Magister Scientiae (Physiotherapy) - MSc(Physio) / Background: Globally, the leading cause of lower limb amputation is diabetes mellitus. In South Africa, there is a rise in diabetes-related lower limb amputation with a marked increase in the number of persons with diabetes mellitus in rural areas. However, there is no information on the number of people who are living with a lower limb amputation. An amputation does not only have an impact on a person’s physical functioning but can result in poor quality of life, dependence and exclusion from societal participation. Rehabilitation and prosthetic interventions are known to facilitate those with a lower limb amputation to return to independence in activities of daily living, improved quality of life and inclusion in society. Access to health care is very challenging for persons living in rural areas. Challenges to accessing health care include limited rehabilitation staff, harsh terrain and far distances from services, a lack of access to transport, or the lack of confidence in the service provided by the healthcare institutions. For optimal and patient-centred outcomes, rehabilitation services are of paramount importance. Due to the challenges with providing services in rural areas, community-based rehabilitation is the ideal model for providing rehabilitation to persons with lower limb amputation in rural settings. In order to plan an appropriate community-based approach to rehabilitation, establishing the prevalence of disability and patient-specific needs are imperative. Aims of the study: The aims of this study were firstly, to determine the period prevalence of people living with a lower limb amputation within the rural OR Tambo District of the Eastern Cape in order to determine the need for services and secondly, to gain a deeper understanding of the rehabilitation needs of persons living with a lower limb amputation within the rural OR Tambo District of the Eastern Cape.

Background: Many hearing impaired children present with one or more health-related conditions, in addition to hearing loss. Families and professionals are therefore faced with numerous challenges when a child presents with co-morbidities of hearing loss. The implications for assessment, management and educational placement of these children are numerous. Appropriate plans for holistic intervention and education are essential for the development of the child as well as improved life quality. This study therefore aimed to describe the co-morbidities that pre-school children with hearing loss present with at the Centre for Language and Hearing Impaired Children (CLAHIC), and its implications for management. Method: A descriptive, retrospective research design was employed for the purpose of this study. A non-probability, purposive sampling strategy was implemented to select the records of children diagnosed with a hearing loss, and who have attended CLAHIC from 1999 to 2010. The records of 62 children were reviewed. Results: The more prevalent co-morbidities identified in this study were fine motor delay, gross motor delay, visual motor integration disorder, bilateral integration disorder , apraxia of speech and attention deficit hyperactivity disorder. Further findings of the study indicated that the co-morbidities of hearing loss are independent of the degree of the hearing loss. It was however found that there is an increased risk for fine-motor difficulties across the sample. Implications: The findings of this research suggest that pre-school children with hearing loss, irrespective of degree of hearing loss, should be screened and or monitored for the risk of prevalent co-morbidities, such as fine and gross motor difficulties. A collaborative, holistic and multi-disciplinary team approach should be implemented to ensure that services are provided to improve the life quality and development of the hearing impaired child.

The main objectives of this dissertation were to examine the effects of bariatric surgery on medication and health services utilization among a cohort of Commercial and Medicare insured members from a large health benefits organization in the U.S.. A total of 1,492 members with morbid obesity underwent gastric bypass (n=785) or gastric banding (n=707) procedure between January 2005 and June 2008. Administrative claims databases were accessed and three data files including a member file, a medical file and a pharmacy file were merged at the member level. Non-parametric Wilcoxon signed rank tests revealed that the average number of all prescription claims were significantly lower during the 12 months post-surgery, compared to the 12 months pre surgery (p<0.0001). Moreover, McNemar’s Chi Square analyses showed that after the surgery, there was a statistically significant (p=<0001) decline in the proportion of members utilizing antihypertensives, antidiabetics and antihyperlipidemics. Our results also showed that the average number of prescription claims for each of these medication groups significantly declined during the 12-month post-surgery period, among members who had at least one prescription for these medications before the surgery (p<0.0001). Logistic regression modeling revealed that members who underwent bypass procedures were more likely to discontinue antihypertensives (OR=2.04; 95% CI= 1.30-3.23) , antihyperlipidemics (OR=3.25; 95% CI 1.96-5.40) and antidiabetics (OR=1.89; 95% CI 1.13–3.08) post-surgery than members who underwent banding procedures. In terms of medical services utilization, our results showed a significant decline in the average number of medical claims for all outpatient services overall from the 12 months pre to the 12 months post-surgery (p<0.0001). In contrast, the average number of medical claims for emergency room and inpatient hospitalizations were significantly increased from the pre to the post-surgery period (p<0.01). Logistic regression modeling revealed that the type of bariatric surgery was a significant positive predictor for inpatient hospitalizations post-surgery (OR =2.33; 95% CI= 1.76-3.08; p<0.0001) but not for emergency room visits (OR=1.23; 95% CI 0.97–1.56). The implications of the findings from a managed care perspective are discussed, along with limitation and future directions.

There is no evidenced-based research on prevention of upper extremity lymphedema following breast cancer treatment. General guidelines have been identified from a basic understanding of the lymphatic system and are considered to be prudent advice for prevention. Cause of lymphedema is hypothesized to be multifactorial and time of onset is widely varied. Exogenous risk factors leading to lymphedema are the removal and destruction of lymph nodes; however, not all women develop lymphedema following axillary lymph node dissection. Co-morbid conditions such as obesity, diabetes, and hypertension are cited as possible endogenous risk factors. Several studies identify hypertension as a significance endogenous risk factor resulting in increased capillary filtration causing an increase in the fluid load on an already compromised lymph drainage system. This retrospective chart review was designed to compare systolic blood pressure in two matched groups to determine if there is a difference between groups. The study population included 147 stage II and III breast cancer patients. after receiving IRB approval, charts of patients with a diagnosis code of lymphedema (n=19) were identified from the 147 possible charts. A matching sample of 18 women without lymphedema was assembled. Vital sign records were then reviewed and 3 measures of systolic blood pressure were used from a time period of two to 15 moths after lymph node dissection. Results revealed mean age and number of lymph nodes removed in the two groups were equivalent. No significant difference in systolic blood pressure was found between the two groups. However, the study was limited by the lack of chart data on the variables of lymphedema and systolic blood pressure. This pilot study pointed out adjustments needed to capture a more diverse sample. Other limitations such as missing demographic data on race, number of participants treated with radiation to the axilla and records of ambulatory blood pressure should be included in future studies.

Most people with dementia live in the community with a family member, commonly a spouse. Together they engage in identity redefinition to maintain continuity. Many people living with dementia also have co-morbidities. The aim of this study was to provide a better understanding of the influence of co-morbidities on the lived experience of couples and to provide knowledge to improve services. This had not been researched before. Drawing on the dialectic relationship between the body, habitus, environment and common sense from Bourdieu’s theory of practice (1977; 1990) combined with identity theory as described by Burke and Stetts (2009) I conducted an ethnographic study with five couples over a six-month period. The resulting data were analysed using a framework approach and are presented using case studies to illustrate key points. Drawing up on the data I developed an identity perspective which provides a better understanding of these couples’ daily life experiences taking into consideration the contextuality of people’s multiple identities, experiences, care and support needs and their interaction with the environment and community. My findings illustrate how people with dementia and co-morbidities and their spouses negotiate their identity in daily life in order to continue their daily life routine and cope with health conditions. Furthermore, these identity negotiations influence the acceptance of the diagnoses of dementia, the access to care, services and information and the experience of dementia, stigma and co-morbidities in daily life. Implications include a presentation of the limitations of current concepts of embodied selfhood and the Aging in Place policy for people with dementia. It points to the potential of the identity perspective to shape policy, services and care practice consistent with couples’ lived experience and their needs and preferences. / The Alzheimer's Society

Made available in DSpace on 2015-05-14T12:56:07Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 553259 bytes, checksum: 223847e29efbc1d96081ed8a564c8d84 (MD5) Previous issue date: 2009-12-11 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: Oral cancer is a public health problem in Brazil, taking into consideration the high incidence and co-morbidities, mainly due to aggressive surgery to treat advanced tumors. Objectives: To determine the mortality, co-morbidities, treatment adherence and survival of patients with mouth malignant neoplasm seen at the Center for Oral Cancer Prevention from the Oncology Center Ulisses Pinto, FAP Hospital - Campina Grande-PB between 1999 and 2008. Materials and Methods: it was performed data collection from medical records of all patients with mouth malignant neoplasm diagnosed between 1999 and 2008. Data were analyzed by descriptive statistics and the chi-square and Pearson correlation were applied considering significant p values &#8804; 0.05. Results: Of the total sample of 473 oral cancer cases, it was observed that 62.71% were males, 65.5 ± 13 mean age and 59.96% were Caucasian. Squamous cell carcinoma was the most prevalent histological type (86.2%) and tongue (29.6%) was the main anatomical site affected. Most injuries were diagnosed in clinical stages III and IV. It was observed 25.42% mortality rate, with median overall prevalent survival among 6-12 months. Co-morbidities occurred in 51.69% of patients, the most prevalent were hypertension, diabetes and depression. Oral co-morbidities occurred in 52.54% of patients, xerostomia was the most prevalent with 32%, followed by mucositis (27.1%) and dysphagia (19.5%). Regarding treatment adherence, it was observed that 82.63% adhered to treatment. There was statistically significant association between the following variables: mortality and TNM classification (p = 0.026), type of treatment (p = 0.027), survival (p = 0.000) and treatment adherence (p = 0.000); the overall co-morbidity rate was significantly associated with gender (p = 0.034) and age (p = 0.040); and the adherence to treatment was associated with age (p = 0.009) and mortality (p = 0.000). The survival rate was significantly associated with TNM classification (p = 0.026) and mortality p = 0.000. Conclusion: Considering the results it is concluded that oral cancer has high mortality rate and low survival rate, being influenced by treatment and TNM classification; there was high prevalence of overall co-morbidities: hypertension, diabetes and depression were the most prevalent; The prevalence of oral co-morbidities was high, being the xerostomia, mucositis and dysphagia the most frequent; most individuals adhered to treatment and this variable influenced the mortality rate and patient survival; survival of patients was influenced by mortality and TNM classification. / Introdução: O câncer de boca é um problema de saúde pública no Brasil, tendo em vista a alta incidência e as co-morbidades, decorrentes principalmente de cirurgias agressivas para tratar tumores avançados. Objetivos: Determinar o índice de mortalidade, co-morbidades, adesão ao tratamento e sobrevida de pacientes portadores de neoplasia maligna de boca atendidos no Núcleo de Prevenção ao Câncer Bucal do Centro de Cancerologia Ulisses Pinto no Hospital da FAP Campina Grande-PB, durante o período compreendido entre 1999 e 2008. Materiais e Métodos: Foi realizada coleta de dados em prontuários de todos os pacientes portadores de neoplasia maligna de boca, diagnosticadas entre 1999 e 2008. Os dados foram submetidos à análise estatística descritiva e aplicado teste qui-quadrado e de correlação de Pearson, considerando significantes valores de p&#8804;0,05.Resultados: Do total da amostra de 473 casos de câncer bucal foi observado que 62,71% eram do gênero masculino, com idade média de 65,5±13 e 59,96% dos indivíduos eram leucodermas (59,96%). O carcinoma espinocelular foi o tipo histológico mais prevalente (86,2%), tendo a língua (29,6%) como principal localização anatômica acometida. A maioria das lesões foi diagnosticada em estádios clínicos III e IV. Foi observada taxa de mortalidade de 25,42%, com tempo de sobrevida médio prevalente entre 6-12 meses. As co-morbidades ocorreram em 51,69% dos pacientes, sendo as mais prevalentes a hipertensão, o diabetes e a depressão. As co-morbidades bucais ocorreram em 52,54% dos pacientes, sendo a xerostomia a mais prevalente com 32%, seguida de mucosite (27,1%) e disfagia (19,5%). Quanto à adesão ao tratamento observou-se que 82,63% aderiram ao tratamento. Houve associação estatisticamente significativos entre as seguintes variáveis: mortalidade e classificação TNM (p=0,026), tipo de tratamento (p=0,027), sobrevida (p=0,000) e com adesão ao tratamento (p=0,000); A taxa de co-morbidade geral teve associação estatisticamente significante com gênero (p=0,034) e com idade (p=0,040); e a adesão ao tratamento teve com idade(p=0,009) e mortalidade (p=0,000). A taxa de sobrevida teve associação estatisticamente significante com a classificação TNM (p=0,026) e mortalidade p=0,000. Conclusão: Diante dos resultados conclui-se que o câncer bucal apresenta elevada taxa de mortalidade e baixa média de sobrevida, sofrendo influência da classificação de tratamento e da classificação TNM; verificou-se elevada prevalência de co-morbidades gerais, sendo hipertensão, diabetes e depressão as mais prevalentes; A prevalência de co-morbidades bucais foi elevada, sendo a xerostomia, a mucosite e a disfagia as mais freqüentes; a maioria dos indivíduos aderiram ao tratamento e esta variável influenciou da taxa de mortalidade e de sobrevida dos pacientes; o tempo de sobrevida dos pacientes sofreu influência das variáveis taxa de mortalidade e classificação TNM.

Master of Public Health - MPH / Background: Severe acute malnutrition contributes disproportionately to child mortality rates despite availability of the WHO protocol, “Ten Steps”, to guide hospital management. Auditing morbidity and mortality rates of malnourished children at hospitals is useful to measure the effectiveness of hospital-based management compared to standards advocated by the WHO protocol. The study aimed to assess the adequacy of clinical management practices for severely malnourished children admitted to three district hospitals in the Western Cape as compared to the WHO guidelines. Objectives: To describe prognostic indicators on admission such as clinical severity of malnutrition and co-morbidities such as HIV, TB, diarrhoea and pneumonia. To assess the management practices of severe malnutrition against the key principles of management during the stabilisation phase as outlined by the WHO guidelines. To describe the number of severely malnourished children who were treated for or died due to preventable complications (hypothermia, hypoglycaemia, dehydration, over-hydration, infection, electrolyte imbalance). Methodology: A retrospective, descriptive study based on a folder review of medical records of 83 severely malnourished children admitted to the Stellenbosch, Helderberg and Eersteriver hospitals from September 2009 to June 2011 was done. viii Structured data collection was undertaken to capture data to allow assessment of the clinician’s management practices, and the adequacy thereof in implementing the first six steps of the WHO protocol guidelines. Results The predominant co-morbidities in the sample were diarrhoea in 51% ofcases and pneumonia in 33%. Thirteen percent were HIV infected, 28% of the sample had TB. Clinical signs were poorly documented by clinicians. The highest percentage of adequate management practices was for treatment of infections with 90% of patients receiving antibiotics. The second best management practice was for treatment of electrolyte and micronutrient deficiency. Hypoglycaemia and hypothermia were poorly managed as children developed these complications in the hospitals and yet these complications were still left untreated. Nineteen percent of the sample needed transfer to a specialist hospital. Conclusion The study concludes that overall management practices for children admitted with severe acute malnutrition to three district hospitals in the Western Cape was poor and often did not adhere to the WHO guidelines. Doctors showed poor understanding of the need for accurate assessment and monitoring in order to reduce the mortality risk of these patients.

Thesis (MPH.) -- University of Limpopo, 2019 / Background: HIV and AIDS is the leading cause of death among adults in subSaharan Africa, and the burden of non- communicable diseases such as diabetes mellitus is high and growing as well. This has resulted in the increase of dual diagnosis of HIV and Diabetes Mellitus in recent years increasing disease burden and self-care challenges being experienced by these patients. This study explored patient challenges arising from this dual diagnosis, and investigated how well the Limpopo healthcare system is servicing these lived experiences, and disease burden challenges these patients have to bear. Methods: A qualitative study approach was used and a phenomenology study design employed in this study. Patients‟ lived experiences and their capability to cope with the co-morbidity of HIV and Diabetes Mellitus was investigated. Sixty four (64) HIV patients with Diabetes Mellitus were identified representing 48% of HIV patients in the HIV/AIDS program at the sites of the study (Mankweng hospital POP clinic, Nobody and Dikgale Clinics) in the Polokwane municipality area of the Limpopo province in South Africa. Fifteen (15) of these patients made the sample and were interviewed. In addition, the five (5) of the seventeen (17) health care providers participated in the interviews. Criterion purposive sampling was used whereby the subjects had to have HIV and AIDS and diabetes in order to be part of the study. The semi-structured interview was conducted. An interview schedule was created to ensure that the key research questions related to workload and capacity are adequately covered during the interviews. Results: The evidence collected suggested that HIV and Diabetes comorbidity patients had increased workload and capacity challenges for self-care. Among the challenges was despondency. Patients found it difficult to adjust to symptoms and demands of the dual diagnosis. Counseling and education was noted as easing anxiety and lowered despondency. Poor services at the clinics worsened their experience and disease burden. Shortage of staff, poor housing of clinics, poor facilities and equipment, lack of training and occasional shortage of drugs were the reasons put forward by the health 2 care professional for the poor services. Separate clinics for HIV and Diabetes Mellitus increased the patients time away from a productive life, increased expenses, and somewhat complicated their lives. Good compliance to treatment was observed. Most patients coped well with medication and had no side effects, the few that had side effects continued to take their medication incorporating additional instructions from the health workers who managed the side effects. Family and buddy support improved the capability to cope with the disease burden and their general attitude to life. Conclusion and recommendations: Primary health care must be strengthened to meet the challenges disease convergence is bringing through continued education of staff and improvement of facilities and equipment, and streamlining service delivery processes. Note of significance is that despite the health care professionals being poorly prepared and under staffed, the clinic facility being poorly housed and poorly equipped, the healthcare professionals are managing to meet their service mandate through commitment and hard work.

INTRODUÇÃO: A cirurgia bariátrica vem a ser uma alternativa, que além da redução do peso dos pacientes, pode reduzir as co-morbidades associadas, como, diabetes mellitus, hipertensão e dislipidemias e assim reduzir o número e os gastos com medicamentos. OBJETIVO: Estimar o impacto do procedimento cirúrgico nos gastos com medicamentos e no risco cardiovascular antes e após a realização da cirurgia bariátrica por pacientes obesos mórbidos. METODOLOGIA: Estudo suplementar, cuja análise dos gastos com medicamentos levou em consideração o gasto médio real do paciente, o gasto médio estimado para o paciente e o gasto médio para o sistema público de saúde. A avaliação do risco cardiovascular foi realizada através da Escala de Framingham. RESULTADOS: Após um período mínimo de 6 meses do procedimento cirúrgico, houve redução significativa nos gastos com medicamentos tanto para o sistema público de saúde (P ≤ 0,016) (R$ 6,71 (0,0-11,1) para R$ 4,2 (0,0-6,9)) como nos gastos estimados para o paciente (P < 0,001) (R$160,0 (58,3 – 225,8) para R$103,1(18,8-144,3)). Considerando o gasto real para o paciente, observou-se diferença somente em relação aos medicamentos adquiridos sem prescrição médica (P < 0,001) (R$ 12,5 (0,0 – 14,6) para R$ 4,9 (0,0 – 13,8)). O risco cardiovascular também reduziu significativamente (P < 0,001) neste período (10,8% (5,8-23,3) para 5,9% (3,4-10,8)), assim como a idade vascular que reduziu em média 11,2 anos (± 10,4) após o procedimento (P < 0,001). CONCLUSÃO: A cirurgia bariátrica reduz as co-morbidades, o risco cardiovascular, o uso de medicamentos e consequentemente os gastos para o paciente e para o sistema público com medicamentos. / INTRODUCTION: The bariatric surgery it´s an alternative that besides the reduction of the patient´s weight can reduce the associated co-morbidities, such as, diabetes mellitus, high blood pressure and dyslipidemias, reducing the number and expenses with drugs as well. OBJECTIVE: To estimate the impact of the surgical procedure on spendings with drugs and the cardiovascular risk before and after the realization of the bariatric surgery by morbid obese patients. METHODOLOGY: Additional study, which analysis of the spending’s with drugs took into consideration the average real spending of the patient, the estimated average spending of the patient and the average spending of the public health system. The evaluation of the cardiovascular risk was performed through the Scale of Framingham. RESULTS: After a minimum period of six months from the surgical procedure, there was a significant reduction of the spending with drugs for the public health system from (P ≤ 0.016) (U$ 6.71 (0.0-11.1) to U$ 4.2 (0.0-6.9)) as well as for the estimated spending’s of the patient from (P < 0.001) (U$160.0 (58.3 – 225.8) to U$103.1(18.8-144.3)). Considering the real spending of the patient, a difference was observed only within the drugs bought without medical prescription from (P < 0.001) (U$ 12.5 (0.0 –14.6) to U$ 4.9 (0.0 – 13.8)). The cardiovascular risk also reduced significantly (P < 0.001) in this period from (10.8% (5.8-23.3) to 5.9% (3.4-10.8)), as well as the vascular age which reduced in average 11.2 years (± 10.4) after the procedure (P < 0.001). CONCLUSION: The bariatric surgery reduces the co-morbidities, the cardiovascular risk and, the use of drugs and consequently, the spending’s of the patient and the public system with drugs.

Magister Public Health - MPH (Public Health) / The presence of highly effective medicines has made very little impact in reducing deaths as a result of tuberculosis (TB), a curable condition but when managed inappropriately, may result in Drug Resistant TB. TB accounts for about one in four deaths that occur in HIV positive people and HIV has been found to be a risk factor for complex unfavorable outcomes in MDR TB patients and a very strong predictor for death and default. The relationship between diabetes and TB has also been explored, with some authors identifying diabetes as a risk factor for TB, and with related poor clinical outcomes in both conditions when they co-exist. Exploring the clinical characteristics and treatment outcomes of MDR TB patients in the presence of these risk factors could present an opportunity to provide better care through increased case-detection activities, improved clinical management and better access to care for all these conditions. The aim of the study was to describe the clinical characteristics and treatment outcomes of MDR TB patients initiated on treatment at Nkqubela and Fort Grey Hospitals.