWI and DTI of the optic nerves. Results and Discussion: Visual loss is common in CM, occurring in 34.6-48%. Optic neuritis was uncommon as evidenced by a lack of signal change and lack of enhancement within the optic nerve in all patients scanned. The peri-optic CSF space was not dilated and the optic nerve diameter was not increased regardless of CSF pressure and visual status. Swollen optic discs occurred in only 25% of patients whereas raised intracranial pressure (> 20cmCSF) was demonstrated in 69-71% of patients. Therefore visual loss could not be explained by papilloedema alone. The VEP P100 latency was shown to be a useful screening test for subclinical optic nerve disease in CM, but HVF was not. The optic nerve diffusion imaging used was reliable and reproducible and produced diffusion parameters equivalent to other investigators in the field. Neither optic nerve movement nor the CSF signal was demonstrated to impact significantly on optic nerve diffusion parameters. Optic nerve diffusion imaging did not demonstrate similarities between CM and papilloedema or optic neuritis regardless of CSF pressure or vision. Conclusion: The rarity of optic neuritis in CM and the disparity between papilloedema and visual loss together with the lack of support from diffusion studies suggest a 3rd mechanism of visual loss viz. the optic nerve compartment syndrome. Good clinical support is provided by a case report for this hypothesis that shows re-opening of the peri-optic CSF space and return of the peri-optic CSF signal on MRI with lowering of intracranial pressure and antifungal treatment.
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    Screening for and diagnosing dementia in an elderly residential home population : a validation study.
    (2014) Ramlall, Suvira.; Pillay, Basil Joseph.; Bhigjee, Ahmed Iqbal.
    Background: With the projected increase in the elderly population and expected rise in the prevalence of dementia, particularly in low-and-middle-income countries, early case identification is necessary for planning and delivering clinical services. The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aims of this research study were to report on the prevalence of cognitive impairment (dementia and Mild Cognitive Impairment-MCI), and to assess the performance of selected screening tools and a neuropsychological battery of tests in a heterogeneous local population. Methodology A cross-sectional study was conducted in a heterogeneous elderly South African population and consisted of three stages of data collection. In the first stage, cognitive screening measures were administered to a group of 302 participants, aged +60 years, living in a residential facility for the aged. The second stage consisted of a sub-sample of 140 participants who were assessed for cognitive impairment based on the Diagnostic and Statistical Manual of Mental Disorders 4th Edition-Text Revised criteria (DSM-IV-TR). Criteria A and B for Alzheimer’s and Vascular dementia were applied to assign a diagnosis of dementia without reference to aetiology. The participants were also assessed for Mild Cognitive Impairment (MCI), based on the criteria of the International Working Group on Mild Cognitive Impairment. Of the 140 participants in stage two, 117 were administered a neuropsychological battery of tests in the third stage. The influence of demographic variables and the sensitivity, specificity and optimum cut-off scores were determined for the following seven selected screening measures, individually and in combination: the Mini- Mental State Examination (MMSE), Subjective Memory Complaint (SMC), Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO), Subjective Memory Complaint Clinical (SMCC) and the Clock Drawing Test (CDT). The sensitivity and specificity of the neuropsychological tests in the detection of dementia were also determined. Results Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Performance on the screening measures was influenced by race, age and education. Using ROC analyses, the SMCC, MMSE and CDT were found to be moderately accurate in screening for dementia with AUC >.70. Neuropsychological test performance was influenced by the age, gender, race and education level of participants. With the exception of the Digit Span (forward), Digit Span (total), COWAT-A, Narrative Memory Test (delayed recall), Token Test and the Luria Hand Sequence Test, all the neuropsychological test measures displayed significance in distinguishing between the three classification groups (controls, MCI, dementia). Conclusion SMCC’s are valid screening questions as a first level of ‘rule-out’ screening. The MMSE can be included at a second stage of screening at general hospital level and the CDT in specialist clinical settings. Several measures from the neuropsychological battery of tests evaluated have discriminant validity and diagnostic accuracy for the differential diagnosis of cognitive disturbances in an elderly heterogeneous South African population .
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    Some aspects of HTLV-1 infection in Natal, South Africa.
    (1992) Bhigjee, Ahmed Iqbal.; Bill, Pierre Louis Alfred.
    Abstract available in PDF.