Browsing by Department "Division of Neurology"

Now showing 1 - 19 of 19
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    Depression in patients with epilepsy
    (1983) Robertson, Mary M
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    Distal sensory polyneuropathy in South Africans infected with human immunodeficiency virus : a cross-sectional analysis of a community cohort
    (2009) Maritz, Jean; Heckmann, Jeannine; Owen, E P
    Introduction: Distal sensory polyneuropathy (DSP), the most common neurological complication of HIV infection, is related to either HIV or antiretroviral therapy (ART). Dideoxynucleoside reverse transcriptase inhibitors such as stavudine are widely used in resource-poor countries and often associated with neuropathy. The prevalence of DSP in developed countries range from 21% to 63%; little data is available from Africa. We aimed to estimate the prevalence of DSP in a South African community clinic-based population and to investigate associated risk factors. Methods: In a cross-sectional study, DSP status was determined in 598 HIV-infected adults using validated tools (Brief Peripheral Neuropathy Screen and a modified version of the Total Neuropathy Score) to categorize subjects. Symptomatic DSP required the presence of at least two neuropathic signs together with at least one symptom. Asymptomatic DSP required the presence of two neuropathic signs. Clinical, anthropometric, quality of life and laboratory evaluations were prospectively performed. Information about CD4 counts, antiretroviral therapy (ART) and questionnaires regarding previous tuberculosis (TB) and alcohol exposure was retrospectively collected Results: Approximately half (49%) of the study population were diagnosed with DSP (30% symptomatic DSP). In the ART-naïve group 37% had evidence of neuropathy (23% symptomatic) compared to 63% of the ART-exposed subjects (39% symptomatic). Overall, subjects with DSP were older (p<0.001) and had lower CD4 counts (p<0.001) compared to those without neuropathy. Previously treated TB infection (p<0.001) and ART use (p<0.001) showed strong associations with DSP. In multivariate analyses the odds (95% confidence interval) of developing DSP was independently associated with ART use (OR 1.7, 1.0-2.9), age (per 10 year increments) (OR 1.7, 1.4-2.2) and previously treated TB infection (OR 2.0, 1.3-3.0). Although stavudine significantly associated with DSP, the duration of exposure was similar irrespective of neuropathy status. Pain or paresthesia was reported by 69% of those with symptomatic DSP and rated as at least moderate to severe. ART-exposed subjects had a tendency towards lower pain scores compared to ART-naïves (p=0.032). Conclusions: DSP is a clinically significant problem in urban HIV-infected Africans. The findings of this study raise the possibility that with avoidance of stavudine-containing regimens in older subjects, especially those with a history of previously treated TB infection, the prevalence of DSP may be reduced.
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    Examination of the nervous system (video tutorial)
    (2011) Eastman, Roland
    Neurology is introduced into the University of Cape Town MBChB programme in the 3rd year. A teaching video of how to conduct the basic neurological examination, designed for 3rd year medical students.
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    Increasing African genomic data generation and sharing to resolve rare and undiagnosed diseases in Africa: a call-to-action by the H3Africa rare diseases working group
    (2022-06-16) Lumaka, Aimé; Carstens, Nadia; Devriendt, Koenraad; Krause, Amanda; Kulohoma, Benard; Kumuthini, Judit; Mubungu, Gerrye; Mukisa, John; Nel, Melissa; Olanrewaju, Timothy O; Lombard, Zané; Landouré, Guida
    The rich and diverse genomics of African populations is significantly underrepresented in reference and in disease-associated databases. This renders interpreting the Next Generation Sequencing (NGS) data and reaching a diagnostic more difficult in Africa and for the African diaspora. It increases chances for false positives with variants being misclassified as pathogenic due to their novelty or rarity. We can increase African genomic data by (1) making consent for sharing aggregate frequency data an essential component of research toolkit; (2) encouraging investigators with African data to share available data through public resources such as gnomAD, AVGD, ClinVar, DECIPHER and to use MatchMaker Exchange; (3) educating African research participants on the meaning and value of sharing aggregate frequency data; and (4) increasing funding to scale-up the production of African genomic data that will be more representative of the geographical and ethno-linguistic variation on the continent. The RDWG of H3Africa is hereby calling to action because this underrepresentation accentuates the health disparities. Applying the NGS to shorten the diagnostic odyssey or to guide therapeutic options for rare diseases will fully work for Africans only when public repositories include sufficient data from African subjects.
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    Intracranial endoscopy
    (Health and Medical Publishing Group, 2006) Figaji, A A; Fieggen, A G; Semple, P L; Peter, J C
    In modern neurosurgery there has been a strong trend towards the use of minimally invasive techniques, one of which is intracranial endoscopy. Endoscopic third ventriculostomy (ETV) is the commonest procedure performed; it is used to treat hydrocephalus caused by an obstruction to the ventricular system anywhere distal to the mamillary bodies of the third ventricle. The obstruction is bypassed by a stoma created in the floor of the third ventricle, allowing cerebrospinal fluid (CSF) to flow freely into the subarachnoid space. Endoscopy can also be used for the fenestration of various intracranial cysts, intraventricular biopsy, the placement and retrieval of ventricular catheters, the removal of small intraventricular lesions, and improved visualisation in microsurgical operations. At Red Cross Children’s Hospital and Groote Schuur Hospital endoscopy has become an indispensable tool in the management of a wide range of neurosurgical conditions. As experience has accumulated worldwide, a better understanding of the benefits and limitations of endoscopy in diverse circumstances has emerged.
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    Neuropsychiatric complications of efavirenz in children with HIV-1 infection
    (2018) Hammond Charles; Eley Brian
    Background: Efavirenz is associated with transient neuropsychiatric manifestations but the impact on neurocognition is unknown. Genetically determined black South Africans who are slow metabolizers of efavirenz may be at risk of toxicity. This study describes neuropsychiatric and neurocognitive manifestations of South African children with suspected efavirenz neurotoxicity. Method: This retrospective study describes clinical features of 12 children with suspected efavirenz neurotoxicity (2008 – 2014). Results: Twelve children were referred (aged 3 years 4 months to 12 years, mean 7 years 8 months; 8 indigenous African (black) and 4 mixed ancestry). Six had acute neuropsychiatric manifestations after 2-8 weeks (mean 5 weeks) on efavirenz including drowsiness, seizures, sleep disturbances, behavioural changes, ataxia and slurred speech. Symptoms resolved over a few weeks in four. Two black children were phenotypically slow metabolizers with high plasma efavirenz concentrations above normal range resulting in discontinuation of efavirenz. Nine children had neurocognitive concerns potentially exacerbated by long-term efavirenz (6-72 months therapy; mean 31 months), and showed poor performance in all neurocognitive domains. Conclusion: Efavirenz causes transient neuropsychiatric adverse effects and may contribute to poor longterm neurocognitive outcomes in HIV-infected children. Genetically slow metabolizers are at risk of neurotoxicity. Prospective studies comparing efavirenz-treated and efavirenz-naïve children are needed.
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    Peripheral reductive capacity is associated with cognitive performance and survival in Alzheimer's disease
    (BioMed Central Ltd, 2006) Minghetti, Luisa; Greco, Anita; Puopolo, Maria; Combrinck, Marc; Warden, Donald; Smith, A David
    BACKGROUND:Oxidative stress is believed to be an early event and a key factor in Alzheimer's disease (AD) pathogenesis and progression. In spite of an intensive search for surrogate markers to monitor changes related to oxidative stress in the brain, there is as yet no consensus about which markers to use in clinical studies. The measurement of peripheral anti-oxidants is an alternative way of evaluating the involvement of oxidative stress in the course of the disease. Given the complexity of peripheral anti-oxidant defence, variations in the levels of individual anti-oxidant species may not fully reflect the overall capacity to fight oxidant conditions. We therefore chose to evaluate the total reductive capacity (herein defined as anti-oxidant capacity, AOC) in serum from control subjects and AD patients in order to study the association between peripheral anti-oxidant defence, cognitive impairment and patient survival. METHODS: We measured the levels of AOC in serum samples from 26 cognitively normal controls and 25 AD patients (12 post-mortem confirmed) who completed the Cambridge Cognitive Assessment. Cognitive decline was assessed in a subgroup of 19 patients who underwent a second cognitive assessment 2 years after the initial visit. RESULTS: Serum AOC levels were lower in AD patients than in controls and were correlated with their cognitive test scores, although AOC levels were unrelated to cognitive decline assessed two years later. On the other hand, AOC levels were predictive of the length of patients' survival, with higher levels giving longer survival. CONCLUSION: This study indicates that peripheral anti-oxidant defences are depleted in AD patients. The results suggest that serum AOC is a good index of the general health status and prognosis of patients but does not necessarily reflect the extent to which vulnerable neuronal populations are protected from oxidant processes. Further studies are required to establish whether peripheral AOC measurements may be useful in identifying asymptomatic individuals or those with early symptoms at high risk of developing significant cognitive impairment or dementia.
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    Plasma cytokine profiles in HIV-1 infected patients developing neuropathic symptoms shortly after commencing antiretroviral therapy: a case-control study
    (2014-02-10) Van der Watt, Johan J; Wilkinson, Katalin A; Wilkinson, Robert J; Heckmann, Jeannine M
    Abstract Background In patients infected with human immunodeficiency virus 1 (HIV-1) neuropathic symptoms may develop within weeks of starting combination antiretroviral therapy (cART). This timing coincides with the occurrence of immune reconstitution inflammatory syndrome. Our objective was to investigate the longitudinal association of plasma cytokine and soluble receptor concentrations with incident neuropathic symptoms within 12 weeks of starting programme-based cART in a nested case-control study. Methods One hundred and twenty adults without neuropathic symptoms and about to initiate cART were followed longitudinally for 24 weeks after cART initiation. Subjects were examined for peripheral neuropathy at baseline (pre-cART) and 2-, 4-, 12- and 24 weeks thereafter. Individuals developing neuropathic symptoms within 12 weeks of starting cART were matched in a nested case-control design with those remaining symptom-free for at least 24 weeks. Plasma was collected at each visit. Cytokines and soluble receptors were quantified using multiplex immunometric assays. Results Incident neuropathic symptoms occurred in 32 (27%) individuals within 12 weeks of starting cART for the first time. Cytokine concentrations increased at 2 weeks, irrespective of symptom-status, returning to baseline concentrations at 12 weeks. Compared to the control group, the symptomatic group had higher baseline levels of interleukin-1 receptor (IL-1R)-antagonist. The symptomatic group also showed greater increases in soluble interleukin-2 receptor-alpha and tumour necrosis factor (TNF) receptor-II levels at week 2 and soluble interleukin-6 receptor levels at week 12. Ratios of pro-inflammatory- vs anti-inflammatory cytokines were higher for TNF-alpha/IL-4 (p = 0.022) and interferon-gamma/IL-10 (p = 0.044) in those developing symptoms. After 24 weeks of cART, the symptomatic group showed higher CD4+ counts (p = 0.002). Conclusions The initiation of cART in previously treatment naïve individuals was associated with a cytokine 'burst’ between 2- and 4 weeks compared with pre-cART levels. Individuals developing neuropathic symptoms within 12 weeks of starting cART showed evidence of altered cytokine concentrations even prior to initiating cART, most notably higher circulating IL-1R-antagonist levels, and altered ratios of “pain-associated” cytokine and soluble receptors shortly after cART initiation.
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    Risk of malignancy in myasthenia gravis patients exposed to azathioprine therapy for a median period of 3 years
    (2006) Rawoot, A; Little, F; Heckman, J
    The long-term risk of malignancies in patients treated with immunosuppressive drugs is a concern among patients and physicians. Patients with myasthenia gravis (MG) respond well to azathioprine (Aza) but many require longterm treatment. The therapeutic effect is presumably largely due to reduced proliferation of actively dividing lymphocytes; however, the benefit of suppressing autoreactive lymphocytes may theoretically result in a concomitant reduction of immunosurveillance and thereby increase the risk of cancer. Many have assessed the malignancy risk in autoimmune diseases such as inflammatory bowel disease (IBD) and rheumatoid arthritis (RA), but these may have their own inherent risk such as colorectal cancer in IBD or lymphoma in RA.1,2 Few studies have been published related specifically to Aza exposure and cancer risk in MG.3,4 This report concerns the incidence of cancer in a South African MG cohort specifically assessing the Aza dose and the duration of treatment.
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    Silent casualties from the measles outbreak in South Africa
    (2011) Albertyn, Christine; Van der Plas, Helen; Hardie, Diana; Candy, Sally; Tomoka, Tamiwe; LeePan, Edward B; Heckmann, Edward B
    South Africa, home to the world’s largest population of people living with HIV (5.7 million), experienced a measles outbreak that started in late 2009.1 There was a stepped increase in cases of measles, with the highest incidence reported in March 2010.2 By September 2010, more than 17 000 new measles cases had been reported to the National Institute of Communicable Diseases since January 2009. A mass vaccination campaign from mid-April to early May 2010 resulted in a significant decline in new measles cases. The measles virus is highly contagious, and outbreaks are fuelled by overcrowding and poor vaccine coverage, making elimination status in South Africa difficult to attain. Measles may infect the central nervous system (CNS) as acute viral encephalitis, or result after 2 - 4 weeks in a post-infectious immune-mediated inflammatory disorder or acute disseminated encephalomyelitis (ADEM). There are 2 further rare and latent CNS complications resulting from a preceding measles infection: subacute sclerosing panencephalitis (SSPE) caused by years of viral persistence in a seemingly immunocompetent host,3 and subacute measles encephalitis (SME), occurring in an immunocompromised host.4 SME manifests 1 - 7 months after the acute measles infection.5 Patients present with seizures, often epilepsy partialis continua, and altered mental status.5 It carries a mortality rate of 85% and survivors often have significant psychomotor retardation.5 SME has hitherto only been described in single case reports as a rare complication of measles in the context of organ transplantation,6,7 immunosuppressive therapy or immunodeficiencies,5,8 and HIV and AIDS.5,9,10 We report 8 cases of SME in HIV-infected patients who presented to a tertiary referral hospital between July and October 2010.
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    A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis
    (BioMed Central Ltd, 2011) Heckmann, Jeannine; Rawoot, Amanullah; Bateman, Kathleen; Renison, Rudi; Badri, Motasim
    BACKGROUND:Long-term immunosuppression is often required in myasthenia gravis (MG). There are no published trials using methotrexate (MTX) in MG. The steroid-sparing efficacy of azathioprine (AZA) has been demonstrated after 18-months of starting therapy. However, AZA is considered expensive in Africa. We evaluated the steroid-sparing efficacy of MTX (17.5 mg weekly) compared with AZA (2.5 mg/kg daily) in subjects recently diagnosed with generalized MG by assessing their average monthly prednisone requirements. METHODS: The primary outcome was the average daily prednisone requirement by month between the two groups. Prednisone was given at the lowest dose to manage MG symptoms and adjusted as required according to protocol. Single-blinded assessments were performed 3-monthly for 2-years to determine the quantitative MG score and the MG activities of daily living score in order to determine those with minimal manifestations of MG. RESULTS: Thirty-one subjects (AZA n = 15; MTX n = 16) satisfied the inclusion criteria but only 24 were randomized. Baseline characteristics were similar. There was no difference between the AZA- and MTX-groups in respect of prednisone dosing (apart from months 10 and 12), in quantitative MG Score improvement, proportions in sustained remission, frequencies of MG relapses, or adverse reactions and/or withdrawals. The MTX-group received lower prednisone doses between month 10 (p = 0.047) and month 12 (p = 0.039). At month 12 the prednisone dose per kilogram bodyweight in the MTX-group (0.15 mg/kg) was half that of the AZA-group (0.31 mg/kg)(p = 0.019). CONCLUSIONS: This study provides evidence that in patients with generalized MG methotrexate is an effective steroid-sparing agent 10 months after treatment initiation. Our data suggests that in generalized MG methotrexate has similar efficacy and tolerability to azathioprine and may be the drug of choice in financially constrained health systems.TRIAL REGISTRATION:SANCTR:DOH-27-0411-2436
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    Subacute measles encephalitis: The neurological sequelae of the measles outbreak in South Africa
    (2014) Albertyn, Christine Herculine; Heckmann, Jeannine
    A measles outbreak occurred in South Africa between 2009 and 2011 with 18 699 confirmed cases. This highly contagious virus can affect the central nervous system in many ways. Early in the disease course there may be direct viral involvement as a primary measles encephalitis or indirectly as an inflammatory immune mediated demyelinating meningoencephalitis. Latent infections are rare and may manifest in two ways: years later as subacute sclerosing panencephalitis (SSPE) caused by viral persistence in a seemingly immunocompetent host or months later as subacute measles encephalitis (SME) in an immunocompromised host. SME is characterised by seizures, typically epilepsia partialis continua, and altered mental status and carries a high mortality. It is an elusive diagnosis and usually confirmed on brain biopsy. Patients and results: Eight patients were diagnosed with SME between July and October 2010 at our tertiary referral hospital. All patients were HIV positive, with a median CD4 lymphocyte count of 37 cells/µl (range 1 to 268). All patients had epilepsia partialis continua during the course of the illness and other common features included encephalopathy, visual loss, hearing loss, and generalised seizures. Strikingly, cerebrospinal fluid (CSF) examination was normal in all patients and computed 4 tomography (CT) Brain imaging was normal in all but one patient. Magnetic resonance imaging (MRI) Brain demonstrated superficial and deep grey matter abnormalities in the majority of patients with contiguous cortical spread over weeks documented in one patient. Electroencephalograms (EEGs) showed periodic epileptiform discharges in seven patients. Diagnosis was confirmed by brain biopsy in one patient, by post-mortem examination in three patients and by supportive laboratory findings (positive measles PCR and/or measles antibodies in urine or CSF) in the remainder. The outcome was fatal in seven of the cases with a median time to death of 3 weeks. Conclusion: South Africa has the greatest number of people living with HIV: 12.6% of the population (6·4 million people) are infected. This is the largest SME case series to date and is seen in the aftermath of a measles outbreak in South Africa. Immunocompromised patients are clearly susceptible and typically present with epilepsia partialis continua and rapid decline in neurological functioning and death ensuing within a month in the majority of cases. MRI T2-weighted signal changes in the cortical grey matter, are typical. In the absence of a brain biopsy, we propose the use of measles virus PCR in urine and CSF. The importance of herd immunity, by enforcing the national vaccination programme, is reiterated.
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    The EEG in psychiatry
    (2004) Eastman, Roland
    The value of EEG in the practice of psychiatry has been a debated issue since the advent of these neurophysiological studies in the 1930’s. Surprisingly, there are few credible studies in this area, and much of the earlier work is bedevilled by poor research design and hence unwarranted conclusions. A brief review in this issue highlights some of the conflicting reports and ventures the opinion that routine referral of all patients attending a psychiatric service is not appropriate in view of the likely low yield of results which will change the patient’s management, and the attendant risk of over-interpretation of minor non-specific findings which may lead to falsepositive diagnoses.
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    The lumbosacral plexus and diseases affecting it
    (1985) Bhigjee, Ahmed Iqbal
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    The role of melatonin in the effective attainment of electroencephalograms in children in a Sub-Saharan setting
    (2018) Chidi, Ibekwe Roland; Wilmshurst, Joanne M
    Rationale: The paucity of access to electroencephalograms (EEGs) in sub-Saharan Africa results in a high patient load attending the few centres with neurophysiology units. Sleep state for EEGs performed on children improves yield and reduces artefact. Melatonin induces “natural sleep” without the risk of airway compromise. This study evaluated the effectiveness of oral melatonin in attainment of useful electroencephalograms in South African children. Methods: Consecutive children booked for routine EEG who were either unable to cooperate or were referred for sleep EEG received oral melatonin (3mg < 15kg; 6mg > 15kg) (September 2013-March 2014). Comparison was made to a retrospective control group who received the previous sleep protocol agent, chloral hydrate. Outcome measures were the proportion of children who achieved sleep, useful EEG study data, sleep latency and duration, presence and level of artifacts and presence of recorded EEG study abnormalities. Results: 173 children were recruited, 88 (51%) male, median age 4 years 9 months (interquartile range of 2 years 2 months – 7 years 6 months). 87% of the children achieved stage 2 sleep and were deemed to have successfully entered sleep state. The median sleep latency was 44.5 minutes and the duration of sleep was 25 minutes (range 18.5 – 29 minutes). Children showed no signs of post-sedation irritability or persistent drowsiness. They were awoken and were immediately able to go home. In the melatonin group there were no adverse events, and no child needed their study deferred due to inter-current illnesses. All children administered melatonin cooperated and permitted a successful EEG recording with useful records even if sleep was not achieved. Sedation with melatonin was less successful (74% compared to 88%) in children with developmental and behavioural problems (χ 2 = 6.18, P= 0.046), they also had higher rate of artifacts (χ 2 = 5.83, P=0.05). 33.5% of the study group children (n=58) had abnormal EEG studies. These outcomes were comparable to a historical cohort of age equivalent children who were sedated with chloral hydrate (45.5%) (χ 2 = 1.22, P= 1.27). 79% that received melatonin compared with 86% of those that were sedated with chloral hydrate had artifacts (χ 2 = 0.63, P= 0.42) Conclusion: Melatonin is effective and safe in inducing sleep for EEG recording in our setting.
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    The role of the HIV-1 Tat protein in acute stroke: more than just a transactivator of transcription?
    (2018) McMullen, Kate Elizabeth; Bateman, Kathleen J; Combrinck, Marc; Bryer, Alan
    Background: Individuals infected with the human immunodeficiency virus (HIV) are at increased risk of developing ischaemic stroke. The reasons for this are multifactorial, but HIV-associated vasculopathy is a potentially important cause. HIVinduced chronic inflammation may initiate endothelial dysfunction or accelerate vascular injury from other disease processes. Viral proteins such as the transactivator of transcription (Tat) are emerging role-players in HIV disease pathogenesis and have a putative role in HIV-associated endothelial dysfunction. Tat has paracrine proinflammatory effects, but its role in HIV-related stroke has not yet been investigated. Aims: The primary aim of this study was to determine whether specific Tat amino acid variants are associated with ischaemic stroke and biomarkers of inflammation and endothelial dysfunction in a group of HIV-1 subtype-C-infected individuals. In order to do so, I first determined the aetiology of stroke in these participants using clinical, biochemical and neuro-imaging data. A secondary aim of the study was to identify any HIV-related and/or other traditional stroke-related risk factors that might independently or cumulatively increase stroke risk. For comparison, these putative risk factors were also determined in a group of age-matched HIV-infected non-stroke controls. Finally, I aimed to identify any HIV-related factors and/or Tat amino acid variants that might distinguish strokes due to HIV-associated vasculopathy from other mechanisms of stroke. Methods: A case-control study was performed on 58 Subtype-C HIV-infected individuals with acute ischaemic stroke and 71 HIV-1 Subtype-C-infected non-stroke controls. Clinical, demographic, laboratory and imaging data were used to determined baseline differences between groups and to distinguish different stroke aetiologies. Exon 1 of the HIV-1 Tat protein was sequenced from peripheral blood samples of stroke participants and controls and amino acid variants were identified using viral epidemiology signature pattern analysis. Regression analyses were used to examine the correlation between residues at signature positions with biomarkers of inflammation and endothelial activation. Results: Stroke and control groups were mostly young (mean age 33 years) females (62.1% & 71.8%), and of Black African ancestry. The strokes showed a higher prevalence of some traditional cardiovascular risk factors. Individuals with strokes had a higher prevalence of antiretroviral treatment interruption (25.9% vs 0.0%, p= 0.003), lower CD4 nadir (112 vs 177.5 cells/μl, p=0.008) and CD4 count (208.5 vs 322.5 cells/μl, p=0.012) than controls. Median viral loads were elevated in both strokes and controls (4.58 & 4.13 log10 copies/ml, p=0.28). The most common causes of stroke were HIV-associated vasculopathy (43.1%) and opportunistic infections (22.4%). Two amino acid variants (proline at position 21 and histidine at position 29) were associated with acute ischaemic stroke. These positions were also associated with modulation of plasma interleukin 6 and monocyte chemoattractant protein 1 levels. Threonine at position 58 distinguished strokes due to alternative mechanisms from strokes due to HIV-associated vasculopathy. Conclusions: Two Tat protein amino acid variants are associated with stroke in HIV. The precise mechanisms by which these associations occur are not known. However, they are likely to be part of a multiple-hit phenomenon in HIV stroke pathogenesis. Tatmediated inflammation with endothelial dysfunction, HIV disease severity, treatment interruption and conventional cardiovascular risk factors probably all contribute to stroke aetiology. Thus, a multi-modal approach is needed to reduce ischaemic stroke risk in HIV infection.
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    The South African stroke risk in general practice study
    (2005) Connor, Myles; Rheeder, Paul; Bryer, Alan; Meredith, Megan; Beukes, Marlene; Dubb, Asher; Fritz, Vivian
    Background. Incidence of stroke is increasing in sub-Saharan Africa and stroke prevention is an essential component of successful stroke management. General practitioners (GPs) are well placed to manage stroke risk factors. To design appropriate strategies for risk factor reduction we need to know the risk factor prevalence in each of the population groups attending GPs. The aim of this study was to establish the prevalence of stroke risk factors in the South African general practice population. Method. We conducted a multicentre, observational study of patients attending general practice in South Africa. Two hundred general practices were randomly selected from lists provided by pharmaceutical representatives. Each GP approached 50 consecutive patients aged 30 years and older. Patients completed an information sheet and the GP documented the patient’s risk factors. The resulting sample is relevant if not necessarily representative in a statistical sense. Results. A total of 9 731 questionnaires were returned out of a possible 10 000. The mean age of particpants was 50.7 years. Seventy-six per cent had 1 or more risk factors and 40% had 2 or more risk factors. Hypertension was the commonest risk factor in all population groups (55%) but was highest in black patients (59%). Dyslipidaemia was commonest in whites (37%) and least common in blacks (5%). Diabetes was commonest in Asians (24%) but least common in whites (8%). Risk factors other than smoking increased with age. Conclusion. This study provides unique data on the prevalence of stroke risk factors in a South African general practice population. Risk factors are common in all population groups, but differ in distribution among the groups. There is considerable opportunity to reduce the burden of stroke in South Africa through GP screening for and treatment of risk factors.
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    Use of phenobarbitone for treating childhood epilepsy in resource-poor countries
    (South African Medical Journal, 2005) Wilmshurst, Jo M; Van Toorn, Ronald
    Should the continued use of phenobarbitone for childhood epilepsy in resource-poor countries be considered a form of discrimination? Phenobarbitone was recommended by the World Health Organization (WHO) as the first-line agent for the control of seizures,1 but this has been contested on the grounds that it is biased against resource-poor countries.2 It was first used as an anticonvulsant in 1912, but now has little role to play in First-World countries where the newer generation agents are readily accessible. Phenobarbitone monotherapy has equivalent efficacy to the newer anticonvulsants (phenytoin, sodium valproate and carbamazepine) in children with partial-onset and generalised tonic-clonic seizures.3 Phenobarbitone is cheap, readily available, and easy to use and store. However, it has definite cognitive and behavioural side-effects in many children. It can exacerbate seizures in about 35% of children, and extreme caution should be taken with children who have a pre-morbid state of behavioural problems or attention deficit hyperactivity disorder (ADHD).