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Browsing Family Medicine by Author "Lalloo, Umesh Gangaram."

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    The ethical dilemmas of critical care specialists encountered in the admission of patients with HIV infection to intensive care.
    (2012) Naidoo, Kantharuben.; Lalloo, Umesh Gangaram.; Singh, Jerome Amir.
    South Africa has one of the fastest growing HIV epidemics in the world with 5.6 million people living with HIV/AIDS. As a consequence of the delayed implementation of the ARV rollout and failure to control the epidemic, the number of people living with HIV/AIDS who seek or need intensive care places a huge burden on precious, expensive and sparse intensive care unit facilities. Critical care specialists are faced with complex challenges when making decisions about the provision of such care. Aim: The aim of the study was to develop best practice criteria for admitting HIV-infected patients to intensive care. Methods: The study was done utilising: 1. A comprehensive literature review of the legal and ethical framework governing such decisions in South Africa and compared with that in different countries, both developed and developing. Further, legal precedents and clinical best practice that could inform policy and practice in South Africa were applied to the decision making process. 2. An audit of ICU beds in South Africa by first making a comprehensive and contemporary review of critical care facilities in South Africa, to place in context the ethical dilemmas faced by critical care specialists in the admission of HIV/AIDS infected patients to intensive care in a resource limited environment. 3. Critical care practitioners’ response to a standardised questionnaire regarding ethical decisions and provision of intensive care to five hypothetical clinical case scenarios. Results: The study showed that: The ICU bed availability in South Africa is limited and the problem is worse in the public sector with widespread variations across the provinces. The lack of skilled staff for ICU is insufficient for our needs in the public sector. For people living with HIV/AIDS, specific variables influence their survival in intensive care. The benefits of anti-retroviral treatment in intensive care are still being debated. Clinical prediction tools should be considered as an aid to clinical judgment on decisions about whom to admit to intensive care. Rational decision making should include central questions such as ‘ whether the patient too ill or too well for ICU care’ and whether there is a reasonable prospect of ‘reversibility of organ-dysfunction’? Non-invasive ventilation using a continuous positive airway pressure (CPAP) ventilation mask is showing promise for patients with Pneumocystis jeroveci pneumonia (PJP), especially in a resource-constrained environment. Further studies need to validate this. People living with HIV/AIDS are not discriminated against on admissions to ICU and are not subjected to medical futility decisions. Discussion: The shortage of ICU beds results in critical care specialists being under pressure to deliberate on resource allocation decisions for competing patients. Strong regulatory and ethical frameworks exist to protect the rights of people living with HIV/AIDS and access to intensive care. The ‘Limitation Clause’ of the South African Constitution, as canvassed by the courts resulting in the refusal of renal dialysis in the case of Mr. Subramoney, a utilitarian judgment, would not be justiciable for people living with HIV/AIDS and access to intensive care. The National Health Insurance Plan envisages making more ICU beds available through a public-private sector partnership. There is a compelling need for regionalisation of intensive care services in the country. Respiratory failure in HIV/AIDS patients remains the commonest indication for intensive care unit admissions, and other diagnosis such as non-PCP pneumonia, sepsis, cardiac, gastrointestinal, and renal diseases, are becoming more common. The ART era has seen an improvement in ICU to ward survival rates of 70% (similar to that of the general medical population) as well as the three month and long-term survival outcomes post-ICU discharge. ICU prognostic systems should be regarded as an aid to clinical judgment. Daniels ‘accountability for reasonableness’ provides a moral framework for ethical decision-making and priority setting. In its determined efforts to control the pandemic of HIV/AIDS, some countries, notably Botswana and South Africa are accused of violating international treaties. Conclusion: South Africa has made many legal provisions to protect the rights of its HIV infected patients. People living with HIV/AIDS are neither discriminated against in admission to intensive care units, nor being subjected to medical futility decisions. With the advent of HAART, people living with HIV/AIDS admitted to ICUs, have similar outcomes to that of the general population. Admission guidelines for ICU as advised by the professional bodies for use by the general population should be equally applicable to people living with HIV/AIDS, i.e. is the patient too ill or too well to warrant ICU admission, and is there a realistic prospective of 'reversibility of organ dysfunction'?
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    A follow-up study of the respiratory health status of automotive spray painters exposed to paints containing isocyanates.
    (1997) Randolph, Bernard Winston.; Lalloo, Umesh Gangaram.
    In order to evaluate the respiratory health status of spray painters exposed to paints containing hexamethylene diisocyanates (HDI) and to obtain more insight into the relationship between occupational exposures to isocyanates and chronic obstructive airway diseases, a follow up study on 33 of an original cohort of 40 randomly selected workers was undertaken. The original investigation was conducted by the author in 1989. The subjects were studied using a standardised American Thoracic Society (ATS) approved respiratory health questionnaire, baseline pre and post shift spirometry and ambulatory peak flow monitoring. Bronchial hyperresponsiveness tests using histamine (PC20) were performed. Immunological tests including IgE, RAST (HDI), and house dust mite evaluations were also made. The subjects were stratified into exposed (n=20), partially exposed (n=5) and no longer exposed (n=7) groups. One subject was excluded from the group analysis because of his indeterminate isocyanate exposure. Warehouse assistants (n=30) in a non-exposed occupation were used as controls. The worker's compliance with safety regulations and the employers provision of safety requirements was assessed by means of a questionnaire. The environmental conditions in the workplace were measured by the evaluation of the isocyanate concentrations at the worker's breathing zone. Spray booth efficiency was measured using measurements of airflow velocities and airflow patterns within the booth. Longitudinal changes in respiratory health status was assessed by comparison with baseline data studied in 1989. The exposed group showed the largest mean cross-shift declines of 297 ml (± 83.8) in forced expiratory volume in one second (FEV1). The decline in the partially exposed group was 282 ml (± 102.7) and 54 ml (± 140) in the no longer exposed group. The results of the first study, when compared with the second study, showed a mean cross-shift decline in FEV1 of 130.5 ml. (± 203) (p=0.0002) and 297ml. (± 323) (p=0.0001) respectively. Furthermore, of the spray painters examined, 10 (25%) showed clinically significant cross-shift declines in FEV1 viz. decreases >250 ml in the first study (n=40) compared with 9 (45%) in the second study (n=33). In contrast to the HDI exposed spray painters, a closely matched control group (n=30) showed a mean cross-shift increase in FEV1 of 17.4 ml ( ± 63.04). Only 2 subjects had a diagnosis of asthma which was made in childhood and not related to occupation. The mean annual baseline decline in FEV1 was greatest in the exposed group 41.25 ml (25% showed a decline greater than >90 ml per annum). These values exceeded the predicted annual declines for both smokers and non smokers due to age. The decline in the no longer exposed group was 7.85 ml per annum. Immunological tests showed no correlation with declines in FEV1 . This study demonstrates the difficulties in correlating immunological status with clinical and lung function findings in workers exposed to HDI, as a means of predicting occupational asthma. Although measurements in cross-shift declines in FEV1 appear to be a suitable predictor of occupational asthma, in some cases it was found that the forced expiratory flow rate (FEF 25-75 %) was a more sensitive predictor of early changes in the small airways. The mean isocyanate concentration in the spray painter's breathing zone was 14.65 mg/m3 (±12.219), exceeding the current South African Occupational Exposure Limit - Control Limit (OEL-CL) of 0.07 mg/m3 for isocyanates. Fifty per cent of the subjects suffered from eye irritation and 40% had dermatitis of the hand. This was expected since none of the spray painters wore goggles or gloves. Whilst no subject had evidence of clinical asthma related to spray painting, a large proportion demonstrated significant cross- shift changes in lung function implying short- term adverse effects of exposure. In addition longitudinal declines in lung function which was worse in those who continued spray painting in the follow-up study, is of major concern. The lack of cases of clinical or occupational asthma may be due to the healthy worker effect. Recommendations include, routine spirometric lung function testing of all spray painters, the use of high volume-low pressure spray guns and the wearing of positive pressure airline masks complying with the South African Bureau of Standards (SABS) safety standard. In terms of current legislation it was further recommended that spray booths be regularly monitored, including the measurement of HDI concentrations, airflow velocities and airflow patterns within the booth and the implementation and enforcement of stricter control measures. Workers demonstrating excessive declines in both cross-shift and longitudinal spirometry, require special attention.
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    Tuberculosis in medical doctors in KwaZulu-Natal, South Africa : personal experiences and perceptions related to their diagnosis and treatment.
    (2011) Naidoo, Ashantha.; Lalloo, Umesh Gangaram.
    Title: Tuberculosis in medical doctors in KwaZulu-Natal (South Africa): Personal experiences and reflections related to their diagnosis and treatment. Background: The high tuberculosis (TB) incidence and prevalence fuelled by the concomitant HIV epidemic in South Africa has resulted in a high rate of tuberculosis infection in health care workers. This is the first study to investigate the experiences and reflections of doctors who were diagnosed with active TB during their employment in high TB burden hospitals in KwaZulu-Natal, South Africa. Methods: Consecutive medical doctors working in both the public and private sectors and who were treated for active tuberculosis between 2007 and 2010 were contacted to participate in the study. Each participant completed an informed consent and a validated anonymous self-administered questionnaire. The study received ethical approval from the University of KwaZulu-Natal. Results: Forty doctors participated in the study. The mean age of participants was 33.67±10.63 years. The majority were between 21 and 40 years of age (males (52.5%), and employed in the public sector (95%). Four (10%) had MDR-TB. A number of participants were referred for costly special investigations which are not considered to be part of first line care in South Africa. For example, 15 participants (37.5%) underwent chest CAT scans during the diagnostic period. Eight doctors reported complications following invasive procedures. Nineteen (47.5%) of the 33 participants (82.5%) who had experienced sideeffects related to anti-TB drugs had considered defaulting on their treatment because of the side-effects of these drugs. Many participants expressed concerns about the uncaring attitudes of senior medical colleagues and hospital management. The majority of participants had introspected on their illnesses and experiences and committed themselves to become more caring and empathic towards their patients in future. Conclusions: All health care workers and particularly nurses and medical doctors working in environments with a high burden of infectious diseases such as HIV and TB, are at increased risk to TB infection. They encounter various personal and professional problems following contraction of TB infection. These experiences had impacted in many ways on their professional lives, and some doctors have since left the medical profession because of these experiences. The risks associated with TB must be minimised. Much more therefore remains to be done in the public health care system if these trends are to be reversed; this includes health policy changes, health system changes and attitudes of medical colleagues towards medical doctors who become “victims of illnesses acquired in the course of duty”.