Theses and Dissertations (Clinical Medicine)

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The identification of differentially expressed cell cycle -related genes in breast and colon cancer cell lines in response to chemotherapeutic drugs
(2010-01-27T11:15:07Z) Rupnarain, Charleen
With the high prevalence and high mortality rate of cancer in the global community, it is increasingly essential to accelerate our understanding of the disease, to identify new genetic targets for therapy, and to pursue avenues for improving on the therapies in development and in current use. The aim of this study is to identify cell cycle-related genes whose expression is influenced by the chemotherapeutic drugs curcumin, SAHA, lycopene and thalidomide in breast and colon cancer and normal cell lines. These drugs are currently not in clinical use for cancer in South Africa, and while there have been investigative studies of these chemotherapeutic agents, this study aims to identify the specific genes that are influenced by the drugs. The result of this is that several genes that were not previously documented as targets of these drugs are highlighted. The cell cycle pathway is the area of focus as loss of regulation in the cell cycle is one of the important factors involved in promoting cancer initiation and progression. In the first instance, flow cytometry was used to identify optimal drug concentrations relative to the cell cycle stages. Following this, alterations in gene expression were assessed using a PCR-based differential display after each drug treatment. Subsequently, a more focussed approach was taken in a PCR-array analysis of panels of cell cyclerelated genes. A subset of genes is identified that is implicated in oncogenic transformation in breast cancer. This has the potential to inhibit the genetic pathways involved in breast malignancy by providing targets that perhaps may not be manipulated in current therapies. The gene expression studies here suggest that lycopene and thalidomide function in inhibiting this transformation, and play significant roles in suppressing the oncogenic state of breast cancer. Curcumin and SAHA also exhibit important functions in inhibiting tumourigenesis in colon cancer. While the results propose that the drugs have clear roles in inhibiting breast and colon cancer, they are also implicated in promoting cancer. This research has defined the genes that must be carefully monitored during drug administering as they may promote these and other cancers. The availability of these results to researchers will aid in selecting the criteria for assessing the success rate of these drugs.
The in vitro and in vivo effects of Bulbine frutescens and Bulbine natalensis on cutaneous wound healing
(2010-01-27T13:28:12Z) Pather, Nalini
In recent years, there has been a growing interest in natural and traditional medicines for the treatment of wounds. Attempts to find agents that promote wound-healing and that are affordable, effective and non-toxic have a long history. In South Africa, hundreds of different indigenous plants are used to treat wounds and burns. The merits of relatively few of these have been scientifically evaluated. Bulbine natalensis and Bulbine frutescens of the Asphodelaceae family are indigenous to southern Africa and are widely used as a skin remedy. This study aimed to investigate the in vitro and in vivo effect of Bulbine natalensis and Bulbine frutescens on cutaneous wound healing. In vitro cell culture study: In vitro studies were carried out on dermal fibroblasts and human keratinocytes cultured under standard conditions using Iscove’s Modified Eagles Medium (MEM) and Dulbecco’s MEM respectively. Confluent cultures of both cell lines were treated with varying concentrations of the leaf extracts of B. frutescens and B. natalensis. These cultures were subjected to the MTT, WST-1 and BrdU assays to determine the cytotoxicity and proliferation effect of the extracts. In addition, migration of cells across a score was analysed over a 48 hour period. In vivo animal study: Excisional and incisional wounds were created on the back of 12 domestic pigs. Mirror imaged wounds were created as control wounds. The excisional wounds were biopsied at days 2, 4, 7, 10 and 16 and the incisional wounds were biopsied at day 16. The rate of closure of the wounds was also recorded. Each excisional wound was analyzed for its biochemical composition by estimating the total amount of protein, DNA, collagen and hexosamine that was present in the wound tissue. The wound healing process was documented histologically (using haematoxylin and eosin and a Mallory’s trichrome stain) and immunohistochemically (using anti- α smooth muscle actin, vascular endothelial growth factor WitsETD and transforming growth factor β receptors I and II). The incisional wounds were used to test tensile strength of the healed wounds using a tensiometer.In the in vitro studies, neither extract caused cytotoxicity to either the fibroblast or keratinocyte cells. Cell proliferation was greater than 100% at 0.1-5 and 100-300 μg/ml for Bulbine natalensis and at 0.1μg/ml for Bulbine frutescens. There was no significant difference in the effects of the two leaf extracts on cell proliferation. The biochemical analysis of the wound tissue showed a significant increase in the collagen, protein and total DNA content of both B frutescens and natalensis treated wounds when compared to the untreated wounds. There was no significant difference in the hexosamine content of both B. frutescens- and B. natalensis-treated and untreated wounds. Analysis of the wound tissue displayed an increase rate of closure of the wound tissue treated with B. frutescens and B. natalensis when compared to the untreated wounds. Full re-epithelialisation of both treated wounds occurred earlier than in the untreated wounds. These findings have important implications for the use of these extracts to treat wound healing.
Knowledge, attitudes and reported practices of general practitioners related to adult female patients with urinary incontinence in greater Johannesburg
(2010-01-28T08:09:44Z) Padayachey, Moganambal
BACKGROUND There is an extraordinary common medical condition that affects millions of people, mostly women. It is associated with high levels of disability, discomfort and loss of productivity. People seldom talk about it and suffer in silence and have a fear of being ridiculed or embarrassed. It is not breast cancer, nor osteoporosis, nor heart disease nor is it depression. It is urinary incontinence – the loss of bladder control, which affects the lives of millions of people globally. General Practitioners (GP‟s) do not have a good knowledge about the topic and are therefore not managing Urinary Incontinence (UI) appropriately. AIM To assess the knowledge, attitudes and reported practices of general practitioners related to adult female patients with urinary incontinence in Greater Johannesburg. OBJECTIVES To determine the demographics of the respondents belonging to the various Independent Practitioner Associations (IPA's). Variables include age, sex, year qualified, postgraduate qualifications, and the number of years in clinical practice. To determine the demographics of the respondents practice. Variables include, age distribution, gender distribution, and the number of patients seen with urinary incontinence per month. To determine the knowledge of the respondents regarding urinary incontinence in adult females. Variables include prevalence, aetiology, types of urinary incontinence, associated risk factors and reversible factors. v To determine the attitudes of the respondents regarding urinary incontinence in adult females. Variables include feelings of empathy, frustration, etc. To determine the management of the respondents regarding urinary incontinence in adult females. Variables include access of referral facilities, screening, examination, investigation, and medication. METHODS The study was done amongst the Independent Practitioner Associations in the greater Johannesburg area. A questionnaire was administered to GP‟s attending IPA meetings, data was collected with regards to the demographics of the GPs and their practices as well as the knowledge, attitudes and reported practices of the GPs. RESULTS The response rate cannot be calculated as the number of GPs who attended the IPA meetings is not known. One hundred and thirteen respondents met the inclusion criteria for the study. The data was collected over a 10-month period during 2006. Males accounted for 76 (68.5%) and females for 35 (31.5%) of all respondents. Two (1.8%) respondents had three postgraduate qualifications, 11 (9.7%) respondents had two postgraduate qualifications and 38 (33.6%) respondents had one postgraduate qualification. The prevalence of patients with UI was higher amongst female respondents, 33 (97.1%) as compared to male respondents 67 (88.2%). Feelings of empathy was experienced by 94 (88.7%) respondents and 81 (81%) respondents would never avoided the discussion about UI with patients. Most respondents rated their knowledge on aetiology 82 (78.1%), diagnosis 79 (73.8%), investigation 58 (54.2%) and management 58 (54.7%) as good and very good.
Acute coronary syndromes in black South African patients with human immunodeficiency virus infection
(2011-10-19) Becker, Anthony Charles
Background: South Africa is considered to be a country in epidemiologic transition with increasing rates of cardiovascular disease. In addition, it faces an HIV pandemic, with an estimated 5.5 million people infected and five hundred thousand HIV-related deaths annually. Current evidence suggests that patients infected with HIV are at a heightened risk for acute coronary syndromes (ACS) related to traditional cardiovascular risk factors, as well as factors related to the virus and its treatment (highly active anti-retroviral therapy (HAART)). HIV infection itself may independently predispose to coronary artery disease (CAD) by promoting endothelial dysfunction, a heightened pro-inflammatory state, dyslipidaemia and thrombosis, the aetiology of which is thought to be multifactoral in nature. Protease inhibitor (PI) therapy, as part of HAART, has the potential to induce an adverse metabolic phenotype, including: dyslipidaemia, insulin resistance, endothelial dysfunction and a prothrombotic state. The attributable risk of these factors in HIV-associated CAD and ACS is currently unknown, but it seems that the risk of ACS is increased by prolonged exposure to PI’s. No data currently exists on CAD in HIV patients not receiving HAART, which is problematic considering that this makes up the majority of patients in sub-Saharan Africa and that the combination of epidemiologic transition and HIV infection has the potential for greater cardiovascular morbidity, particularly with respect to atherothrombotic events. viii Aims: The aims of this thesis are twofold. Firstly, to confirm reports of epidemiologic transition in South Africa from a broad epidemiological perspective. Secondly, by focusing on treatment-naïve HIV positive black South Africans with ACS, it aims to determine differences compared to HIV negative patients with respect to demographics and risk factors, angiographic and treatment related factors as well as markers of thrombosis and inflammation with a view to providing more focused primary and secondary prevention. Methods: All the studies contained in this thesis were conducted in the Department of Cardiology, Chris Hani Baragwanath Hospital and adhere to the declaration of Helsinki. The first of the epidemiological studies, The Heart of Soweto (HOS) study (Chapter 3), was a prospectively designed registry that recorded epidemiologic data relating to the presentation, investigations and treatment of 1593 patients from Soweto with newly diagnosed cardiovascular disease during the year 2006. The second study (Chapter 4) was a cross sectional study of patients with ACS admitted to the Baragwanath coronary care unit over the year 2004 compared to the years 1975-1980. The HIV sub-study (chapters 5-8) was a prospective single centre study conducted from March 2004 to February 2008. During this time, 30 consecutive black HIV patients presenting with ACS (ACS+: HIV+ group) were enrolled. For each HIV patient with ACS, the first presenting non-HIV black patient with ACS was selected as a case control comparator (ACS+ : HIV- group). In addition, a second control group of 30 asymptomatic HIV patients, who were matched for age, sex and ethnicity (ACS- : HIV+ group), were recruited from the HIV clinic. The methodology used to compare the groups involved: clinical and demographic data collection, routine blood test evaluation, angiographic ix analysis and specific laboratory testing of various research blood parameters (including thrombotic screening and markers of inflammation and endothelial activation). Results: Chapter 3 presents the results of the large HOS study, which showed good evidence to support the theory of epidemiologic transition in Soweto. Adding to this data are the results of Chapter 4, which clearly demonstrate a substantial increase in the number of patients diagnosed with ACS at Baragwanath in recent years. Consistent with a population in epidemiologic transition, there was more than a ten-fold increase in the rate of coronary events over two decades, paralleled by increased rates of modifiable risk factors. Chapter 5 presents the clinical and angiographic data from the HIV sub-study. HIV patients with ACS were younger and had fewer traditional risk factors for CAD except for higher rates of smoking and lower HDL cholesterol levels. HIV patients had less atherosclerotic burden angiographically, but a higher thrombus burden in the infarct related arteries, suggesting a possible prothrombotic state. In addition, HIV patients had higher rates of in-stent restenosis of bare metal coronary stents at follow up. Chapters 6 and 7 present data on the thrombotic parameters between the groups, with Chapter 6 focusing mainly on coagulation pathways and Chapter 7 focusing on antiphospholipid antibodies (aPL). Chapter 8 presents data on levels of pro-inflammatory cytokines and endothelial activation markers. Greater evidence of thrombophilia was found in HIV patients with ACS as evidenced by lower Protein C (PC) levels, higher levels of Factor VIII and a higher inflammatory burden with greater degrees of endothelial cell activation - all of which increase thrombotic risk. Antiphospholipid antibodies were more prevalent in HIV patients but did not seem to be causal in the pathogenesis of thrombosis. x Conclusion: Soweto, a large, predominantly black urban area in South Africa, is in a state of epidemiologic transition, with an increasing prevalence of modifiable cardiovascular risk factors and ischaemic heart disease. Treatment-naïve HIV positive black patients presenting with ACS have different clinical and angiographic features compared to the HIV negative population. The patients are younger, more commonly male, with high rates of smoking, lower HDL levels and less atherosclerotic burden. However, there is a higher thrombotic burden, suggesting a prothrombotic state, which was evident by lower PC levels, higher factor VIII levels with a higher inflammatory burden and a greater degree of endothelial cell activation – all factors associated with a pro-atherogenic and prothrombotic state. The exact pathogenic role of HIV, independent of associated modifiable and non-modifiable risk factors, is difficult to determine, but may be important as a contributory factor in an already “vulnerable” patient. Importantly, we identified modifiable risk factors in the HIV group. Smoking may play a crucial role in the pathogenesis of ACS in these otherwise seemingly low risk patients and remains an important target for cardiovascular risk reduction. The role of HDL in the pathogenesis and prevention of HIV-associated CAD needs to be further defined, as does the role of drug eluting coronary stents in the prevention of in-stent restenosis. Cardiovascular risk assessment and appropriate primary prevention should be an important component in the management of HIV patients, regardless of treatment status. With the anticipated increase in CVD in South Africa, further research projects appropriate to the South African context will be vital in order to explore cost effective ways to provide primary and secondary prevention in order to effectively deal with the burden of epidemiological transition as well as the cardiovascular burden likely to be imposed by the HIV pandemic.
A descriptive retrospective record review of paediatric patients with intracardiac thrombi associated with dilated cardiomyopathy at Chris Hani Baragwanath academic hospital
(2016-02-09) Morar, Deksha Faye
Intracardiac thrombi associated with dilated cardiomyopathy in paediatric patients can be a source of significant morbidity and mortality. This study looked at the prevalence, risk factors and outcomes of children complicated by intracardiac thrombi, following a diagnosis of dilated cardiomyopathy at a tertiary centre. METHODS A retrospective review of all children, between the ages of 1 and 14 years, diagnosed with dilated cardiomyopathy from August 1983 to July 2011 were assessed using the paediatric cardiology database at Chris Hani Baragwanath Academic Hospital. The study population comprised of 303 children. RESULTS The prevalence of intracardiac thrombi in the children with dilated cardiomyopathy was 13.2% (40 children). The majority were located in the left ventricle (80%). The children who developed intracardiac thrombi had a lower fractional shortening compared to the group without intracardiac thrombi (p≤0.05). 20 of these children (6.6%) had evidence of embolization (15/20 to the central nervous system). 52 of the 303 children were HIV positive (17.2%). There was no statistically significant association between HIV status and the development of intracardiac thrombi (p = 0.19). The overall mortality was 8.9%. 12 of the 27 deaths occurred in the intracardiac thrombi group showing that the children with intracardiac thrombi had a poorer outcome (p≤0.05). CONCLUSION Intracardiac thrombi is a common occurrence in paediatric patients with dilated cardiomyopathy. There is a significant relationship between the development of intracardiac thrombi and a poor fractional shortening. Patients with echocardiographic evidence of intracardiac thrombi have a worse outcome.
A radiation dose review for paediatric fluoroscopy in an Academic South African referral hospital
(2017) Venter, Mauritz
INTRODUCTION Children are more sensitive to radiation and it is therefore important to reduce their exposure. There are currently no published data on South African paediatric fluoroscopic upper GIT, contrasted enemas and vesico-urethrogram dosage reference levels. AIM To determine the dose area product (DAP) values in common paediatric fluoroscopic examinations: Upper GIT studies, contrasted enemas and vesico-urethrograms. The primary endpoint was comparing our median and upper third quartile DAP values to international standards. METHOD We adhere to the Radiological Society of South Africa (RSSA)/South African Society of Paediatric Imaging’s (SASPI) guidelines to minimise radiation exposure. The upper third quartile and mean DAP values were collected between March 2013 and March 2016 for each study, categorised into four age groups (0–1, 2–5, 6–10 and 11–15 years) and stratified by our three major examinations. The data were compared to literature from the National UK Radiological Protection Board. RESULTS DAP values for upper GIT studies were significantly lower in the three younger age groups. There was no significant difference in the oldest age group. DAP values for vesico-urethrograms were significantly lower in the youngest age group. There was no significant difference in the three older age groups. For our contrasted enemas, there were no suitable data for comparison. CONCLUSION By following the RSSA / SASPI guidelines, our overall DAP values compared better than the UK National Patient Dose Database in the younger age groups and no worse in the older age groups.
A review of congenital heart defects in children with Trisomy 21 over a 5-year period at Charlotte Maxeke Johannesburg Academic Hospital
(2021) Mahomed, Raeesa Moosa Kara
Background: In the first ten years of life, mortality in Trisomy 21 (T21) is strongly associated with the presence of Congenital Heart Defects (CHDs). There is currently a lack ofl ocal and regional data regarding the prevalence, management and outcomes of children with T21 and CHDs. Objectives: To describe the prevalence, type and frequency of CHDs and revie winter ventions (cardiac catheterisation and surgery) and survival post-surgery of children with CHDs in the T21 population at a South African facility ,the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Paediatric Cardiology Unit (PCU). Methods: A retrospective, crosssectional, observational review of 177 participants at CMJAH PCU between January 2013 to December 2017 was performed. Data collected from the PCU data base and clinical records included: demographics, echocardiographic diagnosis, details of Diagnostic Cardiac Catheterisation (DCC), Interventional Cardiac Catheterisation (ICC) and surgery required and performed, age at diagnosis and intervention as well as survival post-surgery. Results: There were 128 participants with laboratory-confirmed T21 and CHD on echocardiography meeting inclusion criteria. The majority of participants were female (56.0%) and African (97.0%). The median age at presentation was six (IQR9.75) months. The prevalence of CHDs was 77/128 (60.2%) and 58/77 (75.3%) had a single CHD. The most frequent CHD was an Atrioventricular Septal Defect (AVSD) (38) (with or without another associated CHD) .DCC was required in 60/77 (77.9%) participants and 25/60 (41.6%) were performed. The median age at DCC was 15 (IQR 15) months. One participant with isolated PDA required and under went successful ICC for PDA closure at 17 months. Surgery was required in 60/77 (77.9%) of participants, while 15/60 (25.0%) surgeries were performed. Almost half of DDCs and surgeries not performed were due to participants lost to follow up (40% and 45% respectively). The median age at first surgery was 31 (IQR 24) months. The most common surgery was an AVSD repair (73%). Post-surgery survival was 93.3% at hospital discharge, 3-week and 6-month follow-up and 86.7% at 1-year follow-up . Conclusion: The prevalence, type and frequency of CHDs in the CMJAH T 21 population is comparable to global data. The age at presentation was not optimal for early intervention, and there was further delay in catheterisation and surgery. Survival post-surgery compares favourably with other centres even though surgery was performed at a much later age than the age recommended for best outcome (sixmonths). Early screening , diagnosis and intervention can prevent morbidity, mortality due to CHDs and may decrease the financial burden on the healthcare system.
The socio-economic impact on health behaviour regarding blood pressure management amongst young adults
(2024) Mhlaba, Mimi
Hypertension (HTN) is a leading cause of cardiovascular disease (CVD), with hypertension prevalence among young adults (YAs) increasing on a global as well as local scale. In South Africa between 1998 and 2016, Hypertension (HTN) rates in YAs (age 15-34 years) have more than doubled. Research reports that the increasing prevalence of HTN in YAs is largely attributed to unhealthy behaviours, such as unhealthy diet, physical inactivity, smoking, drinking alcohol, and poor sleep, with YAs also perceiving themselves as invulnerable to developing HTN at a young age. Formative research has shown that lack of education, employment, and training (NEET status) presents a significant barrier to healthier behaviours in YAs. Currently, 44.7% of South African youth are NEET, indicating the increased risk of pro-HTN behaviour in this group and the need for urgent intervention. While many learnerships addressing NEET rates in the country have been implemented, few are focused on health. Therefore, this study aimed to investigate if transitioning from a NEET status to employment and health education training changes perceptions of HTN risk and health behaviour intentions. METHODS We conducted six focus group discussions (FGDs) comparing HTN-related beliefs and intention for behaviour change between NEET youth (n=20; not in employment, education, or training) and previously NEET youth on a health employment and education training initiative (HETI); n=20). All FGDs were approximately 70 minutes in duration and were recorded and transcribed verbatim. The study utilised the conceptual framework of the Health Belief Model (HBM) to inform the FGD topic guide and a deductive thematic analysis. Frequent debriefing and review sessions with research supervisors were conducted to ensure the quality of the analysis. RESULTS All youth were familiar with HTN but for NEET youth, who only knew it as “high-high” or “high blood”, this was mostly through experiences of others in their social network. While all youth viewed HTN as life-threatening if left untreated and expressed fear of lifelong medication use if diagnosed, only HETI youth felt empowered to implement positive health behaviours for disease prevention. Intention for behaviour change was related to personal relevance resulting from the practical application of HTN knowledge in their daily lives. In contrast, NEET youth felt chronic disease was inevitable at an older age and demonstrated no intention for behaviour change. Past negative experiences in local clinics and the fear of distress in the event of a possible diagnosis were described as major deterrents to blood pressure (BP) screening. CONCLUSION Results suggest that engaging NEET (Not in employment, education, or training) youth in similar HETI (Health employment and education training initiative) programs can increase personal relevance of health information, which serves as a motivator to increase intentions toward healthier behaviours for chronic disease prevention. This may also result in double-duty benefits, reducing a NEET status as well as the risk for chronic illness among the YA population.
Pattern of thyroid disorders in black population referred for thyroid scintigraphy at Chris Hani Baragwanath Hospital, South Africa
(University of the Witwatersrand, Johannesburg, 2024) Zergoug, Nadia
Background: Most endocrine disorders are due to thyroid dysfunction with varying etiologies. Different management protocols exist for the different endocrine disorders, and it is crucial to determine the specific cause due to thyroid dysfunction. This study aimed to describe the spectrum of thyroid diseases in patients who undergo thyroid scintigraphy and to assess the agreement with biochemistry and scintigraphy. Methods: This was a retrospective study to assess the pattern of thyroid disorders in the patients referred for thyroid scintigraphy at Chris Hani Baragwanath Hospital (CHBAH). All cases diagnosed with thyroid dysfunction based on biochemical results and referred for 99m Tc scintigraphy to nuclear medicine from January 2017 to December 2018 were reviewed. All records reviewed were >18 years of age and were a total of 780. Result s Of the 780 patients reviewed, 631 (80.9%) were black while the remaining 19.1% comprises White, Indian, and Coloured individuals. Among the Blacks, 84% were females and 16% were males. Graves’ disease was the commonest thyroid disease diagnosed on scintigraphy in the entire population and among the blacks, constituting 72% (n=454/631) of patients. Other thyroid disorders among the black population include toxic multinodular goitre (13%, n=80/631), non-toxic multinodular goitre (7%, n=45/631), toxic adenoma (3%, n=17/631), and thyroiditis (3%, n=21/631). The black patients’ mean age was 47.3 years with a standard deviation (SD) of ±15.1 years. Graves’ disease as well as other thyroid disorders affected all age groups but were most prominent in the 40-59 years age group in both females and males. The median thyroid stimulating hormone (TSH) was 0.001 mIU/L while free thyroxine (fT4) ranged from 7.4 – 160 pmol/L in black population diagnosed with hyperthyroidism. Conclusion: Graves’ disease is the commonest cause of thyroid disorders among individuals referred for thyroid scintigraphy, being most prevalent in Black females in the reproductive age group. Thyroid scintigraphy is useful for aetiological diagnosis in patients presenting with thyroid disorders.
Development of a list of essential obstetric anaesthetic knowledge and skills for interns in a department of anaesthesiology
(2024) Nibe, Zibele
Background Community service medical officers often practice obstetric anaesthesia without supervision, and complications can occur if they are not adequately equipped with the necessary knowledge and skills. This study aims to develop a list of essential obstetric anaesthetic knowledge and skills for interns in a department of anaesthesiology. Methods and results A prospective, exploratory, and instrumental study design using Lynn’s Model of determination and quantification of content validity was followed. The Developmental Stage involved an extensive literature review, followed by a peer group discussion with expert local anesthesiologists with a special interest in obstetric anaesthesia. Each item on the list was debated until consensus was reached. This stage resulted in a list with 59 items. In the Judgement -Quantification Stage, this list was sent to expert anaesthesiologists with a special interest in obstetric anaesthesia nationally for validation. The anaesthesiologists used a four-point Likert scale ranging from unnecessary to essential information to grade each item. Fifty-seven of the 59 items were deemed essential and retained. This entire list was quantified using the content validity index (CVI). Lynn suggests that a content list should have a CVI of at least 0.8. The list was content valid with a CVI of 0.98. Conclusion This study presents a comprehensive list of essential knowledge and skills for interns in obstetric anaesthesia in the Wits Department of Anaesthesiology that may contribute to interns practising obstetric anaesthesia more safely.
Assessment of the management of inpatient hyperglycaemia by physicians and intensivists in South African hospitals
(2024) Hewson, Peter Llewellyn Blanshard
Background Hyperglycaemia is highly prevalent in patients admitted to hospital and is associated with prolonged hospital stay, increased costs, morbidity and mortality. As there is currently limited local data on the management of hyperglycaemia, this study aimed to investigate physician practices in the management of inpatient hyperglycaemia in South African hospitals Methods: A survey investigated the practices of 154 physicians in general medical wards and intensive care units (ICUs) in the state and private sectors. To validate these responses, an audit of 100 general medical and 111 ICU patient files was performed at three major Johannesburg academic hospitals. Patients with inpatient hyperglycaemia related to diabetes mellitus (DM) or hospital-associated factors were included, while patients admitted with diabetic emergencies were excluded. Results: In the general medical wards, oral hypoglycaemic agents (OHAs) were used in the majority of survey respondents (94.5%) and audited files (64%). In the ICU, OHAs were used by 34.9% of survey respondents and 14.4% of audited patient files. Of the OHAs, metformin use was most frequently reported (93.8% in the survey) and used (64% in the audit) agent in the general medical wards, followed by sulfonylureas (SUs) (75.8% in the survey and 5% in the audit). In the critical care setting, the survey demonstrated frequent use of metformin followed by dipeptidyl peptidase-4 inhibitors (DPP4-i), while the audit showed that metformin and SU use was 14.4% and 0.9% respectively. Surveyed clinicians in general medical wards report most frequently using the basal insulin plus sliding scale insulin (SSI) regimen (36.6%), while the audit showed that SSI alone (36%) or premix insulin-based regimens (34%) are used most often. In the critical care setting, more surveyed clinicians reported using an insulin infusion (34.9%) compared to other insulin regimens, while the audit demonstrated that the majority of patients (59.5%) were managed with SSI alone. Four-to-six hourly glycaemic monitoring was noted as the standard of care in both surveys and audits. While the majority of clinicians reported daily review of their glycaemic management (91.7% and 87.3% of participants in the general medical wards and ICU, respectively), the audit revealed that this was noted in just 34% and 3.6% of participants in the general medical wards and ICU, respectively. Conclusion: Both the survey and audit demonstrated significant discrepancies from current clinical guidelines. This highlights a significant impact on patient care, in particular, as OHAs have not been recommended for use in the ICU setting, one in every three critical care patients may be exposed to potential complications as a result of the use of such agents. The findings of this study suggest further investigations regarding inpatient hyperglycaemia practices as well as implementation of education and in-hospital protocols are needed in the South Africa healthcare context in order to improve clinical outcomes.
A retrospective audit of computed tomography angiography in penetrating wound of lower limb at Chris Hani Baragwanath Academic Hospital
(2024) Abid, Rabia
INTRODUCTION: There is high rate of violence-related injuries in South Africa. These injuries include gunshot wounds, stab wounds and blunt force trauma. Many patients with penetrating wounds present in the emergency department with vascular injuries. Penetrating wounds of lower limbs with or without arterial injuries are managed according to trauma protocols. Patients presenting hard signs vascular injury are transferred to theatre for immediate exploration and repair. Patients with soft signs are clinically examined and, if indicated, imaging is planned. Clinical examination is crucial in diagnosing arterial injuries in penetrating limb injuries and AnkleBrachial index (ABI) is an important parameter to rule out arterial injuries. Doppler ultrasound is a good, non-invasive imaging modality but is operator dependent. Computed Tomography Angiography (CTA) has excellent outcomes in diagnosing arterial injuries in penetrating wounds of lower limb, with a sensitivity and a specificity close to 100%. CTA is a non-invasive, rapid, and reliable modality, but subjects the patient to radiation exposure. This study aimed to determine the prevalence and type of vascular injuries in penetrating injuries of lower limb in on South African academic hospital. METHOD: A retrospective audit of CTAs done for penetrating wounds of lower limbs to rule out vascular injuries at Chris Hani Baragwanath Academic Hospital (CHBAH) was executed. Data of CTAs performed from January 2017 to December 2018 were retrieved from the imaging PACS of the CHBAH radiology department. Ethics approval was obtained from HREC of the University of Witwatersrand, and data was captured from the relevant records. RESULTS: Descriptive statistics were used to describe the characteristics of the population, in the form graphs and figures. Data of 91 CTAs were collected. The average age of subjects was 32.2 years, and 83 of the cohort were males. The most common mechanism of injury was a gunshot wound. Only one case out of 91 of the collected CTAs was positive for arterial injury. CONCLUSIONS: Low rate of positive CTA studies over span of a 2-year period emphasizes the need for thorough examination for the suitability of a CTA. This approach avoids unnecessary radiation exposure to the patients and is cost effective. In low-risk patients, doppler ultrasound should be considered for imaging of potential arterial injuries and has no radiation exposure. The use of lower threshold value of ABI is an option for patients presenting with soft signs of arterial injuries. Revising the management protocol for penetrating injuries of lower limb used by trauma surgeons at CHBAH for requesting CTAs will be cost effective by avoiding unnecessary imaging.

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