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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    Neglected sexual dysfunction symptoms amongst chronic patients during routine consultations in rural clinics in the North West province
    (AOSIS, 2021-04-28) Pretorius, Deidre; Couper, Ian D; Mlambo, Motlatso G.
    Background: Sexual dysfunction contributes to personal feelings of loss and despair and being a cause of exacerbated interpersonal conflict. Erectile dysfunction is also an early biomarker of cardiovascular disease. As doctors hardly ever ask about this problem, it is unknown how many patients presenting for routine consultations in primary care suffer from symptoms of sexual dysfunction. Aim: To develop an understanding of sexual history taking events, this study aimed to assess the proportion of patients living with symptoms of sexual dysfunction that could have been elicited or addressed during routine chronic illness consultations. Setting: The research was carried out in 10 primary care facilities in Dr Kenneth Kaunda Health District, the North West province, South Africa. This rural area is known for farming and mining activities. Methods: This study contributed to a broader research project with a focus on sexual history taking during a routine consultation. A sample of 151 consultations involving patients with chronic illnesses were selected to observe sexual history taking events. In this study, the patients involved in these consultations completed demographic and sexual dysfunction questionnaires (FSFI and IIEF) to establish the proportions of patients with sexual dysfunction symptoms. Results: A total of 81 women (78%) and 46 men (98%) were sexually active. A total of 91% of the women reported sexual dysfunction symptoms, whilst 98% of men had erectile dysfunction symptoms. The youngest patients to experience sexual dysfunction were a 19-year-old woman and a 26-year-old man. Patients expressed trust in their doctors and 91% of patients did not consider discussion of sexual matters with their doctors as too sensitive. Conclusion: Clinical guidelines, especially for chronic illness care, must include screening for sexual dysfunction as an essential element in the consultation. Clinical care of patients living with chronic disease cannot ignore sexual well-being, given the frequency of problems. A referral to a sexual medicine specialist, psychologist or social worker can address consequences of sexual dysfunction and improve relationships.
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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.
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    Serum Metabolomic and Lipoprotein Profiling of Pancreatic Ductal Adenocarcinoma Patients of African Ancestry
    (MDPI, 2021) Elebo, Nnenna; Fru, Pascaline N.; Candy, Geoffrey; Nweke, Ekene
    Pancreatic ductal adenocarcinoma (PDAC) is a lethal cancer with a characteristic dysregulated metabolism. Abnormal clinicopathological features linked to defective metabolic and inflammatory response pathways can induce PDAC development and progression. In this study, we investigated the metabolites and lipoproteins profiles of PDAC patients of African ancestry. Nuclear Magnetic Resonance (NMR) spectroscopy was conducted on serum obtained from consenting individuals (34 PDAC, 6 Chronic Pancreatitis, and 6 healthy participants). Seventy-five signals were quantified from each NMR spectrum. The Liposcale test was used for lipoprotein characterization. Spearman’s correlation and Kapan Meier tests were conducted for correlation and survival analyses, respectively. In our patient cohort, the results demonstrated that levels of metabolites involved in the glycolytic pathway increased with the tumour stage. Raised ethanol and 3-hydroxybutyrate were independently correlated with a shorter patient survival time, irrespective of tumour stage. Furthermore, increased levels of bilirubin resulted in an abnormal lipoprotein profile in PDAC patients. Additionally, we observed that the levels of a panel of metabolites (such as glucose and lactate) and lipoproteins correlated with those of inflammatory markers. Taken together, the metabolic phenotype can help distinguish PDAC severity and be used to predict patient survival and inform treatment intervention.
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    Sexual history taking: doctors’ clinical decision-making in primary care in the North West province, South Africa
    (AOSIS, 2021-09-29) Pretorius, Deidre; Couper, Ian D; Mlambo, Motlatso G.
    Background: Clinical reasoning is an important aspect of making a diagnosis for providing patient care. Sexual dysfunction can be as a result of cardiovascular or neurological complications of patients with chronic illness, and if a patient does not raise a sexual challenge, then the doctor should know that there is a possibility that one exists and enquire. Aim: The aim of this research study was to assess doctors’ clinical decision-making process with regards to the risk of sexual dysfunction and management of patients with chronic illness in primary care facilities of the North West province based on two hypothetical patient scenarios. Setting: This research study was carried out in 10 primary care facilities in Dr Kenneth Kaunda health district, North West province, a rural health district. Methods: This vignette study using two hypothetical patient scenarios formed part of a broader grounded theory study to determine whether sexual dysfunction as comorbidity formed part of the doctors’ clinical reasoning and decision-making. After coding the answers, quantitative content analysis was performed. The questions and answers were then compared with standard answers of a reference group. Results: One of the doctors (5%) considered sexual dysfunction, but failed to follow through without considering further exploration, investigations or management. For the scenario of a female patient with diabetes, the reference group considered cervical health questions (p = 0.001) and compliance questions (p = 0.004) as standard enquiries, which the doctors from the North West province failed to consider. For the scenario of a male patient with hypertension and an ex-smoker, the reference group differed significantly by expecting screening for mental health and vision (both p = 0.001), as well as for HIV (p < 0.001). The participating doctors did not meet the expectations of the reference group. Conclusion: Good clinical reasoning and decision-making are not only based on knowledge, intuition and experience but also based on an awareness of human well-being as complex and multidimensional, to include sexual well-being.
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    Sexual history taking: perspectives on doctor-patient interactions during routine consultations in rural primary care in South Africa
    (Elsevier Inc., 2021-05-03) Pretorius, Deidre; Couper, Ian; Mlambo, Motlatso
    Background: Sexual history taking for risk behavior contributes to improving health outcomes in primary care. Giving the high numbers of people living with AIDS, every patient in South Africa should be offered an HIV test, which implies that a comprehensive sexual history must be taken. Aim: To describe the optimal consultation process, as well as associated factors and skills required to improve disclosure of sexual health issues during a clinical encounter with a doctor in primary health care settings in North West province, South Africa. Methods: This qualitative study, based on grounded theory, involved the video-recording of 151 consultations of adult patients living primarily with hypertension and diabetes. This article reports on the 5 consultations where some form of sexual history taking was observed. Patient consultations were analyzed thematically, which entailed open coding, followed by focused and verbatim coding using MaxQDA 2018 software. Confirmability was ensured by 2 generalist doctors, a public health specialist and the study supervisors. Main outcome measure: Sexual history was not taken and patients living with sexual dysfunction were missed. If patients understand how disease and medication contribute to their sexual wellbeing, this may change their perceptions of the illness and adherence patterns. Results: Sexual history was taken in 5 (3%) out of 151 consultations. Three themes emerged from these 5 consultations. In the patient-doctor relationship theme, patients experienced paternalism and a lack of warmth and respect. The consultation context theme included the seating arrangements, ineffective use of time, and privacy challenges due to interruptions and translators. Theme 3, consultation content, dealt with poor coverage of the components of the sexual health history. Conclusion: Overall, sexual dysfunction in patients was totally overlooked and risk for HIV was not explored, which had a negative effect on patients' quality of life and long-term health outcomes. The study provided detailed information on the complexity of sexual history taking during a routine consultation and is relevant to primary health care in a rural setting. Pretorius D, Couper I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med 2021;9:100389.