Browsing by Subject "Treatment Outcome"

Now showing 1 - 13 of 13
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    Assisted reproductive technology in South Africa: first results generated from the South African register of assisted reproductive techniques
    (2012) Dyer, Silke Juliane; Kruger, Thinus Frans
    OBJECTIVE: We present the first report from the South African Register of Assisted Reproductive Techniques. METHODS: All assisted reproductive technology (ART) centres in South Africa were invited to join the register. Participant centres voluntarily submitted information from 2009 on the number of ART cycles, embryo transfers, clinical pregnancies, age of female partners or egg donors, and use of fertilisation techniques. Data were anonymised, pooled and analysed. RESULTS: The 12 participating units conducted a total of 4 512 oocyte aspirations and 3 872 embryo transfers in 2009, resulting in 1 303 clinical pregnancies. The clinical pregnancy rate (CPR) per aspiration and per embryo transfer was 28.9% and 33.6%, respectively. Fertilisation was achieved by intracytoplasmic sperm injection in two-thirds of cycles. In most cycles, 1 - 2 embryos or blastocysts were transferred. Female age was inversely related to pregnancy rate. CONCLUSION: The register achieved a high rate of participation. The reported number of ART cycles covers approximately 6% of the estimated ART demand in South Africa. The achieved CPRs compare favourably with those reported for other countries.
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    Characteristics and outcome of children with juvenile dermatomyositis in Cape Town: a cross-sectional study
    (2016) Okong’o, Lawrence Owino; Esser, Monika; Wilmshurst, Jo; Scott, Christiaan
    Abstract Background Juvenile dermatomyositis (JDM) is a rare idiopathic inflammatory childhood myopathy of uncertain aetiology. The demographic and clinical presentation of JDM may differ by race and geographic regions. Few studies have described the characteristics of JDM patients from Africa. Methods We conducted a retrospective observational study to determine clinical characteristics and outcomes of patients satisfying the Bohan and Peter criteria for probable JDM seen between 2004 and 2013 in three hospitals in Cape Town, South Africa. Results Twenty five cases were identified: 16 female and 9 male; thirteen (52 %) were of indigenous African, eleven (44 %) mixed and one (4 %) European ancestry. The median ages at disease onset and diagnosis were 6.75 (range 2.0–9.7) and 7.9 (range 3.4–9.75) years respectively. Eleven patients had calcinosis while the mortality was 2/25 (8 %). Only 40 % of the patients had clinically inactive disease by PRINTO criteria (modified) at last review. There was no statistically significant difference in racial distribution (p-value = 1), age at disease onset (p-value = 0.87) and disease duration prior to treatment initiation (p-value = 0.75) between patients who had clinically active and inactive disease. Conclusion The demographic characteristics of children with JDM were similar to that from most other regions of the world with female predominance and similar age at onset. Majority of the patients remained with clinically active disease, which put them at risk of further disease complications. Long term follow up and use of appropriate treatment guidelines may be indicated in management of JDM patients for optimum treatment outcomes.
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    Cost and cost-effectiveness of tuberculosis treatment shortening: a model-based analysis
    (2016) Gomez, G B; Dowdy, D W; Bastos, M L; Zwerling, A; Sweeney, S; Foster, N; Trajman, A; Islam, M A; Kapiga, S; Sinanovic, E; Knight, G M; White, R G; Wells, W A; Cobelens, F G; Vassall, A
    Background Despite improvements in treatment success rates for tuberculosis (TB), current six-month regimen duration remains a challenge for many National TB Programmes, health systems, and patients. There is increasing investment in the development of shortened regimens with a number of candidates in phase 3 trials. Methods We developed an individual-based decision analytic model to assess the cost-effectiveness of a hypothetical four-month regimen for first-line treatment of TB, assuming non-inferiority to current regimens of six-month duration. The model was populated using extensive, empirically-collected data to estimate the economic impact on both health systems and patients of regimen shortening for first-line TB treatment in South Africa, Brazil, Bangladesh, and Tanzania. We explicitly considered ‘real world’ constraints such as sub-optimal guideline adherence. Results From a societal perspective, a shortened regimen, priced at USD1 per day, could be a cost-saving option in South Africa, Brazil, and Tanzania, but would not be cost-effective in Bangladesh when compared to one gross domestic product (GDP) per capita. Incorporating ‘real world’ constraints reduces cost-effectiveness. Patient-incurred costs could be reduced in all settings. From a health service perspective, increased drug costs need to be balanced against decreased delivery costs. The new regimen would remain a cost-effective option, when compared to each countries’ GDP per capita, even if new drugs cost up to USD7.5 and USD53.8 per day in South Africa and Brazil; this threshold was above USD1 in Tanzania and under USD1 in Bangladesh. Conclusion Reducing the duration of first-line TB treatment has the potential for substantial economic gains from a patient perspective. The potential economic gains for health services may also be important, but will be context-specific and dependent on the appropriate pricing of any new regimen.
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    Development and validation of a prognostic score during tuberculosis treatment
    (2017) Pefura-Yone, Eric Walter; Balkissou, Adamou Dodo; Poka-Mayap, Virginie; Fatime-Abaicho, Hadja Koté; Enono-Edende, Patrick Thierry; Kengne, André Pascal
    BACKGROUND: Death under care is a major challenge for tuberculosis (TB) treatment programs. We derived and validated a simple score to predict mortality during tuberculosis treatment in high endemicity areas. METHODS: We used data for patients aged ≥15 years, diagnosed and treated for tuberculosis at the Yaounde Jamot Hospital between January 2012 and December 2013. Baseline characteristics associated with mortality were investigated using logistic regressions. A simple prognosis score (CABI) was constructed with regression coefficients for predictors in the final model. Internal validation used bootstrap resampling procedures. Models discrimination was assessed using c-statistics and calibration assessed via calibration plots and the Hosmer and Lemeshwow (H-L) statistics. The optimal score was based on the Youden's index. RESULTS: A total of 2250 patients (men 57.2%) with a mean age of 35.8 years were included; among whom 213 deaths (cumulative incidence 9.5%) were recorded. Clinical form of tuberculosis (C), age (A, years), adjusted body mass index (B, BMI, kg/m2) and status for HIV (Human immunodefiency virus) infection (I) were significant predictors in the final model (p < 0.0001) which was of the form Death risk = 1/(1 + e - (-1.3120 + 0.0474 ∗ age - 0.1866 ∗ BMI + 1.1637 (if smear negative TB) + 0.5418(if extra - pulmonary TB) + 1.3820(if HIV+))). The c-statistic was 0.812 in the derivation sample and 0.808 after correction for optimism. The calibration was good [H-Lχ2 = 6.44 (p = 0.60)]. The optimal absolute risk threshold was 4.8%, corresponding to a sensitivity of 81% and specificity of 67%. CONCLUSIONS: The preliminary promising findings from this study require confirmation through independent external validation studies. If confirmed, the model derived could facilitate the stratification of TB patients for mortality risk and implementation of additional monitoring and management measures in vulnerable patients.
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    Early severe morbidity and resource utilization in South African adults on antiretroviral therapy
    (BioMed Central Ltd, 2009) de Cherif, Teresa; Schoeman, Jan; Cleary, Susan; Meintjes, Graeme; Rebe, Kevin; Maartens, Gary
    BACKGROUND:High rates of mortality and morbidity have been described in sub-Saharan African patients within the first few months of starting highly active antiretroviral therapy (HAART). There is limited data on the causes of early morbidity on HAART and the associated resource utilization. METHODS: A cross-sectional study was conducted of medical admissions at a secondary-level hospital in Cape Town, South Africa. Patients on HAART were identified from a register and HIV-infected patients not on HAART were matched by gender, month of admission, and age group to correspond with the first admission of each case. Primary reasons for admission were determined by chart review. Direct health care costs were determined from the provider's perspective. RESULTS: There were 53 in the HAART group with 70 admissions and 53 in the no-HAART group with 60 admissions. The median duration of HAART was 1 month (interquartile range 1-3 months). Median baseline CD4 count in the HAART group was 57 x 106 cells/L (IQR 15-115). The primary reasons for admission in the HAART group were more likely to be due to adverse drug reactions and less likely to be due to AIDS events than the no-HAART group (34% versus 7%; p < 0.001 and 39% versus 63%; p = 0.005 respectively). Immune reconstitution inflammatory syndrome was the primary reason for admission in 10% of the HAART group. Lengths of hospital stay per admission and inpatient survival were not significantly different between the two groups. Five of the 15 deaths in the HAART group were due to IRIS or adverse drug reactions. Median costs per admission of diagnostic and therapeutic services (laboratory investigations, radiology, intravenous fluids and blood, and non-ART medications) were higher in the HAART group compared with the no-HAART group (US$190 versus US$111; p = 0.001), but the more expensive non-curative costs (overhead, capital, and clinical staff) were not significantly different (US$1199 versus US$1128; p = 0.525). CONCLUSIONS: Causes of early morbidity are different and more complex in HIV-infected patients on HAART. This results in greater resource utilization of diagnostic and therapeutic services.
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    Identification of losses to follow-up in a community-based antiretroviral therapy clinic in South Africa using a computerized pharmacy tracking system
    (BioMed Central Ltd, 2010) Nglazi, Mweete; Kaplan, Richard; Wood, Robin; Bekker, Linda-Gail; Lawn, Stephen
    BACKGROUND:High rates of loss to follow-up (LTFU) are undermining rapidly expanding antiretroviral treatment (ART) services in sub-Saharan Africa. The intelligent dispensing of ART (iDART) is an open-source electronic pharmacy system that provides an efficient means of generating lists of patients who have failed to pick-up medication. We determined the duration of pharmacy delay that optimally identified true LTFU. METHODS: We conducted a retrospective cross-sectional study of a community-based ART cohort in Cape Town, South Africa. We used iDART to identify groups of patients known to be still enrolled in the cohort on the 1st of April 2008 that had failed to pick-up medication for periods of [greater than or equal to] 6, [greater than or equal to] 12, [greater than or equal to] 18 and [greater than or equal to] 24 weeks. We defined true LTFU as confirmed failure to pick up medication for 3 months since last attendance. We then assessed short-term and long-term outcomes using a prospectively maintained database and patient records. RESULTS: On the date of the survey, 2548 patients were registered as receiving ART but of these 85 patients (3.3%) were found to be true LTFU. The numbers of individuals (proportion of the cohort) identified by iDART as having failed to collect medication for periods of [greater than or equal to]6, [greater than or equal to]12, [greater than or equal to]18 and [greater than or equal to]24 weeks were 560 (22%), 194 (8%), 117 (5%) and 80 (3%), respectively. The sensitivities of these pharmacy delays for detecting true LTFU were 100%, 100%, 62.4% and 47.1%, respectively. The corresponding specificities were 80.7%, 95.6%, 97.4% and 98.4%. Thus, the optimal delay was [greater than or equal to]12 weeks since last attendance at this clinic (equivalent to 8 weeks since medication ran out). Pharmacy delays were also found to be significantly associated with LTFU and death one year later. CONCLUSIONS: The iDART electronic pharmacy system can be used to detect patients potentially LTFU and who require recall. Using a short a cut-off period was too non-specific for LTFU and would require the tracing of very large numbers of patients. Conversely prolonged delays were too insensitive. Of the periods assessed, a [greater than or equal to]12 weeks delay appeared optimal. This system requires prospective evaluation to further refine its utility.
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    Integration of TB and ART services fails to improve TB treatment outcomes: Comparison of ART/TB primary healthcare services in Cape Town, South Africa
    (2014) Kaplan, R; Caldwell, J; Bekker, L- G; Jennings, K; Lombard, C; Enarson, D A; Wood, R; Beyers, N
    BACKGROUND: The combined tuberculosis (TB) and HIV epidemics in South Africa (SA) have created enormous operational challenges for a health service that has traditionally run vertical programmes for TB treatment and antiretroviral therapy (ART) in separate facilities. This is particularly problematic for TB/HIV co-infected patients who need to access both services. OBJECTIVE: To determine whether integrated TB facilities had better TB treatment outcomes than single-service facilities in Cape Town, SA. METHODS: TB treatment outcomes were determined for newly registered, adult TB patients (aged > or = 18 years) at 13 integrated ART/TB primary healthcare (PHC) facilities and four single-service PHC facilities from 1 January 2009 to 30 June 2010. A chi2 test adjusted for a cluster sample design was used to compare outcomes by type of facility. RESULTS: Of 13,542 newly registered patients, 10,030 received TB treatment in integrated facilities and 3,512 in single-service facilities. There was no difference in baseline characteristics between the two groups with HIV status determined for 9,351 (93.2%) and 3,227 (91.9%) patients, of whom 6 649 (66.3%) and 2,213 (63%) were HIV-positive in integrated facilities and single-service facilities, respectively. The median CD4+ count of HIV-positive patients was 152 cells/microl (interquartile range (IQR) 71-277) for integrated facilities and 148 cells/microl (IQR 67-260) for single-service facilities. There was no statistical difference in the TB treatment outcome profile between integrated and single-service facilities for all TB patients (p = 0.56) or for the sub-set of HIV-positive TB patients (p = 0.58) CONCLUSION: This study did not demonstrate improved TB treatment outcomes in integrated PHC facilities and showed that the provision of ART in the same facility as TB services was not associated with lower TB death and default rates.
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    Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared
    (2013) Labhardt, Niklaus Daniel; Keiser, Olivia; Sello, Motlalepula; Lejone, Thabo Ishmael; Pfeiffer, Karolin; Davies, Mary-Ann; Egger, Matthias; Ehmer, Jochen; Wandeler, Gilles
    IntroductionLesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.MethodsThe two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender.ResultsOf 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73–1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20–1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51–0.93).ConclusionsIn rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.
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    Phaco-emulsification versus manual small-incision cataract surgery in South Africa
    (2012) Cook, Colin; Carrara, Henri; Myer, Landon
    OBJECTIVES: To compare the results of phaco-emulsification cataract surgery and manual small-incision cataract surgery. METHODS: Consecutive patients aged >50 years undergoing surgery for age-related cataract were recruited into a randomised prospective clinical trial. Randomisation was done using opaque sequentially numbered envelopes opened by the surgeon immediately prior to surgery. The patients were seen after 1 day, 2 weeks, and 8 weeks. Outcome measures. The primary outcome measure was the uncorrected visual acuity at week 8. The secondary outcome measures were the uncorrected visual acuity on day 1, the best corrected visual acuity at week 8, the refraction at week 8, and the intra- and postoperative complications. RESULTS: One hundred patients were recruited into each arm of the study. There was no difference in the incidence of intra-ocular complications (p=0.19). There was no difference in the day 1 visual acuities (p=0.28). However, both the uncorrected and the corrected week 8 visual acuities were better in the eyes that had phaco-emulsification (p=0.02 and p=0.03), and there was less astigmatism (p=0.001) at week 8 in the eyes that had phaco-emulsification. CONCLUSIONS: While manual small-incision surgery has been recommended as an acceptable alternative to phaco-emulsification in middle- and low-income countries, we have found that the results of phaco-emulsification are better. Where appropriate, consideration should be given to encouraging a transition to phaco-emulsification in our Vision 2020 programmes in Africa.
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    Pre-operative diagnosis of thyroid cancer: Clinical, radiological and pathological correlation
    (2013) Cairncross, Lydia; Panieri, Eugenio
    AIM: Ultrasonography and fine-needle aspiration biopsy (FNAB) are the mainstays of diagnosing thyroid cancer accurately and reducing the number of diagnostic lobectomies. No benchmark for diagnostic accuracy has been published in the South African context. This single-institution study addresses this deficit. METHODS: The oncology, pathology and surgical records of all patients diagnosed with thyroid carcinoma from 2004 to 2010 at Groote Schuur Hospital, Cape Town, South Africa, were reviewed and data were recorded on a standardised confidential proforma. The findings on pre-operative clinical assessment, ultrasound and FNAB were correlated with the histopathology results. Diagnostic accuracy for thyroid cancer was determined by correlating pre-operative investigations with the final diagnosis. Sensitivity of ultrasound and FNAB were calculated. RESULTS: A total of 109 patients, 79 female and 30 male, were identified. The majority (99, 90.8%) had well-differentiated thyroid cancers (56 papillary, 30 follicular, 10 mixed and 3 Hurtle cell carcinomas). There were 6 anaplastic and 4 medullary carcinomas. Of the 109 patients 38 had a definite pre-operative diagnosis, in 61 a malignant tumour was suspected, and 10 had surgery for benign disease. FNAB was inadequate in 11 cases and the findings indicated a benign lesion in 47, a suspicious lesion in 13 and a malignant lesion in 38 patients diagnosed with thyroid carcinoma. FNAB diagnosed all patients with medullary and anaplastic carcinoma but less than half of those with well-differentiated thyroid carcinoma. Ultrasound scans detected at least one suspicious feature in 44 patients. Microcalcification was the most common sign. CONCLUSION: The rate of pre-operative diagnosis of well-differentiated thyroid carcinomas in this unit is under 50%, well below international norms. Our standard practice needs to change to include ultrasound-guided FNAB and standardised reporting of high-resolution ultrasound and cytology, before reassessment of our diagnostic accuracy.
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    Stent graft repair of subclavian and axillary vascular injuries: The Groote Schuur experience
    (2015) Naidoo, N G; Navsaria, P; Beningfield, S J; Natha, B; Cloete, N; Gill, H
    BACKGROUND: Trauma-related subclavian and axillary vascular injuries (SAVIs) are generally associated with high morbidity and mortality rates in the surgical literature. There is an emerging trend towards increasing use of stent grafts (covered stents) for repair, with evidence limited to small case series and case reports. OBJECTIVES: To report on the clinical and device-related outcomes of stent graft repair of trauma-related SAVIs at a single institution. METHODS: A retrospective chart review of all patients with trauma-related SAVIs requiring stent graft repair was performed. Outcome measures included technical success, mortality, amputation rate, device-related complications (early and late), and reintervention rates (early and late). RESULTS: A total of 31 patients was identified between June 2008 and October 2013 (30 males, 1 female). Mean age was 27.9 years (range 19-51). All 31 patients sustained a penetrating injury (93.5% stab, 6.5% gunshot injuries). There were 21 subclavian and 10 axillary artery injuries. Five patients (16%) were HIV-positive. Nine patients (29%) were shocked on presentation. Early results (30 days): There were no periprocedural deaths. Primary technical success was 83.9% (26/31). Five patients required adjunctive interventional or operative procedures. There were no early procedure-related complications, reinterventions or open conversions in this study. Overall, suboptimal results were seen in five patients (one type I endoleak and four type II endoleaks). Follow-up results (>30 days): Nineteen patients (61.3%) were available for follow-up. Mean duration of follow-up was 55.7 weeks (range 4 - 240). Overall stent graft patency was 89.5% (17/19). Four patients (21.1%) had an occluded stent graft. Stent graft salvage was possible in two patients. Three type II endoleaks were seen on follow-up. Late reinterventions were performed in five patients (26.3%). Conversion to an open procedure was not required in any patient. There was one late death and one major amputation of a stented limb in a patient who had sustained severe soft-tissue injuries during the follow-up period. CONCLUSION: Perioperative, early and intermediate results suggest that stent graft repair of select trauma-related SAVIs is relatively safe and effective. Axillary arteriovenous fistulas remain a particular challenge using this treatment modality. Larger prospective studies are required to define the utility of stent grafts for select trauma-related SAVIs better.
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    The impact of HIV status and antiretroviral treatment on TB treatment outcomes of new tuberculosis patients attending co-located TB and ART services in South Africa: a retrospective cohort study
    (2015) Nglazi, Mweete D; Bekker, Linda‐Gail; Wood, Robin; Kaplan, Richard
    BackgroundThe implementation of collaborative TB-HIV services is challenging. We, therefore, assessed TB treatment outcomes in relation to HIV infection and antiretroviral therapy (ART) among TB patients attending a primary care service with co-located ART and TB clinics in Cape Town, South Africa.MethodsIn this retrospective cohort study, all new TB patients aged ≥ 15years who registered and initiated TB treatment between 1 October 2009 and 30 June 2011 were identified from an electronic database. The effects of HIV-infection and ART on TB treatment outcomes were analysed using a multinomial logistic regression model, in which treatment success was the reference outcome.ResultsThe 797 new TB patients included in the analysis were categorized as follows: HIV- negative, in 325 patients (40.8%); HIV-positive on ART, in 339 patients (42.5%) and HIV-positive not on ART, in 133 patients (16.7%). Overall, bivariate analyses showed no significant difference in death and default rates between HIV-positive TB patients on ART and HIV-negative patients. Statistically significant higher mortality rates were found among HIV-positive patients not on ART compared to HIV-negative patients (unadjusted odds ratio (OR) 3.25; 95% confidence interval (CI) 1.53–6.91). When multivariate analyses were conducted, the only significant difference between the patient categories on TB treatment outcomes was that HIV-positive TB patients not on ART had significantly higher mortality rates than HIV-negative patients (adjusted OR 4.12; 95% CI 1.76–9.66). Among HIV-positive TB patients (n = 472), 28.2% deemed eligible did not initiate ART in spite of the co-location of TB and ART services. When multivariate analyses were restricted to HIV-positive patients in the cohort, we found that being HIV-positive not on ART was associated with higher mortality (adjusted OR 7.12; 95% CI 2.95–18.47) and higher default rates (adjusted OR 2.27; 95% CI 1.15–4.47).ConclusionsThere was no significant difference in death and default rates between HIV-positive TB patients on ART and HIV negative TB patients. Despite the co-location of services 28.2% of 472 HIV-positive TB patients deemed eligible did not initiate ART. These patients had a significantly higher death and default rates.
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    Where do HIV-infected adolescents go after transfer? – Tracking transition/transfer of HIV-infected adolescents using linkage of cohort data to a health information system platform
    (2017) Davies, Mary-Ann; Tsondai, Priscilla; Tiffin, Nicki; Eley, Brian; Rabie, Helena; Euvrard, Jonathan; Orrell, Catherine; Prozesky, Hans; Wood, Robin; Cogill, Dolphina; Haas, Andreas D; Sohn, Annette H; Boulle, Andrew
    Introduction: To evaluate long-term outcomes in HIV-infected adolescents, it is important to identify ways of tracking outcomes after transfer to a different health facility. The Department of Health (DoH) in the Western Cape Province (WCP) of South Africa uses a single unique identifier for all patients across the health service platform. We examined adolescent outcomes after transfer by linking data from four International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) cohorts in the WCP with DoH data.