State of the Art Breast Reconstruction the Birth of Venus by Sandro Botticelli

November 2009

Fakulteit Gesondheidswetenskappe Faculty of Health Sciences TYGER Universiteit Stellenbosch University land

Landelike Kliniese Skool vir US Confronting the TB Crisis Pyn in die virtuele ruimte

State of the Art Breast Reconstruction The Birth of Venus by Sandro Botticelli. It depicts the goddess Venus, having emerged from the sea as a full grown woman, arriving at the sea-shore (Venus Anadyomene mo- tif). The painting is currently in the Uffizi Gallery in Florence. This large picture may have been painted around 1482, or even before. TYGER land InhoudContents Bl. 4: Landelike Kliniese skool op Worcester

2 From the Dean’s Desk Landelike Opleiding 4 Landelike opleiding inspireer ‘selfvertroue, nederigheid en empatie’ 5 Kliniese Skool vir Worcester 6 Ukwanda makes a quantum leap 44: Faculty’s prize winning wine- Nuut op die Kampus maker 8 Nuwe hiperbariese drukkamer Research 9 Elsevier analysis: SU a global leader in Health Redakteur Focusing on TB Sybelle Albrecht 10 A formidable research platform Bladontwerp 11 The problem with TB Mandi Barnard 12 At the forefront of drug development Sybelle Albrecht 13 Drug resistant TB studied to develop new drugs 14 A TB partnership with Germany and Russia Druk en bind 15 Nuwe TB-handleiding Shumani Print World 16 Paediatric tuberculosis: When necessity is the mother of invention 18 New laboratory accelerates TB diagnosis 19 Zamstar 20 Gedeelde kundigheid: Internasionale werkswinkel oor Pediatriese TB Tygerland word uitgegee deur die 21 Community interaction: Kicking a goal for TB Afdeling Bemarking en Kommuni- kasie van die Universiteit Stellen- Fokus op MIV / Vigs bosch se Fakulteit Gesondheids- 22 Die Fakulteit se MIV-benadering wetenskappe. Die tydskrif word 23 Searching for a new approach to keep immune cells alive gratis aan oudstudente van die 18 Care and treatment of infants with HIV fakulteit en ander belanghebbendes Articles gestuur. Indien u kommentaar wil lewer op die inhoud van die tydskrif, 26 Assessing the quality of asthma care of voorstelle maak ivm toekomstige 30 Wanneer pyn in die virtuele ruim verdwyn uitgawes, kontak ons gerus. As u 32 Breast surgery and reconstruction Tygerland gratis wil ontvang, stuur 35 New in breast conservation surgery asseblief u pos- en e-pos adres aan: 36 Genetika van hartsiektes ontrafel 38 Nuut in opleiding Mandi Barnard, 40 Our students from Africa Fakulteit Gesondheidswetenskappe, 41 Tygerberg Poison Information Centre Posbus 19063, Tygerberg, 7505. 42 Mixing medicine and wine Faks: 021 931 0088 43 Waking up sleeping genes epos: [email protected] 44 In memoriam Tygerland 2009 Om ’n werkbare Afrika-model te vind vir GESONDHEIDSWETENSKAPPE OPLEIDING

ie meeste akademiese inrigtings wat betrokke is by Worcester, waar verskeie ander US-fakulteite ook voorsien om gesondheidswetenskappe-opleiding – of hulle in Suid- projekte te bedryf. As sulks, sal die nuwe kampus ongeëwenaar- Afrika of in die buiteland is – word vandag gekonfronteer de geleenthede bied vir interfakulteits- en interdissiplinêre na- met unieke vraagstukke en uitdagings ten opsigte van die vorsing, opleiding en gemeenskapsinteraksie en -ontwikkelings- wyseD waarop hulle klinici en ander gesondheidswerkers oplei, en geleenthede. of hierdie opleiding tred hou met die wyse waarop samelewings Die mikpunt van die Universiteit is om ’n volhoubare lan- verander. delike ontwikkelingsprojek tot stand te bring en uitsluitlik te Met die eise en uitdagings wat gesondheidsorg in Suid-Afrika fokus op alle aspekte van menslike sekuriteit op die platteland – aan ’n instansie soos die US Fakulteit Gesondheidswetenskappe onder meer die ontwikkeling van plaaslike vaardighede en kun- stel, het hierdie Fakulteit oor die afgelope dekade deurlopend digheid tot voordeel van die hele streek. Ander fakulteite wat ’n innoverende aanpassings gemaak – aan ons kurrikula, studente rol sal speel is, onder meer, Agriwetenskappe, Teologie, Lettere profiel en die wyse waarop ons studente opgelei word. en Sosiale Wetenskappe en Opvoedkunde. Van hierdie fakultei- Hoewel ons reeds in 2002 begin het om voorgraadse oplei- te is reeds betrokke by volhoubaarheidsprojekte in die streek. ding gedeeltelik uit die akademiese hospitaal te verskuif na plat- (Sien bl. 5). telandse hospitale, klinieke en ander gesondheidsinstansies, het Die Fakulteit is reeds besig om grond aan te koop vir die dit toenemend duidelik geword dat die Fakulteit, deur die uit- oprigting van die akademiese gebou, wat na verwagting in die breiding van landelike opleidings- en navorsingsinisiatiewe, ’n loop van 2011 voltooi sal word. Verblyfgeriewe vir studente wat wesenlike bydrae tot die gesondheid en welsyn van mense op vir lang periodes kliniese opleiding daar sal ontvang, is ook deel die Wes-Kaapse platteland kan maak. van die beplande infrastruktuur ontwikkeling. Op grond van ons ondervinding op hierdie gebied, en ná Die Skool sal nie net uniek wees in Suid-Afrika nie, maar dit heelwat navorsing, konsultasie en onderhandeling met die Uni- het ook die potensiaal om as unieke laboratorium te dien vir ’n versiteit en eksterne vennote is daar derhalwe besluit om ’n werkbare Afrika-model vir gesondheidswetenskappe-opleiding Landelike Kliniese Skool, waarskynlik aangrensend tot die aan- in ’n omgewing met beperkte hulpbronne. sienlik opgegradeerde streekshospitaal in Worcester te vestig. Die Skool sal nie net landelike opleidings- en navorsingsge- A remarkable growth in research leenthede vir studente en akademiese personeel van die FGW It is with immense satisfaction that the Faculty and its research- skep nie, maar dit sal waarskynlik die middelpunt vorm van ’n ers can look back at our research achievements of the past few plattelandse satellietkampus van die Universiteit Stellenbosch in years. Apart from sustained growth and a remarkable increase in

Tygerland 2009 From the Dean’s Desk research outputs between 2004 and 2008, the quality and depth stad en die Universiteit van Würzburg in Duitsland, ’n unieke of these outputs have won the Faculty international recognition navorsingsopleidingsgroep in Afrika geloods. Hierdie projek, wat as world leaders in fields such as TB, mental health and diseases gerig is op die groei van navorsingskapasiteit en die ontwikkeling studied within the context of brain imaging (see article on p9). van eersterangse navorsers vir die land, behels onder andere In terms of a SBA calculation, Stellenbosch University currently studiebeurse vir ses PhD-kandidate van die US en ses van die has the largest publications output in terms of publication units Universiteit Kaapstad (bl. 38). per senior lecturer. While publication output has remained Ons is terselfdertyd betrokke by talle akademiese en kliniese static and even declined at many universities in South Africa, the samewerkingsprojekte met die UK, sowel as die Universiteit van number of research papers published in peer reviewed scientific Wes-Kaapland en Kaapse Skiereiland Universiteit van Tegnologie, journals by academic staff of our Faculty have increased by 33% op gebiede soos Noodgeneeskunde, Kerngeneeskunde, Geneti- over the last 3 years. ka, die opleiding van Tandheelkundestudente en verpleegsters, International funding is also making an important contribu- breinbeelding en navorsingsprojekte deur individuele navorsers tion to our research achievements. Large research grants, pre- van die verskillende departemente en afdelings in die FGW. dominantly from international sources and amounting to more than half a million rand per project, have grown from about R20/ Samewerking met die privaatsektor R30 million in 2004 to more than R110 million in 2008. At the Fakulteitsvennootskappe met die privaatsektor gaan steeds same time, researchers also received smaller grants from lo- voort en behels, onder meer, vennootskappe wat deur die drie cal and international organizations. Most international research grootste private hospitaalmaatskappye in die land befonds word. funding agencies focus their resources on multi-institutional and Befondsing van hierdie aard dra nie net by tot nagraadse oplei- multi-disciplinary projects, rather than funding single-researcher ding vir Suid-Afrikaanse studente nie, maar in 2008 het dit ook research initiatives. Thus, much of the research currently con- gehelp om studentegetalle uit Afrika te verstewig – tot so ’n ducted at the SU Faculty of Health Sciences, involves coopera- mate dat Afrikastudente tans bykans 10% van ons nagraadse stu- tion with international institutions or other South African uni- dentekorps behels. Lees op bl. 40 meer oor hierdie studente en versities – examples of which abound in this edition of Tygerland. hoe hulle hul opleiding aan die US ervaar. As our reputation for research excellence grows, international institutions increasingly show a keen and abiding interest in In this edition of Tygerland working with FHS scientists and clinicians on projects ranging Focusing on two of the strongest areas of research in the Fac- from HIV and TB to mother and child health and various others. ulty, articles in this edition of Tygerland provides you with an The expertise offered by our researchers, as well as the Faculty’s overview of new research and other initiatives in the areas of tu- infrastructure and sophisticated research facilities and its close berculosis and HIV (p. 10 - p. 25). We also feature, among others, proximity to a wide range of both diseases of life style (increas- an interesting article on groundbreaking plastic surgery tech- ingly) and diseases of poverty, including the epidemics of TB and niques for breast reconstruction after a mastectomy (p. 32); the HIV/Aids, present scientists from these institutions with oppor- Faculty’s involvement in the implementation of new guidelines tunities for research that are unique in the world today. for the management of asthma (p. 26); interesting new research from the Physiotherapy division (p. 30); new textbooks from the Inter-universitêre samewerking Faculty (p.15 & p. 39) as well as new academic programmes and Internasionale befondsing het ook oor die afgelope jare same- training initiatives (p. 39). werking tussen die US Fakulteit Gesondheidswetenskappe en The Tygerland format only allows us to feature a limited num- ander gesondheidswetenskappe fakulteite in die Wes-Kaap en ber of subjects in one edition. I hope that the selection in this elders in Suid-Afrika, in die hand gewerk – nie net tot voordeel edition, together with the Faculty news that we share with you van die provinsie nie, maar dikwels ook tot voordeel van die on a regular basis through the electronic newsletter, Tygerberg land, die Afrika-vasteland en die internasionale gemeenskap. Gesprek, has given you a fairly comprehensive outline of new ’n Sprekende voorbeeld is ’n samewerkingsprojek van prof developments, initiatives and achievements at your alma mater. Mark Cotton van die US se KID-CRU-navorsingseenheid vir In- We hope to continue in this fashion to strengthen our ties with feksiesiektes en dr Avy Violari van die Universiteit van die Wit- you, our much valued alumni and other partners and friends watersrand, wat deur die Amerikaanse National Institute of Allergy who share our quest for academic excellence and optimal health and Infectious Diseases (NIAID) befonds word. Die projek behels care for our country and our continent. ’n groot kliniese proef wat fokus op vroeë antiretrovirale behandeling vir MIV-geïnfekteerde kinders en vroeë resultate van With warmest regards, die studie het reeds daartoe aanleiding gegee dat die Wêreld- gesondheidsorganisasie (WGO) en ander gesondheidsinstansies hul riglyne vir die behandeling van MIV infeksie in pediatriese pasiënte aangepas het. Prof Wolfgang Preiser van die US se Afdeling Virologie het in die loop van 2009 in samewerking met die Universiteit Kaap- Wynand van der Merwe, Dean.

Tygerland 2009 Opleiding Landelike opleiding inspireer ‘selfvertroue, nederigheid en empatie’ ’n Oud-Matie vergelyk sy ‘ou skool’-opleiding met dié wat MBChB-studente tans aan die US kry.

ie verskil wat landelike opleiding selfvertroue te diagnoseer en ’n behande- “Hier leer hulle dat die dokter moet maak aan die houding en lingsplan op te stel. Dit is van groot waar- weet waar sy pasiënt vandaan kom en wat Dselfvertroue van die US se de – nie net in terme van dienslewering in sy toegang tot vervoer en ander hulp- mediese studente, aan die vooraand van die hospitaal nie, maar ook vir die student bronne is. Hulle leer byvoorbeeld dat dit hul internskap-opleiding en diensjaar, is wat aan die vooraand staan van sy of haar nie help om ’n pasiënt vir longontsteking ’fenomenaal’. internskap en diensjaar.” te behandel en huis toe te stuur as die Só sê dr Arno Ros- persoon nie ’n dak oor sy kop souw, ’n oud-Matie en het nie. tans verbonde aan die “By Ceres-hospitaal is daar Ceres-hospitaal waar gewoonlik op Dinsdae ’n verga- hy gereeld as toesig- dering van die hospitaal se multi- houdende dokter, stu- dissiplinêre span en na afloop dente van die FGW van die vergadering doen hierdie tydens hul landelike span huisbesoek in die gemeen- opleiding onder sy vlerk skap. Die studente gaan saam neem. op hierdie besoeke en hulle kom Rossouw vertel dat in aanraking met pasiënte binne hy sy MBChB-opleiding die realiteite van die pasiënt se destyds voltooi het daaglikse bestaan, en terselfder- vòòr landelike oplei- tyd leer hulle wat tuisgebaseerde ding deel geword het sorg werklik beteken en wat dit van die kurrikulum, en van gesondheidswerkers verg. vòòr mediese studen- “Ek het as student nooit sulke te soveel blootstelling geleenthede tydens my opleiding aan pasiënte gehad het gehad nie. Vandag sien ek hoeveel as die studente wat dit bydra tot studente se selfver- tans aan die US opgelei troue en hoeveel betrokkenheid, word. nederigheid en empatie dit in die “Ek onthou nog met hand werk.” hoeveel twyfel ek vir die Rossouw sê dat baie van ver- eerste keer onafhank- al die senior studente van die US lik met pasiënte begin met wie hy op Ceres in aanra- Drr Arno Rossouw (links) en Hans Hendriks is albei oud Tygerberg Maties en werk het. Ek het geweet king kom, van ‘bo-gemiddelde trotse oud-inwoners van Hippokrates ek was ’n student maar standaard is’, en hy glo dat die ek was nie seker of ek Fakulteit se benadering tot oplei- ’n dokter was nie.” ding en veral die landelike deel Hy sien min van hierdie twyfel in veral Belangriker nog, sê Rossouw, is die daarvan, bydra tot die besondere gehalte die vierde- en vyfdejaar studente van die studente se aanraking met die mense- van die studente. FGW wat hul landelike rotasies van vyf diens wat by plattelandse hospitale gele- Juis omdat die klem in landelike oplei- weke op Ceres kom doen. wer word. Anders as by groot hospitale ding so sterk op ‘mensediens’ val, en omdat “Uit hulle eerste kontak met pasiën- waar die omset van pasiënte so groot is dit soveel selfvertroue – en terselfdertyd te kan ’n mens reeds sien dat dit nie die dat die individuele pasiënt net ’n nommer nederigheid en empatie – in Suid-Afrika se eerste keer is dat hulle ’n pasiënt onder- en ’n siekte word, leer ken die studente dokters van môre inspireer, glo hy dat ’n soek nie, en na ongeveer drie weke by die hul pasiënte in ’n plattelandse omgewing landelike kliniese skool ’n besondere bate hospitaal, is die meeste van die studente as mense wat in hul totaliteit behandel vir Suid-Afrika en die gesondheidsdiens in staat om pasiënte onafhanklik en met moet word. van die land kan wees.

Tygerland 2009 Kliniese Skool vir Worcester

ie US Fakulteit Gesondheids- kundigheid ten bate van die hele streek. jaar was daar ’n groeiende behoefte aan ’n wetenskappe is tans besig om Benewens die FGW, sal fakulteite soos die uitbreiding van Ukwanda-aktiwiteite. Dit DSuid-Afrika se eerste plattelandse Agriwetenskappe, Teologie, Ingenieurswe- het gepaard gegaan met ’n behoefte aan kliniese skool vir opleiding in die se, Regsgeleerdheid en Opvoedkunde groter interafhanklikheid tussen gesond- gesondheidswetenskappe in Worcester te ook op die satellietkampus verteenwoor- heid en ontwikkeling. vestig. dig word. Die strategiese plan vir die ontwikke- Hierdie skool het die potensiaal om as Die projek is veral gerig op die vyf ling van ’n nuwe Landelike Kliniese Skool unieke laboratorium te dien vir ’n werk- temas van die millennium ontwikkelings- is teen hierdie agtergrond ontwikkel. bare Afrika-model vir gesondheidswe- doelwitte wat deur die Rektor van die Die Skool sal opleiding vir professionele tenskappe-opleiding in ’n omgewing met US, prof Russel Botman, geïdentifiseer is, gesondheidswerkers fassiliteer en voor- beperkte hulpbronne, sê die dekaan van naamlik omgewingsvolhoubaarheid, mens- siening maak vir ’n addisionele jaarlikse die Fakulteit, prof Wynand van der Mer- like waardigheid, die uitwissing van armoe- inname van 15 mediese studente, 10 stu- we. de, demokrasie en sekuriteit, en ook op dente uit die verwante gesondheidswe- In die Fakulteit self, ontvang studente die menslike sekuriteitsinisiatief. Raakpun- tenskappe en tien internasionale studente. vir bykans ’n dekade reeds ’n deel van hul te tussen die fakulteite op gebiede soos Die addisionele inname van voorgraadse voorgraadse opleiding op die platteland voedselbronne, skoon water, gesondheid, studente ondersteun die nasionale De- by distrikshospitale, primêre sorg- en mo- leefstylverbeterings, vaardigheidsontwik- partement van Gesondheid se menslike biele klinieke en ander gesondheidsinstan- keling en omgewingsvolhoubaarheid is hulpbronplan. sies. Die nuwe kliniese skool sal egter on- reeds geïdentifiseer, veral in projekte van In terme van die huidige plan, maak geëwenaarde geleenthede bied – nie net die verskillende fakulteite wat reeds op die Skool voorsiening vir ’n jaarlange vir voorgraadse opleiding nie, maar ook dreef is. kliniese rotasie vir finale jaar mediese vir navorsing, nagraadse opleiding en ge- Worcester en omliggende plattelandse studente en kliniese assistente, asook vir meenskapsdiens. gebiede soos Ceres, Robertson, Citrus- rotasies deur studente in die verwante ’n Terrein vir die oprigting van die dal, Paarl en Grabouw word reeds se- gesondheidswetenskappe. Op nagraadse fisiese infrastruktuur is reeds geïdentifi- dert 2002 deur Ukwanda - die US FGW vlak, maak die Skool voorsiening vir lan- seer en volgens die Dekaan sal die nuwe se Sentrum vir Landelike Gesondheid in delike opleiding vir ’n addisionele sewe fakulteitsgebou, langs die Worcesterhos- die Overberg – bedien. Hierdie platform kliniese assistente, en navorsingsge- pitaal, in 2011 voltooi wees. vir onderrig, opleiding en navorsing is nie leenthede sal geskep word vir studente Die nuwe skool word beplan as sen- net stewig gevestig nie, maar dit word in- wat aan Meesters- en doktorale tesisse trale onderdeel van ’n nuwe landelike tensief benut deur die Fakulteit se voor- werk. Verder word die moontlikheid on- satellietkampus wat die US in Worcester graadse studente wat dwarsdeur die jaar dersoek om ’n leerstoel in landelike ge- wil vestig as ’n Universiteitsbydrae tot kliniese rotasies in hierdie gebiede doen, sondheid tot stand te bring om verdere volhoubare landelike ontwikkeling. Dit asook sommige nagraadse studente en stukrag te gee aan navorsing in landelike sal geleenthede vir verskillende fakulteite Fakulteitsnavorsers. Omdat Ukwanda gesondheid en ontwikkeling sodat die skep om saam te werk aan inisiatiewe wat gemeenskapsinteraksie met onderrig en kennis wat op hierdie wyse gegenereer fokus op alle aspekte van menslike sekuri- navorsing integreer, is vlagskipstatus vir word, uiteindelik kan bydra tot ontwik- teit in landelike gebiede – onder meer die gemeenskapsinteraksie in 2008 aan die keling in die Overbergstreek, sowel as ontwikkeling van plaaslike vaardighede en Sentrum toegeken. Oor die afgelope paar nasionaal en op die Afrika-vasteland.

Tygerland 2009 Training Ukwanda makes a quantum ver the past decade, students of leap the SU Faculty of Health Sciences have been brought into close Health sciences training at Stellenbosch University is gradually moving out of contact with the realities of health inO rural areas of the Cape Winelands and the disease- and speciality-based environment of the academic hospital and Overberg districts of the Western Cape today most of our undergraduates are regularly brought face to face with the – thanks to a unique platform created by needs of patients and the demands of health care in extremely poor and low the Ukwanda Centre for Rural Health. From Worcester to small towns as resource settings during their training. Much of this training is facilitated by far afield as Hermanus, Ceres, Robert- the University’s Ukwanda Centre for Rural Health in Worcester. The academic son, Montagu, Swellendam and Caledon, platform, created by Ukwanda, will provide the backbone for South Africa’s first partnerships have been built and facilities Rural Clinical School, due to be established by the SU and its Faculty of Health established to facilitate undergraduate rotations in district and regional hospitals, Sciences over the next two years. community health centres, family practic- es, day hospitals and mobile clinics as well as schools, old age homes and the homes Health in Worcester. As the central hub of He tries to share his outspoken pas- of patients. Further training facilities have all FHS rural training activities, Ukwanda sion for rural health with his students by also been established at Madwaleni in has not only established accommodation, exposing them to “remarkable roll models Lusikisiki, one of the poorest and most computer facilities and other resources in health in the rural areas of the Western remote parts of the Eastern Cape. At for students at the various sites, but also Cape.” the same time, postgraduates in specialist built partnerships with doctors and other “On my weekly visits to district hos- fields such as obstetrics and gynaecology, health care professionals who supervise pitals I regularly see young doctors who paediatrics, family medicine, physio- and the students during their rural rotations. carry an impossibly heavy workload, but occupational therapy and human nutrition The director of Ukwanda is Prof Hof- still make a real difference to health care are also provided with training opportuni- fie Conradie, an alumni of Stellenbosch in their working environment. It doesn’t ties at the various sites. University who devoted most of his medi- matter how close they are to burn-out, Today large numbers of the Faculty’s cal career to rural health care. Fresh from they still get excited by new initiatives, like students are taken out of the disease- and his training at the Faculty and Tygerberg CPAP for neonates or a colcoscopy ser- speciality-based environment of the aca- Hospital, Conradie started working at a vice in a district hospital. demic hospital and brought face to face rural hospital in the former Transkei – and “These are the doctors that Stellen- with the needs of patients and the de- since then he has never worked in a city bosch University would like to support by mands of health care in extremely poor or urban area again. In the 1990’s, when facilitating projects and research in rural and low resource settings during their the SU division of Family Medicine and areas. They are also the doctors whom training. Primary Care created a number of posts we want to introduce to our postgradu- The cornerstone of the extensive plat- for specialist family physicians to manage ate students.” form that was required to facilitate rural student rotations in rural areas, Conradie Conradie believes that health sciences training, was built in 2002 when the Facul- was appointed to supervise training activi- students can only develop an understand- ty launched the Ukwanda Centre for Rural ties at the Worcester Hospital. ing of rural communities once they are

Tygerland 2009 Training Stellenbosch University can be a pathfinder regarding health sources settings. This is one of the central sciences education in settings with low resources. challenges facing institutions across the world who are grappling with questions brought face to face with the realities that new Rural Clinical School will be estab- and challenges regarding medical training, govern those communities. lished, adjacent to the Worcester Hospital and whether it is adapting to the way so- “It is only when a student visits a bed- – with Ukwanda’s infrastructure forming cieties are changing. ridden patient, cloistered in a tiny, cor- the backbone of the new school’s training The new Rural Clinical School will not rugated iron shack without any means of activities, research and community inter- be operated in isolation but will form the transport to the nearest health care facility, action. centre of a rural satellite campus of Stel- that the student can begin to understand Over the past year, much research, lenbosch University in Worcester. This the hopeless plight of rural communities consultation and negotiation have gone campus will offer a wealth of opportuni- and the lack of proportional distribution into the project, including a seminar with ties for interfaculty and interdisciplinary of health services in the country.” world experts in rural health education research. He says that while the University and representatives of other South Af- According to University authorities, should strive to expose the realities of rican health sciences faculties. Closely the initiative has the potential to develop an under-funded and badly-equipped ru- examined issues and concerns included into a truly sustainable rural develop- ral health system, we should also strive the quality and cost of rural training, the ment project with a dedicated focus on to encourage energy and enthusiasm for recruitment of students from rural areas, the issues that affect all aspects of human change while supporting and facilitating the role of specialist disciplines, partner- security in rural areas, including the de- current initiatives in rural health and de- ships and the involvement with external velopment of local skills and expertise to velopment. stakeholders. benefit the whole region. Candidate fac- Stellenbosch University and the Fac- According to international experts ulties could include the Faculties of Agri- ulty of Health Sciences are set to make a who attended the seminar, Stellenbosch sciences, Theology, Engineering, Law and giant leap towards the realisation of these University can be a pathfinder regard- Education, some of which already have ideals within the next two years when a ing health sciences education in low re- projects that support sustainability.

The graphic below illustrates the new rural platform and potential areas of collaboration:

RURAL EDUCATION INITIATIVE •Faculty of Education

RURAL CLINICAL SCHOOL

RURAL SOCIAL DEVELOPMENT EDUCATION AND TRAINING •Faculty of Theology COLLABORATION •Undergraduate students (2009: 50 students) •Faculty of Arts & Social Sciences •Postgraduate students (2010: 20 students)

HUMAN SECURITY RESEARCH AND EPIDEMIOLOGY RURAL AGRICULTURE DEVELOPMENT INTERVENTION INITIATIVE •Burden of disease•Studies and interventions: •Boosting rural agricultural science and Increased availability of food TB, HIV/AIDS, Diabetes, Cancer, technology increased productivity and resources Cardiovascular & Respiratory diseases growth increased economic growth in Water region COMMUNITY DEVELOPMENT •Empower local farmers to obtain Health CENTRE improved access to finance •Community nutrition initiatives (including •Enhancing human capital through Lifestyle improvements dietary education) •Outreach & home visits (including education) education and improved health Skills development •Short courses in agricultural practice, •Community Interaction projects (improvement management and leadership Environmental sustainability of health care infrastructure; improving •Mentorship programmes for new entrant lifestyles of patients through awareness and farmers education) •Increased amount of fresh produce in rural areas [USAID] COLLABORATION EMPOWERMENT OF COMMUNITY •Skills training, development •Ownership of health responsibility

Establishment of JOB PREPARATION AND CREATION RURAL SUSTAINABILITY •Opportunities for empowerment of local STELLENBOSCH UNIVERSITY

RURAL PLATFORM RURAL INSTITUTE people –improving lifestyle, living standards •Involvement of various faculties with key projects which support sustainability

Tygerland 2009 Nuut op die Kampus HIPERBARIESE DRUKKAMER vir onderrig en navorsing ie US Fakulteit Gesondheids- verpligte geskiktheidstoetse vir vlieëniers wetenskappe het in 2005 ’n unieke en diepsee duikers, sowel as toetse om nisgebied en ’n belangrike internasio- die beroepsverwante mediese geskiktheid nale kundigheidsgebied betree toe van siek of beseerde indiwidue te bepaal. dieD Afdeling Gemeenskapsgesondheid Studente uit verskillende lande is tans die eerste Honneursgraad in Onder- geregistreer vir die Afdeling se onderwa- watergeneeskunde in Suid-Afrika beter- en hiperbariese geneeskunde pro- kend gestel het. gramme, onder meer uit Brittanje, In die afgelope jaar is ’n verdere kom- Romenië, Thailand, Indië, Australia, Nieu- ponent toegevoeg tot onderrig en oplei- Seeland en Saoedi-Arabië. Volgens dr Jack ding in hierdie veld toe ’n Baromedisyne en Meintjes, wat betrokke is by die onder- Beroepsgeneeskunde fasiliteit vir pasiën- rig van hierdie programme, is meer as ’n te op die Tygerbergkampus geopen is. duisend studente sedert 2005 in Onder- Hierdie fasiliteit, wat op die grondvloer watergeneeskunde opgelei. langs die Onderwysblok ingerig is, is toegerus met twee hiperbariese druk- Wat is Hiperbariese Sr Surita Fitchat (links) en dr Frans Cronjé kamers en ’n kliniese sentrum wat tot agt Suurstofterapie? berei ’n pasiënt voor vir behandeling. pasiënte per dag kan akkommodeer. Dr Hiperbariese (i.e. verhoogde druk) suur- Cecilia Roberts, ’n spesialis op die gebied stofterapie of HST is ’n gespesialiseerde van hiperbariese suurstofbehandeling, is behandeling wat gebruik maak van die onder omstandighede waar dit nie aangestel as bestuurder van die fasiliteit, genesende eienskappe van suurstof andersins moontlik sou wees nie. Al die met Suster Surita Fitchat as haar assis- wanneer dit onder verhoogde druk liggaam se primêre genesingsprosesse is tent. ingeasem word. Om dit met veiligheid afhanklik van suurstof en deur gekompli- Dit is slegs die tweede fasiliteit van te kan doen moet suurstof in ’n spesiaal seerde mediese toestande met Hiper- hierdie aard by ’n tersiêre instansie (die vervaardigde drukhouer of hiperbariese bariese Suurstofterapie te behandel kan ander is by die Universiteit Pretoria), en kamer toegedien word. Onder hierdie ledemate soms gered en komplikasies as sulks is dit toegerus om navorsing te omstandighede los daar soveel suurstof verminder word in hoë risiko situasies. doen op die waarde van suurstofterapie in die bloed op dat dit genesende Vir navrae en afsprake, skakel Sr Surita in die behandeling van spesifieke mediese effekte het. Hiperbariese Suurstofterapie Fitchat by (021) 938 9808; 082 772 0775 en chirurgiese toestande. As beroeps- het die vermoë om beseerde en (selfoon); 086 551 5347 (faks) of suritaf@ geneeskundige fasiliteit, doen die sentrum geïnfekteerde weefsels te laat genees sun.ac.za (ePos).

Wie kan baat by hiperbariese suurstofterapie?

Daar is 13 toestande waar hiperbariese suurstofterapie van groot nut of selfs lewensreddend kan wees: • Borrelberoerte (arteriële lugembolisme) • Weerstandige beeninfeksies (osteomiëlitis) • Dekompressie Siekte • Bestraling-skade aan die kakebeen of sagte weefsel in • Koolstofmonoksied vergiftiging die behandeling van kanker • Gasgangreen • Gekompromitteerde veloorplantings, plastiese chirurgie • Vergruisbeserings waar erge weefsel trauma en swel- of weefseloorplantings ling aanwesig is of waar ledemaat swelling bloedtoevoer • Akute Termiese Brandwonde belemmer (kompartement sindroom) • Akute Bloedverlies (waar bloed nie oor getap kan word • Probleem wonde (sekere diabetiese, arteriële, drukseer nie) bv. Jehova Getuies en veneuse stase wonde) • Serebrale Absesse. • Vernietigende weefselinfeksies

Tygerland 2009 Nuut op die Kampus Analysis Stellenbosch University: A global leader in Health

An analysis by the world’s largest publisher of medical and scientific literature highlights the leading role of scientific and clinical researchers of the SU Faculty of Health Sciences in global health research.

(Profs Seedat and Charles Parry); infer- tility studies (Prof Danie Franken); obstetrics focused on intra-uterine growth, gestational age and growth restriction esearch scientists and clini- Leading authors in the field of men- (Prof Hein Odendaal); cytogenetics and cians of the Faculty of Health tal health, with particular reference to genome mapping within the context of TB Sciences, Stellenbosch Univer- anxiety and stress disorders, as well as (Prof Van Helden and his team); diabetes sity, are increasingly taking the schizophrenia, include Profs Robin Ems- and diabetic care (Prof Bob Mash); heart Rlead in international efforts to control ley and Soraya Seedat of the FHS and research concentrated on ischemic pre- the epidemics and other diseases which Prof Abraham Greeff of the Depart- conditioning (Prof Amanda Lochner) and are wreaking havoc on the health of the ment of Psychology on the main campus. psychosis and schizophrenia (Prof Ems- people of South Africa and others living Seedat is also listed as one of the world’s ley). The Faculty is also amongst the top on the African continent. top authors on mental health with regard ten institutions in the world with regard A recent analysis by Elsevier – the to post-traumatic stress disorders, OCD to the study pleural diseases, with Profs world’s largest publisher of medical and and other anxiety disorders. Andreas Diacon, Chris Bolliger, Anton scientific literature – indicates that SU is Apart from tuberculosis and mental Doubell, Colleen Wright, Gerhard Walzl the world’s scientific leader in tubercu- health disorders, the analysis indicates and others making contributions. Prof losis research and mental health studies, that next to the University College of Jean Nachega is listed with regard to stu- especially in the context of anxiety and London, the Faculty’s researchers have dies on aspects of antiretroviral therapy in stress disorders and schizophrenia. made the strongest contributions in the South Africa. Using only the most highly cited ar- field of brain imaging, employed in the A striking feature of the Faculty’s re- ticles, published in international scientific study of TB - with Prof Johan Schoeman search, is the interdisciplinary nature of and medical journals over a period of making a significant contribution. the investigations with numerous scien- five years, Elsevier mapped the research tists and clinicians contributing critical strengths (or competencies) of universi- Emerging strengths expertise, particularly in TB where HIV ties worldwide within focused subject Amongst other emerging research expertise, together with microbiology areas. According to this analysis, Stellen- strengths, listed in the analysis, the SU methods for optimal detection and moni- bosch University as a whole is the world FHS occupies a third position after the toring of treatment response, pharma- leader in five areas of research – two of universities of Harvard and Columbia in cology, immunology, ethical conduct of which are in the Faculty of Health Sci- the United States, in the study field ex- research, clinical trials and molecular biol- ences. ploring the genetics of anxiety and stress ogy are vital elements of the numerous Prof Ben Marais of the DTTC tops disorders. Frequently sited authors in studies published internationally every the lists of leading authors in the field of this field include Profs Soraya Seedat, year. This trend is also evident in mental clinical TB research while Prof Paul van Dana Niehaus, Christine Lochner, Valerie health studies which often bring together Helden is the most cited author with Corfield, Hanlie Moolman-Smook, Paul brain imaging, genetics, clinical trials and regard to laboratory based TB stu-dies. Carey and Drs Greg Kinnear, J Muller pharmacotherapy. Other leading authors in the TB field in- and James Warwick. clude Profs Nulda Beyers, Peter Donald, At the same time, FHS researchers p On the following pages, Tygerland focuses Gerhard Walzl, Rob Warren, Robert Gie, have made leading contributions in areas the spotlight on TB as one of the strongest Simon Schaaf and Mark Cotton. such as HIV prevention in South Africa areas of research in the Faculty.

Tygerland 2009 Focus on TB A formidable research platform The health of South Africa’s population is severely compromised by two epidemics – tuberculosis and HIV. In the SU Faculty of Health Sciences, researchers across various departments, divisions and disciplines continue to contribute new knowledge to these fields by means of investigations relevant to South Africa and the subcontinent. The articles on the next pages focus on new initiatives in the field of TB and HIV over the past year.

rof Peter Donald, A-rated scientist and distinguished middelweerstandige TB te verbeter. clinical researcher in the SU Faculty of Health Sciences, Volgens prof Paul van Helden, een van die voorste TB-navor- embarked on a research career in tuberculosis more sers in Suid-Afrika en internasionaal, is die voorkoms van TB in than 30 years ago when TB was not a subject that Suid-Afrika vandag soortgelyk aan die voorkoms van die siekte commandedP much international interest. in Londen in 1800. In those days, scientist in the developed world believed that Hy sê die probleem hou deels verband met armoede en ver- infectious diseases had been conquered by vaccines and anti- wante toestande soos wanvoeding en mense wat té na aanme- biotics. And for a while then, it looked as if TB had indeed been kaar in beknopte leefruimtes woon, en deels met die aard van conquered – thanks to the availability of specific antibiotics, die bakterium self. Die vermoede is dat die bakterium minder taken over a period of six months to effect a cure. gevoelig is vir antibiotika omdat dit so stadig groei. Dit kan ge- However, in South Africa, and in Cape Town in particular, volglik binne die selle van die menslike liggaam wegkruip en Donald and his colleagues were still confronted by TB in com- weerstand bied teen die liggaam so pogings om dit te vernietig. munities on a daily basis – despite the availability of antibiotics TB-middels moet derhalwe maande lank toegedien word en and a national effort to control the disease. Over the years, dit het onaangename newe-effekte. Daarom gebeur dit dat pa- they continued to study various aspects of the disease and by siënte nie die middels gereeld oor die vereiste periode van be- the time the rest of the world started to take notice of the handeling gebruik nie en sal dikwels selfs die behandeling staak re-emergence of TB, research in the Faculty was already firmly as hulle begin beter voel. Dit gee aanleiding tot die gevaarliker established. vorm van middelweerstandige TB wat veroorsaak word wan- Their studies focused on the epidemiology of the disease, neer die TB-basille weerstandig raak teen die middels wat as die paediatric TB, new TB drugs and TB meningitis – an area in eerste verdedigingslinie teen die siekte gebruik word. XDR TB which Donald and his SU colleague, Prof Johan Schoeman, had is ook weerstandig teenoor tweede-linie middels. Mense wat been doing groundbreaking research which attracted attention met die MI-virus geïnfekteer is, is as gevolg van ’n verswakte worldwide and established them as global leaders in the field. immuunstelsel, veral vatbaar vir TB en in sulke gevalle kan XDR They also laid the foundations for a formidable TB research TB dodelik wees. platform in the SU FHS, comprising close co-operation between Omdat navorsers in die US FGW hulself toespits op siek- scientists and clinicians and between various departments and tes wat Suid-Afrika en die subkontinent affekteer, is tuberku- divisions. This approach stimulated the development of critical lose vandag een van die sterkste fokusgebiede van navorsing in expertise in areas ranging from HIV and microbiology methods die Fakulteit – en word die Universiteit internasionaal erken as for optimal detection and monitoring of treatment response to leier in hierdie veld. Die diepte en omvang van TB-navorsing was pharmacology, immunology, ethical conduct of research, clinical weer vanjaar opvallend uit die voordragte en plakkate wat by trials experience and molecular biology. die Akademiese Jaardag aangebied is. Die meer as 50 TB-projekte wat voorgedra is, het gekom van navorsers uit bykans elke TB-inisiatiewe in die US departement en afdeling in die Fakulteit en die meeste daarvan Fakulteit Gesondheidswetenskappe verteenwoordig noue samewerking tussen navorsers uit verskil- Ten spyte van intensiewe navorsing oor baie jare, sowel as po- lende afdelings en dissiplines. gings van die regering om TB deur middel van die sogenaamde Navorsers is dit eens dat beter TB-beheer afhang van nuwe DOTS-program onder beheer te bring, het Suid-Afrika steeds en verbeterde diagnose, nuwe middels en beter en korter be- die vyfde hoogste voorkoms van TB ter wêreld; die vierde hoog- handelingstrategieë vir TB-pasiënte - volwassenes sowel as kin- ste voorkomssyfer van middelweerstandige TB en die grootste ders – en diegene met of sonder MIV-infeksie. getal MIV-positiewe mense wat ook aan TB ly. In 2008 was 44% van alle nuwe TB-pasiënte in Suid-Afrika ook MIV-positief. Multi- middelweerstandige TB (MDR TB) and die meer dodelike vorm Tygerland fokus in hierdie artikel die soeklig op belangrike nuwe daarvan, nl. uiters middelweerstandige TB (XDR TB) dra verder inisiatiewe in die US FGW wat oor die hele TB-spektrum strek by om die krisis te vererger en navorsers en klinici beklemtoon – vanaf gemeenskapsbetrokkenheid tot navorsing en praktiese die behoefte aan nuwe benaderings om die behandeling van inisiatiewe wat gerig is op beter diagnose en behandeling.

10 Tygerland 2009 Focus on TB The problem with TB

The global burden of tuberculosis

“Some 22 high-burden countries collectively account for 80% of the global tuberculosis burden. In 2007, the countries with the highest prevalence were India (with 2.0 million cases); China (1.3 million); Indonesia (530 000); Nigeria (460 000) and South Africa (460 000). Of the estimated 1.37 million cases in HIV-positive persons, 79% were in Africa and 11% in South East Asia. Disturbingly, there were an estimated 500 000 cases of multidrug- resistant (MDR) tuberculosis in 2007 (including 289 000 new cases). Of these 131 000 were in India; 112 000 in China; 43 000 in Russia; 16 000 in South Africa and 15 000 in Bangladesh. Fifty five countries had reported cases of extensively drug resistant (XDR) TB by the end of 2008. These last figures are reason for considerable concern and highlight a potential threat to our ability to treat tuberculosis, both in individual patients and in the context of a treatment programme.” Profs Peter Donald and Paul van Helden, in an article in the New Eng- land Journal of Medicine, June 2009: The Global Burden of Tuberculosis – Com- bating Drug Resistance in Difficult Times.

Tygerland 2009 11 New TB drugs

No new TB drugs have been developed since the 1950’s and 1960’s, mainly ment programme. It is when patients in- because pharmaceutical companies no longer regard the disease as a threat terrupt or discontinue their medication that TB bacteria develop drug resistance. in the developed world, and because the economies of developing countries A second group of South African with a high TB burden are not regarded as a viable market for new drugs. Con- MDR-TB patients is now undergoing a sequently TB drug research has been held back for decades. In the past year, longer, six-month trial of TCM207. The efficacy demonstrated by the Stellenbosch researchers have played a leading role to ensure better drugs new drug against MDR-TB in particular, become available as fast as possible for those needing it the most. is regarded as one of the most important medical breakthroughs in many years in the fight against tuberculosis. While it is difficult to treat tuberculosis, MDR- TB treatment is even more difficult and At the forefront of much more expensive. It takes at least 18 months to treat MDR-TB, which requires second-line drugs since the first-line drugs are no longer effective because the drug development bacteria have become resistant to them. However, increasing numbers of patients are dying despite treatment. Although the new drug is still in the arlier this year, the first new successfully treated compared to about clinical trial phase, it is almost certain to tuberculosis drug in 40 years ten per cent on the placebo. The team be approved in the near future. E was successfully used to treat continues to monitor the patients to see The research was published in the multidrug-resistant tuberculosis (MDR- if treatment remains effective. New England Journal of Medicine in June TB) patients in a clinical trial conducted “What we saw over the eight weeks 2009. by Prof Andreas Diacon and a team of was a significant difference in the rate in researchers of the Task TB Trials Unit of which tuberculosis disappeared,” Diacon A new clinical trials consortium the SU Faculty of Health Sciences. says. “The drug works on both drug- Diacon is also part of a team of TB According to Diacon, diarylquinoline susceptible and drug-resistant TB in the researchers of the SU FHS who have TMC207 works differently from other laboratory and the implications are that been chosen to participate in a TB Clinical TB drugs by targeting an enzyme of My- this new drug might shorten treatment Trials Consortium (TBTC), comprising cobacterium tuberculosis, the agent that time for all tuberculosis patients.” 15 test sites. causes TB. One of the key problems during the The consortium is funded by the During the clinical trial, the research- treatment of TB is to convince patients American Centres for Disease Control ers gave the drug to 20 patients in ad- to stick to their treatment schedule, (CDC), who awarded the grant after a dition to standard therapy for MDR-TB which usually lasts for a period of six competitive international selection pro- for eight weeks. Twenty-one patients re- months. A drug that shortens the treat- cess. ceived a placebo plus standard treatment. ment time scale could therefore stop Known as SUN-TB, the team is led by About half the patients on TMC207 were people from dropping out of the treat- Prof Anneke Hesseling of the Desmond

12 Tygerland 2009 New TB drugs

Tutu TB Centre, Diacon, who is the director of the Task TB Trials Unit, and Prof Drug resistant TB studied to Mark Cotton, director of the Paediatric Infectious Diseases Unit, KID-CRU. The develop new drugs SU application was written in collaboration with Drs Fred Gordin and Debra Through the study of drug sensitive and drug resistant TB strains, Benator of the George Washington Uni- scientists hope to identify markers for the design of new TB drugs. versity (GWU), representing the US Vet- eran’s Administration TBTC sites. hen it comes to TB research, the SU resistance. So far the team, in collabora- This faculty-wide application draws WFaculty of Health Sciences enjoys tion with partners at the Harvard School on the strong interdisciplinary TB re- competitive advantage in many areas, of Public Health in the United States, search experience at Stellenbosch and mainly as a result of funding, expertise in have identified more than 40 mutations includes numerous co-investigators who the field and valuable resources – such as that can either confer or enhance drug bring critical expertise in HIV, microbiol- a unique bank of samples, collected over resistance in TB bacteria. They hope to ogy methods for optimal detection and many years by Profs Tommie Victor and sequence hundreds of TB bacteria to monitoring of treatment response, phar- Rob Warren of the Molecular Biology derive the most comprehensive view of macology, immunology, ethical conduct and Human Genetics division. drug resistance possible. of research, clinical trials experience and This bank represents one of the Recently, Victor and collaborators molecular biology. The new research ef- largest collections of TB samples in the received a grant amounting to R4 million forts will also build on the strong histori- world, including more than 13 000 drug over a period of three years from the cal research collaborations between the sensitive and 6 000 drug resistant cul- Wellcome Trust to study drug resistant local TB control programme at commu- tures which form a vital resource for TB. nity level and Stellenbosch investigators, studies that use DNA fingerprinting to He and his team plan to identify mo- and also strengthens a formal inter-uni- track the evolution of drug resistant lecular events which can be targeted by versity collaboration with GWU. strains and how they spread through new drugs to prevent the bacterium to Hesseling points out that although populations. become hyper-resistant, Victor says. children are a group highly vulnerable to Working with these strains, the SU This study is also strongly supported TB, few studies of new TB drugs or regi- team are trying to find out how normal by their access to the TB sample bank. mens have included children. The SU in- tuberculosis strains mutate to become “We have already made good vestigators bring paediatric TB expertise resistant to antibiotics. By whole genome progress and our students are currently to the group as well as a strong research sequencing and comparing the DNA of working on a project entitled New hope track record both in adult and paediatric numerous strains, they identify gene vari- for the treatment of drug resistant TB, he HIV research. ations that seem to correlate with drug says. The main aim of the TBTC is to improve treatment for TB through new drugs, better strategies and shorter du- rations of treatment. Initial TBTC studies will investigate novel shorter TB regimens in adults and children with and without HIV infection. This research has the potential to im- pact significantly on improved TB care in South Africa, where we are increasingly faced with the problem of drug resistant TB and an urgent need for new approaches to improve the treatment of drug susceptible drug resistant TB.

Profs Rob Warren (left) and Tommie Victor (right) with Dr Gail Louw seen here with Pictures on opposite page are from left to the poster presentation entitled “New hope for the treatment of drug resistant right: TB” which she delivered at an international congress recently. The presentation also Profs Andreas Diacon, Mark Cotton and won a prize at a TB colloquium held at the MRC. Louw received her PhD last year for Anneke Hesseling. research on this project and is currently continuing the research as part of the team.

Tygerland 2009 13 TB - International Cooperation A TB partnership with Germany and Russia

TB is a global problem and although it affects underdeveloped countries in particular, scientists from all over the world are involved in the quest to improve our understanding of the epidemic, develop new strategies to control the disease and improve TB drugs and diagnostics. Many of these scientists work closely with SU institutions such as the NRF Centre of Excellence for Biomedical Tuberculosis Research and the MRC Centre for Molecular and Cellular Biology – both located in the SU Department of Biomedical Sciences – as well as the Desmond Tutu TB Centre in the Department of Paediatrics and Child Health. In 2008, the Universi- ty forged a new tripartite partnership with Germany and Russia with the purpose of working together to fight tuberculosis and other infectious diseases.

ussia, like South Africa, has been Section of Tuberculosis and currently pointed to many similarities in the epide- identified by the World Health Master of Science student at the London miology of TB in Russia and South Africa. ROrganisation (WHO) as one of the School of Hygiene and Tropical Medicine, “The incidence of multiple drug resist- 22 countries that account for about 80% visited the Desmond Tutu TB Centre ant TB is growing and according to the lat- of all tuberculosis cases in the world. (DTTC) for five weeks to conduct an est WHO estimates, almost 50% of reg- With South Africa listed as the coun- analysis of routine TB surveillance data istered TB cases are multi-drug resistant. try with the 5th highest incidence of TB in to investigate the incidence of recurrent At the same time TB/HIV co-infections the world, and Russia as the country with tuberculosis and predictors of treatment are increasing, especially in populations the 11th highest incidence, researchers default in the Cape Town communities of such as intravenous drug users and pris- from the two countries got together ear- Ravensmead and Uitsig. He completed the oners. In fact, TB is much more prevalent lier this year to look at areas of common study under the supervision of Prof Nulda in Russian prisons than in civilian life.” interest where they can work together in Beyers, director of the DTTC. As in South Africa, factors that play various fields of interest in TB. Marx has worked for the KMF in the a role in the TB in Russia, include social Cooperation between the two coun- Russian Federation for the past three problems, poverty, unemployment and ex- tries and Germany were initiated at a years on TB monitoring and evaluation. cessive alcohol use, says Kosmiadi. Unlike workshop held at the FHS and organised He hopes to make further contributions South Africa, however, intravenous drug by Prof Bernd Rosenkranz, head of the to the scientific partnership and exchange use plays a more central role in TB and Pharmacology Division. among South African, German and Rus- HIV co-infections than sexual transmis- Germany was represented by Dr sian scientists. sion of the HI virus. Florian Marx of the Berlin-based Koch- Marx has worked in high-burden TB “An important factor that led to the Metchnikoff Forum (KMF) and his Rus- areas in all parts of Russia. In an interview explosion of TB in Russia, was the over- sian partner, Dr George Kosmiadi while a with Tygerland, he said 80 out of every crowded conditions in our prisons. Im- strong contingent of researchers from the 100 000 people in Russia were affected by provements of these conditions and more SU FHS and Tygerberg Hospital, who are TB, but the disease was more prevalent in effective treatment of the disease, have involved in TB research, management and rural areas like Siberia than in European contributed to an overall improvement of public health, attended the workshop. The Russia. the TB situation in recent years,” he says. event was subsequently followed up with “For instance, the incidence of the According to Marx and Kosmiadi, 80 a formal agreement between Stellenbosch disease in Moscow is 40/100 000 while million Russians were undergoing X-ray University and the KMF regarding future in some remote parts of Siberia it can be screening for TB annually. They regard cooperation. 300/100 000”. this as an excellent opportunity for joint Marx, who is a member of the KMF’s His colleague, Dr George Kosmiadi research studies, i.e. to find out if case

14 Tygerland 2009 TB - International Cooperation screening – as it is done in South Africa infectious diseases. – is more effective than the Russian ap- South African-German cooperation proach. They also believe that the two will be aimed at improving access to effec- countries have much to learn from each tive diagnosis, treatment and cure, to stop other regarding the dissemination of TB transmission of tuberculosis, to reduce its and the management and treatment of TB social and economic toll, and to assist in patients. development and implementation of new “The KMF’s strongest interests in- preventive, diagnostic and therapeutic clude joint research projects, clinical trials tools and strategies to stop tuberculosis. and capacity building,” says Marx. Working in close collaboration with the The agreement between SU and the World Health Organisation, various fields KMF provides for long-term scientific co- of interest will come under the micro- operation between South Africa and the scope, both in research and clinical prac- Germany/Russian Federation in various tice - among others: areas of TB, such as immunology, micro- • Medical microbiology, biology, epidemiology and public health, • Immunology, and states that SU institutions, responsi- • Biomarkers, ble for tuberculosis control will be mem- • Clinical trials including new drugs and bers of the tuberculosis working group of vaccines, experts of the Koch-Metchnikov-Forum • Pharmacokinetic studies (relationship (KMF). It also provides for the exchange of The representative from Germany, Dr Florian to efficacy and toxicity), students, teachers, doctors and scientists Marx with two study doctors at the Desmond • Databases, aimed at the training of highly qualified Tutu TB Centre; Karen Du Preez (left) and • Tuberculosis in children, scientific experts and teaching personnel. Elizabeth Du Toit (right) during his recent visit • Establishment of study cohorts, One of the main objectives of the work- to the Faculty. • Hospital prevention and control, ing group is to recruit leading researchers • Tuberculosis monitoring, evaluation, and experts from South Africa, Russia, and developments from South Africa, Russia active case finding, Germany into tuberculosis research, with and Germany into practical public health • Adherence to tuberculosis treatment special focus on drug-resistant pulmonary care and attracting big industrial investor regimens, and tuberculosis, the translation of advanced interest to the problems of TB and related • Public health issues of tuberculosis.

ie eerste Domvattende Nuwe TB handleiding kliniese handleiding oor tuberkulose, wat op ontwikkelde, sowel as skrywers van Afrika, Noord-Amerika, Gert Vlok, Martin Storm, Matthys Botha, ontwikkelende lande die Verenigde Koninkryk, Europa en Hayes van der Merwe, Helmuth Reuter, gerig is, is onlangs Asië/Australië.” Elvis Irusen en twee ere-professore, onder die redaksie van Navorsers en klinici uit die FGW Donald Enarson en Madhu Pai. proff Simon Schaaf van het egter ’n leeue aandeel gehad in Daar is twee uitgawes van die die US se Departement die publikasie van die handleiding boek beskikbaar. Albei het dieselfde Pediatrie en deur nie minder nie as 25 bydraes inligting en is deur Saunders, Elsevier, Kindergesondheid en te lewer. Die voorwoord is deur die gepubliseer. Die Europese/VSA Alimuddin I. Zumla van die Universiteit emeritus aartsbiskop, Desmond Tutu uitgawe wat in hardeband verskyn, Kaapstad gepubliseer deur die – beskermheer van die Tygerberg is gedruk op beter kwaliteit papier en vooraanstaande uitgewersmaatskappy, Kinderhospitaal, geskryf. Die FGW- kos ongeveer drie keer meer as die Elsevier. skrywers was Nulda Beyers, Robert Indiese uitgawe. Die Indiese uitgawe is Volgens Schaaf is die boek, Gie, Ben Marais, Anneke Hesseling, ook in hardeband en op ’n aanvaarbare Tuberculosis: A comprehensive clinical Simon Schaaf, Peter Donald, Sharon kwaliteit papier gedruk. Die boek is reference, die eerste handleiding wat Kling, Pierre Goussard, Johan Schoeman, beskikbaar in Suid-Afrika teen R650- volwasse- en kindertuberkulose so Etienne Nel, Jean Nachega, Juanita R700. Dit kan bestel word by Jackie uitgebreid dek. “Ongeveer ’n derde van Bezuidenhout, Colleen Wright, Johann Strydom van Medbookseller by die ePos- die boek handel oor TB in kinders. Dit Schneider, Paul van Helden, Chris adres: [email protected] of is werklik ’n internasionale boek met McEvoy, Rob Warren, Francois Jordaan, telefonies by 021-975 1970.

Tygerland 2009 15 TB - Better Diagnosis Suffer the children

n developing countries such as South Africa, TB is a major cause of disease and death in children under the age of 14 years. At the same time, the parallel HIV epidemic further contributes to Ithe crisis. Studies indicate that in 2007, about 420 000 new HIV infections occurred in children, mainly in sub-Saharan Africa, through perinatal transmission, in a population vulnerable to early contact with tuberculosis. A recent study in the Western Cape recorded a TB incidence of 1 596 in 100 000 HIV-infected, and 66 in 100 000 HIV-uninfected infants. At the same time autopsy studies in sub-Saharan Africa have shown that 20% of deaths in HIV-infected children are due to TB. In Zambia, the Ivory Coast, Malawi and South Africa, TB-related mortality is considerably higher in HIV-infected compared to HIV-uninfected children. Despite the high disease risk experienced by HIV-infected children, the majority of child TB cases are still in HIV uninfected children. Compared to adults, relatively fewer children are HIV-infected and young children are highly susceptible to develop TB irrespective of their HIV status. When children are co- infected with HIV and TB however, they show more rapid progression of the disease and Damien Schumann increased morbidity and mortality.

From a literature review compiled by Profs Colleen Wright, Rob Warren and Ben Marais

Paediatric tuberculosis: When necessity is the mother of invention

he World Health Organisation’s The old and conventional methods for In developing countries with a high research priority guidelines the diagnosis of TB represent one of the burden of infectious diseases such as TB for paediatric TB identified the major obstacles to effective tuberculosis and HIV, fine needle aspiration biopsy can evaluation of new techniques to management and control, causing delays be of inestimable value in confirming the improveT diagnosis and the management that lead to ongoing transmissions of the diagnosis of mycobacterial infection, per- of paediatric TB as an urgent research airborne TB infection in homes and com- mitting early appropriate therapy, as well priority. Prof Colleen Wright, with munities affected by the disease. as a means to obtain specimens for cul- interdepartmental and interdisciplinary ture, bacterial species determination and co-operation from colleagues in the SU Fine needle aspiration sensitivity testing,” Wright says. “Many Faculty of Health Sciences, has made children with pulmonary TB have enlarged significant progress in this direction. Working mainly with children, Wright lymph nodes and we have found that they For the past years, Prof Colleen and her team embarked on their quest tolerate fine needle aspiration very well. Wright, head of the Anatomical Pathology for better and more cost-effective TB Once we acquire the diagnostic mate- division of the SU Faculty of Health Sci- diagnostics by establishing fine needle rial, the provisional diagnosis of TB can ences, has been working in close co-oper- aspiration of enlarged lymph nodes - be given in two days. Thus treatment can ation with colleagues from the Desmond due to possible tuberculosis or other start while we wait for a TB culture, which Tutu TB Centre, the Centre for Molecular infections - as a highly effective and cost- takes up to 6 weeks to complete.” and Cellular Biology in the Department of efficient service at Tygerberg Hospital and The procedure also offers a simple Biomedical Sciences, and the Department at peripheral hospitals and clinics. solution to the problem of distinguish- of Paediatrics and Child Health, to explore Fine needle aspiration is a simple and ing between HIV, TB and other infectious new and innovative ways to eliminate or non-invasive method to acquire cells from agents. minimise the delays in diagnosis and treat- children presenting with enlarged lymph With the establishment of a fine nee- ment of children affected by tuberculosis nodes and it is very successful when used dle aspiration clinic and on-site cytological and the HIV-co-epidemic. for the rapid detection of tuberculosis. diagnostic services, Wright and her team

16 Tygerland 2009 TB - Better Diagnosis revolutionized the diagnosis and manage- inexpensive transport medium in our expensive, time-consuming and techni- ment of children with TB at Tygerberg laboratory which is easy to prepare cally challenging technique which is inap- Hospital – to the extent that they decided and does not require refrigeration. The propriate in routine laboratories, espe- to expand the service to peripheral hos- medium keeps the mycobacteria viable cially in countries with limited laboratory pitals and clinics. “Fine needle aspiration for seven days at room temperature and resources.” is a cost-effective diagnostic modality that it carries minimal risk of contamination. may be performed at the bedside as an The medium was initially intended for A new technique for rapid outpatient procedure. It requires no in- culture testing as an inexpensive transport diagnosis frastructure or sterile environment and bottle, thereby increasing the feasibility of no sophisticated or expensive equipment. diagnosing tuberculosis at primary health With the cooperation of Profs Rob Warren Superficial aspirates may be performed care level. At present we are testing a new and Ben Marais, she recently set out to by clinicians, pathologists or trained nurs- transport method whereby the aspirate is develop and test a new technique that ing personnel and do not require local or directly deposited on special filter paper provides a rapid and accurate diagnosis of general anesthesia.” for subsequent analysis. A sample thus mycobacterial tuberculosis, using routinely To establish the service at clinics and transported carries no infection risk and collected fine needle aspiration samples peripheral hospitals, Wright and her team can even be sent by mail for further testing which were directly inoculated into the established training programmes for clinic in routine laboratories in countries with liquid transport medium, developed in the staff and taught them how to perform limited resources and infrastructure.” Faculty. the aspirations. Consequently the ser- While fine needle aspiration biop- The new technique utilizes the melting vice brought about major efficiencies and sies offer a valuable specimen collection profile or dissociation of double-stranded cost savings for patients and the health technique, Wright points out that culture DNA, which is specific for each species of authorities. confirmation, mycobacterial speciation mycobacteria, using fluorescent dye as a and drug resistance testing are often un- marker. “This technique is rapid and sim- A simple culture transport available in TB endemic areas, resulting in ple and the equipment required for high medium unacceptable diagnostic delays. “For in- resolution melting is relatively inexpen- stance, culture results may take up to six sive and can be used in routine laborato- “However, aspirates still need TB culture weeks. While diagnosis and the detection ries. Up to 72 samples may be processed and clinic staff have no access to culture of drug resistant TB can be accelerated in a cycle and the whole process takes ap- mediums. We therefore developed an significantly by using PCR, this is a very proximately three hours,” she says. With Warren and Marais as her su- pervisors, Wright recently completed a PhD thesis on the above approach. She says this whole new approach to TB diagnosis was developed in response to a real problem, faced by clinicians who work with TB patients in resource-limited environments every day. She believes that this approach may offer a solution to their problems and accelerate the diagnosis of TB significantly once the techniques are fully implemented.

 Wright, in cooperation with the SU Division of Nursing, is currently preparing a one-week course on fine needle aspiration biopsies, the main indication of which will be TB nodes. The course is aimed at professional nurses and will be administered by StellMed. For Seen on the photo are, standing at the back, Profs Colleen Wright, Rob Warren and Ben further information, please contact Sonja Marais with Ms Kim Hoek in front at the Rotorgene, a high resolution melting apparatus. Niemandt at 021 9389602.

Tygerland 2009 17 TB - Better Diagnosis

new PCR laboratory, recently installed in the Medical Microbiology New laboratory accelerates Division of the NHLS laboratories in Tygerberg Hospital, is set to makeA an important contribution towards TB diagnosis addressing some of the most persistent problems that have hampered effective If South Africa is to win the fight against TB, the country needs to strengthen labo- management and control TB in South ratory services and simultaneously improve infection and cure rates, experts have Africa. This includes long delays in warned. This is no longer an elusive goal, thanks to modern technology and laboratory diagnosis and early detection of drug- facilities, recently acquired by Tygerberg Hospital. resistant disease. Conventional methods for diagnosing TB have always had severe limitations be- This means that we can present clinicians cultures, and the application of molecular cause it involves growing a sputum sample with a diagnosis and first line sensitivities techniques for direct detection of first in the laboratory over periods that may within a week.” line sensitivities, Rautenbach says. range from two to six weeks. Consequent Previously, this process could take Although the new technology for rapid delays in treatment meant that an infected from four to eight weeks. “It involved detection (the HAIN technique) has been person would continue to transmit the growing sputum cultures in the laborato- available for about two years, it could not airborne infection to others in his or her ry – a process that takes from two to six be used by the Microbiology laboratory home or community. weeks. If a sample was smear positive, the until the division had access to appropri- However, over the past few years, laboratory still had to determine whether ate laboratory facilities. “The test must be research has shown that thousands of it was M.TB. However, since the facilities done in an extremely sterile environment lives can be saved by using new molecular for this test was not available at Tygerberg to prevent cross-contamination. There- technology techniques to cut delays in the Hospital, the samples had to be sent to fore a new laboratory had to be built diagnosis of the disease and detect signs Groote Schuur Hospital for testing. This within the division to enable us to employ of drug-resistant TB at an early stage. took another week. Then a further week’s the technique.” The recent introduction of a new, work was required to identify drug sen- The NHLS provided the funding to highly sterile laboratory in Microbiology sitivities. build and equip the laboratory during has now provided scientists and medi- “Clinicians therefore had to wait up the second part of 2008, and operations cal technologists in the division with the to eight weeks for a final diagnosis and an were gradually phased in during the first means and the ability to utilise this new indication of drug sensitivities”. months of this year. The facility enhances technology to the advantage of Tygerberg All of this has changed with the in- the research capacity of the Division, and clinicians and their patients. This means troduction of the sophisticated new mo- molecular diagnostic tests for other infec- that diagnosis of TB and the identification lecular techniques for the identification tious diseases will also be implemented in of first line drug susceptibility for TB drugs of mycobacteria from smear positive the near future. such as rifampicin and INH have been accelerated significantly, says Mrs Corné Rautenbach, a medical technologist who has helped to set up the new PCR laboratory in the division. By using a relatively new PCR technique, known as the HAIN technique, Rautenbach says it is now technically possible to diagnose M. tuberculosis complex and identify first line sensitivities within 24 hours on smear positive sputum samples. For smear negative samples, the sample is first cultured in liquid media to obtain sufficient bacilli for molecular detection “Since the HAIN technique involves a long and very detailed process, and is very expensive, it is not cost-effective to perform on only a few sputum samples every Mrs Corné Rautenbach, medical technologist in the Microbiology division, in the mod- day. We therefore set one day per week ern new PCR laboratory. Left in the picture is Ms Yvonne Prince and right, at the back aside to process a large batch of samples. is Ms Wilma van der Horst, both of the division.

18 Tygerland 2009 ZAMSTAR TB Epidemiology a search for novel ways to reduce TB and HIV huge TB and HIV reduction were successful in decreasing the preva- study, collaboratively conducted The huge Zamstar study, lence of HIV and TB. Secondary outcome Aby Stellenbosch University’s which is conducted at com- measures will include tuberculin skin test Desmond Tutu TB Centre, the University surveys in primary school children which munity sites in Zambia and of Zambia School of Medicine and will measure the annual risk of infection, the London School of Hygiene and the Western Cape and in- i.e. TB transmission, and follow-ups of a Tropical Medicine, recently reached a cludes 120 000 participants, cohort of individuals in every community milestone when the first part of the has recently reached its first to measure the transmission of TB and study – comprising various community HIV, as well as stigma in the household. milestone. interventions – was completed. The prevalence survey will Known as Zamstar (Zambia/ focus on a comparison of base- South Africa TB and AIDS Re- line data - gathered at the begin- duction), the study was started ning of the study - with new data in conjunction with Zambart at on prevalence. the University of Zambia in 2005, An exceptional feature of the with funding that was allocated Zamstar study, is the magnitude

by the CREATE consortium spe- Damien Schumann of the survey which allows for cifically for an investigation of 40 000 people at the eight South

novel ways to reduce TB. Picture: African sites, and 80 000 people The Zamstar study is a com- at the sixteen Zambian sites, to munity-randomized trial, the first be tested. The tests will not only part of which comprised specific cover TB, but also include testing interventions at 24 sites – 16 in for HIV, blood sugar levels and Zambia and eight in the Western other health indicators such as Cape. The interventions included weight and height. strategies to enhance the de- The participants expect the tection of TB through increased results of the prevalence sur- testing and diagnosis; household vey to provide them with in- interventions such as the test- formation on the efficacy of the ing of people who have been in interventions. However, it will contact with TB patients, and a also provide essential preva- strengthening of clinic services - lence information needed for specifically activities to strength- the planning of health care initia- en the health care system. tives. This part of the study will The interventions have been be conducted in collaboration in place from 2006 until 2009 with the health department of with DTTC staff working in the City of Cape Town and the close collaboration with national, Provincial Health directorate. At provincial and local departments the same time, the secondary of health. outcome cohorts will continue With the study now entering to gather more information on the next stage, various measures the transmission of TB and HIV/ AIDS amongst individuals. will be employed to measure the Zamstar on the way of completion! efficacy of the different interventions. The The prevalence survey, which will Principal investigator, Professor Nulda primary measure will consists of HIV and be conducted as a cross sectional Beyers of the Desmond Tutu TB Centre, TB prevalence surveys in all the commu- study, will run from late 2009 until the at the recently held four day training nities which have been taking part in the end of 2010 and will signal the conclusion course on the upcoming Prevalence study to determine if the interventions of the Zamstar study. Survey.

Tygerland 2009 19 TB Opleiding

sers, soos proff Peter Donald en Johan Schoeman, oor baie jare op hierdie gebied gelewer het, en die uitgebreide daaropvolgende ervaring van die Universiteit se TB-groep, is van groot waarde vir Gedeelde die internasionale gemeenskap, veral in lande met beperkte hulpbronne en ’n hoë voorkoms van TB. Die IUATLD het die Uni- versiteit dus drie jaar gelede gevra om die jaarlikse werkswinkel kundigheid aan te bied, wat daarop gerig is om klinici met ’n belangstelling Die Universiteit Stellenbosch se TB-groep deel jaarliks in kinder-TB toe te rus met die nodige kennis en vaardighede om ’n daadwerklike verskil te maak in hul onderskeie lande van hul kundigheid op die gebied van pediatriese TB tot herkoms. voordeel van Afrika en ander ontwikkelende lande Die kursus is gewoonlik maande vooruit volbespreek. Dit is waar TB endemies is. vanjaar bygewoon deur afgevaardigdes uit Namibië, Nigerië, die Verenigde Koninkryk, Indonesië, die Verenigde State, Suid-Afrika, Swede, Botswana, Malawi, Duitsland, Kanada, Mosambiek, Tanza- nië, Kenia, Austrialië, Uganda, Nederland, Brazilië, Bangladesh en ie kundigheid van die pediatriese TB-groep in die US se Indië. Prof Ben Marais is as kursusleier bygestaan deur proff Si- Departement van Pediatrie en Kindergesondheid word mon Schaaf en Robert Gie, wat jare se kliniese ervaring met die Dvir die afgelope drie jaar op jaarlikse basis deur die deelnemers kon deel. Die interaktiewe aard van die kursus en International Union Against Tuberculosis and Lung Disease ingespan die bespreking van interessante kliniese gevallestudies was, soos om ’n opleidingswerkswinkel aan te bied vir verteenwoordigers in die verlede, besonder gewild onder die deelnemers. van lande oor die hele wêreld. “Ons glo dat die kursus ’n aanduiding is van die geleenthede Prof Ben Marais, die fasiliteerder van hierdie werkswinkels, wat bestaan vir opvoedkundige inrigtings om navorsing te doen sê pediatriese TB is jare lank oor die hoof gesien in TB-beheer- wat relevant is tot die gesondheidsuitdagings in ons land, die programme, hoofsaaklik omdat kinders se tuberkulose selde met Afrika-vasteland en die res van die ontwikkelende wêreld,” sê roetine sputummikroskopie ondersoek gediagnoseer kan word Marais. “Dit is eweneens belangrik om die resultate van sulke en min bydra tot die verspreiding van TB binne gemeenskappe. studies en die kundigheid van betrokkenes te deel tot voordeel Oor die afgelope jare het ’n sterker bewustheid ontwikkel van van die mense wat ons dien.” Hierdie beginsel is onderliggend die ernstige siektetoestande en hoë sterftesyfer onder jong tot al die navorsing en opleiding wat die Fakulteit se akademici kinders wat TB opdoen. Dit het die soeklig gefokus op die hard- en klinici doen op die gebied van kindersiektes”. nekkige probleme wat verband hou met kinder- TB – onder meer hoe moeilik dit is om ’n definitiewe diagnose sonder toegang tot gespesialiseerde ondersoeke te maak. Daar is egter heelwat wat gedoen kan word om kinders se toegang tot voorkomende behandeling en toepaslike hantering te verbeter, selfs in arm lande en/of in afgeleë gebiede. Die Wêreldgesondheidsorganisasie (WGO), sowel as die International Union Against Tuberculo- sis and Lung Disease (IUATLD) het egter oor die laaste jare groter erkenning begin gee aan kinder- TB om sodoende die toegang van kinders tot beter TB-diagnose en optimale behandeling te verbeter. Hierdie behoefte word veral beklemtoon deur die wisselwerking tussen die MIV- en TB-epidemies wat Suid-Afrika en die res van die sub-koninent teister. Navorsingstudies dui byvoorbeeld op ’n hoë voorkoms van TB-verwante siektes en sterftes in MIV-geïnfekteerde kinders - tot 20 keer hoër in MIV-geïnfekteerde kindertjies onder een jaar as in dié kinders wat nie geïnfekteer is nie. Kursusgangers by die jaarlikse internasionale opleidingskonferensie vir pediatriese TB Die reuse bydraes wat US-klinici en navor- wat vanjaar in September by Goudini Spa gehou is.

20 Tygerland 2009 Community Interaction

Kicking a goal for TB

tellenbosch University’s Desmond Tutu TB “We found that the diamond-shaped segments of a Centre – located in the Faculty of Health soccer ball were ideal for this purpose.” S Sciences – has a way of making people sit up The different symptoms of TB are therefore and take notice of TB and the damage it causes to portrayed on the different segments of the ball the lives of people and to the communities where in the form of animated character drawings, i.e; ‘If they live. you’ve been coughing for more than 2 weeks, getting Their efforts to promote awareness of the epi- thinner, sweating at night, not eating or have a sore demic started some years ago with photographic chest, you must go to your nearest clinic and be tested exhibitions illustrating the devastating effect of TB for TB” and “HIV - get tested.” in Western Cape communities. Then they installed These ‘life-saving’ soccer balls will be distributed a typical township shack, decorated with striking to 250 000 learners across South Africa. Wena says photos from these exhibitions, in the foyer of the the message, TB can be cured, will hit home when FHS Clinical Building on the Tygerberg Campus. teams distributing the balls take along portable soc- The same shack was eventually transported to the cer goal posts to give learners the opportunity to World Tuberculosis Conference in France and af- kick soccer balls at the goal posts and physically terwards to an international Aids Conference in enact the message: I can ‘kick’ TB! TB is a curable Australia and to the Netherlands. disease. The Centre’s latest awareness campaign is due In the meantime, the national Department of to be launched next year to coincide with the 2010 Health has become a partner of Stellenbosch Uni- Soccer World Cup in South Africa and uses soccer versity to make Kick TB 2010 one of the largest na- as a game and soccer balls in particular, to carry tional TB campaigns the country has ever seen. strong TB messages across all nine of the country’s As patron of the project, Archbishop Emeritus provinces. Desmond Tutu will kick off the campaign by kicking “We were looking at ways to link TB awareness the very firstKick TB 2010 soccer ball at the national to the Soccer World Cup which represents such launch on World TB Day in March 2010. a seminal event in our country. That was how we As the campaign is rolled out across the coun- came upon the idea of utilising soccer balls to con- try, a promotional truck will distribute Kick TB 2010 vey TB health messages that will encourage people soccer balls and the TB message at hundreds of to seek treatment timeously,” says the project man- schools in all the different provinces. Each school ager, Mrs Wena Moelich, who has played a leading will also receive an educational DVD for future use. role in the Centre’s various awareness campaigns. The campaign will only end in November 2010.

“Sport is a universal language. At its best it can bring people together, no matter what their origin, background, religious beliefs or economic status to promote education, health, development and peace” – former Secretary General of the United Nations, Kofi Annan.

Tygerland 2009 21 MIV/Vigs

KORTLIKS

Vigssterftes Ongeëwenaarde interdepartementele Die omstredenheid en onsekerheid wat statistiek tov Vigssterftes in Suid-Afrika samewerking kenmerk Fakulteit se kenmerk het beslag gevind in ’n navors- ingstudie van dr Lené Burger van Ge- regtelike Geneeskunde in die US FGW wat daarop dui dat die impak van MIV MIV-benadering op sterftes in die land, ernstig onderskat word in die amptelike sterftesyfers van oewel Suid-Afrika een van vlakke van tuberkulose ko-infeksies te Statistiek Suid-Afrika. die mees omvattende MIV/ voorkom. Daar is aanduidings dat 85% van Burger het hierdie navorsing in Vigs-behandelingsprogramme MIV-positiewe pasiënte ook met TB geïn- samewerking met navorsers van die Uni- ter wêreld het en nagenoeg fekteer is. versiteit van Oxford in Engeland, die MNR H in Suid-Afrika en prof Jimmy Volmink, 850 000 pasiënte in die openbare Die uitdagings wat die Vigspandemie gesondheidsektor (volgens regeringsyfers) aan die gesondheidsektor stel is in 2009 visedekaan (Navorsing) van die FGW, ge- antiretrovirale middels ontvang, verteen- weereens weerspieël in die navorsings- doen. woordig die pandemie steeds die grootste uitsette van die verskillende departe- In ’n Jaardagvoordrag het Burger daar- gesondheidskrisis in die land. mente en afdelings van die Universiteit op gewys dat Statistiek SA se syfers vir Die nasionale gesondheidsdeparte- Stellenbosch se Fakulteit Gesondheids- 2006 aandui dat slegs 2,4% van sterftes ment het onlangs erken dat daar ’n ge- wetenskappe. in die betrokke jaar die gevolg was van weldige agterstand is in die behandeling Voordragte by die Fakulteit se Aka- MIV/Vigs. Wiskundige berekenings wat van Vigspasiënte, hoofsaaklik as gevolg van demiese Jaardag dui daarop dat bykans op vroeëre data en ’n indringende onder- tekort van ’n bykomende een miljard rand elke departement en afdeling betrokke is soek van mediese rekords gebaseer was, om tred te hou met nuwe pasiënte wat by navorsing wat verband hou met MIV, het egter getoon dat 61% van Vigssterf- binne die volgen- sowel as die tes in 2006 verkeerdelik geklassifiseer en de jaar behande- Daar is aanduidings dat 85% van meegaande TB- toegeskryf is aan ander siektes soos tu- ling sal moet kry. MIV-positiewe pasiënte ook met TB epidemie. Dit berkulose, longontsteking of diarree. Volgens pers- dui ook op on- Burger en haar medewerkers het die berigte het die geïnfekteer is. geëwenaarde mediese rekords van mense wat oor ’n regering in 2009 interdeparte- tydperk van een jaar in ’n spesifieke geo- nie eens 50% van sy doelwit bereik om mentele en interdissiplinêre samewerking, grafiese gebied van Kaapstad gesterf het, nagenoeg 1,4 miljoen mense met antire- en samewerkingsvennootskappe met in- onder die loep geneem en vergelyk met trovirale middels te behandel nie. Dit blyk ternasionale instansies. doodsertifikate van dié mense. Uit 129 derhalwe onmoontlik te wees om die doel- Navorsing wat by die Fakulteit gedoen van die sterftes wat hulle ondersoek het wit vir 2010 – om 80% van Vigslyers te be- word, dek die hele MIV-spektrum – onder en wat volgens die mediese rekords aan handel – te bereik. meer nuwe benaderings om beter voor- MIV/Vigs toegeskryf word, word 32 op Intussen word die krisis vererger deur koming van die siekte in die hand te werk; die doodsertifikate toegeskryf aan in- die probleme wat sommige provinsiale beter diagnose, berading en behandeling feksiesiektes soos tuberkulose en diar- gesondheidsdepartemente ervaar ten op- – veral om die oordrag van die virus ty- ree-siektes en 10 aan nie-oordraagbare sigte van die beskikbaarheid van middels, dens geboorte te voorkom; stresfaktore siektes. wat aanleiding gee tot die onderbreking wat ’n rol speel in die lewens van geïn- “Hierdie empiriese studie bevestig dat of opskorting van behandeling – soos fekteerde kinders en adolessente; sukses- die impak van MIV op sterftes in Suid-Af- vroeër vanjaar en verlede jaar in die Vry- se en leemtes in die regering se MIV/Vigs rika ernstig onderskat word in amptelike staat gebeur het. Dit het aanleiding gegee behandelingsprogram oor die afgelope statistieke,” sê sy. tot groot getalle sterftes. Die onderbre- vyf jaar; dieet en MIV; tientalle interde- king van behandeling gee ook aanleiding partementele kliniese studies, veral ten tot middelweerstandigheid – ’n groeiende opsigte van pediatriese MIV; ’n groeiende MIV en ’n rare okulêre siekte probleem in Suid-Afrika. getal studies ten opsigte van antiretro- Vigskenners dring voorts daarop aan virale middelweerstandigheid, sowel as Dr Sven Obholzer, ’n botallige kliniese as- dat die regering sy riglyne vir die aanvang studies wat fokus op die tuberkulose ko- sistent van Namibië wat tans aan die US van behandeling moet aanpas om die hoë epidemie. se Afdeling Oogheelkunde verbonde is,

22 Tygerland 2009 MIV/Vigs het in 2009 die hoogste toekenning van wels verhoed om gesond- die SA Gloukoomvereniging ontvang vir heidsorgklinieke te besoek. ’n gevallestudie oor ’n baie rare okulêre Dit kan aanleiding gee tot komplikasie van MIV wat nog nie voor- die onderbreking van behan- heen in die literatuur beskryf is nie. delings of selfs ’n gebrek aan Obholzer het ’n voordrag gelewer by behandeling. die Vereniging se kongres in 2009 met die In ’n poging om hierdie titel, Bilateral Neovascular Glaucoma in a probleem aan te spreek, is Young HIV Positive Patient. ’n enkele kliniek vir MIV- Die prys wat hy vir hierdie voordrag pasiënte wat ook aan tu- ontvang het is deel van ’n kompetisie wat berkulose ly, onlangs by die deur Alcon geborg word vir ’n uitsonder- Worcesterhospitaal ingerig Op die foto bo is gaste wat by die bekendstelling van die like voordrag oor ’n unieke en ongewone danksy befondsing van die kliniek teenwoordig was. Hulle is, voor vlnr: Dr S Wentler gloukoom-gevallestudie. Holland/Stellenbosch Medie- en prof Hoffie Conradie; in die twee ry, vlnr, dr Therese Obholzer is ’n kliniese assistent van se Stigting. Fish, mee Lindsay-Michelle Meyer en Denise Lynch, en Windhoek. Sy studies aan die Universi- Hierdie ontwikkeling het agter, vlnr: drr Collette Gunst en Lizette Phillips en Sr Anel teit Stellenbosch word deur die Namibiese talle positiewe implikasies vir le Roux. Departement van Gesondheid en Welsyn pasiënte en die Departement geborg in terme van ’n ooreenkoms tus- Gesondheid. Dit beteken sen die US se Afdeling Oogheelkunde en onder meer dat pasiënte nie meer die ’n Ander belangrike komponent van die Namibiese regering. ongerief en ekstra vervoerkostes het die projek is die opleiding wat verskaf wat twee besoeke aan die hospitaal word vir tuisversorgers en pesoneel wat meebring nie en dit beteken bespa- met MIV positiewe persone werk, tov TB Enkele kliniek vir TB en MIV pa- rings vir die Departement omdat dit en die behandeling daarvan by MIV-posi- siënte in Worcester onnodige duplikasie van dokumentasie tiewe pasiënte. en behandelings uitgeskakel. Die Holland/Stellenbosch Mediese Stig- Die hoë voorkoms van tuberkulose in Die eerste pasiënte kon die kliniek ting het fondse van die Backhuys Roosen- mense wat met MIV geïnfekteer is, stel reeds in Julie 2009 begin besoek en ’n boom Stichting in Nederland ontvang om talle nuwe eise aan die gesondheidsek- voltydse verpleegkundige het in Sep- die kliniek te befonds. Die projek word tor – veral op die platteland waar land tember begin om die fasiliteit voltyds deur die US se Ukwanda Sentrum vir afstande en vervoeronkoste pasiënte dik- te beman. Landelike Gesondheid geadministreer.

Searching for a new approach to keep immune cells alive

n an innovative collaboration between science and medi- Ipp started working with Glashoff, a scientist in immunology, cine, Drs Richard Glashoff and Hayley Ipp of the Virol- with the specific aim of helping patients on ARV treatment. Iogy division, SU Faculty of Health Sciences, are working “Recent reports have shown that people on long-term ARV together to find new and different ways to approach the treatment tend to die from causes not related to Aids, such problem of HIV/Aids treatment, especially in South African as strokes, heart attacks and other conditions related to in- patients. flammation. The clinical approach they have in mind is based on sci- “Our approach is to dampen the inflammation which entific data and is aimed at keeping the immune cells of HIV- usually carries on despite ARV treatment.” infected patients alive for as long as possible to delay the She says they hope to develop a drug that will be useful start of antiretroviral treatment, or as an adjunct to ARV in South African conditions, especially in rural areas. “That treatment. means no injections. Hopefully, it will comprise an oral pack- This project, which is already showing promising results, aging or oral spray.” recently received funding of R3.8 million for a period of The two researchers believe that it is important for clini- three years from the SA HIV/Aids Innovation Research Plat- cians and scientists to work together in the search for inno- form (SHARP). Glashoff says SHARP is an initiative of the vative solutions to the medical problems such as HIV/Aids. Department of Science and Technology to sponsor innova- “To find something that will enable people to live with tive new HIV/Aids research. The platform is linked to Life the HI virus without it destroying the immune system is in- Lab, a bio-innovation incubation laboratory. deed a very exciting prospect,” Ipp says. As a medical doctor who specialized in Haematology,

Tygerland 2009 23 HIV/Aids Training

Some four years after the roll-out of South Africa’s HIV treatment programme, and intensified efforts to prevent mother-to-child transmission of the virus, HIV infection remains a major contributor to sickness and death in infants and children – not only in South Africa, but in countries across the African continent. HIV experts of the Stellenbosch University Faculty of Health Sciences, in partnership with international organizations, are involved in major programmes to improve paediatric HIV care and treatment in South Africa and in other countries in Africa.

Transforming the care and treatment of infants with HIV

ver the past three years, more than 370 health care treatment compared to adults in Africa. Fewer than 10% of the workers from African countries as far afield as Rwanda, patients, who are currently receiving antiretroviral treatment, are O Ethiopia and Nigeria, were trained at the Stellenbosch children. At the same time, new approaches towards paediatric University’s Faculty of Health Sciences to enhance and develop HIV care, treatment and prevention have become imperative to their technical and practical skills with regard to the initiation improve mortality rates in babies born with HIV infections. This and implementation of comprehensive paediatric HIV treatment was specifically indicated by new research – conducted by Cot- and services in their countries of origin. ton and Dr Avy Violari of the University of the Witwatersrand – They visited the Faculty as part of our ‘South to South Part- which shows that babies born with HIV infection should receive nership for Comprehensive Paediatric HIV Care and Treatment’ immediate antiretroviral treatment to improve their chances of (S2S) programme, a paedia- survival, and that treatment tric HIV initiative that was Fewer than 10% of patients in Africa who are receiving should not be delayed until launched in 2006 to ‘trans- antiretroviral treatment, are children. they show symptoms of HIV, form training into perfor- such as a drop in CD4 counts. mance and service delivery’ in African countries. The programme In response to this research, the World Health Organization, and is funded by the United States Agency for International Devel- experts from the USA and Europe have changed paediatric HIV opment (USAID) and developed in partnership with Columbia treatment guidelines to recommend immediate treatment. University, New York. South Africa has made tremendous strides since the initia- Managed by Dr Liezl Smit of the SU Department of Paedia- tion of antiretroviral therapy into the public sector in 2004 and trics and Child Health, S2S was launched by Prof Mark Cotton national ARV coverage has increased from 2.7% in 2003 to an and paediatric HIV specialists of Stellenbosch University, in part- estimated 32% in 2006. And although PMTCT coverage in SA nership with Prof Elaine Abrams of the International Columbia has reached 57% of the 220 000 pregnant women living with HIV AIDS Programme (ICAP), as a paediatric HIV care and treatment in 2007 - an increase from 15% in 2004 - an estimated 45,000 training initiative. children were born HIV-infected in 2007/08. The project was a response to the huge gap that exists In 2008 the number of children (ever) on HAART increased between the number of HIV infected children receiving care and by 20,500, but the ratio of new infections to starting on ART

24 Tygerland 2009 HIV/Aids Training remained 2.2:1, highlighting the need for capacity building and systems support to course at Tygerberg Children’s Hospital continued effort to prevent HIV infection initiate, expand, link and/or deepen rel- and has piloted a one week Performance in children and to ensure timely access to evant family-centered services to rapidly and Capacity Enhancement workshop treatment to prevent sickness and death. increase HIV prevention, care and treat- (PACE). The focus of this workshop is Against this background it was de- ment services for pregnant women and on developing and supporting health care cided to re-launch South to South in young children. workers and fostering the skills that en- March 2008 to focus exclusively on the In practical terms, this means that multi- hance their capacity to work effectively needs of South Africa and to expand the disciplinary S2S-teams, comprising doctors, and to remain engaged in their work, mo- focus of S2S to include the Prevention of nurses, psychosocial and monitoring spe- tivated and healthy, while working in an Mother-to-Child Transmission of the HIV cialist, work in close collaboration with environment that is often physically and (PMTCT), to ensure timely quality care Department of Health and USAID part- emotionally demanding. The PACE work- and treatment of HIV-infected children, ners at HIV and primary health care clin- shop recognizes that when health work- as well as supporting TB/HIV integration ics in areas like Gauteng, Limpopo, North ers perform above expectations, it is often through a comprehensive family centered West, the Northern Cape and Mpumalan- due to powerful people skills, strong lead- approach. Since then, the team has grown ga where they offer onsite training, clinical ership and teamwork. Healthcare workers from three permanent members to 22 assistance and mentorship to health care can integrate effective interpersonal skills while Dr Liezl Smit was appointed clinical professionals who deal with families in- and psychosocial principles into practical, programme director and Ms Carin du Toit fected and affected by HIV. person-centered, result-driven interven- operations director. S2S also continued to offer a one tions to produce positive outcomes in the S2S provides technical, programmatic, week Paediatric HIV management training workplace.

Dr Helena Rabe of the Department of Paediatrics and Child Health explains the clinical treatment of the HIV infected babies in the Tygerberg Children’s hospital to a group of students from Limpopo and North West Provinces.

Tygerland 2009 25 ASSESSING THE QUALITY OF ASTHMA CARE

The South African Thoracic Society recently published new guidelines for chronic asthma in adults and adolescents and for the first time funded a multifaceted dissemination and implementation strategy in the Western Cape. Prof Bob Mash of the Division of Family Medicine and Primary Care, Stellenbosch University, was the chairman of the Asthma Guidelines Implementation Project (AGIP). In this article he discusses the recently concluded project, its outcomes and recommendations.

sthma is the eighth leading after publication of the SA Thoracic So- is divided into six districts, each of which contributor to the burden of ciety’s new asthma guidelines. Apart from is served by a network of mobile clinics, disease in South Africa and is Mash, the steering committee comprised clinics, community health centres and dis- the second most important two pulmonologists, Prof Elvis Irusen of trict hospitals. Clinical nurse practitioners chronicA disease after HIV/AIDS. the SU Faculty of Health Sciences and Prof supported by medical officers and phar- Asthma is often not considered par- Gillian Ainslee of the University of Cape macists provide first-line primary care. ticularly serious, but it causes significant Town; another family physician of the SU Chronic asthma is managed by primary morbidity in young and working-age Faculty of Health Sciences, Dr Michael care providers, and acute asthma by dis- adults that adds to the number of disabil- Pather; Prof Angeni Bheekie, a pharmacist trict hospitals and, if necessary, regional ity-adjusted life years in relation to other of the University of the Western Cape; Ms or tertiary hospitals. Patients with com- chronic diseases. The prevalence of recent Pat Mayers of Nursing and Midwifery at plicated or difficult chronic asthma may wheeze in adults is reported as 14.4% in UCT and a project co-ordinator, Sr Hilary be referred to specialists at regional or males and 17.6% in females, with a self-re- Rhode of SU. tertiary levels. ported prevalence of asthma of 3.7% and At the outset, the committee devel- 3.8% respectively. In the Western Cape oped an audit tool to assist primary care Auditing primary care facilities the prevalence of asthma among children facilities with quality assessment and im- aged 13 - 14 years was 14.4%, slightly provement, aimed at eliciting reflection The AGIP team audited all primary care above the global average of 13.7%. The on the quality of care and to plan im- facilities that managed adult patients with prevalence of asthma in children is rising provements at facility level. As the first chronic asthma within all six districts of in sub-Saharan Africa. evaluation of the quality of asthma care at the Western Cape following a specific Access to essential drugs for asthma, provincial level in South Africa, the audit quality improvement cycle, based on the including inhaled steroids, is better in tool sets a benchmark for future audits newly published chronic asthma guidelines South Africa than in other sub-Saharan and gives valuable insights into asthma and literature on asthma audits. countries. Because of the overwhelm- care. As the Western Cape is better re- This included the development of cri- ing HIV/AIDS epidemic, and the primary sourced than other provinces its quality teria for structure, process and outcome health care services’ focus on acute epi- of asthma care is likely to be better than and performance levels to create target sodic conditions, chronic asthma has not elsewhere. standards for, amongst others, the pre- received priority attention. District health services in the West- scription of sufficient inhaled steroids as- It was against this background that ern Cape province serve five million sociated with better quality of life, better the Asthma Guidelines Implementation people, of whom 80% are uninsured and control, fewer symptoms and fewer hos- Project (AGIP) was established, shortly depend on the public sector. The province pitalisations or exacerbations.

26 Tygerland 2009 Better Diagnosis

Structural criteria focused on the hospitalised during the past year and one availability of equipment, patient educa- out of every six visits to the facility being tion material and medication while proc- Practitioners must be for an exacerbation. Emergency visits and ess criteria focused on key activities re- hospitalisation result in hugely increased corded in the medical record. Outcome helped to distinguish health service costs. More effective routine criteria relied on interviewing patients on between asthma care would improve patient quality of life their level of control using the validated and save costs. Asthma Control Test questionnaire and and COPD in terms Many patients appeared to understand score. Patients were asked about exac- of diagnostic criteria, the difference between their relievers and erbations and hospitalisations in the past assessment methods their controllers, although this was deter- year and their understanding of reliever mined by the interviewer and was open versus controller medication. Each facility and treatment options. to subjective interpretation. Better adher- was expected to include 20 randomly or ence can be expected in those who un- systematically selected asthma patients. derstand the difference between reliever The final audit tool consisted of data and controller. collection sheets, patient questionnaires research project. in English, Afrikaans and Xhosa, remind- The audit was done in 46 facilities and Diagnosis of asthma ers of how to calculate the results, a one- with 957 patients. page summary sheet of the final results, The target was only reached for 3 of Patients were often labelled ‘asthmatic’ and a user’s guide. All the materials are the 16 structural criteria: the availability one month and ‘chronic obstructive available for downloading on the Internet of a height measure in the facility, oxygen pulmonary disease (COPD)’ the next. at www.pulmonology.co.za. and a nebuliser in the emergency room. Primary care practitioners do not seem The audit was piloted in a rural dis- Of seven process criteria the target was to make this distinction clearly, and this trict before being finalised.Introductory only reached for the controller/reliever is reflected in one in five patients having workshops were held in the six districts, ratio. None of the outcome criteria was an inconsistent diagnostic label over and primary care providers involved in achieved. the audit period. There was a significant asthma care were invited to attend. Par- The Western Cape has better health correlation between the percentage of ticipants were mainly nurses, but included worker resources than other provin- patients with a consistent diagnosis of doctors and pharmacists who came from ces, and these results would probably be asthma and the control of asthma, which mobile clinics, fixed clinics, community worse elsewhere. implied that as the consistency improved health centres and district hospitals. They the level of control deteriorated. If all were trained to use the audit tool, the Outcomes of care the audited patients had a consistent principles of the quality improvement cy- diagnosis of asthma the percentage that cle and how to collect and calculate the The many deficiencies in quality of care was well controlled might be as low as audit results. The AGIP project manager contributed significantly to the poor 24%. Practitioners must be helped to remained in telephonic contact with the outcomes. Although up to 70% of asthma distinguish between asthma and COPD participants and encouraged facilities to patients can be well controlled when in terms of diagnostic criteria, assessment complete and return the audit data. Out- current guidelines are followed, only methods and treatment options. In our reach visits were conducted on request 31.5% of patients in this audit achieved setting many patients develop COPD as to assist with the audit process. In the this outcome. This finding is supported a result of TB, exposure to the burning metropole data collection was more rig- by high rates of hospitalisation, with of biomass and mining and not only orously supported as part of a doctoral almost one in five patients having been prolonged tobacco smoking. Smoking Continue on page 28

The representatives of Stellenbosch Uni- versity were from left to right: Profs Bob Mash, Elvis Irusen, Dr Michael Pather and Sr Hil- lary Rhode.

Tygerland 2009 27 Better Diagnosis From page 27 status, a key asthma trigger and pointer to the possibility of COPD, was documented in just under a third of patients. Assessment of control The level of control was rarely assessed, and a typical assessment would read ‘known asthmatic’. If the patient appeared stable at the consultation, his or her medication was simply repeated. Health workers may not have been trained in how to assess control using simple questions and may not appreciate that variability in asthma symptoms necessitates asking about symptoms over the past four weeks and not just on the day the patient is seen. The AGIP adapted the 20-second asthma check provided by the National Asthma Education Programme, which is congruent with the latest guidelines. Use of peak flow meters Although cheap, peak expiratory flow (PEF) meters were only available in half of the consulting rooms and PEF was only recorded in about a quarter of all visits. The need for PEF meters remains Local studies have confirmed poor inhaler techniques among patients that contribute to controversial, as control of asthma can be poor deposition of medication and poor control. Seen on the picture is a medical student, adequately assessed using questions alone. doing his clinical training in the Worcester area, demonstrating the correct technique to a It has therefore been argued that PEF patient during a house visit. meters are not essential for prescribing inhaled steroids, in contradiction to the recommendations of the national Essential Drug List (EDL). Nevertheless the PEF although not on the primary care code, delivery devices. Assessment of individual gives an objective and comparable measure as it could be initiated by hospital-based technique was seldom recorded, and few of airways obstruction and identifies physicians and obtained at primary care rooms had placebo metered dose inhalers patients who may have significant airways facilities. The AGIP are motivating that (MDIs) to facilitate demonstration of obstruction without symptoms. Likewise long-acting beta-2-agonists (LABAs) be the technique. The ability of staff to there are a smaller number of patients made more accessible to patients by family demonstrate the MDI is poor even when whose symptoms are out of proportion physicians prescribing them within the district placebos are available. Local studies to the objective clinical signs and PEF. The health services. Guidelines support the use of have confirmed poor inhaler techniques PEF has additional diagnostic benefits and is LABAs with low or moderate doses of inhaled among patients that contribute to poor essential in managing acute asthma. Each steroids rather than doubling the dose of deposition of medication and poor con- facility should therefore have a PEF meter, inhaled steroids. trol. Although patient education is and if PEF is to be recorded as part of the highlighted in all guidelines, including the consultation it should be easily available. Education on spacer and inhaler National EDL, the pharmaceutical depot Medication technique had no provision for supplying facilities with placebo MDIs. The AGIP enabled Overall the availability of medication on Effective supply of medication and staff to demonstrate the delivery devices the EDL was a strong point and may reflect appropriate prescribing is worth nothing and developed demonstration DVDs its emphasis in provincial chronic disease if actual delivery of medication to the in local languages (see the Internet site: policy during 2006 - 2008. Salmeterol lungs is poor. A neglected area of care was www.pulmonology.co.za). DVDs do not availability was included in the assessment, educating patients on how to use their require the local staff to be proficient at

28 Tygerland 2009 Better Diagnosis demonstrating the technique, and there is Supporting patient self-care and emergency care was good. This may re- evidence that they are useful. health literacy flect the historical emphasis on acute epi- Whether all patients on inhaled ster- sodic health care. oids, or only those with a poor technique, Although just over half the consulting should receive a spacer routinely, has been rooms had some educational material, Organisation of chronic care very few had material in all the local debated. Spacers have not been sufficient- The sustained implementation of inno- ly available to provide one to each patient, languages. The province had no official health education materials for asthma vations to improve chronic care depends and yet even in patients with a good in- on at least one person in the health facility haler technique they improve lung deposi- before the AGIP, and therefore any having chronic care of non-communicable tion considerably. Spacers also require a materials were obtained ad hoc by the diseases as a long-term responsibility. degree of technique, but reduce the need facility. It is therefore not surprising that only a small number of patients had Frequent rotation of nursing staff to for co-ordination of actuation and inspi- a written self-management plan. The different duties impedes the development ration and would also be easier for staff AGIP patient leaflet was designed to be of chronic care systems, and in most to demonstrate correctly. A single spacer personalised as part of a self-management facilities there is no one with designated will last for at least a year with minor cost plan. Group education was an option for in relation to improved control. Although responsibility for asthma care. urban CHCs, where large numbers of non-valved spacers are cheaper, the valved Well-trained and supported clinical asthma patients attended on specific days, spacer would support tidal breathing as an nurse practitioners are as competent as but not in the rural clinics and mobiles, effective way of using the spacer. In a non- doctors in providing routine chronic care where they attended randomly. The valved spacer, if the patient exhales first and may be better at patient education. potential for group education in the urban the medication may be blown out of the However, doctors are required for the setting led AGIP to develop a flip-chart spacer. Providing a valved spacer to every initial diagnosis, prescription of certain and a structured educational programme. asthma patient requiring inhaled steroids medication, and managing more com- (See the Internet site: www.pulmonology. is therefore likely to be cost-effective. Al- plicated or difficult cases. Public sector co.za) ternatively dry-powder devices could be pharmacists have not moved beyond dis- made available to improve lung deposition Emergency care pensing to assist with educating patients in selected asthma patients. These are not on using medication and identifying those available in the public sector. Overall the provision of equipment for who need further assessment.

Ten recommendations to improve asthma care

The implementation of 10 recommendations to improve asthma care requires a co-ordinated effort between the managers of the drugs and therapeutics committees, human resources and training, chronic care and district health services at the district, provincial and national levels. They are:

1. Train practitioners to distinguish between asthma and 6. Consider the addition of dry-powder devices to the pro- COPD and understand their different assessment and vincial pharmaceutical catalogue. management. An AGIP desktop manual supports this de- 7. Provide practitioners with placebos, spacers, DVDs and cision making. the expertise they need to assess and demonstrate in- 2. Train practitioners in how to assess the control of asth- haler technique. ma. 8. Consider making LABAs more accessible in the district 3. Routinely provide all asthma patients on inhaled steroids health system via family physicians. with a valved spacer. 9. Improve patient education programmes by providing ma- 4. Make PEF meters and reference charts easy to order and terials for use at individual and group level, in all local lan- available and ensure that they are available in the emer- guages and available in a sustainable way through official gency room. A PEF meter should be available to every channels. practitioner in their consulting room. 10. Have at least one person in the facility with a specific 5. Include placebos in the provincial pharmaceutical cata- long-term responsibility for the organisation and delivery logue and make them available through the pharmaceuti- of chronic care for non-communicable diseases. cal depot.

Tygerland 2009 29 Navorsing Wanneer pynpyn in die virtuele ruim verdwyn

randwonde veroorsaak folterende pyn – en om hierdie pyn te Bbeheer wanneer ’n pasiënt se wonde versorg, en die verbande verander word, is een van die uitdagings waarmee gesondheidswerkers daagliks te make kry. Wanneer kinders die slagoffers van brandwonde is – soos dit té dikwels in Suid-Afrika die geval is – word dit ’n uitdaging van dwingende erns. Brandwonde moet daagliks versorg word om infeksies te voorkom en die genesingsproses te monitor. Omdat dié prosedure erge pyn en gepaardgaande angs veroorsaak, word die pasiënt vooraf behandel met ’n kombinasie van pynmedikasie en kalmeermiddels, maar dit is nie altyd toereikend nie. Navorsing dui daarop dat sielkundige faktore dikwels die persepsie van pyn kan beïnvloed. So, byvoorbeeld, kan pyn vererger word deur angstigheid en die verwagting dat ’n prosedure soos wond- versorging, pyn gaan veroorsaak. In teen- stelling hiermee, kan pyn verminder word deur intervensies wat gerig is op sielkundige faktore, bv iets wat die aandag weglei van die pyn. Om die potensiaal van pyn-afleiding te verken, het navorsers oor die afgelope jare begin kyk of die pynervaring nie dalk verminder kan word as pasiënte toegelaat word om in die skynwêreld van ’n reke- naarspeletjie te ontsnap terwyl hulle wonde versorg en verbande verander word nie. Virtuele realiteit as ’n hulpmiddel in pynbeheer is aanvanklik in volwassenes getoets. Prof Karen Grimmer van die Uni- versiteit van Suid-Australië in Adelaide, en buitengewone professor in die Afdeling Fisioterapie van die Universiteit Stellen- bosch, was egter die eerste navorser om te toon dat kinders wat aan die folterende pyn van brandwondbehandeling blootgestel word, se pyn verminder kan word as hulle ’n speletjie in die virtuele ruim speel terwyl hul wonde versorg word. Tydens ’n besoek aan die Afdeling Fisio- terapie ’n paar jaar gelede, het Grimmer

30 Tygerland 2009 Navorsing Wanneer pyn in die virtuelevirtuele ruimruim verdwyn

en prof Quinette Louw die moontlikheid die wonde skoongemaak is. Albei hierdie blootgestel is nie. Laasgenoemde groep se ondersoek om hierdie studie navorsing in groepe het vooraf pynmedikasie ontvang. pyntellings het ’n dramatiese toename van Suid-Afrika voort te sit, veral omdat die In ’n kleiner studie het sy ook gekyk wat 382% getoon. tegnologie van groot waarde kan wees in gebeur as die kalmeermiddel in die kinders Soos ander navorsers, het Parbhoo hierdie land, waar groot getalle kinders se medikasie onttrek word wanneer hulle tot die gevolgtrekking gekom dat virtuele jaarliks brandwonde opdoen – gewoonlik aan die virtuele realiteitspeletjie blootge- realiteit ’n buitengewone medium is om as gevolg van brande in informele neder- stel word tydens behandeling. die aandag van kinders met brandwonde settings of ongelukke met vuur of kook- Met behulp van die pynskaal het sy sodanig in beslag te neem dat hulle uiters water in die huis. gevind dat kinders wat pynmedikasie pynvolle prosedures, soos die versorging So het dit gekom dat een van Louw se ontvang het en aan die virtuele reali- van brandwonde, met groter gemak kan studente, me Asha Parbhoo, ’n doktorale teitspeletjie blootgestel is terwyl hul ver- hanteer. studie oor die onderwerp aangepak het. bande verander is, 79% minder pyn ervaar Tesame met ander studies wat in Hierdie studie is onlangs afgehandel en het as die kinders wat slegs pynmedikasie hierdie veld gedoen is, is daar sterk aan- Parbhoo is tans besig om die resultate vir duidings dat virtuele realiteit tesame met ’n PhD-tesis te verwerk. pynmedikasie, gesondheidswerkers kan Groot getalle kinders help om die rehabilitasie van pasiënte met ’n Opkomende veld in Suid-Afrika doen brandwonde minder pynlik te maak en Haar studie is die eerste groot studie sodoende funksionele uitkomste te ver- van hierdie aard wat wêreldwyd gedoen jaarliks brandwonde op beter. is. Daar is trouens nog net agt studies in as gevolg van brande in Benewens Parbhoo se studie op pe- hierdie opkomende nuwe veld gedoen – informele nedersettings diatriese pasiënte, is me Linzette Morris die meeste daarvan met net een of twee – ook ’n student in Fisioterapie – besig pasiënte in ontwikkelde lande waar daar en ongelukke in die huis. met ’n M-verhandeling oor die effek van nie so ’n hoë voorkoms brandwonde is Die Afdeling Fisioterapie virtuele realiteit op volwasse pasiënte wat soos in Suid-Afrika nie. het getoon dat ’n stukkie fisioterapie-behandeling kry as gevolg van Parbhoo, wat agt jaar lank aan ’n een- brandwonde. Omdat fisioterapie wat vir heid vir brandwonde verbonde was, het tegnologie van die 21ste brandwonde gebruik word, strekbeweging die studie by die Rooikruis Kinderhospi- eeu, baie doeltreffend in die geaffekteerde liggaamsdeel vereis, is taal gedoen. Benewens ’n voorafgaande ingespan kan word om die dit dikwels ’n baie pynlike prosedure. studie oor brandwonde in kinders, het sy Louw sê daar moet nou gekyk word uiteindelik ’n studiegroep van 108 kinders folterende pyn, waaraan of en hoe hierdie tegnologie in Suid- gekies uit meer as 1 000 kinders met hierdie kinders tydens hul Afrika geïmplementeer kan word. “Ons brandwonde. behandeling blootgestel navorsing is gerig op projekte wat toe- Sy het ’n voorafstudie gedoen om te paslik en koste-effektief is in die Suid- bepaal wat die mees gepaste toetskaal is word, ingrypend te Afrikaanse konteks. Die virtuele realiteits- om pyn in die plaaslike bevolking te meet verminder. apparaat sowel as die drie-dimensionele en toe hierdie skaal bevestig in ’n kohort speletjies wat in die buiteland gebruik van kinders wat by die Brandeenheid van word is baie duur en ons moes dit ver- die Rooikruis Kinderhospitaal behandel is. ontvang het. In laasgenoemde groep was vang met meer koste-effektiewe apparaat Parbhoo het die skaal gebruik om die vlak daar ’n 49% toename in pyn terwyl hul om te verseker dat die prosedure haal- van die jong pasiënte se pyn te meet en verbande verander is. baar is in die Afrika-konteks. toe gekyk of ’n virtuele realiteitspeletjie In die tweede helfte van die behandel- Die gebruik van virtuele realiteit- kan help om die pyn te verminder. Die ing, is die kinders wat in die eerste helfte speletjies in ’n gesondheidskonteks is eg- drie-dimensionele speletjie word op ’n slegs pynmedikasie ontvang het, ook aan ter ’n belowende nuwe veld en Louw en rekenaar, deur middel van ’n spesiale kop- virtuele realiteit blootgestel – met die- haar studente wil verdere navorsing doen stuk met ’n bril gespeel. selfde ingrypende uitwerking op pyntel- om vas te stel hoe dit prakties aangewend In een deel van haar studiegroep het sy lings (78% minder) – in vergelyking met kan word. Een moontlikheid is om dit te die prosedure getoets terwyl die kinders die eerste groep, wat in die tweede deel gebruik om pasiënte te laat ontspan en die se verbande verander is, en in die ander van die behandeling net pynmedikasie ont- aandag van metodiese pyn af te lei tydens deel van die groep is dit getoets terwyl vang het en nie weer aan virtuele realiteit fisioterapie en bewegingsrehabilitasie.

Tygerland 2009 31 Surgery New choices in breast cancer - surgery and reconstruction

ot too many decades ago, breast cancer treatment was a The reconstruction of a breast that was dramatically different procedure than it is today. Until the late 1970’s, if a woman went into surgery removed due to cancer is one of the most for a breast biopsy and the lump in her breast was found rewarding surgical procedures available Nto be malignant, she was likely to wake up and find her breast removed without having had the chance to talk to her doctor today. A team of specialists at Stellenbosch or prepare herself for the emotional and physical ordeal that University have refined breast conservation faces cancer patients. Since many women in those days thought of breast cancer as a death sentence, issues such as the cosmetic and reconstruction to state-of-the-art outcome of breast cancer surgery, were seldom considered in procedures. the management of the disease. However, modern medicine has brought about drastic improvements in breast cancer treatment – mainly as a result of early detection, as well as more, better and less invasive treatment options, including breast conservation surgery. The radical mastectomy, once considered the only operation for breast cancer, no longer has a place in the routine management of patients with breast cancer and instead of one doctor making the final treatment decision, a multidisciplinary team approach regarding the management of the disease is recommended worldwide, says Prof Justus Apffelstaedt, head of the Breast Cancer Clinic at Tygerberg Hospital. “The days of a single practitioner treating a woman with breast cancer are completely over,” he says. Today, survival rates have increased to the extent that the average survival rate for breast cancer is now five years, Apffels- taedt says. Furthermore, about 80 out of a hundred patients with early stage breast cancer are still alive and well after 20 years. Against this background, quality of life issues have become increasingly important. For many women, one of the most important issues in this regard is the cosmetic outcome of breast cancer treatment and more and more women are considering breast reconstruction after a mastectomy. Thus Tygerberg Hos- pital has been offering reconstructive surgery to all women who undergo mastectomies for a number of years, says Apffelstaedt. He emphasizes, however, that such a service requires a well-co- ordinated team approach with oncology surgeons, medical and radiation oncologists and plastic and reconstructive surgeons working together to advise a patient of her choices regarding treatment and the best methods of reconstruction. The Tygerberg team, which comprises medical specialists of the SU Faculty of Health Sciences, has developed into a formidable unit who has refined breast conservation and reconstruction to a state-of-the-art procedure.

32 Tygerland 2009 Surgery

Prof Frank Graewe, head of the Plastic and Reconstructive Surgery division of the FHS, provides the team with wide-ranging expertise regarding the new tools developed by plastic surgeons to reconstruct a breast after cancer surgery. In an interview with Tygerland, Graewe pointed out that the early trials of breast conservation primarily addressed safety issues while cosmetic outcome was only a secondary consideration. Thus, adjuvant radiotherapy treatments – which are required after breast conservation surgery – sometimes led to progressive scarring. “After a few years, the scarring made the cosmetic outcome rather poor.” However, new developments in medicine have improved outcomes quite considerably. This includes progress in radiation planning and new technology to deliver radiation which causes much less scarring than in the past. It also includes a range of new surgical techniques. In the past, the main aim was to elimi- The Faculty’s specialists in breast reconstruction, Professors Frank Graewe (left) and Justus nate the cancer. Today it is understood Apffelstaedt are leading specialists their respective fields. that surgery and radiotherapy must be integrated. The first and most important aim of this integration is to get rid of the tumour and to have the best long term However, Graewe emphasises the best Factors that will play a role in deter- survival and quality of life. possible treatment of a specific patient is mining the best method of reconstruction “The next step is to do the least nec- dependent upon a thorough evaluation by will include, amongst others, the woman’s essary damage to the body and tissue and the combined team. The patient will be ac- age, the kind of treatment she needs to to get a reconstructed breast that is as cordingly advised of her choices, including eradicate the cancer and the shape of her close to perfect as possible; a breast that the best method of reconstruction and all body. will withstand radiotherapy with little the advantages and disadvantages associ- Thanks to the wide-ranging exper- long-term damage.” ated with the particular method. tise of reconstruction specialists like “The team’s recommendations will be Graewe, women in South Africa today Striving for the influenced by the type of excisional sur- have the choice of an immediate or a best possible outcome gery; adjuvant or neoadjuvant therapy; risk delayed reconstruction. They can also profile and co-morbidity and the availabil- choose between a so-called autologous Both Apffelstaedt and Graewe emphasise ity of tissue for reconstruction purposes. reconstruction, which uses the body’s that these aims are best achieved by the “It is important to note that in breast own tissue, or an alloplastic reconstruction multidisciplinary team with a specialised reconstruction, the patient is in the driv- which consists of silicone or saline-filled interest in breast cancer management, er’s seat and she will make the final deci- silicone implants. working together to provide breast can- sion regarding the road we will take.” cer victims of the best possible outcome. Graewe says the role of the recon- Oncoplastic procedures As a result doctors can now offer women structive surgeon is to explain all possible an added benefit, namely the removal of options to the patient; to advise and as- When cancer is detected at an early the tumor and cosmetically repairing the sist her in making a decision. The surgeon stage and a lumpectomy, quadrantectomy breast at the same time. should never influence a patient into a or partial mastectomy is performed, the Known as oncoplastic surgery, this reconstructive option that he/she as the current tendency is to have an immedi- procedure represents the latest trend in surgeon prefers. The subsequent recon- ate reconstruction done during the same breast reconstruction surgery for cancer struction should be performed with the operation. patients. highes care and aim at perfection. 

Tygerland 2009 33 Surgery  The tumour is removed and the breast is reconstructed immedi- Reconstructing the nipple ately with breast reduction techniques, rearrangement of breast tissue internally or flaps from adjacent areas. In most cases the In early stage breast cancer, the cancer surgeon may perform a other breast will need a reduction or a breast lift procedure to nipple-sparing mastectomy which leaves the nipple and areola in achieve symmetry and a natural result. place. Alternatively, the nipple and areola can be reconstruct- In the majority of cases the affected breast will be irradiated ed, says Graewe. This requires a separate operation and the and the patient will receive systemic chemotherapy after the reconstruction is done with local tissue from the reconstructed operation,” Graewe says. breast. Tattooing can be used to match the colour of the areola. Graewe says the reconstruction of a breast that was removed Other reconstruction procedures due to cancer is one of the most rewarding surgical procedures available today, especially since new surgical techniques and de- Implants vices have now made it possible to create a breast that can come The most common implant is a saline-filled implant. This com- close in form and appearance to a natural breast. prises a silicone shell filled with salt water (sterile saline). Silicone gel-filled implants are another option for breast reconstruction. The implant may be done at the same time as the mastectomy, or as a delayed reconstruction if radiation treatment is required. If the skin envelope is insufficient it can be expanded STATE OF THE ART BREAST RECONSTRUCTION with a balloon-like expander which is put under the skin and chest muscle. Small amounts of saline are injected into the expander over a specific period to stretch the skin. Once the skin is sufficiently stretched, the expander is replaced with a permanent implant.

Flap procedures utilising own tissue These procedures use tissue from the abdomen, back or but- tocks to rebuild the breast with the body’s own tissue. The Immediate reconstruction after left skin sparing mastectomy operation leaves scars which will fade over time but will not Graewe disappear completely. and right nipple sparing mastectomy. According to Graewe, excellent results are achieved with new and better flaps which have been developed over recent years.

Some of the flaps used today include: courtesy of Prof. Pictures

 The TRAM (transverse rectus abdominis muscle) flap which uses tissue and muscle from the abdomen. There are two types of TRAM flaps, i.e. the pedicled flap which leaves the flap attached to its original blood supply, and the free flap where the Immediate breast reconstruction after bilateral areola spar- surgeon cuts the flap consisting of skin, fat and muscles free from ing mastectomy for left infiltrating breast cancer in a BRCA1 its original location and attach it to blood vessels in the chest positive patient. area. The procedure requires microsurgical techniques.  The Latissimus dorsi flap uses muscle and skin from the back. The skin, fat muscle and blood vessels are pulled under the skin through to the chest wall. Often the volume is insufficient and then an implant can be added to increase the volume of the reconstructed breast.  The DIEP (deep inferior epigastic artery perforator) flap uses fat and skin from the same area as the TRAM flap but does not include any muscle tissue. The tissue is cut completely The results obtained with the new technique, known as free from the abdominal area and is then microsurgically at- DIEP - deep inferior epigastric artery perforator flap. tached to the blood vessels in the chest area. The advantage is that the abdominal muscle is left intact.

34 Tygerland 2009 Surgery

The first prize in breast conservation

Prof Justus Apffelstaedt.

few years ago, Prof Justus be used - a room that is often under- Apffelstaedt, head of the Surgical utilised in the normal course of events. Oncology Service of the SU In South Africa, breast conser- At the same time, it addresses the psy- Faculty of Health Sciences, ving therapy has been greatly chological and physiological aspects of made a telling contribution enhanced by intra-operative breast conservation. “When you radiate Atowards breast conservation during from the outside in, the radiation travels radiotherapy - thanks to a cancer therapy when he invented a through an awful lot of tissue and does groundbreaking device that limits the groundbreaking device, in- a lot of damage,” says Apffelstaedt. “Us- damage and scarring to a patient’s breast vented by Prof Justus Apffel- ing this device, you’re radiating only one during radiation therapy. centimetre around the sphere. The re- Known as the MammaSphere, the staedt. sult is very little tissue damage, scarring ball-shaped device is used for intra-oper- or fibrosis. ative radiotherapy and provides a once- from medical nylon into which we could “The added advantage is that the off treatment, as opposed to the con- feed a radioactive seed through a stem,” surrounding healthy tissue, with its unaf- ventional 32 daily treatments of external he says. fected blood supply, can better support radiotherapy. Costs are cut roughly in Once the tumour is removed from the healing of the small area that has half and trauma to the patient is signifi- a patient’s breast, she is immediately been treated.” cantly reduced. wheeled to the radiation bunker, under As a strong proponent of a holistic The MammaSphere, which won the conscious sedation. The MammaSphere and multidisciplinary approach to breast social category of the 2005 Grand Prix is inserted into the location where the cancer treatment, Apffelstaedt believes for Excellence in Innovation and Sustain- tumour was, and the radioactive seed in giving patients plenty of options and ability, is an emphatic confirmation of ne- fed in through a protective tube. The 30- proper support. He also believes that cessity as the mother of invention. With minute treatment provides the same breast conservation is always the ‘first the limited resources in South Africa’s dosage of radiation as an entire course prize’, despite the prevailing attitude health sector, Apffelstaedt conceived of external radiation. In conventional ra- that ‘radical’, i.e. a mastectomy, is more the idea of the MammaSphere while he diotherapy, the entire breast - an aver- likely to get rid of all the cancer than a was exploring new ways to deliver in- age of 800ml of tissue - is treated. The lumpectomy. traoperative radiotherapy during breast MammaSphere treats only the 40ml that “This is not necessarily the way to cancer therapy. At the time, oncologists count – a crucial benefit in breast con- go,” he says. “In recent years, a strong and clinicians in developed countries like servation”. body of scientific evidence has shown Italy converted operating theatres at For Apffelstaedt, the MammaSphere that in cases of early breast cancer in great expense for this purpose – in one represents an important victory in the particular, the cancer can be treated instance, this included a 60cm-thick lead fight against breast cancer on many with breast conserving surgery such as wall at a cost of about $2 million. levels. In the first place, the hospital’s a lumpectomy, followed by intraopera- “We constructed a sphere made own, unmodified radiation bunker can tive radiotherapy.”

Tygerland 2009 35 Navorsing Navorsers lig die sluier om die genetika van hartsiektes te ontbloot

Met die samewerking van Suid-Afrikaanse families wat geraak word deur genetiese hartsiektes, het navorsers van die Universiteit Stellenbosch pas die gene geïdentifiseer van twee van hierdie siektes – een wat hartritme storings veroorsaak en ’n ander wat aanleiding gee tot hartstilstand en skielike sterftes in jong, en skynbaar gesonde mense.

avorsers aan die US Fakulteit Gesondheids- siekte – maar net nie so gevorder as dié van wetenskappe het onlangs die vrugte gepluk die kind nie. Dit het Brink laat vermoed dat hy van jarelange navorsing op die gebied van met ’n familiële probleem te make het en hy het oorerflike hartsiektes, toe hulle die gene besluit om die hulp van dr Marie Torrington, ’n Prof Andries Brink Nvan twee van hierdie siektes geïdentifiseer het. spesialis op die gebied van genealogiese navors- Die resultate van die navorsing is binne weke na ing, in te roep. Dr Torrington het uiteindelik die mekaar in vooraanstaande internasionale joernale siekte nagespoor na ander families – van wie die gepubliseer. meeste uit die Oos-Kaap afkomstig was. Sy en Brink snr het gevind dat die draer van die de- fektiewe geen in 1696 uit Madeira, Portugal na Progressiewe familiële Suid-Afrika geëmigreer het. Hier is hy getroud hartblok tipe 1 met ’n vrou van Nederlandse afkoms. Vandag is alle Suid-Afrikaners wat deur progressiewe Die soeke na die genetiese mutasie wat die familiële hartblok geaffekteer word, afstam- hartsiekte, progressiewe familiële hartblok tipe 1 melinge van hierdie egpaar. in sekere Suid-Afrikaanse families veroorsaak, het In 1986, begin Brink se seun, prof Paul oor byna drie dekades gestrek. Die siekte word Brink, in samewerking met prof Valerie Corfield veroorsaak deur ’n onderbreking van die elektriese - beide van die Fakulteit Gesondheidsweten- impulse wat die hart se kontraksies bepaal en dit skappe - met die wetenskaplike soektog na die word gekenmerk deur ’n stadige hartslag wat ’n genetiese mutasie wat die siekte veroorsaak. pasaangeër vereis. Hulle het uiteindelik die mutasie nagespoor Prof Valerie Corfield Dit is vir die eerste keer in 1977 deur die voor- tot ’n klein gebied op chromosoom 19 wat on- malige dekaan van die FGW, prof Andries Brink – geveer 80 gene bevat. Onlangs het hul soektog destyds ’n hartspesialis aan die Tygerberghospitaal na die geen, waar hierdie mutasie lê, tot ’n einde - beskryf nadat hy ’n baba behandel het wat met gekom toe hulle, in samewerking met weten- ’n baie lae hartspoed gebore is. Die kind se toe- skaplikes van Hamburg en Münster in Duitsland, stand was so ernstig dat sy ’n hart pasaangeër moes die spesifieke oorsaaklike geen in die groep van ontvang. Op daardie stadium, toe pasaangeërs nog 80 gene kon identifiseer. in ’n vroeë stadium van ontwikkeling was, was sy Die studie, wat jarelange navorsing verteen- die eerste baba in Suid-Afrika om behandeling van woordig en dikwels ander navorsingspanne, hierdie aard te ontvang. geneeshere, hartspesialiste en tegnoloë van die Terwyl Brink snr nog besig was om oor die beste Fakulteit Gesondheidswetenskappe betrek het, behandeling vir die baba te besin, het hy gehoor van is in die Septemberuitgawe van die internasio- nog ’n baba wat ’n pasaangeër benodig het. Dit nale Journal of Clinical Investigation gepubliseer. het geblyk dat dié kind ’n nabye familielid was van Brink sê die ontdekking van die oorsaaklike die baba onder sy sorg. Hy het gevolglik besluit om geen beteken dat families wat deur die siekte ook die moeder van sy jong pasiënt te ondersoek geraak word, nou ’n akkurate genetiese diag- en bewys gevind van ’n soortgelyke onderliggende nose kan ontvang en in ’n vroeë stadium reeds Prof Paul Brink

36 Tygerland 2009 Navorsing weet watter familielede die gevaar loop noot. Van die 500 mense wat opgespoor so vinnig, of stadig en deurmekaar, klop om die siekte te ontwikkel. Sulke fami- is, was 205 mense draers van Lang QT-sin- dat dit ondoeltreffend begin werk. Uitein- lielede kan dan met gepaste behandeling droom – ’n toestand wat die skielike dood delik lei dit tot ’n floute en/of die dood opgevolg word. en/of vreemde floutes van veral kinders weens die ritmestoornis. Die ontdekking van die geen help en jong mense veroorsaak. Die skielike Behandeling met beta-blokkers het navorsers en klinici ook om ander hart- en onverwagte sterftes word veroorsaak die sterfgevalle onder lyers van Lang QT- toestande wat verband hou met die hart deur hartstilstand wat dikwels volg op sindroom tussen 50% en 60% tot 1% se elektriese stelsel, beter te verstaan. emosionele stres as ’n kind bv groot skrik verminder. Daarom moet ’n EKG altyd Dit sluit in nie-genetiese vertraginge in of aan ondervraging op skool onderwerp gedoen word indien ’n kind of tiener net hartspoed wat betreklik algemeen is word, of dit kan veroorsaak word deur skielik flou word. onder ouers mense. fisieke inspanning soos strawwe oefening Die span se navorsing het getoon dat of sport, of selfs die skielike gelui van ’n algemene genetiese variante teenwoordig telefoon of alarm. is in 20% tot 30% van die geen NOS1AP Oorerflike Wêreldwyd is die siekte egter nie van gesonde mense. Die variante word Lang QT-sindroom uniek nie; een uit elke 2 000 mense ly geassosieer met ’n effense verhoging daaraan. Draers van siekte toon ook nie van die QT-interval in gesonde mense. Prof Paul Brink was ook deel van ’n span almal dieselfde simptome nie. Mense met Lang QT-sindroom wat ook Suid-Afrikaanse en Italiaanse navorsers In Oktober vanjaar het Brink, Swartz die algemene NOS1AP-variante het, se wat onlangs die eerste wetenskaplike en prof Alfred George van die Vander- risiko om skielik te sterf, is twee keer bewyse gepubliseer van die bestaan van bilt-universiteit ’n artikel in die vooraan- so groot. sg modifiseeder-gene wat hartaanvalle en staanste hartjoernaal, Circulation, gepub- “Dit is die eerste keer dat modifi- skielike hartsterftes veroorsaak. liseer wat toon dat twee genetiese fak- seerder-gene vir ’n skielike hartstilstand Terwyl laboratoriums wêreldwyd tore konvergeer om die risiko vir skielike gevind is,” sê hy. betrokke was by ’n soektog na die ge- hartstilstand te verhoog. Die projek is deur die National Insti- netiese faktore wat ’n rol speel in skie- Long QT-sindroom is ’n oorgeërfde tutes of Health in die VSA met $7 miljoen like hartstilstand, het Brink en prof Peter fout in die elektriese verslapping van die (sowat R52 miljoen) befonds. Schwarz van die Universiteit van Pavia hart. Dit beteken die hart verslap te lank Die SA Mediese Navorsingsraad het in Italië, die navorsingsoeklig gefokus op – wat dit sensitief maak vir die effek van ook tot die befondsing bygedra en Tele- ’n unieke groep van 25 Suid-Afrikaanse adrenalien, sê Brink. QT verwys na die thon in Italië het ’n bydrae van R10 mil- families wat in 1993 deur Brink en prof tydsinterval op ’n elektro-kardiogram. In joen gelewer. Valerie Corfield geïdentifiseer is. mense met die siekte is dié interval aan- Mnr Elio Menzione, Italië se ambas- Al hierdie families is afstammelinge sienlik langer as by nie-lyers. sadeur in Suid-Afrika, was ook nou be- van ’n Nederlander en ’n Franse Huge- Die sindroom veroorsaak dat die hart trokke by die projek.

Nuwe ontdekkings span die kroon oor jare se navorsing

rof Paul Brink is ’n klinikus en prof Valerie Corfield ’n gemeen is onder ouer mense. genetiese navorser. Hul samewerking oor baie jare het Brink en Corfield is ook betrokke by ’n wye reeks stu- onlangs aanleiding gegee tot nuwe ontdekkings op die gebied dies van ander genetiese harttoestande wat ook families van van genetiese hartsiektes. Afrikanerherkoms affekteer - en hul toegang tot die families Die navorsing wat proff Paul Brink en Valerie Corfield oor van oorsprong speel ’n belangrike rol in die sukses van hulle baie jare reeds doen op die gebied van oorerflike hartsiektes werk op hierdie gebied. Familielede wat draers is van genetiese het gehelp om genetika as een van die vlagskipprojekte van die mutasies, wat verband hou met oorerflike hartsiektes, word US FGW te vestig. klinies opgevolg by ’n kliniek wat Brink in die Fakulteit bedryf, Hulle bydraes tot die ontdekking van die gene vir pro- en ontvang gepaste, voorkomende behandeling. gressiewe familiële hartblok en Lang QT-sindroom het vir die Een van die oorerflike siektes wat hulle steeds bestudeer twee navorsers die kroon gespan oor navorsing wat oor drie is ’n hartspiersiekte, bekend as hipertrofiese kardiomiopatie, dekades strek. wat skielike en onverwagte sterftes veroorsaak - dikwels in Beide Brink en Corfield glo ontdekkings van hierdie aard jong en skynbaar gesonde manlike en vroulike atlete en ander kan bydra tot beter begrip en insig van ander harttoestande sportmense. Hulle werk ook steeds op die genetika van pro- wat verband hou met die hart se elektriese stelsel - onder gressiewe familiële hartblok tipe II, ’n ander elektriese gelei- meer nie-genetiese vertragings in hartspoed wat betreklik al- dingsiekte van die hart.

Tygerland 2009 37 Opleiding in ’n neutedop Opleiding in ’n neutedop

Vennote in Verloskunde

aar is min universiteite wat soveel spesialiste oplei in die Dsuper-gespesialiseerde areas van Verloskunde en Ginekologie soos die Universiteit Stellenbosch. Hierdie vermoë van die Universiteit se Departement Verloskunde en Gine- kologie kan direk toegeskryf word aan ’n unieke vennootskapsprogram wat reeds in 2003 in die Departement ge- Opleiding vir navorsers vestig is. Die program behels noue samewer- MET DIE OOG OP DIE TOEKOMS king met die private gesondheidsektor wat vennootskappe in spesifieke super- spesialisgebiede befonds. Daar is tans genootskappe in Re- ie bou van navorsingskapasiteit en ’n toename in die aantal navorsers van produktiewe Medisyne, Onkologie en wêreldformaat in Suid-Afrika is een van die groot uitdagings wat die land in Uroginekologie. Sedert die program die gesig staar. Prof Wolfgang Preiser, hoof van die Afdeling Virologie in die US geloods is, is daar reeds twee spesialis- Fakulteit Gesondheidswetenskappe, het in die afgelope jaar ’n aktiewe bydrae Dgemaak om hierdie uitdaging aan te spreek toe hy, in samewerking met die Universiteit te in uroginekologie opgelei – dr Eti- enne Henn wat tans in Bloemfontein Würzburg in Duitsland en die Universiteit van Kaapstad, die eerste internasionale werk, en dr Leonard Juul wat in die de- navorsingsopleidingsgroep in Afrika tot stand gebring het. partement werksaam is. Navorsingsopleidingsgroepe bestaan uit opleidingsprogramme wat vir ’n spesi- In Reproduktiewe Medisyne is dr fieke periode by universiteite gevestig word om jong navorsers te help om ’n doktorale Johannes van Waart (2004) van Stellen- graad te behaal. Die konsep is in Duitsland ontwikkel waar sg Graduiertenkollegs deur bosch, dr Igno Siebert (2004), ’n kon- die Duitse Navorsingstigting befonds word. So ’n groep betrek doktorale kandidate by sultant in die departement, dr Salee- ’n gekoördineerde navorsingsprogram wat aangebied word deur lektore van die be- ma Nosarka (2006) van Pinelands, dr trokke universiteite. Die navorsing- en studieprogramme is interdissiplinêr van aard. Dawie Slabbert (2007) van Panorama Preiser en sy Duitse eweknie, Prof Axel Rethwilm van die Julius-Maximilians Univer- en dr Danie Botha (2008) van Port sität, Würzburg, het ’n sleutelrol gespeel in die vestiging van die eerste SA Navorsings- Elizabeth opgelei. Hierdie spesifieke opleidingsgroep wat bestaan uit 12 navorsingsgroepe – sewe van die US en vyf van die UK. genootskap bestaan uit ’n 4-jaar en ’n Beurse vir die 12 Suid-Afrikaanse PhD-kandidate word deur Nasionale Navorsingstigting 2-jaar program. (NNS) befonds. Die Stigting help ook met die befondsing van internasionale uitruilakti- Dr Kobus Coetsee is tans besig witeite, werkswinkels en simposiums wat deel is van die program. Die betrokke studente met die 4-jaar program en Dr Thabo sal dmv die Opleidingsgroep, blootgestel word aan ongeëwenaarde opleidingsgeleent- Matsaseng met die 2-jaar program. hede saam met ’n eweknie-groep van die Universiteit Würzburg. Die navorsing- en stu- Die Genootskap in Onkologie het dieprogramme is gesamentlik deur die drie vennootskapsinrigtings ontwikkel en dit word twee genote gelewer - dr Heloïse le Ri- ook gesamentlik gemonitor. Studente in die programme sal ses maande per jaar by die che en dr Liz Hugo universiteite van die verskillende vennnote deurbring om navorsing te doen en geleent- van Stellenbosch. hede soos somerskole by te woon. Daar is ook ’n Die tema van die nuwe Opleidingsgroep is MIV/Vigs en verwante infeksiesiektes in genootskap gere- Suidelike Afrika. gistreer in fetale Die foto bo is geneem tydens die bekendstelling van die eerste Internasionale Na- moederlike ge- vorsingsopleidingsgroep in Afrika is dmv ’n vennootskap tussen die universiteite van sondheid (fetal ma- Stellenbosch, Kaapstad en Würzburg, Duitsland. Die projek is tydens ’n simposium ternal medicine). op Stellenbosch bekend gestel, met Suid-Afrikaanse en Duitse navorsers as sprek- ers. Onder die gaste by die geleentheid was, vlnr. Prof Arnold van Zyl (US), dr Jürgen Breitkopf (Würzburg), prof Wolfgang Preiser (US), mnr Christof Mühlberg (Duitsland), Dr Thabo Matsaseng. mnr Robert Kriger (NNS), Prof Axel Rethwilm (Würzburg) en prof Heidrun Moll van Duitsland (voor).

38 Tygerland 2009 Opleiding in ’n neutedop

Nuwe kursus deurslaggewende belang van die geneesheer-pasiënt-interaksie en benut Integrerende Geneeskunde toepaslike, konvensionele en alter- natiewe terapeutiese behandelings- ntegrerende Geneeskunde is ’n nuwe sertifikaatprogram metodes, wat op bewysgebaseerde wat vanaf 2010 deur die US se Afdeling Huisartskunde en basis berus.” Primêre Sorg aangebied word. Die doel van die kursus is Die kursus is binne die Suid- om dokters van addisionele gereedskap, vaardighede en Afrikaanse konteks ontwerp, behandelingsI te voorsien, sê dr Maria Christodoulou, wat die met inagneming van die uitda- een-jaar afstands- en Webgebaseerde kursus saamgestel het. gings wat aan ’n gesondheid- Die kursus word op nagraadse vlak aangebied vir dokters stelsel gestel word in ’n di- in Suid-Afrika en Afrika, sê Christodoulou, ’n oud-MBChB-stu- verse gemeenskap, sê sy. dent van die FGW en ’n bekende gesondheidsgids met wye ervaring op die gebied van geïntegreerde gesondheidsorg. Dr Maria Christodoulou Sy beskryf Integrerende Geneeskunde as ’n gesonheidsorg Vir verdere inligting, dissipline wat op holistiese wyse die bio-psigo-sosiale en raadpleeg asb die webwerf: geestelike welsyn van die mens nastreef. Dit beklemtoon die www.sun.ac.za/integrativemedicine.

’n Medalje vir dr AD Keet Piloriese sfinkter ’n wenner op die Internet r AD Keet, wat vanaf 1956 tot 1986 onderonderbroke en vir ’n rekordtyd van 30 jaar aan die Radiodiagnose afdeling van die FGW betrokke was, is onlangs met ’n medalje van die SA DAkademie vir Wetenskap en Kuns vereeer. Keet is tot op hede die enigste persoon in Suid-Afrika om ’n PhD-graad op die gebied van radiodiagnose te verwerf. Hierdie graad is in 1974 aan hom toegeken vir sy verhandeling, An ani- tomico-physiological principal governing the direction of the gastro-intestinal mucosal folds during life. Hy is in 1921 gebore as die seun van die digter A.D. Keet en het aan die Universiteite van Stellenbosch, Kaapstad en die Gemeentelijke Universiteit van Amsterdam gestudeer. Hy het ’n mediese doktorsgraad in Amsterdam verwerf en dit in 1974 opgevolg met ’n Ph.D (Med.) aan die Universiteit van Stellenbosch. Van al Keet se publikasies, wat in Engels en Afrikaans verskyn het, het hy die hoogste lof in- geoes vir sy handleiding getitel The Pyloric Sphincteric Cylinder in Health and Disease wat in 1993 deur Springer-Verlag van Berlyn in Londen, New York, Boedapest en Tokio gepubliseer is. Sedert die verskyning van die boek word dit beskou as ’n naslaanwerk van internasionale gehalte oor die piloris (d.w.s. die hekwagter tussen die maag en die duodenum). Die boek word steeds beskou as een van die gesaghebbendste bronne oor die onderwerp en Keet ontvang versoeke vir die werk uit alle dele van die wêreld. Sedert die boek in 1998 op die Internet beskikbaar is, is die bron tot Bo: Dr AD Keet, wat meer as Februarie vanjaar 2,242,011 keer geraadpleeg, terwyl 1,162,225 versoeke om bladsye uit die pub- 30 jaar lank aan die Afdeling likasie ontvang is. Die aantal elektroniese besoeke aan die tuisblad gaan nog steeds voort teen ’n Radiodiagnose verbonde was, is tempo van etlike honderde per week. onlangs deur die SA Akademie In 1993 het Keet die Maurice Weinbren-toekenning ontvang vir die beste radiologiese pub- vir Wetenskap en Kuns vereer likasie vir die jaar. The Pyloric Sphincteric Cylinder in Health and Disease is elektronies beskikbaar by vir sy bydraes op die gebied van http://med.plig.org/ geneeskunde. Inleiding tot Urologie / Introduction to Urology deur Chris Heyns en Dick Barnes Nuwe Hierdie boek behoort waardevol te wees vir mediese studente wat hulself voorberei vir eksamens, en ook vir huisartse en spesialiste wat vinnig op hoogte wil kom UROLOGIE oor die hedendaagse hantering van Urologiese siektes. Die boek is verkrygbaar by die Departement Urologie se sekretaresse, me Netha Smuts, Kamer 4079, 4de handboek Verdieping, Kliniese Gebou. Posadres: Posbus 19063, Tygerberg 7505. Tel: 021 938 9282, Faks: 021 933 8010.

Tygerland 2009 39 Postgraduate training

A community of many nations

t present, 657 foreign students are reg- on ONE CAMPUS istered at the Faculty – 156 of them from African countries that stretch As an inevitable part of the global village, the Tygerberg Campus from neighbouring Southern Africa to of the SU Faculty of Health Sciences accommodates almost as Aas far afield as Egypt, Ethiopia, Mali, Rwanda, Cameroon and the Sudan. many nationalities today as those represented by the flags flying For students from European countries, in front of the United Nations building in New York. a visit to the Faculty is an instructive experience because it brings them into contact with a range of diseases no longer seen in modern-day Europe division has trained six African doctors from Ethiopia, Uganda, or the United States. Among them are students from Norway, Nigeria, Kenya and Ghana. Sweden, the United States, France, Belgium, the Netherlands, Registrars and specialists who have trained in the Urology Switzerland, Japan, Australia and New Zealand. division have only the warmest appreciation for the training op- At the same time the Faculty offers visitors from African portunities they have been given in the division. “I was initially and Middle-Eastern countries valuable training opportunities astounded by the sheer scope in Urology and the wide range of that compare well with similar training in Europe or the United equipment in the hospital, to which hitherto I had only limited States, but at considerably lower cost. exposure and no doubt I actually felt inadequate. However I “African medical specialists who wish to make a difference was carefully introduced to Urology practice by the staff whose in Africa, should train in Africa”, Dr Hassan Lameen told Tyger- patience is a virtue worth extolling. I was introduced to a wide land on completion of his training in the Radiology division at range of clinical conditions, excellent diagnostic approaches and the end of 2008. At the time, Lameen made history as the first decision making in the evaluation and management of patients, postgraduate from Libya to complete his registrar training at the based on various levels of evidence,” says Dr Anthony Kariuki FHS. Like Lameen, many students from African countries told of Kenya, who came to the division with a scholarship from the Tygerland that very little was known about South Africa in their Societé Internationale d’Urologie (SIU). countries of origin and they were surprised to find such a highly In Obstetrics and Gynaecology, Dr Abdoulaye Diarra of Mali advanced country at the southern most tip of the continent. has been one of several registrars from Africa to complete his specialist training in this Department. He says without the sup- Supernumerary registrars port of his Faculty mentors “I would never have qualified as a Many of our foreign visitors are supernumerary registrars who gynaecologist. “ are currently training in various clinical departments and divi- Other departments and divisions who currently accommo- sions, often with bursaries or fellowships from their govern- date registrars and other fellowship students include Cardiology; ments or international organizations. the Respiratory Research Unit with a fellow from Zambia; Sur- According to Prof Razeen Davids, the Department of Medi- gery with supernumerary registrars from Zambia and Nigeria; cine and the Nephrology division in particular, has an excellent Pharmacology with a MSc student from Tanzania; Neurosurgery; reputation regarding the training of physicians and nephrologists Dermatology; Internal Medicine, Infectious Diseases; Medical – so much so that the International Society of Nephrology is Microbiology; Human Nutrition; Pharmacology, the Centre for regularly sending doctors from African countries to the Depart- Rehabilitation Studies with two DPhil students and the Centre ment to train as nephrologists. Over the past two years, this for Health Sciences Education with five MPhil students.

In the photo’s above, some of the 156 students from African countries who are currently studying at the FHS. From the left: Dr Hassan Lameen, Libya; Dr Margaret Wazakili, Malawi; Dr Tsitsi Cha- taika; Dr Anthony Liwa, Tanzania; Ms Peninhah Kinya Masibo, a DPhil student from Kenya; Dr Ndosi Aston; Dr Blessing Ngonidzashe Dziwa, Zimbabwe and Dr Anthony Kariuki, Kenya. On the left: Prof Razeen Davids with nephrologists, training in the Department of Medicine.

40 Tygerland 2009 Tygerberg Poison Information Centre

providing a unique, countrywide service

he Tygerberg Poison Information Centre is a unique service, recog- For more than 30 years, the Faculty’s Poison Information Centre has been deal- nized nationally and internationally ing with anxious enquiries on a 24-hour basis, every day. These calls come from – by organisations such as the World HealthT Organisation - as a centre of excel- all parts of South Africa and may relate to accidental or intentional poisonings lence and a national asset. involving anything from plants and pesticides to drug overdoses, medication The Centre has been in operation since errors, household cleaners and snake- and spider bites. 1977 and provides a nationwide 24-hour, emergency telephone consultation service on the prevention and management Staff of the Centre also of poisoning to both health professionals present community education and the general public. It is situated in the programmes to promote safety Pharmacology division of the SU Faculty in the home by means of radio of Health Sciences on the Tygerberg Cam- talks and magazine articles, es- pus, in close proximity to the Tygerberg pecially regarding prevention of Academic Hospital. Presently, the Cen- childhood poisoning and what to tre is one of only two in the country that do in the event of an exposure provides a 24-hour consultant- based and to a poison. The Centre has laboratory-assisted poison information produced a chart on the man- service. The Centre also provides expert agement of poisoning to assist advice on biological toxins such as spider the general public in the early and snake bites, scorpion stings, marine and pre-hospital management of poisons and poisonous plants and mush- poisoning and this chart is avail- rooms. Experienced clinical toxicologists able from the Centre’s website, deal with the calls. www.sun.ac.za/poisoncentre. Callers from all over the country have Staff also lecture to the gen- been making increasing demands of the eral public, health profession- services of the centre. In 2008, for in- als and clubs and organisations stance, 5084 consultations were dealt with on toxicology-related issues. and 66% of the calls were from health care At the same time, they are in- professionals, i.e. doctors, pharmacists, volved in education and training nurses, veterinarians and others, and the through lectures to undergra- rest were from the general public. During duate MBChB students and to this period, 47% of the calls came from Dr Joy Veale, director of the Poison Information Centre, BSc Hons students in Pharmacol- the Western Cape and the remainder with a Parabuthus granulatus, one of the most poi- ogy, as well as the supervision of from the other provinces with calls from sonous scorpions in the Western Cape. postgraduate student research KwaZulu Natal (21.7%), Gauteng (16.8%) projects. They furthermore pro- and Eastern Cape (5.7%) being the most vide Poison Information Centre frequent of these. cluded pesticides, household chemicals Training programmes for Pharmacist in- In 2008, the patient distribution of poi- and cleaning materials, paraffin and other terns and Emergency Medicine and Toxi- soning consultations was children (43%), volatile hydrocarbons such as petrol and cology registrars. The research activities adults (54%), and animals (3%). Of these thinners. of the Centre are diverse and the staff consultations, 39% involved children under “These statistics emphasise the need of the Centre regularly attend and par- the age of 5 years. Poison exposures in- for expert advice on management of in- ticipate in both national and international cluded medicines (31%); non-drug chemi- toxications and other forms of poisoning congresses to showcase their research cals (53%) and environmental poisons such across the country and for various patient results. snake, scorpion and spider envenomations groups”, says the director of the Centre, (16%). Non-drug chemical exposures in- Dr Joy Veale. www.sun.ac.za/poisoncentre

Tygerland 2009 41 A prize-winning meeting of two worlds mergency Medicine attracts people with no attention span, who like adrenaline and rushing around. “Wine- making, on the other hand, requires lots of time, patience and observation. ESo says Dr Lee Wallis, an Emergency Medicine specialist who has surprisingly managed to combine these two worlds to establish a winery that wins one award after the other and accumulates more stars than the top pupil in the local primary school! As head of Emergency Medicine – not only at Stellenbosch University, but also at UCT and the Provincial Government of the Western Cape – Wallis describes his farming and winemaking activities as “a bit of a challenge’ – and considerably more so in the harvest season when his days are spent in the academe and his nights and weekends in the vineyards and cellars on his farm. Over February and March, in particular, things can get a bit rough when “we have to do something to the wine every four hours!” Wallis – a former medical officer with the Royal Marines in the Iraq war - came to the Western Cape from Britain eight years ago to do research for the completion of a MD thesis at the Red Cross Children’s Hospital. Instead of returning to the UK, he and his wife, Abbi, decided to relocate to South Africa and bought a small, 9Ha farm in Wellington where Mrs Wallis established a guest house. In the meantime, SU and UCT joined forces to present the first degree in Emergency Medicine and Wallis was appointed by the two institutions to help build the foundations for this medical speciality in South Africa. Soon after they bought their farm in Wellington, Wallis decided to take out some of the guava trees that grew on the farm and plant some vines, “just for fun,” he says. “Then I thought we may as well build a winery. And then I thought to have a go at making the wine.” As one thing led to another, the ‘Wallis-made’ wines started to attract the attention of the Cape’s wine connoisseurs, and with the attention came formal recognition for one wine after the other. The most recent was his Dunstone Shiraz 2008 which achieved a five star rating in the prestigious John Platter wine guide. At present, the small farm specialises in Shiraz, Merlot and Shi- raz Rose and all the grapes for the wines are grown on the farm. “We only produce what we grow ourselves,” Wallis says. He ascribes the success of this winemaking ventures to the excellent quality of grapes that grow on the farm. “Nature does the work and we simply let the barrels and the wine interact. I don’t interfere once we are out of the tanks and into the barrels. For Dr Lee Wallis in the vineyards. fermentation, we follow a standard but old way of doing it – namely punching through the cap of grape skins every four hours for about two weeks. This is very hard work to do by hand but the results When a British veteran of the Iraq war relocates are great. We keep machines out of the process as much as we can to the Cape to pioneer a new medical speciality – including in the vineyard.” and simultaneously tries his hand at winemaking, Wallis and his wife have a 10-month old son, two dogs called Merlot and Shiraz and apart from grapes, they also grow lavender surprising things can happen. and guavas on their farm.

42 Tygerland 2009 A prize-winning meeting of Waking up sleeping genes

Research that revolutionized our conception of the nature and cure of cancer originated in the SU Department of Medical Biochemistry more than 30 years ago when Prof Peter Jones (right) discovered that ‘sleeping genes’ could be re-awakened.

ore than 30 years ago, a young and spread of cancer. Genes can either scientist, working in the Department be turned on or off inappropriately, lead- Mof Medical Biochemistry in the Fisan ing to abnormal cell growth. However, Building on the Tygerberg Campus, made Jones and Baylin have discovered that a chance discovery in his laboratory that there are additional layers of material took cancer research to a whole new outside of the DNA that regulate, or University of Southern California when field, known as cancer epigenetics, and turn genes on and off. These epigenomes, Jones emigrated to the United States in paved the way for the development of as they are known, have been the focus the 1980’s. Today epigenomes are the fo- a whole new class of drugs that could of their research. They have determined cus of a rapidly emerging, important new convert certain cancer cells back into that inappropriate epigenetic activity area of cancer research – the clinical rel- normal cells. contributes significantly to cancer causa- evance of which has been proven when That young scientist was Prof Peter tion and growth, and that unlike muta- a massive international clinical trial with Jones who emigrated to the United States tions in the DNA, these changes can be epigenetic drugs, based on aza-c, showed in the 1980’s and is now the director of reversed. This has opened the door to that the survival rate of some cancer the Norris Comprehensive Cancer Cen- research that could potentially regulate patients was boosted from 26%, using tre at the University of Southern Califor- this activity or return the affected genes ordinary chemotherapy, to over 50% us- nia. to normal function even after they have ing the ‘epigenetic therapy’. The results of Earlier this year, the Cape Town-born become defective. this trial were published in medical jour- professor received the highest cancer The discovery that triggered Jones’ nal Lancet in March this year. research award in the United States for work in this field, happened entirely by Instead of killing cancer cells, using pioneering not only epigenetic cancer chance while he was working in the SU chemotherapy or radiotherapy, epigen- therapy, ‘but an entirely new field of sci- Department of Medical Biochemistry in etic drugs are used to wake up ‘sleeping ence’. Jones and his research partner, Prof 1977. Working with Dr Phillip Constan- genes’ in those cells and instruct them to Stephen Baylin of the Johns Hopkins Uni- tinides and Prof Wieland Gevers, he made change back to normal. versity, were also appointed joint leaders the seminal discovery that an obscure Epigentic drugs based on aza-c had of a US ‘cancer dream team’ and awarded anti-cancer drug, known as 5-aza-c, could been approved in the US and Europe a grant of R72 million. induce non-muscle cells to become mi- last year, and had since doubled the life During a visit to South Africa in August croscopically visible beating muscle cells expectancy of “tens of thousands” of last year, Jones was awarded the Cancer in tissue culture. mostly elderly people with certain blood Association of South Africa’s AG Oettle If it could do that, Jones thought, then cancers. Lancet reported that 358 pa- memorial award to acknowledge his valu- surely it could also switch on genes in tients in 15 countries were involved in able contributions in the fight against can- cancerous cells to turn them back into the international trial, which found that cer by discovering the epigenetic role of healthy ones. those receiving aza-c survived an aver- DNA methylation of genes. “I can still remember being there in age of 9.4 months longer than those on “My frustration during my visit last the lab at Tygerberg when my grad stu- conventional treatment, “with a two-year year was that I felt that people didn’t re- dent ran in and said, ‘My God, I just saw survival rate that was nearly doubled”. alise that funding from the Cancer Asso- these cells twitching.’ It was completely The drug was approved in South Af- ciation – which could only invest peanuts accidental,” he said in an article in the rica in February. Jones warns, however, for research – actually led to a whole new Sunday Times recently. that it had so far only proved effective in field of science in the world.” This early work was published in two diseases in humans, namely a “pre- Scientists have known for years that the prestigious journal, Nature, in 1977 cancer” called MDS and a kind of leukae- genetic changes contribute to the growth and was subsequently continued at the mia called AML.

Tygerland 2009 43 In Memoriam Dr Nick van Gysen Prof Willie van Niekerk Departement Anestesiologie Oudhoof. Verloskunde en Ginekologie Dr Nick van Gysen, wat jare lank Prof Willie van Niekerk, ’n politikus uit die aan die Departement Anestesiolo- vorige politieke bedeling en ’n gesiene aka- gie en Kritieke Sorg verbonde was, is demikus wat ’n leidende rol gespeel het in in Augustus vanjaar nà ’n lang siekbed die US se Fakulteit Gesondheidsweten- oorlede. skappe, is in Julie vanjaar oorlede. Nick het sy mediese opleiding aan die Prof van Niekerk is in 1970 as hoof van Universiteit Kaapstad voltooi en daarna het hy in anestesiol- die Departement Verloskunde en Ginekolo- ogie aan die Universiteit Stellenbosch en Tygerberghospitaal gie aangestel nadat die eerste hoof van die gespesialiseer. Na afloop van sy opleiding is hy as personeellid departement, prof Jannie de Villiers, as rektor in Anestesiologie aangestel en was hy vir meer as 20 jaar ’n van die US aangestel is. konsultant in die departement. Hy het in 1959 as geneesheer aan die Univer- Nick was ’n uitstekende klinikus wat sy praktyk voortgesit siteit Pretoria gekwalifiseer en vanaf 1960 sy studies in Sitologie in het uit ’n battery-aangedrewe rolstoel nadat hy veelvuldige die buiteland voorgesit. Daarna het hy sy nagraadse studies aan die sklerose in ’n gevordere stadium ontwikkel het. Hy was ’n Universiteit van Pretoria voltooi en in 1965 lid geword van die Royal bekende figuur in sy ouer en meer onlangse rooi rystoele College of Obstetricians and Gynaecologists. Hy was ook ’n genoot van waarop hy by die gange van die teaterkompleks afgeblits het, die South African College of Obstetricians and Gynecologists (CMSA) en en waarvan hy by tye afgeval het as hy te vinnig om die draaie van die International Academy of Cytology. gery het. Sy standaardreaksie tydens sulke ongelukke was om Nà sy aanstelling by die US FGW, het Van Niekerk die grond- sy hande omhoog te gooi en uit te roep: “for goodness sake”! slag gelê vir goeie pasiëntesorg en vir diepgaande navorsing in die Een van Nick se mees innemende kenmerke was sy stoïsyn- departement. “Hy het slegs die hoogste standaarde aanvaar en sy se geaardheid; hy het nooit gekla nie en selde oor sy toestand, jonger kollegas aangemoedig om hulle kennis en vaardighede by uit- of die probleme van sy gestremdheid, gepraat. Ten spyte van staande buitelandse inrigtings op te skerp. Benewens sy bekwaam- ’n daaglikse stryd wat hom dikwels erg uitgeput het, het hy hede as klinikus en vaardige chirurg het hy internasionale erkenning elke oggend teen ligdag by die werk opgedaag sodat hy die geniet vir sy kennis van sitogenetika en ware hermafroditisme,” sê die swaar verkeer kon vermy. Hy was inderdaad toonbeeld van huidige hoof van Verloskunde en Ginekologie, prof Thinus Kruger. dapperheid. Hy was ook ’n opregte en sagmoedige met wat “Hy het die departement met jeugdige entoesiasme uitgebou, geseën was met ’n plesiere kombinasie van insig en humor. As mensgenetika uitgebrei en voorsiening gemaak vir die aankoop van gevolg van hierdie eienskappe was Nick ’n geliefde en gewilde toerusting, wat verseker het dat die departement in daardie stadium persoon. een van die beste toegeruste departemente in die land was”. Met sy ondersoekende ingesteldheid was hy deurlopend Van Niekerk het in 1982 die politiek betree – onder meer as op hoogte van die jongste literatuur in anestesiologie. Sy gun- administrateur-generaal van Namibië vòòr onafhanklikheid en as stelingleesstof was die Canadian Journal of Anesthesia wat hy voorsitter van die destydse Presidentsraad. Hy is later aangestel as gereeld gelees het tot hy nie meer by die biblioteek kon uit- minister van Gesondheid in die kabinet van oud-president PW Botha kom nie. Tydens akademiese vergaderings het hy ons gereeld en het in hierdie hoedanigheid gedien tot sy uittrede uit die politiek vergas met geldige en interessante kommentaar en vrae. in 1992. Nick was ’n opreg-godsdienstige en beleidsvaste mens, met ’n sterk toewyding aan sy pasiënte, sy kollegas en sy gesin. Uit erkenning vir sy stoïsynse teenwoordigheid in die departe- Dr Marie Grobbelaar ment, het ons die jongste uitgawe van die departement se Afdeling Radiodiagnose voorgraadse anestesiologiehandboek aan hom opgedra. Dit was juis as gevolg van sy geaardheid en toewyding dat Dr Marie Grobbelaar was vir net meer as ’n jaar in dit vir Nick moeilik was om af te tree. Hy het sy aftreejare in die Afdeling Radiodiagnose as senior spesialis werk- sy rolstoel-vriendelike huis in Noordhoek deurgebring, waar saam toe sy onlangs skielik oorlede is. lede van die departement hom gereeld besoek het. Hy het ons Marie haar voorgraadse studies aan die US voltooi en gewoonlik met warmte en geesdrif verwelkom en wou alles is in 2000 as lektrise by die Anatomie afdeling aangestel. weet van ons doen en late in die departement en dan sou hy Sy het in Junie 2008 haar M. Med in Radiologie verwerf en ons met een of ander anekdote vergas. is kort daarna aangestel as konsultant in die Afdeling Radiodiagnose. Nick was deel van ons lewe in die departement en ons sal Marie was ’n gewilde dokter, met groot aanhang veral onder die kli- hom met groot hartseer mis. Hy was ’n inspirasie vir almal wat niese assistente om sy hulle verstaan en hul belange op die hart ge- hom geken het. dra het. Sy was ’n steunpilaar en haar heengaan sal verseker ’n groot leemte laat in ons midde wat moeilik gevul kan word. Marie laat haar Andrew Levin. Departement Anestesiologie. man, Johan Colyn en twee kinders, Chris (6) en Jenna (3) agter.

44 Tygerland 2009