*School of Clinical Medicine (Research Outputs)
Permanent URI for this collection
Browse
Recent Submissions
Item Analysis of surgical mortalities using the fishbone model for quality improvement in surgical disciplinesMoeng, Maeyane S.; Luvhengo, Thifhelimbilu E.Background: The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. Aim: This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. Methods: We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). Results: Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33–64 years). The median length of hospital stay before death was three days (IQR: 1–11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. Conclusion: Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.Item Cultureconfirmed neonatal bloodstream infections and meningitis in South Africa 201419 a crosssectional studyMashau, Rudzani C.; Meiring, Susan ; Dramowski, Angela; Magobo, Rindidzani E.; Quan, Vanessa C. ; Von Gottberg, Anne ; Cohen, Cheryl ; Velaphi, Sithembiso ; Govender, Nelesh; Perovic, OlgaBackground: Few population-level estimates of invasive neonatal infections have been reported from sub-Saharan Africa. We estimated the national incidence risk, aetiology, and pathogen antimicrobial susceptibility for cultureconfirmed neonatal bloodstream infections and meningitis in South Africa. Methods: We conducted a cross-sectional study of neonates (<28 days of life) admitted to neonatal or paediatric wards of 256 public sector health facilities in South Africa during 2014–19. Diagnostic pathology records from Jan 1, 2014, to Dec 31, 2019, were extracted from a national pathology data warehouse. A case was defined as a neonate with at least one positive blood or cerebrospinal fluid culture during a 14-day period. Incidence risk was calculated using annual numbers of registered livebirths. Among the causative pathogens identified, we calculated the proportion of cases attributed to each of them, as well as the rates of antibiotic susceptibility of Gram-positive and Gram-negative bacteria. Findings: Among 43 438 records of positive cultures, there were 37 631 incident cases of neonatal infection with at least one pathogen isolated. The overall incidence risk of culture-confirmed infections was 6·0 per 1000 livebirths (95% CI 6·0–6·1). The incidence risk of late-onset sepsis (days 3–27 of life) was 4·9 per 1000 livebirths (4·9–5·0) and that of early-onset sepsis (days 0–2 of life) was 1·1 per 1000 livebirths (1·1–1·1); risk ratio 4·4 (95% CI 4·3–4·5). The cause of infection differed by syndrome, timing of infection onset, facility, and province, although Klebsiella pneumoniae (26%), Acinetobacter baumannii (13%), and Staphylococcus aureus (12%) were the dominant pathogens overall. Gram-negative bacteria had declining susceptibility to most antibiotics over the study period. Interpretation We found a high incidence risk of late-onset sepsis with provincial variations, predominance of K pneumoniae, and declining antibiotic susceptibility among Gram-negative bacteria. This national surveillance in an upper-middle-income country provides a baseline burden of neonatal infections against which the impact of future clinical and public health interventions can be measured.Item Cognitive and motor development in 3 to 6 year old children born to mothers with Hyperglycaemia first detected in pregnancy in an urban African populationSoepnel, Larske ; Nicolaou, Veronique ; Draper, Catherine ; Levitt, N. ; Klipstein-Grobusch, Kerstin ; Norris, ShaneObjectives: Hyperglycaemia first detected in pregnancy (HFDP), on the rise in urban sub-Saharan Africa (SSA), may negatively impact foetal neurodevelopment, with potential long-term cognitive consequences for the child. Data on this association from SSA is lacking, and we aimed to investigate the association in 3- to 6-year-old children in Soweto, South Africa. Methods: In this comparative study, we compared cognitive skills measured with the Herbst Early Childhood Development Criteria test in 95 children born to mothers with HFDP and 99 participants unexposed to maternal HFDP. Fine and gross motor skills were secondary outcomes. Ordinal regression analysis with known confounders was performed for children born at-term. Results Of children exposed to HFDP born at-term, 24.3% scored ‘high’ and 25.7% scored ‘low’ in the cognitive subsection of the test, as opposed to 37.7% and 12.9% in the HFDP-unexposed group, respectively. In ordinal regression, exposed participants had a significantly lower odds of scoring in a higher cognitive category when adjusting for maternal confounders and socio-economic status (OR 0.33, 95% CI 0.15–0.74, p = 0.007). No difference was found in gross motor development between the two groups; differences in fine motor development were attenuated after adjustment for maternal pregnancy factors and household socioeconomic status (OR 0.62, 95% CI 0.28–1.37, p = 0.239). Conclusions: for Practice Exposure to HFDP was negatively associated with cognitive development at preschool age. Optimising maternal (preconception) health and early childhood cognitive stimulation could help more children reach their developmental potential.Item Comorbidities in black South Africans with established rheumatoid arthritisLala, Vikash ; Mohammed, Tickly; Musenge, Eustasius ; Govind, NimmishaObjective: Comorbidities contribute both to morbidity and mortality in rheumatoid arthritis (RA). The aim of the current study was to investigate the prevalence and spectrum of comorbidities in South Africans with established RA. Methods: A retrospective, consecutive case record review of 500 Black South African patients with established disease of ≥5 years attending a tertiary rheumatology service was performed. Common comorbidities including those listed in the Charlson Comorbidity Score (CCS) were documented. Results: Most patients, 463 known alive (AG) and 37 known deceased (DG), were female (87%). Mean (SD) age and disease duration were 60 (11.1) and 10.7 (5.0) years respectively, and 98% had ≥1 comorbidities. Median CCS was 2, significantly higher in DG than AG (4 vs 2, P < .0001). Despite hypertension (70%) and hypercholesterolemia (47%) being the commonest comorbidities overall and type 2 diabetes (T2D) occurring in 15.4%, clinical cardiovascular events were rare (0.6%). Peptic ulcer disease (odds ratio [OR] = 8.67), congestive cardiac failure (OR = 7.09), serious infections (OR = 7.02) and tuberculosis (OR = 2.56) were significantly more common in DG than AG. Multivariate analysis showed that American College of Rheumatology functional class 3/4 was associated with increased risk for serious infections (OR = 3.84) and tuberculosis (OR = 2.10). Conclusion: Despite the high burden of cardiometabolic comorbidities in South Africans with established RA, cardiovascular events were rare. Serious infections and tuberculosis, both associated with severe functional disability, are a major cause of morbidity and mortality.Item Osteogenic competence and potency of the bone induction principle inductive substrates that initiate bone formation by autoinductionRipamonti, Ugo; Duarte, Raquel ; Ferretti, Carlo ; Reddi, H.The de novo induction of bone has always been a fascinating phenomenon, keeping skeletal reconstructionists and cellular developmental biologists continuously engaged to finally provide a molecular and cellular approach to the induction of bone formation. A significant advancement was made by the purification and cloning of the human recombinant bone morphogenetic proteins, members of the transforming growth factor-b supergene family. Human bone morphogenetic proteins are powerful inducers of bone in animal models including nonhuman primates. Translation in clinical contexts has however, proven to be surprisingly difficult. This review also describes the significant induction of bone formation by the human transforming growth factor-b3 when implanted in heterotopic intramuscular sites of the Chacma baboon Papio ursinus. Large mandibular defects implanted with 250mg human transforming growth factor-b3 in human patients showed significant osteoinduction; however, the induction of bone was comparatively less than the induction of bone in P ursinus once again highlighting the conundrum of human osteoinduction: is the bone induction principle failing clinical translation?Item An all-oral 6-month regimen for multidrug resistant Tuberculosis: A multicenter randomized controlled clinical trial (the Next Study)Esmail, Aliasgar ; Oelofse, Suzette ; Lombard, Carl ; Perumal, Rubeshan ; Variava, Ebrahim ; Martinson, NeilRationale: Improving treatment outcomes while reducing drug toxicity and shortening the treatment duration to 6 months remains an aspirational goal for the treatment of multi drug resistant /rifampicin-resistant tuberculosis(MDR/RR-TB). Objectives: To conduct a multicenter randomized controlled trial in adults with MDR/RR-TB(i.e., without resistance to fluoroquinolones or aminoglycosides) . Methods: Participants were randomly assigned(1:1ratio)to a 6 month all-oral regimen that included levofloxacin, bed aquiline, and linezolid or the standard-of-care(SOC)>9-month World Health Organization(WHO)-approved injectable-based regimen. The primary endpoint was a favorable WHO-defined treatment outcome (which mandates that prespecified drugs substitution is counted as an unfavorable outcome)24 months after treatment initiation. The trial was stopped prematurely when bed aquiline-based therapy became the standard of care in South Africa. Measurements and Main Results: In total,93 of 111 randomized participants(44 in the comparator arm and 49 in the intervention alarm) were included in the modified intention-to-treatanalysis;51(55%)were HIV coinfected(medianCD4count,158cells/ml).Participants in the intervention arm were 2.2 times more likely to experience a favorable 24-month outcome than participants in the SOC arm(51%[25of49]vs. 22.7%[10of44];riskratio,2.2[1.2–4.1];P=0.006).Toxicity-related drug substitution occurred more frequently in the SOC arm(65.9%[29of44] vs.34.7%[17of49];P=0.001)],82.8%(24of29)owing to kanamycin (mainly hearing loss; replaced by bed aquiline) in the SOC arm, and 64.7% (11of17) owing to fluoroquinolones or aminoglycosides (mainly anemia) in the intervention alarm. Adverse event–related treatment discontinuation in the safety population was more common in the SOC arm(56.4%[31of55]vs.32.1%[17of 56];P=0.007).However, grade 3 adverse events were more common in the intervention alarm(55.4%[31of56]vs.32.7[18of55];P=0.022). Culture conversion was significantly better in the intervention arm (hazardratio,2.6[1.4–4.9];P=0.003)after censoring those with bed aquiline replacement in the SOC arm(and this pattern remained consistent after censoring for drug replacement in both arms ;P=0.01). Conclusions: Compared with traditional injectable-containing regimens, an all-oral 6-month levofloxacin, bed aquiline, and linezolid–containing MDR/RR-TB regimen was associated with a significantly improved 24-month WHO-defined treatment outcome (predominantly owing to toxicity-related drugs substitution).However, drug toxicity occurred frequently in both arms. These findings form strategies to develop future regimens for MDR/RR-TB. Clinical trial registered with www.clinicaltrials.gov (NCT02454205).Item 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 HospitalBhana, Malini; Fru, Pascaline; Plani, FrancoBackground: 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 databankItem Locked down impact of covid 19 restrictions on trauma presentations to the emergency departmentVenter, Anica; Lewis, Carolyn; Saffy, Patricia; Chadinha, LouisBackground: COVID-19 was recognised as a global pandemic on 11 March 2020. In South Africa (SA), a nationwide lockdown was implemented at midnight on 26 March to prepare for the predicted surge and slow the spread of the virus. Objectives: To compare the volume and type of presentations of trauma secondary to interpersonal violence and road traffic collisions (RTCs) during two 5-month periods, from February to June 2019 and 2020, in the emergency department (ED) of an academic tertiary hospital in Gauteng Province, SA. In 2020, February - June included the lockdown period. Methods: An observational retrospective audit of the patient register at the Helen Joseph Hospital ED was conducted, comparing the number of trauma presentations secondary to interpersonal violence (assaults with gunshot wounds, general assaults including mob assaults, assaults with stab wounds) and RTC presentations between February and June 2019 and 2020. Results: A total of 4 300 trauma presentations secondary to interpersonal violence and RTCs were noted in the 5-month period February - June 2019, as opposed to 3 239 presentations in February - June 2020 (25% decline). A 40% decline in the number of RTCs, from 1 704 in February - June 2019 to 1 026 in the corresponding period for 2020, was noted and found to be statistically significant (p=0.03). Declines in the volume of trauma cases secondary to interpersonal violence and of overall trauma cases were only directional in favour of 2020, but not statistically significant. Conclusions: The volume of trauma presentations secondary to interpersonal violence and RTCs in the Helen Joseph Hospital ED decreased during the lockdown period. The decline in the volume of RTCs was statistically significant, but declines in the volume of trauma presentations secondary to interpersonal violence and in the volume of overall trauma presentations were not.