School of Clinical Medicine

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    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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    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.
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    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.
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    Locked down impact of covid 19 restrictions on trauma presentations to the emergency department
    Venter, Anica; Lewis, Carolyn; Saffy, Patricia; Chadinha, Louis
    Background: COVID-19 was recognised as a global pandemic on 11 March 2020. In South Africa (SA), a nationwide lockdown was implemented at midnight on 26 March to prepare for the predicted surge and slow the spread of the virus. Objectives: To compare the volume and type of presentations of trauma secondary to interpersonal violence and road traffic collisions (RTCs) during two 5-month periods, from February to June 2019 and 2020, in the emergency department (ED) of an academic tertiary hospital in Gauteng Province, SA. In 2020, February - June included the lockdown period. Methods: An observational retrospective audit of the patient register at the Helen Joseph Hospital ED was conducted, comparing the number of trauma presentations secondary to interpersonal violence (assaults with gunshot wounds, general assaults including mob assaults, assaults with stab wounds) and RTC presentations between February and June 2019 and 2020. Results: A total of 4 300 trauma presentations secondary to interpersonal violence and RTCs were noted in the 5-month period February - June 2019, as opposed to 3 239 presentations in February - June 2020 (25% decline). A 40% decline in the number of RTCs, from 1 704 in February - June 2019 to 1 026 in the corresponding period for 2020, was noted and found to be statistically significant (p=0.03). Declines in the volume of trauma cases secondary to interpersonal violence and of overall trauma cases were only directional in favour of 2020, but not statistically significant. Conclusions: The volume of trauma presentations secondary to interpersonal violence and RTCs in the Helen Joseph Hospital ED decreased during the lockdown period. The decline in the volume of RTCs was statistically significant, but declines in the volume of trauma presentations secondary to interpersonal violence and in the volume of overall trauma presentations were not.
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    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.