Clinical Medicine

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Acute pancreatitis in a high HIV prevalence environment: analysis of prevalence, demographics, prognosticators and outcomes.
(2019) Anderson, Frank.; Thomson, Sandie Rutherford.
Background It is unclear what is the true prevalence of HIV related acute pancreatitis and whether diagnostic and prognostic markers used in patients without HIV infection are as effective in HIV related pancreatitis and if morbidity is worse in HIV infected patients. Methods Using a prospective, descriptive design, HIV prevalence was compared in trauma and acute pancreatitis patients. Serum amylase was used to diagnose acute pancreatitis. Prognostication was by CRP, BISAP, Glasgow and APACHE II scores at 24 hours. Sensitivity, specificity and AUC were compared in predicting a severe outcome in acute pancreatitis. Complications and mortality were compared in 238 HIV+ve and HIV-ve patients admitted to 2 regional hospitals in Durban between August 2013 and October 2015. One hundred and eighty one patients were admitted with trauma. Results Between August 2013 and October 2015, 238 patients were admitted with acute pancreatitis and 181 with trauma. HIV infection was higher in patients with acute pancreatitis (38% vs 16%) (p=0.001) and they were also older (40 vs 33 years) (p=0.001). Fifty three percent of HIV +ve patients were female and 65% of the HIV-ve patients were male in the pancreatitis cohort and 59% of the trauma and pancreatitis patients were on Highly Active Antiretroviral Therapy. The prevalence of gallstone (27% vs 30%), alcohol (41% vs 52%), dyslipidaemia (0% vs 3%) and idiopathic (6% vs 14%) aetiologies were similar in HIV+ve and HIV-ve patients and a drug related aetiology (24% vs 0%) (p<0.001) was more prevalent in HIV related acute pancreatitis. CRP was more effective in predicting severe disease in HIV-ve patients (AUC= 0.75) and patients with CD4 counts of ≥ 200 cells/mm3 (AUC=0.73) and not HIV+ve patients (AUC= 0.59) or patients with counts below 200 cells/mm3 (AUC= 0.46). The BISAP system had similar efficacy with AUC of 0,71 and 0.74 in HIV-ve and HIV+ve patients respectively, was poor in CD4 count < 200 cells/mm3 (AUC=0.68) and good in CD4 count> 200 cells/mm3 (AUC=0.9). The Glasgow score was of similar efficacy in HIV-ve (AUC = 0.72) and HIV+ve patients (AUC=0.78) and better in patients with CD4 count < 200 cells/mm3 (AUC=0.83) and CD4 count ≥ 200 cells/mm3 (AUC=0.81). The APACHE II had uniform efficacy in both HIV-ve and HIV+ve patients (AUC >0.8) and both CD4 count ranges (AUC > 0.80). Septic complications occurred in 10(8%) of HIV-ve patients and 4(4%) HIV+ve patients. There was no difference in morbidity (25% vs 33%) and mortality (6% vs 6%). Conclusions HIV infections is more prevalent in acute pancreatitis than in a hospital trauma cohort which represented the general population. The APACHE II system was the most accurate in predicting morbidity and CRP least accurate. The outcomes were similar in HIV+ve and HIV-ve patients but the statistical assumptions in calculating the sample size, given the low frequency of morbidity and mortality observed in this study may have resulted in an alpha error.
Adequate analgesia in caring for paediatric burns patients in a peri-urban setting in KZN.
(2020) Wall, Shelley Lynn.; Clarke, Damian Luiz.; Allorto, Nikki Leigh.
This PhD thesis centres on achieving adequate analgesia in caring for paediatric burn-injured patients in KwaZulu-Natal, South Africa. The burden of burn injuries in sub-Saharan Africa is huge. A large number of children in the under-five age group sustain burns in the region annually. Pain is virtually synonymous with burn injuries. All children with burns experience pain, regardless of the cause, size or depth of the burn. This PhD study aimed to improve the care offered to paediatric burns patients by addressing obstacles to adequate analgesia in paediatric burns patients; and to offer a practical, easy to use, locally applicable analgesia protocol which can be used at district, regional and tertiary hospitals alike. The objectives were to identify deficits in the knowledge of doctors in terms of prescribing procedural analgesia for children with burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes in an outpatient department; to compare the analgesic requirements of children presenting with acute versus chronic burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes for patients admitted to the burns ward; to evaluate obstacles to adequate analgesia in paediatric burns patients; and to develop an analgesia protocol applicable to KwaZulu-Natal and other low-middle-income countries (LMIC), through the consensus of experts in the field. The development of this protocol was conducted in three phases. The first phase involved assessing obstacles to adequate analgesia in paediatric burns patients. The second phase involved assessing Methoxyflurane as an alternative analgesia option in both the inpatient and the outpatient setting; and the final phase involved the addition of Methoxyflurane to our analgesia protocols and reaching an expert consensus that the elements included in the analgesia protocol were applicable to KwaZulu-Natal and other low-middle-income settings. The analgesia protocol for paediatric burns patients has been developed with the local setting and resources as a primary consideration. It was specifically designed to be easy to use, safe in novice hands and locally applicable. In order to ensure that theoretical findings from the study are translated into practices that benefit all burn-injured children, this research should be combined with advocacy efforts.
Adherence to iron prophylactic therapy during pregnancy in an urban regional hospital in Durban, South Africa.
(2017) Mkhize, Princess Zinhle.; Moodley, Jagidesa.; Naicker, Thajasvarie.
Iron and folic acid supplementation plays a major role in prevention and control of iron deficiency anaemia in antenatal care. In South Africa, although all pregnant women receive iron, folate and calcium supplementation throughout pregnancy, anaemia is still common. Low adherence may be a key contributor to the ineffectiveness of supplementation programs.Therefore, this study was conducted to examine adherence to prophylactic iron supplementation during the antenatal period. An observational clinical study was conducted in a regional hospital from January- December 2016. Women (n=100 HIV uninfected and n=100 HIV infected) were recruited and subdivided into three groups: (a) 1st attendees ≤ 34 weeks (n=33), (b) 34-36 weeks (n =34) and (c) ≥ 37 weeks /birth (n=33) respectively. A structured questionnaire was used for data collection. Data were coded and computed onto an excel sheet for statistical analysis using SPSS software. Data from women (n = 24) from 1st visit attendees ≤ 34 weeks and 34-36 weeks subgroups indicated that pill count and self-reported data reflected 50% adherence and 46% non-adherence, being higher in the HIV infected women (75%). Nausea was the commonest side effect in all trimesters (79, 2%). Adherence (27.8%) and non-adherence (72.1%) to iron, folic acid and calcium supplementation were observed in 176 (88%) women. Promoting essential strategies on the importance of consumption and effectiveness of iron prophylactic therapy is essential to maintain and improve anaemia in antenatal attendees during pregnancy.
Admissions for pulmonary embolism at a tertiary South African hospital.
(2017) Kistensamy, Sivaisen Ricardo.; Moodley, Yoshan.; Brown, Susan Lynn.
Background: Published descriptions of pulmonary embolism (PE) from South African (SA) settings are rare. We sought to address this gap in the literature. Methods: This was a case series involving 61 adult patients admitted to a tertiary SA hospital over a five-year period with a primary diagnosis of PE. Data related to patient demographics, PE presentation, risk factors, treatment, and inpatient mortality were collected and analysed using appropriate statistical tests. Results: Most of our study population were younger (86.9%), female (67.2%), and of black African ethnicity (73.8%). Dyspnoea and chest pain were the most common symptoms (prevalence of 86.9% and 41.0%). Prevalent clinical signs included tachypnea (47.5%) and tachycardia (42.6%). The most prevalent established risk factors were cardiac failure (49.2%) and a history of deep vein thrombosis (up to 19.7%). Massive PE was diagnosed in 8.2% of study patients. Most patients received anticoagulation therapy (95.1%), with thrombolysis and embolectomy performed only in smaller proportions (24.6% and 11.5%) of patients. The incidence of inpatient mortality was 23.0%. Characteristics associated with mortality included: admission route (p=0.008), dyspnoea (p=0.002), tachycardia (p<0.001), and embolectomy (p=0.042). Conclusion: Our study findings have important implications related to the management of PE in SA.
An exploration of the learning environment and career intentions: a mixed methods study of paediatric interns at KwaZulu-Natal.
(2018) Naidoo, Kimesh Loganathan.; Van Wyk, Jacqueline Marina.
Background: Globally, there is increased pressure on health professions education to be responsive to inequities in health care. These imperatives are clearly evident in KwaZulu-Natal (KZN) with its high disease burden. Poor doctor to patient ratios here are exacerbated by migration of medical practitioners to urban areas, private practice and developed countries. South Africa’s two–year internship aims at producing primary health care clinicians for the public health system. Gaps in knowledge of internship and intern career intentions, in resource challenged contexts, have translated to the failure by both higher education authorities and national health departments to include the internship period in strategies, to ensure that the inequities in health care are addressed. Aim: This explorative study used a mixed methodology approach to explore the factors that influence perceptions of the learning environment (LE) during internship and their influence on career intentions. Methods: The study used a social constructivist worldview drawing on a sequential explanatory mixed methods design to understand the construct of the LE and its influence on career intentions. Both quantitative and qualitative methods that included surveys using a locally validated version of the Postgraduate Hospital Educational Environment Measure (PHEEM) and focus group discussions were generated. This study was conducted among interns in Paediatrics at four hospital complexes in KwaZulu-Natal in 2015. The Communities of Practice theory and the Social Cognitive Career Theory were drawn on and supplemented by the theory of alienation and engagement to develop a conceptual framework that informed the analyses of the relationship between perceptions of the LE and career intentions. Results/Findings: Perceptions of the LE were found to be influenced by both external (disease burden, workload and resource constraints) and individual related contextual factors (supervisor -intern relationships, mentorship, feedback and demography). These factors acted as alienating influences that curtailed access and restricted participation within communities of practice in internship. A narrow view of the role and scope of interns was reflected in significant differences between interns and their supervisor’s perceptions of the LE and gaps in assessment practices of SA interns compared with international best practices. Poor perceptions of the LE drove interns away from SA’s public health system and from caring for children. There were strong aspirations to specialise and weaker aspirations to enter primary health care amongst the sampled interns. Conclusion: Contextual factors in a resource limited LE impacted on identity and career self-efficacy formation of SA interns who failed to see a future role for themselves in primary health care and child health within the public health system. Expanding on the framework of communities of practice a new model of understanding, of how the interplay of contextual factors in resource challenged contexts affects internship learning and career interest formation, was developed. This new knowledge of context on learning and career interest provides the framework to understand the discordance between national health needs and career aspirations of interns in resource challenged environments. This new understanding provides the theoretical underpinning for changes in policy, practice, curricula content and future research to improve access and create an expansive participatory framework for SA interns. These proposed changes in the SA learning environment has the potential to ensure a sustainable public health system and redress the inequity seen in distorted doctor patient ratios in areas of need.
Application of communication skills in an authentic clinical setting: assessing the communication competency of sixth year medical students during history taking.
(2017) Ntando, Ekanda Alfred.; Van Wyk, Jacqueline Marina.; Matthews, Margaret Glynnis.
The Nelson R. Mandela School of Medicine (NRMSM) launched a new 6 year MBChB programme in 2010. This curriculum includes a clinical communication course which emphasises the patient centred approach in line with the Health Professions Council of South Africa Core Competency Framework for undergraduate students. The Calgary-Cambridge Guide to the Medical Interview was adopted as a method for teaching communication. The 2015 final year medical students constituted the first cohort to have been taught clinical communication skills in this manner in the pre-clinical phase. Aim of the study The study was conducted to investigate the transfer of communication skills taught using the Calgary-Cambridge Method (CCM) in the pre-clinical phase to the clinical setting. This study focused mainly on the process skills of history taking and had the following objectives: 1. to determine whether students used the CCM as taught at medical school. 2. To measure and compare process skills of students in two different phases of MBChB programme. 3. To explore role modelling of the CCM by clinical teachers. 4. To describe challenges encountered by students for or in the application of the CCM. Methods The study was observational, analytical and cross-sectional. The population was the 2015 final year class of medical students (n=198) with exception of 13 students who were trained in a different method in Cuba. The study was conducted in the Internal Medicine wards of four teaching hospitals affiliated to the medical school in the Durban functional region. Results The population of the study comprised 185 eligible students; 107 participants were enrolled, and the final number of participants was 105 (57%). In response to the four objectives of the study, the findings revealed that most students used the CCM in a modified manner. There was a marked decline in some of the process skills of history taking, specifically in subcategories such as providing structure and eliciting the patients’ perspective. Educators in Internal Medicine wards did not model the use of the CCM and discouraged its application due to workload and time constraints. Challenges encountered by students included negative attitudes of clinical trainers towards the CCM and language barriers, as most patients spoke in isiZulu. Discussion Results demonstrated that the clinical communication teaching and learning of the pre-clinical phase had some positive impact on application, even if students only used the Calgary Cambridge Method in a modified manner in the clinical phase. The environment of clinical training influenced the transfer, development and the progress of the communication skills learnt in the pre-clinical phase. The decline of process skills in providing structure and eliciting the patient’s perspective was associated with negative attitudes and the poor role modelling of educators. This observation is contradictory to the increase shown in the process skills of building relationship and initiating the session, which probably reflects students’ accumulated experience in the wards. Students encountered challenges associated with language barriers and with different approaches used for personal and organizational reasons. Conclusion With regard to students’ attainment of the HPCSA core competency of communication, and despite communication teaching in the pre-clinical phase and its application in the disciplines of Family Medicine and Rural Health, communication was not equally valued or reinforced in all disciplines involved in undergraduate teaching on the MBChB programme. Key words: communication skills, transfer, application, clinical setting
Cardiovascular disease profile in patients with established rheumatoid arthritis at King Edward VIII Hospital.
(2018) Govender, Preesha.; Paruk, Farhanah.
Rheumatoid arthritis (RA) is one of the most common chronic systemic autoimmune inflammatory diseases, which is associated with an increased mortality rate, attributed to premature cardiovascular disease (CVD). Key drivers of mortality from CVD in RA are fuelled by multiple factors. Rheumatoid arthritis disease profiling, particularly seropositivity, presence of extra-articular disease and high disease activity, confer an increased mortality risk. Traditional CVD risk factors (hypertension, diabetes mellitus, dyslipidaemia, obesity) are influenced by both inflammation inherent to RA, and pharmacodynamics of anti-rheumatic drugs. Notwithstanding the above, the current paradigm shift recognises RA as an independent risk factor for CVD. Similar to the rest of Africa, local data on the prevalence of CVD in RA are limited. With an increase in non-communicable diseases and longevity, the RA burden in South Africa (SA) is expected to increase. Local studies are needed to stratify practice in cardio-protective strategies and improved long term outcomes in RA. This study aims to determine the prevalence of CVD in RA, describe the prevalence of CVD risk factors in RA and describe the relationship between RA disease activity and CVD. A retrospective, chart review of all patients with RA according to the American College of Rheumatology 1987/2010 Classification criteria, attending the arthritis clinic in King Edward VIII hospital, a tertiary public healthcare academic teaching hospital in KwaZulu-Natal, SA, during the period August 2017 to March 2018, was undertaken. Patients younger than 18 years of age, or with RA and any other concomitant connective tissue disease or overlap syndrome were excluded. The study group included 150 patients with RA. The demographic details, duration of the RA disease, traditional CVD risk factors, simplified disease activity index (SDAI) and health assessment questionnaire (HAQ) were documented. In addition, results of electrocardiogram, echocardiogram, haemoglobin, glycated haemoglobin, lipid studies and estimated glomerular filtration rate were recorded. Cardiovascular disease was found in 16% of the total study cohort, with an age, gender and ethnic differential. Coronary artery disease was the most common CVD finding in RA patients. The burden of traditional CVD risk factors in RA is high, with hypertension, diabetes mellitus, dyslipidaemia, physical inactivity and chronic kidney disease of particular concern. No significant correlation was observed between RA disease activity, seropositivity and CVD in RA however, extra-articular disease was more common among patients with CVD. Echocardiographic evidence of subclinical cardiac disease in RA is common. Significant disparity was observed between various CVD risk assessment models at different levels of risk, which cautions a comprehensive CVD risk assessment model that stratifies discriminately is needed in patients with RA. The study provides knowledge of CVD burden and risk in RA patients locally, and serves as a foundation for further research in preventative strategies that offer significant survival benefits. The main limitation in this study is that the study cohort consisted mainly of Black and Indian patients and therefore the findings may not be generalised across all ethnic groups. Furthermore as this was a relatively small study conducted in a single public hospital, which is urban based, conclusions from this study may not be applicable to a rural setting or to all socio-economic classes.
Cardiovascular evaluation of hypertensive disorders of pregnancy by echocardiography.
(2004) Desai, Dushyant K.; Moodley, Jagidesa.; Naidoo, Datshana Prakesh.
Background: Preliminary observations suggest that aberrations in maternal central hemodynamics and uterine artery Doppler velocimetry reflect the severity of hypertensive disorders of pregnancy. In addition, the precise changes of cardiac output in normal pregnancy, particularly in the third trimester, have remained controversial. Aims and Objective: To measure concomitantly Doppler echocardiographic maternal central hemodynamics and uterine artery Doppler velocimetry and evaluate their association with adverse feto-neonatal outcome in hypertensive pregnant women. To evaluate cardiac output longitudinally in the latter half of pregnancy in normal healthy women. Design and Setting: Prospective study conducted at the Obstetric Unit, King Edward VIII Hospital, Durban, South Africa. Study sample: forty (40) pregnant hypertensives without any prior therapy and a further group of pre-eclamptic women (n=22) treated with stat dose sodium gardinal and alpha-methyldopa were studied. Results: i) A trend to a higher cardiac output was seen in the hypertensives compared to the normotensives. Hypertensive women were of larger stature; there was no difference in cardiac index. Fetal birthweight correlated poorly with cardiac index in pre-eclamptic women (r =0.21). A better correlation was seen with uterine artery resistance index (r = - 0.65) and systemic vascular resistance index (r = -0.49). Critical values for cardiac index and systemic vascular resistance index to predict poor adverse feto-neonatal outcome with good predictive values were not identified. ii) Pre-eclamptics treated with stat dose of sodium gardinal and/or methyldopa prior to echocardiography had a significantly lower systemic vascular resistance index and uterine artery resistance index compared to the untreated group. The lower systemic vascular resistance index in this treated cohort occurred from a combination of non-significant lower blood pressure and higher cardiac index. iii) Compared to normotensive women, untreated pre-eclamptics had a significantly lower heart rate (p< 0.001), a higher stroke index (p=0.018) and no difference in resultant cardiac index (p=0.452). iv) In gestational apoteinuric hypertensives presenting after 34 weeks gestation, maternal hemodynamics and uterine artery resistance index did not help define a higher risk group. v) In chronic hypertensives pregnancies, left ventricular hypertrophy correlated with severity of blood pressure. Higher risk chronic hypertensives were better selected by proteinuria than maternal central hemodynamics or uterine artery resistance index. vi) In normal pregnancy, maternal cardiac output peaked in early to mid third trimester and was maintained till term. Significant correlations were observed among maternal cardiac output, maternal body surface area and fetal birth weight. Discussion: i) This study shows that cardiac index and systemic vascular resistance index measured in the latter part of the second and third trimesters in hypertensive pregnant women were not associated with adverse fetal outcome. Large variations in cardiac index values were observed that restricted detection of satisfactory critical values for cardiac index and systemic vascular resistance index to predict adverse outcome. ii) An improved correlation of uterine artery resistance index with maternal hemodynamics and fetal birthweight in pre-eclampsia supports the hypothesis that poor placentation does not allow for a normal increase in uterine blood flow. iii) The poor correlation between uterine artery resistance index and maternal central hemodynamics, does not support the hypothesis that elevated cardiac output in hypertensive pregnancies (hyperdynamic disease model) occurs as a compensatory response to maintain adequate perfusion in a utero-placental bed with high resistance that did not decrease.
Clinical profile of rheumatoid arthritis associated interstitial lung disease at a tertiary hospital in KwaZulu-Natal, South Africa: a retrospective 5 year review.
(2020) Ghammo, Hosam Mohamed.; Nyamande, Kennedy.; Mitha, Mohamed.
Background: The prevalence, demographic distribution and treatment outcomes in Rheumatoid Arthritis associated interstitial lung disease (RA-ILD) has not been well described in Southern Africa. There is very limited data. Objective: The aim of the study was to determine the demographic profile of the disease as well as treatments used and their outcomes at Inkosi Albert Luthuli Central Hospital (IALCH), a tertiary hospital in Durban, South Africa. Methods. This was a retrospective electronic chart review of 61 patients who were diagnosed with RA-ILD between January 2010 and December 2015 at IALCH pulmonology clinic. Demographic and clinical data, symptom presentation, pulmonary function testing (PFT), high resolution computerised tomography (HRCT) features and treatment modalities were analysed as well as outcome based on symptoms, PFT and HRCT. Results. There were 61 subjects, the majority being female (90.2%). Approximately 86.9% were 50 years and older. The majority of the subjects were Indian 72.1% (n=44), followed by Black Africans 23% (n=14) and then Whites 4.9% (n=3). All patients were HIV negative. Patients treated with a combination of prednisone and azathioprine had a decline in FVC (mean 0.41, p value 0.04). There was no improvements or deterioration in patients treated with either drug alone. Conclusion. The management of RA-ILD is still a challenge. The combination of azathioprine and prednisone did not arrest disease progression in our study while either agent alone did not improve clinical and lung function parameters. Large randomised control studies are needed in Sub-Saharan Africa.
A cross-sectional descriptive study of pre-hospital care providers’ training, knowledge and skills in austere environments emergency medicine in South Africa: a framework for a consensus statement for Wilderness Emergency Medicine.
(2017) Matthew, Jaybalan Allan.; Maharaj, Roshen.; Clarke, Damian Luiz.
There is a lack of research into the resource capabilities and capacity for wilderness emergency medicine practice in South Africa (SA). This is despite SA having vast expanses of populated austere geography that remains difficult to access by conventional health care systems and the country increasingly becoming an attractive ecotourist destination. With increasing needs for skilled health care personnel to deal with medical emergencies in this environment, it is first necessary to determine the extent of the current resources present within SA. This research looked at the human resource potential to deal with medical emergencies in the wilderness emergency environment in SA. Chapter one considers the conceptual and contextual framework of this research in light of the above and a review of the available literature. Chapter two presents research from a study that determined the self-reported extent of training, knowledge and skills that capacitated Emergency Care Practitioners (ECP) registered with the Health Professions Council of South Africa (HPCSA) when operating in the wilderness environment and when dealing with medical emergencies. Chapter three examines data gained from a survey conducted among emergency medicine specialists regarding the competency in knowledge, training and skills that are ideally required in the practice of wilderness emergency medicine (WEM). Chapter four compares the self-reported knowledge, training and skills of ECPs in the wilderness emergency environment, with what is suggested by emergency medicine specialists as the expected level of knowledge, training and skills for practice in this field. Chapter five presents a published editorial that highlights the potential value of this specialised WEM practice in resource-limited countries. This editorial suggests that proper wilderness emergency medicine training, knowledge and skills could perhaps be an alternative solution for frugal innovation for resource-limited pre-hospital and inhospital practice. There is a need for further training and skills uptake in WEM. Additionally, a local framework for a consensus statement on the practice of WEM needs to be established.
Diagnostic evaluation of the BD Affirm™ VPIII assay as a point-of-care test for the diagnosis of bacterial vaginosis, trichomoniasis and candidiasis in a population of pregnant women from South Africa.
(2020) Dessai, Fazana.; Sebitloane, Hannah Motshedisi.; Abbai, Nathlee Samantha.
OBJECTIVE: Untreated Sexually Transmitted Infections (STIs) and Bacterial vaginosis (BV) pose a serious health risk to mother and child. Limited data exist on the use of the BD Affirm VPIII assay as a point-of-care test. This study compared the BD Affirm VPIII assay to the BD MaxTM Vaginal assay (reference test) for the detection of BV, Trichomonas vaginalis, and Candida spp. The prevalence of single and co-infections are also reported here. METHODS: The study enrolled 273 pregnant women from King Edward VIII hospital in Durban. Socio-demographic, sexual behaviour and clinical data were collected from all consenting women. The women provided two self-collected vaginal swabs for testing. The swabs were tested using the BD Affirm VPIII assay and the BD MaxTM Vaginal assay. The prevalence of BV, trichomoniasis and candidiasis was calculated as the percentage of women who tested positive for BV, T.vaginalis and Candida infection and 95% confidence intervals (CIs) were calculated for these percentages using the formulas for calculating CIs for proportions. The number of co-infections was calculated using chi-square analysis. The diagnostic accuracy of the BD AffirmTM VPIII assay compared to the BD Max assay was assessed through the calculation of sensitivity, specificity, Negative Predictive Value (NPV) and Positive Predictive Value (PPV) and their respective 95% confidence intervals. RESULTS: In this study population, 85% of the participants were unmarried; however, 84% reported having a regular partner, and 96.3% did not use a condom regularly. The prevalence of Bacterial Vaginosis, Candidiasis and Trichomoniasis was 49.4%, 57.2% and 10.3%, respectively. A large proportion of women (78.8%) in this study did not have a discharge despite being positive for one or more pathogens. The BD AffirmTM VPIII assay showed a moderate sensitivity (79.8%) and specificity (80.3%) for diagnosing BV in all participants. The assay had an excellent specificity for Candida and T. vaginalis of 97.4% and 100.0%; respectively, however, it exhibited poor sensitivities of 52.9% and 42.4%, respectively. CONCLUSION: Our findings show a higher prevalence of Bacterial Vaginosis in antenatal attendees than previously reported, while the prevalence of Candidiasis and Trichomoniasis was in keeping with previous reports. The high number of asymptomatic infections detected is of concern and indicates the need for the re-evaluation of the syndromic management approach, especially in the antenatal population. The BD AffirmTM VPIII assay was found to be unsuitable as a screening test for vaginal infections in pregnancy. The assay performed better as a confirmatory test and may serve useful if used in conjunction with other clinical parameters such as vaginal pH.
Does gender impact on female doctors' experiences in the training and practice of surgery?
(2016) Umoetok, Flora.; Van Wyk, Jacqueline Marina.; Madiba, Thandinkosi Enos.
Abstract available in PDF file.
The effect of HIV infection on the management of end-stage renal failure among patients undergoing continuous ambulatory peritoneal dialysis.
(2017) Ndlovu, Kwazi Celani Zwakele.; Assounga, Alain Guy Honore.
Continuous ambulatory peritoneal dialysis (CAPD) is cost effective, easy to learn, and requires no complex equipment, thus, is well-suited as a home dialysis modality in areas with distant or limited dialysis facilities. We aimed to evaluate the effects of HIV infection on CAPD outcomes in dialysis-requiring end-stage renal disease (ESRD) patients. The first report (Chapter 2) evaluated the effects of HIV-infection on primary end points of mortality and catheter failure, and primary morbidity outcomes of first peritonitis and hospital admissions at one year. HIV infection was not shown to adversely influence catheter failure rates or patency; however, uncontrolled HIV infection was associated with increased relative risk of mortality, first peritonitis, and hospital admissions. The second report (Chapter 3) evaluated the effects of HIV infection on all peritonitis episodes, including relapses and subsequent episodes at 18 months. HIV infection was associated with increased risk for overall peritonitis and peritonitis relapse. Although peritonitis was also associated with adverse catheter failure outcomes, HIV infection was not shown to result in significantly increased catheter failure rates at 18 months. The third report (Chapter 4) evaluated the effects of HIV infection on nasal carriage of Staphylococcus aureus, staphylococcal peritonitis, and catheter infection rates. HIV infection was shown to be a risk factor for methicillin-resistant S. aureus nasal colonisation, and that it can increase the risks of coagulase-negative staphylococcal peritonitis and S. aureus catheter infections in association with S. aureus nasal carriage. The fourth report (Chapter 5) evaluated shedding of HIV-1 particles into CAPD effluents. HIV particles were shown to be shed in detectable amounts into CAPD effluents even in patients with suppressed plasma viral load, raising concerns of a localised sanctuary site and potential infectivity of HIV-positive CAPD patients on a full complement of antiretroviral therapy. The thesis contributes to our understanding of the morbidity and mortality associated with uncontrolled HIV infection in ESRD patients on CAPD, the shedding of HIV-1 particles into CAPD effluents, and the resistance profiles of S. aureus colonisers and the organism patterns that are likely to cause infection, which may assist in guiding appropriate antibiotic therapy and prophylaxis.
The effect of lifestyle modification on depression amongst myocardial infarction patients after revascularization.
(2020) Arzet, Aminu.; Naidoo, Datshana Prakesh.
Background: Patients with Coronary Artery Disease (CAD) are prone to depression, and its presence is associated with poor adverse cardiac outcomes. Although lifestyle modification (LSM) has been shown to be beneficial in managing depression in patients with CAD, it is not known whether the mode of cardiac intervention (coronary artery bypass graft surgery {CABG} vs percutaneous coronary intervention {PCI}) influences the outcome Objectives: We examined the prevalence of depression and depression traits amongst myocardial infarction (MI) patients after revascularisation and compared the effect of LSM on incidence of depression and depression traits in patients who underwent CABG versus PCI Method: We evaluated the risk factor profile, depression characteristics and lifestyle changes of 100 consecutive participants undergoing coronary revascularization over a 15-month period (Jan 2017 to March 2018). The Beck Depression Inventory II (BDI-II) was used to assess depression and the Goldin leisure-time exercise (GLTE) questionnaire to assess physical activity (PA). Results: 100 patients were recruited (mean age males 60.73±4.52 yr and females 60.29±3.64 yr), with 5 dropouts leaving 95 patients for complete analysis. Most of the patients were low-income earners 53 (53.0%) and 21.0% had tertiary level education. The majority had multiple CAD risk factors and comorbidities (79.0%). Prior to the LSM program 51 patients (51.0%) had depression and depression traits {CABG 34 (66.7%) vs PCI 17 (33.3%), p = 0.047)}. After LSM the overall prevalence of depression and depression traits fell to 33 patients (34.7%), {PCI 8 (23.0%) vs CABG 25 patients (72.0%), p = 0.001}. The mean depression scores also fell from 21.11±7.75 to 14.98±9.61 (p = 0.002). At baseline PCI patients were more physically active compared to CABG {3 (60.0%) vs 2 patients (40.0%), P = 0.715} respectively. After the LSM, more PCI patients undertook PA compared to CABG {24 (60.0%) vs 14 patients (35.0%) respectively, p = 0.012}. The PA score was also higher amongst the PCI group compared to CABG {14.16±9.73 vs 9.40±10.94 respectively, p = 0.024}. In fully compliant subjects the benefit derived was similar regardless of the mode of intervention {OR 1.10, CI 0.98-4.23,P = 0.191}. Using multivariate analysis the main predictors of depression and depression traits were female gender (OR 3.29, 95% CI 1.51-11.03, p = 0.008), CABG (OR 1.86, 95% CI 1.68-5.77, p = 0.003), heart failure (OR 2.65, 95% CI 5.87-13.62, p = 0.000), Kidney failure (OR 1.41, 95% CI 1.30-5.23, P = 0.041), atrial fibrillation (OR 1.60, 95% CI 1.40-4.77, P = 0.023), low PA (OR 1.97, 95%, CI 11.23- 33.20, P = 0.000), previous history of depression (OR 8.99,95% CI 1.90-7.89, p = 0.002) and low income (OR 2.21, 95% CI 1.40-2.85, p = 0.000). Conclusions: Depression and depression traits are common among subjects undergoing coronary revascularization, more so amongst CABG compared to PCI participants. Lifestyle modification reduces the prevalence of depression and depression traits, with fully compliant CABG vs PCI groups deriving nearly the same benefits from the LSM regime. No significant reduction in depression and depression was recorded amongst LSM partlycompliant patients. This study suggests that failure to implement lifestyle changes and engage in PA are major barriers to managing depression after coronary revascularisation.
Effect of mitral valve replacement on left ventricular function in subjects with severe rheumatic mitral regurgitation.
(2019) Maharaj, Sharen.; Naidoo, Datshana Prakesh.
Background. The outcome in patients with severe mitral regurgitation (MR) and impaired ejection fraction (EF) is poorly described in the developing world where rheumatic heart disease is endemic. Objective. This study describes the effects of mitral valve replacement (MVR) on left ventricular (LV) function in patients with rheumatic MR. Methods. This is a retrospective analysis of all subjects with severe rheumatic MR undergoing MVR over a 9 year period (2005-2013). Clinical and echocardiographic parameters were recorded pre-operatively, at 2 weeks, 6 weeks to 3 months and 6 months to 2 years following MVR. Results. Of 132 patients included in the study, 66% (n=87) were NYHA class III-IV, 38% (n=50) presented with clinical features of heart failure and 14% (n=19) had atrial fibrillation prior to MVR. The echocardiogram showed increased end systolic diameter (ESD, 39.9±7.2mm), left atrial size (LA, 61.2±12.6mm), and pulmonary artery systolic pressures (PASP, 59.5mmHg, IQR 45-80mmHg). Pre-operatively, 28% (n=37) of subjects had impaired LV function (EF <60%). At 6 months to 2 years following MVR (n=93), 1% of subjects were NYHA III-IV, 1% were in heart failure, and 7.6% had atrial fibrillation. Paired analysis of 83 patients with complete datasets revealed that the EF was >55% in 87% (n=72) pre-operatively, the number of patients with EF >55% dropped to 20% (n=17) at 2 weeks postoperatively (p<0.001, 95% CI 0.02-0.09) and thereafter an EF > 55% was recorded in 60% (n=53) at the 6 months to 2 year follow up (p<0.001, 95% CI 0.1-0.5). After feeding all clinical and echocardiographic variables into a predictive model only the ESD emerged as a significant predictor of postoperative LV dysfunction (EF< 50%) both on uni- and multivariate analysis. Conclusion. Most subjects with severe rheumatic MR who were subjected to surgery had advanced disease with heart failure, indicating that preoperatively, impairment of LV function was a frequent finding. The preoperative ESD was the only predictor of postoperative LV dysfunction. This study calls for careful clinical assessment with regular imaging and early referral for surgery in subjects with severe MR according to established guidelines in order to ensure preservation of ventricular function.
Effects and mechanisms of interleukin-10 promoter polymorphisms on HIV-1 susceptibility and pathogenesis.
(2012) Naicker, Dshanta Dyanedi.; Ndung'u, Peter Thumbi.
HIV infection has risen to pandemic proportions. Interleukin-10 (IL-10), a potent antiinflammatory cytokine has been shown to enhance the establishment and persistence of chronic viral infections through inactivation of effector antiviral immune responses and it may also directly influence HIV-1 replication in cells of diverse lineages. IL-10 promoter polymorphisms have been shown to affect HIV-1 susceptibility and pathogenesis. However, the underlying mechanisms are poorly understood. We investigated the relationship between IL-10 promoter variants, plasma IL-10 levels, and markers of disease outcome in chronically HIV-1-infected individuals. To investigate the mechanistic role of IL-10 and its genetic variants on HIV pathogenesis, we studied markers of activation on B cells, CD4+ and CD8+ T cells, and assessed effects on CD4+ T cell proliferation with and without blockade of the IL- 10 pathway. We used Taqman genotyping assays to genotype three IL-10 promoter single nucleotide polymorphisms (SNPs) in our study cohort. Baseline plasma IL-10 levels were measured using Luminex technology for 112 individuals. Viral load, CD4+ T cell counts and cytotoxic T lymphocyte (CTL) immune responses were measured at baseline. The rate of CD4+ T cell decrease was calculated in 300 individuals with a median follow-up of 25 months. CD38, CD95, Ki67, IgG and PD-1, markers of activation or exhaustion were measured on B cells, and CD38, CD95, Ki67, HLA-DR and PD-1 were measured on CD4+ and CD8+ T cells in a subset of 63 individuals. CD4+ T cell proliferation was measured using Carboxyfluorescein succinimidyl ester (CFSE) assays, following IL-10 receptor blockade in a subset of 31 individuals. The IL-10 -1082G, -592A and -3575 variants were observed at frequencies of 0.3, 0.34 and 0.23 respectively, in our study cohort. Plasma IL-10 levels were significantly higher in the - 1082GG group than in the combined AA/AG group (p=0.0006). There was a significant association between the 592AA genotype and a greater breadth of CTL responses compared to the CC and CA (p= 0.002 and 0.004 respectively). The -592AA genotype associated significantly with an attenuated loss of CD4 cells (p= 0.0496), with -592AA having the least change in CD4 cells per year. The median expression of HLA-DR, a marker of T cell activation was significantly higher in the-1082AA group for CD8 cells (p= 0.047), and the - 592AA group for CD4 T cells (p= 0.01). The median expression of IgG on the surface of B cells was significantly higher in the -1082GG genotype and the -592CC genotype (p=0.0183 and 0.0659 respectively). Overall, IL-10 variants correlated with IL-10 expression and CD4 decline during chronic HIV-1 infection. IL-10 promoter variants may influence the rate of HIV-1 disease progression by regulating IL-10 levels, which in-turn, may affect the breadth of CTL responses. Furthermore, the increased expression of HLA-DR and PD-1 on CD8+ and CD4+ T cells, indicates that lower IL-10 levels are associated with increased immune activation and immune exhaustion. The increased expression of IgG on B cells, suggests that in a setting of lower IL-10, there is possibly a bias towards a Th2 immune response. These data suggest a significant role for IL-10 genetic variants and IL-10 in HIV pathogenesis. Further studies to determine whether and how the IL-10 pathway may be manipulated for therapeutic or vaccine strategies for HIV are warranted.
Epidemiology of chronic kidney disease in KwaZulu-Natal: evaluation of risk factors, complications and diagnostic methods.
(2017) Madala, Nomandla Daphne.; Assounga, Alain Guy Honore.
Chronic kidney disease (CKD) is associated with increased morbidity and mortality as well as costly renal replacement therapy. The aim was to determine risk factors and complications that contribute to morbidity as well as a suitable diagnostic detection method for CKD. Methods Observational studies were done at 2 hospitals. To assess risk factors, 283 patients were included at the Durban site, and sub-studies undertaken within this sample for CKD complications, while 302 patients were studied at the Empangeni outreach site. To evaluate predictive performance of estimated glomerular filtration rate (eGFR), data from 148 patients were analysed. A further 76 patients were recruited, to develop an African equation. Cockcroft Gault, Modified Diet in Renal Disease and CKD Epidemiology Collaboration eGFR equations were compared with technicium-99-mdiethylenetriaminepentaacetic acid (99mTc-DTPA)-GFR as the gold standard. Body composition was assessed by anthropometry and dual energy X-ray absorptiometry. Data were analysed with STATA. Results The commonest CKD risk factors were hypertension (75%), diabetes (29%) and human immunodeficiency virus (HIV) infection (24%), with HIV commoner at the outreach site (28.5% vs 19.8%). Over 80% of females and ∼60% males were overweight/obese overall; however, clinical cardiovascular disease was commoner in Durban (28% vs 5%). Complications were observed in early CKD; prevalence increased as eGFR declined from ≥90 ml/min/1.73m2 to <30 ml/min/1.73m2: hyperuricaemia increased from 17% to 74%, metabolic acidosis (11.6% to 72.7%), anaemia (2.9% to 69.7%), hyperphosphataemia (10.1% to 48.5%), all p<0.001, respectively, and hypocalcaemia from 1.5% to 18.2% (p=0.003). Lower GFR levels were also associated with lower serum albumin levels, and lower whole body as well as regional lean mass and fat mass in males. A further observation at GFR <30 ml/min/1.73m2 was that eGFR underestimated 99mTc-DTPA-GFR in African patients. Prediction of 99mTc DTPA-GFR was also poor at GFR levels ≥60 ml/min/1.73m2, with eGFR overestimating 99mTc-DTPA-GFR. An eGFR equation developed in African patients resulted in significantly better GFR prediction and showed the lowest bias, highest precision as well as accuracy. Conclusion Efforts are needed to enable non-nephrologists to manage CKD risk factors and complications. Prediction of GFR may be substantially improved by using an equation developed in Africans.
An explorative review of the distribution, incidence, prevalence, diabetes related amputations and defaulters of patients with diabetes mellitus and podiatrists in the public health care sector of KwaZulu-Natal.
(2015) Sahadew, Nikita.; Singaram, Veena S.; Brown, Susan Lynn.
The prevalence of diabetes is increasing globally, especially in African countries, where 62% of cases are undiagnosed and are seen by a medical professional only once complications have manifested. Among the tangle of complications, the diabetic foot is a cause of morbidity and mortality. The management of foot ulcerations, non-ulcerative pathologies and the prevention of subsequent amputation is a challenge, resulting in physiological, psychological and economic consequences. Including a podiatrist in the multidisciplinary healthcare team involved in the care of the lower limbs of the diabetic patient has the potential to improve patient outcomes and reduce the economic burden incurred by both the patient and the state. The global increase in the prevalence of diabetes is most marked in African countries. The District Health Information System (DHIS) is the primary data collection system of the Department of Health in KwaZulu- Natal (KZN). Data is routinely collected at all public healthcare facilities in the province and is aggregated per facility. This study aimed to investigate the distribution of diabetic patients and podiatrists in the public health sector of the eleven KZN districts. A retrospective audit was conducted of the KZN Department of Health databases on diabetes in and between the years 2010 and 2014. The data was cleaned, tested for capture errors, verified and analysed. Using pivot tables, derived metrics, and graphs using Microsoft Excel were constructed. Additional open source databases were accessed to allow further exploration of the data collected. The prevalence of diabetes in the public health sector of KwaZulu-Natal was found to be 14.3% higher than national prevalence estimates. Thirty-eight per cent of the cases were found in the highly urbanised district of eThekwini. A total of 1 329 275 diabetic patients were recorded and, according to national guidelines for the treatment of diabetes, required podiatric care. However, only two podiatrists work in the KwaZulu-Natal public health sector. The number of podiatrists is totally insufficient to serve the growing diabetic population in this province’s public health sector. A major infusion of more podiatry graduates, appropriate distribution and inclusion of podiatric services into the diabetic foot care team needs to therefore be considered to enable compliance with national and international diabetic foot care guidelines. In the interim, existing public health care practitioners can be educated to offer diabetic foot care information to the patient and on the correct referral patterns to allow the patient access to a podiatrist. The findings of this study are consistent with the well-established relationship between diabetes and urbanisation. Correlation calculations support the assumption of a directly proportional relationship between diabetes prevalence and the number of diabetes-related amputations. This study highlights the need for at least 319 podiatrists in the province of KwaZulu-Natal to satisfy the national guidelines for minimal diabetic care regarding assessment, screening and education of patients only; not considering the treatment of existing and future foot complications. Short and long term recommendations such as changes in the data collection process at public health facilities and the assessment of existing tertiary medical institutions for the establishment of additional departments of podiatric medicine can greatly contribute to addressing the calculated shortage of podiatric practitioners in the public health sector.
Exploring the impact of experience-based medical learning on students' clinical preparedness : a case study of the South African-Cuban medical training collaboration programme at the University of KwaZulu-Natal, South Africa.
(2014) Motala, Munirah Ismail.; Van Wyk, Jacqueline Marina.
Background: The South-African-Cuban Medical Collaboration (SACMC) programme involves medical training being offered to rural South African (SA) origin students in Cuban facilities with the view of future medical practice in local rural SA settings. The students on the SACMC programme return to South African medical schools to complete their training and clinical practice in their 4th academic year. The students experience difficulty in adapting to local clinical demands and integrating their prior knowledge as required at the Nelson R Mandela, School of Medicine, (NRMSM) of the University of KwaZulu-Natal (UKZN) in Durban, South Africa as evidenced from examination board minutes. Aim: In an effort to inform educators of the extent to which students’ prior clinical training and experiences in Cuba matched the clinical skills taught at the NRMSM, this study investigated the similarity or difference in approach to the curriculum, clinical skills content and perceived competence of the SACMC students to a set of 75 core clinical skills which are deemed essential during training in years 1-3 at the institution. Methods: A mixed methodology study used a phenomenological approach to explore the clinical experiences of 11 South-African-Cuban medical collaboration students. Qualitative data collected by means of interviews and a questionnaire were used to determine the curriculum approach and content. A questionnaire generated quantitative data about students’ familiarity; exposure and perceived competence (ability to perform independently, with supervision or not at all) on 75 specific skills which are considered a prerequisite to enter the 4th academic year at the NRMSM. The skills in 9 major categories, included communication, resuscitation, adult examination, new-born examination, general procedural skills, specimen collection, obstetrics and gynaecology procedures, airway management procedures and radiological examination. Findings: The didactic, lecture intensive Cuban curriculum with its emphasis on primary health care principles and predominance of ward-based clinical training was found to be vastly different from the problem-based, systematic and practical oriented laboratory-based clinical training offered to local students. The majority of students self-reported a lack of exposure to 35 of the overall 75 identified skills. Most students claimed an inability to independently perform 95% (4 out of 75 skills- able to perform 5%) of clinical skills. The qualitative data revealed that many primary health care skills were neither taught nor practiced by students within the first 5 years of training in Cuba. Conclusion: This study has highlighted the mismatch between the focus and scope of clinical training offered to students on the South African-Cuban Medical Collaboration programme and those at the NRMSM. In the light of continued collaboration in health education and to ensure that returning students are adequately supported and integrated into the SA clinical setting, it is important that educators work towards improving the alignment of the training programs.
Genetic diversity of Gardnerella vaginalis in pregnant women diagnosed with intermediate and positive bacterial vaginosis.
(2019) Nzimande, Silondiwe Philiswa.; Abbai, Nathlee Samantha.
Bacterial vaginosis (BV) is the main cause of abnormal vaginal discharge in women of reproductive age. Gardnerella vaginalis, has been detected in almost all women with BV. However, there is limited information on the genetic diversity of G. vaginalis isolated from BV intermediate and positive cases. In this study we investigated the genetic diversity of G. vaginalis strains from South African pregnant women. Vaginal swabs were characterized by the Nugent method. A total of n= 87 samples were included in the genetic analysis, (n=50 BV positive) and (n=37 BV intermediate). The presence of G. vaginalis was detected by PCR using bacterium specific 16S rRNA primers. All PCR positive amplicons were sequenced by the Sanger method and the edited sequence data was used for the phylogenetic analysis using the PHYLIP software. The sialidase A gene was amplified by PCR using specific primers and the copy numbers of sialidase A gene was quantified by droplet digital PCR. To assess the diversity of the sialidase A gene, Sanger sequencing was performed. The 16S rRNA gene from G. vaginalis was amplified in all BV positive and BV intermediate samples. All PCR amplicons were successfully sequenced and the nucleotide BLAST results revealed 100% identify to G. vaginalis. The phylogenetic analysis revealed that there is no diversity in G. vaginalis present in BV positive and intermediate cases. The phylogenetic tree of sialidase A sequences from intermediate and positive BV cases revealed two major clades which showed differences related to sialidase A copy number. Quantification of sialidase A showed that the average number of copies per cell was much higher in the BV positive group compared to the intermediate group. Some of the intermediate cases showed high copy numbers for the virulence gene and clustered with the BV positive cases. In the present study the 16S rRNA sequences of the G. vaginalis from BV intermediate and positive women showed that there is no genetic diversity in G. vaginalis detected in BV positive and intermediate samples. The phylogenetic tree of sialidase A gene sequences of intermediate and positive BV revealed two major clades which showed differences related to sialidase A copy number. This data was previously lacking in our setting, especially in a pregnant population. We further demonstrate for the first time that the genetic information present within the sialidase A gene has a direct influence on BV status.

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