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Open Access
A support framework to facilitate social learning and integration skills of first-year undergraduate medical students
(South African Medical Association, 2024/07/31) Tlalajoe-Mokhatla, N.; van der Merwe, L. J.; Jama, M. P.
𝗕𝗮𝗰𝗸𝗴𝗿𝗼𝘂𝗻𝗱. Limited research exists on medical students’ coping and adjustment skills, especially in the South African context. Stakeholders planning medical curricula need to be aware of emotional and communication skills that allow students to cope and adjust to stress associated with transitioning to medical studies. 𝗢𝗯𝗷𝗲𝗰𝘁𝗶𝘃𝗲. To design a support framework to facilitate first-year undergraduate medical students’ social learning and integration skills. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀. This descriptive qualitative case study used multiple data collection methods, nominal group meetings and Delphi questionnaires to explore and understand undergraduate medical students’ challenges with social learning and integration factors. These insights were then used to develop the support framework. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀. The support framework articulates levels of engagement and actions required to address social learning and integrated factors, namely under- preparedness, peer support, confidence, self-management, alienation and academic advice. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻. Implementing the proposed support framework on social learning and integration could facilitate the successful transition of first-year undergraduate medical students from high school to university. This framework aids students in dealing with social learning and integrated factors, such as under-preparedness, peer support, confidence, self-management and alienation as well as academic advice using contextualised and appropriate skills and tools.
Open Access
Accuracy of iodine-131 activity quantification and dosimetry for three-dimensional patient-specific models
(University of the Free State, 2019-03) Ejeh, John Enyi; Van Staden, J. A.; Du Raan, H.
Iodine-131 (131I) therapy of thyroid related and other diseases is limited by critical organ toxicity. Therefore, accurate activity quantification and dose calculation are important to optimise dose to tumours while limiting dose to critical organs. The aim of this study was to evaluate the accuracy of 131I activity quantification and dosimetry for three-dimensional (3-D) patient-specific models. Retrospective patient Computed Tomography (CT) data were segmented to create clinically realistic patient 3-D voxel-based models. These were used to simulate Single Photon Emission Computed Tomography (SPECT) data with a Monte Carlo (MC) simulation software, which was validated against physical measurements. The simulated SPECT data were reconstructed using an ordered-subsets expectation maximization (OS-EM) algorithm which includes scatter correction, CT-based attenuation correction, and 3-D collimator-detector response compensation. Predetermined recovery coefficients were used to compensate for partial volume effects. Image counts were converted to activity by using a predetermined calibration factor. The patients’ reconstructed activity maps and density maps were used to perform 3-D dosimetry with the MC program, LundADose. LundADose calculated mean tumour and organ absorbed doses were compared with OLINDA/EXM calculated mean absorbed doses using statistical analysis. Validation of the simulation software resulted in a percentage difference of -6.50 % between the measured and simulated extrinsic energy resolution at the 131I peak energy of 364 keV and - 18.57 % error for the measured and simulated intrinsic energy resolution. The measured and simulated FWHM and FWTM of the camera for system spatial resolution had percentage differences of -7.41% and -7.38 % and an error of -1.50 % and -2.6 % for system sensitivity and collimator septal penetration fraction. SPECT activity quantification was evaluated by comparing the true tumour activities defined for the patient models with the quantified activities obtained from the models’ reconstructed SPECT images. The quantification error for the studied patient models was < 9.0 % and < 5.1 % for 3.0 and 6.0 cm spherical tumours situated in the lungs (mean values were 3.9 ± 3.3 % and -1.6 ± 1.9 %). The error for the two tumours in the liver was < 11.2 % (mean values of 7.7 ± 3.9 % and 8.4 ± 2.9 %). The mean percentage differences between the mean absorbed doses calculated by LundADose and OLINDA/EXM for the left lung, right lung, liver, 3.0 cm ‘tumour’ and 6.0 cm ‘tumour’ were comparable. These mean percentage differences were -2.23 ± 1.98 %, -3.06 ± 1.67 %, 1.31 ± 4.15 %, -28.44 ± 18.36 %, and -5.10 ± 2.87% for the listed organs and tumours when the 3.0 cm tumour was located in the lung and the 6.0 cm tumour in the liver. For the scenario where the 3.0 cm tumour was positioned in the liver and the 6.0 cm tumour in the lung, the corresponding results were -2.84 ± 3.42 %, -1.49 ± 2.68 %, 3.97 ± 4.12 %, -28.80 ± 5.05 %, - 8.21 ± 17.06 %. The SIMIND MC model of the gamma camera was accurately validated with good agreement between results calculated from the physical measurements and simulation. Good accuracy of 131I activity quantification and 3-D dosimetry was found for 3-D patient-specific models. Statistical analysis of the results of the comparison of LundADose and OLINDA/EXM showed that the two dosimetry programs were strongly correlated with R2 values ranging from 0.85 to 1.00 for the mean absorbed dose in the various organs and tumours. Furthermore, the two (MC and MIRD) methods were found to agree well using Bland-Altman analysis of the dosimetry results. For 131I, activity quantification and dosimetric accuracy better than 10 % were achieved using state-of-the-art hybrid equipment and sophisticated correction methods for image degrading factors.
Open Access
Accuracy of lutetium-177 SPECT activity quantification and patient-specific dosimetry: a Monte Carlo study
(University of the Free State, 2021) Ramonaheng, Keamogetswe; Van Staden, Johannes A.; Du Raan, Hanlie
𝑬𝒏𝒈𝒍𝒊𝒔𝒉 The goal of radiopharmaceutical therapy (RPT) is to deliver the maximum dose to cancerous tumours while sparing healthy tissue. Ideally, the radiopharmaceutical should accumulate in the tumorous tissue and the radiation entirely absorbed for tissue destruction; however, this is not the case. Dosimetry strives to balance the efficacy of delivering the maximum dose to the tumour cells with minimal toxicity to the healthy tissue. Patient-specific dosimetry offers the potential for RPT to reach its full potential as a powerful precision-based treatment. Efforts for patient-specific dosimetry remain a challenge due to the steps involved in the clinical dosimetry workflow. SPECT/CT imaging allows the estimation of the bio-kinetic distribution of the radiopharmaceuticals with good precision, which is required for accurate dosimetry. Different dosimetry software is available (commercial and non-commercial), but these should be benchmarked before being used. Optimising the imaging process for activity quantification and dosimetry in the NM discipline is essential, and Monte Carlo (MC) techniques have been used successfully in this endeavour. Furthermore, full MC dosimetry gained wide acceptance as the gold standard and the most accurate means for patient-specific dosimetry. MC simulations offer the advantage of having a gold standard against which the dosimetry can be benchmarked, and the dosimetry accuracy evaluated. Therefore this thesis aimed to assess the accuracy of 177Lu SPECT activity quantification and patient-specific dosimetry using MC simulations. The focus was on the bio-distribution of 177Lu- DOTATATE due to its clinical relevance in RPT of patients with metastasised neuroendocrine tumours. The kidneys are the dose-limiting organs for RPT with 177Lu-DOTATATE. Studies have shown kidney doses to vary significantly between patients. Given the relation between tumour absorbed dose and tumour reduction, for a complete efficacy evaluation, absorbed doses should be determined not only for the kidneys but, where possible, extended to the tumours. This study incorporated voxel-based phantoms generated from phantom and patient CT data to perform virtual image-based activity quantification and dosimetry using MC simulations. The voxel-based phantoms were modified to include spherical structures mimicking tumours. The first objective of this study was to validate a model of the Siemens Symbia T16 dual-head SPECT/CT gamma camera available in our clinic using the SIMIND MC program for 177Lu imaging. The validation was achieved by comparing experimental and simulated gamma camera performance planar and SPECT criteria tests. The results were in good agreement and provided adequate confidence that SIMIND could emulate the Symbia T16 successfully and be used for further investigations of 177Lu SPECT/CT image quantification. The second objective investigated the effect of sphere and cylinder calibration factor (CF) geometries and their corresponding recovery coefficients (RCs) on the quantification accuracy of 177Lu SPECT images using MC simulations. The investigations were performed using geometries of a cylindrical, an anthropomorphic torso, and patient-specific phantoms. The quantification accuracy was evaluated for tumours and the kidneys. The results demonstrated that 177Lu SPECT quantification accuracies compared favourably for sphere-based and cylinder-based CF and RC combinations when all SPECT corrections were applied. The absolute quantification accuracy of ≤ 3.5% compared well to literature findings and complied with the 5% requirements for accurate dosimetry. The third objective of the thesis aimed to compare the accuracy of the absorbed doses computed with the software LundADose and OLINDA/EXM 1.0 using three patient-specific voxel-based phantoms. The dosimetry accuracy was assessed by comparing the computed doses to the “true” activity images combined with full MC dosimetry to define the gold standard. The accuracy between LundADose (6.6%) and OLINDA/EXM 1.0 (8.1%) was comparable. The ≤ 10% dosimetry accuracy suggested that the software platforms approximated the true dose estimates and advocated for the dosimetry accuracy to be reliable. ___________________________________________________________________
Open Access
Accuracy of patient-specific dosimetry using hybrid planar-SPECT/CT imaging: a Monte Carlo study
(University of the Free State, 2021-07) Morphis, Michaella; Van Staden, J. A.; Du Raan, H.; Du Plessis, F. C. P.
Introduction: Theragnostics is a precision medical discipline aiming to individualise patient targeted treatment. It aims at treating cancer by the systemic administration of a therapeutic radiopharmaceutical, which targets specific cells based on the labelling molecule. With the renewed interest in radiopharmaceutical therapy, the importance of accurate image quantification using iodine-123 (I-123) and iodine-131 (I-131), for dosimetry purposes, has been re-emphasised. Monte Carlo (MC) modelling techniques have been used extensively in Nuclear Medicine (NM), playing an essential role in modelling gamma cameras for the assessment of activity quantification accuracy, which is vital for accurate dosimetry. This thesis aimed to assess the accuracy of patient-specific I-131 dosimetry using hybrid whole-body (WB) planar-SPECT/CT imaging. The study was based on MC simulations of voxel-based digital phantoms, using the SIMIND MC code emulating the Siemens SymbiaTM T16 gamma camera. To achieve the aim, the thesis was divided into four objectives, (i) validating the accuracy of an energy resolution (ER) model, (ii) verifying the SIMIND setup for simulation of static, WB planar and SPECT images for I-123 with a low energy high resolution (LEHR) and a medium energy (ME) collimator and for I-131 with a high energy (HE) collimator, (iii) evaluating SPECT quantification accuracy for the three radionuclide- collimator combinations and (iv) assessing the accuracy of I-131 absorbed dose calculations for tumours and organs at risk, based on hybrid WB planar-SPECT/CT imaging. Methodology: The proposed ER model was fit to measured ER values (between 27.0 and 637.0 keV) as a function of photon energy. Measured and simulated energy spectra (in-air, in-scatter and a voxel-based digital patient phantom) were compared. The SIMIND setup was validated by comparing measured and simulated static and WB planar (extrinsic energy spectra, system sensitivity and system spatial resolution in-air and in-scatter), as well as SPECT (simple geometry sensitivity) results. Quantification accuracy was assessed in voxel- based digital simple and patient phantoms, using optimised OS-EM iterative reconstruction updates, calibration factor and recovery curves. Finally, using the true and quantitative activity data from I-123 and I-131 voxel-based digital patient phantoms, full MC radiation transport was performed, to determine the accuracy of the absorbed dose for I-131-mIBG radiopharmaceutical therapy. Results: The fitted ER model better simulated the energy response of the gamma camera, especially for high energy photopeaks, (I-123: 528.9 keV and I-131: 636.9 keV). The measured and simulated system energy spectra (differences ≤ 4.6 keV), system sensitivity (differences ≤ 6.9%), system spatial resolution (differences ≤ 6.4%) and SPECT validation results (difference ≤ 3.6%) compared well. Quantification errors less than 6.0% were obtained when appropriate corrections were applied. I-123 LEHR and I-123 ME quantification accuracies compared well (when corrections for septal scatter and penetration are applied), which can be useful in departments that perform I-123 studies and may not have access to ME collimators. Average I-131 absorbed doses of 2.0 ± 0.4 mGy/MBq (liver), 20.1 ± 4.0 mGy/MBq (3.0 cm tumour) and 22.6 ± 4.2 mGy/MBq (5.0 cm tumour) were obtained in simulated patient studies. When using a novel method of replacing the reconstructed activity distribution with a uniform activity distribution, eliminating the Gibbs artefact, the dosimetry accuracy was within 10.5%. Conclusion: Using the proposed fitted ER model, SIMIND could be used to accurately simulate static and WB planar and SPECT projection images of the Siemens SymbiaTM T16 SPECT/CT for both I-123 and I-131 with their respective collimators. Accurate quantification resulted in absorbed dose accuracies within 10.5%. The hybrid WB planar-SPECT/CT dosimetry method proved effective for personalised treatment planning of I-131 radiopharmaceutical therapy, with either I-123 or I-131 diagnostic imaging.
Open Access
Accuracy of patient-specific I-131 dosimetry using hybrid whole-body planar-SPECT/CT I-123 and I-131 imaging
(SpringerOpen, 2024) Morphis, Michaella; van Staden, Johan A.; du Raan, Hanlie; Ljungberg, Michael; Sjögreen Gleisner, Katarina
𝗣𝘂𝗿𝗽𝗼𝘀𝗲: This study aimed to assess the accuracy of patient-specific absorbed dose calculations for tumours and organs at risk in radiopharmaceutical therapy planning, utilizing hybrid planar-SPECT/CT imaging. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀: Three Monte Carlo (MC) simulated digital patient phantoms were created, with time-activity data for mIBG labelled to I-123 (LEHR and ME collimators) and I-131 (HE collimator). The study assessed the accuracy of the mean absorbed doses for I-131-mIBG therapy treatment planning. Multiple planar whole-body (WB) images were simulated (between 1 to 72 h post-injection (p.i)). The geometric-mean image of the anterior and posterior WB images was calculated, with scatter and attenuation corrections applied. Time-activity curves were created for regions of interest over the liver and two tumours (diameters: 3.0 cm and 5.0 cm) in the WB images. A corresponding SPECT study was simulated at 24 h p.i and reconstructed using the OS-EM algorithm, incorporating scatter, attenuation, collimator-detector response, septal scatter and penetration corrections. MC voxel-based absorbed dose rate calculations used two image sets, (i) the activity distribution represented by the SPECT images and (ii) the activity distribution from the SPECT images distributed uniformly within the volume of interest. Mean absorbed doses were calculated considering photon and charged particle emissions, and beta emissions only. True absorbed doses were calculated by MC voxel-based dosimetry of the known activity distributions for reference. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀: Considering photon and charged particle emissions, mean absorbed dose accuracies across all three radionuclide-collimator combinations of 3.8 ± 5.5% and 0.1 ± 0.9% (liver), 5.2 ± 10.0% and 4.3 ± 1.7% (3.0 cm tumour) and 15.0 ± 5.8% and 2.6 ± 0.6% (5.0 cm tumour) were obtained for image set (i) and (ii) respectively. Considering charged particle emissions, accuracies of 2.7 ± 4.1% and 5.7 ± 0.7% (liver), 3.2 ± 10.2% and 9.1 ± 1.7% (3.0 cm tumour) and 13.6 ± 5.7% and 7.0 ± 0.6% (5.0 cm tumour) were obtained for image set (i) and (ii) respectively. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻: The hybrid WB planar-SPECT/CT method proved accurate for I-131-mIBG dosimetry, suggesting its potential for personalized treatment planning
Open Access
Adapting to and implementing a problem- and community-based approach to nursing education
(AOSIS, 2000) Fichardt, A. E.; Viljoen, M. J.; Botma, Y.; Du Rand, P. P.
English: The process of change, implemented by the School of Nursing at the University of the Orange Free State so that a paradigm shift in approaches to nursing education at undergraduate level could be achieved, is outlined. The necessity to change, the identification of external and internal variables that impact on change, the founding of a support system, the process of overcoming resistance to change, the evaluation of the process of change and options for the future, are discussed. The rationale for the implementation of a problem-based teaching strategy and the phasing in of a community-based approach to teaching as the heart of the process of change are discussed.
Open Access
Adaptive immune response in COVID-19 patients and innate immune modulation of SARS-CoV-2
(University of the Free State, 2023) Litabe, Matefo Millicent; Burt, Felicity
In December 2019, a cluster of cases of atypical pneumonia were reported in Wuhan, China. All patients had a history of attending a large seafood market. Surveillance and detection methods established during the 2003 severe acute respiratory syndrome coronavirus (SARS-CoV)-1 outbreak contributed towards the identification of the virus as a novel coronavirus (CoV). The virus was later named SARS-CoV-2 and identified as the causative agent of Coronavirus Disease 2019 (COVID-19). Despite massive attempts to contain the virus in China, the cases rapidly increased and spread globally, and the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern on 30 January 2020 and characterized the outbreak as a pandemic on 11 March 2020. Assessing immunoglobulin (Ig)-G and neutralizing antibodies is essential to comprehensively evaluate the efficacy and duration of immunity conferred by natural infection and the COVID-19 vaccines. Effectively determining SARS-CoV-2 seroprevalence within a population is important as it helps to improve our understanding of virus circulation dynamics, identify individuals at risk of infection, and the extent of virus exposure in the community. Therefore, this study investigated the duration and kinetics of adaptive immunity, particularly the persistence of IgG and neutralizing antibodies, in patients who recovered from SARS-CoV-2 in the Free State, South Africa. Commercial assays are expensive, and hence two anti-spike (S) inhouse assays, enzyme-linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA), were developed and validated for detection of anti-S IgG. A total of 89 serum samples were collected from COVID-19 PCR-confirmed patients between 2-94 days post-symptom onset to validate the assay. A 100 prepandemic samples were used as a negative control panel to determine the cutoff of the assay. A cutoff value of 30% was considered accurate to differentiate between negative and positive samples using a two-graph receiver operating characteristic (TG-ROC). The assays exhibited a sensitivity of 100% for ELISA and 98.8% for IFA when testing samples collected more than one week after the onset of illness. The positive predictive values (ppv) were 92.1% for ELISA and 91.0% for IFA on PCR-confirmed positive samples. The assays were also compared to a commercially available SAPRHA-approved assay, where the ELISA showed a higher ppv of 95.8 %, while the Roche assay was 89.6 %, and the commercial lateral flow was 93.9 %. The two in-house assays also detected IgG antibodies in samples collected from waves in which new variants were circulating, showing that despite mutations of the SARS-CoV-2 S protein, the assay was still sensitive to detect IgG antibodies in circulating variants. This indicates that these assays could be used for surveillance of the South African population. To investigate the duration of anti-S IgG and neutralizing antibodies against SARS-CoV-2, 100 individuals with previously confirmed COVID-19 infection were recruited for the study. The cohort included 64/100 vaccinated and 36/100 unvaccinated individuals. Initial samples were collected between March 2021 and January 2022, with confirmed infection between June 2020 and December 2021. Follow-up samples were collected from 82/100 in 2022 and 62/100 in 2023 of the initial cohort. Samples were tested for anti-S IgG antibodies and neutralizing antibodies against Ancestral strain, Delta, and Omicron variants. A total of 95/100 baseline samples tested positive for anti-S IgG and 79/82 and 53/62 for follow-up samples. A total of 99/100, 78/100, and 72/100 baseline samples tested positive for neutralizing antibodies against the Ancestral strain, Delta, and Omicron variants. A total of 80/82, 63/82, 77/82 in 2022 and 53/62, 50/62, 56/62 in 2023 tested positive for neutralizing antibodies against the Ancestral, Delta, and Omicron variants, respectively. Samples were grouped based on the time (days) the samples were collected post-onset of illness. Results showed that IgG antibodies were significantly higher directly after infection, between 1-180 days, then gradually declined significantly with time. Neutralizing antibody titers against the Ancestral strain and Delta variant were significantly higher early after infection, between 1-180 days, remained relatively stable for an extended period, and then waned gradually before declining significantly. In contrast, although not significant, neutralizing antibodies against the Omicron variant increased with time, but this may be because samples were collected when the Omicron variant was still prevalent. Results also showed that vaccinated individuals had significantly higher antibody titers than unvaccinated, highlighting the importance of continued vaccination. The study shows the longevity of antibodies against SARS-CoV-2, as most individuals still had detectable titers at least 24 months post-acute infection, possibly boosted by vaccination or reinfection. The study also shows that the dynamics of antibodies vary among individuals; most individuals display declining antibody titers with time, and a smaller proportion maintain stable antibodies or a fluctuation of antibodies over time. Traditional medicinal plants have been proposed as promising, cost-effective treatments for SARS-CoV-2, with studies showing the potential to induce protection against different viral infections. The study also investigated the potential of Phela, a traditional medicine prepared from the extracts of four South African plants, and the individual components to modulate the release of cytokines in SARS-CoV-2 Omicron-infected mammalian cells and to investigate the influence of the plant extracts on viral replication. Cells were treated with the plant extracts before or after infection with SARS-CoV-2. Subsequently, cell culture media was collected at 12, 24, 48, and 72 hours post-infection and tested for virus replication and levels of Interleukin (IL)-1β, IL-2Rα, IL-6, IL-10, tumour necrosis factor (TNF)-α, and interferon (IFN)-γ cytokines. There was no statistically significant difference in viral load between infected cells treated with plant extracts compared to infected and untreated cells, showing that the plant extracts may have little to no effect on virus replication. Treatment with plant extracts resulted in significantly lower release of IL-1β, IL-2Rα, and TNF-α, with better response post-treatment than pretreatment, showing that the plant extracts may have the potential to manage cytokine storms and be a potential source of treatment for SARS-CoV-2.
Open Access
Adherence of patients with type 2 diabetes mellitus with the SEMDSA lifestyle guidelines
(University of the Free State, 2017-01) Birkinshaw, Amy; Walsh, C. M.
English: Over the last decade, the global burden of disease and mortality has shifted from infectious diseases to chronic diseases. Type 2 diabetes mellitus (T2DM) is considered to be the fastest growing chronic disease in the world. T2DM is a progressive disease that is associated with a high degree of morbidity and premature mortality in many countries, including South Africa. The global rise in overweight and obesity is considered to be the main reason that the prevalence of T2DM is increasing at such an alarming rate. T2DM is largely preventable. Multi-sectoral, population-based strategies and approaches are, however, needed to address the modifiable risk factors involved in the development of T2DM. Evidence-based nutrition principals and recommendations are continuously summarised by the Society for Endocrinology, Metabolism and Diabetes in South Africa (SEMDSA) into guidelines for the management of T2DM. In the present study, a cross-sectional study design was applied in a convenient sample (n=50) to determine the adherence of patients with T2DM with the SEMDSA lifestyle guidelines. Participants were over 18 years old and being treated for T2DM at a private physician’s practice in Bloemfontein. The study was approved by the Health Sciences Research Ethics Committee of the University of the Free State and all participants signed written informed consent. Three questionnaires were completed by the researcher in a structured interview with each participant. A Food Frequency Questionnaire (FFQ) was used to obtain information about dietary intake to determine both macronutrient and micronutrient intake. Physical activity intensity and duration was calculated using the Global Physical Activity Questionnaire (GPAQ), developed by the WHO. Information related to travel to and from work/ other places, activity at work and recreational activities as well as sedentary behaviour was obtained. Information related to socio-demographics (age, gender, language, marital status and level of education) and smoking and alcohol intake were collected using a questionnaire developed by the researcher (based on the SEMDSA guidelines). Anthropometric measurements were taken by the researcher according to standardised techniques, to determine BMI, waist circumference and waist-height ratio. The median age of participants was 57.9 years and the median time since T2DM diagnosis was seven years. The majority of participants were married (74%). About half spoke Afrikaans at home (52%) and worked full-time (54%). Gender was fairly equally distributed. The majority of participants were overweight (22%) or obese (66%). Most (90%) had a waist circumference above the high-risk cut point, while 92% had a high risk waist-height ratio above 0.5. The SEMDSA guidelines recommend that carbohydrates should make up 45-60% of total energy intake, total fat should be restricted to < 35% of total energy and of this, < 7% should come from saturated fat. It is recommended that sodium should be restricted to < 2 300 mg daily and that two portions of oily fish should be consumed each week to meet the recommended omega 3 fatty acid intake. Information related to dietary intake indicated that the SEMDSA lifestyle guidelines were poorly adhered to. Most participants followed a diet that was low in carbohydrates, high in fat (especially saturated fat) and low in omega 3 fatty acids. Sodium intake was high. Sedentary behaviour and lack of physical activity were common in the majority of participants, with 84% not meeting the guideline for aerobic exercise and 92% not meeting the guideline for resistance training. Ten percent of the participants were current smokers and of the men that regularly consumed alcohol, two thirds (66.67%) fell into the ‘high’ consumption (> 2 units daily) category. In conclusion, the adherence of participants to the SEMDSA guidelines was poor, thus increasing their risk of long term complications and poor glycaemic control. Complying with the SEMDSA guidelines can assist in maintaining a healthy weight, consuming a healthy diet and performing regular exercise. Further research related to the barriers that prevent patients from following the guidelines is warranted, in order to motivate practical, cost-effective and relevant interventions. researcher according to standardised techniques, to determine BMI, waist circumference and waist-height ratio. The median age of participants was 57.9 years and the median time since T2DM diagnosis was seven years. The majority of participants were married (74%). About half spoke Afrikaans at home (52%) and worked full-time (54%). Gender was fairly equally distributed. The majority of participants were overweight (22%) or obese (66%). Most (90%) had a waist circumference above the high-risk cut point, while 92% had a high risk waist-height ratio above 0.5. The SEMDSA guidelines recommend that carbohydrates should make up 45-60% of total energy intake, total fat should be restricted to < 35% of total energy and of this, < 7% should come from saturated fat. It is recommended that sodium should be restricted to < 2 300 mg daily and that two portions of oily fish should be consumed each week to meet the recommended omega 3 fatty acid intake. Information related to dietary intake indicated that the SEMDSA lifestyle guidelines were poorly adhered to. Most participants followed a diet that was low in carbohydrates, high in fat (especially saturated fat) and low in omega 3 fatty acids. Sodium intake was high. Sedentary behaviour and lack of physical activity were common in the majority of participants, with 84% not meeting the guideline for aerobic exercise and 92% not meeting the guideline for resistance training. Ten percent of the participants were current smokers and of the men that regularly consumed alcohol, two thirds (66.67%) fell into the ‘high’ consumption (> 2 units daily) category. In conclusion, the adherence of participants to the SEMDSA guidelines was poor, thus increasing their risk of long term complications and poor glycaemic control. Complying with the SEMDSA guidelines can assist in maintaining a healthy weight, consuming a healthy diet and performing regular exercise. Further research related to the barriers that prevent patients from following the guidelines is warranted, in order to motivate practical, cost-effective and relevant interventions.
Open Access
Adherence to the Mediterranean diet of pregnant women in Central South Africa: the NuEMI study
(SAGE, 2022) Spies, Hermina Catharina; Nel, Mariette; Walsh, Corinna May
Introduction: The Mediterranean diet (MeD) has been shown to have significant health benefits for adults and children. A mother’s diet during pregnancy directly impacts the health of her offspring. This study aimed to investigate the adherence to the MeD of pregnant women attending antenatal care at a Regional Hospital in Bloemfontein, South Africa (SA). Methods: A cross-sectional study was conducted on a consecutive sample of 681 pregnant women who attended the antenatal clinic of a Regional Hospital in Bloemfontein. Socio-demographics included: age, highest level of education, household income, employment status, and income stability. Food group intake was assessed with a quantitative food frequency questionnaire. The adapted Mediterranean Diet Adherence Screener (MeDAS) consisted of 13 of the original 14 questions that measured intake of key food groups (score of ⩽7 poor, 8-9 moderate, ⩾10 good) (wine intake was excluded for pregnant women). Results: A total of 681 pregnant women with a median age of 31.8 years (IQR: 26.8-36.5 years) and a median gestational age of 32.0 weeks at the time of the interview participated in the study. The vast majority showed poor adherence to the MeD (99.6%), with only 0.4% (n = 3) having moderate adherence and 0% good adherence. The median adherence score was 5 points and the maximum 8 points. Of those with poor adherence, only 11.5% had tertiary education, 43.2% earned less than R 3000 (<201 USD) per month, 52.5% were unemployed, and 42.0% did not have a stable income in the past 6 months. Of the 3 participants with moderate adherence, all had grade 11 to 12 education, 2 out of the 3 earned more than R3000 (201 USD), one was unemployed, and 2 had a stable income over the past 6 months. Compared to those with an income ⩽ R3000 (⩽201 USD), those with an income above R3000 were significantly more likely to eat nuts (including peanuts) (2.0% vs 4.6%, P = .05), and adhere to sofrito (similar to tomato and onion relish) intake (9.2% vs 15.6%, P = .02). Compared to those who only had a primary education level up to grade 10 (n = 229), those who had a secondary education level or more (grade 11 and higher, n = 452) were significantly more likely to consume enough olive oil per day (1.3% vs 5.0%, P = .01), and to consume sofrito (6.6% vs 18.0%, P = .02). Conclusion: Pregnant participants showed poor adherence to the MeD. Although almost all women fell in the poor adherence group, secondary education contributed to consuming recommended amounts of olive oil and sofrito and higher income was associated with an adequate intake of nuts and sofrito. Based on the findings, we recommend the development of a contextualized MeDAS tool that includes foods that are typically eaten by most South Africans for similar MeD benefits.
Open Access
Adherence to zinc supplementation guidelines in the management of acute diarrhoea in hospitalized children
(University of the Free State, 2016-01-30) Audie, Lyndal Claire; Lategan, Ronette; Nel, Riette
English: The aim of this research study was to determine adherence to zinc supplementation as part of the treatment guidelines for diarrhoea in infants and children at a tertiary hospital in the Eastern Cape, South Africa. Zinc supplements are recommended by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) to be given to all children experiencing diarrhoea, as zinc is a proven treatment, known to reduce the severity and duration of diarrhoea. Permission to conduct the study was obtained from the management of the tertiary hospital, as well as the Ethics Committee of the Faculty of Health Sciences, University of the Free State. In this study the researcher gathered information from the case folders of infants and children admitted to the general medical paediatric ward (GMPW) for diarrhoea between 1 January 2013 and 31 December 2013. From statistics obtained from the Department of Information Technology at the hospital, it was determined that 385 infants and children under five years of age were admitted to the ward, and of these, 290 cases were included in the study. The study was a retrospective, prescription audit and all information was obtained from case folders, specifically the prescription charts and medical notes. General patient information, prescription information and medical information was collected from the case folders. Data were captured by the researcher in duplicate and compared and verified electronically. Statistical analysis was performed by the Department of Biostatistics, University of the Free State. Descriptive statistics were mainly used and medians and percentiles where calculated for continuous data, and frequencies and percentages for categorical data. This study reported poor adherence levels to treatment guidelines for zinc supplementation in children with diarrhoea at a tertiary hospital in the Eastern Cape, South Africa. The researcher recommends the need to perform training among health care professionals to increase awareness and improve implementation of zinc supplementation guidelines. Continued monitoring and surveillance were also recommended to ensure sustainability of implementation. It is also recommended that the hospital develop an institutional policy that incorporates zinc supplementation guidelines as part of the management of diarrhoea in hospitalized children.
Open Access
Adult learning: what nurse educators need to know about mature students
(AOSIS, 2015) Spies, Cynthia; Seale, Ielse; Botma, Yvonne
Background: Most nurse educators regard students who enter postgraduate studies as adult learners capable of self-direction and independent learner behaviour. Therefore, a mismatch between the nurse educator’s expectation of adult learners and actual adult learner conduct may result in disappointment and even frustration for both educator and learner. Purpose: This article is a report of a secondary analysis of data that were collected to explore the high-fidelity simulation learning experiences of a group of postgraduate nursing students. The secondary analysis was done to determine whether adult learners who bring professional knowledge and experience to a postgraduate learning environment displayed adult learner conduct as proposed by educational theorist Malcolm Knowles. Method: Using a qualitative descriptive research design, data were gathered from 18 postgraduate nursing students who participated in high-fidelity simulation in a nursing school at a higher education institution in South Africa. The nominal group technique was used to collect the students’ ideas about improving their simulation learning experiences. A secondary qualitative analysis of the primary nominal group data was done. Findings: Data either confirmed or belied adult learner behaviour. Although the findings suggested self-directed and independent learner behaviour, they also revealed behaviour evident of dependence on the educator. Conclusion: Mature students have well established ways of thinking and doing that may hinder learning. Educators have to support adult learners in developing effective learning techniques in order to maximise the benefits of their experience and knowledge by fostering independence and self-direction.
Open Access
Algemene voetversorging van die bejaarde
(AOSIS, 1985) Botma, Y.; Viljoen, M. J.
The role of the nurse in the prevention of problems of the feet in the elderly is discussed, and the common foot problems that could be caused by negligence and ignorance are referred to. Routine foot care including care of the skin, nails, choice of shoes and massaging of the feet is discussed, and exercises that the elderly can do to prevent foot problems are illustrated.
Open Access
The amount of morphine administered per patient, for postoperative pain, using a Patient-Controlled Analgesia (PCA) device: at Universitas Academic Hospital, Bloemfontein, from January 2015 to December 2017
(University of the Free State, 2020-12) Kotze, George Petrus Johannes; Lamacraft, Gillian
Background: Intravenous morphine patient-controlled analgesia (PCA) is one of the modalities used by anaesthesiologists to treat patients after operation for acute postoperative pain. About 50% of patients experience inadequate pain control post-surgery when treated with traditional intramuscular (IM) opioids prescribed pro re nata (PRN). Patient-controlled analgesia can also be used to treat patients with chronic pain conditions, advanced metastatic cancer, and in pregnant patients during normal vaginal delivery. The development of intravenous morphine patient-controlled analgesia has led to more effective management of acute postoperative pain, especially in older patients with more comorbid conditions, where a more controlled administration of opioid analgesia is preferred. Other modalities of pain management, like neuraxial and regional analgesia techniques also provide efficacious control of post-surgical pain versus morphine PCA. These techniques are sometimes difficult to perform and contraindicated in patients taking anticoagulation therapy or patients with pre-existing neurological deficits. Intravenous morphine patient-controlled analgesia remains the gold standard for treating pain in these patients. Objectives: The aim and primary objective of the study was to determine how many intravenous (IV) morphine is being used via intravenous morphine patient-controlled analgesia at Universitas Academic Hospital per patient over a 24-hour period and to determine the amount of morphine unused and discarded as wastage. Methods: A retrospective study was conducted including all adult patients that underwent surgery and received intravenous morphine patient-controlled analgesia at Universitas Academic Hospital in Bloemfontein from 2015 to 2017. Data related to morphine PCA usage and presence of side-effects were collected from the PCA record form which is kept in the patient’s file after discharge. Results: A total of 155 patients who received intravenous morphine patient-controlled analgesia after surgery were included in the study. The median age were 55 years with 48.6% female patients and 51.4% male. The median total dosage of morphine received per patient was 22.75 mg over 24 hours. The median volume of morphine solution discarded per patient was 60 ml. Morphine PCA was mostly used for neurosurgical procedures (28.2%), followed by general surgery (20.8%), and orthopaedic surgery (16.1%). 86.9% of patients reported sufficient analgesia with intravenous morphine patient-controlled analgesia and 77.8% of patients did not require breakthrough pain medication. The intravenous morphine PCA device was used with insight by 76.5% of patients. Only 53.6% of the PCA record forms were assessed as correct and completely documented. Conclusion: This study found that the average total dosage of morphine being used per patient receiving intravenous morphine patient-controlled analgesia was 22.75 mg over a 24-hour period. This is much less than the 90 mg morphine solution being used in the morphine PCA pump. A large volume of morphine gets discarded as wastage. We recommend reviewing the intravenous morphine PCA protocol of Universitas Academic Hospital to decrease unnecessary morphine wastage. Further research opportunities include a cost analysis study of intravenous morphine PCA usage per patient at Universitas Academic Hospital.
Open Access
Amplitude of accommodation in 9 to 13 year old school children of Mankweng circuit, Limpopo province
(University of the Free State, 2020-09) Mafeo, M. E.; Oberholzer, M.; Rasengane, T. A.
Background: Amplitude of accommodation (AA) is the function of accommodation referred to as the dioptric difference between the far point (the eye is at rest) and near point (when the eye is fully accommodated) and is known to reduce with increase in age. To determine if an individual has low, normal or high amplitude of accommodation (AA) for his / her age, norms calculated from Hofstetter’s formulae are still used as reference all over the world. However, these norms were found to be irrelevant to Ghanaian and Swedish children. Out of the few accommodation studies conducted in South Africa, none of the studies documented the AA of learners from the Mankweng circuit, Limpopo province in South Africa. Aim of the study: The aim of this study was to investigate the AA in 9 to 13 year old school children of Mankweng circuit, Limpopo province. Method: A cross - sectional, analytical, descriptive study was conducted on 291 learners aged 9 to 13 years of age (median age = 11.3 years). Learners were conveniently selected but schools were randomised. Learners who passed visual screening tests consisting of habitual visual acuity at 6 m and 40 cm right eye and left eye (RE and LE), +2.50 D lens test at 6 m (RE and LE), prism cover test at 40 cm and direct ophthalmoscopy (RE and LE), were included in this study. One hundred and eighty - five (185) learners met the inclusion criteria and proceeded to the measurements of AA which were determined subjectively using the push - up (PU) to - blur (first data set) and pull - away (PA) to - clear (second data set) techniques, and objectively using the dynamic retinoscopy (DR) (fourth data set). The PU and the PA results were thereafter used to determine the average AA for each participant, which were regarded as the third AA measurement data set for the current participants. Results: The subjective and objective techniques of measuring AA yielded different results among the same participants aged 9 to 13 years. Dynamic retinoscopy (DR) technique measured the highest AA (median = 19.7 D), with PU (median = 14.3 D), PA (median = 13.4 D) and the average results of PU / PA techniques (median = 13.8 D) measuring lower. The median AA were reducing from 21.2 D to 18.3 D as age increased in 9 to 13 year old participants when measured with DR; from 15.5 D to 12.9 D with PU; from 14.4 D to 12.2 D with PA and from 15.0 D to 12.5 D when using the average results of PU / PA measurements. The rate at which AA changed between different age groups was found to be inconsistent. Furthermore, a significant difference existed between the AA of groups of 2 years or more apart. There was no statistical significant difference between the AA in female and male participants. The results further showed that the type of technique used to collect AA measurements, may have influenced the prevalence rate of a LOW AA. The results showed a high prevalence of LOW AA with PA technique 18.4% (CI of [13.5% to 24.6%]), followed by the average results of PU / PA techniques 12.4% (CI of [8.4% to 18.0%]) and lastly PU technique 7.6% (CI of [4.6% to 12.3%]). For the same participants, the DR technique did not measure LOW AA amongst any of the age groups. In each technique, there were outliers reported, with the majority in the 9 - year - old age group. Conclusion: The measured AA decreased with increasing age with all the techniques used, although the rate of reduction was not constant between the age groups. Furthermore, the AA between the age groups 12 and 13 years was statistically significantly different and also between the age groups of two or more years apart (e.g. 9 and 11 years). The AA in female and male participants showed no statistical significant difference. The prevalence of LOW AA determined, was higher with the PA technique as compared to the PU technique. The objective measurements were statistically significantly higher to the subjective measurements.
Open Access
An analysis of births outside health facilities in Maseru Health Service Area Lesotho
(University of the Free State, 2007-12) Seipobi, Esther M.; Myburgh, Reinette
English: According to the Ministry of Health/Social Welfare, 95% of all pregnant women attend ante-natal care at the health facility provided by skilled providers (MOH/SW, 2003:17). However, less than 50% of those pregnant women give birth at the health facility. The aim of the study was to describe births outside a health facility as a phenomenon. The objectives were to identify the place of birth outside a health facility, identify who the helper/attendant was during the birth, identify the reasons why the women gave birth at home, explore the mothers experiences regarding the birth, the outcomes of the health process, and describe cultural practices adhered to during birth. A non-experimental descriptive and exploratory design with a survey as a method was used. A semi-structured interview with an interview schedule with closed ended and open ended questions were used to gather data. A purpose sampling method was used to select 8 health facilities in the Maseru Health Service Area as well as 344 respondents for the study. Ethical principles relevant to conduct research involving human subjects was adhered to, such as obtaining the necessary permission to enter the field and complying with the human rights of the respondents. Semi-structured interviews were used to collect data from respondents of all ages, living in town, peri-urban and rural settings of Maseru Health Service Area. The methodology of the study was simply but thoroughly explained. The results of the study showed that women gave birth at home, assisted by their mother or family members. The reasons why they gave birth at home were either intentional (e.g. wanted to be amongst family members) or unintentional (e.g. baby came too fast). The mothers experience regarding the birth was generally good and the outcomes of the birth process were positive because there were no negative consequences for mother and baby. Mothers gave birth at home with the help of a family member or TBA who sometimes is the only help available in the community and that is why one of the recommendations is to train the community members (e.g. traditional birth attendant) to support safe motherhood as well as the mothers right to choose her own place of birth.
Open Access
Analysis of performance indicators in IPL Twenty20 Cricket from 2015 to 2017
(University of the Free State, 2020-01) Sloane, Surita; Schoeman, Riaan
Introduction: Cricket teams practice various batting and bowling strategies when preparing for matches or tournaments. Within the IPLT20 tournament these performance variables are considered as vital due to these variables discriminating between winning and losing teams. All teams participating in the IPLT20 seek a competitive advantage therefore an analysis of performance variables such as boundaries hit by batsmen and runs scored during the power play can be used to predict future success or failure of a cricket team based on the match outcome. Objectives: The purpose of this study was to identify which batting and bowling performance variables correlate with winning and losing teams in the IPLT20 Cricket tournament from 2015-2017. Furthermore, this study is aimed to supply coaches and players with performance outcomes that most significantly influence the winning and losing of an IPLT20 cricket match. Methods: A total of 150 IPLT20 cricket matches between 2015 and 2017 were captured. Six teams were selected for the purpose of this study, namely Delhi Daredevils, Kings XI Punjab, Kolkata Knight Riders, Mumbai Indians, Royal Challengers Bangalore and Sunrisers Hyderabad. These teams all participated in all three season from 2015 to 2017. This will result in 150 matches over the 3 seasons. Measuring Instruments: Retrospective data from the 2015, 2016 and 2017 Indian Premier League Tournament was collected from ESPN Cricinfo website. Data Analysis: A reliable data source for this research was found in Statsguru. Statsguru is ESPN Cricinfo’s cricket statistics maintenance database. The data was then analysed using the SAS Statistical Software (SAS, 2017). Data were analysed separately for the team batting first and for the team batting second. The outcome of the match is a binary variable (win/lose) since drawn matches were excluded from the analysis. The association of the potential predictor variables with the match outcome was analysed using univariate logistic regression, fitting each predictor variable, one at a time. The statistical significance of each predictor variable was tested using an exact test (exact conditional logistic regression); the exact P-value is reported. The analysis was carried out using SAS procedure LOGISTIC (see SAS, 2017). Results: Variables that predict success in T20 cricket differed for teams batting first and second, respectively. The significant predictors of winning an IPLT20 cricket match when batting first were: total runs scored in a match (p=0.0001), total wickets lost in a match (p=<0.0001), and wickets taken in a match (p=<0.0001). The significant predictors of winning an IPLT20 cricket match when batting second were: wickets taken in a match (p=<.0001) and wickets lost in a match (p=<.0001). Conclusions: The results of this study concludes that there are various performance variables such as the influence of a higher total runs scored, wickets taken in a match and wickets lost in a match correlates positively with success in Indian Premier League T20 cricket between teams batting first and second and can be used as success performance predictors. In contrast to other studies, this study focusses on variables in T20 cricket that reflect the performance of the entire team. From this study it can be concluded that batting first has a higher success rate although bowling data such as wickets taken and wickets lost for teams batting second are the most important predictors of winning.
Open Access
The analysis of the needs of Free State emergency care practitioners with regard to continuous professional development
(University of the Free State, 2016-01) Sookram, Bradley Paul; Van Wyk, C.
English: The Health Professions Council of South Africa (HPCSA) recognises and endorses continuing professional development as a means of ensuring best possible practice to the public. The lack of literature regarding continuing professional development for emergency medical care practitioners and the number of non-compliant emergency medical care practitioners, provided evidence for the need to investigate the possible needs faced by emergency medical care practitioners to be compliant to the HPCSA guidelines for continuing professional development in South Africa. The overall goal of the study was to conduct an analysis of the needs of Free State emergency medical care practitioners with regard to continuous professional development. A literature study was done to gain a deeper understanding of continuous professional development with reference to health professionals and specifically emergency medical care practitioners. A questionnaire was compiled considering some barriers that were identified which affected compliance with continuous professional development regulations. The questionnaire was compiled electronically and printed in a hard copy using the Evasys system. The target population was emergency medical care practitioners in the Free State province that were active and registered with the HPCSA. The study revealed that resources, improved communication and access to continuous professional development activities were the main needs of emergency medical care practitioners. Although there were some limitations during this study, it was evident that continuous professional development accreditors, and continuous professional development service providers need to plan, organise and provide information in advance for emergency medical care practitioners to be able to attend continuous professional development activities. Addressing the needs of emergency medical care practitioners with regard to continuous professional development will contribute positively not only towards the workplace but to the community at large.
Open Access
Analysis of tries scored during the 2018 and 2019 super rugby tournaments
(University of the Free State, 2021-11) Greef, Gabriel Pieter; Coetzee, F. F.; Kraak, W. J.
Introduction: The last few years, the professional rugby union defensive system improved and lead to teams scoring fewer tries. The growth of professionalism in sport has aided this with many teams now having a performance analysis staff to support the coaching process. Part of their job is to analyse performances of their teams and conduct analysis on opposition teams to then share this information with the management and support team. Analysing and understanding the performance indicators pertaining to tries can assist coaching staff with information to develop and rethink attacking strategies. Aim of the study: The primary aim of the study is to analyse the try scoring profile of the 2018 and 2019 Super Rugby competition. Methods: The current study included all the Super Rugby matches that was played during the 2018 and 2019 seasons. Video footage of all Super Rugby matches were supplied by the South African Rugby Union technical department. All videos was then analysed according to set performance indicators using Nacsport Scout+ video analysis software. All data was captured using data Microsoft Excel software. Results: The current study revealed that tries were responsible for most of the modes of scoring and points for both the 2018 and 2019 rugby seasons. The results indicated that during 2018 the percentage points contribution of tries was 65% (4,570 out of 7,069) and during 2019 it was 46% (811 out of 1,779). When looking at zonal locations where the tries orginated from the results revealed that 75% of the tries for the 2018 and 2019 seasons originated from the attacking half of the field (Zone A & B) and 64% Channel 1. Lineouts were the set piece origin for 37% and 39% of the tries for 2018 and 2019. Turnovers won were the general play origin for 22% of the tries for both the 2018 and 2019 seasons. Conclusions: In summary, tries were scored originating from all over the field, but more tries were scored in Zone A and B. Tries originated from several different possession platforms, where set pieces: lineouts and general play: turnovers won were the main ones platforms in both 2018 and 2019 seasons. Fundamentally, coaches and specialist attacking coaches will be able to use these try scoring profiles to improve technical and tactical skills and develop a framework to plan and execute effective plays and tactics in training to score more tries and concede less tries in matches. The results found in this study can be used to guide further research around this topip. Future studies should compare the findings with that of other professional rugby tournaments for the example the United Rugby Championships, Top14 and the newly formed Super Rugby tournament. Lastly, research should focus on the try scoring profile in women’s rugby to see if similar trends are evident.
Open Access
Anthropometric measurements and biochemical parameters in black women at the unit for reproductive care at Universitas Hospital, Bloemfontein
(University of the Free State, 2004-11) Motseke, Lucia; Slabber, M.; Nortjé
English: The prevalence of infertility in Africa is overshadowed by the high population growth rate in this continent. The number of infertile black African women seeking treatment is on the increase due to the fact that more black women are concentrating on their careers and postponing having children. The desire to reproduce is a highly motivating factor in most marriages and failure to do so places a lot of stress on the couple. Infertile women in most parts of Africa are treated as outcasts due to their infertile status. In most cases these women are either abused or divorced by their husbands. In sub-Saharan Africa, sexually transmitted diseases are the most common causes of infertility. Other causes of infertility in women include endometriosis, anovulation, tubal diseases, cervical factors and unexplained infertility. Anorexia and bulimia nervosa, as well as obesity, produce alterations in the reproductive system of women. Obesity has an effect on ovulation and on the outcomes of in vitro fertilization and assisted reproduction therapy. Anorexia nervosa on the other hand, has also been associated with amenorrhoea and oligoamenorrhoea. Insulin resistance is another factor that is linked to polycystic ovarian syndrome and infertility. Insulin resistance has also been shown to be prevalent in obese individuals, especially those with android fat distribution. Lowering insulin resistance by weight loss, results in spontaneous ovulation. The main objective of this study was to determine the anthropometrical and biochemical parameters in infertile black South African women. A total of sixty participants attending the Unit for Reproductive Health, Universitas Hospital, Bloemfontein were included in the study. Anthropometrical data measured included: body mass index; waist-to-hip ratio; waist circumference; neck circumference and body fat percentage. Blood samples were also obtained to determine the levels of fasting insulin, glucose, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, leptin, prolactin, progesterone, testosterone and C-reactive protein. The results of this study show that tubal factor infertility was the most prevalent cause of infertility and the second highest cause of infertility was male factors. The median age of the subjects of this study was 32 years. Sixty percent of the subjects had a gynoid fat distribution. More than a third of the subjects had a body mass index of more than 25 kg/m² and none of the subjects in this study had a body mass index of less than 18.5 kg/m². Eighty five percent of the subjects had a body fat percentage of more than 32 percent. These results indicate that obesity is a problem among these subjects. Biochemical parameters indicate that the median concentrations of the reproductive hormones were normal. Only 35 percent of the subjects had hyperinsulinaemia. Almost all of the subjects (83.6%) had leptin concentrations above normal. Median C-reactive protein level was also normal. No association was found between body mass index and C-reactive protein and insulin. An association was established between leptin concentrations and body mass index and the correlation between these two parameters was very strong. An association was also found between android fat distribution and hyperinsulinaemia. The high rate of obesity among the subjects of this study, places the subjects of this study at a risk of developing metabolic syndrome and other obesity-related factors. Their obesity status may also be a contributory factor to their infertile status. There should, be increased awareness of the impact of obesity on infertility and on their general health. Increased physical activity and healthy food choices should be encouraged among black infertile women. Black women should still be made aware of the fact that there are facilities available for treatment of infertility.
Open Access
Antibiotic resistance in anaerobic bacteria
(University of the Free State, 2000) Theron, Maria Magdelena; Chalkley, Lynda; Van Rensburg, Nolan
English: Anaerobic bacteria are important human pathogens capable of causing serious debilitating infections ranging from abscesses to life threatening infections and warrant more attention than they are currently receiving. Anaerobes are often present in mixed infections in association with other anaerobes/facultative anaerobes and aerobic bacteria and it is imperative to administer correct antimicrobial therapy ab initio. Antibiotic resistance development in anaerobic bacteria has a tremendous impact on selection of effective antimicrobial agents for empiric therapy. β-Lactam antibiotics are frequently used and have for many years been the first choice in the treatment and prophylaxis of anaerobic and mixed aerobic/anaerobic infections. Current knowledge of β-lactam resistance progression and resistance mechanisms in anaerobic bacteria is, however, limited. Metronidazole is often used empirically against suspected anaerobic infections, but anaerobes can no longer be considered to be universally susceptible as resistance has been noted in strains of Bacteroides fragilis, clostridia and peptostreptococci. The objectives of the study were to: 1) assess antibiotic susceptibilities of anaerobic bacteria isolated in the Bloemfontein area to antimicrobial agents currently employed in empiric treatment, 2) compare the in vitro activity of currently employed antibiotics with new antimicrobial agents, and 3) conduct studies on antibiotic resistance development. Anaerobic bacteria were isolated from clinically significant infections from April 1996 to March 1997 from the Universitas and Pelonomi Hospitals, Bloemfontein. Infection sites traced for 302 of 378 of the isolates, were from blood, brain abscesses, liver abscesses, lung infection/abscesses, eustachian infection/sepsis, neoplasms, bone fracture/infection, post-operative/amputation sepsis, gunsho/stab wound infection/ sepsis, genital tract isolates, general abscesses, and intestinal tract infections. Isolates were identified in the routine diagnostic laboratory by presumptive and preliminary methods and results confirmed by the Rapid ID32A identification system. Minimum inhibitory concentrations (MICs) were determined by the National Committee for Clinical laboratory Standards (NCCLS) agar dilution method for the following 18 antimicrobial agents: six β-lactams (amoxicillin, ampicillin, penicillin, piperacillin, cefoxitin, cefepime and cefpirome), two carbapenems (imipenem and meropenem), metronidazole, clindamycin, chloramphenicol, ciprofloxacin, trovafloxacin, vancomycin, dalfopristin/quinupristin, linezolid and loracarbef. Screening for β-lactamase production was performed by employing nitrocefin and inhibition of β-lactamases determined using amoxicillin/clavulanic acid combination. For detection of carbapenernase/metallo-β-lactarnase production a biological assay was performed; cell extracts and imipenem being added to agar seeded with E. coli ATCC 25922. Detection of metallo-β-lactamase genes was undertaken with primers directed to cfiA, cphA and blalMP genes. PBP profiles and penicillin affinities were determined by labelling with [3H]penicillin, separation of proteins by SOS-PAGE and visualisation after fluorography. In PBP competition studies whole cell samples were initially preincubated with rupenern, piperacillin or ampicillin at different concentrations and post-labelled with [3H]penicillin, followed by SOS-PAGE and fluorography. Metronidazole MICs of 64 isolates were correlated with inhibitory concentrations (ICs) obtained with two batches of Etest strips (range 0.006 - 32 µg/ml and 0.016 - 256 µg/ml). Membrane proteins of parental and metronidazole mutant strains of a VeilIonelIa sp. and Peptostreptococcus prevotii were separated by SOS-PAGE and profiles compared. The prevalence of rdxA genes was investigated in 16 anaerobic/ facultative anaerobic bacteria with metronidazole MICs 1 µg/ml employing two sets of primers and fragments of approximately 937 bp and 491 bp sequenced. The prevalence of nim genes were investigated in 64 anaerobic/facultative anaerobic isolates with metronidazole MICs 0.5 µg/ml using a pair of universal mm gene primers. Amplification was performed at two annealing temperatures (52°C & 62°C) and fragments at approximately 458 bp recorded as presumptive positives and sequenced. Positive strains were subjected to plasmid extraction. MICs indicated overall susceptibility of Gram-positive anaerobic isolates to be higher than for the Gram-negative isolates. Reduced susceptibility to penicillin (MICs ≥1 µg/ml) was found in 20 Peptostreptococcus strains and seven non-perfringens Clostridium spp. β-Lactamases hydrolysing both penicillins and cephalosporins were demonstrated in all Bacteroides and Prevotella isolates with ampicillin MICs> 4 Iµg/ml. Only 8% Peptostreptococcus spp. were resistant to piperacillin in contrast to 41% Bacteroides spp. and 68% Veillonella spp. Veillonella spp. exhibited selective β- Iactam resistance to piperacillin. Cefoxitin showed excellent activity against both Gram-positive and Gram-negative isolates, except for Bacteroides and Fusobacterium species. The majority of Gram-positive isolates were susceptible to cefepime and cefpirome, whereas < 50% Bacteroides spp. and < 70% Prevotella spp. were susceptible. High-level resistance to imipenem/meropenem (MICs> 128 µg/ml) was seen for 13/37 Fusobacterium spp. Two P. magnus isolates were resistant to metronidazole (MIC >128 µg/ml), three C. perfringens strains showed reduced susceptibility (MICs 4-8 µg/ml), while two Prevotella spp. had metronidazole MICs of 32 µg/ml. Eighty five percent of all isolates were susceptible to clindamycin. Oalfopristin/quinupristin exhibited excellent activity throughout the Gram-positive bacterial spectrum with only one Peptostreptococcus sp. showing reduced susceptibility (MIC 8 µg/ml), but poor activity against B. tragiIis group isolates. Trovafloxacin was effective against all the Gram-positive anaerobes except for two P. anaerobius strains (MICs 8 µg/ml), and demonstrated superior activity to ciprofloxacin against the Gram-negative isolates. Overall, chloramphenicol was the most effective antibiotic, with only two Clostridium spp. being resistant (MICs 16 µg/ml). PCR products of predicted size of cfiA genes were found in two strains of B. vulgatus, a B. capillosus and a P. loescheii strain and of cphA genes in three B. tragi/is strains and a strain of P. loescheii. None of the PCR products on sequencing, however, were seen to be positive for ctiA or cphA genes. No bla/MPgenes were amplified. PBP profiles were analysed with respect to identification based on the API Rapid ID 32A system. Seven major groups of fusobacteria PBPs could be identified, but although PBP profile/API agreement was evident for the majority of F. mortiterum strains, the API system did not lend itself to reliable identification of fusobacteria. PBP profiles were seen to distinguish species/subspecies of Clostridium species other than C. perfringens, while comparison with the API identification method showed some correlation, but not with most of the species investigated. Comparing PBP profiles of nine Veillonella spp. assigned three groups of species/subspecies. Commercial identification systems appeared not to be as reliable as promoted. The differentiation of anaerobic bacterial species by PBP profiling could certainly assist in situations of therapeutic failure. For F. mortiterum the PBP with the lowest affinity for penicillin and imipenem was the highest-molecular-weight PBP, 74 kDa. The PBP profile of an imipenem-resistant variant of F. varium (MIC >128 µg/ml) demonstrated an additional PBP (±69 kDa) when compared to that of the parental strain (apparent MIC 0.5 µg/ml). In two C. tertium strains, a C. sporogenes and a C. bitermentans strain low-molecularweight< 50 kDa) PBPs exhibited reduced affinity towards penicillin. In Veillonella isolates a PBP (66 kDa) that possessed the highest affinity for penicillin, was seen to exhibit the lowest affinity for piperacillin. Regression analysis revealed good correlation between metronidazole agar dilution MIC and Etest IC values. In the clinical setting, metronidazole Etests provide an important role in the susceptibility testing of anaerobes. Inducing metronidazole resistance in a P. prevotii and a VeilIonelIa strain produced mutants with only a twofold increase in metronidazole MICs increase, yet alterations to several membrane proteins were apparent. Such findings, as were also found with PBP analysis conducted in this study, complexes interpretation as to how antibiotic resistance has developed in anaerobic bacteria. Nim genes were demonstrated in 14/64 strains (MICs ≥ 0.5 µg/ml) and identified as NimA genes in five propionibacteria, a P. bivia, a C. bitermentans and an A. odonto/yticus strain, with nimB genes identified in five isolates of B. tragi/is and a P. magnus strain. Sequence divergence was < 4% from the respective documented nimA and nimB gene sequences. Although the origin of nim genes is unknown, predominance of nimA genes in facultative anaerobes, propionibacteria, may indicate a transferable nimA gene source in anaerobic environments. To avert the clinical problem of untreatable anaerobic infections, it is necessary to continuously monitor for the emergence of antibiotic-resistant strains, conduct investigations into how resistance has developed, and understand conditions that foster inter- and intra-dissemination of resistance genes among anaerobic bacteria.