Masters Degrees (Clinical Medicine)

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The prevalence of hand pathology in regional orthopaedic hospitals in KwaZulu-Natal: a cross sectional study.
(2023) Thabit, Swaleh Hassan Abdalla.; O'Connor, Megan.
Hand pathology in the international context is common, and contributes to; time off work, loss of income, change or loss of occupation and residual dysfunction. In South Africa, investigation has been performed into traumatic and infective hand pathology and its ramifications for occupation. The broader burden of hand pathology, other than traumatic and infective pathology, had not been investigated locally. This observational cross-sectional study aimed to quantify the burden of hand pathology on regional hospitals in KwaZulu-Natal (KZN) that offer orthopaedic services, over the course of a single week. In addition, the investigation determined which patients are affected by these pathologies and which pathologies cause the greatest burden, by number, to the KZN health system. The results of which identified focus areas that need more attention and directs future research to address areas of concern. Hand pathology broadly encompasses infection, degenerative and inflammatory arthropathy, trauma, peripheral neuropathies, tumours, and congenital deformities. We conducted an observational, cross-sectional data collection, from patient and hospital records, for the course of a week at all 10 regional hospitals that offer orthopaedic services in KZN. Data was captured for all patients who presented to the orthopaedic services at these facilities. With this information, we calculated the prevalence of hand pathology at regional health facilities that offer orthopaedic services in KZN. We were able to describe the patients most commonly affected by hand pathology, and determined which pathologies occur most commonly. This epidemiological study provides important insights. Hand pathology represents around one fifth of the presentations to regional orthopaedic facilities in KZN, and nearly a quarter of trauma cases presenting to these facilities occur in the hand. Resource allocation and training should be directed toward awareness, education and management of these common pathologies.
Mortality rate in elderly patients over the age of sixty with a surgically treated hip fracture at a regional hospital in South Africa.
(2024) Mahomed, Farhaad.; Rajpaul, Jitesh.
Hip fractures are prevalent and serious injuries among patients over the age of 60, representing a significant public health issue with substantial morbidity, mortality, and healthcare costs. In recent decades, there has been a notable increase in the incidence of hip fractures, reflecting demographic shifts and an aging population. While conservative treatment may be appropriate for incomplete fractures, surgical intervention is typically required to restore mobility and reduce complications. Research indicates that several factors significantly influence the mortality rate in patients with hip fractures. Advanced age, poor physical status, male gender, and delayed treatment have been identified as critical determinants of mortality. These patients often present with significant comorbidities, such as cardiovascular disease, diabetes, and osteoporosis, which complicate their overall health status and elevate the risk of pre-operative and post-operative complications. Consequently, the mortality rate for hip fractures is higher compared to other types of fractures. The mortality rate following hip fractures is not only a measure of the severity of the injury but also serves as a crucial metric for evaluating the quality of care provided by healthcare facilities. It reflects the effectiveness of medical interventions, surgical procedures, and post-operative care. High mortality rates may indicate deficiencies in healthcare delivery, while improvements in these rates can signify advancements in medical practice and patient management. Understanding and identifying risk factors for increased mortality is essential for developing targeted interventions and improving patient outcomes. Anticipating potential complications and implementing strategies to mitigate these risks can enhance the overall care of patients with hip fractures. Given the importance of this issue, this study aims to determine the one-year post-surgery mortality rate of patients with hip fractures and to identify the comorbidities associated with these patients. By analysing these factors, the study seeks to provide insights into the prognosis of hip fracture patients and to inform clinical practices and healthcare policies aimed at reducing mortality and improving the quality of care for this vulnerable population.
Aerosolization during intubation and extubation and its associated risk of transmission of SARS-CoV-2 to healthcare workers: a scoping review.
(2023) Naidoo, Verushka.; Govender, Komalan.
Background: Healthcare workers, in particular anesthesiologists, are at risk for many infectious diseases that could potentially be transmitted during intubations and extubations. Although intubation and extubation are known to stimulate coughing and to promote the generation of aerosols, their risk of transmission of COVID-19 infection is still not clearly understood. Among the aerosol generating procedures, intubation and extubation is thought to be especially harmful due to the proximity of the anaesthetist to the patient’s airway. The aim this study is to explore and describe the risk of aerosolisation of SARS-CoV-2 to the anaesthetist during airway management. Methods: We conducted a scoping review of PubMed, MEDLINE, LANCET, and grey literature related to intubations and extubations, and the risk of transmission of infections to the anaesthetist. The scoping review was conducted using the Arksey and O’ Malley framework for scoping reviews. We conducted a narrative synthesis of the evidence gathered. There were no restrictions on study design, year of publication, and study location. The literature search was updated on the 15th of July 2023. Results: Our scoping review showed that healthcare workers involved in airway procedures specifically intubation and extubation are at an increased risk of contracting SARS-COV-1 and SARS-COV-2. Aerosol generation during these procedures has been shown to generate less aerosol than that of a cough. Extubations are particularly riskier regarding aerosol exposure than intubations. The relationship between aerosol exposure and virus transmission is uncertain. Conclusions: Anaesthetists are at increased risk of infection during intubations and extubations. There remains a lack of evidence of the exact mechanisms of transmission from patients to healthcare workers during aerosol-generating procedures. There is also a lack of consistency in the definition of aerosol-generating procedures.
Feasability of focused parathyroidectomy in developing countries - a scoping review.
(2023) Rugnath, Kapil.; Suman, Mewa Kinoo.
Hyperparathyroidism (HPT) is characterized by pathologically excessive parathyroid hormone production. This may be as a consequence of pathology within the parathyroid gland (primary HPT) or as a sequela of pathology outside the parathyroid gland (secondary & tertiary HPT). The gold standard surgical management of HPT was bilateral neck exploration (BNE) but with improvement in localising methods, focused parathyroidectomy (FP) has made the gold standard contentious. BNE, entailing a large neck incision and 4 gland exploration, demonstrates excellent cure rates of 95%. FP, whereby a single targeted miniature incision is made over the offending gland, is possible in the category of primary HPT as in up to 80% of cases the aetiology is a single gland adenoma. The prerequisites to embarking on this minimally invasive operative technique are accurate pre-operative localisation of the exact site of the offending gland adenoma and assistance of intra-operative adjuncts to confirm successful excision. Considering the prerequisites required for FP, the initial concern of cost arose. Additionally, concerns of potential inferior success rates were initially entertained. Subsequently, numerous studies revealed this technique to be superior in terms of operative time; cost; convalescence; cosmesis; success rates and the ability to be performed under local anaesthetic, as a day case. As such, the current standard of care for primary HPT where a single gland adenoma is localised, is the FP. The majority of the studies and trials demonstrating the superiority of FP emanate from developed high-income countries where there is a relative abundance of resources, and as such, the questioning of applicability or relevance of these studies to developing middleincome countries is valid. With the natural hesitancy to adopt these recommendations uncritically in developing countries, where the lack of resources might impede this technique, this concern of applicability, and therefore feasibility, needed to be addressed. To address this, a scoping review of the literature was conducted, looking specifically at FP, pre-operative localisation and intra-operative adjuncts, in developing countries (upper and lower-middle income). The aim of this review was to ascertain if FP is feasible in these countries by assessing the availability and accuracy of pre-operative localisation, success of FP judged by cure rates and the availability and utility of intra-operative adjuncts. This review will benefit surgeons in developing countries by demonstrating that FP is not an esoteric procedure described in ivory towers to be entertained in reverie only. Dispelling the myth of non-applicability due to resource constraints, by establishing the technique to be feasible in developing countries, more local surgeons can now, for localised single parathyroid gland adenomas, diverge away from knee-jerk routine bilateral neck explorations. Reassured with support of relevant local literature, they may now confidently embark on learning and performing the technique of FP resulting in satisfied patients who enjoy the superior outcomes associated with this technique.
The clinical profile, serological profile and management of patients diagnosed with systemic sclerosis in South Africa. A single center experience.
(2023) Shandu, Nokwazi.; Cassim, Bilkish.; Paruk, Farhanah.
Systemic sclerosis (SSc) is a complex and clinically heterogeneous disease with protean clinical manifestations, a chronic and frequently progressive course, and significant disability and mortality. The disease is characterized by fibrosis of the skin, internal organs and vasculopathy. While it can affect every organ, there is marked variability in patterns of skin and organ involvement, rates of disease progression, response to treatment and survival. The limited studies of SSc in South Africa (SA) have largely described the clinical manifestations and antibody profile in African patients. Since the last study from Durban in 1991 looking at the serological profile of SSc, there have been advances in serological and imaging investigations and therapeutics. Recent studies are predominantly from Johannesburg (JHB), and this study was conducted to look at the demographic profile, clinical characteristics and serological profile of patients with SSc in our local population. Inkosi Albert Luthuli Central Hospital (IALCH), a quaternary hospital, serves as a referral hospital for KwaZulu-Natal and part of the Eastern Cape. The Rheumatology Department provides outpatient and inpatient service for patients with SSc. Given the demography of KZN, the majority of patients attending the clinic are Indian and African Blacks subjects and this study brings the opportunity to document SSc in these populations. A retrospective chart review of the electronic records of all patients with SSc attending the rheumatology clinic IALCH was undertaken for the period January 2010 to December 2020. All patients with confirmed diagnosis of SSc and at least two visits to the clinic were included. Comparisons were made between limited and diffuse SSc and African and Indian patients using two-sided Fisher’s exact tests, Student’s t-tests and the Mann-Whitney U test for normally distributed and skewed numerical variables, respectively. This is the first study to report the differences in presentation of SSc between African and Indian patients in SA, which is reflective of the KZN population. African patients were significantly younger than Indian patients and more likely to have diffuse disease and a shorter disease duration. Interstitial lung disease and PAH, which are associated with poor outcomes, remain common manifestations, especially in diffuse disease. We confirm the absence of ACA in African patients; the mechanism of which requires further research.
Observed birth prevalence of structural congenital disorders among live births at a regional facility in South Africa.
(2021) Saib, Muhammad Zubayr.; Dhada, Barnesh Lalloo.
Congenital disorders (CDs) are a global health issue and an important contributor to childhood mortality and morbidity. In South Africa (SA), the size and nature of the problem is unknown because reporting of CDs has been unreliable. Inaccurate assessment and under-reporting have led to an underestimate of the contribution of CDs to the burden of disease. As SA undergoes a positive epidemiological transition, the CD burden will be expected to increase. This study aimed to fill the void in empiric CD data in the country. The objectives were to measure the birth prevalence of CDs of live births and describe the pattern of CDs at a regional hospital in KwaZulu Natal Province in 2018 using the Birth Defects Notification Tool (BDNT) developed by the National Department of Health. The collected data was then compared with existing published data in SA and country-specific modelled estimates. A retrospective, observational, descriptive review of CDs diagnosed within the neonatal service at Edendale Hospital (EDH) was conducted in 2018. All in-house live births diagnosed with CDs were included in the study. Stillbirths and neonates with identified CDs born elsewhere and referred to EDH after birth were excluded from the study. Data were obtained from the birth registry, neonatal admission register, and the individual BDNT. A total of 117 neonates were diagnosed and notified with a CD from the 7516 live births examined at EDH. The total birth prevalence for the study period was 15.57 per l000 live births, which equates to 1 in every 64 live births affected by a CD at EDH in 2018. The most affected systems were the musculoskeletal (31.6%) and circulatory systems (18.8%). Birth prevalence rates of key CDs were comparable to previously published SA data and are in line with current modelled estimates. This study responds to the paucity of birth prevalence data on CDs in SA and serves as a starting point for comparison locally and with other national and international data. It offers additional evidence on the health burden represented by CDs in SA and the need to address the surveillance, care and prevention of these conditions as a healthcare priority.
Genotyping of gardnerella vaginalis from pregnant women in Durban by amplified ribosomal DNA restriction analysis.
(2020) Pillay, Kayla.; Abbai, Nathlee Samantha.; Naicker, Meleshni.
Gardnerella vaginalis is one of the most frequently isolated microorganisms associated with bacterial vaginosis (BV). However, limited information concerning the genetic diversity of G. vaginalis isolated from BV positive and intermediate cases, has been documented. This study investigated the diversity of G. vaginalis in pregnant women, a currently under-researched area in South Africa. The study population included pregnant women recruited from a public hospital in Durban, South Africa. The women provided 2 self-collected vaginal swabs for microscopy and the genotyping assays. The BV status of the women was determined using Nugent scoring. A total sample of n=137 specimens was selected for analysis. The 16S ribosomal ribonucleic acid (rRNA) gene of G. vaginalis was used for the genotyping assays. The 16S rRNA gene polymerase chain reaction products were digested with TaqI to generate genotyping profiles and genotypic subtypes were determined by correlating BamHI and HindIII digestion profiles. Phylogenetic analysis was performed on the 16S rRNA gene sequences. The data analysis was performed in R Statistical Computing software, version 3.6.2. Restriction digestion with TaqI revealed the presence of two different genotypes i.e. GT1 and GT2. Within both BV positive and intermediate sample groups, GT1 was the most prevalent genotype (54%). Overall, 4 subtypes (1, 2B, 2AB and C) were shown to be present in the sample population. The most prevalent subtype was 2B (15/37, 40.5%), followed by subtypes 1 (11/37, 29.7%), 2C (4/37, 10.8%) and 2AB (4/37, 10.8%). The phylogenetic analysis of the 16S rRNA genes showed the presence of 5 clusters. The tree displayed clusters which contained groups of specimens from the same BV group with different genotypes and subtypes present. There were also clusters which contained specimens from across the BV groups carrying the same genotype and subtype. Finally, the study did not find a significant association (p>0.05) between reported symptoms of discharge and genotype harboured. This study provides the first report on the diversity of G. vaginalis in South African pregnant women. Diversity assessments of G. vaginalis with respect to genotypes and subtypes may aid in a greater understanding on the pathogenesis of this microorganism.
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.
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.
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.
Morbidity and mortality in the modern antiretroviral treatment era in a tertiary teaching hospital in Durban, South Africa.
(2020) Riziki, Manimani Ghislain.; Magula, Nombulelo Princess.
Background: Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is recognized as the chief cause of morbidity and mortality in Sub-Saharan Africa. South Africa is known to bear the highest number of people living with HIV globally, while KwaZulu-Natal is the worst affected province in this country. Aim: To identify the determinant of morbidity and mortality in the modern antiretroviral therapy (ART) era in South Africa. Study design: A cross-sectional study. To achieve the objective, a mixed data acquisition method was applied using qualitative and quantitative data. These included a systematic review and a retrospective chart review. Data collection and analysis: For the systematic review, relevant studies were searched from the following databases: Google Scholar, PubMed, CINAHL. Two review authors independently screened titles abstracts and full-text articles in duplicate, extract data and assess the bias. Discrepancies were resolved by discussion or arbitration of a third review author. The study used the Preferred Reporting Item of Systematic Review (PRISMA 2015) guideline. This study used R software version 3.6.2. to synthesis the data, graphic displays were used to visually compare the prevalence of comorbidities across the study region. With the retrospective chart review, we conducted a study of all patients admitted at King Edward medical wards, Durban, South Africa from January to December 2018. Data were obtained from medical records, including demographic profile, clinical attributes and laboratory records. Data were analysed using R software version 3.6.2. In addition, the association between the covariates was tested either with the Chi-Square test, Kruskal Wallis or Wilcoxon rank-sum test depending on the type of variables. A p-value < 0.05 was used as a benchmark for determining the level of statistical significance Results: For the systematic review a total of 409 articles were obtained from the database search, finally12 articles were eligible for data extraction. All 12 studies included were published between 2008 and 2018 in English and they were conducted in Sub-Saharan Africa. Among them, three were conducted in Nigeria, two were conducted in Uganda, three were conducted in South Africa, one in Gabon, one in Ethiopia, one in Ghana, and one in Burkina Faso. In most of the included studies, tuberculosis was the first commonest causes of hospitalization accounted for 40.7% followed by anaemia with 34.2% and toxoplasmosis with 29.3%. It was as well the first cause of death accounted for 44.3% followed by anaemia with 30.2% and toxoplasmosis 27.5%. Contrary one study reported anaemia as the first causes of hospitalization and two studies reported each respectively wasting syndrome and meningitis as the first causes of death. With regards to the chart review, a total of 577 (50.6%) females and 564 (49.4%) males were included in the study. The mean age of all the participants was 39.6±12.2, 506 (44.3%) patients had CD4 less than 200 cells /mm3 and 273 (23.9%) had VL ˃ 1000 copies/ml. Male gender [OR 1.39(1.07-1.8) p=0.015], age [OR1.02(1.01-1.03) p˂ 0.001], CD4 <200 cells/mm3 [OR 2.14(1.37-3.45) p=0.001], VL ˃ 1000 copies/ml [ OR 1.93(1.08-3.63) p=0.032] were associated with mortality among HIV infected patients admitted in the cohort. Tuberculosis (TB) was the most common diagnosis on admission and the leading cause of death which accounted for 257 (22.5%) and 73 (24.3%) respectively, followed by kidney disease with 83(7.2%) for admission and with 38(12.6) for death. Only 70% of patients had been reported to be on ART. Age, men gender, CD4 cell and viral load were associated with mortality. Association between CD4 cell count and viral load was found. Conclusion: Despite the recent improvement of modern antiretroviral treatment, HIV/AIDS still causes hospitalization and death among HIV infected patients. For the systematic review as well as for the chart review, tuberculosis was the commonest cause of hospitalization and death in Sub-Saharan Africa and South Africa, but it was always followed by other opportunistic infection and other non-AIDS related conditions. There is a need to prevent opportunistic infection (especially tuberculosis) and to tackle the non-communicable disease related to HIV infection. Also, a need to start antiretroviral treatment early for patients living with HIV. Keywords: Morbidity, Mortality, Antiretroviral therapy, Sub-Saharan Africa, South Africa.
Resistance to β-lactam and fluoroqinolone antibiotics in enterobacteriaceae from chicken : an observational study in Maputo, Mozambique.
(2016) Faife, Sara Lino.; Essack, Sabiha Yusuf.; Sundsfjord, Arnfinn Staale.; Zimba, Tomas Francisco.
Extended-spectrum β-lactamase (ESBL) and/or plasmid-mediated AmpC (pAmpC)-producing Enterobacteriaceae with co-resistance to fluoroquinolones are increasingly identified in food-borne pathogens globally. This study investigated ESBL- and pAmpC-mediated β-lactam resistance as well as plasmid-mediated fluoroquinolone resistance in 198 samples taken from 99 frozen chickens (99 samples from the liquid thaw and 99 from carcass swabs), Brazil, South Africa and Mozambique each produced 33 chicken. Species identification was undertaken using in-house biochemical tests and antibiotic susceptibility was ascertained by the disc diffusion test following CLSI guidelines. ESBL production was determined using the double-disk synergy test and isolates were subjected to PCR to detect the presence of blaCTX-M, blaSHV, blaTEM, blaCMY, blaMOX, blaFOX, blaDHA, qnrB, qnrD, qnrS and qepA genes. A random selection of CTX-M genes was sequenced. The 198 samples yielded 27 putative ESBL-positive isolates: Citrobacter diversus (1), Citrobacter freundii (3), Enterobacter aglomerans (1), Enterobacter cloacae (1) and Escherichia coli (21). Of the 27 isolates, 19 were from South African chicken, five from Mozambican chicken and three from Brazilian chicken. Resistance to ampicillin was 100,0%, followed by 88.8% to ceftriaxone, 77.8% to trimethoprim-sulphamethoxazole, 74.0% to cefotaxime, 70.4% to ciprofloxacin, 66.6% to ceftazidime, 22.2% to cefoxitin and 7.6% to gentamicin. Multi-drug resistance was evident in 19 (70.4%) isolates, 15 of which were from South Africa. The predominant ESBL gene was blaSHV (85%), followed by blaCTX-M (62.9%) and blaTEM (44.4%) whilst blaMOX (33, 3%) and blaDHA (33.3%) were the most common pAmpC genes. The predominant plasmid-mediated fluoroquinolone-resistance gene was qepA (22.2%). DNA sequencing of the blaCTX-M genes putatively identified differentiation of the E. coli and Citrobacter spp. isolates. There was no strong evidence of clonality, however, South African isolates shared more similarity. qnr and qepA genes were predominantly identified in South African E. coli isolates while CTX-M and SHV genes were prevalent in isolates from diverse origins. The Mozambican population is thus exposed to a reservoir of plasmid-mediated and hence, mobile β-lactam and fluoroquinolone resistance genes from imported, and to a lesser extent, locally-produced chicken. The complexity and diversity of mobile resistance genes combinations and permutations is of concern in the food safety context.blaCTX-M-55/-79/-101/-164, with blaCTX-M-164 being most common. ERIC–PCR profiles allowed the differentiation of the E. coli and Citrobacter spp. isolates. There was no strong evidence of clonality, however, South African isolates shared more similarity. qnr and qepA genes were predominantly identified in South African E. coli isolates while CTX-M and SHV genes were prevalent in isolates from diverse origins. The Mozambican population is thus exposed to a reservoir of plasmid-mediated and hence, mobile β-lactam and fluoroquinolone resistance genes from imported, and to a lesser extent, locally-produced chicken. The complexity and diversity of mobile resistance genes combinations and permutations is of concern in the food safety context.
Retrospective review of prostate biopsies at a regional level hospital.
(2018) Ramloutan, Vishan Mohanlal.; Urry, Ronald James.
No abstract available.
The utility of basic fibroblast growth factor as a non-invasive biomarker of focal segmental glomerulosclerosis in HIV positive and negative children.
(2018) Gumede, Nokwanda Zamahlubi.; Naicker, Thajasvarie.; Bhimma, Rajendra.
Abstract available in pdf.
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.
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.
Quantifying the clinical exposure required to adequately prepare surgeons for deployment to conflict zones and to manage mass casualty situations.
(2018) Uchino, Hayaki.; Kong, Victor.; Clarke, Damian Luiz.
Introduction: The ongoing state of global geo-political instability means that it is prudent, even in peaceful countries, to prepare civilian surgeons to manage major military-type trauma. However, preparing a modern surgeon to manage mass shooting or terrorist-related injuries remains an ongoing challenge in many countries. In addition, there is no consensus on the key skill set a modern trauma or military surgeon requires to competently manage major trauma patients. Chapter 1 of this thesis reviews the trauma workload and operative exposure in a major South African trauma center and provides a comparison with contemporary experience from major military conflicts. It would appear that a South African trauma center has a sufficient burden of trauma and academic capability to train both military and civilian trauma surgeons. Based on our trauma workload, a 6-month rotation through a major South African trauma center should be sufficient to provide exposure to almost all major injuries in appropriate volumes to prepare a military surgeon for combat deployment. Chapter 2 of this thesis reviews the state of trauma training and preparedness in Japan and the trauma workload of a major Japanese emergency medical center, and goes on to compare it with that of a major South African trauma center. The intention is to quantify and compare the time required to gain adequate exposure to major trauma at the two respective centers. It is apparent that trauma training in Japan is hampered by a lack of clinical material as well as by systematic factors. South Africa, in contrast, has a huge burden of trauma, sufficient academic infrastructure, and relatively modern facilities, which ensures that surgeons have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries. Chapter 3 of this thesis is a structured survey designed to investigate the role of international trauma clinical electives in South Africa, and to assess the impact these have had on the career of the various foreign surgeons who have undertaken them. The data demonstrated that an international trauma clinical elective in South Africa provides unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. The trainees who completed such an elective all felt that the trauma training with clinical exposure was of inestimable value and substantially enhanced their career. Conclusion: South Africa has a sufficient burden of trauma to train surgeons to manage military and major civilian trauma. In addition, South African major trauma centers have sufficient academic support and capacity to ensure such training is structured and academically sound. In contrast, trauma training in Japan is impeded by a lack of clinical material as well as by systematic factors. Training a trauma-competent military or civilian surgeon in such an environment is difficult. An international trauma clinical elective in South Africa provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. For peaceful countries such as Japan, developing academic exchange programs with countries such as South Africa, which can offer broader trauma experience, is essential and can be mutually beneficial.
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.
The role of a contrast study in the investigation of Paediatric Gastroesophageal Reflux disease.
(2018) Sewlall, Janice.; Wiersma, Rinus.
Background: Gastroesophageal reflux (GER) is a common finding in the pediatric population. This can either be physiological re flux or established disease that may require surgical intervention. There is currently no consensus on a gold standard in the diagnosis of gastroesophageal reflux disease (GERD). The purpose of this article is to describe the role of contrast radiography in this process, looking in particular at the subset of neurologically impaired (NI) children. Methods: A retrospective chart review of children admitted for the work-up of GER or for gastronomy insertion, to the Department of Paediatric Surgery at Inkosi Albert Luthuli Central Hospital (IALCH) from January 2014-December 2015. Results: 42 patients (25 male, 17 female) were admitted during this period. 27(64%) were neurologically impaired. All patients had a contrast study performed. Twenty (48%) contrast studies showed GER. Twenty-two (52%) studies were negative for GER and these children subsequently had oesophageal pH monitoring studies performed. Twelve (55%) pH monitoring studies were positive for GER. Ten (45%) pH studies were negative for GER. The sensitivity of a contrast study to show GER was 62.5%. Anatomical anomalies diagnosed on contrast radiography were hiatal hernias (3), oesophageal strictures (2), situs inversus (1) and pylorospasm (1). Conclusions: Contrast radiography has a low sensitivity in diagnosing GER and adjuvant studies are sometimes necessary. However, it is useful in recognising anatomical anomalies that either predispose to GER or is a consequence of GER. It is a particularly helpful diagnostic tool in the management of neurologically impaired children who require feeding gastrostomy tubes.
Risk factor profile of female patients presenting with acute myocardial infarction: a South African perspective.
(2017) Govender, Jaqueline Cindy.; Ranjith, Naresh.
The study was a retrospective single center study conducted at RK Khan hospital in Durban. The primary aim was to look at the incidence of acute myocardial infarction (AMI) in the female population in our setting with particular interest in the cardiovascular risk profile of female patients presenting with AMI. Data was extracted from a computerized database for the duration of the study period, which was from 2003 to 2016. Patient anonymity was maintained. All adult female patients that presented to the study center during the study period, with a diagnosis of AMI, based on the European and American Society of Cardiology guidelines, were included in the study. Females with unstable angina were excluded. The cardiovascular disease (CVD) risk factor profile was based on the Framingham risk profile for CVD and included the following: diabetes mellitus (DM), hypertension (HPT), cigarette smoking, dyslipidemia, obesity, a previous history of coronary artery disease and positive family histories of DM, HPT and coronary artery disease. The study population was broadly categorized into 2 age groups, namely <65 years of age and >65 years. Both groups were analyzed identically in terms of their age, clinical presentation, CVD risk factors, initial electrocardiogram, medical therapies and whether or not they were referred for an angiogram and/or coronary artery bypass surgery. We also divided the study population into those with ST elevation myocardial infarction (STEMI) versus Non ST elevation myocardial infarction. In the STEMI group we assessed the use of thrombolytic therapy or not. Finally we looked at the presence of major adverse cardiac events (MACE) in each of the age groups. MACE was defined as follows: Arrhythmias, cardiac failure, cardiogenic shock, complete heart block, recurrence of angina or myocardial infarction and death. In addition to the primary study aim, by categorizing patients into 2 age groups we could determine if there was a difference in CVD risk factor profile and the presence of MACE between the younger and older age groups. Finally, by comparing the outcome of our study to studies done in male counterparts we were able to see if there was a difference in CVD risk profile between male and female patients, which in fact there was not. So basically in the presence of the traditional risk factors for coronary artery disease (CAD), males and females can be considered at equal risk of developing acute myocardial infarction and females are not protected by the cardioprotective effects of oestrogen hormone in the pre-menopausal age group as was previously thought. Females are an understudied population when it comes to coronary artery disease and very few studies have been conducted on females with cardiac disease. We believe that this study offers some very valuable information with regards to cardiac disease in females and that treatment strategies should be targeted to include optimizing risk factor control in at-risk females, so that the burden of disease can be reduced in this population.

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