Paper of the week
In our Paper of the Week, Rulan Griesel and Gary Maartens together with a host of other members of the Department including Annemie Stewart, Helen van der Plas, Welile Sikhondze, Molebogeng Rangaka, Andre Kengne and Marc Mendelson and Mark Nicol from the Division of Microbiology report on a new clinical prediction rule for optimising the diagnosis of tuberculosis in HIV-infected persons with a high degree of diagnostic utility for a WHO-defined group of patients. In this study, conducted initially at GF Jooste Hospital and later at Khayelitsha Hospital, they found the following variables to be most important for diagnosis tuberculosis in HIV: cough >14 days, inability to walk unaided, temperature >39 degrees Celsius, abnormal chest radiograph, haemoglobin and white cell count with a C statistic of 0.8. The classic symptoms of fever, night sweats and weight loss added no discriminatory value in the diagnosis of tuberculosis in this population.
Certainly, a worthwhile read for anyone who is involved in the management of patients with tuberculosis.
In our Paper of the Week, Edda Weimann and colleagues remind us how we can borrow from concepts of business process management to improve patient flow in emergency units in South African hospitals. In our busy emergency units plagued by overcrowding, long waiting times, and inefficient healthcare delivery they propose a pragmatic and integrated approach drawing on basic business principles of process improvement through consideration of strategies, culture, people and resources, governance, information technology and methods.
In our Paper of the Week, Solly Benatar and colleagues from Canada provide a comparative analysis and critique of the healthcare systems in Canada and South Africa. They describe the flagrant health disparities and challenges with equity and access in both health systems and conclude that the challenges for South Africa are more daunting, particularly in the current political and economic climate. They remind us that “even in the wealthiest societies, resources for healthcare are not limitless” and that “providing expensive care with minimal benefits to some either diminishes equitable access to effective treatments for others or increases the costs of healthcare.” In this thought-provoking article, which should be required reading for all in healthcare, Benatar and colleagues end on a sobering note: achieving equity in health or even access to healthcare will remain elusive in both societies.
South Africa has the third highest burden of tuberculosis in the world, after India and China; with an estimated incidence of 450, 000 cases of active tuberculosis in 2013, an increase of 400% over the last 15 years (WHO, 2014). An estimated 60-75% of the 450, 000 incident cases have coinfection with HIV and tuberculosis. Despite being a major public health challenge in many parts of the world, there has been a dire dearth of new tuberculosis drugs in the last few decades.
In the first Paper of the Week, Richard Court, Gary Maartens, Helen McIlleron, Tawanda Gumbo and colleagues provide the largest report on the steady state pharmacokinetics of cycloserine in patients on teridizone for MDR-TB, and found the steady-state levels of cycloserine to be elevated in MDR-TB patients also receiving teridizone, which supports once-daily dosing. I attach an accompanying editorial which is complimentary. In the second Paper of the Week, keeping with antituberculous drug pharmacokinetics, Gary Maartens, Michal Pandie and colleagues report on the pharmacokinetic interaction between bedaqualine and clofazimine in patients with MDR-TB. They found that there was no significant drug-drug interaction between the two, even thought there was a slight increase in the clearance of bedaqualine when clofazimine was co-administered.
Please find attached 2 papers on the epidemiology, risk factors, fibrosis assessment, recommendations and elimination strategies for viral hepatitis B and C reflecting a supranational perspective of sub-Saharan Africa. These papers are led by members of the Division of Hepatology: Prof. Wendy Spearman, Prof. Mark Sonderup and Dr Neliswa Gogela and written in collaboration with other regional experts including Drs Barbara Scholz and Chris Kassianides, who have been associated with our Department. These are important publications, calling for universal implementation of the HBV birth-dose vaccine, full vaccine coverage, access to affordable diagnostics for HBV and enablement of linkage to care and antiviral therapy. Importantly, political will and appropriate funding is needed from African governments to implement these important recommendations.
After a brief hiatus, it is a great pleasure to share the Paper of the Week; in this instance, by Dr Nabeela Kajee, a medical intern who has just rotated through the G-floor. In this well-written article, Dr Kajee and colleagues make the compelling case of a synergistic approach to implementing the United Nation’s 2015 Sustainable Development Goals together with the Developmental Origins of Health and Disease goals for the improved health of the African continent. A worthwhile read indeed.
In our Paper of the Week, three members of the Department, Prof. Bongani Mayosi, Prof. George Mensah and Dr David Watkins together with other colleagues, report on the global and regional burden of rheumatic heart disease. This is a timely publication, demonstrating that in high burden areas (like South Africa), the mortality remains high in these regions. The well-written accompanying editorial highlights the number of important gaps that exist in our knowledge about the condition.
Our Paper of the Week is a very well-presented and wide-ranging systematic review and meta-analysis of epidemiology of high blood pressure in children and adolescents in sub-Saharan Africa. This excellent review, published in the Lancet Public Health, is written by one of our medical registrars, Dr Jean Jacques Noubiap, together with colleagues from the Cameroon who are all postgraduate students. Such excellence inspires great optimism for the future of our continent.
Our Paper of the Week by Professors Robin Wood and Linda-Gail Bekker is an important, but rather depressing, reality check on the exigencies of managing tuberculosis in Cape Town, despite the availability of state-of-the-art diagnostics and wide availability of evidence-based chemotherapies.
In our Paper of the Week, Prof. Dinky Levitt and Dr Mahmoud Werfalli, together with other colleagues from the continent, review the epidemiology, risk factors, outcomes and challenges to optimal management of diabetes in Africa. This is an important article, which I think should be prescribed reading for every physician. In addition, I also attach an appendix that contains country-specific information on diabetes for South Africa.
In our Paper of the Week, Drs Dlamini and Chivese and Prof. Rayner report on the demographics, management and outcomes of patients with acute kidney injury (AKI) in Cape Town. The incidence of AKI was 3.4% of all hospital admissions and the median age was 44 years, with 60% of those affected being male. Over 70% of subjects had community acquired AKI. Common underlying comorbidities included hypertension, diabetes, HIV, heart disease and chronic kidney disease. Renal biopsies were performed in 10% of patients. 55% of patients with AKI were treated in the ICU and 55% of AKI patients were dialysed. The overall 3 month mortality was 39%. The 3 month ICU mortality was 49%. 80% of patients had full renal recovery and 3% had end-stage renal disease. Importantly, in this study, HIV status did not affect outcome.
A very important contribution to the literature from our own wards and Department. Enjoy reading!
In our Paper of the Week, Prof. Ambroise Wonkam and colleagues review the neurological complications of sickle cell disease (SCD). SCD is the commonest inherited single-gene disorder in the world, with most affected persons on the African continent. Hence, our burden of complications from SCD are disproportionately higher, and worrisome when taken in the context of fragmented health systems.
It is with great pleasure to share with you our Paper of the Week, which is written by Dr Phindile Gina under the supervision of Professor Keertan Dheda. Following pioneering work by this group, the World Health Organization has approved urine LAM testing for use in hospitalised patients with advanced immunosuppression for the diagnosis if disseminated tuberculosis. In this new study, they explored the incremental diagnostic sensitivity of early morning urine versus random urine sampling and found that early morning urine improved the sensitivity of LAM for the diagnosis of disseminated tuberculosis. This is an important paper with novel findings that have important implications for the care of patients co-infected with HIV and tuberculosis.
Our Paper of the Week, co-authored by Professors Okpechi and Swanepoel, is on an important subject: the integration of care in management of chronic kidney disease in resource-limited settings. Noncommunicable disease burden, including chronic kidney disease, is on the rise. While management of chronic kidney disease is unaffordable and unavailable for many on the African continent, the authors argue that current structures of health systems in resource-poor settings are not set up to deliver comprehensive and optimal care for chronic diseases, including chronic kidney disease. In this paper, they make a number of important recommendations on integrated management of chronic diseases, including chronic kidney disease.
In this Paper of the Week, Prof. Dheda and his team report on the outcomes, infectiousness and transmission dynamics of patients with extensively drug-resistant tuberculosis and home-discharged patients with programmatically incurable tuberculosis. In this study of 273 patients, more than half with programmatically incurable tuberculosis were discharged to the community where they remained for an average of 16 months, at risk of expectorating infectious aerosols and posed a threat of transmission of extensively drug-resistant tuberculosis. The authors call for action, including appropriate containment strategies and access to new drugs. A worthwhile read. View paper
In the week’s Paper of the Week, a collaboration between the Division of Infectious Diseases and HIV Medicine, led by Dr Tom Boyles and Prof. Marc Mendelson, the GSH Pharmacy, the GSH management and the Division of General Medicine reports on the 4 year outcomes of the antibiotic stewardship program at GSH and the sustained reduction in antibiotic use. The significant public health implications of an effective antibiotic stewardship program cannot be overstated. View paper
In this issue of the Department of Medicine Paper of the Week, we remember the life and contributions of Stephen Lawn, a much loved member of our Department who died in the second half of 2016. In his honour, the Stephen Lawn Memorial Fund for TB and AIDS Research Leadership has been set up to commemorate his life and work. The fund will support a lecture, to be given annually at the time of World TB Day (24 March) in London and Cape Town by a leading TB researcher, as well as a monetary prize for an upcoming researcher conducting promising work focused on reducing the disease burden of TB and HIV/AIDS in Africa. The fund will be jointly managed by the TB Centre in London, the International Union against Tuberculosis and Lung Disease in Paris, and the Desmond Tutu HIV Centre in Cape Town. This year’s Stephen Lawn Memorial Lecture will be given by Prof. Robin Wood who knew him as a good friend and with whom many of Steve’s papers at UCT were co-authored.
In this week, the Desmond Tutu HIV Centre and Foundation were announced as the recipients of the 2017 Ubuntu Award for Passion and Social Responsiveness (awarded by the State President on Saturday). Colleagues, I hope that you shall join me in celebrating this latest accolade to Linda-Gail Bekker, Robin Wood and their phenomenal team at the Desmond Tutu HIV Foundation/Centre. Indeed, we all bask in their reflected glory. Through their work, the memory of Stephen Lawn lives on. View paper
In our paper of the week, Dr Mutyaba and Prof. Ntsekhe review the disease mechanisms and clinical manifestations of tuberculosis in the heart, and area where our own Department has significantly advanced understanding and the state of knowledge. I hope you will enjoy it as much as I did. View paper
In our first Paper of the Week, Prof. Weimann and Dr Patel remind us of the impact of climate change on health and the important role that green leadership has on minimising the impact of healthcare on the environment. In the paper and accompanying editorial, published in this issue of the SAMJ, Prof. Weimann and Dr Patel outline the efforts made to reduce the carbon footprint of Groote Schuur Hospital, for which the institution has received an innovation award in 2016. A worthwhile read! View paper View paper from Editor
It is with great pleasure to share with you our Paper of the Week recently published in Lancet Respiratory Diseases on the burden of tuberculosis in intensive care units in Cape Town and the effect of the diagnostics on tracheal aspirate samples on patient outcome. The paper is and authored by Dr Greg Calligaro and Profs. Ivan Joubert and Keertan Dheda. It is a true example of collaboration within the clinical disciplines to address some of our bigger challenges. In recognition of the importance of the work, it was recently awarded the Best Publication Award by the Faculty of Health Sciences at the end of 2016.
I hope that you shall enjoy the read. View paper
Our Paper of the Week is by Dr Bana and colleagues and provides a contemporary description of the clinical features and risk factors of tuberculous associated immune reconstitution inflammatory syndrome (IRIS). One of the key findings is the prolonged duration (>90 days) of tuberculous associated IRIS . This paper builds on the pioneering work of Prof. Meintjes, who has established himself as a global expert on the subject. A pleasure to read. View paper
As many of you know, our Antibiotic Stewardship Program has been a tremendous success and has been adopted by many other institutions around the country. This Paper of the Week is a timely reminder of the benefits of suck an approach at a systems level and also reviews the implementation of antibiotic stewardship in 5 countries: the USA, South Africa, Columbia, Australia and the UK. The main author of the paper is Prof. Mendelson, and the title of the paper is poignant: ‘united we succeed, divided we might fail’. A worthwhile read. View paper
In our final Paper of the Week for 2016, Prof. Dirk Blom and colleagues review the biology and evidence for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition in the management of dyslipidaemia, in particular, for evolocumab, which his group has contributed significantly in expanding our understanding of concepts of hyperlipidaemia and alternative/novel approaches to management. With the very best of wishes. View paper