3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Scintigraphic assessment of cardiovascular diseases in asymptomatic diabetic black patients(2012-01-10) Vangu, Mboyo Di Tamba Heb'En WillyThe association between diabetes and coronary artery disease (CAD) has been recognized as a major public health problem in the developed world. While there is an increased prevalence of silent myocardial ischaemia among asymptomatic individuals with diabetes, diabetic individuals with CAD in their larger number are usually asymptomatic, and when they present with signs of disease, there is extensive and severe CAD. It should be noted that amongst black South African, ischemic heart disease (IHD) remains rare, and there is little data linking diabetes mellitus with IHD. However, contrary to early reports that have suggested a low prevalence of CAD in black population in Africa, many studies have indicated a rapid change on the spectrum of CAD in numerous parts of the African continent. Despite the emerging report of high prevalence of risk factors there are only limited data investigating prevalence of CAD in black African with diabetes. The purpose of this thesis was to use myocardial perfusion imaging (MPI) at rest and after stress testing to detect CAD in a group of asymptomatic black patients suffering from diabetes and therefore assess the prevalence of CAD; to assess the changes in myocardial perfusion in asymptomatic diabetic black individuals and compare the differences seen in myocardial perfusion changes between the asymptomatic diabetic black and, the asymptomatic diabetic white and Indian individuals; to include data from symptomatic diabetic patients who were referred for MPI as part of their routine clinical management for possible comparison Consecutive 94 asymptomatic diabetic black patients and 50 asymptomatic diabetic white and Indian patients were recruited from the outpatient diabetic clinic of the Johannesburg hospital. Data from 90 subjects forming a group of symptomatic diabetic patients, 45 blacks and 45 whites and Indians referred for MPI as part of their clinical management were also analyzed. A two-day protocol for SPECT MPI was used in all participants: on the first day the stress testing MPI while the rest MPI was consistently done on the second day. Both exercise and pharmacologic stress testing were used. Technetium-99m methoxy-isobutylisonitrile (MIBI) was used as the myocardial perfusion radiopharmaceutical. Myocardial perfusion was assessed by means of semi-quantitative scoring system to measure the extent and severity of perfusion abnormality. Visual inspection of the reconstructed SPECT MPI images was carried out to assess perfusion deficit where there was a doubt on the extent and severity of perfusion abnormality. The QPS/QGS software allows obtaining resting and post stress left ventricular ejection fraction (LVEF). The means and percentages on study variables were obtained. The Spearmen correlation coefficient was used to calculate correlations between variables. The Kruskal-Wallis test was used to assess differences between black diabetic and white or Indian diabetic patients and Wilcoxon scores (rank sum) two-sided were used to measure differences within these racial groups. There were 123 females (52.6%) and 111 males (47.4%) in total. From the recruited participants, 53 (56.4%) asymptomatic females and 41 (43.6%) asymptomatic males were blacks whereas 24 (48%) asymptomatic females and 26 (52%) asymptomatic males were whites or Indians. The symptomatic group was comprised of 26 (57.8%) female and 19 (42.2%) male black patients and 20 (44.5%) female and 25 (55.5%) male white or Indian patients. Asymptomatic diabetic black participants were younger than the participants from the asymptomatic diabetic white and Indian group with a mean age of 60 (SD±7.2) years Vs 64 (SD±7.7) [p=0.003]. Fourteen percent of asymptomatic black participants had evidence of ischaemia by showing improvement of perfusion on stress testing versus twenty eight percent of white and Indian asymptomatic participants (p=0.62). Perfusion defects that did not change from rest to post stress testing MPI (fixed defects) were also noted in 20% of asymptomatic black and 26% of asymptomatic white and Indian diabetic participants. These fixed perfusion defects are indicative of previous myocardial infarctions and therefore suggestive of CAD. No significant difference was noted on the changes of perfusion that could account either for ischaemia or infract between asymptomatic diabetic black participants and their white and Indian counterparts (p=0.47). The difference on the improvement of perfusion from rest to post-stress MPIs or reversibility of perfusion to suggest only the presence of ischaemia did not also show a significant difference between these two racial groups (p=0.62). Our data demonstrated a high prevalence of CAD in asymptomatic diabetic black participants similar to other racial groups. Our study has demonstrated evidence to recommend screening of asymptomatic diabetic black individuals in equal manner than other races for the detection of CAD. More importantly, stress MPI should be routinely used as a noninvasive investigation in our environment and be utilized more actively in the management of all asymptomatic diabetic patients.Item Patients seen at the university hospital in Johannesburg: their views on truth-telling(2009-04-29T09:11:46Z) Vangu, Mboyo Di Tamba Heb'En WillyTruth telling forms part of the contemporary debate in clinical bioethics and centers around the right of the patient to know honest information concerning his or her medical condition / illness and the duty of the doctor to inform the patient of such. Anecdotal evidence seems to imply that patients have concerns with the practice of truthtelling. Many often complain that they are not being informed and sometimes simply being ignored in matters that primarily concerns their health. On the other hand, there may be patients who do not to want a truthful answer to their health problems-they would in fact rather not know. The aim of this study was to explore my intuition that patients who attend the Johannesburg General Hospital are not given full information about their condition(s) and / or treatment(s) although they would like to know. The study explored the preferences of patients regarding the practice of truth telling and their attitudes toward truth telling in four out patient clinics of the Johannesburg General Hospital. Four hundred and sixty five participants completed and retuned the questionnaire from four different out patient clinics, namely oncology, surgical (general surgery and orthopedics), medical (gastro, renal and general internal medicine) and the nuclear medicine unit that represented the mixed out patient clinic. The majority of participants stated that the doctor had disclosed information about their condition (92.90%). Almost all participants were of the opinion that patients have the right to know about their condition (98.28%) and also that the doctor has the duty to inform them of their condition (98.02%). If they were suffering from a serious condition, a higher percentage of participants (86.28%) would prefer to know about their condition while a small but significant percentage (13.72%) would prefer not to know. The vast majority of participants (96.64%) also preferred to know about information relating to their treatment in detail while a high percentage (87.83%) supported disclosure to relatives. Variables such as gender, age and level of education did not seem to impact on the participants’ opinions of the truth telling process with significance with the exception of iv gender in relation with knowledge of one’s condition (p=0.0176) and education with regard to opinions on the right of patients to disclosure (p=0.0430). From the above results it can then be concluded that: 1. Participants in our study supported the right of patients to disclosure and the vast majority also felt that doctors have the duty to inform patients of their condition. 2. A significant percentage of participants felt that the level of information given to them was not satisfactory even when they have requested for more. This should be looked at and means for improvement should be sought. 3. A small but significant group did not support disclosure and must be respected as autonomous beings. 4. Gender seems to influence opinions of patients concerning their condition and education impacts on opinions relating to right of patients to disclosure of information. 5. To our appeasement, we found that patients attending the Johannesburg hospital are in fact given information about their condition. It is rather the quality and the quantity of information given that should be subject to scrutiny if we would like to move towards full disclosure in the process of truth telling in our institution. 6. Future studies should be considered to assess the attitudes of doctors towards disclosing, as well as further assess conflicting opinions in small group of patients by means of direct interviews.