3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Time until first analgesic requirement, post caesarean section under spinal anaesthesia, in HIV-positive patients at Chris Hani Baragwanath Hospital(2011-10-11) Wagner, Janine LouiseBACKGROUND Multiple studies have been conducted comparing the efficacy and duration of analgesia obtained from spinal anaesthesia containing local anaesthetics as well as opioids. The literature available has not considered the individual‟s HIV status as a variable. Postoperative analgesic duration and requirements in this group of patients may differ due to the occurrence of acute and chronic pain syndromes, pain arising from the disease itself, side effects of treatment for HIV infection, or opportunistic infections. Response to opioid analgesia may be altered due to previous opioid exposure, potential increase in nociception, drug interactions and emotional status. OBJECTIVES The primary objective of this study was to determine the time to post-operative analgesic request in HIV-positive and negative individuals having caesarean sections under spinal anaesthesia containing bupivacaine or bupivacaine and fentanyl. The secondary objectives of this study were to determine if factors such as height, ethnicity, level of education, CD4 count, and antiretroviral therapy impacted on the duration of analgesia obtained.Item Bartonella species in human and animal populations in Gauteng, South Africa, 2007-2008(2010-10-20) Trataris, Anastasia NatashaBartonella is a genus of fastidious bacteria responsible for a wide range of both symptomatic and asymptomatic infections. Bartonellae are often considered obligate pathogens where infection is concurrent with immunological suppression of the host. The objectives of this study were: to determine the prevalence of Bartonella infections in HIV-positive patients presenting for treatment at a Gauteng HIV-clinic, to determine the extent of bartonellae affecting the healthy population, to determine the seroprevalence of Bartonella henselae and Bartonella quintana antibodies in HIV-negative antenatal patient sera taken from various maternity units in Gauteng public hospitals, and to investigate cats, dogs, and rodents in Johannesburg for carriage of bartonellae. A total of 382 HIV-positive patients attending the HIV clinic and 42 clinically healthy volunteers agreed to participate. Three-hundred and forty-two residual sera from the national antenatal survey were selected and tested for IgG and IgM antibodies against Bartonella. There were 179 dogs, 98 cats and 124 rodents enrolled in this study. The seroprevalence for Bartonella in humans was carried out using IgG and IgM commercially available kits. HIV-positive patients were found to have 32% IgG and 14% IgM seroprevalence, whereas the healthy volunteers had a lower IgG (19%) and higher IgM seroprevalence than the HIV-positive counterparts. All blood samples were cultured, but only the cat and rodent specimens yielded isolates. These were sequenced for species identification. The cat isolates were 99 and 100% similar to B. henselae URBHLIE 9 previously isolated from a patient with endocarditis, and the rat isolates were 98 – 99% similar to either RN24BJ (candidus ‘B. thailandensis’) or RN28BJ, previously isolated from rodents in China. The PCR prevalences were: 22.5% in HIV-positive patients; 9.5% in clinically healthy volunteers; 23.5% in cats; 9% in dogs; and 25% in rodents. Findings of this study have important implications for HIV-positive patientsItem The burden of metabolic diseases amongst HIV positive patients on HAART attending the Johannesburg Hospital(2010-10-15) Julius, Henry PatrickBackground: The increase use of highly active antiretroviral therapy (HAART) among patients with HIV infection and AIDS has led to increasing reports of metabolic abnormalities such as diabetes mellitus, hypertension, dyslipidaemia and obesity. Therefore, it is important to explore the burden of these diseases among HIV infected patients. Objectives: To determine the burden of metabolic diseases (hypertension, diabetes, obesity and dyslipidaemia) in patients attending HIV clinic at the Charlotte Maxeke Johannesburg Academic Hospital (JHBH). Methodology: It was a cross-sectional study. The study population included patients attending JHBH HIV clinic and on HAART for more than one year. A sample size of 304 patients, including 237 females and 67 males partook in this study. Anthropometric measurements were taken from patients and blood samples of these patients were sent to laboratory for lipograms, HbA1c, random glucose, CD4 lymphocytes counts as well as HIV viral load testing. The data was analysed with standard statistical software Epi-info version 6.0. Both descriptive and analytical statistics was used. Results: The prevalence of metabolic syndrome according to the IDF was 20.4 %; obesity (BMI 30 kg/m2) was 16.8% and patients that were overweight (BMI > 25 kg/m2 and BMI < 29.9 kg/m2) was 28.6%; hypercholesterolemia (TC 5.0 mmol/l) = 35.5%; HDL< 1.29 mmol\L in females was 58% and HDL <1.04 mmol/l in males was 36%; elevated triglycerides 1.7 mmol/l was 30% and only 16% was classified as being hypertensive (BP 140/90 mmHg and / or on Hypertensive medication). The majority of the patients (86.2%) had a CD4 lymphocyte count 200 X 106 cells/l and 84% of patients had less than detectable limits for viral loads (VL< 40 copies / μl), which has been reported as optimum levels for metabolic diseases in HAART recipients. Conclusion: These results clearly indicate that there is a growing burden of metabolic diseases among HIV patients on HAART attending the Johannesburg hospital HIV clinic. The current study also indicates that the metabolic disturbances are more frequent in women than in men, except for hypertension.Item Depression and anxiety in HIV infected individuals attending HIV treatment facilities at various sites in South Africa: occurrence and related factors. A descriptive-analytic study(2009-05-08T12:08:31Z) Thom, RitaInternational literature, most of which originates from First-world countries where HIV predominantly affects socially marginalised minority populations, has well-described the burden of mental disorder, particularly depressive and anxiety disorders in HIV-infected individuals. The few studies conducted in developing countries show contradictory results. This study aimed to describe the occurrence of mental disorders; particularly depressive and anxiety disorders, in a population of HIV-infected individuals attending HIV-treatment sites in Gauteng and Mpumalanga in South Africa from November 2004 to November 2005. A cross-sectional descriptive-analytic study, it included a clinical diagnostic interview and a semi-structured interview to explore postulated risk and protective factors, including demographic, clinical and psychosocial variables, for depressive and anxiety disorders in HIV-infected individuals. Three hundred and two (302) individuals were interviewed at the Perinatal HIV Research Unit’s associated Wellness clinics and at the Chris Hani Baragwanath Hospital’s Nthabiseng HIV clinic. Just over thirty percent of participants had a current mental disorder and the lifetime prevalence of mental disorder was 40%. Almost 17% of participants had a current depressive disorder and almost 16% had a lifetime depressive disorder. The occurrence of major depressive disorder, current and lifetime, was 3.64% and 10.26% respectively. Sixty percent of participants with lifetime major depressive disorder had their first onset after diagnosis of HIV status. The occurrence of current and lifetime anxiety disorder was almost 4%. Substance use disorders were common, affecting 7.6% of the participants at time of interview. Lifetime prevalence of substance use disorders was 18.9%, suggesting that knowledge of HIV status or other interventions may have resulted in this significant decrease. Identified significant risk factors for depressive disorder included a history of a lifetime depressive disorder, moderate or severe psychosocial stress and feelings of isolation. Being in a support group was found to be a protective factor against depressive disorder. While the results in this study are conservative compared to those of other similar South African studies in HIV-infected individuals, there was a statistically significantly increased occurrence of depressive and anxiety disorders (combined) compared to general population prevalence studies of these disorders in South Africa. Ways of improving access to mental healthcare for HIV-infected individuals and the general population, are discussedItem Proteinuria in HIV seropositive individuals(2009-05-08T11:29:59Z) Fabian, JuneABSTRACT This study was designed to screen antiretroviral therapy (ART)-naïve human immunodeficiency virus (HIV) infected patients for proteinuria, using urine dipsticks, at the HIV outpatient clinic at Johannesburg Hospital in an attempt to detect and treat early renal disease. In those with persistent proteinuria, a marker of kidney disease, renal biopsy was performed, ART with and without angiotensin-converting enzyme inhibitors (ACE-I) was initiated and patients were followed up for immunological and renal responses. After a minimum period of 12 months, a repeat biopsy was performed, where possible, to determine whether the histological lesions had responded to treatment. During urinary screening, proteinuria, leucocyturia and microscopic haematuria were common. Sterile leucocyturia may be associated with co-morbid sexually transmitted infection or tuberculosis. In the group that underwent renal biopsy with treatment, the renal and immunological response, before and after ART was highly statistically significant. Renal and immunological responses to ART were assessed by reduction in proteinuria with increased GFR, increased CD4 count with reduction in HIV viral load, respectively. On biopsy, HIV-associated immune complex disease was more common than HIVAN, a finding that contradicts international and some local data. Resolution of proteinuria was relatively rapid in comparison to the histological response to treatment, an effect not previously shown. This is the first study of its kind, to the author’s knowledge, that prospectively evaluates the effect of ART with/ ACE-I in ART-naïve HIV infected patients with both clinicopathological and histological criteria. It has shown unequivocally, that renal disease, particularly if detected and treated early in HIV infection, is responsive to treatment. These findings suggest screening for early detection and treatment of HIV-associated renal disease should be mandatory in HIV clinics in South Africa.Item Perianal surgery in HIV infected patients(2009-05-05T07:33:09Z) Tun, MyintIntroduction Human immunodeficiency virus (HIV) infection is becoming a global epidemic. In HIV-infected individuals, anorectal diseases are common and the commonest indications for surgical intervention. However, it has not been clear whether the cause and management of anorectal conditions differ in patients who are HIV negative and those who are HIV positive. Aim To compare the presentation of perianal diseases in HIV +ve and HIV –ve patients and to determine the best therapy for perianal diseases in HIV +ve patients Methods The study period was from 1999 to 2002. Patients seen at Helen Joseph Hospital during the author’s gastroenterology fellowship period and those from his private practice were recruited. Those who agreed to HIV testing and who were treated by the author were included in the study. The patients were categorized according to HIV status, CDC classification and perianal pathology. Standardized questionnaires were used for every patient. Patients were reviewed every two weeks after the procedure until fit for discharge. Results The sample comprised 241 patients: 100 HIV+ve (63 males and 37 females) and 141 HIV-ve (61 males and 80 females). The mean age of the HIV+ve patients was 34,8y (range 17-62y), and the mean age of the HIV-ve patients was 41y (range 5-82y). Follow-up was from two weeks to two years. The pathology included 62 (25 +ve, 37 -ve) haemorrhoids, 67 (27 +ve, 40 –ve) fistulas, 59 (25 +ve, 34 -ve) abscesses, 46 (11 +ve, 35 -ve) fissures, 24 (22 +ve, 2 -ve) anal ulcers, four (3 +ve, 1 -ve) anal warts, two (both +ve) pilonidal sinuses, three (all -ve) anal cancers and two (1 +ve, 1 -ve) hidradenitis suppurativa. Nine patients with haemorrhoids (4+ve, 5-ve) were treated conservatively, 11 patients with haemorrhoids (6+ve, 5-ve) had rubber band ligation and 42 patients with haemorrhoids (15+ve, 27-ve) had haemorrhoidectomy. Thirteen patients (1+ve, 12-ve; p<0.001) had complex fistulas and 8 patients (7+ve, 1-ve; p=0.006) had multiple fistulas. Ten HIV -ve patients with complex fistulas and seven patients with trans-sphincteric fistulas (3+ve, 4-ve) needed more than six weeks to heal after treatment. Thirty patients with anal fissures had sentinel piles, but there were none in the patients with anal ulcers (p<0.0001). Thirteen HIV +ve patients with anal ulcers had an abnormally weak anal tone, but only one HIV +ve patient with anal fissure had a weak anal tone (p<0.001). In the patients with anal fissure, 37 (8+ve, 29-ve) had a high anal tone, but none of the patients with anal ulcers had increased anal tone (p<0.0001). Of the 59 patients with perianal suppuration, 23 (8+ve, 15-ve) had primary fistulotomy as well as drainage of the abscess. Conclusions Multiple fistulas were more commonly seen in advanced HIV patients, whereas complex fistulas were more commonly seen in HIV negative individuals. Healing after fistula surgery is determined more by the type of fistula than the HIV status or stage. Anal fistulas associated with perianal suppuration can be treated the same way in both HIV negative and positive patients, without increased complications. Careful physical examination is essential to differentiate between anal ulcers and fissures. Both conditions are common, and have similar symptoms in HIV positive patients. They can, however, be readily and safely distinguished on clinical examination, since fissures are associated with high anal tone, and a sentinel pile, while the AIDS ulcer lacks the sentinel pile, and the pressure is low. Anal malignancies, especially squamous cell carcinoma, have been uncommon in our experience. With the addition of anti-retroviral therapy and antibiotics, haemorrhoids may be safely treated according to standard principles (rubber band ligation and haemorrhoidectomy, as appropriate). Our practice has favoured a conservative approach in patients with advanced HIV disease. However, anti-retroviral therapy and antibiotics may improve the safety and outcome after surgical procedures.