Browsing by Author "Chu, Kathryn"

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    Open Access
    AIDS-associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa
    (BioMed Central Ltd., 2010) Chu, Kathryn; Mahlangeni, Gcina; Swannet, Sarah; Ford, Nathan; Boulle, Andrew; Van Cutsem, Gilles
    BACKGROUND: AIDS-associated Kaposi's sarcoma is an important, life-threatening opportunistic infection among people living with HIV/AIDS in resource-limited settings. In western countries, the introduction of combination antiretroviral therapy (cART) and new chemotherapeutic agents has resulted in decreased incidence and improved prognosis of AIDS-associated Kaposi's sarcoma. In African cohorts, however, mortality remains high. In this study, we describe disease characteristics and risk factors for mortality in a public sector HIV programme in South Africa. METHODS: We analysed data from an observational cohort study of HIV-infected adults with AIDS-associated Kaposi's sarcoma, enrolled between May 2001 and January 2007 in three primary care clinics. Paper records from primary care and tertiary hospital oncology clinics were reviewed to determine the site of Kaposi's sarcoma lesions, immune reconstitution inflammatory syndrome stage, and treatment. Baseline characteristics, cART use and survival outcomes were extracted from an electronic database maintained for routine monitoring and evaluation. Cox regression was used to model associations with mortality. RESULTS: Of 6292 patients, 215 (3.4%) had AIDS-associated Kaposi's sarcoma. Lesions were most commonly oral (65%) and on the lower extremities (56%). One quarter of patients did not receive cART. The mortality and lost-to-follow-up rates were, respectively, 25 (95% CI 19-32) and eight (95% CI 5-13) per 100 person years for patients who received cART, and 70 (95% CI 42-117) and 119 (80-176) per 100 person years for patients who did not receive cART. Advanced T stage (adjusted HR, AHR = 5.3, p < 0.001), advanced S stage (AHR = 5.1, p = 0.008), and absence of chemotherapy (AHR = 2.4, p = 0.012) were associated with mortality.Patients with AIDS-associated Kaposi's sarcoma presented with advanced disease and high rates of mortality and loss to follow up. Risk factors for mortality included advanced Kaposi's sarcoma disease and lack of chemotherapy use. Contributing factors to the high mortality for patients with AIDS-associated Kaposi's sarcoma likely included late diagnosis of HIV disease, late accessibility to cART, and sub-optimal treatment of advanced Kaposi's sarcoma. CONCLUSIONS: These findings confirm the importance of early access to both cART and chemotherapy for patients with AIDS-associated Kaposi's sarcoma. Early diagnosis and improved treatment protocols in resource-poor settings are essential.
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    Bowel preparation for colonoscopy: is diet restriction necessary?
    (2021) Chang, Hung-Jou; Goldberg, Paul; Chu, Kathryn
    Background: Bowel preparation is essential for quality colonoscopy. Although most bowel preparation regimens recommend dietary restriction for 24 to 48 hours before the procedure, the evidence for this is poor. Objectives: To establish whether dietary restriction during bowel preparation improves the quality of bowel preparation. Methods: A prospective single blind, randomised controlled pilot study. The dietary restriction (DR) group was instructed not to ingest high fibre foods for 48 hours prior to the use of a polyethylene glycol (PEG) bowel preparation. The non-dietary restriction (NDR) group was not given any dietary modification, but received instructions for the use of the PEG-based preparation solution. On the day of colonoscopy, the quality of the bowel effluent was assessed, and additional preparation given as necessary. The primary endpoint was quality of bowel cleansing using the Harefield Cleansing Scale during colonoscopy. The secondary endpoint was the need for additional bowel preparation and quantity of additional bowel preparation given prior to endoscopy. Data were analysed on an intention to treat basis. Results: Twenty-three participants were randomised to the intervention group and thirty-four to the control group. Patient demographics were similar in both groups. Dietary restriction did not influence the success rate of bowel preparation: 97% successful bowel preparation in the DR group, vs 91% successful bowel preparation in the NDR group (p=0.559). Additional bowel preparation requirement were similar in both groups: 35% in DR group vs 39% in NDR group (p=0.768). Mean amount of additional bowel preparation required was similar: 560 ml in the DR group vs 460 ml in the NDR group (p=0.633). Conclusion: The quality of bowel preparation was comparable in patients with and without dietary restrictions prior to colonoscopy. Non-restrictive diets prior to bowel preparation should be considered to increase compliance. The sample size of this pilot study prohibited definite statistical conclusions but demonstrated this to be a reasonable methodology for a larger study.
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    Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres
    (Public Library of Science, 2012) Chu, Kathryn; Cortier, Hilde; Maldonado, Fernando; Mashant, Tshiteng; Ford, Nathan; Trelles, Miguel
    Objectives The World Health Organization considers Cesarean section rates of 5-15% to be the optimal range for targeted provision of this life saving intervention. However, access to safe Cesarean section in resource-limited settings is much lower, estimated at 1-2% reported in sub-Saharan Africa. This study reports Cesarean sections rates and indications in Democratic Republic of Congo, Burundi, and Sierra Leone, and describe the main parameters associated with maternal and early neonatal mortality. METHODS: Women undergoing Cesarean section from August 1 2010 to January 31 2011 were included in this prospective study. Logistic regression was used to model determinants of maternal and early neonatal mortality. RESULTS: 1276 women underwent a Cesarean section, giving a frequency of 6.2% (range 4.1-16.8%). The most common indications were obstructed labor (399, 31%), poor presentation (233, 18%), previous Cesarean section (184, 14%), and fetal distress (128, 10%), uterine rupture (117, 9%) and antepartum hemorrhage (101, 8%). Parity >6 (adjusted odds ratio [aOR] = 8.6, P = 0.015), uterine rupture (aOR = 20.5; P = .010), antepartum hemorrhage (aOR = 13.1; P = .045), and pre-eclampsia/eclampsia (aOR = 42.9; P = .017) were associated with maternal death. Uterine rupture (aOR = 6.6, P<0.001), anterpartum hemorrhage (aOR = 3.6, P<0.001), and cord prolapse (aOR = 2.7, P = 0.017) were associated with early neonatal death. CONCLUSIONS: This study demonstrates that target Cesarean section rates can be achieved in sub-Saharan Africa. Identifying the common indications for Cesarean section and associations with mortality can target improvements in antenatal services and emergency obstetric care.
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    Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa
    (2021) Amer, Akrem; Chu, Kathryn
    Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.
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    An integrated approach of community health worker support for HIV/AIDS and TB care in Angonia district, Mozambique
    (BioMed Central Ltd, 2009) Simon, Sandrine; Chu, Kathryn; Frieden, Marthe; Candrinho, Baltazar; Ford, Nathan; Schneider, Helen; Biot, Marc
    BACKGROUND:The need to scale up treatment for HIV/AIDS has led to a revival in community health workers to help alleviate the health human resource crisis in sub-Saharan Africa. Community health workers have been employed in Mozambique since the 1970s, performing disparate and fragmented activities, with mixed results. METHODS: A participant-observer description of the evolution of community health worker support to the health services in Angonia district, Mozambique. RESULTS: An integrated community health team approach, established jointly by the Ministry of Health and Medecins Sans Frontieres in 2007, has improved accountability, relevance, and geographical access for basic health services. CONCLUSION: The community health team has several advantages over 'disease-specific' community health worker approaches in terms of accountability, acceptability, and expanded access to care.
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    Long term mortality after lower extremity amputation in South Africa
    (2019) Husein, Salah; Chu, Kathryn
    Introduction: Long-term mortality after lower extremity amputation is not well reported in low- and middleincome countries. The primary aim of this study was to report 30-day and one-year mortality after lower extremity amputation in South Africa. The secondary objective was to report risk factors for one-year mortality. Methods: This was a retrospective cohort study of patients undergoing lower extremity amputations at New Somerset Hospital from October 1, 2015, to October 31, 2016. A medical record review was undertaken to identify co-morbidities, operation details, and perioperative mortality rate. Outcome status was defined as alive, dead, or lost to follow-up. Outcomes at 30 days and one year were reported. Results: There were 152 patients; 90 (59%) males and the median age (interquartile range, IQR) was 60 (54-67) years. At 30 days, 102 patients were traced and 12 (12%) were dead. At one year, 86 (57%) were traced and 37 (43%) were dead. Conclusion: At this South African hospital, 43% of patients undergoing lower extremity amputations were dead after one year. In resource-constrained settings, mortality data are necessary when considering resource allocation for lower extremity amputations and essential surgical care packages.
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    Misdiagnosis of Appendicitis in Women in a Resource Limited Setting: Lessons from South Africa
    (2023) Kariem, Nazmie; Chu, Kathryn
    Introduction: Acute appendicitis (AA) is a common surgical emergency. In low and middleincome countries, the diagnosis is often made clinically due to the lack of access to specialised imaging. Misdiagnosis in females is common, given the potential broad differential diagnosis. The rate of misdiagnosis varies between countries, but there is a paucity of data in the developing world. The aim and objectives of this study were to describe the routine workup of females with suspected AA at a South African government hospital and to determine factors associated with the misdiagnosis of AA. Methods: A retrospective review of all females older than 12 years operated on by general surgeons with a suspected diagnosis of AA over a 2-year period was reviewed. Data including age, gender, presenting complaints and physical findings, laboratory and radiological results, pre and post-operative diagnoses were extracted and analysed using descriptive and inferential statistics. Results: A total of 180 females were included and 48 (26.7%) of them were misdiagnosed with AA. Of these 48 that were misdiagnosed, 22 (46%) had pelvic inflammatory disease (PID), 15 (31%) had a normal appendix, 10 (21%) had ovarian cysts and (2%) had endometriosis. Gynaecologic bimanual examination was performed in 123 (68.3%) patients. Twelve (6.7%) patients had a CT scan and 16 (8.9%) had an abdominal ultrasound. In the multivariate model, the absence of nausea, vomiting and anorexia (odds ratio (OR)=2.43; p=0.023), the presence of cervical excitation tenderness (CET) (OR: 4.32; p=0.009) and adnexal tenderness (OR=3.06; p=0.021) were significantly associated with a diagnosis other than appendicitis. These factors remained significant in the multivariate model after adjusting for relevant covariates. Conclusion: More than 25 % of females referred to general surgeons with suspected AA were misdiagnosed. Since imaging is not accessible at most resource-limited settings, it is imperative to conduct a gynaecologic examination on every female since adnexal and cervical tenderness were associated with PID and not AA.
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    Misdiagnosis of Appendicitis in Women in a Resource Limited Setting: Lessons from South Africa
    (2023) Kariem, Nazmie; Chu, Kathryn
    Introduction: Acute appendicitis (AA) is a common surgical emergency. In low and middleincome countries, the diagnosis is often made clinically due to the lack of access to specialised imaging. Misdiagnosis in females is common, given the potential broad differential diagnosis. The rate of misdiagnosis varies between countries, but there is a paucity of data in the developing world. The aim and objectives of this study were to describe the routine workup of females with suspected AA at a South African government hospital and to determine factors associated with the misdiagnosis of AA. Methods: A retrospective review of all females older than 12 years operated on by general surgeons with a suspected diagnosis of AA over a 2-year period was reviewed. Data including age, gender, presenting complaints and physical findings, laboratory and radiological results, pre and post-operative diagnoses were extracted and analysed using descriptive and inferential statistics. Results: A total of 180 females were included and 48 (26.7%) of them were misdiagnosed with AA. Of these 48 that were misdiagnosed, 22 (46%) had pelvic inflammatory disease (PID), 15 (31%) had a normal appendix, 10 (21%) had ovarian cysts and (2%) had endometriosis. Gynaecologic bimanual examination was performed in 123 (68.3%) patients. Twelve (6.7%) patients had a CT scan and 16 (8.9%) had an abdominal ultrasound. In the multivariate model, the absence of nausea, vomiting and anorexia (odds ratio (OR)=2.43; p=0.023), the presence of cervical excitation tenderness (CET) (OR: 4.32; p=0.009) and adnexal tenderness (OR=3.06; p=0.021) were significantly associated with a diagnosis other than appendicitis. These factors remained significant in the multivariate model after adjusting for relevant covariates. Conclusion: More than 25 % of females referred to general surgeons with suspected AA were misdiagnosed. Since imaging is not accessible at most resource-limited settings, it is imperative to conduct a gynaecologic examination on every female since adnexal and cervical tenderness were associated with PID and not AA.
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    Surgical catastrophic health expenditure at New Somerset Hospital, a South African public sector hospital
    (University of Cape Town, 2020) Naidu, Priyanka; Chu, Kathryn; Ataguba, John
    Background: Catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) are significant barriers to surgical care. Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations in LMICs. Surgical CHE and IHE are not described in the South African context. The objectives of this study were: 1) to determine the proportion of surgical participants at New Somerset Hospital (NSH) ), a second-level public sector South African hospital, who experienced CHE and IHE and 2) to determine the risk factors associated with out-of-pocket (OOP) payments. Methods: This study used a cross-sectional retrospective questionnaire administered to participants admitted to any department of surgery (obstetrics, gynaecology, general surgery, urology, otorhinolaryngology, or orthopaedics) for a surgical procedure at NSH. Direct healthcare expenditure for the surgical admission was defined to be catastrophic according to three definitions: 1) OOP payments 10% or more of annual household expenditure (HHE) (CHE10); 2) OOP payments 25% or more of annual HHE (CHE25); 3) OOP payments 40% or more of capacity to pay (CHE40). IHE was based on the national poverty lines and was defined according to new impoverishment or worsening impoverishment, as a result of OOP expenditure on the surgical admission. Multivariate regression analysis was used to assess the relationship between OOP payments and per capita HHE, age, type of procedure, department to which participant was admitted, distance from NSH, and length of stay. Results: Out of the 274 participants interviewed: 263 were included in the analysis (4% attrition rate). Two (0.8%), five (1.9%), and three (1.1%) participants experienced CHE according to the CHE40, CHE10, and CHE25 definitions, respectively. About 98.5% of participants spent less than 10% of their annual HHE, while 95.4% spent less than 10% of their annual non-food expenditure OOP. Median OOP expenditure was R100 (IQR R15 – R350). About 23% of the participants (n=62) were not charged for their surgical admission. Low per capita HHE (p=0.02), cancer (p=0.001), having a non-generous health insurance plan (p=0.002), and the hospital bill amount (p<0.001) correlated positively with OOP expenditure on healthcare. Linear regression revealed that there was no correlation between the proportion of OOP payments and LOS or distance. One in five patients (n=50, 19%) experienced new or worsening impoverishment and were pushed below the poverty line for receiving surgical care at a public hospital. Furthermore, 65 (25%) patients reported their household was unable to cope or household still recovering from the financial burden of the surgical admission. Discussion: Surgical CHE was not common among this study population, however IHE was substantial and the majority of participants incurred OOP for surgical care, with the main drivers of OOP costs being the hospital bill and transport. Financial catastrophe might have been low because: 1) most participants were protected by the uniform patient fee schedule and therefore did not incur a medical bill and 2) direct non-medical costs did not account for a significant proportion of OOP payments. Understanding the financial impacts of OOP health care expenditure is essential in the planning of the impending National Health Insurance in South Africa.
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    Surgical trainee supervision during non-trauma emergency laparotomy in Rwanda and South Africa
    (2021) Pohl, Linda M; Chu, Kathryn
    Objective: The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation. Design, Setting, and Participants: This was a prospective, observational study of NTEL operations at three teaching hospitals in South Africa and Rwanda over a oneyear period from September 1, 2017 – August 31, 2018. A total of 543 operations on adults over the age of 18 years who underwent NTEL performed by the acute care and general surgery services were included. Results: surgical trainees led three quarters of NTEL operations, and of these, 72% were performed autonomously in Rwanda and South Africa. Trainees were less likely to perform the operations autonomously for patients who were: age ≥ 60 years, had ASA classification ≥ III, had cancer or TB. Notably, trainee autonomy was not significantly associated with reoperation or mortality. Conclusions: trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting. More in-depth studies to understand the association of high trainee autonomy with surgical competency and patient safety is needed.
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    Treatment response and mortality among patients starting antiretroviral therapy with and without Kaposi sarcoma: a cohort study
    (Public Library of Science, 2013) Maskew, Mhairi; Fox, Matthew P; Cutsem, Gilles van; Chu, Kathryn; MacPhail, Patrick; Boulle, Andrew; Egger, Matthias; Africa, for IeDEA Southern
    BACKGROUND: Improved survival among HIV-infected individuals on antiretroviral therapy (ART) has focused attention on AIDS-related cancers including Kaposi sarcoma (KS). However, the effect of KS on response to ART is not well-described in Southern Africa. We assessed the effect of KS on survival and immunologic and virologic treatment responses at 6- and 12-months after initiation of ART. METHODS: We analyzed prospectively collected data from a cohort of HIV-infected adults initiating ART in South Africa. Differences in mortality between those with and without KS at ART initiation were estimated with Cox proportional hazard models. Log-binomial models were used to assess differences in CD4 count response and HIV virologic suppression within a year of initiating treatment. RESULTS: Between January 2001-January 2008, 13,847 HIV-infected adults initiated ART at the study clinics. Those with KS at ART initiation (n = 247, 2%) were similar to those without KS (n = 13600,98%) with respect to age (35 vs. 35yrs), presenting CD4 count (74 vs. 85cells/mm 3 ) and proportion on TB treatment (37% vs. 30%). In models adjusted for sex, baseline CD4 count, age, treatment site, tuberculosis and year of ART initiation, KS patients were over three times more likely to have died at any time after ART initiation (hazard ratio[HR]: 3.62; 95% CI: 2.71-4.84) than those without KS. The increased risk was highest within the first year on ART (HR: 4.05; 95% CI: 2.95-5.55) and attenuated thereafter (HR: 2.30; 95% CI: 1.08-4.89). Those with KS also gained, on average, 29 fewer CD4 cells (95% CI: 7-52cells/mm 3 ) and were less likely to increase their CD4 count by 50 cells from baseline (RR: 1.43; 95% CI: 0.99-2.06) within the first 6-months of treatment. CONCLUSIONS: HIV-infected adults presenting with KS have increased risk of mortality even after initiation of ART with the greatest risk in the first year. Among those who survive the first year on therapy, subjects with KS demonstrated a poorer immunologic response to ART than those without KS.