Masters Degrees (Clinical Medicine)

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Observed birth prevalence of structural congenital disorders among live births at a regional facility in South Africa.
(2021) Saib, Muhammad Zubayr.; Dhada, Barnesh Lalloo.
Congenital disorders (CDs) are a global health issue and an important contributor to childhood mortality and morbidity. In South Africa (SA), the size and nature of the problem is unknown because reporting of CDs has been unreliable. Inaccurate assessment and under-reporting have led to an underestimate of the contribution of CDs to the burden of disease. As SA undergoes a positive epidemiological transition, the CD burden will be expected to increase. This study aimed to fill the void in empiric CD data in the country. The objectives were to measure the birth prevalence of CDs of live births and describe the pattern of CDs at a regional hospital in KwaZulu Natal Province in 2018 using the Birth Defects Notification Tool (BDNT) developed by the National Department of Health. The collected data was then compared with existing published data in SA and country-specific modelled estimates. A retrospective, observational, descriptive review of CDs diagnosed within the neonatal service at Edendale Hospital (EDH) was conducted in 2018. All in-house live births diagnosed with CDs were included in the study. Stillbirths and neonates with identified CDs born elsewhere and referred to EDH after birth were excluded from the study. Data were obtained from the birth registry, neonatal admission register, and the individual BDNT. A total of 117 neonates were diagnosed and notified with a CD from the 7516 live births examined at EDH. The total birth prevalence for the study period was 15.57 per l000 live births, which equates to 1 in every 64 live births affected by a CD at EDH in 2018. The most affected systems were the musculoskeletal (31.6%) and circulatory systems (18.8%). Birth prevalence rates of key CDs were comparable to previously published SA data and are in line with current modelled estimates. This study responds to the paucity of birth prevalence data on CDs in SA and serves as a starting point for comparison locally and with other national and international data. It offers additional evidence on the health burden represented by CDs in SA and the need to address the surveillance, care and prevention of these conditions as a healthcare priority.
Genotyping of gardnerella vaginalis from pregnant women in Durban by amplified ribosomal DNA restriction analysis.
(2020) Pillay, Kayla.; Abbai, Nathlee Samantha.; Naicker, Meleshni.
Gardnerella vaginalis is one of the most frequently isolated microorganisms associated with bacterial vaginosis (BV). However, limited information concerning the genetic diversity of G. vaginalis isolated from BV positive and intermediate cases, has been documented. This study investigated the diversity of G. vaginalis in pregnant women, a currently under-researched area in South Africa. The study population included pregnant women recruited from a public hospital in Durban, South Africa. The women provided 2 self-collected vaginal swabs for microscopy and the genotyping assays. The BV status of the women was determined using Nugent scoring. A total sample of n=137 specimens was selected for analysis. The 16S ribosomal ribonucleic acid (rRNA) gene of G. vaginalis was used for the genotyping assays. The 16S rRNA gene polymerase chain reaction products were digested with TaqI to generate genotyping profiles and genotypic subtypes were determined by correlating BamHI and HindIII digestion profiles. Phylogenetic analysis was performed on the 16S rRNA gene sequences. The data analysis was performed in R Statistical Computing software, version 3.6.2. Restriction digestion with TaqI revealed the presence of two different genotypes i.e. GT1 and GT2. Within both BV positive and intermediate sample groups, GT1 was the most prevalent genotype (54%). Overall, 4 subtypes (1, 2B, 2AB and C) were shown to be present in the sample population. The most prevalent subtype was 2B (15/37, 40.5%), followed by subtypes 1 (11/37, 29.7%), 2C (4/37, 10.8%) and 2AB (4/37, 10.8%). The phylogenetic analysis of the 16S rRNA genes showed the presence of 5 clusters. The tree displayed clusters which contained groups of specimens from the same BV group with different genotypes and subtypes present. There were also clusters which contained specimens from across the BV groups carrying the same genotype and subtype. Finally, the study did not find a significant association (p>0.05) between reported symptoms of discharge and genotype harboured. This study provides the first report on the diversity of G. vaginalis in South African pregnant women. Diversity assessments of G. vaginalis with respect to genotypes and subtypes may aid in a greater understanding on the pathogenesis of this microorganism.
Clinical profile of rheumatoid arthritis associated interstitial lung disease at a tertiary hospital in KwaZulu-Natal, South Africa: a retrospective 5 year review.
(2020) Ghammo, Hosam Mohamed.; Nyamande, Kennedy.; Mitha, Mohamed.
Background: The prevalence, demographic distribution and treatment outcomes in Rheumatoid Arthritis associated interstitial lung disease (RA-ILD) has not been well described in Southern Africa. There is very limited data. Objective: The aim of the study was to determine the demographic profile of the disease as well as treatments used and their outcomes at Inkosi Albert Luthuli Central Hospital (IALCH), a tertiary hospital in Durban, South Africa. Methods. This was a retrospective electronic chart review of 61 patients who were diagnosed with RA-ILD between January 2010 and December 2015 at IALCH pulmonology clinic. Demographic and clinical data, symptom presentation, pulmonary function testing (PFT), high resolution computerised tomography (HRCT) features and treatment modalities were analysed as well as outcome based on symptoms, PFT and HRCT. Results. There were 61 subjects, the majority being female (90.2%). Approximately 86.9% were 50 years and older. The majority of the subjects were Indian 72.1% (n=44), followed by Black Africans 23% (n=14) and then Whites 4.9% (n=3). All patients were HIV negative. Patients treated with a combination of prednisone and azathioprine had a decline in FVC (mean 0.41, p value 0.04). There was no improvements or deterioration in patients treated with either drug alone. Conclusion. The management of RA-ILD is still a challenge. The combination of azathioprine and prednisone did not arrest disease progression in our study while either agent alone did not improve clinical and lung function parameters. Large randomised control studies are needed in Sub-Saharan Africa.
The effect of lifestyle modification on depression amongst myocardial infarction patients after revascularization.
(2020) Arzet, Aminu.; Naidoo, Datshana Prakesh.
Background: Patients with Coronary Artery Disease (CAD) are prone to depression, and its presence is associated with poor adverse cardiac outcomes. Although lifestyle modification (LSM) has been shown to be beneficial in managing depression in patients with CAD, it is not known whether the mode of cardiac intervention (coronary artery bypass graft surgery {CABG} vs percutaneous coronary intervention {PCI}) influences the outcome Objectives: We examined the prevalence of depression and depression traits amongst myocardial infarction (MI) patients after revascularisation and compared the effect of LSM on incidence of depression and depression traits in patients who underwent CABG versus PCI Method: We evaluated the risk factor profile, depression characteristics and lifestyle changes of 100 consecutive participants undergoing coronary revascularization over a 15-month period (Jan 2017 to March 2018). The Beck Depression Inventory II (BDI-II) was used to assess depression and the Goldin leisure-time exercise (GLTE) questionnaire to assess physical activity (PA). Results: 100 patients were recruited (mean age males 60.73±4.52 yr and females 60.29±3.64 yr), with 5 dropouts leaving 95 patients for complete analysis. Most of the patients were low-income earners 53 (53.0%) and 21.0% had tertiary level education. The majority had multiple CAD risk factors and comorbidities (79.0%). Prior to the LSM program 51 patients (51.0%) had depression and depression traits {CABG 34 (66.7%) vs PCI 17 (33.3%), p = 0.047)}. After LSM the overall prevalence of depression and depression traits fell to 33 patients (34.7%), {PCI 8 (23.0%) vs CABG 25 patients (72.0%), p = 0.001}. The mean depression scores also fell from 21.11±7.75 to 14.98±9.61 (p = 0.002). At baseline PCI patients were more physically active compared to CABG {3 (60.0%) vs 2 patients (40.0%), P = 0.715} respectively. After the LSM, more PCI patients undertook PA compared to CABG {24 (60.0%) vs 14 patients (35.0%) respectively, p = 0.012}. The PA score was also higher amongst the PCI group compared to CABG {14.16±9.73 vs 9.40±10.94 respectively, p = 0.024}. In fully compliant subjects the benefit derived was similar regardless of the mode of intervention {OR 1.10, CI 0.98-4.23,P = 0.191}. Using multivariate analysis the main predictors of depression and depression traits were female gender (OR 3.29, 95% CI 1.51-11.03, p = 0.008), CABG (OR 1.86, 95% CI 1.68-5.77, p = 0.003), heart failure (OR 2.65, 95% CI 5.87-13.62, p = 0.000), Kidney failure (OR 1.41, 95% CI 1.30-5.23, P = 0.041), atrial fibrillation (OR 1.60, 95% CI 1.40-4.77, P = 0.023), low PA (OR 1.97, 95%, CI 11.23- 33.20, P = 0.000), previous history of depression (OR 8.99,95% CI 1.90-7.89, p = 0.002) and low income (OR 2.21, 95% CI 1.40-2.85, p = 0.000). Conclusions: Depression and depression traits are common among subjects undergoing coronary revascularization, more so amongst CABG compared to PCI participants. Lifestyle modification reduces the prevalence of depression and depression traits, with fully compliant CABG vs PCI groups deriving nearly the same benefits from the LSM regime. No significant reduction in depression and depression was recorded amongst LSM partlycompliant patients. This study suggests that failure to implement lifestyle changes and engage in PA are major barriers to managing depression after coronary revascularisation.
Diagnostic evaluation of the BD Affirm™ VPIII assay as a point-of-care test for the diagnosis of bacterial vaginosis, trichomoniasis and candidiasis in a population of pregnant women from South Africa.
(2020) Dessai, Fazana.; Sebitloane, Hannah Motshedisi.; Abbai, Nathlee Samantha.
OBJECTIVE: Untreated Sexually Transmitted Infections (STIs) and Bacterial vaginosis (BV) pose a serious health risk to mother and child. Limited data exist on the use of the BD Affirm VPIII assay as a point-of-care test. This study compared the BD Affirm VPIII assay to the BD MaxTM Vaginal assay (reference test) for the detection of BV, Trichomonas vaginalis, and Candida spp. The prevalence of single and co-infections are also reported here. METHODS: The study enrolled 273 pregnant women from King Edward VIII hospital in Durban. Socio-demographic, sexual behaviour and clinical data were collected from all consenting women. The women provided two self-collected vaginal swabs for testing. The swabs were tested using the BD Affirm VPIII assay and the BD MaxTM Vaginal assay. The prevalence of BV, trichomoniasis and candidiasis was calculated as the percentage of women who tested positive for BV, T.vaginalis and Candida infection and 95% confidence intervals (CIs) were calculated for these percentages using the formulas for calculating CIs for proportions. The number of co-infections was calculated using chi-square analysis. The diagnostic accuracy of the BD AffirmTM VPIII assay compared to the BD Max assay was assessed through the calculation of sensitivity, specificity, Negative Predictive Value (NPV) and Positive Predictive Value (PPV) and their respective 95% confidence intervals. RESULTS: In this study population, 85% of the participants were unmarried; however, 84% reported having a regular partner, and 96.3% did not use a condom regularly. The prevalence of Bacterial Vaginosis, Candidiasis and Trichomoniasis was 49.4%, 57.2% and 10.3%, respectively. A large proportion of women (78.8%) in this study did not have a discharge despite being positive for one or more pathogens. The BD AffirmTM VPIII assay showed a moderate sensitivity (79.8%) and specificity (80.3%) for diagnosing BV in all participants. The assay had an excellent specificity for Candida and T. vaginalis of 97.4% and 100.0%; respectively, however, it exhibited poor sensitivities of 52.9% and 42.4%, respectively. CONCLUSION: Our findings show a higher prevalence of Bacterial Vaginosis in antenatal attendees than previously reported, while the prevalence of Candidiasis and Trichomoniasis was in keeping with previous reports. The high number of asymptomatic infections detected is of concern and indicates the need for the re-evaluation of the syndromic management approach, especially in the antenatal population. The BD AffirmTM VPIII assay was found to be unsuitable as a screening test for vaginal infections in pregnancy. The assay performed better as a confirmatory test and may serve useful if used in conjunction with other clinical parameters such as vaginal pH.
Morbidity and mortality in the modern antiretroviral treatment era in a tertiary teaching hospital in Durban, South Africa.
(2020) Riziki, Manimani Ghislain.; Magula, Nombulelo Princess.
Background: Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is recognized as the chief cause of morbidity and mortality in Sub-Saharan Africa. South Africa is known to bear the highest number of people living with HIV globally, while KwaZulu-Natal is the worst affected province in this country. Aim: To identify the determinant of morbidity and mortality in the modern antiretroviral therapy (ART) era in South Africa. Study design: A cross-sectional study. To achieve the objective, a mixed data acquisition method was applied using qualitative and quantitative data. These included a systematic review and a retrospective chart review. Data collection and analysis: For the systematic review, relevant studies were searched from the following databases: Google Scholar, PubMed, CINAHL. Two review authors independently screened titles abstracts and full-text articles in duplicate, extract data and assess the bias. Discrepancies were resolved by discussion or arbitration of a third review author. The study used the Preferred Reporting Item of Systematic Review (PRISMA 2015) guideline. This study used R software version 3.6.2. to synthesis the data, graphic displays were used to visually compare the prevalence of comorbidities across the study region. With the retrospective chart review, we conducted a study of all patients admitted at King Edward medical wards, Durban, South Africa from January to December 2018. Data were obtained from medical records, including demographic profile, clinical attributes and laboratory records. Data were analysed using R software version 3.6.2. In addition, the association between the covariates was tested either with the Chi-Square test, Kruskal Wallis or Wilcoxon rank-sum test depending on the type of variables. A p-value < 0.05 was used as a benchmark for determining the level of statistical significance Results: For the systematic review a total of 409 articles were obtained from the database search, finally12 articles were eligible for data extraction. All 12 studies included were published between 2008 and 2018 in English and they were conducted in Sub-Saharan Africa. Among them, three were conducted in Nigeria, two were conducted in Uganda, three were conducted in South Africa, one in Gabon, one in Ethiopia, one in Ghana, and one in Burkina Faso. In most of the included studies, tuberculosis was the first commonest causes of hospitalization accounted for 40.7% followed by anaemia with 34.2% and toxoplasmosis with 29.3%. It was as well the first cause of death accounted for 44.3% followed by anaemia with 30.2% and toxoplasmosis 27.5%. Contrary one study reported anaemia as the first causes of hospitalization and two studies reported each respectively wasting syndrome and meningitis as the first causes of death. With regards to the chart review, a total of 577 (50.6%) females and 564 (49.4%) males were included in the study. The mean age of all the participants was 39.6±12.2, 506 (44.3%) patients had CD4 less than 200 cells /mm3 and 273 (23.9%) had VL ˃ 1000 copies/ml. Male gender [OR 1.39(1.07-1.8) p=0.015], age [OR1.02(1.01-1.03) p˂ 0.001], CD4 <200 cells/mm3 [OR 2.14(1.37-3.45) p=0.001], VL ˃ 1000 copies/ml [ OR 1.93(1.08-3.63) p=0.032] were associated with mortality among HIV infected patients admitted in the cohort. Tuberculosis (TB) was the most common diagnosis on admission and the leading cause of death which accounted for 257 (22.5%) and 73 (24.3%) respectively, followed by kidney disease with 83(7.2%) for admission and with 38(12.6) for death. Only 70% of patients had been reported to be on ART. Age, men gender, CD4 cell and viral load were associated with mortality. Association between CD4 cell count and viral load was found. Conclusion: Despite the recent improvement of modern antiretroviral treatment, HIV/AIDS still causes hospitalization and death among HIV infected patients. For the systematic review as well as for the chart review, tuberculosis was the commonest cause of hospitalization and death in Sub-Saharan Africa and South Africa, but it was always followed by other opportunistic infection and other non-AIDS related conditions. There is a need to prevent opportunistic infection (especially tuberculosis) and to tackle the non-communicable disease related to HIV infection. Also, a need to start antiretroviral treatment early for patients living with HIV. Keywords: Morbidity, Mortality, Antiretroviral therapy, Sub-Saharan Africa, South Africa.
Resistance to β-lactam and fluoroqinolone antibiotics in enterobacteriaceae from chicken : an observational study in Maputo, Mozambique.
(2016) Faife, Sara Lino.; Essack, Sabiha Yusuf.; Sundsfjord, Arnfinn Staale.; Zimba, Tomas Francisco.
Extended-spectrum β-lactamase (ESBL) and/or plasmid-mediated AmpC (pAmpC)-producing Enterobacteriaceae with co-resistance to fluoroquinolones are increasingly identified in food-borne pathogens globally. This study investigated ESBL- and pAmpC-mediated β-lactam resistance as well as plasmid-mediated fluoroquinolone resistance in 198 samples taken from 99 frozen chickens (99 samples from the liquid thaw and 99 from carcass swabs), Brazil, South Africa and Mozambique each produced 33 chicken. Species identification was undertaken using in-house biochemical tests and antibiotic susceptibility was ascertained by the disc diffusion test following CLSI guidelines. ESBL production was determined using the double-disk synergy test and isolates were subjected to PCR to detect the presence of blaCTX-M, blaSHV, blaTEM, blaCMY, blaMOX, blaFOX, blaDHA, qnrB, qnrD, qnrS and qepA genes. A random selection of CTX-M genes was sequenced. The 198 samples yielded 27 putative ESBL-positive isolates: Citrobacter diversus (1), Citrobacter freundii (3), Enterobacter aglomerans (1), Enterobacter cloacae (1) and Escherichia coli (21). Of the 27 isolates, 19 were from South African chicken, five from Mozambican chicken and three from Brazilian chicken. Resistance to ampicillin was 100,0%, followed by 88.8% to ceftriaxone, 77.8% to trimethoprim-sulphamethoxazole, 74.0% to cefotaxime, 70.4% to ciprofloxacin, 66.6% to ceftazidime, 22.2% to cefoxitin and 7.6% to gentamicin. Multi-drug resistance was evident in 19 (70.4%) isolates, 15 of which were from South Africa. The predominant ESBL gene was blaSHV (85%), followed by blaCTX-M (62.9%) and blaTEM (44.4%) whilst blaMOX (33, 3%) and blaDHA (33.3%) were the most common pAmpC genes. The predominant plasmid-mediated fluoroquinolone-resistance gene was qepA (22.2%). DNA sequencing of the blaCTX-M genes putatively identified differentiation of the E. coli and Citrobacter spp. isolates. There was no strong evidence of clonality, however, South African isolates shared more similarity. qnr and qepA genes were predominantly identified in South African E. coli isolates while CTX-M and SHV genes were prevalent in isolates from diverse origins. The Mozambican population is thus exposed to a reservoir of plasmid-mediated and hence, mobile β-lactam and fluoroquinolone resistance genes from imported, and to a lesser extent, locally-produced chicken. The complexity and diversity of mobile resistance genes combinations and permutations is of concern in the food safety context.blaCTX-M-55/-79/-101/-164, with blaCTX-M-164 being most common. ERIC–PCR profiles allowed the differentiation of the E. coli and Citrobacter spp. isolates. There was no strong evidence of clonality, however, South African isolates shared more similarity. qnr and qepA genes were predominantly identified in South African E. coli isolates while CTX-M and SHV genes were prevalent in isolates from diverse origins. The Mozambican population is thus exposed to a reservoir of plasmid-mediated and hence, mobile β-lactam and fluoroquinolone resistance genes from imported, and to a lesser extent, locally-produced chicken. The complexity and diversity of mobile resistance genes combinations and permutations is of concern in the food safety context.
Retrospective review of prostate biopsies at a regional level hospital.
(2018) Ramloutan, Vishan Mohanlal.; Urry, Ronald James.
No abstract available.
The utility of basic fibroblast growth factor as a non-invasive biomarker of focal segmental glomerulosclerosis in HIV positive and negative children.
(2018) Gumede, Nokwanda Zamahlubi.; Naicker, Thajasvarie.; Bhimma, Rajendra.
Abstract available in pdf.
Cardiovascular disease profile in patients with established rheumatoid arthritis at King Edward VIII Hospital.
(2018) Govender, Preesha.; Paruk, Farhanah.
Rheumatoid arthritis (RA) is one of the most common chronic systemic autoimmune inflammatory diseases, which is associated with an increased mortality rate, attributed to premature cardiovascular disease (CVD). Key drivers of mortality from CVD in RA are fuelled by multiple factors. Rheumatoid arthritis disease profiling, particularly seropositivity, presence of extra-articular disease and high disease activity, confer an increased mortality risk. Traditional CVD risk factors (hypertension, diabetes mellitus, dyslipidaemia, obesity) are influenced by both inflammation inherent to RA, and pharmacodynamics of anti-rheumatic drugs. Notwithstanding the above, the current paradigm shift recognises RA as an independent risk factor for CVD. Similar to the rest of Africa, local data on the prevalence of CVD in RA are limited. With an increase in non-communicable diseases and longevity, the RA burden in South Africa (SA) is expected to increase. Local studies are needed to stratify practice in cardio-protective strategies and improved long term outcomes in RA. This study aims to determine the prevalence of CVD in RA, describe the prevalence of CVD risk factors in RA and describe the relationship between RA disease activity and CVD. A retrospective, chart review of all patients with RA according to the American College of Rheumatology 1987/2010 Classification criteria, attending the arthritis clinic in King Edward VIII hospital, a tertiary public healthcare academic teaching hospital in KwaZulu-Natal, SA, during the period August 2017 to March 2018, was undertaken. Patients younger than 18 years of age, or with RA and any other concomitant connective tissue disease or overlap syndrome were excluded. The study group included 150 patients with RA. The demographic details, duration of the RA disease, traditional CVD risk factors, simplified disease activity index (SDAI) and health assessment questionnaire (HAQ) were documented. In addition, results of electrocardiogram, echocardiogram, haemoglobin, glycated haemoglobin, lipid studies and estimated glomerular filtration rate were recorded. Cardiovascular disease was found in 16% of the total study cohort, with an age, gender and ethnic differential. Coronary artery disease was the most common CVD finding in RA patients. The burden of traditional CVD risk factors in RA is high, with hypertension, diabetes mellitus, dyslipidaemia, physical inactivity and chronic kidney disease of particular concern. No significant correlation was observed between RA disease activity, seropositivity and CVD in RA however, extra-articular disease was more common among patients with CVD. Echocardiographic evidence of subclinical cardiac disease in RA is common. Significant disparity was observed between various CVD risk assessment models at different levels of risk, which cautions a comprehensive CVD risk assessment model that stratifies discriminately is needed in patients with RA. The study provides knowledge of CVD burden and risk in RA patients locally, and serves as a foundation for further research in preventative strategies that offer significant survival benefits. The main limitation in this study is that the study cohort consisted mainly of Black and Indian patients and therefore the findings may not be generalised across all ethnic groups. Furthermore as this was a relatively small study conducted in a single public hospital, which is urban based, conclusions from this study may not be applicable to a rural setting or to all socio-economic classes.
Effect of mitral valve replacement on left ventricular function in subjects with severe rheumatic mitral regurgitation.
(2019) Maharaj, Sharen.; Naidoo, Datshana Prakesh.
Background. The outcome in patients with severe mitral regurgitation (MR) and impaired ejection fraction (EF) is poorly described in the developing world where rheumatic heart disease is endemic. Objective. This study describes the effects of mitral valve replacement (MVR) on left ventricular (LV) function in patients with rheumatic MR. Methods. This is a retrospective analysis of all subjects with severe rheumatic MR undergoing MVR over a 9 year period (2005-2013). Clinical and echocardiographic parameters were recorded pre-operatively, at 2 weeks, 6 weeks to 3 months and 6 months to 2 years following MVR. Results. Of 132 patients included in the study, 66% (n=87) were NYHA class III-IV, 38% (n=50) presented with clinical features of heart failure and 14% (n=19) had atrial fibrillation prior to MVR. The echocardiogram showed increased end systolic diameter (ESD, 39.9±7.2mm), left atrial size (LA, 61.2±12.6mm), and pulmonary artery systolic pressures (PASP, 59.5mmHg, IQR 45-80mmHg). Pre-operatively, 28% (n=37) of subjects had impaired LV function (EF <60%). At 6 months to 2 years following MVR (n=93), 1% of subjects were NYHA III-IV, 1% were in heart failure, and 7.6% had atrial fibrillation. Paired analysis of 83 patients with complete datasets revealed that the EF was >55% in 87% (n=72) pre-operatively, the number of patients with EF >55% dropped to 20% (n=17) at 2 weeks postoperatively (p<0.001, 95% CI 0.02-0.09) and thereafter an EF > 55% was recorded in 60% (n=53) at the 6 months to 2 year follow up (p<0.001, 95% CI 0.1-0.5). After feeding all clinical and echocardiographic variables into a predictive model only the ESD emerged as a significant predictor of postoperative LV dysfunction (EF< 50%) both on uni- and multivariate analysis. Conclusion. Most subjects with severe rheumatic MR who were subjected to surgery had advanced disease with heart failure, indicating that preoperatively, impairment of LV function was a frequent finding. The preoperative ESD was the only predictor of postoperative LV dysfunction. This study calls for careful clinical assessment with regular imaging and early referral for surgery in subjects with severe MR according to established guidelines in order to ensure preservation of ventricular function.
Quantifying the clinical exposure required to adequately prepare surgeons for deployment to conflict zones and to manage mass casualty situations.
(2018) Uchino, Hayaki.; Kong, Victor.; Clarke, Damian Luiz.
Introduction: The ongoing state of global geo-political instability means that it is prudent, even in peaceful countries, to prepare civilian surgeons to manage major military-type trauma. However, preparing a modern surgeon to manage mass shooting or terrorist-related injuries remains an ongoing challenge in many countries. In addition, there is no consensus on the key skill set a modern trauma or military surgeon requires to competently manage major trauma patients. Chapter 1 of this thesis reviews the trauma workload and operative exposure in a major South African trauma center and provides a comparison with contemporary experience from major military conflicts. It would appear that a South African trauma center has a sufficient burden of trauma and academic capability to train both military and civilian trauma surgeons. Based on our trauma workload, a 6-month rotation through a major South African trauma center should be sufficient to provide exposure to almost all major injuries in appropriate volumes to prepare a military surgeon for combat deployment. Chapter 2 of this thesis reviews the state of trauma training and preparedness in Japan and the trauma workload of a major Japanese emergency medical center, and goes on to compare it with that of a major South African trauma center. The intention is to quantify and compare the time required to gain adequate exposure to major trauma at the two respective centers. It is apparent that trauma training in Japan is hampered by a lack of clinical material as well as by systematic factors. South Africa, in contrast, has a huge burden of trauma, sufficient academic infrastructure, and relatively modern facilities, which ensures that surgeons have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries. Chapter 3 of this thesis is a structured survey designed to investigate the role of international trauma clinical electives in South Africa, and to assess the impact these have had on the career of the various foreign surgeons who have undertaken them. The data demonstrated that an international trauma clinical elective in South Africa provides unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. The trainees who completed such an elective all felt that the trauma training with clinical exposure was of inestimable value and substantially enhanced their career. Conclusion: South Africa has a sufficient burden of trauma to train surgeons to manage military and major civilian trauma. In addition, South African major trauma centers have sufficient academic support and capacity to ensure such training is structured and academically sound. In contrast, trauma training in Japan is impeded by a lack of clinical material as well as by systematic factors. Training a trauma-competent military or civilian surgeon in such an environment is difficult. An international trauma clinical elective in South Africa provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. For peaceful countries such as Japan, developing academic exchange programs with countries such as South Africa, which can offer broader trauma experience, is essential and can be mutually beneficial.
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.
The role of a contrast study in the investigation of Paediatric Gastroesophageal Reflux disease.
(2018) Sewlall, Janice.; Wiersma, Rinus.
Background: Gastroesophageal reflux (GER) is a common finding in the pediatric population. This can either be physiological re flux or established disease that may require surgical intervention. There is currently no consensus on a gold standard in the diagnosis of gastroesophageal reflux disease (GERD). The purpose of this article is to describe the role of contrast radiography in this process, looking in particular at the subset of neurologically impaired (NI) children. Methods: A retrospective chart review of children admitted for the work-up of GER or for gastronomy insertion, to the Department of Paediatric Surgery at Inkosi Albert Luthuli Central Hospital (IALCH) from January 2014-December 2015. Results: 42 patients (25 male, 17 female) were admitted during this period. 27(64%) were neurologically impaired. All patients had a contrast study performed. Twenty (48%) contrast studies showed GER. Twenty-two (52%) studies were negative for GER and these children subsequently had oesophageal pH monitoring studies performed. Twelve (55%) pH monitoring studies were positive for GER. Ten (45%) pH studies were negative for GER. The sensitivity of a contrast study to show GER was 62.5%. Anatomical anomalies diagnosed on contrast radiography were hiatal hernias (3), oesophageal strictures (2), situs inversus (1) and pylorospasm (1). Conclusions: Contrast radiography has a low sensitivity in diagnosing GER and adjuvant studies are sometimes necessary. However, it is useful in recognising anatomical anomalies that either predispose to GER or is a consequence of GER. It is a particularly helpful diagnostic tool in the management of neurologically impaired children who require feeding gastrostomy tubes.
Risk factor profile of female patients presenting with acute myocardial infarction: a South African perspective.
(2017) Govender, Jaqueline Cindy.; Ranjith, Naresh.
The study was a retrospective single center study conducted at RK Khan hospital in Durban. The primary aim was to look at the incidence of acute myocardial infarction (AMI) in the female population in our setting with particular interest in the cardiovascular risk profile of female patients presenting with AMI. Data was extracted from a computerized database for the duration of the study period, which was from 2003 to 2016. Patient anonymity was maintained. All adult female patients that presented to the study center during the study period, with a diagnosis of AMI, based on the European and American Society of Cardiology guidelines, were included in the study. Females with unstable angina were excluded. The cardiovascular disease (CVD) risk factor profile was based on the Framingham risk profile for CVD and included the following: diabetes mellitus (DM), hypertension (HPT), cigarette smoking, dyslipidemia, obesity, a previous history of coronary artery disease and positive family histories of DM, HPT and coronary artery disease. The study population was broadly categorized into 2 age groups, namely <65 years of age and >65 years. Both groups were analyzed identically in terms of their age, clinical presentation, CVD risk factors, initial electrocardiogram, medical therapies and whether or not they were referred for an angiogram and/or coronary artery bypass surgery. We also divided the study population into those with ST elevation myocardial infarction (STEMI) versus Non ST elevation myocardial infarction. In the STEMI group we assessed the use of thrombolytic therapy or not. Finally we looked at the presence of major adverse cardiac events (MACE) in each of the age groups. MACE was defined as follows: Arrhythmias, cardiac failure, cardiogenic shock, complete heart block, recurrence of angina or myocardial infarction and death. In addition to the primary study aim, by categorizing patients into 2 age groups we could determine if there was a difference in CVD risk factor profile and the presence of MACE between the younger and older age groups. Finally, by comparing the outcome of our study to studies done in male counterparts we were able to see if there was a difference in CVD risk profile between male and female patients, which in fact there was not. So basically in the presence of the traditional risk factors for coronary artery disease (CAD), males and females can be considered at equal risk of developing acute myocardial infarction and females are not protected by the cardioprotective effects of oestrogen hormone in the pre-menopausal age group as was previously thought. Females are an understudied population when it comes to coronary artery disease and very few studies have been conducted on females with cardiac disease. We believe that this study offers some very valuable information with regards to cardiac disease in females and that treatment strategies should be targeted to include optimizing risk factor control in at-risk females, so that the burden of disease can be reduced in this population.
Prevalence of low serum testosterone levels among men with type 2 diabetes mellitus attending two outpatient diabetes clinics in Durban, South Africa.
(2017) Paruk, Imran Mahomed.; Motala, Ayesha Ahmed.; Pirie, Fraser James.
Background: Studies showing a high prevalence of low serum testosterone in men with type 2 diabetes mellitus (T2DM) are well documented but evidence from sub-Saharan Africa is scanty. Aim: To determine the prevalence and associated risk factors of low serum testosterone and the prevalence of androgen deficiency symptoms in South African men with T2DM. Methods: A cross-sectional observational study was performed among men with T2DM attending two outpatient adult diabetes clinics in KwaZulu-Natal. Androgen deficiency symptoms were assessed using the Ageing Male’s Symptom Scale (AMS) questionnaire and direct enquiry. Serum total testosterone (TT), sex-hormone binding globulin (SHBG), luteinising hormone (LH), HbA1c, fructosamine, serum lipids were measured and free-testosterone (FT) was calculated. TT, SHBG and FT levels were measured in control subjects with no history of diabetes. Results: The study included 148 men with T2DM (Study Group) and 50 control subjects (Control Group). The mean age of the control group was 43.9 ± 10.7 years and the mean BMI was 27.11 ± 4.2 kg/m2. In the study group, the majority were African (Black) (58.7%); Indians (39.2%) and Whites (2.1%) constituted the remainder. Mean age was 57.5 ± 11.2 years; mean duration of diabetes 11.4 ± 8.9 years; mean HbA1c was 8.6 ± 1.9%. Metabolic syndrome was found in 86.4% (n:127) of the Study group. Mean TT, SHBG, FT and median LH (IQR) in the Study group were within normal range (14.5 ± 5.8 nmol/l, 40.7 ± 20.3 nmol/l, 265.9 ± 90.4 pmol/l and 5.3 [3.8-7.3] IU/l, respectively). However, mean serum TT and FT was lower in the Study group than Control subjects (14.5 ± 5.8 vs. 18.8 ± 7.2 nmol/l, p <0.001 and 265.9 ± 90.4 vs. 351.7 ± 127.3 pmol/l, p<0.001). The prevalence of LSTT and LSFT was 35.8% and 16.2%, respectively. Prevalence of LSFT increased with age and higher body mass index (BMI) categories with the highest rate noted in >40 kg/m2 BMI category (50%). In multivariate analysis, LSFT was significantly associated with age [OR 1.05 (95% CI 1.02-1.218), p=0.043] and waist circumference (WC) [OR 1.033 (95% CI 0.999- 1.068), p=0.059]. LSTT was associated with BMI only [OR 1.138 (95%CI 1.063- 1.218), p<0.0001]. TT correlated inversely with BMI, WC and the number of metabolic syndrome criteria. FT correlated inversely with BMI, WC and WHR. For both FT and TT, no significant correlation was observed with HbA1c. The prevalence of androgen deficiency symptoms using AMS score was 74.5%. The prevalence of any androgen deficiency symptom on direct enquiry was 68.9%. The AMS score correlated poorly with LSTT or LSFT and was not superior to direct enquiry. Conclusion: In this group of predominantly African and Indian men with T2DM from KwaZulu-Natal, there was a high prevalence of LSTT and LSFT. Serum TT and FT was lower in men with T2DM compared to control subjects. Waist circumference was a significant risk factor associated with LSFT while LSTT was associated with higher BMI and older age. There was a high prevalence of androgen deficiency symptoms using both the AMS score and on direct enquiry. The AMS score was a poor predictor of low testosterone and was not superior to direct enquiry. More research is required locally and from other sub-Saharan African countries before routine screening can be recommended.
Prevalence and outcome of cryptococcal meningitis among HIV infected patients admitted to a tertiary level facility in an HIV endemic setting in art era.
(2018) Gasem-Agha, Najua.; Magula, Nombulelo Princess.; Naidoo, K.
Background: Cryptococcal meningitis (CM) is a common AIDS (acquired immunodeficiency syndrome) - defining illness that contributes to morbidity and mortality among HIV-infected adults in South Africa (SA). Methods: We conducted a retrospective study among HIV infected patients aged ≥13 years, admitted to medical wards to better understand factors that contribute to ongoing high mortality among patients presenting with cryptococcal meningitis. Results: There were 322 lumbar punctures (LP) received from medical wards, from patients presenting with features suggestive of meningitis. A total of 44 CSF samples were deemed abnormal.26 patients had confirmed cryptococcal meningitis. Among those patients, 51.8% (14/27) were female and 48.2% (13/27) were male. No further clinical data available for 3/27 patients due to missing charts,1/27 was HIV uninfected therefore excluded from the study. Headache was the most common 91.3% (21/23) presenting feature, with overall mean duration of symptoms of 2 weeks (range: 1 -3 weeks). On admission 87% (20/23) were known HIV positive, with 13.0% (3/23) confirmed HIV positive during admission. Mean length of stay was 18 days IQR (1-15 day). Lumbar puncture (LP) was done to 95.6% (22/23) and therapeutic LPs were done only in 31.8% (7/22). Renal impairment developed in 39 % (9/23), 2/23 (8.7%) patients developed hydrocephalus, 26.1% (6/23) died, 30.4% (7/23) required further care, while 43.4% (10/23) were discharged. XXII Conclusion: Improving medical management through more effective treatment and prevention services for cryptococcal disease is required.
Genetic diversity of Gardnerella vaginalis in pregnant women diagnosed with intermediate and positive bacterial vaginosis.
(2019) Nzimande, Silondiwe Philiswa.; Abbai, Nathlee Samantha.
Bacterial vaginosis (BV) is the main cause of abnormal vaginal discharge in women of reproductive age. Gardnerella vaginalis, has been detected in almost all women with BV. However, there is limited information on the genetic diversity of G. vaginalis isolated from BV intermediate and positive cases. In this study we investigated the genetic diversity of G. vaginalis strains from South African pregnant women. Vaginal swabs were characterized by the Nugent method. A total of n= 87 samples were included in the genetic analysis, (n=50 BV positive) and (n=37 BV intermediate). The presence of G. vaginalis was detected by PCR using bacterium specific 16S rRNA primers. All PCR positive amplicons were sequenced by the Sanger method and the edited sequence data was used for the phylogenetic analysis using the PHYLIP software. The sialidase A gene was amplified by PCR using specific primers and the copy numbers of sialidase A gene was quantified by droplet digital PCR. To assess the diversity of the sialidase A gene, Sanger sequencing was performed. The 16S rRNA gene from G. vaginalis was amplified in all BV positive and BV intermediate samples. All PCR amplicons were successfully sequenced and the nucleotide BLAST results revealed 100% identify to G. vaginalis. The phylogenetic analysis revealed that there is no diversity in G. vaginalis present in BV positive and intermediate cases. The phylogenetic tree of sialidase A sequences from intermediate and positive BV cases revealed two major clades which showed differences related to sialidase A copy number. Quantification of sialidase A showed that the average number of copies per cell was much higher in the BV positive group compared to the intermediate group. Some of the intermediate cases showed high copy numbers for the virulence gene and clustered with the BV positive cases. In the present study the 16S rRNA sequences of the G. vaginalis from BV intermediate and positive women showed that there is no genetic diversity in G. vaginalis detected in BV positive and intermediate samples. The phylogenetic tree of sialidase A gene sequences of intermediate and positive BV revealed two major clades which showed differences related to sialidase A copy number. This data was previously lacking in our setting, especially in a pregnant population. We further demonstrate for the first time that the genetic information present within the sialidase A gene has a direct influence on BV status.
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
A cross-sectional descriptive study of pre-hospital care providers’ training, knowledge and skills in austere environments emergency medicine in South Africa: a framework for a consensus statement for Wilderness Emergency Medicine.
(2017) Matthew, Jaybalan Allan.; Maharaj, Roshen.; Clarke, Damian Luiz.
There is a lack of research into the resource capabilities and capacity for wilderness emergency medicine practice in South Africa (SA). This is despite SA having vast expanses of populated austere geography that remains difficult to access by conventional health care systems and the country increasingly becoming an attractive ecotourist destination. With increasing needs for skilled health care personnel to deal with medical emergencies in this environment, it is first necessary to determine the extent of the current resources present within SA. This research looked at the human resource potential to deal with medical emergencies in the wilderness emergency environment in SA. Chapter one considers the conceptual and contextual framework of this research in light of the above and a review of the available literature. Chapter two presents research from a study that determined the self-reported extent of training, knowledge and skills that capacitated Emergency Care Practitioners (ECP) registered with the Health Professions Council of South Africa (HPCSA) when operating in the wilderness environment and when dealing with medical emergencies. Chapter three examines data gained from a survey conducted among emergency medicine specialists regarding the competency in knowledge, training and skills that are ideally required in the practice of wilderness emergency medicine (WEM). Chapter four compares the self-reported knowledge, training and skills of ECPs in the wilderness emergency environment, with what is suggested by emergency medicine specialists as the expected level of knowledge, training and skills for practice in this field. Chapter five presents a published editorial that highlights the potential value of this specialised WEM practice in resource-limited countries. This editorial suggests that proper wilderness emergency medicine training, knowledge and skills could perhaps be an alternative solution for frugal innovation for resource-limited pre-hospital and inhospital practice. There is a need for further training and skills uptake in WEM. Additionally, a local framework for a consensus statement on the practice of WEM needs to be established.

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