Stellenbosch University - Scopus Tygerberg Hospital Publications

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Electronic decision protocols for ART patient triaging to expand access to HIV treatment in South Africa : a cross sectional study for development and validation
(2012-02-22) Mitchell M.; Hedt B.L.; Eshun-Wilson I.; Fraser H.; John M.-A.; Menezes C.; Grobusch M.P.; Jackson J.; Taljaard J.; Lesh N.
Background: The shortage of doctors and nurses, along with future expansion into rural clinics, will require that the majority of clinic visits by HIV infected patients on antiretroviral therapy (ART) are managed by non-doctors. The goal of this study was to develop and evaluate a screening protocol to determine which patients needed a full clinical assessment and which patients were stable enough to receive their medications without a doctor's consultation. For this study, we developed an electronic, handheld tool to guide non-physician counselors through screening questions. Methods: Patients visiting two ART clinics in South Africa for routine follow-up visits between March 2007 and April 2008 were included in our study. Each patient was screened by non-physician counselors using the handheld device and then received a full clinical assessment. Clinicians' report on whether full clinical assessment had been necessary was used as the gold standard for determining "required referral". Observations were randomly divided into two datasets - 989 for developing a referral protocol and 200 for validating protocol performance. Results: A third of patients had at least one physical complaint, and 16% had five or more physical complaints. 38% of patients required referral for full clinical assessment. We identify a subset of questions which are 87% sensitive and 47% specific for recommended patient referral. Conclusions: The final screening protocol is highly sensitive and could reduce burden on ART clinicians by 30%. The uptake and acceptance of the handheld tool to support implementation of the protocol was high. Further examination of the data reveals several important questions to include in future referral algorithms to improve sensitivity and specificity. Based on these results, we identify a refined algorithm to explore in future evaluations. © 2011.
Nerve-sparing Radical Cystectomy: A New Technique
(2011-05-15) Hautmann R.E.; Hautmann O.; Volkmer B.G.; Hautmann S.
Background: The results of post-radical cystectomy (RC) erectile function are notoriously disappointing, except when a prostate-sparing technique is used. However, valid concerns regarding oncologic safety still predominate, and protocols for patient selection and technique are not well defined. Objective: We describe a new technique for nerve-sparing RC and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, and neurovascular bundles (NVB). No prostatic tissue is left behind, thus eliminating the risk of local recurrence from bladder cancer (BCa) as well as de novo prostate cancer. Design, setting, participants: Between March 2008 and October 2009, nine patients with intact erectile function and non-muscle-invasive bladder cancer (NMIBC) or stage ≤pT3a away from the trigone underwent this type of procedure. Prostatic carcinoma was excluded by normal digital rectal examination (DRE) and transurethral ultrasound (TRUS), a prostate-specific antigen (PSA) value ≤4.0 ng/ml, and a free-to-total PSA ratio >20%. Intervention: The procedure starts as a standard nerve-sparing radical prostatectomy (RP). After transection of the urethra with Denonvillier's fascia still intact, vasa deferentia and seminal vesicles are transected at the base of the prostate, and the trigone is undermined to the space of Douglas. The cystectomy is completed in ascending or preferably descending fashion. Measurements: Patients were evaluated pre- and postoperatively using the International Index of Erectile Function (IIEF) questionnaire. Patients were followed up regularly at 2 mo, 6 mo, and 12 mo. Results and limitations: Four out of nine patients maintained spontaneous complete tumescence, and five patients had partial tumescence using sildenafil as a successful erectogenic aid. PSA was <0.1 ng/ml in all cases. All patients showed no evidence of disease (NED). Conclusion: With correct patient selection, excellent functional results can be obtained. © 2010 European Association of Urology.
Secondary Analysis of Anthropometric Data from a South African National Food Consumption Survey, Using Different Growth Reference Standards
(2010) Bosman L.; Herselman M.G.; Kruger H.S.; Labadarios D.
The National Center for Health Statistics (NCHS) references were used to analyse anthropometric data from the 1999 National Food Consumption Survey (NFCS) of South Africa. Since then, however, The Centers for Disease Control and Prevention (CDC) 2000 reference and the World Health Organization (WHO) 2006 standards were released. It was anticipated that these reference and standards may lead to differences in the previous estimates of stunting, wasting, underweight and obesity in the study population. The aim was to compare the anthropometric status of children using the 1977 NCHS, the 2000 CDC growth references and the 2006 WHO standards. All children 12-60 months of age with a complete set of anthropometric data were included in the analyses. Data for 1,512 children were analysed with SAS 9.1 for Windows. A Z-score was calculated for each child for weight-for-age (W/A), weight-for-length/height (W/H), length/height-for-age (H/A) and body mass index (BMI)-for-age, using each of the three reference or standards for comparison. The prevalence of stunting, obesity and overweight were significantly higher and the prevalence of underweight and wasting were lower when using the WHO standards compared to the NCHS and the CDC references. The higher than previously established prevalence of stunting at 20.1% and combined overweight/obesity at 30% poses a challenge to South African policy makers to implement nutrition programmes to decrease the prevalence of both stunting and overweight. The 2006 WHO growth standard should be the standard used for assessment of growth of infants and children younger than 5 years in developing countries. © 2010 Springer Science+Business Media, LLC.
Specific exercises to treat pregnancy-related low back pain in a South African population
(2011-05-15) Kluge J.; Hall D.; Louw Q.; Theron G.; Grove D.
Objective: To investigate the effect of an exercise program, including specific stabilizing exercises, on pain intensity and functional ability in women with pregnancy-related low back pain. Methods: Fifty women between 16 and 24 weeks of pregnancy were recruited at Tygerberg and Paarl Hospitals, Western Cape, South Africa. Twenty-six women were randomized to a 10-week exercise program and 24 were randomized as controls. Results: Overall, the most frequent type of back pain experienced was lumbar pain (36 [72.0%]). Pain intensity (P = 0.76) and functional ability (P = 0.29) were comparable between the groups on study entry. In the study group, there was a significant improvement in pain intensity (P < 0.01) and an improvement in functional ability (P = 0.06) at the end of the study. In the control group, there were no significant changes in pain intensity (P = 0.89) or functional ability (P = 0.70) at the end of the study. Conclusion: A specific exercise program decreased back pain intensity and increased functional ability during pregnancy in South African women with lumbar and pelvic girdle pain. © 2011 International Federation of Gynecology and Obstetrics.
The pharmacokinetics and pharmacodynamics of rifampicin in adults and children in relation to the dosage recommended for children
(2011-05-15) Donald P.R.; Maritz J.S.; Diacon A.H.
The dosages of antituberculosis agents recommended for treatment of childhood tuberculosis often reflect those for adult patients with similar mg/kg body weight dosages and ranges advised. Literature relating to the pharmacokinetics and pharmacodynamics of rifampicin (RMP) is reviewed and the serum concentrations reached by adults, both patients and healthy volunteers and children, established or not established on RMP, compared. Straight line regression of maximum RMP serum concentrations (Cmax) on dosage, weighted for the number of individuals, found slopes (SE) of 1.025 (0.067) and 0.881 (0.046) respectively for adult volunteers not established and established on RMP (P = 0.076), and similarly 0.748 (0.057) and 0.684 (0.038) respectively for adult patients (P < 0.001) and 0.622 (0.050) and 0.368 (0.041) respectively for children (P < 0.001). These results indicate that for equivalent RMP dosages adult patients reach a lower Cmax than adult volunteers and that adults, both volunteers and patients established on RMP reach higher Cmax values than children; children established on RMP require approximately twice the mg/kg body weight dosage of RMP to reach serum concentrations equivalent to those of adults. It is noteworthy that many adult patients receiving currently recommended RMP dosages also do not reach the often recommended RMP 2 h serum concentration of 8 μg/mL. © 2011 Elsevier Ltd. All rights reserved.
The potential to transmit Mycobacterium tuberculosis at a South African tertiary teaching hospital
(2011-05-15) Sissolak D.; Bamford C.M.; Mehtar S.
Objectives: To assess the risk of nosocomial transmission by confirmed pulmonary tuberculosis (PTB) patients in a high TB/HIV incidence environment. Methods: Between November 2006 and April 2007, we carried out a cross-sectional survey of PTB patients with positive smears or cultures at an academic tertiary hospital in the Western Cape, South Africa. Results: Of 394 confirmed PTB patients, only 199 (50.5%) had a known HIV status, of whom 107 (53.8%) were HIV-co-infected. Sensitivity testing for Mycobacterium tuberculosis (TB) was done in 49.3% of patients with available cultures (140/284). Of these patients, 9.3% (13/140) had multidrug-resistant (MDR) TB strains. The turnaround times (TAT) for culture and susceptibility testing were delayed: mean TAT for cultures was 27 days (range 63 days) and for susceptibility testing was 42 days (range 63 days). One fifth of PTB patients (82/394) were diagnosed from wards that do not deal with TB on a daily basis. PTB inpatients were hospitalized for an average of 13 days and were on average transferred twice. Only 14.2% of all PTB patients were notified to the South Africa Provincial Department of Health. Throughout their hospitalization, PTB patients were potentially infectious. Conclusions: The potential for nosocomial TB transmission in a setting of high TB and HIV co-infection with a high MDR prevalence, inconsistent infection prevention and control measures, and delayed diagnosis cannot be ignored. Barriers to TB infection control must urgently be addressed. © 2009 International Society for Infectious Diseases.
Tracheostomy home care: In a resource-limited setting
(2010) Vanker A.; Kling S.; Booysen J.R.; Rhode D.; Goussard P.; Heyns L.; Gie R.P.
Introduction: Home tracheostomy care for children in South Africa dates back to 1989. Objective: This study aimed to describe the tracheostomy home programme at Tygerberg Children's Hospital (TCH), situated in a resource-limited setting in Cape Town, South Africa. Design: Retrospective descriptive study. Setting: Tracheostomy home programme at TCH. The primary care giver is trained by nurses. Results: Fifty-six children (29 girls) were discharged to the home programme (47 to home and 9 to institutions). The median age at tracheostomy was 3 months, mainly for airway obstruction. The mean duration of home care was 26.6 months. Twenty-seven children (43%) were successfully decannulated. Seven children lived in informal housing. The 56 children generated 745 social work contacts. The overall survival was 82%. Conclusion: Children with tracheostomies can be safely cared for at home, even in a resource-constrained environment, provided training, appropriate technology and social support services are available. Copyright Article author (or their employer) 2010.
Tuberculous broncho-oesophageal fistula: images demonstrating the pathogenesis
(2010) Goussard P.; Andronikou S.
[No abstract available]

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