BACKGROUND. Rheumatoid arthritis (RA) is a highly prevalent disease with a significant impact on morbidity and life expectancy. There is a paucity of literature relating to the current state of disease control in South Africa, and none on Free State Province.OBJECTIVES. To evaluate control of RA with conventional disease-modifying antirheumatic drugs (DMARDs) in the rheumatology outpatient department of Universitas Academic Hospital, Bloemfontein, and to determine the relative impact of various factors contributing to the prevention of disease control.METHODS. A cross-sectional study was undertaken over a period of 8 months from December 2016 to August 2017 in the rheumatology outpatient department of Universitas Academic Hospital. Data were collected by means of information sheets and questionnaires completed by attending doctors. The information pertained to disease activity, possible factors contributing to poor control, and relevant demographic data.RESULTS. Information was collected from 169 patients, and data analysis was performed on 161. The results revealed that RA was controlled in 34 patients (21.1%). Of the 127 patients with uncontrolled disease, 61 (48.0%) reported dispensing issues relating to poor drug availability. Seventy-two (56.7%) of the patients with uncontrolled disease were deemed to be on insufficient treatment for their disease state, of whom 33 (45.8%) also reported concomitant dispensing issues. Other factors such as transport/access problems, administrative issues, adverse events and poor compliance/insight contributed to the inadequate control of RA to a minor extent. In terms of monthly dispensing, 159 patients (98.8%) reported receiving all their DMARDs during the first month. The vast majority of these drugs were dispensed from Universitas Hospital. This figure decreased to 119 patients (73.9%) who received all their DMARDs during the second month, mostly from district units. Only 55.3% (n=89) of the patients reported receiving all of their DMARDs from their down-referral units.CONCLUSIONS. Control of RA at this institution is suboptimal compared with national and international standards. The main contributors to poor control appear to be problems relating to dispensing of medication and inadequate escalation of therapy by doctors. Most of the concern with the dispensing of medication lies with the poor availability of DMARDs in peripheral unit pharmacies. These factors are remediable and should be attended to.

The cytokine tumor necrosis factor and other as yet unidentified factor(s) which together mediate the killing of intraerythrocytic malaria parasites are transiently elevated in sera during paroxysms in human Plasmodium vivax infections in non-immunes. These factors which included TNF and parasite killing factor(s) are associated with the clinical disease in malaria to the extent that their transient presence in infection sera coincided with paroxysms, the most pronounced clinical disturbances of P. vivax malaria and secondly because their levels were markedly lower in paroxysm sera of semi-immune patients who were resident of an endemic area. Further, a close parallel was obtained between serum TFN levels and changes in body temperature that occur during a P. vivax paroxysm in non-immune patients, suggesting a causative role for TNF in the fever in malaria. P. vivax rarely if ever cause complicated clinical syndromes. Nevertheles serum TFN levels reached in acutely ill P. vivax patients were as high as in patients suffering from cerebral complications of P. falciparum malaria as reported in studies from the Gambia. Cytokine profiles and other changes accompanying clinical disease in P. vivax and P. falciparum malaria are compared in this paper with a view to discussing the potential role of cytokines in the causation of disease in malaria.