Browsing by Author "Fieggen, Graham"

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    Functioning, disability, health and quality of life in adults with cerebral palsy more than 25 years after selective dorsal rhizotomy: a long-term follow-up study during adulthood
    (2019) Veerbeek, Berendina Egbertine; Langerak, Nelleke; Lamberts, Robert; Fieggen, Graham
    Cerebral palsy (CP) is the most common cause of physical disability in childhood. Today, most children with CP survive into adulthood with life expectancies similar to typically developing (TD) adults. One of the biggest challenges during the lifespan of individuals with CP is healthy aging; to prevent or minimize the secondary effects of CP on the musculoskeletal system (e.g. bone deformities due to spasticity) as well as to improve functional status and quality of life. There is currently no treatment that is able to cure the brain damage which causes CP, but a variety of options exist to address spasticity, the most prevalent primary condition which is estimated to be present in 80% of people with CP. One of these options is the neurosurgical procedure of Selective Dorsal Rhizotomy (SDR) which entails selective sectioning of dorsal rootlets in the lumbosacral area, diminishing spasticity through reducing muscle tone. SDR gained increasing acceptance following the work of Peacock and Arens in the 1980s, and although a large number of studies have demonstrated the benefits of this procedure, they largely comprise relatively short-term follow-up assessments in children and adolescents. There is thus a need for long-term follow-up studies focussed on all facets of daily living (International Classification of Function, Disability and Health (ICF) model domains: body structure and function, activity and participation) and quality of life in adults with CP who underwent SDR in their childhood. The aim of this doctoral thesis was to address this need, and provide information that might help guide parents, caregivers and clinicians in their clinical decision-making process for a child with CP. This aim was addressed through three key investigations. First, the status of adults with CP and spastic diplegia - related to all domains of the ICF-model and health-related quality of life - was determined more than 25 years after SDR. Second, changes in gait pattern, spinal deformities and level of activities and participation in adults with CP were determined nine years after a similar assessment. Third, associations between results in the different ICFmodel domains along with personal and environmental context factors. This PhD thesis forms part of a longitudinal investigation tracking the health and wellness of adults with CP. The former studies were performed in 2008 and consequently a recent follow-up was conducted in 2017 in the same CP cohort. All participants underwent SDR according to the Peacock method (strict selection criteria were adhered) at Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, between 1981 and 1991. This PhD thesis is based on four studies, with the first being a cross-sectional study conducted in 2017 (Chapter 2) and the other three are nine-year follow-up studies (comparing findings in 2017 with studies conducted in 2008 (Chapter 3 - 5). Each study included a matched TD group, except for the spine study (Chapter 4). Participants were observed and assessed for functioning, health, disability and quality of life based on a physical examination, gait analysis, functional mobility tests, spine radiographs and several questionnaires. With respect to the ICF-model Body structure and function domain, adults with CP showed sustained reduction in muscle tone and minimal signs of spasticity in their gait pattern, with no increased prevalence of scoliosis, hyperkyphosis or hyperlordosis, and did not experience limitation of daily activities due to pain. Some challenges were found regarding ROM, muscle strength, selectivity and back pain but they were comparable with what would be expected in adults with CP who did not undergo SDR. Concerning, the Activity domain, the majority of the cohort was independent in functional mobility and the accomplishment of daily activities with no increased risk for falls. They were as satisfied with accomplishing daily activities as the TD adults, though as might be expected, they were found to be less content with their level of mobility. Regarding Participation domain, the adults with CP greater than 25 years post-SDR were independent and satisfied with their attainment of social roles. Most were married or had a relationship, lived independently (with or without partner), finished higher education and were engaged in paid employment. The perceived health-related quality of life was similar to that of TD adults in most of the health concepts (physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning and mental health), except for physical functioning. No increased prevalence of anxiety and depression was found, which was in line with the reported mental health findings of the health-related quality of life questionnaire. This suggests that while adults with CP have on-going physical challenges following SDR, this might not directly impact their mental health and levels of anxiety and depression. The majority of the cohort viewed the SDR they had undergone as worthwhile due to mobility and functional walking gains. Importantly, no changes were found over the nine-year interval in overall gait, functional mobility, spinal deformities, pain and level of accomplishment and satisfaction in daily activities and social participation. This indicates stability of function which is remarkable since functional decline might be expected in adults with CP while aging. However, correlations were found between functional mobility and daily activities and social participation as well as between functional mobility and strength. This highlights the possible importance of resistance training and maintaining walking ability to enable daily activities and social participation and prevent functional deterioration in the future.
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    Mitigation of intrarenal pressure in retrograde intrarenal surgery with a novel isoprenaline eluting guidewire
    (2025) John, Jeff; Kaestner, Lisa-Ann; Lazarus, John; Fieggen, Graham
    Urolithiasis ranks as the third most prevalent condition in urology, with statistical evidence indicating a lifetime risk of 13% in males and 7% in females, alongside a recurrence rate of 50% within a decade. The surgical care of urolithiasis is intricate, with various competing therapeutic techniques available, including retrograde intrarenal surgery (RIRS). Over the years, leading urological associations have progressively broadened the criteria for RIRS in the surgical treatment of urolithiasis. While it offers enhanced stone-free rates relative to shockwave lithotripsy and reduced patient morbidity compared to percutaneous nephrolithotomy, it is not devoid of problems, many of which are associated with intrarenal pressure (IRP). To alleviate the challenges associated with increased IRP, surgeons may utilize diverse approaches to regulate IRP. Pharmacologic therapies in the perioperative period to mitigate IRP have been documented, although none of these strategies have been integrated into clinical practice. This thesis aims to report on the design, safety, and efficacy of an innovative isoprenaline-eluting guidewire (IsoWire), a platform guidewire intended for the administration of topical isoprenaline, a beta-receptor agonist, to the genitourinary system. This is the first study to report the delivery of isoprenaline using a drug-eluting guidewire. This dissertation comprises six chapters. The initial five chapters each have an overview, abstract, introduction, methodology, results, discussion, and conclusion sections. Chapter 1 is a narrative literature review addressing the problems associated with high IRP and outlines techniques to mitigate elevated IRP in RIRS to promote safer endourological practices. To prepare for our investigation on the porcine model, we required a simulation model to precisely outline the procedural procedures. Commercially available models are expensive and not readily accessible. Chapter 2 delineates the design and fabrication of the Frere Intrarenal Surgery Trainer (FiST) bench-top model. This chapter further elucidates its validation through the involvement of individuals with prior competence in the RIRS technique. This high-fidelity, cost-effective, portable, durable, and reusable training model is, to our knowledge, the inaugural published 3D model that integrates all components of RIRS, allowing us to meticulously optimise the procedural stages for our research. The porcine model has frequently been utilized by researchers and urological surgeons for medical advancements. Despite the multiple advantages of this model, the specific anatomical knowledge that qualifies it as the optimal model in urology remains inadequately defined. In Chapter 3, we present the first reported study that precisely delineates pertinent endoscopic and CT-based urological anatomy of female Landrace pigs. The insights acquired from this research were essential for proceeding with the two studies described in Chapters 4 and 5. Furthermore, this unprecedented research will help other researchers use the porcine model to conduct research in endourology with confidence. Chapter 4 delineates the design of the IsoWire and examines the results of the preliminary in vitro release studies. Furthermore, we evaluated IsoWires of three distinct strengths, specifically wires that release 5 μg, 7.5 μg, and 10 μg in the first minute minute, respectively. Our investigation demonstrated that the IsoWire, which released 7.5 μg of isoprenaline within the initial minute, is safe, showing no alterations in mean arterial pressure (MAP), heart rate (HR), or other irregular electrocardiographic (ECG) abnormalities. Moreover, the in vitro release assays demonstrated that the IsoWire released all isoprenaline exponentially within the initial 4 minutes. Chapter 5 delineates the impact of the IsoWire, which dispenses 7.5 μg of isoprenaline within the initial minute, on IRP, the duration of this effect, and its safety in a porcine model. Chapter 6 presents a conclusion and reflection on this thesis, emphasising its original contributions to the field of urology and addressing prospective avenues for future research.
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    The management of post-infectious hydrocephalus in people living with HIV: a prospective observational study
    (2024) Lekoloane, Reneiloe M; Fieggen, Graham; Dlamini, Sipho K
    Post-infectious hydrocephalus (PIH) in people living with HIV (PLHIV) is a common complication presenting to neurosurgeons in South Africa, but there is limited evidence to guide management of these patients. Objectives The study aimed to prospectively document the in-hospital management and 12 month neurological and survival outcomes of PIH in people living with HIV (PLHIV). Methods The study included a consecutive series of 23 people living with HIV (PLHIV) presenting to a tertiary hospital in 2018 with a diagnosis of post infectious hydrocephalus who were followed up for a 12-month period. Baseline demographics, HIV data, and Glasgow Coma Score, aetiology of post infectious hydrocephalus and treatment modality were documented. Survival outcomes and neurological function (modified Rankin Scale) were assessed. The cohort was divided into non-randomised treatment groups, surgical (ventriculoperitoneal shunts/ external ventricular drain) and medical (lumbar spinal taps) based on institutional practice. Results PIH aetiologies were noted as tuberculous in 78.3% (n=18) and cryptococcal in 21.7% (n=5). Overall survival at discharge was 69,9% (n=16) and 47.8% (n=11) at 12 months follow up. Functional outcomes expressed as mRS, resembled the survival data, showing favourable outcomes at 12 months within the survival group. Linear regression analysis showed that the cohort had an unchanged mRS during the 12-month period (p=0.008) Conclusion The limited data from this study suggest that a proactive therapeutic approach to PIH should be offered to virologically suppressed individuals. A tiered treatment algorithm is proposed to guide the treatment of these patients. Further studies using this treatment algorithm could provide a more accurate representation of outcomes in this population.