School of Clinical Medicine (Journal Articles)
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Item The impact of diferences in plasma glucose between glucose oxidase and hexokinase methods on estimated gestational diabetes mellitus prevalence(Nature Research, 2019-05) Dickson, Lynnsay M.; Buchmann, Eckhart J.; Janse Van Rensburg, Charl; Norris, Shane A.We evaluated the extent of measurement discordance between glucose oxidase and hexokinase laboratory methods and the efect of this on estimated gestational diabetes mellitus (GDM) prevalence in a routine clinical setting. 592 consecutive urban African women were screened for GDM. Paired venous specimens were submitted to two independent calibrated laboratories that used either method to measure plasma glucose concentrations. World Health Organisation diagnostic criteria were applied. GDM prevalence determined by the glucose oxidase and hexokinase methods was 6.9% and 5.1% respectively. The overall GDM prevalence was 9%. Only 34% of GDM positive diagnoses were common to both laboratory methods. Bland Altman plots identifed a bias of 0.2mmol/l between laboratory methods. Plasma glucose concentrations measured by the glucose oxidase method were more platykurtic in distribution. Low diagnostic agreement between laboratory methods was further indicated by a Cohen’s kappa of 0.48 (p<0.001). Reports of GDM prevalence using either the glucose oxidase or hexokinase laboratory methods may not be truly interchangeable or directly comparable.Item The prevalence of malnutrition and growth percentiles for urban South African children(BMC Public Health, 2019-05) Nyati, Lukhanyo H.; Pettifor, John M.; Norris, Shane A.Background: Low- and middle-income countries (LMIC) are experiencing a double-burden of malnutrition characterised by high prevalence of both under- and over-nutrition. We set out using data from the mixedlongitudinal Birth-to-Twenty Plus (Bt20+) birth cohort, to evaluate the patterns of malnutrition and growth in a large South African (SA) city by; (i) assessing the prevalence of undernutrition from birth to 5 years of age and overweight and obesity from ages 2 to 21 years in black and white, male and female children, and (ii) determining percentiles for height, weight, BMI, waist and hip circumferences and comparing the centiles to American and Dutch references. Methods: Height, weight, waist and hip circumferences were measured on urban black and white SA children from the Bt20+. A total of 3273 children born between April and June 1990 in the Greater Johannesburg Metropolitan area were included in the cohort. Z-scores were derived using the WHO 2006 child growth standards (0–5 years), for defining stunting, underweight and wasting. The International Obesity Task Force (IOTF) references were used to define overweight and obesity. Percentiles were developed using the lambda mu sigma (LMS) method and compared to American and Dutch references. Results: Black children were consistently shorter and black males lighter than white children and American references. The prevalence of stunting peaked at 2 years and was significantly higher in males than females and in black than white children. Black females had a greater prevalence of overweight and obesity than black males from 10 to 17 years. The percentiles for black females for weight and BMI were similar to those of South African white and American references but both black and white South African females had lower waist circumferences than American references. Conclusion: The growth percentiles show that young South African urban black females are experiencing general but not central obesity due to a secular change which is faster in weight than height. High levels of undernutrition persist alongside high levels of over-nutrition with adolescence being a critical period for the upsurge in obesity in females. Early intervention is needed to combat the rise in obesity.Item Fat redistribution and accumulation of visceral adipose tissue predicts type 2 diabetes risk in middle-aged black South African women: a 13-year longitudinal study(Springer Nature, 2019-03) Mtintsilana, Asanda; Micklesfield, Lisa K.; Chorell, Elin; Olsson, Tommy; Goedecke, Julia H.Background: Cross-sectional studies in South Africa (SA) have shown that black SA women, despite being more insulin resistant, have less visceral adipose tissue (VAT) and more subcutaneous adipose tissue (SAT) than white women. This study aimed to investigate whether baseline and/or change in body fat and its distribution predict type 2 diabetes (T2D) risk in middle-aged black SA women, 13 years later. Methods: We studied 142 black SA women who are the caregivers of the Birth-to-Twenty plus cohort, and who had normal glucose tolerance (NGT) at baseline. At baseline and follow-up, fasting blood samples, basic anthropometry and dual-energy X-ray absorptiometry-derived body composition were measured. At follow-up, an oral glucose tolerance test was completed. The WHO diabetes diagnostic criteria were used to define NGT, impaired fasting glucose (IFG)/impaired glucose tolerance (IGT), impaired glucose metabolism (IGM) and T2D. Results: At follow-up, 64% of participants remained NGT, whereas 25% developed IGM, and 11% developed T2D. The IGM and the T2D groups were combined for statistical analyses. At baseline, trunk fat mass (FM), VAT but not SAT (measures of central FM) were higher in the IGM/T2D group than the NGT group (p < 0.0001). In contrast, the IGM/T2D group had lower leg %FM at baseline than the NGT group (p < 0.0001). Baseline trunk FM (Odds ratio per 1 kg increase (95% confidence interval, 1.95 (1.43–2.67))), and VAT (OR per 10 cm2 increase, 1.25 (1.10–1.42)), and the change in VAT (1.12 (1.03–1.23)) were associated with greater odds of developing IGM/T2D, whereas baseline leg FM (OR per 1 kg increase, 0.55 (0.41–0.73)) were associated with reduced IGM/T2D risk at follow-up (p < 0.05). Conclusions: Relative fat redistribution, with VAT accumulation, predicted the development of IGM/T2D 13 years before its onset. Prevention of central obesity is a key factor to reduce the risk of developing T2D among middle-aged urban black SA women.Item Increases in statin eligibility to reduce cardiovascular risk according to the 2013 ACC/AHA cholesterol guidelines in the Africa Middle East region: a sub-analysis of the Africa Middle East Cardiovascular Epidemiological (ACE) study(BioMed Central, 2019-03) Raal, Frederick J.; Hamoui, Omar; Omar, Mohamed I.; Rashed, Wafa; Kane, Abdoul; Alami, Mohamed; Abreu, Paula; Mashhoud, Walid; Alsheikh-Ali, Alawi A.Background: With development of cholesterol management guidelines by the American College of Cardiology/ American Heart Association (ACC/AHA), more individuals at risk of cardiovascular disease may be eligible for statin therapy. It is not known how this affects statin eligibility in the Africa and Middle East Region. Methods: Data were used from the Africa Middle East Cardiovascular Epidemiological (ACE) study. The percentage of subjects eligible for statins per the ACC/AHA 2013 cholesterol guidelines and the 2002 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III) recommendations were compared. Analyses were carried out according to age, gender, community (urban/rural), and country income categories based on World Bank definitions. Results: According to the ACC/AHA recommendations, 1695 out of 4378 subjects (39%; 95% confidence interval [CI], 37–40%) satisfied statin eligibility criteria vs. 1043/4378 (24%; 95% CI, 23–25%) per NCEP-ATP recommendations, representing a 63% increase in statin eligibility. Consistent increases in eligibility for statin therapy were seen according to the ACC/AHA vs. NCEP-ATP guidelines across sub-groups of age, gender, community, and country income. Notable increases for statin eligibility according to ACC/AHA vs. NCEP-ATP were seen, respectively, in subjects aged ≥65 years (86% vs. 39%), in males (46% vs. 25%), in low-income countries (28% vs. 14%), and rural communities (37% vs. 19%). Conclusion: An increase in statin eligibility was seen applying ACC/AHA cholesterol guidelines compared with previous NCEP-ATP recommendations in the Africa Middle East region. The economic consequences of these guideline recommendations will need further research.Item Exploring the sorting of patients in community health centres across Gauteng Province, South Africa(BioMed Central, 2019-01) Stott, B. A.; Moosa, S.Background: Primary health care worldwide faces large numbers of patients daily. Poor waiting times, low patient satisfaction and staff burnout are some problems facing such facilities. Limited research has been done on sorting patients in non-emergency settings in Africa. This research looked at community health centres (CHCs) in Gauteng Province, South Africa where queues appear to be poorly managed and patients waiting for hours. This study explores the views of clinicians in CHCs across Gauteng on sorting systems in the non-emergency ambulatory setting. Methods: The qualitative study design used one-to-one, in-depth interviews of purposively selected doctors. Interviews were conducted in English, with open-ended exploratory questions. Interviews were recorded, transcribed, anonymised and checked by interviewees later. Data collection and analysis stopped with information saturation. The co-author supervised and cross-checked the process. A thematic framework was developed by both authors, before final thematic coding of all transcripts was undertaken by the principal author. This analysis was based on the thematic framework approach. Results: Twelve primary health care (PHC) doctors with experience in patient sorting, from health districts across Gauteng, were interviewed. Two themes were identified, two major themes, namely Systems Implemented and Innovative Suggestions, and Factors Affecting Triage. Systems Implemented included those using vital signs, sorting by specialties, and using the Integrated Management of Childhood Illnesses approach. Systems Implemented also included doctor - nurse triage, first come first serve, eyeball triage and sorting based on main complaint. Innovative Suggestions, such as triage room treatment and investigations, telephone triage, longer clinic hours and a booking system emerged. There were three Factors Affecting Triage: Management Factor, including general management issues, equipment, documentation, infrastructure, protocol, and uniformity; and Staff Factor, including general staffing issues education and teamwork; and Patient Factor. Conclusion: Developing a functional triage protocol with innovative systems for Gauteng is important. Findings from this study can guide the development of a functional triage system in the primary health care non-emergency outpatient setting of Gauteng’s CHCs. The Emergency Triage, Assessment and Treatment (ETAT) tool, modified for adult and non-clinician use, could help this. However, addressing management, staff and patient factors must be integral.Item Lipid levels, insulin resistance and cardiovascular risk over 96 weeks of antiretroviral therapy: a randomised controlled trial comparing low-dose stavudine and tenofovir(BioMed Central, 2018-12) Vos, Alinda G.; Chersich, Matthew F.; Klipstein‑Grobusch, Kerstin; Zuithof, Peter; Moorhouse, Michelle A.; Lalla‑Edward, Samanta T.; Kambugu, Andrew; Kumarasamy, N.; Grobbee, Diederick E.; Barth, Roos E.; Venter, Willem D.Background: HIV infection and antiretroviral treatment are associated with changes in lipid levels, insulin resistance and risk of cardiovascular disease (CVD). We investigated these changes in the first 96 weeks of treatment with lowdose stavudine or tenofovir regimens. Methods: This is a secondary analysis of a double blind, randomised controlled trial performed in South-Africa, Uganda and India comparing low-dose stavudine (20 mg twice daily) with tenofovir in combination with efavirenz and lamivudine in antiretroviral-naïve adults (n = 1067) (Clinicaltrials.gov, NCT02670772). Over 96 weeks, data were collected on fasting lipids, glucose and insulin. Insulin resistance was assessed with the HOMA-IR index and 10-year CVD risk with the Framingham risk score (FRS). A generalized linear mixed model was used to estimate trends over time. Results: Participants were on average 35.3 years old, 57.6% female and 91.8% Black African. All lipid levels increased following treatment initiation, with the sharpest increase in the first 24 weeks of treatment. The increase in all lipid subcomponents over 96 weeks was higher among those in the stavudine than the tenofovir group. Insulin resistance increased steadily with no difference detected between study groups. FRS rose from 1.90% (1.84–1.98%) at baseline to 2.06 (1.98–2.15%) at week 96 for the total group, with no difference between treatment arms (p = 0.144). Lipid changes were more marked in Indian than African participants. Conclusion: Lipid levels increased in both groups, with low-dose stavudine resulting in a worse lipid profile compared to tenofovir. Insulin resistance increased, with no difference between regimens. CVD risk increased over time and tended to increase more in the group on stavudine. The low CVD risk across both arms argues against routine lipid and glucose monitoring in the absence of other CVD risk factors. In high risk patients, monitoring may only be appropriate at least a year after treatment initiation.Item A comparison between raw and predicted mortality in a paediatric intensive care unit in South Africa(BioMed Central, 2018-11) Ballot, Daynia Elizabeth; Ramdin, TanushaObjective: Paediatric intensive care resources are limited in sub-Saharan Africa. The mortality rate in a combined Paediatric/Neonatal Intensive Care Unit in Johannesburg, South Africa was almost double that in a dedicated paediatric intensive care unit in the same country. This study aimed to compare the raw mortality rate with that predicted with the Paediatric Index of Mortality (version 3), by doing a retrospective analysis of an existing database. Results: A total of 530 patients admitted to the intensive care unit between 1 January 2015 and 31 December 2017 were included. The raw mortality rate was 27.1% and the predicted mortality rate was 27.0% (p = 0.971). Cardiac arrest during ICU admission (p < 0.001), non-reactive pupils (0.035), inotropic support (p < 0.001) and renal disease (p = 0.002) were all associated with an increased risk of mortality. These findings indicate that the high mortality rate is due to the severity of illness in the patients that are admitted. It also indicates that the quality of care delivered is acceptable.Item Developing a model for integrating sexual and reproductive health services with HIV prevention and care in KwaZulu-Natal, South Africa(BioMed Central, 2018-11) Milford, Cecilia; Scorgie, Fiona; Greener, Letitia Rambally; Mabude, Zonke; Beksinska, Mags; Harrison, Abigail; Smit, JenniferBackground: There are few rigorous studies evaluating the benefits of vertical versus integrated delivery of healthcare services, and limited published studies describing conceptual models of integration at service-delivery level in public healthcare facilities. This article seeks to fill this gap, by describing the development of a district-based model for integrating sexual and reproductive health (SRH) and HIV services in KwaZulu-Natal, South Africa. Methods: Baseline data were collected from seven urban public healthcare facilities through client and provider interviews, and a facility inventory was completed to assess current service integration practices. Feedback sessions were held with health providers from participating facilities to share data collected and explore appropriate integration scenarios. A conceptual model of potential service integration was then designed, and subsequently implemented and evaluated in the research sites. Results: Key principles of the model included a focus on health system strengthening and strong community input and involvement. The model was designed primarily to support the integration of family planning into HIV services, and included measures to improve client and commodity monitoring; capacity building through training and mentorship; and a ‘health navigation’ strategy to strengthen referrals within and between public healthcare facilities. Endline evaluation data were collected in the same facilities following implementation of the model. Conclusions: This manuscript demonstrates the utility of the conceptual model. It shows that service integration can be accomplished in a phased manner with support of community and healthcare providers. In addition, local context must be taken into account and the components of the model should be flexible to suit the needs of the health system.Item Neurodevelopmental outcome of late preterm infants in Johannesburg, South Africa(BioMed Central, 2018-10) Ramdin, Tanusha; Ballot, DayniaBackground: Late preterm infants, previously considered low risk, have been identified to be at risk of developmental problems in infancy and early childhood. There is limited information on the outcome of these infants in low and middle income countries. Methods: Bayley scales of infant and toddler development, version III, were done on a group of late preterm infants in Johannesburg, South Africa. The mean composite cognitive, language and motor sub-scales were compared to those obtained from a group of typically developed control infants. Infants were considered to be “at risk” if the composite subscale score was below 85 and “disabled” if the composite subscale score was below 70. Infants identified with cerebral palsy were also reported. Results: 56 of 73 (76.7%) late preterm infants enrolled in the study had at least one Bayley assessment at a mean age of 16.5 months (95% CI 15.2–17.6). The mean birth weight was 1.9 kg (95%CI 1.8–2.0) and mean gestational age 33.0 weeks (95% CI 32.56–33.51). There was no difference in the mean cognitive subscales between late preterm infants and controls (95.4 9, 95% CI 91.2–99.5 vs 91.9.95% CI 87.7–96.0). There was similarly no difference in mean language subscales (94.5, 95% CI 91.3–97.7 vs 95.9, 95% CI 92.9–99.0) or motor subscales (96.2, 95% CI 91.8–100.7 vs 97.6, 95% CI 94.7–100.5). There were four late preterm infants who were classified as disabled, two of whom had cerebral palsy. None of the control group was disabled Conclusions: This study demonstrates that overall developmental outcome, as assessed by the Bayley scales of infant and toddler development, was not different between late preterm infants and a group of normal controls. However, 7.1% of the late preterm infants, had evidence of developmental disability. Thus late preterm infants in low and middle income countries require long term follow up to monitor developmental outcome. In a resource limited setting, this may best be achieved by including a parental screening questionnaire, such as the Ages and Stages Questionnaire, in the routine well baby clinic visits.Item A survey of knowledge and attitudes relating to cervical and breast cancer among women in Ethiopia(BioMed Central, 2018-08) Chaka, Bekele; Sayed, Abdul-Rauf; Goeieman, Bridgette; Rayne, SarahBackground: Breast cancer and cervical cancer are the two leading cancers among women in Ethiopia. This study investigated knowledge and attitudes related to these two types of cancer among women in 4 zones of Ethiopia. This is the first study employing a validated questionnaire to investigate knowledge and attitudes relating to breast and cervical cancer in Ethiopia. Methods: A community based cross-sectional study was conducted from September to November 2015 in the North Shewa zone (Amhara region), Gamo Gofa zone (Southern Nations, Nationalities and Peoples’ region) and zones 1 and 3 (Afar region) of Ethiopia. A total of 799 women aged 18 years and older participated in the survey. Multiple logistic regression analysis was used to investigate the association of possible predictors with breast and cervical cancer knowledge. Results: A total of 799 women aged 18 years and older participated in the survey. Of the women interviewed, 63.0% had heard of breast cancer and 42.2% had heard of cervical cancer. Among those who had heard of breast cancer, 21.3% (107/503) had heard of breast cancer screening and 1.4% of women aged 40 years and older had undergone at least one breast screening examination. Fewer than half of the participants provided the correct response to questions related to risk factors for breast and cervical cancer. Among those who had heard of cervical cancer, 41.5% (140/337) had heard of cervical cancer screening and 3.3% had undergone at least one cervical cancer screening examination. Women with primary and higher levels of education were more likely to have heard of breast cancers (OR = 3.0; 95% CI: 2.1–4.2; p < 0.001) and cervical cancer (OR = 1.9; 95% CI: 1.4–2.6; p < 0.001). From the overall attitude score, the majority of the women were found to have negative attitudes towards breast cancer (67.4%) and cervical cancer (70.6%). Conclusions: This study found that the overall knowledge of risk factors for breast cancer and cervical cancer among women was low. Lack of cancer awareness, and lack of education in general, are the most potent barriers to access and care, and should be addressed through multi-faceted strategies including peer-education, mass media and other community-based interventions.