A mini-thesis submitted in partial fulfilment of the requirements for the degree of Master of Public Health at the School of Public Health, University of the Western Cape

Doctor EducationisBackground: Since 2005 the Chronic Dispensing Unit (CDU) has been part of the Western Cape Government’s strategy to address increasing demand for chronic medication for patients with non-communicable diseases. However, some patients are unable to collect their pre-packed chronic medication parcels from health care facilities on the due date. Recent research reported that some patients utilise collectors or medicine agents to collect their prepacked chronic medication parcels. Currently little is known about this phenomenon of collectors. Aim and Objectives: This study explored the acceptability of collectors of CDU chronic medication parcels to improve access to medicines for patients with non-communicable diseases at Lotus River Community Day Centre (LRCDC). Methodology: An exploratory descriptive qualitative study using semi-structured interviews in English and Afrikaans was conducted with six purposively selected collectors, three patients who use collectors and three key informants who have intimate knowledge of the collectors and system at the health facility. Interviews were recorded, transcribed, translated into English (where applicable) and thematically coded to derive themes from the data. Ethical approval was provided by the University of the Western Cape Bio-Medical Research Ethics Committee and informed consent was obtained from all study participants. Results: Patients reported that their collectors exhibited positive characteristics such as trust, patience and reliability, as well as, a passion for helping the community and organisational skills. All patients acknowledged the benefits of utilising a collector and found them to be highly acceptable. Key informants, however, had some reservations about the characteristics of collectors and their role in medication distribution and were sceptical as to whether collectors were suitably equipped to perform this function. Patients were grateful when their collector had some knowledge about their condition and were able to converse with them regarding their medication. Key informants suggested that with sufficient training and skills development, collectors could potentially improve access to chronic medication parcels and impart basic knowledge about chronic medication adherence to patients. iv Conclusion: The collector system that has emerged at LRCDC is highly acceptable to patients, but health facility staff were more measured in their assessments. Health facility staff, however, acknowledged the potential of collectors to improve access to chronic medication parcels for patients with chronic conditions and the benefit of upskilling collectors to perform this function. Recommendations: As a short-term measure, collectors should be formally accepted at facilities as medicine agents. They should receive basic education about safe medication distribution practices. Patients should screen collectors to ensure that they have the desired positive attributes. Furthermore, future research is necessary to comprehensively understand the current scope of practice of collectors within communitie

Effects of Dietary Fish-oil Supplement and Acute Eccentric Exercise on Inflammatory Markers during Different Phases of Menstrual Cycle

Fish-oil supplementation may play a positive role in inflammation. Matrix Metalloproteinases (MMPs) are important in controlling tumor growth, metastasis, angiogenesis, and inflammation. Several tissue inhibitors of MMPs (TIMPs) are known to regulate the activity of specific MMPs. PURPOSE: To examine the effects of dietary fish-oil supplementation and acute eccentric exercise on MMP-1, -2, -9, and -10 and TIMP-1, -2, -3, and -4 during two different phases of menstrual cycle. METHODS: As a randomized, double-blind, and placebo-controlled design, 22 college-aged women (age= 20.86 ± 1.39 years) were randomly assigned to either a fish oil (FOG, N=11) or a placebo group (PG, N=11). Participants in the FOG ingested 6 capsules of fish oil per day (total 6.0g, containing 2.4g eicosapentaenoic acid and 1.8g docosahexaenoic acid), while the PG took 6 capsules of safflower oil per day for 3 weeks. Participants in each group performed an acute bout of eccentric single-leg exercise (10 sets of 10 repetitions with a 3-min rest between sets at an isokinetic speed of 30⁰/second) during the mid-follicular (MF) and mid-luteal (ML) phases. The leg exercised for the MF phase was randomly selected and the opposing leg exercised during the ML phase. Overnight blood samples were collected at baseline, 6-hr post-exercise (6hr-PE), and 24-hr PE during the MF and ML phases. Data were analyzed by a separate 2 x 2 x 3 ANOVA with repeated measures along with an appropriate post-hoc test for any significant interactions (p \u3c 0.05). RESULTS: A significant interaction effect (p=0.005) in MMP-1 indicated that MMP-1 in the FOG (193.71±21.72 pg/mL) was higher than that of the placebo group (120.79±21.72 pg/mL) during the MF phase. Both TIMP-1 and -3 were significantly higher (p=.043 and p=.037, respectively) in the FOG (68674.71±2238.56 and 3827.12±193.67 pg/mL, respectively) than the placebo group (62119.26±2178.86 and 3238.94±186.73 pg/mL, respectively). CONCLUSION: Acute eccentric exercise did not affect MMPs and TIMPs in healthy, young females. MMP-1 was the only proteinase affected by the menstrual cycle and a decrease in MMP-1 during the ML phase might be related to elevated estradiol levels. Elevated TIMP-1 and -3 following the 3-weeks of fish-oil supplementation suggested a potential anti-inflammatory effect of the fish-oil supplementation by inhibiting activation of MMPs. It is recommended that an extended period of fish oil supplementation be implemented to further examine its anti-inflammatory effect on other inflammatory biomarkers in different sample groups including both pre- and post-menopausal women

Omega-3 Supplementation, Menstrual Cycle, and Acute Eccentric Exercise on Plasma Lipid Profiles

Omega-3 fatty acids supplementation and the menstrual cycle may independently influence plasma lipids and lipoproteins following acute exercise. PURPOSE: The current study investigated the effects of dietary fish oil supplement and acute eccentric exercise on plasma lipids and lipoproteins during two different phases of the menstrual cycle [mid-follicular (MF) vs. mid-luteal phase (ML)]. METHODS: As a double-blind, placebo-controlled design, 22 healthy young females (age= 20.86±1.39 years) volunteered. Participants were randomly assigned to either the fish oil (N=11) or the placebo (N=11) group. The fish oil group took a total of 6 capsules of fish oil per day (6g total; each capsule with 2.4 g of eicosapentaenoic acid and 1.8 g of docosahexaenoic acid), while the placebo group took 6 capsules of safflower oil/day (6g total; 2.8 g of lauric acid, 1.1g of myristic acid, 0.4 g of caprylic acid, 0.4 g of oleic acid, and 0.09 mg of linoleic acid) for 3 weeks. Participants in each group performed an acute eccentric single-leg exercise protocol during the MF and ML phases, which consisted of 10 sets of 10 repetitions with a 3-min resting between sets at an isokinetic speed of 30⁰/sec. The leg exercised for the MF phase was randomly selected and the opposing leg exercised during the ML phase. Plasma samples were collected at pre-, 6-hours post-exercise (6-hr PE), and 24-hours post-exercise (24-hr PE)] to analyze total cholesterol (TC), high-density lipoprotein (HDL-C), lipoprotein (a), very low-density lipoprotein (VLDL-C), and low-density lipoprotein (LDL-C). Data were analyzed using a multivariate analysis of variance (p \u3c 0.05). If a significant interaction was found, a Tukey’s post-hoc test was performed. RESULTS: Plasma lipids and lipoproteins were not different between the fish oil and placebo groups or before and after the acute eccentric leg exercise. However, HDL-C was significantly higher (p = 0.041) during the ML (61.66 ± 2.44 mg/dL) phase than that of the MF (54.53 ± 2.44 mg/dL) phase. CONCLUSION: Although it didn’t reach a statistical significance, the overall lipid and lipoprotein profile tended to improve following a relatively short-term fish oil supplement in healthy, young women. Acute eccentric exercise may not negatively affect plasma lipids and lipoproteins. Elevated HDL-C during the mid-luteal phase may possibly be associated with increased estradiol levels. It is recommended for future studies that an extended period of fish oil supplement using different dosages and exercise regimen be implemented to examine a long-term benefit of fish oil supplement in a variety of sample groups

Predictors of gastrointestinal lesions on endoscopy in iron deficiency anemia without gastrointestinal symptoms

<p>Abstract</p> <p>Background</p> <p>Iron deficiency anaemia (IDA) due to occult gastrointestinal (GI) blood loss usually remains unnoticed until patient become symptomatic. There is sparse data in IDA patients without gastrointestinal symptoms. This study was designed to find out the frequency and predictors of endoscopic lesions in IDA without gastrointestinal symptoms. Cross-sectional study performed on a convenience sample of consecutive subjects.</p> <p>Methods</p> <p>Ninety five consecutive patients with laboratory based diagnosis of IDA having no gastrointestinal symptoms were interviewed and their clinical and biochemical variables were recorded. All the study patients underwent esophago-gastroduodenoscopy (EGD) and colonoscopy. Endoscopic findings were documented as presence/absence of bleeding related lesion and presence/absence of cause of IDA. Multiple logistic regressions were performed to identify variables significantly related to outcome variables.</p> <p>Results</p> <p>Possible cause of anaemia was found in 71% and bleeding related lesions were found in 53% of patients. Upper gastrointestinal tract lesions were found in 41% of patients with bleeding related lesions. On multivariable logistic regression; advancing age, low mean corpuscular volume (MCV ≤ 60 fl), and positive fecal occult blood test were predictive factors for bleeding related GI lesions and cause of IDA</p> <p>Conclusion</p> <p>Clinical and Biochemical markers can predict gastrointestinal lesions on endoscopy in IDA patients without gastrointestinal symptoms. High proportion of upper gastrointestinal involvement warrants EGD as initial endoscopic procedure however, this needs validation by further studies.</p

Roflumilast in moderate-to-severe chronic obstructive pulmonary disease treated with longacting bronchodilators: two randomised clinical trials

Background Patients with chronic obstructive pulmonary disease (COPD) have few options for treatment. The efficacy and safety of the phosphodiesterase-4 inhibitor roflumilast have been investigated in studies of patients with moderate-to-severe COPD, but not in those concomitantly treated with longacting inhaled bronchodilators. The effect of roflumilast on lung function in patients with COPD that is moderate to severe who are already being treated with salmeterol or tiotropium was investigated. Methods In two double-blind, multicentre studies done in an outpatient setting, after a 4-week run-in, patients older than 40 years with moderate-to-severe COPD were randomly assigned to oral roflumilast 500 mu g or placebo once a day for 24 weeks, in addition to salmeterol (M2-127 study) or tiotropium (M2-128 study). The primary endpoint was change in prebronchodilator forced expiratory volume in 1s (FEV(1)). Analysis was by intention to treat. The studies are registered with ClinicalTrials.gov, number NCT00313209 for M2-127, and NCT00424268 for M2-128. Findings In the salmeterol plus roflumilast trial, 466 patients were assigned to and treated with roflumilast and 467 with placebo; in the tiotropium plus roflumilast trial, 371 patients were assigned to and treated with roflumilast and 372 with placebo. Compared with placebo, roflumilast consistently improved mean prebronchodilator FEV(1) by 49 mL (p<0.0001) in patients treated with salmeterol, and 80 mL (p<0.0001) in those treated with tiotropium. Similar improvement in postbronchodilator FEV(1) was noted in both groups. Furthermore, roflumilast had beneficial effects on other lung function measurements and on selected patient-reported outcomes in both groups. Nausea, diarrhoea, weight loss, and, to a lesser extent, headache were more frequent in patients in the roflumilast groups. These adverse events were associated with increased patient withdrawal. Interpretation Roflumilast improves lung function in patients with COPD treated with salmeterol or tiotropium, and could become an important treatment for these patients

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. METHODS: The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. RESULTS: Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? CONCLUSIONS: ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p&lt;0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p&lt;0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p&lt;0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP &gt;5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification