Browsing by Author "Allwood, Brian W."
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- ItemBenefit v. risk when using chloroquine in patients with severe COVID-19 disease(Health & Medical Publishing Group, 2020-04-02) Decloedt, Eric H.; Allwood, Brian W.; Parker, Arifa; Koegelenberg, Coenraad F. N.; Blockman, Marc; Taljaard, Jantjie; Reuter, HelmuthENGLISH ABSTRACT: Chloroquine (CQ) is widely advocated as treatment for coronavirus disease 2019 (COVID-19), including the president of the USA publicly supporting the use of hydroxychloroquine (HCQ) as a ‘game-changer’ on the social media platform Twitter. CQ and HCQ are structurally similar, with HCQ having an N-hydroxyl-ethyl side-chain in place of the N-diethyl group. Currently only CQ is being marketed in South Africa. We encourage the development of curative directed therapy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using appropriate designed trials and regulatory oversight, and caution against the indiscriminate use of CQ or HCQ. Careful patient selection is essential, including assessing prognosis, anticipated benefit and potential harms prior to initiating CQ/HCQ therapy.
- ItemChronic obstructive pulmonary disease in South Africa : under-recognised and undertreated(Health & Medical Publishing Group, 2015) Allwood, Brian W.; Van Zyl-Smit, Richard N.Chronic obstructive pulmonary disease (COPD) is a common, preventable but incurable condition currently ranked third in global mortality estimates. Worldwide, 65 million people are estimated to have moderate to severe COPD, and the disease accounts for 3 million deaths annually, of which 90% are said to occur in low- and middle-income countries. Yet, despite these staggering numbers, COPD remains both under-recognised and undertreated in most populations, also in South Africa (SA). There are many reasons for this, not least of which is the attitude of clinicians, which can often be fatalistic with regard to COPD. This edition of CME highlights key aspects of the diagnosis and treatment – pharmacological and non-pharmacological – and new developments in the management of severe disease. Furthermore, we have included articles focusing on non-smokingrelated COPD and tips for good spirometry.
- ItemClinical evolution, management and outcomes of patients with COVID-19 admitted at Tygerberg Hospital, Cape Town, South Africa : a research protocol(BMJ Publishing Group, 2020-08-06) Allwood, Brian W.; Koegelenberg, Coenraad F. N.; Irusen, Elvis; Lalla, Usha; Davids, Razeen; Chothia, Yazied; Davids, Ryan; Prozesky, Hans; Taljaard, Jantjie; Parker, Arifa; Decloedt, Eric; Jordan, Portia; Lahri, Sa'ad; Moosa, Rafique; Schrueder, Neshaad; Du Toit, Riette; Viljoen, Abraham; English, Rene; Ayele, Birhanu; Nyasulu, Peter; COVID-19 Research Response TeamIntroduction The outbreak of the SARS-CoV-2 virus causing COVID-19, declared a global pandemic by the WHO, is a novel infection with a high rate of morbidity and mortality. In South Africa, 55 421 cases have been confirmed as of 10 June 2020, with most cases in the Western Cape Province. Coronavirus leaves us in a position of uncertainty regarding the best clinical approach to successfully manage the expected high number of severely ill patients with COVID-19. This presents a unique opportunity to gather data to inform best practices in clinical approach and public health interventions to control COVID-19 locally. Furthermore, this pandemic challenges our resolve due to the high burden of HIV and tuberculosis (TB) in our country as data are scarce. This study endeavours to determine the clinical presentation, severity and prognosis of patients with COVID-19 admitted to our hospital. Methods and analysis The study will use multiple approaches taking into account the evolving nature of the COVID-19 pandemic. Prospective observational design to describe specific patterns of risk predictors of poor outcomes among patients with severe COVID-19 admitted to Tygerberg Hospital. Data will be collected from medical records of patients with severe COVID-19 admitted at Tygerberg Hospital. Using the Cox proportional hazards model, we will investigate the association between the survival time of patients with COVID-19 in relation to one or more of the predictor variables including HIV and TB. Ethics and dissemination The research team obtained ethical approval from the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences, Stellenbosch University and Research Committee of the Tygerberg Hospital. All procedures for the ethical conduct of scientific investigation will be adhered to by the research team. The findings will be disseminated in clinical seminars, scientific forums and conferences targeting clinical care providers and policy-makers.
- ItemComplete resolution of apparently definite radiological and histological usual interstitial pneumonia(Health & Medical Publishing Group, 2018-08-30) Simon, D.; Irusen, E. M.; Allwood, Brian W.; Rigby, J.; Koegelenberg, C. F. N.ENGLISH ABSTRACT: Idiopathic pulmonary fibrosis is considered to be the most common form of pulmonary fibrosis. It is a progressive and irreversible disease with a reported median survival of ~3 years. The pathological correlate is usual interstitial pneumonia (UIP), and although antifibrotic agents can slow down lung function decline, they do not completely reverse the disease process. To date, there have been no case reports describing reversal of UIP. We present a case where both the imaging and histology were compatible with definite UIP, yet it reversed with immunosuppressive therapy without the use of antifibrotic agents.
- ItemConsent for critical care research after death from COVID-19 : arguments for a waiver(Health & Medical Publishing Group, 2020-05-26) Moodley, Keymanthri; Allwood, Brian W.; Rossouw, T. M.Pandemics challenge clinicians and scientists in many ways, especially when the virus is novel and disease expression becomes variable or unpredictable. Under such circumstances, research becomes critical to inform clinical care and protect future patients. Given that severely ill patients admitted to intensive care units are at high risk of mortality, establishing the cause of death at a histopathological level could prove invaluable in contributing to the understanding of COVID-19. Postmortem examination including autopsies would be optimal. However, in the context of high contagion and limited personal protective equipment, full autopsies are not being conducted in South Africa (SA). A compromise would require tissue biopsies and samples to be taken immediately after death to obtain diagnostic information, which could potentially guide care of future patients, or generate hypotheses for finding needed solutions. In the absence of an advance written directive (including a will or medical record) providing consent for postmortem research, proxy consent is the next best option. However, obtaining consent from distraught family members, under circumstances of legally mandated lockdown when strict infection control measures limit visitors in hospitals, is challenging. Their extreme vulnerability and emotional distress make full understanding of the rationale and consent process difficult either before or upon death of a family member. While it is morally distressing to convey a message of death telephonically, it is inhumane to request consent for urgent research in the same conversation. Careful balancing of the principles of autonomy, non-maleficence and justice becomes an ethical imperative. Under such circumstances, a waiver of consent, preferably followed by deferred proxy consent, granted by a research ethics committee in keeping with national ethics guidance and legislation, would fulfil the basic premise of care and research: first do no harm. This article examines the SA research ethics framework, guidance and legislation to justify support for a waiver of consent followed by deferred proxy consent, when possible, in urgent research after death to inform current and future care to contain the pandemic in the public interest.
- ItemCOVID-19 in Africa : care and protection for frontline healthcare workers(BioMed Central, 2020) Chersich, Matthew F.; Gray, Glenda; Fairlie, Lee; Eichbaum, Quentin; Mayhew, Susannah; Allwood, Brian W.; English, Rene; Scorgie, Fiona; Luchters, Stanley; Simpson, Greg; Mosalman Haghighi, Marjan; Duc Pham, Minh; Rees, HelenMedical staff caring for COVID-19 patients face mental stress, physical exhaustion, separation from families, stigma, and the pain of losing patients and colleagues. Many of them have acquired SARS-CoV-2 and some have died. In Africa, where the pandemic is escalating, there are major gaps in response capacity, especially in human resources and protective equipment. We examine these challenges and propose interventions to protect healthcare workers on the continent, drawing on articles identified on Medline (Pubmed) in a search on 24 March 2020. Global jostling means that supplies of personal protective equipment are limited in Africa. Even low-cost interventions such as facemasks for patients with a cough and water supplies for handwashing may be challenging, as is ‘physical distancing’ in overcrowded primary health care clinics. Without adequate protection, COVID-19 mortality may be high among healthcare workers and their family in Africa given limited critical care beds and difficulties in transporting ill healthcare workers from rural to urban care centres. Much can be done to protect healthcare workers, however. The continent has learnt invaluable lessons from Ebola and HIV control. HIV counselors and community healthcare workers are key resources, and could promote social distancing and related interventions, dispel myths, support healthcare workers, perform symptom screening and trace contacts. Staff motivation and retention may be enhanced through carefully managed risk ‘allowances’ or compensation. International support with personnel and protective equipment, especially from China, could turn the pandemic’s trajectory in Africa around. Telemedicine holds promise as it rationalises human resources and reduces patient contact and thus infection risks. Importantly, healthcare workers, using their authoritative voice, can promote effective COVID-19 policies and prioritization of their safety. Prioritizing healthcare workers for SARS-CoV-2 testing, hospital beds and targeted research, as well as ensuring that public figures and the population acknowledge the commitment of healthcare workers may help to maintain morale. Clearly there are multiple ways that international support and national commitment could help safeguard healthcare workers in Africa, essential for limiting the pandemic’s potentially devastating heath, socio-economic and security impacts on the continent.
- ItemThe current aetiology of malignant pleural effusion in the Western Cape Province, South Africa(Health & Medical Publishing Group, 2018-04) Koegelenberg, C. F. N.; Bennji, S. M.; Boer, E.; Schubert, P. T.; Shaw, J. A.; Allwood, Brian W.; Irusen, E. M.Background: Malignant pleural effusion (MPE) represents a very common cause of pleural exudates, and is one of the most challenging pleural disorders to manage. This could be attributed to the paucity of high-quality experimental evidence, and inconsistent practice worldwide. South Africa (SA) currently has no data regarding the aetiology of MPE. Objectives: To identify the most common malignancies causing MPE in a population served by a large tertiary hospital in SA, and specifically the relative contribution of mesothelioma. A secondary objective was to evaluate the efficacy of chemical pleurodesis in a subset of patients. Methods: We retrospectively included all known cases of MPE evaluated at our institution over a 3-year period with a tissue diagnosis of MPE. Results: The most common causes of MPE in a total of 274 patients were lung cancer (n=174, 63.5%), breast cancer (n=32, 11.7%), unknown primary (n=22, 11.7%) and mesothelioma (n=27, 9.9%). Talc pleurodesis was performed in 81 of 194 patients (41.8%) referred to our division, and was radiologically successful in 22 of 25 (88.0%) followed up to 3 months. Conclusions: The main cause of MPE in our setting was lung cancer, followed by breast cancer, unknown primary and mesothelioma. Chemical pleurodesis was a viable palliative measure for MPE in this population.
- ItemEndoscopic lung volume reduction in severe emphysema(Health & Medical Publishing Group, 2015) Koegelenberg, Coenraad Frederik N.; Theron, Johan; Bruwer, J. W.; Allwood, Brian W.; Vorster, Morne J.; Von Groote-Bidlingmaier, Florian; Dheda, KeertanENGLISH ABSTRACT: Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced emphysema with the aim of obtaining similar functional advantages to surgical lung volume reduction, while reducing risks and costs. There is a growing body of evidence that certain well-defined subgroups of patients with advanced emphysema benefit from ELVR, provided that a systematic approach is followed and selection criteria are met. In addition to endobronchial valves, ELVR using endobronchial coils is now available in South Africa. The high cost of these interventions underscores the need for careful patient selection to best identify those likely to benefit from such procedures.
- ItemFatal tumour pulmonary embolism(Wiley Open Access, 2017) Masoud, Salim Rashid; Koegelenberg, Coenraad Frederik Nicolaas; Van Wyk, Abraham Christoffel; Allwood, Brian W.A 30-year-old female with no significant past medical history was referred to our facility with sudden onset of shortness of breath. She had a low clinical probability for pulmonary thromboembolism and a computed tomography angiogram showed enlarged pulmonary arteries but no in situ thrombi. She developed recurrent episodes of hypotension and hypoxia, and was transferred to the intensive care unit where she died despite active resuscitation. An autopsy revealed extensive lymphatic and pulmonary vascular tumour emboli as the immediate cause of death. Pulmonary tumour embolism is a very rare cause of death, but can occur in patients who have an occult neoplasm.
- ItemFive-year follow-up of participants diagnosed with chronic airflow obstruction in a South African Burden of Obstructive Lung Disease (BOLD) survey(Health & Medical Publishing Group, 2018-02-01) Allwood, Brian W.; Gillespie, R.; Bateman, M.; Olckers, H.; Taborda-Barata, Luis; Calligaro, G.; Van Zyl-Smit, R.; Cooper, C. B.; Beyers, Nulda; Bateman, E. D.Background. A community-based prevalence survey performed in two suburbs in Cape Town, South Africa (SA), in 2005, using the international Burden of Obstructive Lung Disease (BOLD) method, confirmed a prevalence of chronic airflow obstruction (CAO) in 23.1% of adults aged >40 years. Objectives. To study the clinical course and prognosis over 5 years of patients with CAO identified in the 2005 survey. Methods. Patients with CAO in 2005 were invited to participate. Standard BOLD and modified questionnaires were completed. Spirometry was performed using spirometers of the same make as in 2005. Results. Of 196 eligible participants from BOLD 2005, 45 (23.0%) had died, 8 from respiratory causes, 10 from cardiovascular causes and 6 from other known causes, while in 21 cases the cause of death was not known. On multivariate analysis, only age and Global initiative for Obstructive Lung Disease (GOLD) stage 4 disease at baseline were significantly associated with death. Of the 151 survivors, 11 (5.6% of the original cohort) were unavailable and 33 (16.8%) declined or had medical exclusions. One hundred and seven survivors were enrolled in the follow-up study (54.6%, median age 63.1 years, 45.8% males). Post-bronchodilator spirometry performed in 106 participants failed to confirm CAO, defined as a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of <0.7, in 16 participants (15.1%), but CAO was present in 90. The median decline in FEV1 was 28.9 mL/year (interquartile range –54.8 - 0.0) and was similar between GOLD stages. The median total decline in FVC was 75 mL, and was significantly greater in GOLD stage 1 (–350 mL) than in stages 2 or 3 (–80 mL and +140 mL, respectively; p<0.01). Fifty-eight participants with CAO in 2005 (64.4%) remained in the same GOLD stage, while 21 (23.3%) deteriorated and 11 (12.2%) improved by ≥1 stage. Only one-third were receiving any treatment for chronic obstructive pulmonary disease (COPD). Conclusions. The prevalence, morbidity and mortality of CAO and COPD in SA are high and the level of appropriate treatment is very low, pointing to underdiagnosis and inadequate provision of and access to effective treatments and preventive strategies for this priority chronic non-communicable disease.
- ItemObstructive pulmonary disease in patients with previous tuberculosis : pathophysiology of a community-based cohort(Health & Medical Publishing Group, 2017) Allwood, Brian W.; Gillespie, Rencia; Galperin-Aizenberg, Maya; Bateman, Mary; Olckers, Helena; Taborda-Barata, Luis; Calligaro, Gregory L.; Said-Hartley, Qonita; Van Zyl-Smit, Richard; Cooper, Christopher B.; Van Rikxoort, Eva; Goldin, Jonathan; Beyers, Nulda; Bateman, Eric D.Background. An association between chronic airflow limitation (CAL) and a history of pulmonary tuberculosis (PTB) has been confirmed in epidemiological studies, but the mechanisms responsible for this association are unclear. It is debated whether CAL in this context should be viewed as chronic obstructive pulmonary disease (COPD) or a separate phenotype. Objective. To compare lung physiology and high-resolution computed tomography (HRCT) findings in subjects with CAL and evidence of previous (healed) PTB with those in subjects with smoking-related COPD without evidence of previous PTB. Methods. Subjects with CAL identified during a Burden of Obstructive Lung Disease (BOLD) study performed in South Africa were studied. Investigations included questionnaires, lung physiology (spirometry, body plethysmography and diffusing capacity) and quantitative HRCT scans to assess bronchial anatomy and the presence of emphysema (<–950 HU), gas trapping (<–860 HU) and fibrosis (>–200 HU). Findings in subjects with a past history and/or HRCT evidence of PTB were compared with those in subjects without these features. Results. One hundred and seven of 196 eligible subjects (54.6%) were enrolled, 104 performed physiology tests and 94 had an HRCT scan. Based on history and HRCT findings, subjects were categorised as no previous PTB (NPTB, n=31), probable previous PTB (n=33) or definite previous PTB (DPTB, n=39). Subjects with DPTB had a lower diffusing capacity (Δ=–17.7%; p=0.001) and inspiratory capacity (Δ=–21.5%; p=0.001) than NPTB subjects, and higher gas-trapping and fibrosis but not emphysema scores (Δ=+6.2% (p=0.021), +0.36% (p=0.017) and +3.5% (p=0.098), respectively). Conclusions. The mechanisms of CAL associated with previous PTB appear to differ from those in the more common smoking-related COPD and warrant further study.
- ItemPathogenesis of chronic obstructive pulmonary disease : an African perspective(Health & Medical Publishing Group, 2015) Allwood, Brian W.; Calligaro, G .The importance of chronic obstructive pulmonary disease (COPD) as a global health problem cannot be overstated. According to the latest World Health Organization statistics (2005), 210 million people suffer from COPD worldwide, and 5% of all deaths globally are estimated to be caused by this disease. This corresponds to >3 million deaths annually, of which 90% are thought to occur in low- and middle-income countries. While cigarette smoking remains the major risk factor, and much of the increase in COPD is associated with projected increases in tobacco use, epidemiological studies have demonstrated that in the majority of patients in developing countries the aetiology of COPD is multifactorial. This article summarises the epidemiology of and risk factors for COPD in Africa, including influences other than cigarette smoking that are important contributors to chronic irreversible airflow limitation in our setting.
- ItemPost-pulmonary tuberculosis complications in South Africa and a potential link with pulmonary hypertension : premise for clinical and scientific investigations(Health & Medical Publishing Group, 2018) Allwood, Brian W.; Maarman, G. J.; Kyriakakis, C. G.; Doubell, A. F.The magnitude of the pulmonary tuberculosis (TB) epidemic in South Africa (SA) and globally has received increased attention. Efforts have been made to explore new and improved diagnostic and treatment strategies, but the story does not end with treatment, and TB frequently results in long-term lung damage.
- ItemTransition from restrictive to obstructive lung function impairment during treatment and follow-up of active tuberculosis(Dove Press, 2020-05) Allwood, Brian W.; Maasdorp, Elizna; Kim, Grace J.; Cooper, Christopher B.; Goldin, Jonathan; van Zyl-Smit, Richard N.; Bateman, Eric D.; Dawson, RodneyBackground: Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB. Methods: Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment. Results: Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P<0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P<0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC <80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC>45%), and 78.6% had reduced DLco. Conclusion: Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process. Keywords: airflow obstruction; chronic obstructive pulmonary disease; computed tomography; lung function; post-tuberculosis; tuberculosis.
- ItemTransition from restrictive to obstructive lung function impairment during treatment and follow-up of active tuberculosis(Dove Medical Press, 2020) Allwood, Brian W.; Maasdorp, Elizna; Kim, Grace J.; Cooper, Christopher B.; Goldin, Jonathan; Van Zyl-Smit, Richard N.; Bateman, Eric D.; Dawson, RodneyBackground: Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB. Methods: Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment. Results: Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P< 0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P< 0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC < 80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC> 45%), and 78.6% had reduced DLco. Conclusion: Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process.
- ItemThe utility of high-flow nasal cannula oxygen therapy in the management of respiratory failure secondary to COVID-19 pneumonia(Health & Medical Publishing Group, 2020-05-07) Lalla, Usha; Allwood, Brian W.; Louw, Elizabeth H.; Nortje, Andre; Parker, Arifa; Taljaard, Jantjie J.; Moodley, Desiree; Koegelenberg, Coenraad F. N.COVID-19 is a potentially fatal infection caused by SARS-CoV-2. As of 4 May 2020, more than 6 000 cases had been confirmed in South Africa (SA) with numbers rising steadily, a situation that will place a major strain on the country’s health resources, including its ability to provide intensive care and ventilatory support to patients with severe disease.