School of Clinical Medicine

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A 10-year institutional review of surgery for structural valve dysfunction in the developing world.
(2017) Chih-Yuan, Chen.
Background Prosthetic heart valves do not fulfil the requirements for an ideal valve, resulting in the development of prosthetic dysfunction or complications over time. Structural valve dysfunction may be influenced by multiple components which include patient’s factors, valve related factors and intraoperative factors. The inter-relation of these factors has a significant impact on morbidity and mortality associated with reoperative surgery for prosthetic valve dysfunction, particularly in a developing world where a large burden of communicable diseases together with lack of health care resources affect surgical outcome. In this study we examined the clinical records of the patients who underwent reoperative valve surgery to evaluate the clinical profile and factors that affect the surgical outcome after reoperation at a large tertiary referral center in a developing country. Objectives 1) To describe the demographic profile of patients with malfunctioning prosthetic heart valves and define their clinical presentation 2) To describe the clinical presentation of valve dysfunction 3) To determine the possible mechanisms of mechanical and bioprosthetic valve failure 4) To determine the factors affecting the immediate surgical outcomes in subjects undergoing redo cardiac prosthetic valve surgery. Materials and methods A retrospective analysis of the clinical, perioperative and follow-up data of patients who underwent redo cardiac valve surgery for structural valve dysfunction between January 2005 and December 2014 at Inkosi Albert Luthuli Central Hospital, Durban, South Africa was undertaken. Patients were identified using the Speedminer software program which is a Data Warehouse software package used to store data collected on the hospital Medicom database. The file of each of patient who underwent redo cardiac prosthetic valve replacement for structural valve dysfunction was accessed and data were extracted on age, gender, potential risk factors for valve thrombosis, symptomatology, investigations including International normalized Ratio (INR) status and follow up. All patients were evaluated preoperatively by the cardiologist and the cardiothoracic surgical team and submitted for either an elective or emergency valve replacement. Excluded from the study were those patients who underwent cardiothoracic surgery for nonvalvular reasons, i.e. coronary artery bypass surgery and congenital heart disease. Results During the ten year period (2005 to 2014) 2618 valve replacement operations were performed. During the same period 128 reoperations (4.9%) were performed in 113 patients (mean age 35.59 (SD±16.66) years). The majority of the patients were Black (72.6%) and female (75%). Fifteen patients (13.3%) were HIV infected and nine were pregnant. Acute dyspnoea (NYHA class III 34.37% and class IV 21.88%) was the presenting feature in 72 patients (56.25%). Clinical presenting features of an obstructed valve (flash pulmonary oedema with or without clinically audible prosthetic valve clicks) were documented in the clinical records of 44 of the 128 (34.4%) reoperations. In seventeen instances subjects presented with acute onset of cardiac failure (13.3%) and in eleven the presentation was characterised by signs of low cardiac output state (5.3%). There were no clinical indicators of an obstructed valve in the remaining 56 (43.8%). Of these 56 patients: 38 presented with change in effort tolerance and 18 where asymptomatic. Valve dysfunction was detected by echocardiography and confirmed fluoroscopically in 71/128 cases (55.47%). In the remaining patients the diagnosis was made either at fluoroscopy (11.72%) or on echocardiography (32.81%). The ejection fraction (EF) was severely impaired (EF<40%) in 7.08% of patients. The mean left atrial size was 52.28mm and mean pulmonary systolic pressure 45mmHg (range 26-104). Mechanical valve dysfunction was documented in 110/128 reoperations (obstructed valve (100) and prosthetic infective endocarditis (10). In almost two thirds of instances with obstructed mechanical prostheses levels of anticoagulation achieved were poor (INR<2.0); 30/110 (27.27%) were within therapeutic ranges of 2-4 and 9/110 (8.18%) was >4.0. HIV status did not influence the outcome of surgery and did not appear to be the main mechanism of valve obstruction. The bioprosthetic valve group comprised the remaining 18 of 128 reoperations. In this group 13/18 patients had structural valve deterioration with periprosthetic leaks, and remaining 5 had prosthetic infective endocarditis (aortic root abscess (1) and annular dehiscence (4).Emergency surgery was performed in 54.7% of the study population, of which 60.2% were in the mitral position. There was a total of 13 early in-hospital deaths (11.5%) of which one “on table” death was due to a low cardiac output state (LCOS). Postoperative mortality was related to prosthetic endocarditis (5/13) and high grade dyspnoea at presentation (7/13). Multivariate analysis revealed that bypass time >3.5 hours (HR 5.58, 95%CI 1.24-24.95), cross clamp time >120 minutes (HR 4.48, 95%CI 1.25-18.73), and third time redo operations (HR 4.26, 95%CI 1.23-14.75) were the independent predictors for early in-hospital mortality. Conclusion Our study shows a 4.9% reoperation rate after the previous valve replacement surgery with 11.5% perioperative mortality. Our results confirm that reoperative surgery is associated with significant morbidity and mortality. More than half the patients presented acutely for mechanical valve obstruction which was due to inadequate levels of anticoagulation and required emergency surgery. Early mortality was related to poor NYHA class at presentation and to the presence of infective endocarditis. An important finding of this study was the high rate of valve obstruction associated with poor anticoagulation in patients who received the Cryolife On–X valve. They had a shorter interval to valve obstruction requiring redo valve replacement compared to the other mechanical prostheses.
Abnormal IgA1 O-glycosylation in a multi-ethnic population of IgA nephropathy patients in KwaZulu-Natal, South Africa.
(2013) Nansook, Prishani.; Assounga, Alain Guy Honore.
Background: The pathogenesis of IgA Nephropathy (IgAN) is poorly understood globally and curative therapy currently does not exist. Variable presentation among IgAN patients globally may be indicative of various underlying pathogenic mechanisms. Pathogenetic data on IgAN in Africa is scarce to nil. The current study provides the first O-glycosylation data for IgAN in South Africa or Africa. Methods: An enzyme-linked immunosorbent assay-type lectin binding assay was used to compare the serum IgA1 O-galactosylation in 19 IgAN patients and 20 controls. During 2007, 2009, and 2011, blood was extracted from consenting biopsy-diagnosed South African IgAN patients of African, Caucasian, Indian (predominantly) and mixed-race descent in KwaZulu Natal. The mean absorbance value corresponding to the degree of degalactosylation for the IgAN group was compared to that of the normal control group for each test. A non-parametric Wilcoxon matched-pairs test was used accordingly. The two-tailed p-value was used to assess for statistical significance between the groups. The low number of attending and consenting IgAN patients precluded IgA1 O-galactosylation analyses between race, gender, and disease stage. Results: The average means of the experiments for the IgAN group is 0.3678 ± 0.0790 (SEM) and is statistically significantly greater than the normal control group which is 0.2969 ± 0.0586 (SEM); (p = 0.0076). Conclusion: Thus, IgAN patients exhibited abnormal IgA1 O-glycosylation with a greater level of terminal degalactosylation of IgA1 in comparison to controls. Such a finding is consistent with other studies in Caucasian and Asian populations globally. Future specific therapeutic strategies that target the formation of abnormal glycosylation in IgA1 may be potentially beneficial in the study population.
The accuracy, sensitivity and specificity of rapid point-of-care testing for CD4+ T cell count enumeration and TB diagnosis.
(2014) Skhosana, Mandisa.; Kiepiela, Photini.; Coutsoudis, Anna.
Objectives: The PIMA CD4+ T cell count analyser has been favourably evaluated for use in point-of-care (POC) situations in Mozambique and Zimbabwe, has also been recommended by the World Health Organisation (WHO), however, there is limited information on its use in Primary Healthcare (PHC) settings in KwaZulu Natal (KZN) South Africa. The main aim of this study therefore assessed the accuracy, sensitivity and specificity of the Alere PIMA Point of Care (POC) analyser CD4+ T cell count enumeration compared to the South African National Health Laboratory Services (SA-NHLS) methodology, which uses Beckman Coulter with Panleucogating (PLG/CD4). The potential role of using the PIMA CD4 analyser as a predictor of antiretroviral therapy (ART) eligibility was also assessed. Material and Methods: The study took place at Lancers Road clinic, a busy primary health clinic (PHC) facility under the eThekwini Health Unit. An extra two millilitres of venous blood was drawn from the same blood draw as for the routine CD4 NHLS test (Beckman Coulter) into another EDTA tube for the comparison of the enumeration of CD4+ T cells using the PIMA analyser during January – July 2013. Results: A total of 268 patients were recruited for the PIMA analyser comparison with NHLS PLG/CD4 while a sub-set of 100 blood samples were also analysed on the FACS calibur. In the 100 samples the PIMA analyser results correlated better with the FACS calibur results (mean bias of 7.52, Bland Altman limits of agreement -111 to 126 and correlation of 0.970) than with the NHLS PLG/CD4 results (mean bias of -12.78, Bland Altman limits of agreement -226.041 to 200.481 and correlation of 0.90). In the 268 samples the overall mean difference between the PIMA analyser – NHLS PLG/CD4 was 17.5 cells/μl (95% CI 6.2 to 28.8). The percentage similarity (SIM) between the two (Mean ± SD) was 106 ± 15.5; indicative of acceptable agreement between the two tests. When categorised by the following CD4+ T cell counts of: ≤350 cells/μl; 351-500 cells/μl; ≤500 cells/μl and > 500 cells/μl , the mean difference of PIMA analysers – NHLS PLG/CD4 was 33 cells/μl (95% CI 23 to 42); 22 cells/μl (95% CI -3.5 to 47); 30 cells/μl (95%CI 21 to 39); and cells/μl (95% CI -78 to 6.1) respectively. Under the current South African guidelines of ≤350 cells/μl CD4+ T cells, the sensitivity of the PIMA analyser was 83.5% and specificity 92%. At this threshold of ≤ 350 cells/μl there were 35 (13%) misclassifications, of which 27 were false negatives. This implies that 27 patients would have been falsely deemed ineligible for ART according to the PIMA analyser. The mean difference between the PIMA analyser and NHLS PLG/CD4 in this group of 27 patients was 112 cells/μl. The positive predictive value was high at 95% such that 95% of the patients eligible for treatment according to PIMA analysers would have also been deemed eligible for treatment on the NHLS PLG/CD4 test. Using future South African treatment guidelines threshold of CD4+ T cell counts ≤500 cells/μl , a high sensitivity of 94% was observed at the sacrifice of lower specificity of 78%. According to the NHLS PLG/ CD4 test result, 164/268 (61%) of patients were eligible for ART (CD4+ T cell count ≤350 cells/μl) compared to 145/268 (54%) with the PIMA analyser POC CD4+ T cell test. Of those eligible for ART according to the ART register at Lancers Road PHC, 110/164 (only 67%) of these patients were initiated on ART. Of those who did not return for their results 35/268 (13%), twenty of 35 (57%) were eligible for ART according to the NHLS PLG/CD4 laboratory CD4 test result, all of whom were not initiated on ART. Conclusion: The overall agreement between the PIMA analyser POC and NHLS PLG/ CD4+ T cell count enumeration in adult HIV positive individuals was acceptable with clinically insignificant mean bias. Together with high positive predictive value, and sensitivity and acceptable specificity the PIMA analyser POC lends itself to an excellent facilitator of improved healthcare.
Acute pancreatitis in a high HIV prevalence environment: analysis of prevalence, demographics, prognosticators and outcomes.
(2019) Anderson, Frank.; Thomson, Sandie Rutherford.
Background It is unclear what is the true prevalence of HIV related acute pancreatitis and whether diagnostic and prognostic markers used in patients without HIV infection are as effective in HIV related pancreatitis and if morbidity is worse in HIV infected patients. Methods Using a prospective, descriptive design, HIV prevalence was compared in trauma and acute pancreatitis patients. Serum amylase was used to diagnose acute pancreatitis. Prognostication was by CRP, BISAP, Glasgow and APACHE II scores at 24 hours. Sensitivity, specificity and AUC were compared in predicting a severe outcome in acute pancreatitis. Complications and mortality were compared in 238 HIV+ve and HIV-ve patients admitted to 2 regional hospitals in Durban between August 2013 and October 2015. One hundred and eighty one patients were admitted with trauma. Results Between August 2013 and October 2015, 238 patients were admitted with acute pancreatitis and 181 with trauma. HIV infection was higher in patients with acute pancreatitis (38% vs 16%) (p=0.001) and they were also older (40 vs 33 years) (p=0.001). Fifty three percent of HIV +ve patients were female and 65% of the HIV-ve patients were male in the pancreatitis cohort and 59% of the trauma and pancreatitis patients were on Highly Active Antiretroviral Therapy. The prevalence of gallstone (27% vs 30%), alcohol (41% vs 52%), dyslipidaemia (0% vs 3%) and idiopathic (6% vs 14%) aetiologies were similar in HIV+ve and HIV-ve patients and a drug related aetiology (24% vs 0%) (p<0.001) was more prevalent in HIV related acute pancreatitis. CRP was more effective in predicting severe disease in HIV-ve patients (AUC= 0.75) and patients with CD4 counts of ≥ 200 cells/mm3 (AUC=0.73) and not HIV+ve patients (AUC= 0.59) or patients with counts below 200 cells/mm3 (AUC= 0.46). The BISAP system had similar efficacy with AUC of 0,71 and 0.74 in HIV-ve and HIV+ve patients respectively, was poor in CD4 count < 200 cells/mm3 (AUC=0.68) and good in CD4 count> 200 cells/mm3 (AUC=0.9). The Glasgow score was of similar efficacy in HIV-ve (AUC = 0.72) and HIV+ve patients (AUC=0.78) and better in patients with CD4 count < 200 cells/mm3 (AUC=0.83) and CD4 count ≥ 200 cells/mm3 (AUC=0.81). The APACHE II had uniform efficacy in both HIV-ve and HIV+ve patients (AUC >0.8) and both CD4 count ranges (AUC > 0.80). Septic complications occurred in 10(8%) of HIV-ve patients and 4(4%) HIV+ve patients. There was no difference in morbidity (25% vs 33%) and mortality (6% vs 6%). Conclusions HIV infections is more prevalent in acute pancreatitis than in a hospital trauma cohort which represented the general population. The APACHE II system was the most accurate in predicting morbidity and CRP least accurate. The outcomes were similar in HIV+ve and HIV-ve patients but the statistical assumptions in calculating the sample size, given the low frequency of morbidity and mortality observed in this study may have resulted in an alpha error.
Adequate analgesia in caring for paediatric burns patients in a peri-urban setting in KZN.
(2020) Wall, Shelley Lynn.; Clarke, Damian Luiz.; Allorto, Nikki Leigh.
This PhD thesis centres on achieving adequate analgesia in caring for paediatric burn-injured patients in KwaZulu-Natal, South Africa. The burden of burn injuries in sub-Saharan Africa is huge. A large number of children in the under-five age group sustain burns in the region annually. Pain is virtually synonymous with burn injuries. All children with burns experience pain, regardless of the cause, size or depth of the burn. This PhD study aimed to improve the care offered to paediatric burns patients by addressing obstacles to adequate analgesia in paediatric burns patients; and to offer a practical, easy to use, locally applicable analgesia protocol which can be used at district, regional and tertiary hospitals alike. The objectives were to identify deficits in the knowledge of doctors in terms of prescribing procedural analgesia for children with burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes in an outpatient department; to compare the analgesic requirements of children presenting with acute versus chronic burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes for patients admitted to the burns ward; to evaluate obstacles to adequate analgesia in paediatric burns patients; and to develop an analgesia protocol applicable to KwaZulu-Natal and other low-middle-income countries (LMIC), through the consensus of experts in the field. The development of this protocol was conducted in three phases. The first phase involved assessing obstacles to adequate analgesia in paediatric burns patients. The second phase involved assessing Methoxyflurane as an alternative analgesia option in both the inpatient and the outpatient setting; and the final phase involved the addition of Methoxyflurane to our analgesia protocols and reaching an expert consensus that the elements included in the analgesia protocol were applicable to KwaZulu-Natal and other low-middle-income settings. The analgesia protocol for paediatric burns patients has been developed with the local setting and resources as a primary consideration. It was specifically designed to be easy to use, safe in novice hands and locally applicable. In order to ensure that theoretical findings from the study are translated into practices that benefit all burn-injured children, this research should be combined with advocacy efforts.
Adherence to iron prophylactic therapy during pregnancy in an urban regional hospital in Durban, South Africa.
(2017) Mkhize, Princess Zinhle.; Moodley, Jagidesa.; Naicker, Thajasvarie.
Iron and folic acid supplementation plays a major role in prevention and control of iron deficiency anaemia in antenatal care. In South Africa, although all pregnant women receive iron, folate and calcium supplementation throughout pregnancy, anaemia is still common. Low adherence may be a key contributor to the ineffectiveness of supplementation programs.Therefore, this study was conducted to examine adherence to prophylactic iron supplementation during the antenatal period. An observational clinical study was conducted in a regional hospital from January- December 2016. Women (n=100 HIV uninfected and n=100 HIV infected) were recruited and subdivided into three groups: (a) 1st attendees ≤ 34 weeks (n=33), (b) 34-36 weeks (n =34) and (c) ≥ 37 weeks /birth (n=33) respectively. A structured questionnaire was used for data collection. Data were coded and computed onto an excel sheet for statistical analysis using SPSS software. Data from women (n = 24) from 1st visit attendees ≤ 34 weeks and 34-36 weeks subgroups indicated that pill count and self-reported data reflected 50% adherence and 46% non-adherence, being higher in the HIV infected women (75%). Nausea was the commonest side effect in all trimesters (79, 2%). Adherence (27.8%) and non-adherence (72.1%) to iron, folic acid and calcium supplementation were observed in 176 (88%) women. Promoting essential strategies on the importance of consumption and effectiveness of iron prophylactic therapy is essential to maintain and improve anaemia in antenatal attendees during pregnancy.
Admissions for pulmonary embolism at a tertiary South African hospital.
(2017) Kistensamy, Sivaisen Ricardo.; Moodley, Yoshan.; Brown, Susan Lynn.
Background: Published descriptions of pulmonary embolism (PE) from South African (SA) settings are rare. We sought to address this gap in the literature. Methods: This was a case series involving 61 adult patients admitted to a tertiary SA hospital over a five-year period with a primary diagnosis of PE. Data related to patient demographics, PE presentation, risk factors, treatment, and inpatient mortality were collected and analysed using appropriate statistical tests. Results: Most of our study population were younger (86.9%), female (67.2%), and of black African ethnicity (73.8%). Dyspnoea and chest pain were the most common symptoms (prevalence of 86.9% and 41.0%). Prevalent clinical signs included tachypnea (47.5%) and tachycardia (42.6%). The most prevalent established risk factors were cardiac failure (49.2%) and a history of deep vein thrombosis (up to 19.7%). Massive PE was diagnosed in 8.2% of study patients. Most patients received anticoagulation therapy (95.1%), with thrombolysis and embolectomy performed only in smaller proportions (24.6% and 11.5%) of patients. The incidence of inpatient mortality was 23.0%. Characteristics associated with mortality included: admission route (p=0.008), dyspnoea (p=0.002), tachycardia (p<0.001), and embolectomy (p=0.042). Conclusion: Our study findings have important implications related to the management of PE in SA.
An aetiological study of white vulval skin lesions amongst patients attending the gynaecological clinic at R.K. Khan Hospital, Durban.
(1998) Moodley, Manivasan.; Moodley, Jagidesa.
BACKGROUND White vulva! skin lesions may be due to various conditions, including benign and non-benign causes. The dilemma faced by the clinician with such a patient is the aetiology of the lesion, as well as the approach to management. AIM To establish the aetiology of white vulva! skin lesions in patients attending the gynaecology clinic and to evaluate the role of Collin's test and vulvoscopy. SETTING R. K. Khan Hospital, which is a secondary level hospital in Durban, KwaZulu Natal. METHOD Sixty-two patients with white vulva! skin lesions whom consented to the study were recruited. The investigations consisted of Pap smear, colposcopy of the vulva [Vulvoscopy], perineum and where appropriate, vaginoscopy and colposcopy; Collin's test and biopsy of all abnormal areas detected by these tests. RESULTS Pruritus vulvae was the commonest presenting symptom [70%1. No vulvoscopic abnormalities were detected in 97% of patients, whilst 3% had acetowhite areas indicative of Human papilloma virus infection. Collin's test was positive in 40% of patients, although, histologically these areas were benign. All patients in the study had benign lesions on histology. CONCLUSION All patients in this study had benign causes of white vulval skin lesions. However, this cannot lead us to conclude that there is no role for doing Vulvoscopy and Collin's test, as premalignant and malignant lesions should be detected by these tests had they been present.
Aids for the early diagnosis of tuberculous meningitis (TBM)
(1985) Ramkissoon, Arthi.; Coovadia, Hoosen Mahomed.
Mortality and morbidity rates associated with tuberculous meningitis (TBM) are substantial. The average duration of the untreated disease from onset to death is about 17 days. The prognosis of TBM is known to correlate with the stage of the disease at the time of diagnosis and commencement of chemotherapy. Early diagnosis improves the chances of recovery without neurological sequelae. Early diagnosis is a problem because the presenting symptoms are non-specific and the onset of the disease is typically insidious. To date no single test is available that is totally reliable and specific for TBM. I have attempted to develop a reliable and easily applicable test for the diagnosis of TBM. In fulfilling this objective, the work undertaken may be divided into three major sections:- 1. Detection of soluble Mycobacterium tuberculosis antigens in the cerebrospinal fluid (CSF) of patients with TBM and in control groups by using Mycobacterium bovis BCG antigens. The technique used was that of inhibition enzyme-linked immunosorbent assay (ELISA). The principle of this technique is illustrated in Fig. 5. 2. Detection of soluble M. tuberculosis antigens in the CSF of tuberculous and control groups of patients by using antibodies raised against M.bovis BCG. The technique used was that of the double antibody sandwich ELISA. An outline of this ELISA is given in Fig. 6. 3. Correlation of chloride levels in the blood and CSF of patients with tuberculous and other forms of meningitis. It has been established that the SERUM/CSF ratio of bromide tends towards unity in patients with TBM because the permeability of the blood-brain barrier is impaired. Since both bromide and chloride are chemically similar (both being halides), it was thought that a similar pattern may exist for BLOOD/CSF chloride ratios; and this was investigated. The method used for the INHIBITION ELISA had to be standardized before the samples could be tested. This involved investigating the acceptability of various microtitre plates; determination of the optimal working dilutions for the coating solution and conjugate; and determination of optimal conditions for the various incubation periods, both in terms of time and temperature. A total of 70 specimens was tested. These consisted of 25 normal CSF controls; 25 pleural and ascitic fluid samples; 10 TBM samples, and 10 bacterial meningitis CSF samples. It was found that a distinction existed between the absorbance values obtained from positive TBM CSF samples (Mean 0,658 + 0,043) and that from normal CSF samples (Mean 1,089 + 0,224). The mean absorbance of the culture-positive bacterial CSF's also differed significantly from the other 2 groups (Tables VII; IX). Some overlap occurred amongst the absorbance values of bacterial culture positive CSF's (Range 0,975-0,879) and normal CSF's (Range 1,486-0,934). The mean absorbance value for bacterial positive CSF samples (0,920 _+ 0,029) differed significantly (p <0,01) from those of normal CSF (1,089 + 0,224) and TBM CSF's (0,658 + 0,043). The difference between the mean values obtained with tuberculous and non-tuberculous groups of pleural and ascitic fluid was also significant (p < 0,01). The method used for the DOUBLE ANTIBODY SANDWICH ELISA was that of Sada et al. (1983). Before the samples could be tested, the method had to be standardized and similar investigations to those for the INHIBITION ELISA were performed. In addition, antibodies raised against M.bovis BCG were conjugated to alkaline phosphatase since no commercial preparation was available. Unfortunately no distinction was recorded between negative and positive test specimens, even on repetition of the entire procedure. Measurement of chloride was done by a fully automated procedure using the BECKMAN ASTRA-8. A total of 149 samples were tested. Of these 10 were tuberculous, 34 were viral, and the remainder were bacterial meningitis. No pattern was established that could differentiate TBM from viral or bacterial meningitis. The results obtained are tabulated in Table III and illustrated in Figures 9, 10, and 11. In summarizing, the use of the INHIBITION ELISA technique for the accurate diagnosis of TBM seems promising. However, its validity in the clinical situation will have to be assessed further and with greater numbers of specimens before it can be adopted as a diagnostic procedure for TBM. OBJECTIVE. To determine 1. The ability and reliability of the INHIBITION ELISA1 technique to detect mycobacterial antigens in pleural, ascitic, and cerebrospinal fluids. 2. The accuracy and reproducibility of the double antibody sandwich ELISA in the detection of mycobacterial antigens in CSF of patients with tuberculous meningitis (TBM). 3. Whether a correlation exists between blood and CSF chloride levels in patients with tuberculous and other forms of meningitis.
An exploration of the learning environment and career intentions: a mixed methods study of paediatric interns at KwaZulu-Natal.
(2018) Naidoo, Kimesh Loganathan.; Van Wyk, Jacqueline Marina.
Background: Globally, there is increased pressure on health professions education to be responsive to inequities in health care. These imperatives are clearly evident in KwaZulu-Natal (KZN) with its high disease burden. Poor doctor to patient ratios here are exacerbated by migration of medical practitioners to urban areas, private practice and developed countries. South Africa’s two–year internship aims at producing primary health care clinicians for the public health system. Gaps in knowledge of internship and intern career intentions, in resource challenged contexts, have translated to the failure by both higher education authorities and national health departments to include the internship period in strategies, to ensure that the inequities in health care are addressed. Aim: This explorative study used a mixed methodology approach to explore the factors that influence perceptions of the learning environment (LE) during internship and their influence on career intentions. Methods: The study used a social constructivist worldview drawing on a sequential explanatory mixed methods design to understand the construct of the LE and its influence on career intentions. Both quantitative and qualitative methods that included surveys using a locally validated version of the Postgraduate Hospital Educational Environment Measure (PHEEM) and focus group discussions were generated. This study was conducted among interns in Paediatrics at four hospital complexes in KwaZulu-Natal in 2015. The Communities of Practice theory and the Social Cognitive Career Theory were drawn on and supplemented by the theory of alienation and engagement to develop a conceptual framework that informed the analyses of the relationship between perceptions of the LE and career intentions. Results/Findings: Perceptions of the LE were found to be influenced by both external (disease burden, workload and resource constraints) and individual related contextual factors (supervisor -intern relationships, mentorship, feedback and demography). These factors acted as alienating influences that curtailed access and restricted participation within communities of practice in internship. A narrow view of the role and scope of interns was reflected in significant differences between interns and their supervisor’s perceptions of the LE and gaps in assessment practices of SA interns compared with international best practices. Poor perceptions of the LE drove interns away from SA’s public health system and from caring for children. There were strong aspirations to specialise and weaker aspirations to enter primary health care amongst the sampled interns. Conclusion: Contextual factors in a resource limited LE impacted on identity and career self-efficacy formation of SA interns who failed to see a future role for themselves in primary health care and child health within the public health system. Expanding on the framework of communities of practice a new model of understanding, of how the interplay of contextual factors in resource challenged contexts affects internship learning and career interest formation, was developed. This new knowledge of context on learning and career interest provides the framework to understand the discordance between national health needs and career aspirations of interns in resource challenged environments. This new understanding provides the theoretical underpinning for changes in policy, practice, curricula content and future research to improve access and create an expansive participatory framework for SA interns. These proposed changes in the SA learning environment has the potential to ensure a sustainable public health system and redress the inequity seen in distorted doctor patient ratios in areas of need.
An anatomical exploration into the variable patterns of the venous vasculature of the human kidney.
(1993) Satyapal, Kapil Sewsaran.; Haffejee, A. A.; Robbs, John Vivian.
In clinical anatomy, the renal venous system is relatively understudied compared to the arterial system. This investigation aims to clarify and update the variable patterns of the renal venous vasculature using cadaveric human (adult and foetal) and Chacma baboon (Papio ursinus) kidneys and to reflect on its clinical application, particularly in surgery and radiology. The study employed gross anatomical dissection and detailed morphometric and statistical analyses on resin cast and plastinated kidneys harvested from 211 adult, 20 foetal and 10 baboon cadavers. Radiological techniques were used to study intrarenal flow, renal veins and collateral pathways and renal vein valves. The gross anatomical description of the renal veins and its relations were confirmed and updated. Additional renal veins were observed much more frequently on the right side (31 %) than previously documented (15.4%). A practical classification system for the renal veins based on the number of primary tributaries, additional renal veins and anomalies is proposed. Detailed morphometric analyses of the various parameters of the renal veins corroborated and augmented previous anatomical studies. Contrary to standard anatomical textbooks, it was noted that the left renal vein is 2.5 times the length of its counterpart and that there are variable levels of entry of the renal veins into the IVC. Justification for the distal segment of the left renal vein to be termed the surgical trunk, and the proximal segment to be the homologue of the right renal vein is presented. Radiological investigations demonstrated a non-segmental and non-lobar intrarenal venous architecture, an absence of renal vein valves and extensive venous collaterals centering on the left renal vein. These collateral channels, present in the foetus, and persisting in the adult, may be operative and of clinical significance in pathological states. No sex differences and no race differences of note were recorded in this study. The Chacma baboon displayed similar intra-renal venous anatomy. The applied clinical anatomy of these findings with particular regard to renal surgery and uro-radiology is emphasised.
Anatomical variations of the frontal sinus outflow tract in the paediatric population in KwaZulu-Natal: a cause of complicated sinusitis with intracranial complications?
(2021) Nandkishore, Tanusha.; Rennie, Carmen Olivia.; Schlemmer, Kurt.
Thesis overview in a PDF.
The antenatal management of the twin fetus from 30 weeks gestation.
(1979) Houlton, M. C. C.; Philpott, R. Hugh.
The antibody response to different measles vaccine strains given by the aerosol and subcutaneous routes to schoolchildren.
(2003) Dilraj, Athmanundh.; Coovadia, Hoosen Mahomed.; Cutts, Felicity T.
Abstract available in PDF.
Anxiety and depressive symptoms amongst caregivers of children with mental illness.
(2016) Ramdhial, Mayuri.; Burns, Jonathan Kenneth.
Abstract not available.
Aortobifemoral bypass for aorto-iliac occlusive disease in the population of KwaZulu-Natal: an in-depth assessment.
(1995) Madiba, Thandinkosi Enos.; Robbs, John Vivian.
Abstract available in PDF.
Aphakic iris-claw (Artisan®/Verisyse) lens implantation in low-income African population.
(2007) Kruse, Carl-Heinz.; Linda, Visser.
Purpose: To test the viability of implanting the Artisan®/VerisyseTM lens in a low-income monocular aphakic African population with insufficient capsular support where contact lens wear is expensive and spectacle correction is not possible, by assessing the postoperative visual functions. To further assess whether adverse effects (e.g.: pigment dispersion with secondary glaucoma, prolonged uveitis) in patients with highly pigmented irises would be as low as with patients in European and American trials. Methods: A prospective, randomised, controlled clinical trial comparing outcomes in two groups of unilateral aphakic patients. The patients in the first group received an Artisan intra-ocular iris-claw lens as a secondary procedure while the second group remained aphakic (the current treatment status quo for public patients in KwaZulu-Natal province in South Africa). Follow-up was done for 1 year. Results: The study was terminated early due to ethical and statistical reasons. Nine treated and five control patients were included. Monocular uncorrected vision was significantly higher in the treatment group (P=0,012) and patient satisfaction was higher (p=0,002). Changes in other variables (intraocular pressure, angle pigmentation, change in cup-to-disc ratio, iris pigment changes and best spectacle corrected vision) were not significantly different between the two groups. Conclusion: The Artisan®/VerisyseTM lens is a feasible option for aphakic African patients with regard to visual outcome, safety and patient satisfaction. This form of refractive correction should be the standard for patients with no capsular support and where other options are too expensive or carry greater risk.
Apoptosis - a comparative study of its role on the trophoblast cell in normotensive and hypertensive placental bed.
(2006) Dorsamy, Enbavani.; Moodley, Jagidesa.; Naicker, Thajasvarie.
Abstract available in PDF.
Application of communication skills in an authentic clinical setting: assessing the communication competency of sixth year medical students during history taking.
(2017) Ntando, Ekanda Alfred.; Van Wyk, Jacqueline Marina.; Matthews, Margaret Glynnis.
The Nelson R. Mandela School of Medicine (NRMSM) launched a new 6 year MBChB programme in 2010. This curriculum includes a clinical communication course which emphasises the patient centred approach in line with the Health Professions Council of South Africa Core Competency Framework for undergraduate students. The Calgary-Cambridge Guide to the Medical Interview was adopted as a method for teaching communication. The 2015 final year medical students constituted the first cohort to have been taught clinical communication skills in this manner in the pre-clinical phase. Aim of the study The study was conducted to investigate the transfer of communication skills taught using the Calgary-Cambridge Method (CCM) in the pre-clinical phase to the clinical setting. This study focused mainly on the process skills of history taking and had the following objectives: 1. to determine whether students used the CCM as taught at medical school. 2. To measure and compare process skills of students in two different phases of MBChB programme. 3. To explore role modelling of the CCM by clinical teachers. 4. To describe challenges encountered by students for or in the application of the CCM. Methods The study was observational, analytical and cross-sectional. The population was the 2015 final year class of medical students (n=198) with exception of 13 students who were trained in a different method in Cuba. The study was conducted in the Internal Medicine wards of four teaching hospitals affiliated to the medical school in the Durban functional region. Results The population of the study comprised 185 eligible students; 107 participants were enrolled, and the final number of participants was 105 (57%). In response to the four objectives of the study, the findings revealed that most students used the CCM in a modified manner. There was a marked decline in some of the process skills of history taking, specifically in subcategories such as providing structure and eliciting the patients’ perspective. Educators in Internal Medicine wards did not model the use of the CCM and discouraged its application due to workload and time constraints. Challenges encountered by students included negative attitudes of clinical trainers towards the CCM and language barriers, as most patients spoke in isiZulu. Discussion Results demonstrated that the clinical communication teaching and learning of the pre-clinical phase had some positive impact on application, even if students only used the Calgary Cambridge Method in a modified manner in the clinical phase. The environment of clinical training influenced the transfer, development and the progress of the communication skills learnt in the pre-clinical phase. The decline of process skills in providing structure and eliciting the patient’s perspective was associated with negative attitudes and the poor role modelling of educators. This observation is contradictory to the increase shown in the process skills of building relationship and initiating the session, which probably reflects students’ accumulated experience in the wards. Students encountered challenges associated with language barriers and with different approaches used for personal and organizational reasons. Conclusion With regard to students’ attainment of the HPCSA core competency of communication, and despite communication teaching in the pre-clinical phase and its application in the disciplines of Family Medicine and Rural Health, communication was not equally valued or reinforced in all disciplines involved in undergraduate teaching on the MBChB programme. Key words: communication skills, transfer, application, clinical setting
Arthroscopic arthrolysis after total knee arthroplasty.
(2020) Desai, Yussuf Mohammed.; Ryan, Paul Vincent.
Arthrofibrosis is an uncommon reason for poor outcomes after Total Knee Arthroplasty (TKA). There is paucity of evidence for the management of this complication. The aim of this study was to assess the longitudinal changes in the range of motion pre- and post-TKA, pre- and post-arthroscopy and at final follow up in patients who had arthroscopic arthrolysis for arthrofibrosis after TKA. Patients were identified from a prospectively collected database who had an arthroscopic arthrolysis for decreased range of movement following TKA which was not present immediately post-TKA and not attributable to any other cause. Patients underwent a systematic arthrolysis, manipulation under anaesthesia (MUA) and intensive physical therapy thereafter. The main outcome measures were range of motion (ROM) recorded at different intervals and overall patient satisfaction. A total of 16 patients were included for analysis. Patients were followed-up for a mean of 20 months (range 1 - 48 months) after the arthroscopic arthrolysis and MUA. The median prearthroscopic ROM was 28° (IQR 18°- 40°) and following arthroscopy was found to be 90° (IQR 88°- 100°). These gains however decreased with time to a median of 65° (IQR 38°- 88°) at final follow up. The mean improvement in the range of motion from the pre-arthroscopy value to that v found at final follow-up was 32 (95% CI = 19.0 - 45.3, p < 0.001). Three quarters of patients were satisfied with the outcome of the procedure. One patient developed a complication in the form of an iatrogenic patella fracture. Where other causes for knee loss of movement and pain have been ruled out, and arthrofibrosis is likely to be the sole cause of knee stiffness, arthroscopic debridement may be of benefit to improve ROM even if performed more than one year after the arthroplasty.

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