Research Outputs (Clinical Medicine)
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Item A long walk to freedom: the epidemiology of penetrating trauma in South Africa- analysis of 4 697 patients over a six year period at Chris Hani Baragwanath Academic HospitalBhana, Malini; Fru, Pascaline; Plani, FrancoBackground: Despite the city of Johannesburg having one of the highest rates of crime in the world, no national databank for trauma exists. This study profiles the victims of penetrating trauma and identifies geographical areas in which it occurs, while describing the outcomes and patterns of injury. Methods: A retrospective study including penetrating trauma patients triaged as Priority 1, presenting at the Chris Hani Baragwanath Academic Hospital's (CHBAH) trauma department over a six-year period (2011-2016). Results: A total of 4 697 patients were included. The majority of victims were Black African males (92.1%) between the ages of 29-40 years, and stabbings were the most common mechanism of injury (71.8%), followed by gunshots. The commonest body area affected was the thorax, with a consequent haemothorax the most likely result. Weekends accounted for over 48% of all presentations - the last weekend of the month being the busiest. Region D was the area in Johannesburg with the highest trauma incidence (51.9%), with the oldest townships in Soweto found to be "hot spots". Conclusion: Penetrating trauma is inherently linked to alcohol abuse and interpersonal violence in South Africa,1 primarily affecting its young economic, working-class citizens. The data provided some insight into the burden, structure and challenges of our trauma system. These should be regarded as opportunities to implement change and improve our surveillance and prevention, beginning with a national trauma databankItem A brief history of South Africa's response to Aids(2014) Simelela, N.P.; Venter, W.D.F.The story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile system to bring about change.Item The challenges of managing breast cancer in the developing world- a perspective from sub- Saharan Africa(2014-05) Edge, J; Buccimazza, I; Cubasch, H; et al.Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.Item Charting the path along the continuum of PMCT or HIV-1 to elimination and finally to eradication(2014-01) Ramkissoon, A; Coovadia, HIn this editorial we traverse the continuum of transmission of HIV-1 from mothers to children to highlight the biomedical history of this problem. Treatment has progressed from prevention with antiretrovirals (ARVs) through to a broader set of interventions, including various breastfeeding options and other health system improvements, that have increased the possibility of eliminating mother-to-child-transmission (MTCT) of HIV.Item Clinical access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis(2014-03) Conradie, F; Meintjies, G; Hughes, J; et alWhile clinical disease caused by drug-sensitive Mycobacterium tuberculosis (MTB) can usually be treated successfully, clinical disease caused by drug-insensitive MTB is associated with a poorer prognosis. In December 2012, a new drug, bedaquiline, was approved by the US Food and Drug Administration. This article documents the process whereby the National Department of Health, Right to Care and Médecins Sans Frontières obtained access to this medication for South Africans who might benefit from subsequent implementation of the Clinical Access to Bedaquiline Programme.Item The cost of harmful alcohol use in South Africa(2014-02) Matzopoulos, R G; Truen, S; Bowman, B; et al.Background. The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. Methods. We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. Results. The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. Discussion. The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. Conclusions. Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms.Item Epidemiology of maxillofacial fractures at two maxillofacial units in South Africa(South African Dental Association, 2018-04) Mogajane, Brampie; Mabongo, MzubanziThis article compares epidemiologic characteristics of maxillofacial fractures seen in patients presenting at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) with those seen at Polokwane – Mankweng Hospital Complex (PMHC).Item Factors associated with mortality in HIV-infected people in rural and urban South Africa(2014) Otwombe, KN; Petzold, M; Modisenyane, TBackground: Factors associated with mortality in HIV-infected people in sub-Saharan Africa are widely reported. However rural urban disparities and their association with all-cause mortality remain unclear. Furthermore, commonly used classical Cox regression ignores unmeasured variables and frailty. Objective: To incorporate frailty in assessing factors associated with mortality in HIV-infected people in rural and urban South Africa. Design: Using data from a prospective cohort following 6,690 HIV-infected participants from Soweto (urban) and Mpumalanga (rural) enrolled from 2003 to 2010; covariates of mortality were assessed by the integrated nested Laplace approximation method. Results: We enrolled 2,221 (33%) rural and 4,469 (67%) urban participants of whom 1,555 (70%) and 3,480 (78%) were females respectively. Median age (IQR) was 36.4 (31.0 44.1) in rural and 32.7 (28.2 38.1) in the urban participants. The mortality rate per 100 person-years was 11 (9.7 12.5) and 4 (3.6 4.5) in the rural and urban participants, respectively. Compared to those not on HAART, rural participants had a reduced risk of mortality if on HAART for 6 12 (HR: 0.20, 95% CI: 0.10 0.39) and 12 months (HR: 0.10, 95% CI: 0.05 0.18). Relative to those not on HAART, urban participants had a lower risk if on HAART 12 months (HR: 0.35, 95% CI: 0.27 0.46). The frailty variance was significant and 1 in rural participants indicating more heterogeneity. Similarly it was significant but B1 in the urban participants indicating less heterogeneity. Conclusion: The frailty model findings suggest an elevated risk of mortality in rural participants relative to the urban participants potentially due to unmeasured variables that could be biological, socio economic, or healthcare related. Use of robust methods that optimise data and account for unmeasured variables could be helpful in assessing the effect of unknown risk factors thus improving patient management and care in South Africa and elsewhere.Item Focus on adolescents with HIV and AIDS(2014-12) Fairlie, L; Sipambo, N; Fick, C; et alAdolescents living with HIV, including those infected perinatally and non-perinatally, bear a disproportionate burden of the HIV epidemic in South Africa. This article discusses HIV management in adolescents including the following aspects: (i) burden of HIV disease, modes of HIV acquisition and implications for management; (ii) initiation of combination antiretroviral therapy (ART), outcomes and complications of ART in adolescents,including virological failure and switching regimens; (iii) adherence in adolescence, including factors that may contribute to poor adherence and advice to improve adherence; (iv) issues particular to adolescents, including sexual and reproductive health needs, disclosure to adolescents and by adolescents, and transition to adult care. This article aims to provide insights based on the literature and experience to assist the clinician to navigate the difficulties of managing HIV in adolescence and achieving successful transition to adult care.Item Health-seeking behaviours by gender among adolescents in Soweto, South Africa(2015) Otwombe, K.; Dietrich, J.; Laher, F.BACKGROUND: Adolescents are an important age-group for preventing disease and supporting health yet little is known about their health-seeking behaviours. OBJECTIVE: We describe socio-demographic characteristics and health-seeking behaviours of adolescents in Soweto, South Africa, in order to broaden our understanding of their health needs. DESIGN: The Botsha Bophelo Adolescent Health Study was an interviewer-administered cross-sectional survey of 830 adolescents (14-19 years) conducted in Soweto from 2010 to 2012. Health-seeking behaviours were defined as accessing medical services and/or being hospitalised in the 6 months prior to the survey. Chi-square analysis tested for associations between gender, other socio-demographic and behavioural characteristics, and health-seeking behaviours. RESULTS: Of 830 adolescents, 57% were female, 50% were aged 17-19 years, 85% were enrolled in school, and 78% reported experiencing medium or high food insecurity. Males were more likely than females to report sexual debut (64% vs. 49%; p<0.0001) and illicit drug use (11% vs. 3%; p<0.0001). Approximately 27% (n=224) and 8% (n=65) reported seeking healthcare or being hospitalised respectively in the previous 6 months, with no significant differences by gender. Services were most commonly sought at medical clinics (75%), predominantly because of flu-like symptoms (32%), followed by concerns about HIV (10%). Compared to females, males were more likely to seek healthcare for condom breakage (8% vs. 2%; p=0.02). Relative to males, a significantly higher proportion of females desired general healthcare services (85% vs. 78%; p=0.0091), counselling (82% vs. 70%; p<0.0001), and reproductive health services (64% vs. 56%; p=0.02). CONCLUSIONS: A quarter of male and female adolescents accessed health services in the 6 months prior to the interview. Adolescents reported a gap between the availability and the need for general, reproductive, and counselling services. Integrated adolescent-friendly, school-based health services are recommended to bridge this gap.Item HIV-related knowledge, perceptions, attitudes, and utilisation of HIV counselling and testing: a venue-based intercept commuter population survey in the inner city of Johannesburg, South Africa(2015) Chimoyi, L; Tshuma, N; Muloongo, KBackground: HIV counselling and testing (HCT) and knowledge about HIV have been key strategies utilised in the prevention and control of HIV/AIDS worldwide. HIV knowledge and uptake of HCT services in sub-Saharan Africa are still low. This study was conducted to determine factors associated with HCT and HIV/AIDS knowledge levels among a commuter population in Johannesburg, South Africa. Objective: To identify the factors associated with HCT uptake among the commuter population. Design: A simple random sampling method was used to select participants in a venue-based intercept survey at a taxi rank in the Johannesburg Central Business District. Data were collected using an electronic questionnaire. Logistic regression analysis assessed factors associated with HIV testing stratified by gender. Results: 1,146 respondents were interviewed, the ma[j]ority (n = 579, 50.5%) were females and (n = 780, 68.1%) were over 25 years of age. Overall HCT knowledge was high (n = 951, 83%) with more females utilising HCT facilities. There was a significant difference in HIV testing for respondents living closer to and further away from health facilities. Slightly more than half of the respondents indicated stigma as one of the barriers for testing (n = 594, 52%, p-value = 0.001). For males, living with a partner (aOR: 1.68, 95% CI: 1.02-2.78, p-value: 0.041) and possessing a post-primary education were positively associated with testing (aOR: 2.00, 95% CI: 1.15-3.47, p-value: 0.014), whereas stigma and discrimination reduced the likelihood of testing (aOR: 0.40, 95% CI: 0.31-0.62, p-value: <0.001). For females, having one sexual partner (aOR: 2.65, 95% CI: 1.19-5.90, p-value: 0.017) and a low perceived benefit for HIV testing (aOR: 0.54, 95% CI: 0.30-0.96, p-value: 0.035) were associated with HIV testing. Conclusion: The overall HIV/AIDS knowledge was generally high. Gender-specific health education and HIV intervention programmes are needed for improved access to HCT services. One favourable intervention would be the use of home-based HCT programmes.Item Locked down impact of covid 19 restrictions on trauma presentations to the emergency departmentVenter, Anica; Lewis, Carolyn; Saffy, Patricia; Chadinha, LouisBackground: COVID-19 was recognised as a global pandemic on 11 March 2020. In South Africa (SA), a nationwide lockdown was implemented at midnight on 26 March to prepare for the predicted surge and slow the spread of the virus. Objectives: To compare the volume and type of presentations of trauma secondary to interpersonal violence and road traffic collisions (RTCs) during two 5-month periods, from February to June 2019 and 2020, in the emergency department (ED) of an academic tertiary hospital in Gauteng Province, SA. In 2020, February - June included the lockdown period. Methods: An observational retrospective audit of the patient register at the Helen Joseph Hospital ED was conducted, comparing the number of trauma presentations secondary to interpersonal violence (assaults with gunshot wounds, general assaults including mob assaults, assaults with stab wounds) and RTC presentations between February and June 2019 and 2020. Results: A total of 4 300 trauma presentations secondary to interpersonal violence and RTCs were noted in the 5-month period February - June 2019, as opposed to 3 239 presentations in February - June 2020 (25% decline). A 40% decline in the number of RTCs, from 1 704 in February - June 2019 to 1 026 in the corresponding period for 2020, was noted and found to be statistically significant (p=0.03). Declines in the volume of trauma cases secondary to interpersonal violence and of overall trauma cases were only directional in favour of 2020, but not statistically significant. Conclusions: The volume of trauma presentations secondary to interpersonal violence and RTCs in the Helen Joseph Hospital ED decreased during the lockdown period. The decline in the volume of RTCs was statistically significant, but declines in the volume of trauma presentations secondary to interpersonal violence and in the volume of overall trauma presentations were not.Item Making the case for an obstetric medicine subspecialty in South Africa(Health & Medical Publishing Group, 2020-11) Zamparini, J; Wium, LObstetric medicine is a subspecialty of internal medicine that involves the management of medical conditions that may affect the course of pregnancy. It is an established subspecialty in many parts of the world, with recognised training programmes and an active international society; however, no formal training programme has been developed in South Africa (SA) as yet. Medical problems are responsible for the majority (60%) of maternal deaths in SA and women of childbearing potential are disproportionately affected by medical conditions such as HIV and obesity. Obstetric physicians would play a complementary role in the care of pregnant patients and could contribute to improving maternal health and lowering the maternal mortality rate in SAItem Management of HIV-associated cryptococcal disease in South Africa(2014-12) Govender, N.P; Dlamini, SItem National expenditure on health research in South Africa : What is the benchmark ?(2014-07) Paruk, F.; Blackburn, J.M.; Friedman, I.B.; et al.The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors,was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure.Item Neglected sexual dysfunction symptoms amongst chronic patients during routine consultations in rural clinics in the North West province(AOSIS, 2021-04-28) Pretorius, Deidre; Couper, Ian D; Mlambo, Motlatso G.Background: Sexual dysfunction contributes to personal feelings of loss and despair and being a cause of exacerbated interpersonal conflict. Erectile dysfunction is also an early biomarker of cardiovascular disease. As doctors hardly ever ask about this problem, it is unknown how many patients presenting for routine consultations in primary care suffer from symptoms of sexual dysfunction. Aim: To develop an understanding of sexual history taking events, this study aimed to assess the proportion of patients living with symptoms of sexual dysfunction that could have been elicited or addressed during routine chronic illness consultations. Setting: The research was carried out in 10 primary care facilities in Dr Kenneth Kaunda Health District, the North West province, South Africa. This rural area is known for farming and mining activities. Methods: This study contributed to a broader research project with a focus on sexual history taking during a routine consultation. A sample of 151 consultations involving patients with chronic illnesses were selected to observe sexual history taking events. In this study, the patients involved in these consultations completed demographic and sexual dysfunction questionnaires (FSFI and IIEF) to establish the proportions of patients with sexual dysfunction symptoms. Results: A total of 81 women (78%) and 46 men (98%) were sexually active. A total of 91% of the women reported sexual dysfunction symptoms, whilst 98% of men had erectile dysfunction symptoms. The youngest patients to experience sexual dysfunction were a 19-year-old woman and a 26-year-old man. Patients expressed trust in their doctors and 91% of patients did not consider discussion of sexual matters with their doctors as too sensitive. Conclusion: Clinical guidelines, especially for chronic illness care, must include screening for sexual dysfunction as an essential element in the consultation. Clinical care of patients living with chronic disease cannot ignore sexual well-being, given the frequency of problems. A referral to a sexual medicine specialist, psychologist or social worker can address consequences of sexual dysfunction and improve relationships.Item New imaging approaches for improving diagnosis of childhood tuberculosis(2014-03) Bélard, S; Andronikou, S; Pillay, T; et alItem Parents' perceptions of HIV counselling and testing in schools : Ethical, legal and social implications(2014-01) Gwandure, R; Ross, E; Dhai, A; et alIn view of the high prevalence of HIV and AIDS in South Africa, particularly among adolescents, the Departments of Health and Education have proposed a school-based HIV counselling and testing (HCT) campaign to reduce HIV infections and sexual risk behaviour. Through the use of semi-structured interviews, our qualitative study explored perceptions of parents regarding the ethico-legal and social implications of the proposed campaign. Despite some concerns, parents were generally in favour of the HCT campaign. However, they were not aware of their parental limitations in terms of the Children’s Act. Their views suggest that the HCT campaign has the potential to make a positive contribution to the fight against HIV and AIDS, but needs to be well planned. To ensure the campaign’s success, there is a need to enhance awareness of the programme. All stakeholders, including parents, need to engage in the programme as equal partners.Item Perceptions of mental illness among Muslim general practitioners in South Africa(2014-05) Mohamed- Kaloo, Z; Laher, SBackground: Mental health literacy on the part of medical practitioners is an important component of mental healthcare. General practitioners (GPs) are typically the first doctors consulted by a person who is ill. Exploration of their perceptions regarding mental illness, aetiological issues and treatment is important. Objective: To investigate perceptions of mental illness in a sample of ten South African Muslim GPs (five male, five female) in the Lenasia area (Johannesburg, South Africa). Methods: Using a qualitative approach, semi-structured interviews were conducted with each GP. The questionnaire encompassed 37 questions relating to the context in which the GPs practised, perceptions of mental illness, understanding of religion and culture, and treatment of mental illness (including aspects of spiritual illness). Thematic content analysis was used to analyse the data. Results: Six dominant themes were identified, namely GPs' understanding of mental illness and its causation; stigma, secrecy and somatisation; the beneficial effects of religion in mental illnesses; perceptions of spiritual illnesses; collaboration with traditional healers; and collaboration with psychiatrists and psychologists. Conclusion: Greater awareness regarding the stigmatisation of mental illness is needed. Furthermore, it is important that healthcare professionals have an understanding of religious and cultural taxonomies of illness as well as the use of traditional healing as a mode of treatment. Participants identified a need for increased collaboration between healthcare professionals, including traditional healers.