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A 15 -Year Review of Multiple Myeloma in HIV-1 Seropositive Patients at Chris Hani Baragwanath Academic Hospital
(University of the Witwatersrand, Johannesburg, 2024) Baxter, Jayson McNeil
Background: Multiple Myeloma (MM) is a haematological malignancy characterized by the malignant proliferation of plasma cells in the bone marrow and manifesting with skeletal related events as the clinical and radiological hallmark of the disease. The incidence of MM varies substantially across the different continents, with intermediate rates being encountered in Africa. MM occurs more commonly in people of Afro-Caribbean descent, with the incidence being 2-fold higher in African Americans compared to Caucasians. In South Africa, prior to the advent of and impact of HIV, MM was the most common haematological malignancy in adults. However, since 2002, Non-Hodgkin Lymphoma (NHL) has superseded MM, with MM being the second most common haematological malignancy encountered in adults, currently. At Chris Hani Baragwanath Academic Hospital (CHBAH), MM has been a stable disease since the 1970’s, with a noticeable increase in numbers since 2016. MM is characteristically a disease of middle-aged and elderly individuals. In the Western world, ninety-eight percent of cases occur over the age of 40 years with a peak in incidence in the seventh decade. The median age at diagnosis is 66 years. However, in Africa, the disease presents at a younger median age (approximately 5-10 years younger), with 7% of the patients being under the age of 40 years. In 2020, globally there were 36 million adults with HIV-1 of which 67% were living in sub- Saharan Africa. Women accounted for 63% of all new HIV-1 infections, compared to men with 37%. South Africa has the highest number of HIV-1 sero-positive individuals in the world and is home to approximately 8 million people living with HIV (PLWH). In South Africa, HIV has reached epidemic proportions and is impacting on a number of haematological malignancies, including MM. This study was undertaken to better characterize and describe the demographics, clinical, laboratory and radiological findings of patients presenting with HIV-1 sero-positivity and concomitant MM in our patient population. In addition, it describes the therapy, response to therapy, outcome and survival of the patients with this association. b. Patients and Methods: This is a retrospective study of all adult patients with a confirmed diagnosis of MM, together with HIV-1 sero-positivity, seen at the Clinical Haematology Unit, Department of Medicine, from January 2006 to December 2020 (15 years). Demographic, clinical, radiological and therapeutic data was retrieved from the patient files and laboratory data from the NHLS data base. Data was processed in Microsoft Excel and the appropriate statistical software was used to analyse the results. Descriptive analysis was conducted through the computation of frequency tables for categorical variables and appropriate measures of central tendency, i.e., mean, ± SD/median and (IQR), for continuous variables. Kaplan-Meier survival curves were plotted to determine the survival probability of the patients based on the clinical, laboratory and treatment characteristics. c. Results and Discussion: During the study period (01/01/2006 to 31/12/2020 – 15 years), a total of 601 patients were diagnosed with MM. 84 patients were HIV-1 seropositive (14%). Of these 84 patients, 14 were excluded. A total of 70 evaluable HIV-1 seropositive patients were included in this study (12%). Of these 70 patients, there were 42 females and 28 males with a female to male ratio of 1.5:1. The mean age for females was 49.9 years (range 31-77 years), and males was 50.6 years (range 36-73 years), while the mean age for the whole group was 50.2 years (range 31-77years). All the patients in the study were of Black African ethnicity, in keeping with the demographic of CHBAH, where >90% of the patients admitted to the hospital are of Black African ethnicity. The pertinent findings in this study were the following: 1. An increase in the number of MM patients from 165 (2006-2010) and 168 (2011-2015), to 268 (2016-2020), in the latter five years of the study. A corresponding increase in HIV seropositivity of 10.9% (2006-2010) and 10.1% (2011-2015), to 18.3% (2016-2020) in the latter 5 years of the study, with a background seroprevalence in Gauteng of 14.9% (2005) to14.4% (2008) and 18.8% (2012) to 18.7% (2017), 2. A younger mean age of 50 years, with a female predominance of 1.5:1, 3. More than half the patients (54.7%) had an ECOG PS ≥2, 4. Bone pain and anaemia were the dominant clinical features, 5. A higher proportion of cytopenias, including leucopenia, neutropenia and thrombocytopenia was noted in the study population compared to other studies done locally at CHBAH on MM. 6. Plasmacytomas were evident clinically in 29% of patients and radiologically in 52% of patients. 7. Biochemical features of note were: hypercalcaemia in 56% of patients, renal dysfunction in 33% of patients, hypoalbuminaemia in 65% of patients and an elevated B2M level in 96.3% of the patients. The mean CD4 count was 367 cells/ul, with a range of 23-964 cells/ul. Approximately a quarter of the patients (26.1%) had a CD4 count <200 cells/ul, 8. IgG isotype (74%) was the most common subtype of MM, 9. Lytic lesions were found in up to 77% of the patients on CT scan, with vertebral compression fractures being present in 77% of patients on MRI. 10. Most patients had advanced stage of disease, with DS stage III in 92% of the patients and ISS stage III in 70% of the patients. 11. Specific therapy in the form of chemotherapy (different combinations of cytotoxics, corticosteroids and immunomodulatory agents such as thalidomide etc.) was administered to 76% of the patients. Furthermore, 34% had radiotherapy and only 6% had an ASCT, 12. Despite the use of cART and specific therapy, the overall outcome was poor, with a median survival of 5.64 months (Interquartile range 0.82-19.24 months), 13. Survival was statistically significantly better in those who received chemotherapy and/or radiotherapy compared to those who received supportive care only (p=<0.001) and those who had ISS stage I and II disease, compared to ISS stage III disease (p=0.006), and 14. Although survival was better in those who had a higher CD4 count (≥200 cells/ul versus <200 cells/ul) (p=0.081), and those who achieved at least a PR versus
A comparison of early onset pre-eclampsia and late onset preeclampsia
(2024) Joomratee, J.
Background: Early onset pre-eclampsia (EOPE) occurs before 34 weeks while late onset preeclampsia (LOPE) occurs after 34 weeks. The maternal and neonatal outcomes has are different with EOPE having a higher frequency of maternal and neonatal complications. Objectives To compare the clinical presentations, laboratory parameters, maternal and neonatal outcomes in women with EOPE and LOPE. Methods: This was a cross sectional prospective record review. Convenient sampling was performed every fifth day and recruited preeclamptic women that delivered at Chris Hani Baragwanath Academic Hospital (CHBAH) and Rahima Moosa Mother and Child Hospital (RMMCH). Descriptive statistics were employed. Results: There were 104 women of which 64 (61.5%) had EOPE and 40( 38.5%) had LOPE. A higher frequency of Posterior Reversible Encephalopathy Syndrome (P=0.040), blurred vision (P=0.009), headache (P= <0.001) eclampsia (P=0.011) and HELLP syndrome (0.004) was observed in EOPE. The number of still births (P<0.001), neonates with an APGAR of less than 7 at 5 minutes (p=0.001), and neonatal admissions (P= <0.001) were higher in EOPE. There was no difference in the outcome between the HIV positive and negative women Conclusion: With EOPE, end organs appear to be more severely affected than in LOPE. The HIV prevalence between the two groups was comparable
A comparison of percutaneous tracheostomy and of surgical tracheostomy in patients in the Neurosurgical ICU at Charlotte Maxeke Johannesburg Academic Hospital
(2024) Marais, Ruan
Introduction A tracheostomy is a surgically created opening in the anterior wall of the trachea through which a tube can be inserted. Egyptian hieroglyphic paintings that depict a tracheostomy procedure can be dated back to 3100 BC.1 Tracheostomy is a procedure that is commonly performed on Intensive Care Unit (ICU) patients and, with an increasing need for intensive care services, the number of patient referrals for tracheostomy will likely increase as well. Aim The purpose of this study was to compare various clinical characteristics of patients who received either a percutaneous tracheostomy (PT) or a surgical tracheostomy (ST) during their stay in the Neurosurgical Intensive Care Unit (NSICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Method A retrospective study of the records of all patients who underwent a tracheostomy procedure during their stay in NSICU at CMJAH between 1st January 2017 and 31st December 2020 was undertaken. Clinical information collected for all patients included age, gender, Glasgow Coma Score (GCS), Simplified Acute Physiology Score (SAPS II), duration of stay in NSICU before and after tracheostomy, duration of mechanical ventilation pre- and post-tracheostomy and in-NSICU actual mortality. Predicted mortality percentage for each patient was calculated from SAPS II. A Glasgow Outcome Score (GOS) was assigned to each patient on discharge from NSICU. Patients were allocated to one of two groups. Those who received PT were allocated to GroupPT while those who received ST were allocated to GroupST. The percentage case fatality risk for each tracheostomy group was calculated. Results Of the 66 patients who underwent a tracheostomy procedure during the study period, 19 patients (28.8%) fell into GroupPT. The remaining 47 patients (71.2%) fell into GroupST. The median age of GroupPT was 28 years with lower and upper interquartile range (IQR) of 25 and 32 years, respectively. The median age of GroupST was 40 years (IQR 31, 54). This difference was statistically significant (p < 0.05). The median SAPS II score for Group PT was 41 (IQR 29, 47) and that of Group ST was 44 (IQR 30, 50). This difference was not significant. There were no differences in GCS, duration of stay in NSICU, number of days of mechanical ventilation pre- or post-tracheostomy procedure, actual mortality or GOS between the two groups. Conclusion In this group of 66 patients ST was the commoner of the two procedures performed. Even so, the findings of this study suggest that PT is a suitable procedure that may be performed safely on patients in the NSICU.
A comparison of rebound and applanation tonometry in anaesthetised children with and without Primary Congenital Glaucoma: A cross-sectional comparative study
(University of the Witwatersrand, Johannesburg, 2024) Kruger, Hester
Intraocular pressure (IOP) measurement should be accurate in a paediatricpopulation with primary congenital glaucoma. Aim To investigate the difference between the change in IOP measurements using rebound tonometry (RBT) and handheld applanation tonometry (Perkins Applanation Tonometer / PAT) in patients with and without primary congenital glaucoma (PCG). Setting Soweto, South Africa. Methods Demographic data, including age and gender was analysed. IOP measurements were done under anaesthesia, using RBT and PAT at 0, 5 and 10 minutes after induction and prior to intubation. Corneal pachymetry and corneal diameters were measured. Results 65 children were included, 19 with PCG and 46 without PCG. The mean age (SD) was 3.2 (2.27) and 4.8 (2.42) years respectively. The overall mean difference in IOP between RBT and PAT across both PCG and non-PCG groups was found to be 4.92 mmHg (95% CI 2.80 – 7.03) p <0.001, with RBT having higher readings. This difference was greater in the PCG group, with the IOP difference of 9.05 mmHg (95% CI 2.6 – 15.5) p=0.004. Mean corneal pachymetry (SD) was 585.6 (81.48) μm in the PCG group and 518.31(39.90) μm in the non-PCG group. Univariate analysis showed that IOP was significantly related to corneal pachymetry, with a 11 mmHg increase in IOP for every 100 μm change in corneal thickness for measurements done with RBT (p<0.001), compared to 4mmHg using PAT. (p=0.008). Mean horizontal corneal diameter (SD) was 13.95(1.24) mm in the PCG group, compared to 11.09(0.32) mm in the non PCG group. Conclusions IOP measurements done with RBT in children with and without PCG were overestimated compared to PAT. This difference was more pronounced in PCG patients. In addition, IOP was significantly related to corneal thickness.
A comparison of the warming capabilities of two Baragwanath Rewarming Appliances with the Hotline® fluid warming device
(2024) Wilson, Kyle
Background: Accidental intraoperative hypothermia is a common and avoidable adverse event of the perioperative period and is associated with detrimental effects on multiple organ systems and postoperative patient outcomes. In a resource limited environment the prevention of intraoperative hypothermia is often challenging. Resourceful clinicians overcome these challenges through creative devices and frugal innovations. This study aims to investigate the thermal performance of two such Baragwanath Rewarming Appliances (BaRA) against that of the Hotline® in an attempt to describe an optimal setup of these devices. Methods: This was a quasi-experimental laboratory study that measured the thermal performance of two BaRA devices and the Hotline® under a number of scenarios. Independent variables fluid type, flow rate, warming temperature and warming transit distance were sequentially altered and temperatures measured along the stream of fluid. DeltaT was calculated as the difference between entry and exit temperature for each combination of variables for each warming device. Results : A total of 219 experiments were performed. The BaRA A configuration at a temperature of 43ºC with a transit distance of 200 cm either matched or exceeded the DeltaT of the Hotline® over all fluid type and flow rate combinations. The BaRA B configuration does not provide comparable thermal performance to the Hotline®. Measured flow rates were noticeably slower than manufacturer quoted values for all intravenous (IV) cannulae used. Conclusion: A warm water bath at 43ºC with 200 cm of submerged IV tubing provides thermal performance comparable to the Hotline, with all fluid type and flow rate combinations.
A cross-sectional study investigating knowledge, attitudes and health choices in relation to diabetes mellitus among nondiabetic patients attending Chiawelo community practice, Soweto, Republic of South Africa
(2024) Tshibeya, M. R.
Background: The knowledge, attitudes and health choices of non-diabetic patients in resourcelimited settings to prevent the onset of diabetes mellitus (DM) are poorly understood. Aim: The aim of this study was to investigate and describe the knowledge, attitudes and health choices of non-diabetic patients in relation to DM at the Chiawelo Community Practice (CCP), Soweto, South Africa. Methods: In this cross-sectional study, a self-reported questionnaire was administered to 165 adult participants attending the CCP from 2nd March to 17th April 2020. Descriptive analysis, Chi square and univariate logistic regression were included in the analysis. Multivariate analysis was done for variables with a p-value <0.25 Results: In total, the study had 165 participants, of whom 112 (68%) were women, 35% were older than 45 years and 16% were younger than 25 years of age. Almost half (49%) of participants had good knowledge of DM, with 60% indicating good attitudes and 52% making good health choices to prevent DM. Participants who received education from clinicians were 4.31 times more likely to develop better attitudes (p=0,003) and 3.34 times more likely to adopt better health choices (p=0.004) towards DM compared to those who obtained information from media or other sources. Conclusion: The study found that poor knowledge of DM does not necessarily translate into poor attitude towards the disease, which is noteworthy. The study also highlighted the important role of healthcare workers in influencing behaviour change
A Descriptive Study of MRI Findings of Children with Suspected Hypoxic Ischaemic Injury at a Tertiary Academic Hospital in Johannesburg, South Africa
(University of the Witwatersrand, Johannesburg, 2024) Lorentz, Liam; Mahomed, Nasreen
Background: Hypoxic ischaemic brain injury and its clinical sequalae present a global health burden. MRI is the imaging modality of choice to investigate hypoxic ischaemic injury. As there is limited data from low and middle-income countries describing MRI findings of children with suspected hypoxic ischaemic brain injury, we describe the MRI findings of children with suspected hypoxic ischaemic brain injury in a resource-limited setting. Materials and methods: MRI studies performed for children under the age of 15 years, with clinically suspected hypoxic ischaemic injury were retrospectively evaluated over a 2- year period. A simplified MRI classification of injury, with a final, majority consensus reading was used at the data analysis phase. The 3 readers were blinded to each other and all clinical details, except for age. All clinical information available at the time of MRI was collated by the principal investigator, who was not an imaging reader. Results A total of 128 MRI studies were evaluated. MRI evidence of hypoxic ischaemic injury was found in 42.2% of children. Normal MRI findings were present in 41 (32.0%) children; and punctate periventricular white matter injuries in 19.5%, watershed injury in 3.1%, central injury in 10.2% and diffuse injury in 23.4% of MRI studies. Preterm infants more commonly demonstrated periventricular white matter injury. Conclusion: Periventricular white matter pattern of injury was the most common type in premature infants, congruent with international cohorts. Despite the majority of children with suspected hypoxic ischaemic injury being imaged beyond the infant period, MRI findings may have implications for medicolegal recourse
A fifteen year review of chronic lymphocytic leukaemia in adults, at Chris Hani Baragwanath academic hospital
(University of the Witwatersrand, Johannesburg, 2024) Khosa, Cain Mikateko
Background: Chronic Lymphocytic Leukaemia (CLL) is one of the four common types of leukaemia encountered in adults. CLL is characterized by the clonal proliferation and accumulation of small, mature, neoplastic, CD-5 positive, B-lymphocytes in the blood, bone marrow and lymphoid tissues. There are geographical variations in the incidence of CLL worldwide, with CLL being the commonest form of leukaemia in some parts of Europe and the Western World. The median age at diagnosis is approximately 70 years, with less than 10% of patients presenting under 45 years of age. Most studies show a male predominance of 1.5-1.9:1. While the incidence in Europe is similar to that reported in the United States, the incidence is lower in Asia and Africa. Moreover, in Africa, the disease tends to present in individuals who are 5-10 years younger, primarily because of the younger age structure of the African population. At Chris Hani Baragwanath Academic Hospital (CHBAH), CLL ranks 5th in order of frequency, amongst the haematological malignancies that are encountered in adult patients. Based on a small study done at CHBAH in 1994, the disease presents at a younger median age of 63 years, with a male predominance of 1.5:1. Although CLL is generally a stable disease at CHBAH, there has been a noticeable increase in the number of patients by 1.5 fold, from 2015 to 2019. This study was undertaken to better characterize and describe the demographics, clinical and laboratory features, staging and treatment outcome of adult patients with CLL, seen at our centre over a 15 year period. b. Patients and Methods: This was a retrospective study of all adult patients with a confirmed diagnosis of CLL, seen over a 15 year period (01/01/2005 to 31/12/2019), at the Clinical Haematology Unit, Department of Medicine, CHBAH (15 years). Demographic, clinical, and therapeutic data was retrieved from the patient files and laboratory data from the NHLS data base. Data was obtained retrospectively from patient files, captured onto a data sheet and entered onto an Excel spread sheet prior to statistical analysis, using a programme such as Stata/Statistica (and/with the assistance of a statistician). The patient demographics were summarized using descriptive statistics for dependent variables that are normally distributed, including means and standard deviations. For comparisons between normally distributed variables, a Student t-test was be used. For comparing the different staging systems, a Chi squared test was used. Where a comparison was required in more than two groups, the Anova test was used. When data was not normally distributed, the Mann-Whitney or Kruskal-Willis test was used for correlation between variables. For the purpose of statistical analysis, a 95% confidence interval, with a p-value (p<0.05) was considered significant c. Results and Discussion: The key findings in this study were: 1. A stable number of patients in the first ten years of the study (01/01/2005 to 31/12/2014), with a 1.5 fold increase in the latter 5 years of this study (2015-2019). 2. A younger median age of 64 years, with a male predominance of 1.87:1. 3. Most of the patients were symptomatic, with an ECOG PS ≥1 in 92.8% of the patients. 4. Fatigue (49.2%), loss of weight (47%) and fever (43%) were the most common symptoms at presentation. 5. Lymphadenopathy was the dominant physical sign (91.2%). Hepatosplenomegaly was evident in 49.2% of the patients. 6. The vast majority of patients had anaemia (82.9%), with a mean haemoglobin of 9.44 g/dl. The mean white cell count and lymphocyte counts were 173 x109/l and 158.7 x 109/l, respectively. The mean platelet count was 155 x 109/l. Clinical thrombocytopenia was present in 37% of the patients. 7. More than half the patients presented with advanced stage/high risk disease, with a Rai stage III and IV accounting for 62.5% and Binet C for 56.4% of the patients at presentation. 8. A diffuse pattern of bone marrow infiltration, indicating adverse prognosis was evident in 89.5% of the patients. 9. Cytogenetics showed a favourable genotype (13q) in 43%, an intermediate phenotyope (trisomy 12) in 31.7% and an unfavourable phenotype (11q and 17p) in 14% and 11%, of the patients, respectively. 10. HIV sero-positivity was present in 8.8% of the patients, with sero-positive patients showing a number of differences, including a younger median age at presentation, a more marked male predominance, similar clinical presentation and staging of the disease, a higher proportion of TB, hepatitis B and C, and a lower mean survival, with a similar median survival. 11. Supportive care only was offered to 22.7%, while chemotherapy was administered to 69% of the patients. 12. The outcomes of the patients at the end of study were: i) Lost to follow up (65.2%), ii) Deceased (31.5%) and Alive (3.3%). 13. The mean survival for the whole group was 32 months, with a median survival of 6 months, while for the HIV sero-positive group the median survival was 20 months, with a median survival of 6 months. d. Conclusions and future recommendations: Based on the findings of this study, the following conclusions and future recommendations are suggested: Education with regard to the key clinical manifestations of CLL, early suspicion of the possible diagnosis and timeous referral to a tertiary or specialized centre, so that the diagnosis can be confirmed and appropriate treatment (where indicated), can be initiated as soon as possible. Every effort should be made to improve compliance and attendance at follow up visits. This is vital in order to assess response to treatment and to detect early relapse or progression of the disease. Efforts to improve accessibility of ‘state of the art’ and novel therapies for public sector patients should be prioritised and ongoing. Prospective, randomised, multi-centre studies should be performed to assess the benefits of various therapeutic options and to compare existing therapies with novel treatment options in our local South African patient population (including both the private and public sector). Although HIV sero-positivity is not a major problem, the numbers of sero-positive patients is steadily increasing, with a doubling of the number in the latter 5 years, compared to the first 10 years of the study. In principle, these patients should be offered the same treatment options as HIV-1 sero-negative individuals, with the proviso that every attempt is made to achieve optimal virological suppression and immune reconstitution, with combination anti- retroviral therap
A Multicenter Retrospective audit on the treatment modalities of sternal sepsis: A 10-year review
(University of the Witwatersrand, Johannesburg, 2024) Phalafala, Refilwe Palesa Mokgadi; Ndobe, Elias; Fru, Pascaline
Background: Mediastinitis is a life-threatening complication, of a septic sternal wound. The key treatment is for early radical debridement and adequate reconstruction. The aim of this study was to perform a comparative review of the management modalities undertaken on patients with sternal sepsis from 2007–2017 at one public and two private surgical practices in Johannesburg, South Africa. Methodology: The study was a retrospective series of 120 chronologically selected patients from three hospital units (40 from each unit): The Cardiothoracic Unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH - public) and two private plastic surgery practices within Netcare Milpark Hospital (NMH). The patients were categorized into three groups: 1) Vacuum-Assisted Closure (VAC), 2) VAC and reconstruction (muscle flaps or alloplastic material) and 3) reconstruction alone (muscle flaps or alloplastic material). Results: Of the120 patients, the median age, was 58yrs (19yrs – 89yrs). Hypertension was the most common comorbidity. Patients in NMH were more likely to undergo VAC dressing for a shorter period. Patients in NMH were more likely to be reconstructed with a flap (44%, n=35/78), of which the bilateral pectoralis major flaps (19%, n=43) was more frequent. Out of the 120 patients, 61% had one debridement and VAC therapy as a temporizing modality prior to reconstruction. CMJAH had a higher mean length of hospital stay of 41 days and re-do operations 27% (n=11/40) compared to NMH which had a mean hospital stay of 31 days and a re-do operations of 16% (n= 13/78). Plastic surgeons were more likely to be involved in initial debridement’s in NMH 96% (n=32/33) compared to CMJAH with 3% (n= 1/33). Conclusion: NMH, private hospital, demonstrated to have statistically significant better outcomes with a shorter hospital stay compared to its counterpart CMJAH, public hospital, with regards to management of sternal sepsis. NMH, showed a shorter VAC dressing period to be an effective temporizing modality, however the most efficient management of, sternal sepsis, would be to involve a plastic surgeon early on for radical and fewer number of debridements, and early reconstruction. The bilateral pectoralis major flap was the option of choice in this study. The incidence of sternal sepsis from both hospitals was in keeping with international rates.
A Phenomenographic study of Clinician Educators' conceptions of clinical medical students' vocational habitus
(University of the Witwatersrand, Johannesburg, 2024) Bocchino, Loredana
Background: Many medical educators have expressed concern about producing the ‘right kind of doctor’, noting that students’ professional identities are not always aligned with societal and professional expectations. The concept of habitus, whilst similar to identity, offers a more complex understanding of the process of ‘becoming’ inherent in vocational training, in that it can both shape students’ educational experiences as well as be shaped by them. There is currently little literature addressing clinicians’ perceptions or experiences of medical students’ vocational habitus. Methods: To explore the ways clinician educators understand clinical medical students’ vocational habitus, a phenomenographic study was undertaken in which fourteen semi- structured interviews were conducted with clinician educators from various clinical departments. Findings: Four conceptions of student vocational habitus were identified: 1) the Dependent Spectator, 2) the Interested Fledgling, 3) the Independent Contributor, and 4) the Interdependent Altruist. Conceptions were characterised by seven dimensions of variation: attitude to learning, communication skills, fortitude, values, professionalism, technical competence and relationship to technology. Two associated factors in the field were repeatedly reported that provide important context for the interpretation and development of these conceptions: failure to fail, and fitness for purpose of assessments. Conclusion: Different conceptions exist about clinical medical student vocational habitus, with the narrowest conceptions viewing students as ‘not right for the job’. There is dissonance between clinicians’ general perceptions of students’ habitus, and the idealised expectation. The progressive development of these conceptions along the continuum is likely shaped by the identified associated factors within the field, and other potential factors such as program characteristics, the hidden curriculum, or focus on research versus clinical service delivery.
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.
A retrospective audit of the cytogenetic profile and management outcome in Acute Myeloid Leukemia patients treated at Charlotte Maxeke Johannesburg Academic Hospital (2017 - 2021)
(University of the Witwatersrand, Johannesburg, 2022) Mpanza, Mbongi V.; Ruff, P.
Acute Myeloid Leukemia (AML) is a highly heterogenous blood cancer that affects the non- lymphoid lineage. It is a most common acute leukemia in adults. The worldwide incidence is relatively low with inordinately high cancer mortality. The recent advances done by on-going research has elevated our understanding of cytogenetic and abnormalities associated with AML. This understanding further aids in stratifying AML patients into favourable, intermediate, and poor prognosis groups. However, despite these insights into disease, patient outcome often remains poor. In this review, we discuss findings in AML at CMJAH, with particular focus into cytogenetic profile and molecular gene mutations. These recurrent genetic alterations provide novel insights into the pathogenesis, clinical characteristics, and outcome of these patients. These alterations play a major role in prognosticating the outcome in AML and are also important in developing novel therapies. The most common type of AML, called de novo AML, occurs sporadically with no prior history of underlying myelodysplastic syndrome (MDS), myeloproliferative neoplasms (MPN) or exposure to potentially leukaemogenic therapies or agents. The less common is secondary AML which has poorer prognosis and is define as any leukemic process which may arise from previous haematological disorder like MDS, NPM or can be a result of prior cytotoxic chemotherapy or radiation therapy (t-AML).T-AML is defined as AML that develops from prior cytotoxic drugs, radiation or immunosuppressive agents which was given for unrelated illness. T-AML accounts for 7%-8% of all AML and is known to have a dismal outcome with an adverse cytogenetic and molecular profile. To our current knowledge there is no local study that has previously analysed t-AML in detail hence this study may provide such critical data.
A retrospective descriptive study of demographics, treatment modalities and outcomes of childhood immune thrombocytopenia at a tertiary hospital in Soweto, South Africa
(University of the Witwatersrand, Johannesburg, 2023) Mahlalela, Gcebile; MacKinnon, D
Background: Primary immune thrombocytopenia (ITP) is an autoimmune mediated disorder and is the most common cause of acquired thrombocytopenia in childhood. Many children will recover spontaneously but treatment may be required to prevent life threatening bleeding. There are controversies regarding treatment options, response rates and predictors of remission in childhood ITP. Objectives: A retrospective review of demographics, treatment modalities and outcomes of children diagnosed with immune thrombocytopenia at a tertiary hospital Methods: Patient records of children between the ages 0-16 years, diagnosed with ITP at Chris Hani Baragwanath Academic Hospital from 01 July 2010 to 30 June 2020 wereretrieved. Data on demographics, clinical presentation, treatments, and outcomes were collected. Outcomes were measured at 1, 3- and 12-months follow-up. Statistica software was used to perform descriptive statistics, and bivariate analyses and logistic regression. Results: 80 files were reviewed but 5 patients were lost to follow-up at 1 month. At 12 months, many patients had been lost to follow-up, with only 35 patients remaining. The mean age at diagnosis was 6.3 years, with 80% of patients less than or equal to 10 years of age. In the study group, 16.3% patients did not receive pharmacologic treatment, and all of these went into remission except one patient lost to follow-up. Younger age, ≤ 10 years was associated with higher rates of remission for all 3 follow-up intervals. Corticosteroids was the most common treatment used and a large proportion of the patients in remission at 1, 3 and 12 months received corticosteroids. The likelihood of remission with a preceding illness in the whole study group was higher, with odds ratios of 2.81, 2.03, and 2.97 at 1, 3, and 12 months respectively. Platelet count, sex and haemoglobin at diagnosis had no significant association with remission. Conclusions: A strategy of watchful waiting can be used in the management of childhood ITP. Younger aged patients with a preceding illness had the highest likelihood of remission, while other predictors showed no significant association with remission. There are no significant differences between our population and the population described in the literature.
A retrospective study of the epidemiology, management and outcomes of patients with dialysis-requiring acute kidney injury, over a 24-month period, at Helen Joseph Hospital, Johannesburg, South Africa
(University of the Witwatersrand, Johannesburg, 2024) Naidu, Yashika
Background Dialysis-requiring acute kidney injury (AKI) carries significant morbidity and mortality. A cohort of patients was reviewed at Helen Joseph Hospital (HJH) to contribute to local knowledge on the epidemiology, referral patterns, and outcome of dialysis-requiring AKI. Methods A retrospective review was conducted of patients receiving dialysis for AKI at HJH between 1 January 2019 and 31 December 2020. Patient demographics and aetiologies of AKI were described. Effects of baseline characteristics and aetiology of AKI on patient survival, duration of hospitalisation, and renal function recovery were analysed using Cox proportional hazards modelling and binomial regression analyses. Results Dialysis-requiring AKI occurred in younger median age. Human immunodeficiency virus (HIV) infection (38.7%), hypertension (27.4%) and diabetes mellitus (12.3%) were common comorbidities. Community-acquired AKI predominated with significant renal dysfunction at presentation. Leading causes of AKI were sepsis (51.9%) and hypovolaemia (26.4%). Mortality was high (56.6%). Age and diabetes increased mortality and reduced renal recovery. Sepsis (HR 1.48, 95% CI 1.37–1.60, P < 0.001) and cardiorenal syndrome (CRS) type 1 (HR 1.78, 95% CI (1.57–2.01, P < 0.001) increased mortality. HIV infection did not increase the risk of mortality and showed an increased likelihood of renal recovery (OR 1.71, 95% CI 1.51–1.95, P < 0.001). Chronic kidney disease was prevalent in survivors. Conclusion Results resemble that of other low- and middle-income countries. People living with HIV may be at increased risk of dialysis-requiring AKI. AKI carries a high mortality rate. Sepsis and CRS carry an increased risk of death; sepsis-associated AKI and comorbid diabetes are associated with reduced odds of renal recovery to dialysis-free levels.
A Review of HIV-Positive Patients at Chris Hani Baragwaneth Hospital on Third Line Antiretroviral Therapy
(University of the Witwatersrand, Johannesburg, 2024) Brozin, Daniel; Van Blydenstein, Sarah Alexandra; Venter, Michelle
In South Africa’s battle against the Human Immunodeficiency Virus/Acquired Immune Deficiency Virus (HIV/AIDS) epidemic, the ability of patients to readily access antiretroviral therapy (ART), has led to a significant reduction in mortality due to AIDS associated diseases. As per the Joint United Nations Program on HIV/AIDS (UNAIDS), there are approximately 7.5 million people in Sub-Saharan Africa with HIV/AIDS. Of this subset, approximately 7 million people are aware of their status, with 5.5 million people currently on ART, and approximately 5 million people with an undetectable viral load. As we have more patients who are on first-line ART for a longer period, we are experiencing an increasing rate of treatment failure, with patents having to undergo regime switches, often to Protease Inhibitor (PI) based second line regimens, As a result of more patients being on PI-based regimens for longer periods of time, a subset of patients with virological failure on second-line treatment has emerged. These patients require more costly and clinically challenging third-line therapy regimens (1) . As one spends a longer period of time on a particular regime, in the setting of non-compliance, which will create a ‘non-suppressed state‘ or low level viraemia, the inevitability of an accumulation of mutations to standard ART will increase. Studies done investigating the reasons for treatment failure in the South African context have provided many explanations concerning the above-mentioned issu
A Review of the Use of CT Pulmonary Angiography in Pregnant and Postpartum Patients at an Academic Centre
(University of the Witwatersrand, Johannesburg, 2024) Herbst, Wilhelm; Zamparini, Jarrod; Moodley, Halvani; Bhoora, Shastra
The most common cause of maternal death during pregnancy and the puerperium in developed countries is venous thromboembolic events, including pulmonary embolism (PE).1 The risk for venous thromboembolism (VTE) is significantly increased during pregnancy and the postpartum period, as these patients are in a state of hypercoagulability, are prone to venous stasis and may have superimposed endothelial damage.2 Data has shown that women have a 5-fold increased risk of developing VTE during pregnancy, as compared to their non-pregnant counterparts,3 and, according to a Scottish study, the incidence of antenatal VTE has increased over the last 26 years.4 Past research has observed an incidence of PE in pregnant or postpartum women of 3 in 10,0002,5, with one death in every 100,000 deliveries.6 Some studies have found an absolute incidence of VTE in pregnancy to be as high as 1 to 2 cases per 1000 pregnancies3; a risk that is nearly five times higher than that among non-pregnant women.7 More than half the cases of VTE in pregnancy occur in the first trimester, before 20 weeks’ gestation.5 Yet, 80% of VTE cases in the postpartum period have been observed to occur within the first 3 weeks following delivery.8 Recent studies haveM revealed a raised relative risk (however low absolute risk) that remains up to 12 weeks following delivery.9 A large meta-analysis and systematic review of seventeen studies, which included 25,339 patients, found that 2% of patients presenting to the emergency department with symptoms suggestive of PE, were pregnant.10 This translates to a 12.4% positivity rate for VTE in nonpregnant patients, compared with 4.1% in pregnant patients.10 The perceived lower yield of confirmed VTE in pregnancy can be ascribed to the low threshold physicians have to scan pregnant patients, due to the high risk of devastating sequelae of PE in pregnancy
A study to determine the causes of death in neonates weighing <1500g at Kleksdorp Hospital
(2024) Mwala, Nalishebo
Background: The continuing challenge of neonatal mortality in very low birth weight (VLBW) neonates in South African hospitals highlights the need to better understand the causes of these deaths as well as their associated modifiable factors. Objectives 1. Determine the causes of death and factors that contribute to death in VLBW neonates at Klerksdorp Hospital (KH) 2. Determine key modifiable factors to improve the survival of VLBW neonates at KH. Methods: Retrospective, descriptive study based on the review of 183 patient records (100 who survived and 83 who died) between January 2015 to December 2016. The study population is from the neonatal unit at a secondary hospital in the North-west province of South Africa. The unit consists of eight beds with ventilatory support. Fifty-five Perinatal Problem Identification Program (PPIP) forms were audited to determine causes of death and associated modifiable factors. Logistic regression analysis was used to determine predictors of death. Results: The most common causes of death were 1) sepsis (24%), 2) extreme multiorgan immaturity (20%) and with the most vulnerable neonates born between 26 and 32weeks’ gestation. An increase in birthweight is shown to incur protection against death (OR 0.993, CI 0.989-0.996, p = 0.000). Key predictors of death are metabolic acidosis during the course of their NICU admission (OR 17.785, CI 4.711-67.145, p = 0.000) and hypotension-requiring-inotropes (OR 26.074, CI 5.403-125.827, p = 0.000) secondary to septic shock. Critical modifiable factors include preventing nosocomial sepsis (18%), timely initiation of antenatal care (12%) and improving timeous health seeking behaviour (10%), administration of antenatal steroids (6%) and availability of adequately trained medical personnel (6%). Conclusion: Sepsis is the leading cause of death in very low birth weight neonates. Its complications in the form of metabolic acidosis and septic shock requiring inotropic support are key predictors 2 of 2 of death. Seventy seven percent the deaths occurred in the first week of life, highlighting a vital window for intervention. Key modifiable factors pertain to medical and patient factors. Barriers that may preclude this lie in the poor socio-economic setting of the population that is mostly peri urban with constrained resources.
A Survey of Caudal Anaesthesia practice in an academic anaesthesia unit
(University of the Witwatersrand, Johannesburg, 2022) Julius, Sepheu Letshokge; Mamoojee, Anisah; Mogane, Palesa
Background Caudal blockade is a means of providing intra and postoperative analgesia and minimises the sympathetic stress response to abdominal and lower limb surgery. Clear anatomical landmarks and ease of performing the procedure make it one of the most commonly performed regional techniques in the paediatric population. Methods A prospective, contextual, descriptive study was conducted between 2020 and 2021 on anaesthetists working in an academic anaesthesia unit. Data was collected anonymously through a digital questionnaire and participation was voluntary. Results The study sample is made up of 40 consultants and career medical officers (27%), 87 registrars (61%), 15 medical officers (10.6%) and two community service medical officers (1.4%). Plain bupivacaine at 2.5mg/kg was found to be the local anaesthetic of choice. Most participants,90 (63.1%), did not use an adjunct in their caudal blocks, with the risk of excessive sedation and risk of postoperative apnoea being the most frequently cited reasons. Where an adjunct was used, the alpha-2 agonists; clonidine (64.5%) and dexmedetomidine (53.2%) were chosen. The majority,122 (85.1%), anaesthetists acquired consent specifically for caudal blocks. Potential complications of caudal blockade, the duration of analgesia and the technique of the caudal block were frequently discussed with patients and their caregivers when obtaining consent. Use of ultrasound is not in widespread practice, and block failure was reported by 91 (63.8%) participants. Paracetamol was the most regularly employed rescue analgesia. Conclusion This study found that the academic unit’s caudal blockade practice compared well with local and international literature. The use of adjuncts, ultrasound and caudal catheters is not a widespread practice, and clear guidelines may be beneficial in this regard. Use of standardised informed consent protocols may improve the patient and caregiver experience
A survey of current practice in anaesthesia for caesarean delivery in a Department of Anaesthesiology
(2024) Watermeyer, Benjamin David
South Africa has an increasing caesarean delivery (CD) rate and as such anaesthesia for CD has become a fundamental skill for all levels of anaesthetists. The Essential Steps in the Management of Obstetric Emergencies (ESMOE) guidelines provide a framework for practitioners with specific focus on dosage in neuraxial anaesthesia, perioperative fluids and management of hypotension. Aims The aim of this study was to describe the current practices of anaesthesia for patients requiring CD, including the management practices of common complications, within the University of the Witwatersrand Department of Anaesthesiology. Methods: A prospective, contextual and descriptive study design was followed using an anonymous, self-administered online questionnaire. Descriptive statistics were used to assess adherence to guidelines and comparison made between senior and junior anaesthetist’s practices. Results: Junior anaesthetists performed significantly more CD anaesthetics per month and had more training in ESMOE guidelines compared to senior anaesthetists. Senior anaesthetists were more likely to use a higher dose of bupivacaine. Phenylephrine as a first line anti-hypotensive agent was used by 99.4% of participants. The considered safe minimum platelet count for spinal anaesthesia was 75 x 10^9/l by 61.3% of participants. A significant difference between junior and senior anaesthetists was found where senior anaesthetists were more likely to accept a lower platelet count. A sensory level post administration of spinal anaesthetic was assessed by all participants with 53.1% using an ice brick and 35.0% requesting the surgeon to pinch the patient. Conclusion: In the Witwatersrand Department of Anaesthesiology anaesthetists do follow the ESMOE guidelines of clinical practice for CD. While there are some differences in practice approaches, these were found to be within internationally accepted practice. There would be a benefit of improved awareness of the ESMOE guidelines within the department as well as further training on the different approaches to CD anaesthesia.
A survey of postdural puncture headache management practices within an academic department
(2024) Monteith, Kathryn
Background: Postdural puncture headache (PDPH) is a common consequence of neuraxial anaesthesia, especially among parturients, in whom it is associated with maternal morbidity, prolonged hospital stay, and increased healthcare costs. Although international guidelines for PDPH management are available, variable management practices exist. There are no published studies which document current practices, nor guidelines available, with respect to PDPH management in South Africa. This study aims to describe PDPH management practices within the Wits Department of Anaesthesiology, which may assist in future local guideline or protocol development. Methods: An electronic questionnaire was distributed to the Wits Department of Anaesthesiology. The survey instrument was developed following a literature review targeting recent evidence based PDPH management guidelines, including the Obstetric Anaesthetists Association (OAA) guidelines from 2018, after which it was reviewed for content and face validity. Data were downloaded, analysed, and presented with the aid of statistical software. Participant responses were then compared to the OAA guidelines, which were considered the standard of practice. A score relating to this was determined and compared to demographic variables to assess for possible correlations. Results: Participants’ practice with respect to conservative management strategies and the performance of EDBPs was in keeping with the OAA guidelines, despite evidence of limited provider experience with performing these procedures, as well as the lack of available departmental guidelines. Ninety six percent of anaesthetists perceived they would benefit from the institution of formal guidelines. Conclusions: Management practices for the treatment of PDPH among anaesthetists within the Wits circuit are variable, but generally consistent with current international guidelines, however, limited experience in treating PDPH has been demonstrated. The development, and institution, of formal guidelines to assist in the management of PDPH is recommended, as well as continuous medical education of staff, to ensure good patient outcomes.

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