Browsing by Author "Sissolak, Dagmar"

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    Human immunodeficiency and Hodgkin lymphoma
    (Elsevier, 2010-04) Sissolak, Gerhard; Sissolak, Dagmar; Jacobs, Peter
    Presentation of Hodgkin lymphoma (HL) is distinctive in the infected individual being more advanced, accompanied by B symptoms and the presence of extranodal disease particularly lymphadenopathy of the head and neck. Bone marrow involvement may be found in over 50% of cases. Virtually all co express gamma-herpesvirus. Phenotypically there is prominence of the mixed-cellularity and lymphocyte depleted histopathologic subtypes that define an aggressive clinical course in comparison to other variants. Prior to the induction of cART, median survival was only 1–2 years. Notably the first chemotherapy trial using ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) in 21 patients, without treating the viral infection, resulted in a 43% complete remission rate accompanied by severe haematological toxicities but did not extend median survival with this being 1.5 years matching the negative cases. Significant change accompanied concomitant anti-retroviral therapy that could be given safely even with dose intensive regimens exemplified by BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) in 12 patients or the Stanford V regimen (doxorubicin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin, prednisone) coupled with involved-field radiation for bulky disease studied in 59 patients. BEACOPP extended overall survival (OS) to 83% at 2 years. A similar trend was seen when using the Stanford V regimen with an OS rate of 51% at 3 years, disease- free survival (DFS) of 68% and freedom from progression (FFP) in 60%. Additional benefits accrued from supportive care with stimulatory peptides such as G-CSF and when combined with bacterial prophylaxis results approached that found in the uninfected reference group. Current consensus holds this particular lymphoma as still among the non-AIDS defining cancers being lung, stomach, liver or anal despite these having recently gained more attention as several of these neoplasms may be occurring more commonly in the era of cART. While the relative risk of developing a non-AIDS-defining neoplasm in HIV-infected persons on the average is 2–3 times, the risk for developing HL in HIV-infected cases impressively ranges between 5 and 25 times when compared to the general population. Based on the precedent in which Kaposi sarcoma and the non-Hodgkin lymphomas distinctively alter the course of this retroviral infection in a way indistinguishable from concurrent Hodgkin lymphoma we propose that this entity be similarly regarded and the hypothesis tested in large randomised prospective study.
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    Lymphoma : emerging realities in sub-Saharan Africa
    (Elsevier, 2011-04) Sissolak, Gerhard; Juritz, June; Sissolak, Dagmar; Wood, Lucille; Jacobs, Peter
    Substantial geographical differences exist for Hodgkin and other lymphoproliferative disorders with these having previously been documented in a report from the lymphoma reclassification project. In the light of rampant human immunodeficiency syndrome, largely centred in sub-Sahara, this experience is updated in a further 512 consecutive individuals treated over an 8-year period in a privately based academic centre. Median age was 55.2 years 61% were males, 10% had Hodgkin lymphoma and, overall, constitutional symptoms were present in 20%. Prior to referral 19% had received chemotherapy and a further 20% some form of irradiation. Median survival in hairy cell leukaemia (n = 14), chronic lymphocytic leukaemia–small lymphocytic lymphoma (n = 103), Hodgkin (n = 41) and follicular lymphoma (n = 59) was not reached at the time of analysis and exceeded 36 months. This was followed by 32 months for those with mantle cell (n = 7), splenic (n = 2) and extranodal marginal cell (n = 11), 24 months for T-cell lymphomas (n = 24), 20 months for diffuse large B-cell variants (n = 88) but only 12 months for the aggressive tumours exemplified by Burkitt (n = 7) and lymphoblastic subtypes (n = 6). The remaining 36 patients had to be excluded because numbers were too small for statistical analysis or unreliable staging. Adverse factors were constitutional symptoms, prior treatment with chemotherapy, intermediate or high-risk scores as defined by the international prognostic index, histologic grading and certain anatomical sites of primary tumour. In contrast gender, staging by Rye or Rai classification, retroviral infection and prior treatment with radiotherapy were without effect. Overall survival at 3 years in each category was compared to the curve for the entire cohort and was 100% in hairy cell leukaemia receiving two chlorodeoxyadenosine and greater than 88% in Hodgkin lymphoma treated according to the German study group protocols (p = 0.0004). Corresponding figures for chronic lymphocytic leukaemia–small lymphocytic lymphoma were 82% (p = 0.0006), follicular lymphoma 71% (p = 0.060), peripheral T-cell lymphoma 43% (p = 0.0156), diffuse large B-cell lymphoma 39% (p < 0.0001), aggressive tumours 25% (p = 0.0002) and for the indolent categories including mantle cell, splenic and extra nodal marginal cell lymphomas 22% (p = 0.2023). Outcome argues in favour of patient management by a multidisciplinary team implicit in which are standardised protocols for diagnosis, staging and treatment. Under these circumstances the well recognized centre effect applies when results approximate those from first world reference centres. Conversely any deviation from such a disciplined approach is unlikely to achieve comparable benefit and therefore to be strongly discouraged
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    Mind the gap! Risk factors for poor continuity of care of TB patients discharged from a hospital in the Western Cape, South Africa
    (Public Library of Science, 2018) Dudley, Lilian; Mukinda, Fidele K.; Dyers, Robin E.; Marais, Frederick; Sissolak, Dagmar
    Background: TB patients discharged from hospitals in South Africa experience poor continuity of care, failing to continue TB treatment at other levels of care. Factors contributing to poor continuity of TB care are insufficiently described to inform interventions. Objective: To describe continuity of care and risk factors in TB patients discharged from a referral hospital in the Western Cape, South Africa. Design: This retrospective observational study used routine information to describe continuity of care and risk factors in TB patients discharged from hospital. Results: 788 hospitalized TB patients were identified in 6 months. Their median age was 32 years, 400 (51%) were male, and 653 (83%) were urban. A bacteriological TB test was performed for 74%, 25% were tested for HIV in hospital, and 32% of all TB patients had documented evidence of HIV co-infection. Few (13%) were notified for TB; 375 (48%) received TB medication; 284 (36%) continued TB treatment after discharge; 91 (24%) had a successful TB treatment outcome, and 166 (21%) died. Better continuity of care was associated with adults, urban residence, bacteriological TB tests in hospital and TB medication on discharge. Fragmented hospital TB data systems did not provide continuity with primary health care information systems. Conclusions: Discharged TB patients experienced poor continuity of care, with children, rural patients, those not tested for TB in hospital or discharged without TB medication at greatest risk. Suboptimal quality of hospital TB care and a fragmented hospital information system without linkages to other levels underpinned poor continuity of care.
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    TB infection prevention and control experiences of South African nurses : a phenomenological study
    (BioMed Central, 2011-04) Sissolak, Dagmar; Marais, Frederick; Mehtar, Shaheen
    Abstract. Background. The tuberculosis (TB) epidemic in South Africa is characterised by one of the highest levels of TB/HIV co-infection and growing multidrug-resistant TB worldwide. Hospitals play a central role in the management of TB. We investigated nurses' experiences of factors influencing TB infection prevention and control (IPC) practices to identify risks associated with potential nosocomial transmission. Methods. The qualitative study employed a phenomenological approach, using semi-structured interviews with a quota sample of 20 nurses in a large tertiary academic hospital in Cape Town, South Africa. The data was subjected to thematic analysis. Results. Nurses expressed concerns about the possible risk of TB transmission to both patients and staff. Factors influencing TB-IPC, and increasing the potential risk of nosocomial transmission, emerged in interconnected overarching themes. Influences related to the healthcare system included suboptimal IPC provision such as the lack of isolation facilities and personal protective equipment, and the lack of a TB-IPC policy. Further influences included inadequate TB training for staff and patients, communication barriers owing to cultural and linguistic differences between staff and patients, the excessive workload of nurses, and a sense of duty of care. Influences related to wider contextual conditions included TB concerns and stigma, and the role of traditional healers. Influences related to patient behaviour included late uptake of hospital care owing to poverty and the use of traditional medicine, and poor adherence to IPC measures by patients, family members and carers. Conclusions. Several interconnected influences related to the healthcare system, wider contextual conditions and patient behavior could increase the potential risk of nosocomial TB transmission at hospital level. There is an urgent need for the implementation and evaluation of a comprehensive contextually appropriate TB IPC policy with the setting and auditing of standards for IPC provision and practice, adequate TB training for both staff and patients, and the establishment of a cross-cultural communication strategy, including rapid access to interpreters.