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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.
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.
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.
The impact of lower limb amputation on quality of life: a study done in the Johannesburg Metropolitan area, South Africa
(University of the Witwatersrand, Johannesburg, 2010-01-29T07:15:06Z) Godlwana, Lonwabo L.
Background: The impact of non-traumatic lower limb amputation on participant’s quality of life (QOL) is unknown. In an effort to provide better care for people with lower limb amputation, there is a need to first know the impact of this body changing operation on people’s quality of life. Aim of the study: To determine the impact of lower limb amputation on QOL in people in the Johannesburg metropolitan area during their reintegration to their society/community of origin. Objectives: 1. To establish the pre-operative and post-operative:  QOL of participants (including the feelings, experiences and impact of lower limb amputation during the time when they have returned home and to the community).  The functional status of participants.  Household economic and social status of these participants. 2. To establish factors influencing QOL. Methods: A longitudinal pre (amputation) test –post (amputation) test study utilized a combination of interviews to collect quantitative data and in-depth semi-structured interviews to gather qualitative data. Consecutive sampling was used to draw participants (n=73) for the interviews at the study sites pre-operatively. The three study sites were Chris Hani Baragwanath Hospital, Charlotte Maxeke Johannesburg General Hospital and Helen Joseph Hospital. Participants were then followed up three months later for post-operative interviews and key informants were selected for in-depth interviews (n=12). Inclusion criteria: Participants were included if they were scheduled for first time unilateral (or bilateral amputation done at the same time) lower limb amputation. The participants were between the ages of 36-71 years. Exclusion criteria: Participants who had an amputation as a result of traumatic or congenital birth defects were excluded from the study. Participants with comorbidities that interfered with function pre-operatively were not included. Procedures: Ethics: Ethical clearance was obtained from the Committee for Research on Human Subjects at the University of the Witwatersrand and permission was obtained from the above hospitals. Participants gave consent before taking part in the study. Instrumentation: A demographic questionnaire, the EQ-5D, the Modified Household Economic and Social Status Index (HESSI), the Barthel Index (BI) and semi-structured in-depth interviews were used. Data collection: Participants were approached before the operation for their preoperative interviews using the above questionnaires and then followed up postoperatively using the same questionnaires and some were selected to participate in semi-structured in-depth interviews three months later. Pilot study: The demographics questionnaire and the modified HESSI were piloted to ensure validity and reliability. iii Data analysis: Data were analyzed using the SPSS Version 17.0 and STATA 10.0. The significance of the study was set at p=0.05. All continuous data are presented as means, medians, standard deviations and confidence intervals (CI 95%). Categorical data are presented as frequencies. Pre and post operative differences were analyzed using Wilcoxon Signed-rank test. A median regression analysis (both the univariate and multivariate regression) was done to establish factors influencing QOL. Pre and post operative differences in the EQ-5D items and the BI items were analyzed using Chi square/Fischer’s exact depending on the data. Data were pooled for presentation as statistical figures in tables. Both an intension to treat analysis and per protocol analysis were used. A grounded theory approach was used to analyze the concepts, categories and themes that emerged in the qualitative data. Results: Twenty-four participants (33%) had died by the time of follow up. At three months, n=9 (12%) had been lost to follow up and 40(55%) was successfully followed up. The preoperative median VAS was 60 (n=40). The postoperative median VAS was 70. The EQ-5D items on mobility and usual activities were reported as having deteriorated significantly postoperatively (p=0.04, p=0.001respectively) while pain/discomfort had improved (p=0.003). There was no improvement in QOL median VAS from the preoperative status to three months postoperatively The preoperative median total BI score was (n=40). The postoperative median total BI score was 19. There was a reduction in function (median BI) from the preoperative status to three months postoperatively (p<0.001). The ability to transfer was improved three months postoperatively (p=0.04). Participants were also found to have a decreased ability to negotiate stairs (p<0.001). Mobility was significantly reduced three months postoperatively (p=0.04). During the postoperative stage (n=40), 38% of the participants were married. Most (53%) of the participants had no form of income. The highest percentage of participants in all instances (35%) had secondary education (grade10-11), while 25% had less than grade 5. Only one participant was homeless, 18% lived in shacks, 55% lived in homes that were not shared with other families. People with LLA in the Johannesburg metropolitan area who had no problem with mobility preoperatively (EQ-5D mobility item), who were independent with mobility (BI mobility item) preoperatively, who were independent with transfer preoperatively (BI transfer item) had a higher postoperative quality of life (postoperative median EQ-5D- VAS) compared to people who were dependent or had problems with these functions preoperatively. Being females was a predictor of higher reported quality of life compared to being male. Emerging themes from the qualitative data were psychological, social and religious themes. Suicidal thoughts, dependence, poor acceptance, public perception about body image, phantom limb related falls and hoping to get a prosthesis were reported. Some reported poor social involvement due to mobility problems, employment concerns, while families and friends were found to be supportive. Participants had faith in God. Conclusion: Participants’ QOL and function were generally scored high both preoperatively and postoperatively but there was a significant improvement in QOL and a significant reduction in function after three months although participants were generally still functionally independent. Good mobility preoperatively is a predictor of good QOL postoperatively compared to people with a poor preoperative mobility status. Generally, most participants had come to terms with the amputation and were managing well while some expressed that they were struggling with reintegration to their community of origin three months postoperatively with both functional and psychosocial challenges.
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.
Record review of patients with brain abscess and empyema.
(University of the Witwatersrand, Johannesburg, 2010-01-22T10:28:25Z) Schwenke, Katherine Linda
Studies of patients presenting with brain abscess (BA) and Empyema are not routinely focused on occupational therapy (OT). There is a paucity of literature on deficits other than hemiplegia. Aims of this study were to determine the relationship between BA, Empyema, motor and other deficits and whether an OT intervention protocol is needed. Record review was used to establish clinical presentation trends. Hemiplegia was the most common motor deficit and the majority scored below the norm on the Beery- Buktenika Developmental Test of Visual Motor Integration (VMI). Patients with Brain Abscess generally had more significant deficits than those with Empyema for both motor and process deficits. Part B followed up a small sample (n=8) which indicated clinical improvement on the VMI test with the score on the supplemental test of motor coordination remaining a concern. Occupational Therapy is recommended to address these issues based on the Occupational Therapy Practice Framework-II.
The socio-economic impact on health behaviour regarding blood pressure management amongst young adults
(2024) Mhlaba, Mimi
Hypertension (HTN) is a leading cause of cardiovascular disease (CVD), with hypertension prevalence among young adults (YAs) increasing on a global as well as local scale. In South Africa between 1998 and 2016, Hypertension (HTN) rates in YAs (age 15-34 years) have more than doubled. Research reports that the increasing prevalence of HTN in YAs is largely attributed to unhealthy behaviours, such as unhealthy diet, physical inactivity, smoking, drinking alcohol, and poor sleep, with YAs also perceiving themselves as invulnerable to developing HTN at a young age. Formative research has shown that lack of education, employment, and training (NEET status) presents a significant barrier to healthier behaviours in YAs. Currently, 44.7% of South African youth are NEET, indicating the increased risk of pro-HTN behaviour in this group and the need for urgent intervention. While many learnerships addressing NEET rates in the country have been implemented, few are focused on health. Therefore, this study aimed to investigate if transitioning from a NEET status to employment and health education training changes perceptions of HTN risk and health behaviour intentions. METHODS We conducted six focus group discussions (FGDs) comparing HTN-related beliefs and intention for behaviour change between NEET youth (n=20; not in employment, education, or training) and previously NEET youth on a health employment and education training initiative (HETI); n=20). All FGDs were approximately 70 minutes in duration and were recorded and transcribed verbatim. The study utilised the conceptual framework of the Health Belief Model (HBM) to inform the FGD topic guide and a deductive thematic analysis. Frequent debriefing and review sessions with research supervisors were conducted to ensure the quality of the analysis. RESULTS All youth were familiar with HTN but for NEET youth, who only knew it as “high-high” or “high blood”, this was mostly through experiences of others in their social network. While all youth viewed HTN as life-threatening if left untreated and expressed fear of lifelong medication use if diagnosed, only HETI youth felt empowered to implement positive health behaviours for disease prevention. Intention for behaviour change was related to personal relevance resulting from the practical application of HTN knowledge in their daily lives. In contrast, NEET youth felt chronic disease was inevitable at an older age and demonstrated no intention for behaviour change. Past negative experiences in local clinics and the fear of distress in the event of a possible diagnosis were described as major deterrents to blood pressure (BP) screening. CONCLUSION Results suggest that engaging NEET (Not in employment, education, or training) youth in similar HETI (Health employment and education training initiative) programs can increase personal relevance of health information, which serves as a motivator to increase intentions toward healthier behaviours for chronic disease prevention. This may also result in double-duty benefits, reducing a NEET status as well as the risk for chronic illness among the YA population.

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