Browsing by Subject "Internal Medicine"

Now showing 1 - 14 of 14
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    Audit of the quality and cost of acute inpatient stroke care in the general medical wards at Groote Schuur Hospital
    (2016) Viljoen, Charle André; De Villiers, Linda
    Introduction: Stroke is the leading cause of death and disability amongst South Africans older than 60 years. The majority of stroke patients in South Africa are managed in general medical wards where little is known about the quality and cost of care. The aim of this study was to determine the cost of stroke care and to identify factors associated with increased expense , as well as to evaluate the quality of stroke care in general medical wards in order to identify areas where quality of care could be improved. Methods: We conducted a retrospective folder review of all acute stroke admissions to the general medical wards at Groote Schuur Hospital from 1 January to 31 December 2012. Patients younger than 45 years and those that received thrombolysis were excluded. The hospital's finance department provided the bed costs, as well as expenditure on consumables, pharmacy, laboratory and radiology for each subject. The quality of care was measured according to the South African Stroke Guidelines. Results: The inpatient care of 261 patients was evaluated. Although neuroradiology was performed on 95% of patients, carotid duplex Doppler ultrasonography and echocardiography were not often done. Although all patients with ischaemic stroke received inpatient antiplatelet or anti - coagulation therapy, not all risk factors were adequately addressed on discharge. The median cost of a stroke admission was R19,072.07 (IQR R10,899.85 to R27,789.43 ). The strongest correlation with cost 12 was with length of stay (LOS), r = 0.9977. The median LOS was 6 days (IQR 3 to 9 days). Using non -¬‐ parametric univariable analysis, clinical factors prolonging LOS were previous stroke ( P = 0.0 2 8) and inpatient complications: fever ( P < 0.0 0 1), urinary tract infections ( P < 0.0 0 1) and acute kidney injury ( P < 0.0 0 1) . The LOS increased as the number of inpatient complications increased (P = 0.059). Mortality was 20% and 68% of patients experienced at least one medical complication during admission. Fever and pneumonia were predict ors of death. Pneumonia was less prevalent amongst patients who were mobilised early (P = 0.002). Early nutritional support was beneficial in reducing the incidence of acute kidney injury (P < 0.001). The median LOS was significantly prolonged by delaying speech therapy (P < 0.001), nutritional support (P < 0.01), physiotherapy (P < 0.01) and occupational therapy (P < 0.001). Discharge to inpatient rehabilitation centres significantly prolonged LOS as compared with patients discharged home (P < 0.001). Conclusions: This is the first study evaluating the cost of acute stroke care in South Africa. Length of stay was the greatest determinant of cost. Improving the quality of care to reduce the number of complications, early referral to allied health professionals and effective discharge planning would result in shorter length of hospital stay and therefore cost saving. There is a need for increased access to stroke unit beds, albeit dedicated stroke beds in the general medical wards, to ensure specialised nursing care and early inpatient rehabilitation to reduce the number of inpatient complications, as well as implementation of protocols to allow for better adherence to national guidelines.
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    Case report: Severe central nervous system manifestations associated with aberrant efavirenz metabolism in children: the role of CYP2B6 genetic variation
    (2015) Abrams, Elaine
    BackgroundEfavirenz, widely used as part of antiretroviral drug regimens in the treatment of paediatric human immunodeficiency virus infection, has central nervous system side effects. We describe four children presenting with serious, persistent central nervous system adverse events who were found to have elevated plasma efavirenz concentrations as a result of carrying CYP2B6 single nucleotide polymorphisms, known to play a role in the metabolism of EFV. None of the children had a CYP2B6 wildtype haplotype. We believe this is the first case of cerebellar dysfunction associated with efavirenz use to be described in children.Case presentationFour black African children, between the ages of 4 and 8years presenting between 1 and 20months post-efavirenz initiation, are described. Cerebellar dysfunction, generalised seizures and absence seizures were the range of presenting abnormalities. Plasma efavirenz levels ranged from 20-60mg/L, 5–15 times the upper limit of the suggested reference range. All abnormal central nervous system manifestations abated after efavirenz discontinuation.ConclusionEfavirenz toxicity should always be considered in human immunodeficiency virus-infected children with unexplained central nervous system abnormalities. Our findings further our understanding of the impact of genetic variants on antiretroviral pharmacokinetics in children across various ethnic groups. Screening for potential EFV-toxicity based on the CYP2B6 c.516 SNP alone, may not be adequate.
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    The control of prolactin secretion and the role of gonadotrophin releasing hormone in the production of concordant secretory spikes of luteinizing hormone and prolactin in the luteal phase of the menstrual cycle
    (1988) Kaplan, Hilton; Bonnici, François
    The control of prolactin secretion is a complex interaction of peptides and neurotransmitters acting either in an inhibitory or stimulating way to effect final secretion of this hormone from the lactotrope cell in the anterior hypothalamus. These factors may act either directly on the lactotrope cell or indirectly by changing either dopamine restraint of prolactin secretion or by modulating peptide substances or neurotransmitters higher up in the hypothalamus. Gonadal steroids may also modulate the effect of peptides or dopamine at the level of the lactotrope. Prolactin's major role in the female rat is one of milk production post - partum, nurturing the young. It probably also has other physiological functions and may play a part in the menstrual cycle although this is controversial. Certainly, pulsatile secretion of prolactin during the menstrual cycle is well established and in the luteal phase this is concomitant with the secretion of luteinizing hormone. Theories explaining the synchronous surges seen during this phase of the menstrual cycle have been proposed and GnRH has been implicated in the genesis of the concordance of these secretory spikes. Using a potent GnRH antagonist an experiment was undertaken to establish the role of GnRH by blocking this hypothalamic peptide and observing the effect that this had on luteinizing hormone, prolactin and follicle stimulating hormone. In the first part of the thesis the control of prolactin secretion is reviewed. In the following section, an experiment was performed using a potent GnRH antagonist. A dose response curve was established for the antagonist action on LH. Then a twice maximum dose of this peptide was administered to three subjects in the midluteal phase of the menstrual cycle and the response of LH, prolactin and FSH was measured. The results indicate that although the GnRH antagonist significantly blocked LH secretory peaks, this action was not observed for either prolactin or FSH. This result is perhaps at variance with previous data which suggested that GnRH was responsible for concordant secretory spikes of LH and prolactin in the midluteal phase of the menstrual cycle.
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    Early morning urine collection to improve the sensitivity of LAM in hospitalised TB/HIV co-infected patients
    (2016) Gina, Ntombenhle Phindile; Dheda, Keertan; Peter, Jonathan G; Randall, Philippa
    Point-of-care detection of urine lipoarabinomannan (LAM) is a low-cost rapid TB diagnostic for use in HIV co-infected patients. However, its sensitivity in these patients is suboptimal. Strategies to improve its performance is a need. The hypothesis was that early morning urine (EMU), rather than random urine sampling, would improve LAM's sensitivity. Methods Recruitment process conducted between June 2012 and February 2014 for HIV-infected patients from four hospitals in Cape Town, South Africa presenting with possible TB (all patients initiated on TB treatment). Fresh random and early morning urine (EMU) samples (~10-30 ml) collected in sterile containers. Following the manufacturer's instructions, an Alere Determine® TB Lateral flow assay performed on each sample, using both grade 1 and 2 cut-points. A single sputum Xpert MTB/RIF and/or liquid TB culture was a reference standard. Those designated probable TB patients were sputum Xpert MTB/RIF and/ TB culture negative, but started on TB treatment.
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    Early outcomes of thrombolysis for acute ischaemic stroke in a South African tertiary care centre
    (2012) Wasserman, Sean; Bryer, Alan
    Stroke is an important cause of death and disability in sub-Saharan Africa. Recombinant tissue plasminogen activator (tPA) thrombolysis is effective in treating acute ischaemic stroke, but may not be a viable option in developing countries. This prospective observational study was designed to assess the short-termoutcomes and safety of tPA for the treatment of stroke at Groote Schuur Hospital.Data was collected from January 2000 to February 2012, and included patients witha clinical diagnosis of acute stroke with onset of stroke symptoms within 4.5 hours ofreceiving thrombolysis. Exclusion criteria were based on the National Institute ofNeurological Disorders and Stroke (NINDS) rt-PA trial protocol (upper age limit was 75 years). Primary outcomes were the proportion of patients achieving significant early neurological recovery defined as an improvement of 4 or more points on the National Institutes of Health stroke scale (NIHSS) score and functional independence defined as a modified Rankin score of 2 or less at discharge. The primary safety measures were the rates of symptomatic intracranial haemorrhage (SICH) and death. From January 2000 to February 2011 42 patients were thrombolysed, with a mean time to tPA infusion of 160 minutes (standard deviation (SD) 50; range 60 - 270). By discharge the median NIHSS score fell from 14 (interquartile range (IQR) 10.5 - 17) to 7.5 (IQR 1 - 15); 28 (66.7%) achieved significant neurological improvement, and 17 (40.5%) were functionally independent. Two patients (4.8%) suffered SICH and there were 3 (7.1%) deaths. Thrombolysis in routine clinical practice in a South African setting has similar safety and early efficacy outcomes to controlled trials and open-label studies in developing and developed countries.
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    The effect of structured reflection on the diagnostic accuracy of postgraduate trainees during real patient encounters
    (2016) Rush, Colin James; Burch, Vanessa
    Structured reflection has been shown to improve the diagnostic competence of undergraduate and postgraduate trainees in a range of experimental settings using written case scenarios. Evidence supporting the use of this strategy during real patient encounters is lacking. This paper reports on a study conducted to determine the effects of structured reflection on the diagnostic accuracy of postgraduate medical trainees during bedside tutorials using real patient encounters. Method Fifty-five postgraduate trainees in Internal Medicine at the University of Cape Town, South Africa, were prospectively studied during 18 beside tutorials using real patient encounters. Each patient encounter was conducted as a 4-stage diagnostic process and a diagnostic accuracy score (DAS) was calculated for all participants at each stage: • DAS 1: immediately upon arrival at the patient's bedside (visual cues only); • DAS 2: after an oral presentation of the interview and physical examination findings (pre-reflection); • DAS 3: after review of the clinical data using a process of structured reflection (post-reflection); • DAS 4: after discussion of the patient facilitated by the attending physician (facilitated reflection). Memory structure and flexibility in thinking of participants were evaluated using the Diagnostic Thinking Inventory (DTI) and compared to their post-reflection diagnostic accuracy scores. Results A total of 212 diagnostic events were studied. Friedman's test demonstrated a significant difference when comparing the median diagnostic accuracy scores (DAS) of the respective stages of the diagnostic process (χ² (3) = 406.34, p value < 0.001). The Wilcoxon signed-rank test confirmed that there was a significant difference between the immediate DAS (DAS 1) and the pre-reflection DAS (DAS 2) (Z = 8.66, p value < 0.001), the pre-reflection DAS (DAS 2) and the post reflection DAS (DAS 3) (Z = 4.98, p value < 0.001). Linear regression identified a significant relationship between DTI scores and DAS 3 (p value = 0.035), however this explains only a small portion of the variation in the data (r² = 0.093). Conclusion Structured reflection improved the diagnostic accuracy of postgraduate trainees during real patient encounters at the bedside. These data provide support for the suggestion that clinical teachers should consider adding structured reflection to their toolbox of bedside teaching strategies. In addition, DTI scores may help clinical teachers identify trainees struggling with the development of diagnostic expertise.
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    Impairments in signaling cascades mediating the progression of liver disease from chronic hepatitis to hepatocellular carcinoma in animal and human models
    (2011) Setshedi, Mashiko; De la Monte, Suzanne M
    The most common risk factors for chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC) include chronic alcohol abuse and infection with hepatitis B (HBV) or hepatitis C (HCV) virus. Growing evidence from human studies and experimental models suggests that pre-degenerative and premalignant abnormalities include disturbances in intracellular signaling and ongoing injury with oxidative stress, inflammation, and lipotoxicity. The major signal transduction pathways affected in both degenerative and neoplastic disease states in liver include: insulin/IGF, Wnt/β-catenin, and others.
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    Implementation of the JAK2V617F mutation analysis in the pathway of suspected myeloproliferative neoplasms in Groote Schuur Hospital
    (2016) Poulet, Erma; Verburgh, Estelle
    We studied the implementation of JAK2 mutation analysis in conjunction with the World Health Organisation (WHO) guidelines in the pathway to MPN diagnosis in 279 patients presenting with one of three clinical scenarios: erythrocytosis, OR leukocytosis and/or thrombocytosis and/or splenomegaly; OR patients with thrombosis without cytoses. Patients were investigated for MPN and managed in the haematology clinic of Groote Schuur Hospital. We studied the association of clinical and laboratory variables with clonal vs non-clonal diagnoses. In 120/297 patients MPN was confirmed: Polycythemia vera (PV), (n=51, 100% JAK2 mutated); essential thrombocytosis, (n=41, 42% JAK2 mutated); primary myelofibrosis (n=28, 57% JAK2 mutated). The 2016 WHO haemoglobin/haematocrit thresholds in PV were validated. Idiopathic erythrocytosis (IE) found in 44 patients. Bone marrow histology, but not serum EPO level, was essential to differentiate between clonal and non-clonal erythrocytosis. Both PV and IE patients complied with the criteria of absolute erythrocytosis on peripheral blood, yet nuclear red cell mass identified critical differences between clonal and non-clonal erythrocytosis. No patient venesected for nonclonal erythropoiesis developed thrombocytosis. JAK2 mutation analysis applied with the WHO diagnostic algorithm efficiently differentiated true clonal myeloproliferation from reactive cytoses. Lifestyle and metabolic factors such as smoking and thrombosis were not associated with either clonal or non-clonal erythrocytosis, and were equally present in mutated and unmutated essential thrombocytosis.
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    Inflammatory arthritis in HIV positive patients: A practical guide
    (2016) Adizie, T; Moots, R J; Hodkinson, B; French, N; Adebajo, A O
    BackgroundMusculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome.MethodsWe carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed.ResultsThere are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals.ConclusionsThis review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.
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    Long-term HIV and tuberculosis outcomes in co-infected patients with treatment limiting severe cutaneous adverse reactions
    (2023) Veenstra, Simon; Peter, Jonathan
    Background Treatment-limiting severe cutaneous adverse reactions (SCAR) occur more commonly amongst persons co-infected with tuberculosis (TB) and advanced HIV. The impact of SCAR on long-term HIV and TB outcomes is unknown. Methods Patients with active TB and/or HIV admitted to Groote Schuur Hospital, Cape Town, South Africa with SCAR between 1/10/2018 and 30/09/2021 were eligible. Clinical and laboratory follow-up data was collected for 6 and 12-month outcomes: mortality, TB and antiretroviral therapy (ART) regimen changes, TB treatment completion, and CD4 count recovery. Results Forty-eight SCAR admissions included: 34, 11, and 3 HIV-associated TB, HIV-only and TB-only patients with 32, 13 and 3 cases of drug reaction with eosinophilia and systemic symptoms, StevensJohnson syndrome/toxic epidermal necrolysis and generalised bullous fixed drug eruption respectively. Nine (19%), all HIV-positive, were deceased at 12-months, and 12 (25%) were lost to all care levels. Amongst TB-SCAR patients, seven (21%) were discharged on all four first-line anti-TB drugs (FLTD), while 12 (33%) had discharge regimens with no FLTDs; 24/37 (65%) completed TB treatment. Amongst HIV-SCAR patients, 10/31 (32%) changed ART regimen. If retained in care (24/36), median (IQR) CD4 counts increased by 12-months post-SCAR (115 (62-175) vs. 319 (134-439) cells/uL). Conclusion SCAR admission amongst patients with HIV-associated TB results in substantial mortality, and considerable treatment complexity. However, if retained in care, TB regimens are successfully completed, and immune recovery is good despite SCAR.
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    Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysis
    (2019) Nzeale, Jean Jacques Noubiap; Kengne, Andre Pascal
    Background The burden of dyslipidaemia in Africa remains inadequately characterised. We aimed to estimate the prevalence of dyslipidaemia in African adults from hospital-based and community-based studies. Methods In this systematic review and meta-analysis, we searched MEDLINE via PubMed, EMBASE, African Journals Online, and African Index Medicus for studies published between Jan 1, 1980, and July 31, 2017, without language restriction. We assessed methodological quality of all crosssectional studies reporting on the prevalence of elevated concentrations of total cholesterol, LDL cholesterol, or triglycerides, or low concentrations of HDL cholesterol in adults residing in African countries. We excluded reports on Africans living outside Africa, studies of individuals selected on the basis of existing dyslipidaemia or those including children and adolescents, and case series with a small sample size. The most frequently used cutoffs in the included studies were chosen for the subgroup analysis. We used random-effect model meta-analysis to derive the pooled prevalence of elevated total cholesterol, low HDL cholesterol, elevated LDL cholesterol, and elevated triglyceride concentrations. This study is registered with PROSPERO, number CRD42014015376. Findings 177 studies (294063 participants) were included in the meta-analysis. The pooled prevalence of dyslipidaemia in the general population from population-based studies was 25·5% (95% CI 20·0– 31·4) for elevated concentrations of total cholesterol with a cutoff of at least 5·2 mmol/L, 37·4% (29·4–45·7) for low concentrations of HDL cholesterol with a cutoff of less than 1·0 mmol/L, 28·6% (15·8–43·5) for elevated concentrations of LDL cholesterol with a cutoff of at least 3·3 mmol/L, and 17·0% (11·9–22·7) for elevated concentrations of triglycerides with a cutoff of at least 1·7 mmol/L. Interpretation The prevalence of dyslipidaemia is high in the general adult population in Africa. Ongoing efforts to reduce cardiovascular diseases in Africa should integrate effective detection and treatment of dyslipidaemia.
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    Promoting equality for ethnic minority NHS staff—what works?
    (2015) Priest, Naomi; Esmail, Aneez; Kline, Roger; Rao, Mala; Coghill, Yvonne; Williams, David R
    NHS organisations are now being judged on indicators of ethnic diversity. Naomi Priest and colleagues look at the international evidence on how they should tackle discrimination
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    Radiological predictors of PCP in HIV-positive adults in South Africa: a matched case-control study
    (2024) Wills, Nicola; Wasserman, Sean
    Background Definition of chest X-ray (CXR) features associated with laboratory-confirmed pneumocystis pneumonia (PCP) among HIV-positive adults is needed to improve diagnosis in high-burden settings. Methods We conducted a case-control study involving HIV-positive adults with laboratory-confirmed PCP and a matched cohort with non-PCP respiratory presentations at regional hospitals in Cape Town, South Africa (2012 - 2020). The primary objective was to identify CXR features associated with confirmed PCP diagnosis and severe PCP (defined by hypoxia, ICU referral/admission, and/or in-hospital death). We explored the performance of logistic regression models, incorporating selected clinical and CXR predictors, for PCP diagnosis and severe PCP. Results Records from 104 adults (52 PCP cases and 52 non-PCP controls) were included. Diffuse versus patchy ground glass opacification was associated with increased odds of PCP diagnosis (adjusted odd's ratio (aOR) 6.2, 95% confidence interval (CI) 1.6 - 28.9, p = 0.01) and severe PCP (aOR 4.5, 95%CI 1.6 - 14.4, p = 0.008). Consolidation was associated with severe PCP (aOR 3.3, 95%CI 1.2 - 11.0, p =0.03) as was increasing ground glass zone involvement (aOR 2.1 for each one-unit increase in involved zone; 95% CI, 1.4 - 3.2, p = 0.0004). Models incorporating hypoxia (hypoxia model) or tachypnoea (respiratory rate model) with diffuse ground glass opacities, absence of pleural effusion or reticular/reticulonodular changes on CXR performed well in predicting PCP (area under the receiver operating characteristic curve 0.828 (hypoxia model) and 0.857 (respiratory rate model)). Conclusions CXR evaluation alongside bedside clinical information offers good accuracy for discriminating definite PCP from other HIV-associated respiratory diseases
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    Spectrum Of Causes Of Isolated Aortic Regurgitation At A South African Public Sector Tertiary Care Institution
    (2023) Masikati, Malcolm; Ntsekhe, Mpiko; Pennel Timothy
    BACKGROUND Aortic Regurgitation (AR) is due to primary abnormalities of the aortic valve, peri-valvular apparatus and/or the aortic root and the ascending aorta. Whereas the etiology and mechanisms of AR are relatively well described in Europe and North America, little information exists about their spectrum and frequency in sub-Saharan and South Africa. Understanding the precise mechanisms of AR informs surgical planning of valve and aorta repair. Reports from local studies suggest that rheumatic heart disease in the commonest cause of valvular heart disease in RSA particularly in population under 40 but whether it's the most common cause of isolated AR is not known. The aims of this study were to report the spectrum of causes of isolated aortic regurgitation and their distribution, including the main mechanisms of aortic regurgitation in our setting. The accuracy of pre-op assessment of etiology by clinical and imaging evaluation was also analyzed along with its concordance to surgical findings. METHODS This is a retrospective review of hospital records of patients who had aortic valve replacement (AVR) for isolated AR from Jan 2003 to June 2018 at Groote Schuur Hospital (GSH). Most patients had a presumptive etiological diagnosis determined by pre-operative echocardiography. For this study the etiology and pathological mechanism was confirmed by macroscopic examination at surgery and pathological examination of explanted valves. RESULTS There were 141 patient records available over the period. The mean age for the cohort was 43 years (range 29-57) with a male predominance of 63%. Baseline co-morbid conditions of the participants included hypertension 43.3%, Human immunodeficiency virus (HIV)16.9%, and chronic kidney disease 4.3%. The mechanistic and etiological diagnosis was available for all 141 study participants. The five predominant mechanisms were: 1- thickening/fibrosis/retraction with commissary fusion in 32.6%. 2- cusp perforation/leaflet destruction in 24.8%. 3- prolapse of the aortic leaflet cusps in 7.1%. 4- aortic root or annular dilatation in 27%. 5- Mixed mechanisms in 8.5%. The most common diseases which caused aortic regurgitation by affecting the valve leaflets were rheumatic heart disease, infective endocarditis, degenerative valve disease and bicuspid aortic valve. Diseases that affect the root and aorta included hypertension, Marfan' syndrome, syphilitic aortitis, Takayasu's arteritis; and pyogenic aortitis. Of the 141 patients in the study complete information on the pre-op echo, surgical macroscopic inspection and histological evaluation was available in 92. Of the 92 patients there was consistency in the pre and post of diagnosis in 93.5% (86/92). The most common discrepant diagnosis was rheumatic heart disease at histology or on surgical inspection but having been referred with a preoperative echo diagnosis of infective endocarditis.