Browsing by Author "Singh, Bhugwan."

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Complex regional pain syndrome (CRPS) and the role of sympathectomy in the management : a review.
(2012) Kinoo, Suman Mewa.; Singh, Bhugwan.
Complex Regional Pain Syndrome (CRPS) is an extremely debilitating condition, characterized by chronic pain with associated trophic changes. The 1st description of this condition dates back to 1864. The condition has been variously described over the years as “causalgia”, “Sudeck’s dystrophy” and “reflex sympathetic dystrophy”. In 1993 the International Association for the Study of Pain (IASP) introduced the term Complex Regional Pain Syndrome (CRPS) with diagnostic criteria that are currently used. CRPS was subdivided into type I and type II. CRPS type I is diagnosed when there is no obvious nerve injury, whereas CRPS type II refers to cases with nerve injury. It follows that the present diagnostic criteria depend solely on meticulous history and physical examination without any confirmation by specific gold standard tests. The pathophysiology of this pain syndrome is poorly understood; however there is growing evidence for an inflammatory or sympathetic cause. It is therefore not surprising that there is no uniform approach to its management. Therapy is often based on a multi-disciplinary team approach with use of non –pharmacological therapy (physiotherapy and occupational therapy), pharmacological therapy (analgesics, neuroleptics, bone metabolism drugs), and invasive therapy (stellate ganglion blocks and sympathectomy). This review acknowledges the humble beginnings of this condition, and provides an understanding for the evolution of its terminology. It objectively reviews the current IASP diagnostic criteria, challenging its efficacy and sensitivity. Despite its pathophysiology remaining an enigma, the latest pathophysiological advances are reviewed in the endeavour to better understand this condition and enhance treatment options. The role of surgical sympathectomy for this condition is reviewed, highlighting its importance and underappreciated success in the management of CRPS.
The pathophysiology of cholesterol gallstones amongst Black South African women living with HIV.
(2021) Mewa Kinoo, Suman.; Singh, Bhugwan.; Chuturgoon, Anil Amichund.
Thirteen percent of South Africans are living with HIV and of those infected, 52% are on antiretroviral therapy (ART). ART has changed the course of this terminal illness to one of a chronic illness. However, the longer life span of people living with HIV has brought about numerous metabolic disorders particularly with change in cholesterol metabolism and risk of cardiovascular disease. Gallstone disease (GD) is also known to be triggered by cholesterol metabolism changes; thus, it is postulated that people living with HIV and ART may be at risk for developing gallstones as well. In South Africa (SA), there is evidence of an increase incidence of GD in black South Africans, a disease once with a low incidence amongst this population group which makes up over 80% of the country’s population. GD also ranks as one of the world’s most expensive disorders to health care systems and thus investigating a causative relationship between HIV, ART and GD has relevance to reduce the burden on our already constrained health care system in SA. Aim The aim of this study was to determine differences in clinical profiles and regulators of hepatic cholesterol and bile acid metabolism in HIV+ve Black South African women on ART presenting with gallstones compared to HIV-ve Black South African women with gallstones. Methods A case series study was conducted amongst all Black South African women undergoing cholecystectomy for gallstone disease over a 1-year period at King Edward VIII Hospital, Durban, SA. A total of 52 patients (34 HIV-ve and 18 HIV+ve) were assessed. Classical risk profiles (age, BMI, children, family history) and lipogram levels. (LDL-c, HDL-c, triglycerides, total cholesterol) were compared between the HIV+ve and HIV-ve women. Categorical variables were tested using either the Fisher’s exact test or Pearson’s Chi-square test. Means were compared using independent t-tests. For non-normally distributed data, the Mann-Whitney test was used. Statistical tests were two-sided, and p values of less than 0.05 were considered as statistically significant. Liver biopsies from five HIV+ve women and five HIV-ve women were analyzed for hepatic expression of key genes in cholesterol metabolism (LDLr, HMGCR, ABCA1) and transcriptional regulators of these genes (microRNA-148a, SREBP2) using quantitative PCR. The same five HIV+ve and five HIV-ve women were evaluated for gene expression of CYP7A1, HNF1α, HNF4α, LXRb, miR-194-5p and miR-122*_1 using RT-qPCR. Messenger RNA and miRNA levels were reported as fold change expressed as 2-ΔΔCt (RQ min; RQ max). Fold changes >2 and <0.5 were considered significant. Results The median age of HIV+ve vs HIV-ve women was 35 years and 50 years respectively (p=0.015). The HIV-ve group had a statistically significant number of patients in the overweight/obese category (BMI > 25kg/m2) compared to the normal weight category (BMI <25kg/m2) (p<0.001). The number of obese women in the HIV+ve group however did not reach statistical significance. Circulating total cholesterol was elevated in the HIV+ve group with significantly elevated LDL-c levels (3.16±0.64mmol/L) relative to uninfected women (2.10±0.74mmol/L; p=0.04). A scavenging receptor for LDL-c, LDLr was significantly decreased (0.18-fold) in this group, possibly contributing to higher LDL-c levels. Transcriptional regulator of LDLr, SREBP2 was also significantly lower (0.13-fold) in HIV+ve women. Regulatory microRNA, miR-148a-3p, was reduced in HIV+ve women (0.39-fold) with a concomitant increase in target ABCA1 (1.5-fold), which regulates cholesterol efflux. HIV+ve women displayed higher CYP7A1 [2.078-fold (RQ min: 1.278; RQ max: 3.381)], LXRb [2.595-fold (RQ min: 2.001; RQ max: 3.000)] and HNF1α [3.428 (RQ min: 1.806; RQ max: 6.507] levels. HNF4α [0.642-fold (RQ min: 0.266; RQ max: 1.55)], miR-194-5p [0.527-fold (RQ min: 0.37; RQ max: 0.752)] and miR-122*_1 [0.595-fold (RQ min: 0.332; RQ max: 1.066)] levels were lower in HIV-ve women. Conclusion HIV+ve women do not conform entirely to the normal known risk profile for GD. Black South African HIV+ve women with GD were significantly younger. Black South African HIV-ve women conform to the known risk factor of obesity with a statistically higher BMI whilst HIV+ve women do not. HIV+ve women also had fewer 1st degree relatives with GD compared to HIV-ve women, and less oestrogen exposure. HIV+ve women have a significant increase in circulating LDL-c coupled with reduced mRNA expression of hepatic LDLr. However, the suppression of miR-148, an epigenetic regulator of LDLr, was downregulated in the HIV+ve group. This would indicate a possible alternate pathway in the downregulation of LDLr in HIV+ve women linked with raised LDL-c and gallstone formation and will require further investigation. MiR-148a however did appear to regulate ABCA1 with an inverse relationship being observed in the HIV+ve woman. HIV+ve women displayed elevated expression of CYP7A1, HNF1α and LXRb. This could have been further influenced by ART and aging. HNF4α, which is known to cause upregulation of CYP7A1, was suppressed with upregulation of CYP7A1 and LXR, known to cause downregulation of CYP7A1 in humans as opposed to mice, also had the opposite effect in HIV+ve women. The best theoretical explanation for this will be an interruption in the enterohepatic circulation, as evident by HIV+ve patients known to have chronic inflammatory and relative malabsorptive disorders of the ileum, which may result in upregulation of CYP7A1 to produce more bile salts. However, these conclusions are drawn from a case series. Larger cohort studies are required into the effects of HIV on GD and the impact of ART on GD in order to put strategies in place to curb this disease process and reduce the morbidity from it and reduce the cost to the overburdened health system.
A review of the clinical presentation, diagnostic challenges of retained abdominal swabs and the medico-legal implications of gossypiboma.
(2015) Naidoo, Ruvashni.; Singh, Bhugwan.
Abstract no available.
The scope and spectrum of challenges presented to the general surgeon by patients affected with the human immunodeficiency virus (HIV) : a review.
(2012) Ebrahim, Sumayyah.; Singh, Bhugwan.; Ramklass, Serela Samita.
Background: Surgical disease related to HIV is scantily documented with a paucity of data detailing the manifestations of HIV in surgery especially in resource-poor, high prevalence settings such as in South Africa. This review provides an update on the topical issues surrounding HIV and surgery. Objectives: The objective of the study was to determine the incidence, pathogenesis, clinical presentation, aspects of diagnosis and management of: HIV- associated salivary gland disease in particular parotid gland enlargement; Kaposi’s sarcoma (KS) and lower limb lymphoedema; AIDS- related abdominal malignancies due to KS and lymphoma; Acalculous cholecystitis and HIV- cholangiopathy and HIV- associated vasculopathy. Methods: A collective review of the literature was performed and data sourced from a search of relevant electronic medical databases for literature from the period 2000 to the present date. Studies under each section were selected based on inclusion and exclusion criteria. Content analysis was used to analyse data. Results: The HIV pandemic has resulted in an increased frequency of benign lymphoepithelial cysts making it the commonest cause of parotidomegaly in most surgical practices. KS should be considered in the differential diagnosis of a patient with chronic lymphoedema. Lymphoedema may be present without cutaneous lesions, making clinical diagnosis of KS difficult. The gastrointestinal tract is the commonest site of extra- cutaneous KS. Surgical management of the lymphoma patient is restricted nowadays to determining the diagnosis and in some cases to evaluate disease stage. Highly active antiretroviral therapy (HAART) is an important part of the management of biliary tract conditions in addition to relevant surgical procedures. HIV- vasculopathy represents a distinct clinico- pathological entity characterized by a vasculitis with probable immune- mediated or direct HIV- related injury to the vessel wall. Conclusion: The rising incidence of HIV in South Africa and other developing countries has been associated with new and unusual disease manifestations requiring surgical management for diagnostic, palliative or curative intent. It is crucial that surgeons remain abreast of new developments related to the challenging spectrum of HIV and its protean manifestations.
Surgery for pulmonary tuberculosis: a comparison between active and sequelar disease with implications for management.
(2006) Naidoo, Rishendran.; Singh, Bhugwan.
Abstract available in PDF.
Upper limb sympathectomy in current surgical practice.
(2002) Singh, Bhugwan.; Robbs, John Vivian.
Abstract available in PDF.