A comparison of coronary angiography and myocardial perfusion studies, using quantitative scoring systems

Background: Results of myocardial perfusion for screening coronary artery disease (CAD), and angiography for diagnosing CAD, can be quantified using summed difference score (SDS) and Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, respectively. Aim: The aim is to quantitatively compare myocardial perfusion studies with angiography amongst South African patients using scoring systems. Methods: SDS on myocardial perfusion and SYNTAX score on angiography were compared. Regional scores within each vessel (left anterior descending (LAD), circumflex and right coronary artery (RCA)) were also compared. Scores were further risk categorised and evaluated. Results: The weak correlation between SDS and SYNTAX score (rs=0.210, p=0.015), became slightly negative when SYNTAX scores were stratified into low and intermediate-high risk groups. Regionally, LAD had very slight positive correlation (rs=0.171, p=0.048), circumflex (rs=0.164, p=0.058), and RCA (rs=0.116, p=0.184) no correlation. Conversely, comparison of scores categories was signifi cant (p=0.001). Conclusions: Inherent differences in the design of 2 scoring systems that evaluate the LAD territory may explain these findings. These differences were dominance, regional blood flow distribution and significant luminal diameter reduction. This study highlights the need to interpret myocardial perfusion results contextually during CAD screening

The value of exercise stress testing in prediction of angiography amongst South African patients using quantitative scoring systems

Background: Accurate pre-test assessment of high risk patients may increase positive yield on angiography. Exercise stress testing (EST) prediction of angiography, may be evaluated by Duke Treadmill Score (DTS), and Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, respectively. Aim: To investigate the value of EST in prediction of angiography amongst South African patients using quantitative scoring systems. Methods: The DTS and SYNTAX score were compared in patients with high risk pre-test assessments selected for angiography. Logistic regression modelling determined the odds ratio of abnormal angiograms using EST as a predictor. Results: Pre-test assessment of 525 suspected coronary artery disease patients, indicated angiography in 131 high risk individuals. The positive yield of abnormal angiograms was 58.0%, with no correlation between DTS and SYNTAX scores (Pearson’s correlation coefficient = 0.113, p=0.200). There was low predictive probability on receiver-operator-curve for DTS when compared to angiogram results (area under curve (AUC)=0.529, p=0.574), and SYNTAX categories (AUC=0.432, p=0.378). Chi-square tests had no significance between angiography and EST (all p-values >0.05). However DTS predicted abnormal angiograms with odds ratio of 1.92 when relevant cardiovascular risk factors (smoking, BMI, age) were added. Conclusion: Pre-test assessment of high risk patients represented a homogenous group with prevalent cardiovascular risk factors. However, the high risk group had no relationship between DTS and SYNTAX scores, indicating DTS alone discounts risk factors. Modelling accounted for DTS limitation by demonstrating an obese, elderly smoker with high risk category DTS is 1.92 times more likely to have an abnormal angiogram

Prevalence of chronic kidney disease among HIV-infected adults on antiretroviral therapy in northern Namibia: a cross-sectional study

Introduction: There is an epidemic of chronic kidney disease (CKD) in Africa and human immunodeficiency virus (HIV) infection is among the major drivers. However, the burden of CKD in HIV-infected patients in Africa varies widely by country and study, ranging from 0.5–59.3%. Published data on the prevalence of CKD in the Namibian HIV-infected population are scarce. In this study, we aimed to estimate the prevalence of CKD and associated factors in HIV-infected adults on antiretroviral therapy in northern Namibia. Methods: We conducted a cross-sectional study in the four regions of northern Namibia, using existing electronic records used in the management of HIV-infected patients. Variables captured included the two most recent serum creatinine measurements, date of birth, sex, date of initiating antiretroviral therapy, current antiretroviral treatment, and most recent HIV viral load results. We used standardised serum creatinine measurements to estimate the glomerular filtration rate (GFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. CKD was defined as estimated GFR (eGFR) < 60 mL/min/1.73 m2 on two occasions at least three months apart. Factors associated with CKD were assessed using logistic regression. Results: We included 1 993 participants, of whom 1 362 (68%) were female and mean age was 44.5 ± 11.5 years.The proportion of participants who were virally suppressed was 97% (95% CI 96, 98%) and the median durationon antiretroviral therapy was 107 months (IQR 62–149). The prevalence of CKD was 1.4% (95% CI 1.0, 2.0%).CKD cases were 13 times more likely to be 45 years or older and 3.5 times more likely to be male than thosewithout CKD. Conclusions: Our findings suggest a low prevalence of CKD among the HIV-infected population in northernNamibia. Patients older than 45 years may need additional monitoring for kidney function using eGFR

Impact of Pharmacists’ Intervention on the knowledge of HIV infected patients in a public sector hospital of KwaZulu-Natal.

Background: The study site started its roll-out of the human immunodeficiency virus (HIV) prevention of mother-to-child transmission in 2006. All patients were counselled by trained counsellors, before seeing a doctor. At the pharmacy the medicines were collected with no intense counselling by a pharmacist as the patients would have visited the trained counsellors first. Subsequently it was found that there were many queries regarding HIV and acquired immune deficiency syndrome (AIDS). Thus a dedicated antiretroviral pharmacy managed by a pharmacist was established to support the counsellors. Objectives: The objective of the study was to assess the impact of a pharmacist intervention on the knowledge gained by HIV and AIDS patients with regard to the disease, antiretroviral drug use (i.e. how the medication is taken, its storage and the management of side effects) as well as adherence to treatment. Method: This study was undertaken at a public sector hospital using anonymous structured questionnaires and was divided into three phases: pre-intervention, intervention and postintervention phases. After obtaining patient consent the questionnaires were administered during the first phase. A month later all patients who visited the pharmacy were counselled intensely on various aspects of HIV and antiretroviral medication. Thereafter patients who participated in Phase 1 were asked to participate in the second phase. After obtaining their consent again, the same questionnaire was administered to them. Quantitative variables were compared between pre-intervention and post-intervention stages by using paired t-tests or Wilcoxon signed ranks tests. Categorical variables were compared using McNemar’s Chi-square test (Binary) or McNemar-Bowker test for ordinal variables. Results: Overall the mean knowledge score on the disease itself had increased significantly (s.d. 6.6%), (p < 0.01), after the pharmacists’ intervention (pre-intervention was 82.1% and post-intervention was 86.3%). A significant improvement was noted in the overall knowledge score with regard to medicine taking and storage (p < 0.05) and the management of the side effects. There was a non-significant difference between the adherence in pre-intervention and in post-intervention (p = 0.077). Conclusion: Pharmacists’ intervention had a positive impact on HIV infected patients’ HIV and AIDS knowledge on both the disease and on the antiretroviral drug use and storage

Medical practitioners’ reactions towards family medicine as a speciality in South Africa.

Background: Family physicians are trained to treat a wide range of diseases, treatment being centred on the patient, family and community irrespective of age, gender, or ethnic or racial background. To deal with inequalities in health care, the South African government introduced the concept of a district health system in 1997. It was only in August 2007, however, that family medicine was legislated as a speciality. This study was undertaken prior to the enactment of this legislation. Method: A descriptive quantitative study using a self-administered questionnaire was undertaken. A convenience sampling technique was used (N = 60) to assess the reactions of medical practitioners towards the impending legislation. Results: Overall, 60% of the sample was in favour of the legislation. There were no significant differences between those working in the private and public sectors or between generalists and specialists. With regard to those not in favour of the legislation compared to those in favour of the legislation, a significantly increased number answered the following statements in the affirmative: (i) ‘I already carry out the functions of a family physician’ (p = 0.001), (ii) ‘They [specialist family physicians] will not be as qualified as specialists in other categories’ (p = 0.005), (iii) ‘It will have a negative impact on general practice’ (p < 0.001), (iv) ‘It will increase competitiveness’ (p = 0.021), (v) ‘It will not have any effect on patient care’ (p = 0.010) and (vi) ‘There is no need for such a speciality’ (p = 0.001). Conclusion: We concluded that the majority were in favour of the legislation being implemented

An empirical comparison of time-to-event models to analyse a composite outcome in the presence of death as a competing risk

CITATION:Haushona N, Esterhuizen TM, Thabane L, Machekano R. An empirical comparison of time-to-event models to analyse a composite outcome in the presence of death as a competing risk. Contemp Clin Trials Commun. 2020;19:100639. Published 2020 Aug 14. doi:10.1016/j.conctc.2020.100639Introduction: Competing risks arise when subjects are exposed to multiple mutually exclusive failure events, and the occurrence of one failure hinders the occurrence of other failure events. In the presence of competing risks, it is important to use methods accounting for competing events because failure to account for these events might result in misleading inferences. Methods and Objective: Using data from a multisite retrospective observational longitudinal study done in Ethiopia, we performed sensitivity analyses using Fine-Gray model, Cause-specific Cox (Cox-CSH) model, Cause-specific Accelerated Failure Time (CS-AFT) model, accounting for death as a competing risk to deter- mine baseline covariates that are associated with a composite of unfavourable retention in care outcomes in people living with Human Immune Virus who were on both Isoniazid preventive therapy (IPT) and antiretrovi- ral therapy (ART). Non-cause specific (non-CSH) model that does not account for competing risk was also per- formed. The composite outcome comprises of loss to follow-up, stopped treatment and death. Age, World Health Organisation (WHO) stage, gender, and CD4 count were the considered baseline covariates. Results: We included 3578 patients in our analysis. WHO stage III-or-IV was significantly associated with the composite of unfavourable outcomes, Sub-hazard ratio (SHR) = 1.31, 95% confidence interval (CI):1.04–1.65 for the sub-distribution hazard model, hazard ratio [HR] = 1.31, 95% CI:1.05–1.65, for the Cox-CSH model, and HR = 0.81, 95% CI:0.69–0.96, for the CS-AFT model. Gender and WHO stage were found to be signifi- cantly associated with the composite of unfavourable outcomes, HR = 1.56, 95% CI:1.27–1.90, HR = 1.28, 95% CI: 1.06–1.55 for males and WHO stage III-or-IV, respectively for the non-CSH model. Conclusions: Results show that WHO stage III-or-IV is significantly associated with unfavourable outcomes. The results from competing risk models were consistent. However, results obtained from the non-CSH model were inconsistent with those obtained from competing risk analysis models

The influence of second-hand cigarette smoke exposure during childhood and active cigarette smoking on crohn’s disease phenotype defined by the montreal classification scheme in a Western Cape population, South Africa

CITATION: Chivese, T., et al. 2015. The influence of second-hand cigarette smoke exposure during childhood and active cigarette smoking on crohn’s disease phenotype defined by the montreal classification scheme in a Western Cape population, South Africa. PLoS ONE, 10(9):1-12, doi:10.1371/journal.pone.0139597.The original publication is available at http://journals.plos.org/plosoneBackground: Smoking may worsen the disease outcomes in patients with Crohn’s disease (CD), however the effect of exposure to second-hand cigarette smoke during childhood is unclear. In South Africa, no such literature exists. The aim of this study was to investigate whether disease phenotype, at time of diagnosis of CD, was associated with exposure to second-hand cigarette during childhood and active cigarette smoking habits. Methods: A cross sectional examination of all consecutive CD patients seen during the period September 2011-January 2013 at 2 large inflammatory bowel disease centers in the Western Cape, South Africa was performed. Data were collected via review of patient case notes, interviewer-administered questionnaire and clinical examination by the attending gastroenterologist. Disease phenotype (behavior and location) was evaluated at time of diagnosis, according to the Montreal Classification scheme. In addition, disease behavior was stratified as ‘complicated’ or ‘uncomplicated’, using predefined definitions. Passive cigarette smoke exposure was evaluated during 3 age intervals: 0–5, 6–10, and 11–18 years. Results: One hundred and ninety four CD patients were identified. Cigarette smoking during the 6 months prior to, or at time of diagnosis was significantly associated with ileo-colonic (L3) disease (RRR = 3.63; 95%CI, 1.32–9.98, p = 0.012) and ileal (L1) disease (RRR = 3.54; 95%CI, 1.06–11.83, p = 0.040) compared with colonic disease. In smokers, childhood passive cigarette smoke exposure during the 0–5 years age interval was significantly associated with ileo-colonic CD location (RRR = 21.3; 95%CI, 1.16–391.55, p = 0.040). No significant association between smoking habits and disease behavior at diagnosis, whether defined by the Montreal scheme, or stratified as ‘complicated’ vs ‘uncomplicated’, was observed. Conclusion: Smoking habits were associated with ileo-colonic (L3) and ileal (L1) disease at time of diagnosis in a South African cohort.Publisher's versio

Characteristics of subjects with diabetes mellitus diagnosed before 35 years of age presenting to a tertiary diabetes clinic in Durban, South Africa, from 2003 to 2016

Background: Most patients diagnosed with diabetes mellitus &lt; 35 years will have type 1 diabetes (T1D). The increase in youthonset type 2 diabetes  (T2D) parallels the obesity epidemic and in African subjects ketosis-prone type 2 diabetes (KPD) may occur in this age group.Objectives, setting and subjects: To evaluate the clinical, biochemical and immunologic characteristics of patients diagnosed with diabetes &lt; 35 years presenting to a tertiary diabetes clinic in Durban, South Africa over 13  years.Design: A retrospective chart review of patients &lt; 35 years diagnosed with diabetes was conducted. Data included clinical and laboratory variables, complications and follow-up status.Results: The study included 517 patients of whom 445 (86.1%) were  diagnosed with T1D, 27 (5.2%) with T2D, 27 with KPD (5.2%) and 18 (3.5%) with other forms of diabetes. Mean age of the total group was 28 ± 10 years. Subjects with T1D were younger at diagnosis with a lower BMI than both T2D and KPD. HbA1c was higher in subjects with T1D. Overall mortality was low (3.5%) and follow-up was poor in all groups.Conclusion: The majority of young people with diabetes in KwaZulu-Natal, South Africa, have T1D, with small numbers of other types. Glucose control is poor with a high loss to follow-up.Keywords: diabetes in youth, South Afric

Evaluation of the clinical management of HIV-infected patients by private sector doctors in the eThekwini Metro, KwaZulu-Natal.

Background: Although private sector doctors are the backbone of treatment service in many countries, caring for patients with HIV entails a whole new set of challenges and difficulties. The few studies done on the quality of care of HIV patients, in the private sector in developing countries, have highlighted some problems with management. In South Africa, two-thirds of doctors work in the private sector. Though many studies on HIV/AIDS have been undertaken, few have been done in the private sector in terms of the management of this disease. Therefore, a study was undertaken to evaluate the clinical management of HIV-infected patients by private sector doctors. Methods: A descriptive cross-sectional study was undertaken in the eThekwini Metro in KwaZulu-Natal, South Africa, with 190 private sector doctors who, in the first phase of the study, indicated that they manage HIV and AIDS patients and would be willing to participate in the second phase of the study. The HIV guidelines of the Department of Health and Human Services and the South African National Department of Health were used to compare the treatment of HIV patients by these doctors. Results: Eighty-five doctors (54.5%) always measured the CD4 count and viral load levels at diagnosis. Both CD4 counts and viral load were always used by 76 doctors (61.8%) to initiate therapy. Of the doctors, 134 (78.5%) initiated therapy at CD4 count < 200 cells/mm3. The majority of doctors prescribed triple therapy regimens using the 2 NRTI + 1 NNRTI combination. Doctors who utilised CD4 counts tended to also use viral load (VL) to assess effectiveness and change therapy (p < 0.001). At initiation of treatment, 68.5% of the doctors saw their patients monthly and 64.3% saw them every three to six months, when stable. Conclusion: The majority of private sector doctors were compliant with current guidelines for HIV management, hence maintaining an acceptable quality of clinical healthcare

Patient satisfaction and treatment adherence of stable human immunodeficiency virus-positive patients in antiretroviral adherence clubs and clinics

Background: South Africa has experienced a substantial increase in access to antiretroviral treatment (ART) in recent years. Effective strategies to manage access to treatment need to be incorporated into and implemented in ART programmes. Antiretroviral treatment adherence clubs are a new strategy that is being implemented in various parts of South Africa. Aim: The aim of the study was to investigate treatment adherence and patient satisfaction of stable human immunodeficiency virus (HIV) patients on ART in ART adherence clubs and clinics. Setting: The study was conducted in the Eden district of the Western Cape, South Africa. Methods: A cross-sectional analytical study was conducted to examine the relationships between patient satisfaction and treatment adherence in ART adherence clubs and clinics in the Eden district, Western Cape province, South Africa. Validated questionnaires were used to measure patient satisfaction and self-reported treatment adherence. Results: The study included 320 participants (98 club and 222 clinic) from 13 primary health care clinics. The analyses showed that higher levels of satisfaction could be predicted with club participants compared to clinic participants (p = 0.05). There was no significant difference between clinic and club participants with regards to treatment adherence. However, being adherent was more likely in participants who were satisfied (odds ratio = 3.18, 95% confidence interval [1.14–7.11], p < 0.01). Conclusion: Antiretroviral treatment adherence clubs provide a service that patients are more satisfied with although they are not more adherent to treatment. This strategy may be effective for the delivery of long-term care for patients on ART