OpenUCT :: Browsing by Subject "medicine"

Browsing by Subject "medicine"

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Open Access
A functional magnetic resonance imaging study of cognitive emotion regulation in relation to individual differences in self-esteem
(2020) Swan, Freda Zoë; Groenewold, Nynke; Uhlmann, Anne; Stein, Dan
Objectives Self-esteem may affect the processing and regulation of emotion. However, it is unclear whether differences in self-esteem are associated with changes in initial emotional appraisal or engagement of emotion regulation. I investigated whether individual differences in self-esteem predicted brain responses to negative emotional stimuli: 1) when they were viewed without intentional regulation; and 2) during downregulation using cognitive reappraisal. Thirdly, I investigated whether self-esteem predicted reappraisal success. Method Twenty-nine healthy adults (age M=47, SD=15; 16 female) performed a cognitive reappraisal emotion regulation task during fMRI scanning. Participants viewed and subsequently reappraised or attended to negative and neutral images. Trait self-esteem (Rosenberg Self-Esteem Scale) was included as a predictor in a whole-brain multiple regression analysis. Analyses were thresholded at p<.005, k>p20, p<.05 family-wise error (FWE)-corrected at cluster-level. The anterior cingulate cortex (ACC; BA32) and the dorsal prefrontal cortex (PFC; BA6) were a priori regions of interest (ROI), since both have previously been reported in fMRI studies of self-esteem and cognitive reappraisal. A post-hoc ROI analysis tested the correspondence of self-esteem-related ACC activation with findings from a meta-analysis of emotion regulation. Ratings of negative emotional intensity following reappraisal trials were subtracted from ratings following attend-negative trials to index reappraisal success. Results Self-esteem was associated with potentiated ACC ROI activation during viewing of negative, compared to neutral, images (MNI x, y, z = -6, 17, 38, k=43, punc=.001 at peak, pFWE=.368 at cluster-level). For reappraisal compared to attended negative images, self-esteem was positively associated with activation in the left posterior insula (MNI x, y, z = -30, -10, 17, k=30, punc<.001 at peak, pFWE=.959 at cluster-level) and negatively associated with activation in the mid cingulate cortex (MNI x, y, z = 3, -34, 35, k=50, punc=.001 at peak, pFWE=.805 at clusterlevel). However, only the post-hoc ACC ROI analysis was significant after multiple comparison correction (MNI x, y, z = -6, 23, 38, k=22, punc=.001 at peak, pFWE=.021 at clusterlevel). For reappraisal, self-esteem was not related to activation in the ACC or dorsal PFC ROIs. Trait self-esteem did not correlate with reappraisal success, r =.16, p =.208. Conclusion Trait self-esteem may affect recruitment of the ACC during initial emotional appraisal. This may reflect successful automatic emotion regulation for high self-esteem, consistent with the demonstrated spatial overlap with a meta-analytic emotion regulation cluster. While selfesteem may affect brain responsivity during cognitive reappraisal, the observed trends must be interpreted carefully, since the findings do not survive correction for multiple comparisons, and emotional outcomes of applying reappraisal do not differ as a function of self-esteem. Taken together, these findings suggest that high trait self-esteem may be advantageous for rapid automatic emotion regulation, but not deliberate cognitive reappraisal.
Open Access
A retrospective description of primary immunodeficiency diseases at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, 1975 – 2017
(2020) Moodley, Sashmi; Eley, Brian
Background. The primary immunodeficiency diseases (PIDs) constitute a diverse and everexpanding group of inborn errors affecting a wide range of immune functions. They are not well documented in Sub-Saharan Africa. An important barrier to care is limited awareness of PIDs and their management among health care professionals. This fascinating spectrum of diseases is rapidly expanding worldwide, and not as rare as we think. Genetic characterization and newborn screening for primary Immunodeficiency diseases (PIDs) may be the gold standard in the first world setting but are neither practical nor feasible for our doctors. Yet, other low and middle income countries in the world have also established reasonable services and created registries for children with PIDs, including other African countries. Objective. To describe the spectrum of PIDs at a tertiary paediatric hospital. Methods. A retrospective descriptive study of PIDs diagnosed at Red Cross War Memorial Children's Hospital, Cape Town, South Africa between 1975 and 2017 was undertaken. Results. 252 children with PIDs were identified, spanning 8 of the 9 categories listed in the 2017 classification of the International Union of Immunological Societies. Predominantly antibody deficiencies, combined immunodeficiencies with associated syndromic features, and immunodeficiencies affecting cellular and humoral immunity accounted for 79% of all PIDs. The mean age (standard deviation) at diagnosis was 46 (50) months and the male to female ratio was 1.5:1. A history of parental consanguinity was present in 3 children (1.2%). Recurrent infection was the most prevalent presenting phenotype, manifesting in 70.2% of the patients. Genetic or chromosomal confirmation was obtained in 42/252 (16.7%) of the children. Common interventions used to prevent infection were antimicrobial prophylaxis and immunoglobulin replacement therapy, administered to 37.7% and 36.9% of the patients respectively. Six of seven children who underwent haematopoietic stem cell transplantation (HSCT) had successful outcomes. The 7th patient died 2 months post-HSCT from overwhelming infection. Although we could not account for the children lost to follow up during the study period, 53 (21.0%) deaths were confirmed. Conclusions. Several challenges exist in the recognition and treatment of children with PIDs in our setting. These include limited access to genetic diagnostics and HSCT. Sub-optimal treatment options contribute to the overall mortality of PIDs in South Africa. Greater awareness among clinicians treating children and more laboratory diagnostic capacity are needed to increase the recognition PIDs among children in South Africa. The treatment options that are available in South Africa are unevenly distributed. Hence, treatment capacity should be expanded throughout the country, especially advanced interventions such as HSCT. Ongoing reporting of registries such as ours and increased community awareness should strengthen the lobby for greater investment in rare diseases such as the PIDs.
Open Access
A retrospective description of primary immunodeficiency diseases at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, 1975 – 2017
(2020) Moodley, Sashmi; Eley, Brian
Background. The primary immunodeficiency diseases (PIDs) constitute a diverse and everexpanding group of inborn errors affecting a wide range of immune functions. They are not well documented in Sub-Saharan Africa. An important barrier to care is limited awareness of PIDs and their management among health care professionals. This fascinating spectrum of diseases is rapidly expanding worldwide, and not as rare as we think. Genetic characterization and newborn screening for primary Immunodeficiency diseases (PIDs) may be the gold standard in the first world setting but are neither practical nor feasible for our doctors. Yet, other low and middle income countries in the world have also established reasonable services and created registries for children with PIDs, including other African countries. Objective. To describe the spectrum of PIDs at a tertiary paediatric hospital. Methods. A retrospective descriptive study of PIDs diagnosed at Red Cross War Memorial Children's Hospital, Cape Town, South Africa between 1975 and 2017 was undertaken. Results. 252 children with PIDs were identified, spanning 8 of the 9 categories listed in the 2017 classification of the International Union of Immunological Societies. Predominantly antibody deficiencies, combined immunodeficiencies with associated syndromic features, and immunodeficiencies affecting cellular and humoral immunity accounted for 79% of all PIDs. The mean age (standard deviation) at diagnosis was 46 (50) months and the male to female ratio was 1.5:1. A history of parental consanguinity was present in 3 children (1.2%). Recurrent infection was the most prevalent presenting phenotype, manifesting in 70.2% of the patients. Genetic or chromosomal confirmation was obtained in 42/252 (16.7%) of the children. Common interventions used to prevent infection were antimicrobial prophylaxis and immunoglobulin replacement therapy, administered to 37.7% and 36.9% of the patients respectively. Six of seven children who underwent haematopoietic stem cell transplantation (HSCT) had successful outcomes. The 7th patient died 2 months post-HSCT from overwhelming infection. Although we could not account for the children lost to follow up during the study period, 53 (21.0%) deaths were confirmed. Conclusions. Several challenges exist in the recognition and treatment of children with PIDs in our setting. These include limited access to genetic diagnostics and HSCT. Sub-optimal treatment options contribute to the overall mortality of PIDs in South Africa. Greater awareness among clinicians treating children and more laboratory diagnostic capacity are needed to increase the recognition PIDs among children in South Africa. The treatment options that are available in South Africa are unevenly distributed. Hence, treatment capacity should be expanded throughout the country, especially advanced interventions such as HSCT. Ongoing reporting of registries such as ours and increased community awareness should strengthen the lobby for greater investment in rare diseases such as the PIDs.
Open Access
A study of urinary tract infections in renal transplant patients
(1997) Walele, Abdul Aziz; Moosa, Rafique; Swanepoel, Charles
Background: Sepsis remains a serious complication in renal transplant recipients. Urinary tract infections (UTI's) are the most common bacterial infection occurring in these patients. The aim of the study was to document the clinical experience of UTI in renal transplant patients. Methods: A descriptive study of UTI occurring in consecutive renal transplant patients attending the transplant clinic, Tygerberg Hospital between 1st January and 31st July 1995 was undertaken. A UTI was defined as a positive organism culture of > 100 000 cfu/ml on a single urine sample. Data were assessed to determine patient demographics, clinical presentation, risk factors and outcome. The infecting organisms and their antibiotic sensitivity spectrum were determined. Results: Of 166 patients, 76 female and 90 male, urinary tract infections were diagnosed in 43 patients. The incidence of UTI was 26% during the study. In the subgroup of patients who received their renal allograft during the study period the cumulative incidence of UTI was 40% at one month, 53% at three months and 55% at six months post-transplantation. Asymptomatic bacteriuria was present in the majority of patients. Symptoms occurred in 18% predominantly in the early post-transplant (<6 months) period. The risk factors for bacteriuria were female sex, peri-operative urinary catheterization, graft rejection episodes and the early post-transplant period. A strongly suggestive risk factor was a high steroid dose effect. Gram-negative organisms were the predominant urinary organisms cultured. E. Coli was the single most common causative organism in both the early and late (>6 months) post-transplant period. Gram-negative organisms were more than 80% sensitive to only gentamicin or ofloxacin. Gram-positive organisms, sensitive to penicillin or cloxacillin, accounted for 22% of infections predominantly in the late post-transplant period. Urinary tract infections complicated by systemic sepsis were associated with a poor outcome. Conclusions: A high incidence of UTI complicates renal transplantation especially during the early post-transplant period. The risk factors observed are relevant to the local experience. An important observation was the antibiotic sensitivity spectrum of the infecting urinary organisms. This may have bearing on management in the renal transplant patient.
Open Access
A study to understand the experiences of adolescents and young adults living with cancer in a northern cape public health setting
(2020) Spies, Leana; Gwyther, Liz; van Jaarsveld, Dalene
Introduction: The challenges and holistic care needs of adolescents and young adults (AYAs) with cancer in low- and middle-income countries are under-researched. This limits evidencebased information regarding their experiences related to palliative care and quality healthcare services, resulting in a neglect in planning services for this population. Aim: The aim of the research study was to explore and identify the challenges experienced by AYAs with cancer in a Northern Cape public health setting. Objectives: The objectives were to describe the key concerns and priorities experienced by AYAs with cancer, to determine their holistic care needs and to identify the current limitations of healthcare resources that influence the provision of appropriate palliative care for AYAs with cancer in the Northern Cape. Methodology: In this qualitative study, purposive sampling was utilized to select AYAs with cancer and between the ages of 18 and 39 years. The participants recruited were patients from the Northern Cape public health setting who received curative or non-curative cancer treatment at either Robert Mangaliso Sobukwe Hospital or Harry Surtie Hospital oncology centres. Their experiences were explored using individual, open-ended semi-structured interviews. Data were analysed using thematic analysis. Results: A total of twelve participants between the ages of 22 and 39 were identified. Male and female participants were equally representative of the sample and their cancer diagnosis included many diverse tumour types that ranged from Hodgkin's lymphoma, breast cancer, testicular cancer, larynx cancer, melanoma, and colon cancer, to Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome-related malignancies such as Kaposi's sarcoma, cervical cancer, and non-Hodgkin's lymphoma. Six key themes emerged that provided insight into the challenges experienced by AYAs with cancer. These challenges were interrelated on a physical, psychosocial, spiritual and healthcare level, and they included the physical impact of cancer, additional illness burdens such as Human Immunodeficiency Virus and Tuberculosis, health system issues such as poor communication, delayed diagnosis, negative nursing attitudes, poor health services, inadequate resources, and transport problems. Apart from similar challenges experienced by AYAs with cancer in developed countries, such as overwhelming emotional responses, threatened dreams and hopes, a need for emotional counselling and better support systems, participants from this study also reported the impact of socio-cultural influences such as stigmatization, cultural beliefs, socio-demographics, poverty, unemployment, and a lack of cancer awareness and education within communities. Conclusion: AYAs with cancer experience complex, multidimensional, interrelated challenges that include many health system issues. In a middle-income country, these challenges are amplified by additional factors such as communicable diseases, sociocultural influences, and poverty. Consequently, their holistic care needs are largely unmet. Even though the findings may only be generalizable to limited settings, they can be transferred to form specific recommendations on how to improve the quality of life of AYAs with cancer and that of their families in the Northern Cape public health setting. As reflected by these findings, higher interventions on a National Health level in order to implement the current national palliative care policy, are required. Advancements in AYA oncology care that acknowledge their unique developmental age, emotional capacity, distinct life stage, and social background are also pivotal. Notwithstanding the significant challenges that plague quality healthcare delivery in the Northern Cape, further research to elucidate the meaning of age-appropriate care and the development of comprehensive, integrated oncology and palliative care guidelines for AYAs with cancer in South Africa, is necessary in order to acknowledge and address their total pain.
Open Access
Access to acute stroke care: a description of stroke patients' journey to a district hospital
(2024) O'Meara, Ryan Mark; Hendrikse, Clint; Ganas, Ushira
Introduction The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes. Methods A descriptive analysis was performed using retrospective folder and database review. All adult patients with a confirmed ischaemic stroke presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1st of January 2019 to 31st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes. Results A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5 hours of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24 hours (IQR 12-72 hours). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16 hours. Conclusion The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.
Open Access
Acute kidney injury in tenofovir exposed patients in HIV infected individuals admitted at Groote Schuur hospital, Cape Town and Livingstone hospital, Gqeberha, South Africa
(2021) Mazondwa, Simthandile Fiona; Dave, Nicola; Davidson, Bianca
Introduction: Tenofovir disoproxil fumarate (TDF) is vastly used in South Africa (SA) as a first line agent for the treatment of human immunodeficiency virus (HIV). TDF is known to be associated with nephrotoxicity with identified risk factors. This study aimed to describe the demographics, clinico-biochemical features, kidney function and mortality outcomes in TDF exposed patients with acute kidney injury (AKI) in two tertiary centres in SA. Method: This observational cohort study reviewed all HIV infected in-patients presenting with AKI referred to the nephrology units at both Groote Schuur Hospital, Cape Town and Livingstone hospital, Gqeberha. Baseline characteristics, contributory factors to the AKI, associated clinical and biochemical features were recorded. Where a kidney biopsy was indicated, histological features were documented. Kidney and mortality outcomes of the enrolled patients were assessed over a 1-year period. Results: There were 213 patients enrolled from 1 August 2013 to 30 September 2016, 114/213 (51.8%) of the patients were TDF-exposed and 99/213 (45%) were TDF-unexposed. The median age was 37 years (IQR: 31 - 45yrs). The TDF-exposed were significantly older, 40 years versus 34 years (p<0.01) The TDF-unexposed group had a higher prevalence of hypertension: 21/99 (21.2%) versus 11/114 (9.7%), (p=0.02). The median creatinine at referral was 642 µmol/L (IQR: 340 - 1116 µmol/L) and 96/210 (45.7%) required dialysis. HIV/tuberculosis (TB) coinfection was common, 119/199 (59.8%). There was significant exposure to nephrotoxic drugs and drugs associated with idiosyncratic drug reactions in both groups, with anti-tuberculous treatment being the most common. Rifampicin was used by 51/212 (24.1%) [TDF-exposed 31/114 (27.2%) and TDF-unexposed 20/98 (20.4%), p=0.25]. There were no differences in serum and urinary biochemical features between the TDFexposed and unexposed groups. Of the enrolled patients, 57/213 (26.8%) underwent a kidney biopsy. On histology, the incidence of acute tubular necrosis (ATN) was higher in TDFexposed individuals (TDF-exposed: 47% versus TDF-unexposed: 22% p=0.05) whilst in TDF-unexposed, HIV associated nephropathy was most common. In the total cohort, chronic kidney disease (CKD) developed in 22/212 (10.4%) and the mortality was 62/213 (29.1%). There were no significant differences between the TDF-exposed and non-exposed cohorts in terms of CKD or mortality. Conclusion: This study demonstrated that hospitalized people living with HIV in SA have a high rate of tuberculosis co-infection and significant drug exposures. The clinical characteristics, severity of AKI and outcomes were similar in TDF-exposed and -unexposed. TDF exposure was associated with a greater degree of ATN on kidney biopsy. AKI in this HIV infected cohort carried a high mortality, regardless of the aetiology.medicib
Open Access
An exploration of parents' and guardians' perspectives on facilitators and barriers to menstrual cup usage amongst adolescent girls in De Doorns, Cape Winelands
(2024) Ruya, Natasha; Githaiga, Jennifer; Perera, Shehani
Adolescent girls in low-income communities in South Africa often cannot afford to buy disposable sanitary pads. Though menstrual cups are considered relatively cost-effective, uptake in South Africa remains low. This qualitative study investigated parents' and guardians' perspectives on factors that enable or hinder menstrual cup use among adolescent girls. Two focus group discussions and 10 individual interviews were conducted with study participants in De Doorns, a farming community in Cape Winelands. Data were uploaded onto NVivo 14 and analysed thematically. The study findings indicate that parents and guardians viewed menstrual cups as a viable option for upholding adolescent girls' dignity and alleviating the financial burden of purchasing menstrual products. This emerged as a supportive factor for adolescent girls' adoption. Further, parents and guardians believed that adolescent girls are a diverse group with varying needs, emphasising the importance of promoting their autonomy in choosing menstrual products. However, they encountered various challenges in adapting to menstrual cups, which left them feeling ill equipped to provide support to their adolescent girls. Concerns related to menstrual cup sizing and fears about potential impacts on virginity were common issues that contributed to their hesitation in endorsing usage among adolescent girls. To facilitate adoption, manufacturers of menstrual cups and community organisations involved in supporting the use of the same should consider parents' and guardians' perspectives, bearing in mind their pivotal roles as caregivers of adolescent girls. Further, there is a need for further knowledge dissemination to increase community buy-in.
Open Access
Anti-neutrophil cytoplasmic antibody (ANCA) testing at Groote Schuur Hospital: Adherence to indications for testing
(2021) Govender, Ramona; Hodkinson, Bridget
Appropriate use of laboratory investigations is increasingly important in resource-constrained environments. We receive the anti-neutrophil cytoplasmic antibody (ANCA) testing practices in a tertiary hospital in South Africa.
Open Access
Axial Spondyloarthropathies in the Western Cape
(2019) Smith, Robert; Hodkinson, Bridget; Gould Trevor
Impaired Health-Related Quality of Life and Work Productivity amongst South African patients with Axial Spondyloarthritis. Background: No studies have investigated health-related quality of life (HRQoL) or work productivity in patients with axial spondyloarthritides (axSpA) living in sub-Saharan Africa. Methods: This cross-sectional study of adults with axSpA collated demographic particulars and patient questionnaires: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); Bath Ankylosing Spondylitis Functional Index (BASFI); Bath Ankylosing Spondylitis Global Score (BASG); Medical Short Form (SF)-36; and Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP). Results: Of 36 patients, the mean (SD) age was 40.3 (13.3) years and mean (SD) diagnostic delay was 8.7 (8.4) years. Most patients were male (80.6%) and of mixed racial ancestry (69.4%). Most (66.7%) patients were smokers and only 5 (13.9%) patients received tumor necrosis factor inhibitor (TNFi) therapy. The mean (SD) BASDAI was 5.3 (2.1), and 72.2% had a BASDAI ≥ 4. Patients with a high BASDAI (i.e. BASDAI ≥ 4) had higher BASG scores (p=0.003), higher WPAI:SHP activity impairment scores (p=0.003), and poorer SF-36 scores, particularly in the role-physical, bodily pain, and social functioning domains (p=0.0001, 0.001 and 0.02 respectively). Activity impairment according to the WPAI:SPH was 57.4%, with the BASDAI and activity impairment correlating closely (p=0.006). The SF-36 scores were low in physical (particularly role-physical, bodily pain, and general health) and mental (notably vitality and role emotional) domains. 6 Conclusion: This study describes a cohort of South African patients with axSpA who have poor prognostic features including diagnostic delay and cigarette smoking. Active disease, impaired function, poor physical- and mental HRQoL, and work disability are unmet needs.
Open Access
Cardiac sarcoidosis defined by cardiovascular magnetic resonance: patient characteristics and outcomes
(2022) Emhemed, Mohamed; Ntusi, Ntobeko A B
Introduction: Sarcoidosis is an inflammatory disorder that affects multiple systems. On histologic examination, sarcoidosis is defined by the production of non-caseating granulomas. Cardiac sarcoidosis (CS) is common, occurring in 20% or more of patients with systemic sarcoidosis, but because many people with CS may have nonspecific clinical manifestations or subclinical disease, the real extent of the disease prevalence is uncertain and possibly underestimated. Methods: Medical records of patients with CS diagnosed by cardiovascular magnetic resonance (CMR) were selected for inclusion into this study. We identified patients with a diagnosis of CS by CMR between March 2005 and January 2018 at Groote Schuur Hospital, Cape Town, South Africa and included into the South African Cardiovascular Magnetic Resonance (SA-CMR) registry. The demographics, clinical profile, and outcomes of patients diagnosed with CS via CMR were summarised utilising proportions, medians with interquartile ranges (IQRs), and means with standard deviations (SDs), as appropriate. Fisher's exact test was utilised to compare proportions, while T tests and Mann-Whitney U-tests were utilised to compare means and medians, respectively. Statistical Package for Social Sciences (version 26) program was used to analyse the data. Results: Medical records of 35 patients with a confirmed diagnosis of CS using CMR during the study period were identified. There were 21 (60%) males, and a male: female ratio of 1.5:1. The mean age of study participants was 50.3 ± 11 years. Most patients (84%) were overweight and obese, and comorbidities included hypertension (9%) and diabetes mellitus (3%). Nearly a quarter (23%) of patients presented with complete heart block and a third (31%) had ventricular tachycardia (VT) as the initial presentation. Half (54%) of patients had a permanent pacemaker or implantable cardioverter defibrillator implanted. A third (34%) of patients had evidence of acute myocardial oedema on T2-weighted imaging and T2 mapping, and 91% of subjects had evidence of focal fibrosis/infiltration on late gadolinium enhancement (LGE). Most patients (80%) had normal pericardial thickness and small pericardial effusions (< 1 cm) were noted in 49%. Extra-cardiac findings of sarcoidosis were characterised by hilar lymphadenopathy and pulmonary interstitial involvement (49%) and pleural effusions (11%). There were no deaths during the study period and median follow-up of 7 years. Conclusions: Sarcoidosis is a granulomatous systemic multiorgan condition that is a challenge to diagnose and manage in many settings. The availability of CMR has made it possible to diagnose CS noninvasively. We show that in our setting CS is characterised by oedema in a third of patients and evidence of LGE in almost all patients. Heart block and VT are common presentations; however, the prognosis is good with modern device therapies once the diagnosis has been made.
Open Access
Clinical profiles and outcomes of patients receiving acute renal replacement therapy in the cardiac intensive care unit at a South African tertiary centre
(2022) Mbanga, Luyanda C; Ntsekhe, Mpiko
Background At least a quarter of patients admitted to the Cardiac Intensive Care Unit (CICU) will develop Acute Kidney Injury (AKI) and some of these patients receive Renal Replacement Therapy (RRT). The clinical profiles and outcomes of CICU patients receiving RRT in resource constraint settings like South Africa is unknown. Objectives The objectives of this study were to determine the clinical profiles and outcomes of patients receiving RRT in the CICU in a South African Tertiary Centre. Methods In this retrospective study we included consecutive patients admitted and receiving RRT at the Groote Schuur Hospital CICU from 01/01/2012 to 31/12/2016. Results During the study period 3247 patients were admitted to the CICU and 46 received RRT. The RRT patients had a mean (SD) age of 52 (17) years, 56% were males, and 65% had a background history of systemic hypertension. Heart failure syndromes accounted for 60.9% of CICU admission in the RRT patient group, followed by acute coronary syndromes and arrhythmias, which accounted for 26.1% and 13.0% respectively. The RRT patient population had an in-hospital and 30-day mortality of 58.7% and 60.9% respectively. Baseline use of Angiotensin Converting Enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) was associated with a reduced 30 day mortality, Hazards Ratio (HR) 0.43; 95% Confidence interval (95%CI) 0.20 – 0.93; p = 0.031. In addition, heart failure was associated with an increased 30 day mortality, HR 2.52; 95% CI 1.10 – 5.78; p = 0.029. Conclusion Heart failure syndrome accounts for a majority of RRT patients admitted to the our CICU. Patients receiving RRT in CICU have a high in-hospital and 30-day mortality.
Open Access
Clinicopathological correlation in erythema induratum
(2020) van den Worm, Lerinza; Ngwanya, Reginald; Isaacs, Thuraya
Background - Erythema induratum (EI) is a reactive disorder to mycobacterium tuberculosis infection, a diagnosis not to be missed. Erythema nodosum (EN) is the main clinical differential of EI, but a distinctly different pathological condition that can be difficult to distinguish from EI. Methods – In this retrospective review we assess clinical and histological features of 40 EI cases and 16 EN cases. Six experienced dermatologists blindly diagnosed these cases based on clinical images, thereafter the histology was revealed, and they adjusted their diagnoses accordingly. Fleiss Kappa statistics were applied to determine inter-rater variability. A multi-variate logistic regression model determined the clinical and histological features that contribute most to an accurate diagnosis. Results - After assessing the clinical picture 48.8% of the EI cases and 74% of the EN cases were correctly diagnosed. With added histology results 67.1% EI and 81.2% EN cases were correct. EI cases showed inter-rater variability of 0.478 (pvalue < 0.01) before and 0.469 (p-value < 0.01) after histology was revealed. These features combined in a logistic regression model had a higher diagnostic accuracy than the assessors with regard to EI cases. The model was accurate in 100% and 80% of EI and EN cases respectively. Conclusions - While the study was limited by its retrospective nature and small sample size, valuable features (ulceration, vasculitis and lobular or septal panniculitis) were identified. A biopsy of the lower leg markedly increased the diagnostic accuracy, but there was less concordance between assessors, more research is needed to confirm these results.
Open Access
Cognitive outcomes in adults with HIV-associated Tuberculous Meningitis
(2017) Albertyn, Christine Herculine; Solms, Mark; Marais, Suzaan; Gouse, Theta; Bateman, Kathleen
Tuberculous meningitis (TBM) is a common cause of meningitis in adults in South Africa (1-3), second only to cryptococcal meningitis in studies of microbiologically confirmed meningitis, and accounting for 28% of cases in one (1). Conventional diagnostic tests for TBM are, however, relatively insensitive, and the true incidence is likely to be underreported. When both microbiological and clinical diagnostic criteria (4) are used in the same setting, the incidence of TBM rose to 57% (3), emerging as the most common cause of meningitis in adults in a district level hospital in the Western Cape. In the setting of high human immunodeficiency virus (HIV) and tuberculosis (TB) prevalence, approximately 88% of patients with definite or probable TBM are co-infected with HIV (3, 5) and six-month mortality in this group approaches 50% (3). Survivors may be left with long-term disability secondary to hydrocephalus, cranial neuropathies, seizures and strokes (6).
Open Access
Determinants of patient and physician global assessment of disease activity and their discrepancies amongst South Africans with Rheumatoid Arthritis
(2025) Didi, Sariu Ali; Hodkinson, Bridget
Background: Patient and physician global assessments (PGA and PhGA) play a crucial role in treatment decisions, yet discordance in these assessments is common. Factors influencing PGA and PhGA and discordance in South African (SA) RA patients remain poorly understood. Methods: This cross-sectional study included consenting adults with RA attending a tertiary hospital. Demographic, disease-specific, and patient-reported outcome data were collected. A discordance score was calculated by subtracting the PhGA score from the PGA score, and discordance was defined as PGA-PhGA ≥ 2.5. Determinants of PGA, PhGA, and determinants were explored using correlation analyses, linear regression, and logistic regression. Results: Of 550 patients, most were female (84.9%), with a mean (SD) age and disease duration of 55.8 (12.9) and 11.5 (9.7) years. Discordance was seen in 27.5%. Pain severity significantly influenced PGA, while tender and swollen joint counts predominantly influenced PhGA. A large portion of the variance in PGA and PhGA (62.0 % and 50.3% respectively) was unexplained. Patients with discordance reported higher pain scores, and problems with usual activities but had lower swollen joint counts and were more likely to be in remission or low disease activity than concordant patients. Conclusion: Discordance in patient-physician assessments exists in a considerable proportion of SA RA patients. Pain severity and functional limitations greatly influence patient perceptions. Addressing pain and activity limitations could help reduce discordance, optimize disease management, and foster shared decision-making. Further longitudinal and qualitative research is essential for a more comprehensive understanding of our RA patients' perspectives.
Open Access
Does alopecia have diagnostic weight in systemic lupus erythematosus?
(2022) Knight, Lauren Kerry; Jessop, Susan; Gcelu, Ayanda
Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder characterised by autoantibody production and a wide spectrum of clinical manifestations. Non-scarring alopecia (hair loss) is reported to occur in up to 80% of individuals with SLE, occurring primarily in the active phase. Alopecia is also reported in up to a third of the general population, begging the question of how much diagnostic weight alopecia really has in SLE. METHODS We conducted a cross-sectional cohort study of patients with confirmed SLE, by the 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria, managed at the Lupus clinic at Groote Schuur Hospital, a tertiary referral hospital in Cape Town, South Africa. Age, sex and race matched controls were recruited from the Dermatology clinic at the same hospital. Participants were questioned about alopecia (‘self-reported') and examined for alopecia clinically and dermoscopically (‘confirmed alopecia'). Alopecia was classified according to the likely cause and evaluated as to whether or not it was related to SLE and to disease activity. RESULTS The study included 90 participants with SLE and 90 controls. Females predominated in the study population, with a mean age of 37.13 (range 18-69) for cases and 37.62 (range 18-72) in controls. Demographics of the 2 groups were equally matched, with two thirds (64.4%) of cases and controls self- identified as being mixed race, 33.3% as black african and 2.3% as white. Alopecia (self-reported and confirmed) was found equally in cases and control groups. In a third of the people with SLE (34, 38%) alopecia was recorded by the clinician as one of the classification criteria used by the clinician in recording the diagnosis of SLE. In 7/34 (21%) of these patients, the classification of SLE would not have been made by criteria in the absence of alopecia. Forty patients were found to have clinically apparent alopecia, 7 of these (17.5%) having diffuse alopecia. Of the remaining 33 patients with alopecia, androgenic alopecia (12/33) was the commonest form. Likewise, androgenic alopecia was the commonest type of confirmed alopecia in controls (11/33, 33.3%). Patients with self-reported alopecia had significantly higher Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores than people without hair loss. However, there was no statistically significant difference in SLEDAI scores between those with clinically confirmed alopecia and those with self-reported alopecia (n = 40, M = 2.88, SD = 3.35 vs n = 50, M = 2.56, SD = 3.37; t = 0.44, p = 0.660, d = 0.09). CONCLUSION Within our population the incidence of alopecia was the same in people with SLE and in controls. Hair loss was identified as androgenic alopecia in the majority of affected cases and controls. This lack of difference in type of alopecia among participants highlights the low specificity of non-scarring alopecia as a criterion for SLE and further supports the weighting of classification criteria within the various domains in the EULAR/ACR criteria.
Open Access
Efficacy and safety of novel and repurposed drugs for the treatment of drug-resistant tuberculosis
(2020) Olayanju, Olatunde; Dheda, Keertan; Esmail, Aliasgar
Background: There is widespread concern about the rise of drug-resistant TB because treatment outcomes of affected patients remain poor and treatment options are limited. After more than a forty-year gap without any breakthrough discovery, several new (bedaquiline and delamanid) and repurposed drugs (linezolid) are increasingly becoming available for use. However, data regarding the efficacy and safety of these drugs in drug-resistant TB patients, with or without HIV infection, from a real-life programmatic setting are lacking. This thesis aims to address that knowledge gap and provide information for management of drug-resistant TB in countries with high disease burden. Methods: A total of 326 drug resistant TB patients were prospectively followed up between January 2008 and April 2018. The efficacy and safety of two new drugs (bedaquiline and delamanid) and one repurposed drug (linezolid) was determined in these patients in three studies. In the first study, 24 months treatment outcomes and adverse event profiles were compared between extensively drug resistant (XDR) TB patients who received programmatic treatment regimens with the backbone of second line injectables and fluoroquinolones (nonbedaquiline-based) and those who received a bedaquiline- and/ or linezolid-based treatment regimen. The second study determined the frequency of system-specific adverse events associated with linezolid. The third study interrogated the safety and effectiveness of a strengthened treatment regimen containing a combination of delamanid and bedaquiline in patients with poor prognostic features compared to bedaquiline-based regimen. Results: In the first study, patients who received a bedaquiline-based treatment regimen had a significantly greater favourable outcome rate (66.2% vs 13.2%; p<0.001) ), more than a fourfold reduction in treatment failure rate (5.9% vs 26%; p<0.001 ) and less than a half of mortality rate compared to patients who received a non-bedaquiline-based regimen. The bedaquiline survival and favourable outcome effect remained significant in HIV-infected patients (p<0.001). The second study showed that linezolid interruption was common in patients receiving a bedaquiline-based treatment regimen, and that system-specific toxicity occurred within predictable time frames. It also showed that anaemia (77.3% versus 7.3%; p<0.001), peripheral neuropathy (63.6% versus 14.6%; p=0.003), and optic neuritis (18.2% versus 9.8%; p=0.34) occurred more frequently in linezolid interrupters than in non-interrupters. The third study showed that the use of delamanid-bedaquiline combination regimen was safe and efficacious in drug resistant TB patients with poor prognosis when compared with outcomes in the less sick patients who received a bedaquiline-based regimen. It also showed no significant difference in culture conversion rate at 6 months (92.5% versus 81.8%; p=0.26) or favourable treatment outcome rate (63.4% versus 67.5%; p=0.66) between the two groups. Although patients who received the combination regimen had more frequent occurrence of QTcF prolongation greater than 60 ms from baseline (p=0.001) and more episodes of QTcF greater than 450 ms during treatment (p=0.001), none of them were symptomatic or had delamanid or bedaquiline withdrawn from their regimen. Conclusion: These data demonstrated that new and repurposed drugs remarkably improved treatment outcomes in patients with drug-resistant TB. Although linezolid, which is an important component of the bedaquiline-based treatment regimen, is often associated with system-specific adverse events, these occurred at predictable time frames thereby guiding physicians to make informed management decisions. Lastly, drug resistant TB patients with poor prognosis may benefit from a regimen containing delamanid and bedaquiline which seems relatively safe from an adverse event perspective. These data, despite some limitations, make a case for a widespread and accelerated roll-out of new and repurposed drugs for the treatment of drug resistant TB.
Open Access
Epidemics in South African history
(2013) Phillips, Howard
by Professor Howard Phillips, Department of Historical Studies, University of Cape Town, this lecture series explores five major epidemics that have ravaged South Africa, namely smallpox, the bubonic plague, Spanish Flu, Polio and HIV. This lecture series will be useful for anyone interested in learning about epidemics in SA history.
Open Access
Exploring how a genetic attribution to disease relates to internalised stigma experiences of Xhosa people with schizophrenia and rheumatic heart disease in South Africa
(2019) Matshabane, Olivia Precious; De Vries, Jantina; Campbell, Megan
Advances in genomics research have brought forth a number of psychosocial concerns. In Africa, in particular, one of the concerns relates to the potential impact of genomics research on stigma experienced by specific population groups. Using a mixed-methods approach, this study sought to explore how genetic causal explanation relates to the internalised stigma experiences of a sample of South African Xhosa people with schizophrenia (n= 36) and rheumatic heart disease (n= 46). Additionally, a pilot study was conducted with another sample of schizophrenia (n= 65) and rheumatic heart disease (n= 55) patients to translate and adapt an internalised stigma of mental illness scale into isiXhosa. The aim of the study was operationalised into three research questions, namely; 1. What causal attribution models do Xhosa people with schizophrenia and rheumatic heart disease employ to explain their illness and to what extent do genetic explanations play a role in these causal models? 2. What are the internalised stigma experiences of Xhosa people with schizophrenia and rheumatic heart disease? 3. How do the genetic causal explanations of Xhosa people with schizophrenia and rheumatic heart relate to their internalised stigma experiences, if at all? Through focus-group discussions participants were introduced to non-genetic and genetic causal explanations and then asked a series of open-ended questions eliciting their perceptions of disease causation, genetic causation and the possible implications these perceptions may have on internalised stigma they may have experienced. Next, an internalised stigma of mental illness scale (ISMI) was translated through a mixed-methods translation approach into Xhosa and adapted for use in both disease groups. Insights from this translation were used to gain an understanding of how the Xhosa language supports particular descriptions and conceptualisations of stigma experiences. Psychometric results provided further insights into particularly relevant internalised stigma items for each disease group. Findings from the FGDs and translation process suggested that firstly Xhosa people with schizophrenia and those with rheumatic heart disease have a general understanding of genetics and genetic attribution to disease. Secondly, and not withstanding this knowledge, these participants hold a multitude of disease explanations. In consideration of the alternative causal explanations, and the factors these participants are exposed to, the genetic explanation did not appear to relate to their internalised stigma. While there was evidence of stigma in the two disease groups - schizophrenia patients reporting more stigma than the rheumatic heart disease sample - this stigma was not often related to a genetic attribution of disease. Findings suggest that the link between genetic attribution and stigma is complex. Due to the variable nature of the evidence derived from the study we cannot conclude that a genetic attribution is not related to stigma, however the findings provide clues as to why this is an unlikely implication for Xhosa people in these disease groups. This finding is different to empirical research which has been conducted in North American and European contexts. Although research in Western and European contexts suggests that attributing a disease to genetics may have an impact on disease-stigma, there have been minimal efforts to explore that assumption in the African context. This study, being one of the first to explore that assumption in an African population group, did not find consistent evidence to support it.
Open Access
Exploring how Health-related Quality of Life (HRQOL) is experienced among patients living with HIV associated TB in Khayelitsha, South Africa
(2020) Hickman, John-Henry; Swartz, Alison; Sicwebu, Nmhla
Health-related quality of life (HRQOL) is a construct that has received attention in research for nearly four decades. However, renewed interest in this field came about with advances in medical technology and health policies. Better treatment options and policies, which enables greater access to health care, have improved health outcomes, such as leading to an extension in life expectancy. This rings particularly true for Human Immunodeficiency virus (HIV) and associated illnesses such Tuberculosis (TB). However, improvements in health outcomes are not necessarily accompanied by satisfactory patient experiences of HRQOL. Health-related quality of life is predominantly studied through quantitative research methodologies. However, the measures used are not entirely tailored to the South African context. Consequently, this mini-dissertation aims to explore HRQOL using qualitative methodological inquiry within the South African context. This mini dissertation is structured around the three following components: A research protocol (Part A) which addresses HRQOL in a South African context with particular focus on HIV and TB. Part B is a literature review examining existing HIV, TB and HRQOL literature, with emphasis on the South African context. The final section (Part C) is a manuscript for a journal article prepared to be published. Part C focuses on the social experience of HRQOL and how it is the central construct to experiencing HRQOL in South Africa as opposed to an individualised view in Western settings. The findings from this mini dissertation can add to the limited existing HRQOL literature in South Africa, by providing a perspective on how HRQOL is experienced in this country. The knowledge obtained here can further aid in the development or improvement of interventions and policies which aim to not only improve patient health outcomes, but HRQOL as well. Lastly, it can provide valuable information to those focused on developing quantitative HRQOL tools that are appropriate for use in South Africa.

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