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Item 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.Item 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.Item 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.Item 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.Item 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.Item 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, AnandanBackground: 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.Item 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, CloeteA 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.Item 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.