School of Clinical Medicine

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    A long walk to freedom: the epidemiology of penetrating trauma in South Africa- analysis of 4 697 patients over a six year period at Chris Hani Baragwanath Academic Hospital
    Bhana, Malini; Fru, Pascaline; Plani, Franco
    Background: Despite the city of Johannesburg having one of the highest rates of crime in the world, no national databank for trauma exists. This study profiles the victims of penetrating trauma and identifies geographical areas in which it occurs, while describing the outcomes and patterns of injury. Methods: A retrospective study including penetrating trauma patients triaged as Priority 1, presenting at the Chris Hani Baragwanath Academic Hospital's (CHBAH) trauma department over a six-year period (2011-2016). Results: A total of 4 697 patients were included. The majority of victims were Black African males (92.1%) between the ages of 29-40 years, and stabbings were the most common mechanism of injury (71.8%), followed by gunshots. The commonest body area affected was the thorax, with a consequent haemothorax the most likely result. Weekends accounted for over 48% of all presentations - the last weekend of the month being the busiest. Region D was the area in Johannesburg with the highest trauma incidence (51.9%), with the oldest townships in Soweto found to be "hot spots". Conclusion: Penetrating trauma is inherently linked to alcohol abuse and interpersonal violence in South Africa,1 primarily affecting its young economic, working-class citizens. The data provided some insight into the burden, structure and challenges of our trauma system. These should be regarded as opportunities to implement change and improve our surveillance and prevention, beginning with a national trauma databank
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    A qualitative study to identify critical attributes and attributelevels for a discrete choice experiment on oral preexposure prophylaxis PrEP delivery among young people in Cape Town and Johannesburg South Africa
    Janan Dietrich; Millicent Atujuna; Gugulethu Tshabalala; Stefanie Hornschuh; Mamakiri Khunwane; Michelle Koh; Nadia Amed; Richard Muhumuza; Kennedy Otwombe; Neil Martinson; A Et Al
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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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    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.
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    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.
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    Are adults just big kids? Can the newer paediatric weight estimation systems be use in adults
    Oluromini Akinola; Michael Wells; Pano Parris; Lara Goldstein
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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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    A brief history of South Africa's response to Aids
    (2014) Simelela, N.P.; Venter, W.D.F.
    The story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile system to bring about change.
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    Career choice of anaesthetists in a department of anaesthesiology at tertiary institution in South Africa
    Grace Manjooran; Juanett Scribante; Helen Perrie; Cara Redelinghuys
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    Challenges in recruiting children to a multidrugresistant TB prevention trial
    S Purchase; E Batist; N Mmile; S Nkosi; J Workman; Neil Martinson; Lee Fairlie; H. S. Schaaf; et al et al
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    The challenges of managing breast cancer in the developing world- a perspective from sub- Saharan Africa
    (2014-05) Edge, J; Buccimazza, I; Cubasch, H; et al.
    Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.
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    Charting the path along the continuum of PMCT or HIV-1 to elimination and finally to eradication
    (2014-01) Ramkissoon, A; Coovadia, H
    In this editorial we traverse the continuum of transmission of HIV-1 from mothers to children to highlight the biomedical history of this problem. Treatment has progressed from prevention with antiretrovirals (ARVs) through to a broader set of interventions, including various breastfeeding options and other health system improvements, that have increased the possibility of eliminating mother-to-child-transmission (MTCT) of HIV.
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    Clients experiences utilizng a safer conception service for HIV affected individuals implications for differentiated care service delivery models
    Sheree Schwartz; Natasha Davies; Nicolette Naidoo; Diantha Pillay; Nokuthula Makhoba; Saiqa Mullick
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    Clinical access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis
    (2014-03) Conradie, F; Meintjies, G; Hughes, J; et al
    While clinical disease caused by drug-sensitive Mycobacterium tuberculosis (MTB) can usually be treated successfully, clinical disease caused by drug-insensitive MTB is associated with a poorer prognosis. In December 2012, a new drug, bedaquiline, was approved by the US Food and Drug Administration. This article documents the process whereby the National Department of Health, Right to Care and Médecins Sans Frontières obtained access to this medication for South Africans who might benefit from subsequent implementation of the Clinical Access to Bedaquiline Programme.
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    Clinicopathological characteristics among South African women with breast cancer receiving antiretroviral therapy for HIV
    Boitumelo Phakathi; Herbert Cubasch; Sarah Nietz; Caroline Dickens; Therese Dix-Peek; Maureen Joffe; A Neugut; J Jacobson; Raquel Duarte; Paul Ruff
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    Congenital Rubella Syndrome Surveillance in South Africa using a sentinel site approach A crosssectional study
    Nkengafac Villyen Motaze; Jack Manamela; Sheilagh Smit; Helena Rabie; Gary Reubenson; Daynia Ballot; David Moore; E et al; Cheryl Cohen; Melinda Suchard