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Open Access
Assessing adherence to recommended HIV Post Exposure Prophylaxis regimens prescribed to doctors working at the Free State Academic Complex in Bloemfontein, South Africa
(University of the Free State, 2021-05) Asmal, Taahir; Van Vuuren, C.; Potgieter, S.
Background: The prevalence of HIV infection in South Africa is one of the highest in the world and healthcare workers in this setting are particularly at risk of being infected through occupational exposures. All high-risk exposures to infective bodily fluids are considered as important, warranting the use of post exposure prophylaxis (PEP). This study determined adherence to PEP in doctors, regardless of specialty and rank. Methods: A cross sectional study was conducted by distributing a structured anonymous questionnaire to doctors working in 3 teaching hospitals in central South Africa. Results: A total of 233 of 400 distributed questionnaires were completed (response rate 58,2%) from 543 employed doctors across 3 different hospitals and over 16 specialties (coverage 42.9%). Almost all the respondents (84,7%) had at least one high risk exposure, with an average of 2,3 exposures per respondent. Most (49%) of the respondents were exposed when performing venesection. Majority (58%) thought that the exposure could have been avoided. Of those exposed, 83% used PEP at least once. Of those who took PEP, 56% stopped prematurely with 71% of them citing adverse side effects as the main reason. Workload impacted adherence negatively in at least 50% of respondents. Conclusion: Majority of doctors had more than two occupational exposures. Adherence to PEP is generally poor. This is mainly due to the side effect profile of PEP regimens used at the time of the study. The recent widespread availability of better tolerated ART drugs and more tolerable regimens for PEP, may improve adherence.
Open Access
Bone health in Graves’ disease: a comparison of black and white South African women
(University of the Free State, 2019) De Lange, Willem; Mollentze, W. F.; Pettifor, John M.
Objectives: The negative effects of thyrotoxicosis on bone health in white populations have been widely studied. In non-South African black populations, it has been showed that the skeleton is protected against the negative effects of other endocrinopathies, for e.g.: hyperparathyroidism. The aim of the study was to determine whether black South African women are also protected against the detrimental effects of Graves’ disease (GD)? Background and motivation: The detrimental effects of thyrotoxicosis on bone health has been known for more than a century. In white females, thyrotoxicosis has been shown to increase the rate of bone resorption along with bone formation. However, the rate of bone formation is inadequate to compensate for bone resorbed, leading to a net loss of bone volume. This negatively impacts on the structural integrity of bone with an increased fracture risk. Little is known about the effect of thyrotoxicosis on bone health in black African-, and especially black South African women. Ethnic differences in bone metabolism and fat distribution do exist between black and white South African women. Dual-energy X-ray absorptiometry (DXA) studies have shown that the bone mineral density at the lumbar spine of healthy premenopausal black South African women, is equal or lower than that of their white counterparts. The bone mineral density of postmenopausal black- and white women at the lumbar spine is comparable. Vertebral fracture risk of the lumbar spine is equal for black- and white South African women. Significant differences in femoral bone density do exist when black and white South African women are compared. Black South African women have a greater bone mineral density at the femur neck site. Histomorphometric and radiometric differences between these two ethnic groups may explain the lower incidence of femoral fragility fractures in the black population. Black South African women, when compared to their white counterparts, have thicker and less porous cortices as well as thicker trabeculae. These micro architectural differences could explain the decreased number of fractures seen in black females when compared to white females. There are also ethnic differences in the abdominal adipose tissue depot distribution. White men and women have increased abdominal visceral adipose tissue and decreased subcutaneous adipose tissue when compared to black men and women. Thyrotoxicosis has detrimental effects on bone metabolism and bone structure in white women. These effects can lead to an increased risk of fracture that persists even after normalization of the bone mineral density. Study design: This was a prospective exploratory and comparative study. Methods: A convenience sample of 40 consecutive and consenting black female patients (age ≥ 25 and ≤ 65 years) and 20 consecutive and consenting white female patients (age ≥ 25 and ≤ 65 years) with confirmed GD referred to the Endocrine service at Universitas Hospital were recruited for the study. Patients were matched with 40 black and 20 white healthy control females according to age (± 5 years), body mass index (BMI) and seasonality. Black- and white South African women suffering from GD were compared with each other at baseline, 6- and 12 months according to pre-determined objectives. Women suffering from GD were also compared with healthy controls from the same ethnic group. This comparison was performed to rule out effects of ethnicity versus effects of GD on bone health. The main objectives included differences in biochemical markers, bone mineral density and body composition. Histomorphometric data on the effect of GD on bone in white ethnic groups has been published before. Therefore, bone histomorphometry was only performed in black women suffering from GD to ascertain whether ethnic differences do exist. Results: In this prospective study, 39 black women and 20 white women with newly diagnosed GD were included. The median parathyroid hormone (PTH) level of black women suffering from GD was suppressed and significantly lower when compared to white patients (p = 0.04). The suppressed PTH in black patients were accompanied by increased serum calcium levels. The markers of bone formation as well as bone resorption were increased in both patient groups. The median urine deoxypyridinoline (DPD) to creatinine ratio (Urine DPD), a marker of bone resorption, was significantly higher in black women suffering from GD compared to white patients (p = 0.026). Although the median 25-hydroxyvitamin D (25(OH)D) level of black patients with GD was lower compared to their white counterparts and suppressed below the lower limit of the laboratory threshold, it did not differ significantly. The median 1,25dihydroxyvitamin D (1,25(OH)2D) levels of black- and white patients were normal and not different. A marker of inflammation, tumour necrosis factor alpha (TNFα), was significantly higher in black patients compared to white patients (p = 0.022) while the other markers included, interleukin 6 (IL-6) and C-reactive protein (CRP), did not differ. The median insulin-like growth factor 1 (IGF-1) levels of both patient groups were lower compared to healthy controls. The median IGF-1 of black patients was significantly lower compared to that of healthy black controls (p = 0.001). The same was observed in white patients and – controls with white patients having a significantly lower median IGF-1 level (p = 0.05). There was no difference between the two patient groups. The actual bone mineral density (BMD) of white patients at the left femoral neck was significantly lower compared to black patients at baseline (p = 0.033). This difference was not observed between white patients and –controls. The BMD at the left forearm distal 3rd was lower in black patients compared to white patients (p = 0.049). Although the same pattern was observed when comparing the median Z-scores at baseline, it did not reach significance. The median Z-score at the left total hip of white patients were significantly lower when compared to white controls (p = 0.039). A greater proportion of black patients had a median Z-score of the lumbar spine ≤ -2.0 compared to white patients (p = 0.028). The difference observed of actual BMD at the left femoral neck between black- and white patients at baseline was maintained at 6- and 12 months after therapy. The difference at the left forearm distal 3rd disappeared at months 6 and 12. The actual BMD of white patients at the right femoral neck was significantly lower at 12 months compared to black patients (p = 0.030). The body composition of both black- and white patients were comparable at baseline. However, the percentage change in body mass index (BMI) did differ significantly from 0-6 and 0-12 months between the two patient groups. Black patients had a significantly higher percentage increase in BMI at 0-6 months (p = 0.042) and 0-12 months (p = 0.01) compared to white patients. The body composition of white patients and –controls did not differ significantly at baseline, 6- and 12 months. Although the body composition of black patients and –controls were comparable at baseline, black patients had a significant increase of especially fat tissue after treatment. This is confirmed by a significantly higher fat mass index (FMI) found in black patients at 12 months compared to controls (p = 0.011). The bone histomorphometry revealed a state of accelerated bone turnover, predominant stimulation of bone resorption and histological evidence of demineralization as evidenced by abundant osteoid on histology. Conclusions: Ethnic differences between black- and white South African women suffering with GD were shown. Black South African women are not protected against detrimental skeletal effects of GD. It is hoped that this study will contribute to a better understanding of bone health in the South African population in general, but especially those patients with GD. It is also envisioned that this may lead to improved management of patients once thought to be protected against the skeletal complications of GD. Further South African research is warranted.
Open Access
Diabetes mellitus hypertension and related factors in black subjects residing in Qwaqwa and Bloemfontein
(University of the Free State, 2003) Mollentze, Willem Frederik; Weich, D. J. V.; Joubert, G.; Steyn, K.; Steyn, A. F.
English: BACKGROUND The black population of South Africa underwent rapid urbanisation during the last century. This process was accompanied by major changes in lifestyle including less physical activity, the moving away from traditional low-fat diets to diets high in saturated fat, and the acquiring of unhealthy habits such as the smoking of cigarettes. Previously rare chronic diseases of lifestyle such as diabetes mellitus, hypertension, obesity, dyslipidaemia and atherosclerotic cardiovascular disease started to emerge during this period. AIMS The primary aims of the study were to determine the prevalence of diabetes mellitus, hypertension, obesity, and dyslipidaemia, in a partly rural and an urban black community. The secondary objectives were to investigate the hypotheses that the metabolic syndrome existed in the black population and that hypertension was associated with hyperinsulinaemia in the study populations. STUDY DESIGN A cross-sectional study SETTING: The study was conducted in the semi-rural area of Qwaqwa and in Mangaung, the main black residential area of Bloemfontein. METHODS A representative sample of 853 subjects 25 years and older (279 males and 574 females) was selected from Qwaqwa, a partly rural community in the Free State, and a similar sample of 758 subjects (290 males and 468 females) from Mangaung, the black residential area of Bloemfontein, as the urban sample for comparison. After informed consent, the prevalence of the following conditions was determined according to standardised procedures: diabetes mellitus, impaired glucose tolerance, impaired fasting glucose, hypertension, dyslipidaemia, and overweight and obesity. In addition, anthropornetrlcal measurements including the measurement of selected skinfold thickness and body circumferences were measured. A 12- lead resting electrocardiograph was obtained from each subject and blood specimens were collected for the measurement of insulin, proinsulin and C-peptide. A trained nurse administered a questionnaire to each respondent in his or her own language to obtain demographic and biosocial information. RESULTS The response rates were 68% in Qwaqwa and 62% in Mangaung. The age-standardised prevalence rates for the chronic diseases that were studied, are provided in the Table 51. Table A1 will be attached on the full document. The prevalence rates of the risk factors that were studied did not differ significantly between the Qwaqwa and Mangaung samples. Although the metabolic syndrome was present in 31% of subjects in both samples, no electrocardiographic evidence of an increased prevalence of coronary heart disease was found in subjects with the metabolic syndrome. Hyperinsulinaemia and thus insulin resistance was not associated with hypertension in any of these two black populations with a high prevalence of obesity and hypertension. It is unlikely that a population with such a clustering of cardiovascular risk factors can much longer escape the emergence of coronary artery disease as an important public health problem. CONCLUSION The black populations of Qwaqwa and Mangaung are well advanced on the raad of urbanisation and the nutrition transition. Chronic diseases of lifestyle are as prevalent in these communities as elsewhere in the Western world. Coronary artery disease is usually the last of the typical Western diseases to emerge in a population in transition and it is unlikely that these black populations will escape this disease much longer.
Open Access
Diagnostic accuracy of ultrasound-guided fine needle aspiration cytology of thyroid nodules at Universitas Academic Hospital, Bloemfontein
(University of the Free State, 2020-06) Ahmad, Fayyaz; Moodley, Anandan
Background: Fine Needle Aspiration Cytology (FNAC), is safe, reliable and minimally invasive first-line investigation used to evaluate thyroid nodules. Aim: To determine the diagnostic accuracy of FNAC performed at our institution by correlating its results with histopathological diagnoses. Methods: A retrospective analysis was conducted of cytology and histopathology results of patients who underwent both FNAC and thyroidectomy at Universitas Hospital, Bloemfontein, over a 5-year period (2014–2018). Cytological findings were classified into six Bethesda categories while histological results were categorised as benign or malignant. Adult patients (≥ 18 years) who underwent both thyroidectomy and FNAC for nodular thyroid disease were included. Results: Sixty-one cases fulfilled the inclusion criteria. On cytological examination, 28/61 (45.9%) were reported as benign, 11/61(18.0%) as malignant and 10/61(16.4%) as suspicious. On histopathological reports, 29 cases were confirmed as benign and 10 as malignant. Among 10 suspicious cases, four were malignant on histopathology. False positive and false negative rates were 15.3% and 12.8%, respectively. The sensitivity and specificity were 50.0% and 79.3%, respectively. The positive and negative predictive values were 45.5% and 82.1%, respectively. The diagnostic accuracy of FNAC was 71.8%. Conclusions: FNAC at our institution has not performed as good as most similar studies published previously.
Open Access
Drug interactions between HIV-associated lymphoma treatment and antiretroviral therapy
(University of the Free State, 2019-11) Meyer, Lana; Barrett, C. L.; Van Zyl, P.
Despite the large-scale roll-out of ART in the mid-1990s, HIV and HIV-associated diseases remain a major health problem in South Africa. HIV-associated lymphoma contributes significantly to the morbidity and mortality of the HIV-positive population. The majority of HIV associated lymphomas are diffuse large B cell lymphomas (DLBCL), which have been reported to occur 60 to 200 times more commonly in patients with HIV than in the general population. Drug interactions are inevitable when treating HIV-associated lymphoma and can alter the efficacy of treatment and ultimately patient outcomes. Therapeutic questions have been raised pertaining to the need to find a balance between the administration of effective cytotoxic treatment and the effect it has on immune function. Complications such as infections and chemotherapeutic toxicity can occur. Dosing schedules may need to be adapted and certain combinations may be prohibited. The aim of this study was to conduct a critical overview of drug interactions between antiretroviral therapy used in the treatment of HIV and antineoplastic drugs used in the treatment of HIV-associated lymphoma. The purpose was to develop a quick reference tool to serve as a guide for clinicians to assist in identifying important drug interactions. Known drug interactions between 19 antiretroviral drugs and 13 antineoplastic agents used in the treatment of HIV and HIV-associated lymphoma respectively were investigated. Standard antiretroviral therapy (ART) regimens proposed by the national protocol were compared to drugs used in the following antineoplastic regimens: ABVD, CODOX-M-IVAC, CALGB9251, hyper- CVAD, dose adjusted R-EPOCH and R-CHOP. Data were obtained during March and April 2019 from three different internet-based drug interaction checkers, namely Medscape Drug Interaction Checker (https://reference.medscape.com/drug-interactionchecker), Lexicomp Online (https://www.wolterskluwercdi.com/lexicomp-online/) and RxList (https://www.rxlist.com/druginteraction-checker.htm). Interactions were classified as not clinically significant, no interaction, decreased or increased effect, contraindicated, increased toxicity, increased toxicity of both drugs due to synergism and loss of virological response. In total, 117 drug interactions were identified, of which 105 were deemed clinically significant. No interactions were found when the nucleoside reverse transcriptase inhibitors (NRTIs) lamivudine, abacavir and emtricitabine were used. The integrase inhibitors raltegravir and dolutegravir and the fusion inhibitor enfuvirtide also had no documented drug interactions. Chemotherapeutic agents that were found to have no significant drug reactions include cytarabine, rituximab and dacarbazine. Important drug interactions between the non- nucleoside reverse transcriptase inhibitors (NNRTIs) tenofovir and zidovudine and antineoplastic drugs were noted. Toxicity of tenofovir may be increased with concomitant use of bleomycin and ifosfomide. Caution must be taken when using zidovudine in combination with methotrexate, ifosfamide, vincristine and vinblastine, as the toxicity of both drugs is increased when used in combination. Efavirenz, a NNRTI, was found to have many interactions with antineoplastic drugs, the most significant being decreased levels of doxorubicin. Many drug interactions were noted between protease inhibitors and antineoplastic drugs. Anthracycline-associated cardiomyopathy may be induced when used concurrently with protease inhibitors. In general, rilpivirine is known to have a good side-effect profile. However, it must be noted that when combined with dexamethasone, this combination may lead to a loss of virologic response. Other significant interactions with drugs not included as standard ART is discussed in the article. Tailoring drug therapy according to individuals' specific requirements and proper medication reconciliation is critical when treating patients with HIV-associated lymphomas. Clinicians need to be aware of important interactions between antiretroviral therapy and antineoplastic drugs. Therapeutic monitoring and close interaction between role-players in the management of these patients is crucial. Communication between the clinic issuing the antiretroviral therapy, the attending haematologist or oncologist and the patient is vital to continuity of care. A quick referencing tool was developed as a guide to clinicians involved in the treatment of HIV associated lymphoma.
Open Access
Dyslipidaemia pattern and prevalence among type 2 diabetes mellitus patients on lipid-lowering therapy at a Tertiary Central South African Hospital
(University of the Free State, 2020-09) Pitso, Lebohang; Mofokeng, T. R. P.; Nel, R.
Background: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of death worldwide. A large number of deaths due to ASCVD occur among people with diabetes mellitus (DM). One of the important modifiable risk factors associated with ASCVD is dyslipidaemia and its prevalence is not known in central South Africa (SA). This study aimed to determine the pattern and prevalence of dyslipidaemia among type 2 diabetes mellitus (T2DM) patients on lipid-lowering therapy. Methods: This descriptive, retrospective patient record study was conducted at Universitas Academic Hospital, Bloemfontein, in central SA. The study population included 143 consecutive T2DM patients of any age that attended the Diabetes Clinic from 1 January to 31 March 2019. The patients had to be on lipid-lowering therapy for a minimum duration of 3 months. Data was sourced from the clinic files and it included lipid profile, anthropometric and demographic data. Dyslipidaemia was defined using the 2018 SA dyslipidaemia guidelines. Result: The median age of the study participants was 63 years (interquartile range 52-71 years). Majority of the participants (n=92; 64.3%) were female. The median duration of DM diagnosis was 18 years (interquartile range 13-23 years). The prevalence of dyslipidaemia was 86.7% that occurred in 124 out of the 143 subjects. Combined dyslipidaemia, namely triglycerides (TG) + low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) + TG or HDL + LDL, was the most common pattern (n=51; 42.5%) largely due to raised TG+LDL contributing 37.2% to this pattern. The second and third most common pattern was isolated (LDL, HDL or TG) and mixed dyslipidaemia (TG+HDL+LDL) at 40.8% and 16.7%, respectively. The most frequent abnormal lipid particle (n=84; 70%) was LDL cholesterol ≥ 1.8mmol/L. Of the 140 participants on statin therapy, only 5% were on high-intensity statin therapy. Conclusion: There is a high prevalence of dyslipidaemia among DM patients despite the use of lipid-lowering therapy in this small retrospective study. The study highlights the need for better education of healthcare providers regarding the intensification of lipid-lowering therapy, along with improved strategies to address poor glycaemic control and other modifiable lifestyle factors.
Open Access
Integrating HIV care into primary health care services in the Free State : process and impact
(University of the Free State, 2014-11-21) Uebel, Kerry Elizabeth; Mollentze, W. F.; Van Rensburg, H. C. J.
Abstract not available
Open Access
National profile of the characteristics of patients treated for TTP an extension of the study: the characteristics of patients with TTP at the Universitas Haematology Department from 2010-2017 (HSD2018/0114)
(University of the Free State, 2021) Mohale, M.; Barrett, C.; Janse van Rensburg, W.
Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening haematological disorder. It is caused by a deficiency in ADAMTS13. ADAMTS13 is a zinc-containing Metalloprotease enzyme that cleaves Von Willebrand factor (VWF). The deficiency of ADAMTS13 results in VWF accumulation and causes platelet rich thrombi, resulting in haemolytic anaemia and thrombocytopenia. There is an increased risk of TTP among female patients, patients from black races and patients with blood group O, based on previous studies. It is also most commonly seen among patients with HIV. The mainstay of treatment is plasma exchange and fresh frozen plasma. A retrospective study aimed At describing the national characteristics of TTP from 2010 to 2017 was done. Permission to conduct the study was obtained from the Health Sciences Research Ethics Committee of the University of the Free State (HSREC), Western Cape Blood Service (WCBS) ethics committee and South African National Blood Service (SANBS). The described characteristics are the age, gender, blood group and the blood products given to the patients.
Open Access
Necrotising migratory erythema leading to the diagnosis of a metastatic glucagonoma without diabetes
(University of the Free State, 2020-08) Makan, Rahm; Van Vuuren, Cloete
A case of necrotising migratory erythema (NME), which is one of the distinctive paraneoplastic skin manifestations associated with the glucagonoma syndrome, is described and discussed. In 80% of all patients with glucagonoma, NME is the first clinical sign. The glucagonoma syndrome is a constellation of clinical features: NME, weight loss, anaemia, diabetes, diarrhoea, thromboembolism and neuropsychiatric symptoms. The global incidence of glucagonoma is one in 20 million people per year. The male to female ratio is 0.8: 1 with the mean age of diagnosis being 52.2 years. The median time in relation to the initial onset of symptoms and the correct diagnosis is 3.5 years. The IO-year survival rate in patients with metastatic disease is 51.6% and without metastatic disease 64.3%. SPECT scan has a sensitivity range of 67-100% for detecting neuroendocrine tumours. Differential diagnoses of other skin conditions that mimic NME are: bullous pemphigoid, vasculitis, acrodermatitis enteropathica, chronic mucocutaneous candidiasis, seborrhoeic dermatitis, contact dermatitis, pellagra, inflammatory bowel disease, liver cirrhosis, coeliac disease, chemical bums, eczema, herpes etc. A satisfactory response to somatostatin as medical therapy in a casestudy patient with metastatic disease is reported.
Open Access
The prevalence of polypharmacy and prescription of potentially inappropriate medications in the elderly
(University of the Free State, 2021-03) Isaacs, Gavin Sean; Harmse, M.
Background: The proportion of the elderly population, considered to be the main consumers of medicine, is on the increase. High multimorbidity prevalence in elderly increases the risk for appropriate- and inappropriate polypharmacy. Polypharmacy increase the risk for adverse drug reactions and drug events, drug-interactions and is associated with an increased risk of patient harm. Polypharmacy in the elderly correlates with potentially inappropriate medication prescription. Objectives: To determine the prevalence of polypharmacy and potentially inappropriate medication (PIM) prescription at the geriatric outpatient clinic, Universitas Academic Hospital between 1 January 2015 and 31 December 2019. Methods: A retrospective descriptive analytical study evaluating chronic medication prescriptions of all participants aged 65 years and older that attend the geriatric outpatient clinic at Universitas Academic Hospital over a 5-year period. Prescriptions were reviewed for quantity of medicines prescribed per participant and potentially inappropriate medication prescription. Results: A total of 786 participants were included in the study. The majority of patients were aged between 75 and 84 years. The prevalence of polypharmacy was 84.3% of which the majority was female. A mean number of 9.5 medications were prescribed, ranging from 0 to 23 medications. Overall PIM prevalence was 90.2%. Proton pump inhibitors, amitriptyline, insulin sliding scale, promethazine, doxazosin, digoxin and antipsychotics were the most frequently prescribed PIMs. The three most frequently used PIMs in the category of drugs to be used with caution in older adults were aspirin, the loop diuretic furosemide and tramadol. Fifty-two participants (6.6%) were on a combination of ≥ 3 drugs which can lead to potentially clinically important drug-drug interactions. Conclusion: A high prevalence of both polypharmacy and PIM was found. Limited data is available for the South African geriatric population.
Open Access
Radionuclide cisternography: imaging and study of the cerebrospinal fluid circulation
(University of the Free State, 1975-12) Iturralde, Mario Paulino; Retief, F. P.
English: English: Radionuclide cisternography performed in 200 selected patients with neurological disease has proved to be a simple and relatively safe procedure, v,rithminimal disturbing side effects, which can provide useful information about cerebrospinal fluid (eSF) flow and dynamics. Following the subarachnoid or ventricular injection of an appropiate radiopharmaceutical, the tracer flows with the eSF and demonstrates the pathways of circulation under normal and abnormal conditions with virtually no disruption of the existing eSF physiology. The eventual distribution of the tracer is complex. The range of normal varies from rapid ascent with early absorption of the radiopharmaceutical to slower ascent and absorption, frequently with laterilization of flow to one or other side intracranially and occasionally with transient ventricular reflux. In pathological states the cisternographic picture varies ac= cation (or lack of it) of the ventricles with the subarachnoid cording to the underlying disease. It may lack the ability to establish the precise anatomical features available from air encephalography. However ventricular dilatation, the communispace, and the delay or lack of absorption are only satisfactorily demonstrated by radionuclide cisternography. Repeated examinations may be readily performed to show progression of the disease or the results of surgical treatment. The abnormal flow pattern in patients with normal pressure hydrocephalus proved to be the most important criterion in their selection for extracranial neurosurgical eSF shunting. When properly selected, these patients often respond to surgical treatment. The routine use of radionuclide cisternography in the examination of patients with suspected presenile dementia and compensated hydrocephalus results in a low yield of operable patients. When operation is contraindicated conservative management of the patient is then instituted and unnecessary surgical intervention avoided. Radionuclide cisternography gained wide acceptance in the evaluation of shunt patency. The test is fast and safe in the presence of extracranial diversionary eSF shunts. The rapid flow into the cerebral ventricles and the fast disappearance of the radioactive tracer, as well as the relative size of the ventricular system, are valuable indexes for the determination of patency and efficaccy of the shunt. Another important use of radionuclide cisternography is the investigation of eSF leaks and eSF spinal flow obstruction. It may demonstrate the existence and site of eSF leakage or block and offer valuable assistance to the neurosurgeon. Radionuclide cisternographic images are usually interpreted subjectively on the basis of abnormal regional and temporal concentrations of radiopharmaceuticals in the eSF space. The evaluation of images can be improved by the use of quantitative computerized digital scanning, increasing the sensitivity and value of the measurements. The further extension of these studies involving abnormalities of cerebrospinal fluid dynamics would seem worthwhile, and the value of the methods described in this thesis and their limitations, remain a potential and challenging field for further exploration.
Open Access
Transfusion practices in the Eastern Cape Province of South Africa in the era of HIV and HAART
(University of the Free State, 2014) Van den Berg, Karin; Louw, V. J.; Murphy, E. L.; Pretorius, L.
The HIV/AIDS pandemic has irrevocably changed the face of healthcare delivery and research. This is especially true in South Africa with its estimated 5.26 million HIV-infected people. It was not until the significant up scaling of the anti-retroviral therapy roll-out that the HIV-incidence rate in South Africa started declining substantially from an estimated 1.32% in 2005 to an estimated 0.85% in 2013. Cytopaenias are common in HIV-infected individuals. Their risk of developing anaemia ranges from 60 to 95% during the course of the disease. The impact of HIV/AIDS on blood utilisation in the country is largely unknown. With this study we aimed to address the lack of knowledge regarding the blood requirements of the HIV-positive population and how the changing epidemic may affect future blood utilisation, by establishing what proportion of blood issued to medical and surgical patients admitted to a large referral hospital in the Eastern Cape Province of South Africa, was issued to HIV-positive patients Methods We conducted a retrospective cross-sectional study analysing the prevalence of HIV among patients receiving blood and blood products. Baseline demographic data was collected on all patients admitted during a three-month period with additional clinical data collected on patients who received a blood transfusion. Ethics approval was obtained from the UFS and the South African National Blood Service (SANBS). Approval to complete the study was obtained from the senior management of the Hospital and the local blood service offices. Following a short pilot study during which the various systems were tested, data collection commenced on 7 January 2013 and was completed on 6 April 2013. Results A total of 3438 patient admissions were included in the study with equal distribution between male and female patients. Patients tended to be younger with almost 75% of patients younger than 60. Almost 8% of patients were transfused. HIV status was poorly recorded. Only 25% of patients had a HIV test result on file. The reported HIV prevalence was 14%. The median LOS was 7 days and in-patient mortality 8%. During 330 transfusion episodes, 267 patients received 609 units of RBC, i.e. 1.24 transfusion episodes per patient. Except for 6 units, all units issued were recorded as transfused, translating to a transfused ratio of 1.00:0.99. Being HIV-positive, surgical admissions, having been admitted to ICU, extended LOS and death at discharge were independently association with having received a transfusion. Mean pre- and post-transfusion Hb levels were significantly lower in HIV-positive patients and these patients were less likely to have had a correctly completed consent form on record, but were more likely to have had their anaemia investigated. Discussion The complex HIV-testing at this facility hampered the analysis of the data and raises serious public health questions. Despite this, it is clear that HIV significantly impacts blood utilisation at this facility. HIV-prevalence among all admissions was found to be ~ 14%, as compared to the almost 20% among the recipients of blood. Similarly 26% of the transfusion episodes involved HIV positive patients. However, only 16% of the units issued were issued to HIV-positive patients. The data suggests that HIV-status significantly influenced doctors’ transfusion practices. HIV-positive patients had significantly lower pre- and post-transfusion Hb levels suggesting lower transfusion triggers and targets for HIV-positive patients. These patients were also less likely to have had correctly completed consent forms; only a third of HIV-positive patients had correctly completed forms on record. Conclusion HIV contributes significantly to the blood utilisation at a tertiary hospital in the Eastern Cape and would appear to influence clinicians’ transfusion practice. The exact nature of the interaction between HIV and transfusion requires further investigation.

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