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Development of a list of essential obstetric anaesthetic knowledge and skills for interns in a department of anaesthesiology
(2024) Nibe, Zibele
Background Community service medical officers often practice obstetric anaesthesia without supervision, and complications can occur if they are not adequately equipped with the necessary knowledge and skills. This study aims to develop a list of essential obstetric anaesthetic knowledge and skills for interns in a department of anaesthesiology. Methods and results A prospective, exploratory, and instrumental study design using Lynn’s Model of determination and quantification of content validity was followed. The Developmental Stage involved an extensive literature review, followed by a peer group discussion with expert local anesthesiologists with a special interest in obstetric anaesthesia. Each item on the list was debated until consensus was reached. This stage resulted in a list with 59 items. In the Judgement -Quantification Stage, this list was sent to expert anaesthesiologists with a special interest in obstetric anaesthesia nationally for validation. The anaesthesiologists used a four-point Likert scale ranging from unnecessary to essential information to grade each item. Fifty-seven of the 59 items were deemed essential and retained. This entire list was quantified using the content validity index (CVI). Lynn suggests that a content list should have a CVI of at least 0.8. The list was content valid with a CVI of 0.98. Conclusion This study presents a comprehensive list of essential knowledge and skills for interns in obstetric anaesthesia in the Wits Department of Anaesthesiology that may contribute to interns practising obstetric anaesthesia more safely.
Maternal deaths due to hypertensive disorders in pregnancy: a four year review in a tertiary hospital
(2024) Khan, Z. L.
Background Hypertensive disorders of pregnancy (HDP) are leading causes of maternal mortality worldwide. In South Africa (SA) they account for the second most important cause of maternal mortality. Despite its prevalence and devastating consequences, no progress has been made in reducing deaths due to HDP during the last decade. Objectives The aim of this research study is to describe maternal deaths due to complications arising from HDP, in a tertiary hospital, specifically looking at maternal characteristics, management, timing, causes and avoidable factors. Methods This is a retrospective cross-sectional study involving a review of patient records at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between January 2015 and December 2018. Patient files were retrieved from records, captured onto an Excel Spreadsheet and analysed using basic statistics. Results Patients that died were young, booked early and attended antenatal care. Few patients had risk factors for HDP but aspirin prophylaxis was not given. Antihypertensive treatment as well as Magnesium Sulphate (MgSO4) was often not initiated appropriately. Eclampsia was the most common cause of death and 87% of patients died in the post-partum period. Conclusions Early, quality antenatal care, early detection of disease, referral to the appropriate level of care and adequate treatment as well as timely delivery is necessary to reduce maternal deaths due to HDP. Large scale studies are needed to identify specific quality of care issues at all levels of care in order to implement measures to improve the outcomes.
Presentation and therapeutic outcomes of thrombotic microangiopathy in HIV positive and HIV negative patients at Helen Joseph Hospital during the period 2010-2019
(2024) Moola, Yusuf
Background: Thrombotic microangiopathies (TMAs) are heterogeneous disorders characterized by widespread occlusive microvascular disease, causing thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and end-organ dysfunction due to ADAMTS-13 deficiency. TMAs are broadly classified into primary and secondary, with HIV being an increasingly common secondary aetiology, specifically in HIV endemic regions, like South Africa. Methods: 106 records of patients, diagnosed with TMA and treated with plasma exchange (PLEx) from 2010-2019, were assessed at presentation for clinical features of fever, renal and neurological involvement; laboratory parameters including haemoglobin, platelet count, and creatinine levels; treatment required such as blood product support, renal replacement therapy and use of corticosteroids and patient outcomes such as recurrence, mortality and creatinine at termination of PLEx. Further information was gleaned from the NHLS laboratory database to assess patients’ response to PLEx. Results: HIV was the most common aetiology, accounting for 82.2% of TMA. More than two-thirds of the cohort were females of Black-African ethnicity, and the median age at presentation was 36 years. Patients with HIV-associated TMA had lower haemoglobin levels, lower platelet counts, and were older at presentation compared to HIV negative patients. The diagnosis of TMA was typically associated with advanced HIV disease (median CD4 count of 147 cells/mm3 ). Irrespective of the TMA aetiology, this study found that a median of 10 PLEx sessions was required to induce remission of TMA, with the crude mortality found to be 16.8% in this cohort. Conclusion: HIV-associated TMA remains an important cause of secondary TMA in South Africa. It presents more often in Black-African females and in those with advanced stages of HIV. Compared to HIV negative individuals, HIV-infected patients present with lower IV haemoglobin and lower platelet counts potentially signifying a more severe form of disease. PLEx remains an integral component in the management of TMA and is crucial to improving survival. While this modality is crucial to eliminating the pathogenic ULvWF multimers and auto-antibodies, the important role of combination antiretroviral therapy (cART) in maintaining remission and preventing relapse of TMA should not be underestimated.
Audit of evolving roles of laparoscopy in the current surgical practice at Chris Hani Baragwanath Academic Hospital: a 5 year review
(2024) Ngwisanyi, Weludo
Objective: The objective of this study was to determine the evolution of LS in selected procedures. Design: This was a retrospective cross-sectional study to investigate and analyse the frequency of nine selected procedures (MAS versus open) performed from January 2014 to December 2019. Setting: The study was conducted at the Chris Hani Baragwanath Academic Hospital. Outcome measures: Data were collected from theatre registries. Statistical analysis was performed using the software IMB SPSS. The data were analysed using descriptive statistics of mean and standard deviation for age, and percentage and frequencies for categories of variables. Results: Of the 3745 patients involved in the study, 59.1% were males and 40.9% were females. The mean age of the patients was 35.17±17.30 years. Laparoscopic surgery was represented in 43.2% of the procedures, with laparoscopic appendicectomy (46.73%) and laparoscopic cholecystectomy (32.69%) being the most commonly performed procedures.. Twenty-five adrenalectomies were performed over the study period, and of those 12 (52%) were performed laparoscopically. All the thymectomies (12) were performed thoracoscopically, with one conversion. Conclusion: The findings of this study suggest that there has been an increase in the overall incidence of laparoscopic surgery in selected procedures at CHBAH.
Pathologic response after primary chemotherapy for breast cancer : outcome from two South African breast centres
(2024) Moodley, Treven
Background: Neoadjuvant chemotherapy (NACT) has evolved to become an integral component in the management of both early and locally advanced breast cancer. Histologic response classification systems make use of pathologic complete response (pCR) which is also a surrogate endpoint for estimation of long term clinical outcome such as disease free survival and overall survival. This study aimed to evaluate pCR rates and the use of histopathological reporting systems among breast cancer patients receiving NACT in two Johannesburg breast units. Methods : This is a retrospective review of prospectively collected data from the South African Breast Cancer and HIV Outcomes (SABCHO) study. Patients were selected from the respective databases of two academic hospitals based in Johannesburg. All histopathological specimens were assessed by the National Health Laboratory Service (NHLS). Results : A total of 399 patients were enrolled for NACT but only 321 proceeded to surgery. 40 patients (12.5%) had a pCR with tumour grade (P = 0.005), receptor status (P = 0.004) and clinical response being predictive values of a pCR (P = 0.038). 61 specimens were reported using the Sataloff method, 15 specimens were reported using the Miller-Payne method and the remaining majority had no documented classification system. Conclusion: Our pCR rate of 12.5% is much lower than reported in other studies. Triple negative breast cancer achieved the highest pCR rates. Histopathological reporting post chemotherapy needs to improve and there should be uniformity in reporting.The Sataloff method is favoured as it easier to apply and takes into consideration tissue response both in the breast and lymph nodes.
Audit of ultrasound in adult patients presenting with scrotal pathology at Chris Hani Baragwanath Academic Hospital
(2024) Nkosi, Winile
BACKGROUND: Scrotal ultrasound is one of the most frequently requested and performed radiological procedures worldwide. It is cheap, easily accessible and can significantly reduce the morbidity and mortality if prompt diagnosis and treatment are provided. OBJECTIVES: To determine the frequencies of the most common scrotal symptoms and scrotal ultrasound findings in adult patients presenting at Chris Hani Baragwanath Academic Hospital(CHBAH). METHOD: Reports of all scrotal ultrasounds completed at CHBAH from the 1st of January 2020 - 31st of December 2020 were retrospectively reviewed. The indication for and the findings of each ultrasound were recorded. Subjects were then categorized based on corresponding indications and ultrasound findings. RESULTS: There were a total of 267 scrotal ultrasounds performed with 141 studies meeting the inclusion criteria. CONCLUSIONS: Routine scrotal ultrasound places a significant burden on radiology services in our clinical setting. In view of the significant percentage of benign and normal ultrasounds (about 97.9 %) with only 6.4 % presenting with organ threatening pathology, the referring clinicians should reconsider which patients to send for imaging based on their clinical findings and assessment.
The effect of magnesium sulphate on clinical outcomes of low-birth-weight babies at the Chris Hani Baragwanath Academic Hospital
(2024) Odubunmi, Temitope Olawale Oluwadare
Introduction Magnesium sulphate (MgSO4) has been used for neuroprotection in the management of preeclamptic toxaemia (PET) and eclampsia in mothers of neonates at a lower gestational age and its’ use is recommended in preterm deliveries less than 30-32 weeks of gestation. There may be greater effects at an earlier gestational age, with no associated long term adverse foetal or maternal effects; resulting in increased survival of preterm babies. The aim of the study was to assess if the administration of MgSO4 improved the neonatal outcomes in low birth weight (LBW) infants whose mothers received magnesium sulphate. Methods This was a retrospective descriptive study of neonates, whose mothers’ received MgSO4 (as indicated by MgSO4+ group) admitted to the neonatal unit within a two-year period (January 2016 – December 2017). The demographics and outcome at hospital discharge were collected and analysed. Results A total of 485 (7.5%) of 6510 LBW neonates’ mothers received MgSO4. Pre-eclamptic toxaemia (PET) [n=235 (48%)], eclampsia [n=90 (19%)] and Haemolysis, Elevated Liver enzymes, Low platelets (HELLP) syndrome [n=28 (6%)] were the main indicators for the administration of MgSO4. Mothers in the MgSO4+ group were older and had a higher parity. Seventy percent received antenatal steroids in the MgSO4+ group and 30% of these were HIV positive. Neonates in the MgSO4+ group had a lower gestational age (p < 0.001) and birthweight (p<0.001). A smaller number of neonates in the MgSO4+ group required resuscitation and had higher oxygenation (p=0.005) on admission. A higher proportion of neonates in the MgSO4+ group had lethargy, hypotonia (p<0.001), asphyxia (p<0.001), early onset sepsis (EOS) (p<0.001), intraventricular haemorrhage (IVH) (p<0.001), respiratory distress syndrome (RDS) (p<0.001), required respiratory support (p<0.001) and died (p<0.001). In the multivariate logistic regression analysis; PET, asphyxia and hypotonia were associated with mortality. Conclusion There was an increase in neonatal morbidities and mortality in neonates whose mothers received MgSO4+. Monitoring of these neonates, in addition to monitoring MgSO4+ levels to document a dose effect, is essential
Osteoporosis in patients with rheumatoid arthritis at Chris Hani Baragwanath Academic Hospital
(2024) Naidoo, Tania
Background Osteoporosis is a common comorbidity associated with rheumatoid arthritis (RA). The aim of this study was to determine the risk factors and possible predictors of osteoporosis in black patients with RA. Methods One hundred and twenty RA patients, 60 patients with and 60 without osteoporosis were studied. The demographics, disease activity, American college of Rheumatology (ACR) functional status, treatment and Dual Energy X-Ray Absorptiometry (DEXA) characteristics were then compared. Results The mean age of the overall cohort was 66.6 ± 9.5 years, majority (95.5%) were female, of which 97.4% were postmenopausal. The mean disease duration from diagnosis to the DEXA was 8.6 ± 6.2 years. Rheumatoid Factor (RF) positivity was 89.2% and Anti-cyclic Citrullinated Peptide (ACCP) positivity was 82.7%. The median (IQR) for Disease Activity Score 28 swollen and tender joint count using the erythrocyte sedimentation rate (DAS-28 ESR) was 3.4 (2.8-4.7) and the median (IQR) for ESR was 41(22,64.3) mm/hr mmHg. There were significantly more patients treated with triple therapy in the no osteoporosis group 38 (63.3%) than the osteoporosis group 21 (35%) (p = 0.00). The ACR functional class was significantly worse in the RA patients with osteoporosis than the RA without osteoporosis [median (IQR), 2 (2, 3) vs 2 (1, 2), (p = 0.03, respectively. Conclusion This study found that worse ACR functional class was significantly associated with osteoporosis. In addition, the use of triple therapy had a protective effect. Early recognition of the risk factors for osteoporosis should be sought, with prompt preventative measures, screening and treatment.
Comparison of ultrasound and magnetic resonance Imaging findings in patients with suspected placenta accreta spectrum at Chris Hani Baragwanath Academic Hospital
(2024)
Background: Placenta accreta spectrum (PAS) is a serious condition that is increasing in prevalence with an increase in the caesarean section rate. This condition is associated with significant haemorrhage. Accurate diagnosis and adequate surgical planning are associated with favourable outcomes. Ultrasound and MRI are used in prenatal diagnosis of this condition. • Objectives: To compare ultrasound and MRI report findings with histopathology or surgical findings in patients with suspected PAS at Chris Hani Baragwanath Academic Hospital. To compare the diagnostic accuracy of PAS between the junior and senior (>5 years’ experience) radiologists’ MRI reports. Method: A retrospective comparison of 14 MRI and 18 ultrasound report findings of patients with suspected PAS were compared with histopathologic or surgical report findings. These imaging modalities' sensitivity, specificity, accuracy, true positive, true negative, false negative and false positive values were determined. The accuracy, sensitivity and specificity of MRI reports were determined based on radiologists’ experience. Results: Ultrasound correctly diagnosed PAS in 10/18(56%) of the patient reports. MRI correctly diagnosed PAS in 6/14(43%) of reports. Ultrasound reports had sensitivity and specificity of 90.9% and 28.6%, respectively, while MRI reports had sensitivity and specificity of 20% and 75%, respectively. The senior radiologists correctly diagnosed PAS in 3/7(42%) of reports, while junior radiologists correctly diagnosed PAS in 4/6(67.7%) of MRI reports. Conclusion: There was no statistically significant difference in the accuracy of Ultrasound and MRI in diagnosing PAS. There was no statistically significant difference in diagnosis of PAS between junior and senior radiologists
The effectiveness of topical bupivacaine application versus placebo in managing pain in paediatric and adult adenotonsillectomy patients: a systematic review & metaanalysis
(2024) Desai, Shainal
Background: There is a high incidence of severe post-operative pain experienced by patients undergoing adenotonsillectomies. During this procedure, there is often a need for local anaesthetic use which has minimal side effects, is cost effective and is easy to administer. Bupivacaine is a long acting and potent local anaesthetic that is widely available in resource constrained settings. Its topical application into the tonsillar fossa could provide sufficient analgesia whilst avoiding complications seen with its infiltrative technique. Objective: To determine the efficacy of topical bupivacaine in the management of postadenotonsillectomy pain compared to placebo using data from randomised controlled trials (RCTs). Methods: This systematic review and meta-analysis was registered with PROSPERO (CRD42020180502) and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive search of the scientific literature was conducted on PubMed, Scopus and the Cochrane Library online databases. RevMan 5.4 software was used for statistical analysis. The risk of bias and quality of the studies included was determined using the Cochrane Risk of Bias (ROB) Tool Version 2. Results: Seven studies out of 58 were included in the systematic review with a total of 406 patients. Six of these studies had investigated post-operative pain scores for tonsillectomy alone. Three of the studies showed low risk of bias, three had some concerns and one was at high risk of bias. Topical bupivacaine produced a significant reduction in pain score estimates at 1-hour [−2.32 (95% CI: −3.98; −0.66)], 4-hours [−2.93 (95% CI: −5.05; −0.81)] and 5-6- hours [−1.73 (95% CI: −3.15, −0.30)] (standardised mean differences) postadenotonsillectomy when compared to placebo. The analysis also reports no complications associated with use of topical bupivacaine. The dose of bupivacaine was 0.5% for six of the seven studies, and 0.25% for the one study. The included trials varied according to volume and duration of application of bupivacaine. There was significant heterogeneity in the analysis undertaken. Conclusion: Topical bupivacaine was effective and safe in reducing post-adenotonsillectomy pain scores up to 6 hours post-operatively. This method of administration is ideal in resource constrained environments as it avoids potentially serious complications that are associated with the infiltration technique
Knowledge and attitude towards cardiopulmonary resuscitation by non-medical staff at a medical school in Gauteng
(2024) Jarghon, Saeb
Background: Sudden cardiac arrest can occur unexpectedly to any person and at any place including at medical schools. Improved outcomes after cardiac arrest are dependent on the initiation of early first responder high quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. There is a lack of data pertaining to the knowledge, attitudes, and perceptions of non-medical staff at medical schools regarding CPR. Objective: To determine the knowledge, attitudes and perceptions of non-medical staff at a medical school in South Africa regarding CPR. Methods: A paper-based questionnaire was administered to non-medical staff fulfilling inclusion criteria at the medical school. Data was collected between 01 August and 25 October 2020. Results: The final study sample comprised of 150 participants. Of these, 68.7% were female, 72.7% were ≤ 40 years old, 41.3% had a postgraduate university degree, 48.0% had witnessed a medical emergency at the medical school premises and 30.7% had previously undertaken first aid or CPR training. The mean knowledge score was 4.4 ± 1.6 out of 12 with only 16.7% knowing what was the first thing to look out for during a medical emergency and 18.7% knowing the location of the automated external defibrillator. Most participants (90.7%) indicated that CPR training should be mandatory for all employees. Conclusion: Non-medical staff surveyed displayed suboptimal knowledge but positive attitudes and perceptions towards CPR. Although this was a single centre study, these results can be used to motivate for CPR training of non-medical staff at all medical schools.
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.
Lipid changes on Protease Inhibitors in South Africa: a retrospective cross-sectional analysis comparing metabolic profiles and lipid management in patients living with HIV on different protease inhibitors at Charlotte Maxeke Johannesburg Academic Hospital
(2024) Bruce, Robyn
Background People living with HIV (PLWH) are at risk of cardiovascular (CV) disease, with few studies having assessed CV risk in Southern Africa. Protease inhibitors (PIs) are known to cause dyslipidaemia, in particular, lopinavir more so than darunavir. The WRHI 052 study by Venter et al, a randomised parallel-group open label non-inferiority phase 3 trial, at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), demonstrated that low dose darunavir/ritonavir (400 mg/ 100 mg) sustained viral load suppression equivalently to lopinavir/ritonavir (800 mg/ 200 mg). This could be a costeffective option with improved metabolic effects. Objective: To assess CV risk screening in PLWH receiving two different PI based antiretroviral therapy (ART) regimens and exploring the difference in the metabolic profiles between the two PI groups. Methods: A retrospective sub-analysis of the WRHI 052 study. Between June 30 2016, and June 15 2017, 300 PLWH on a lopinavir/ritonavir regimen were randomized into two groups, 152 continued the lopinavir/ritonavir combination and 148 were switched to darunavir/ritonavir. The metabolic parameters of the two PI arms were compared at 24 and 48 weeks. A 2-year post study completion retrospective analysis was performed at the CMJAH HIV clinic where routine care was continued. An analysis of CV risk using the Framingham CV risk score, lipid management and achievement of low-density lipoprotein cholesterol (LDLC) goals was performed. Results: In the darunavir/ritonavir group, a significant decrease in total cholesterol (TC) of 7.7% at 48 weeks (95% CI, p<0.001 was observed, and the TC/HDLC ratio declined at 24 and 48 weeks by 1.7% and 3.9% respectively (95% CI, p=0.09; p=0.99). The TC increased by 0.4% at 48 weeks in the lopinavir/ritonavir group (95% CI, p=0.01) and the TC/HDLC ratio increased by 3.3% and 0.9% at 24 and 48 weeks (95%CI, p=0.04 and p=0.12). There was no statistical significance between the median differences and median percentage difference in TC/HDLC ratios between PI groups. LDLC decreased significantly in both PI groups at 24 and 48 weeks, however there was no statistical significance between PI groups. Weight and consequently body mass index (BMI) increased over time with a consistent trend in both groups and genders. Due to weight gain, the percentage of participants with a normal BMI declined from 41.5% at baseline to 33% and 35% at 24 and 48 weeks. Eighty-three percent of all participants had dyslipidaemia with 22% receiving lipid lowering therapy. Eighty-five percent of all participants had a low Framingham CV risk score with 52% achieving target LDLC. Conclusion TC and TC/HDLC ratio improved when switched to darunavir/ritonavir. Significant weight gain was observed in participants on a PI over time. Longitudinal studies on weight gain in individuals on PIs are warranted. Increased awareness and assessment of CV risk is needed.
Management of women with hypertensive disorders in pregnancy in the immediate postpartum period: a retrospective review of practices in a busy tertiary hospital in Gauteng, South Africa
(2024) Mashoene, Rangwato Pearl
Background Hypertensive disorders in pregnancy (HDP) are a leading cause of maternal morbidity and mortality globally, accounting for14,8% of the total maternal deaths in South Africa. The burden of HDP continues beyond pregnancy with a third of women continuing to have persistent hypertension beyond pregnancy. Objective To describe the management and outcomes of women with hypertension in pregnancy during the immediate postpartum period. Methods This was a prospective study conducted at the postnatal ward of Chris Hani Baragwanath Hospital over 12 months on women with hypertensive disorders of pregnancy, who still required blood pressure treatment postdelivery. Post ethics approval, data were collected from patients and their files managed using REDCap® electronic data capture tools hosted by the University of the Witwatersrand. Results A total of 200 participants were included,163 (81,5%) had an abnormal blood pressure of more than the target BP of ³150/100mmHg within 24 hours of delivery and 37 (18,5%) within 48 hours at an average 3 day duration of stay for BP control. The choices of drugs for blood pressure control were not in line with the stepwise national guidelines on postpartum hypertension management, the commonest of which were Nifedipine, Enalapril, and Methyldopa. Sixty-seven participants (33,5%) still had uncontrolled blood pressure, higher than target BP at the time of discharge but less than severe hypertension of 160/110 mmHg. All discharged participants including those on 3 agents for BP were given a routine postnatal follow up at a local clinic. Conclusion The high number of patients that required treatment within 24 hours of delivery has highlighted the need for continued vigilance and enhanced postnatal care by clinicians beyond delivery. This includes strict adherence to institutional and national guidelines and protocols on the management of hypertension postdelivery and proper follow-up channels at discharge.
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.
Clinicians’ perspective of pacs at Charlotte Maxeke Johannesburg Academic Hospital
(2024) Tshalibe, Polite
Background: Picture archiving and communication systems (PACS) are now an established means of capturing, storing, distribution and viewing of all radiology images. The study was conducted in a quaternary hospital, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), part of University of Witwatersrand teaching circuit, in South Africa. There are few studies conducted in our local environment evaluating the clinicians’ perception of PACS in public teaching hospitals. Objectives: To measure the clinicians’ perceived benefits and challenges of PACS. To document their perceived views on how the current PACS can be improved. Methods This was a cross-sectional observational study over a period of five months, from September 2021 to January 2022, carried out at CMJAH. Questionnaires were distributed to clinicians with PACS experience. Descriptive statistics were conducted. Categorical variables were presented as frequencies and percentages. The continuous variables were presented as mean ± standard deviation. Results: The response rate was 54%. The survey found the benefits most reported by clinicians were improved patient care, less time needed to review an exam, improved image comparison, and consultation efficiency. With respect to perceived challenges, the unavailability of images at the bedside, problems with access, and a lack of advanced image manipulating software were noted most frequently. The most frequent recommendations for improvements focused on the aforementioned challenges. Conclusion: Although a small majority of respondents found PACS beneficial, there were also significant issues with accessibility and functionality of the system. Contribution: The findings will assist in future hospital or provincial-wide PACS deployment projects.
The prevalence of autism spectrum disorders at Tara Hospital Child and Adolescent Clinic
(2024) Pitjeng, Philemon M.
Introduction: There are limited studies on the prevalence of Autism Spectrum Disorders (ASD) in Africa as a continent, and in South Africa in particular. This study is aimed at determining the prevalence of Autism Spectrum Disorders at a specialised psychiatric hospital in Johannesburg. Method: This is a retrospective study based on a sample of 1370 patients aged between 1-17 years of age who were evaluated over a period of 6 years at the Tara Hospital Child and Adolescent Clinic. 76 received a clinical diagnosis of ASD as per the DSM-IV-TR or the DSM-5. All patients that were not diagnosed with ASD and those that were diagnosed with ASD but were above the age of 18, were excluded. Results: The prevalence of ASD was 5.5% with a 95% confidence interval of 4.4% to 6.9%. These children also presented with co-morbid psychiatric illnesses, the most common being ADHD at 72% followed by GAD at 34%. Patients that received OT made up 21%, while 17% were at remedial school as per the recommendation made by the multi-disciplinary team. Conclusion: The findings of this study correlate with other studies that have been conducted. There was also an incidental finding that indicated a higher paternal than maternal heritable contribution of ASD. Further research is recommended to measure the outcomes of the cases that were diagnosed.
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.
Identification of novel HIV-1 envelope mutations that confer resistance to VRC01
(2024) Cohen, Paula
The Antibody Mediated Prevention Trials showed that passively infused VRC01, a potent and broadly neutralizing antibody, was able to protect individuals against HIV-1 infection if they were exposed to sensitive viruses. However, breakthrough HIV-1 infections occurred when individuals in the VRC01 arms were exposed to viruses either resistant to VRC01 or to sensitive viruses when participants were in a VRC01 serum trough. We identified seven individuals with multi-lineage breakthrough HIV-1 infections, where one variant was resistant to VRC01 but another was VRC01 sensitive. By comparing the Env sequences of the resistant and sensitive clones from each participant, we identified mutations that were predicted to confer differential VRC01 neutralization phenotypes. These mutations were reverted to sensitive residues by site-directed mutagenesis, and the wildtype and mutant envelopes were screened against VRC01 and other CD4 binding site antibodies in TZM-bl neutralization assays. In four of the seven pairs of clones, a single mutation was sufficient to confer sensitivity to VRC01. In each case, the mutations responsible for the differential neutralization phenotypes occurred at different sites across the Env, such as 279 and 280 in loop D, 369 in the CD4 binding-loop and 459 between β23 and the V5 loop. In two cases, the resistant backbones were mutated (through generation of chimeras) to contain either the entire V1V2 region or the β23-V5 loop of their matched sensitive clones. This resulted in the transfer of 8 or 20 amino acid mutations to confer VRC01 neutralization sensitivity. We were unable to identify the mutations conferring VRC01 resistance in one participant, where the resistant and sensitive clones differed by both length and 100 amino acid changes. Interestingly, all VRC01 resistant clones were sensitive to other, clinically relevant, related CD4 binding-site bNAbs, such as VRC07-523 LS and N6, which are being tested in future passive immunization trials. Further studies will investigate the kinetics of VRC01 resistance mutations within the AMP multi-lineage transmissions over time.
Review of factors associated with prolonged hospital stay in very low birth weight infants at a teriary hospital in South Africa
(2024) Thambe, Amelia N.
Background: Many factors have been shown to influence the duration of hospital stay, namely gestational age, birth weight and neonatal morbidities. In middle-income countries with limited resources such as South Africa, understanding factors associated with PHS will assist in resource planning, policy amendments and highlight areas for quality improvement projects. Objectives: Our objectives were to determine the prevalence of PHS in VLBW infants and maternal, postnatal and neonatal factors associated with PHS and compare the characteristics of neonates with and without PHS. Methods: This was a retrospective observational study. The population included all neonates with a 500 to 1500-gram birth weight, born at Charlotte Maxeke Johannesburg Academic hospital (CMJAH) in Johannesburg, South Africa, between 1 January 2013 and 31 December 2017. Pre-hospitalisation maternal and neonatal factors and complications were analysed. Maternal and neonatal characteristics of infants with PHS were compared to those without, defined by a hospital stay of 60 days or more. Results: The survival rate in this study was 87.3%, and the prevalence of PHS was 11,8%. The mean birth weight was 993 grams (SD 186.144), and the average gestational age was 28.27 weeks (SD2.179). Lower birth weight and gestational age were associated with PHS. NOS (odds ratio 2.329; 95% Confidence interval 0.3 – 3.1), BPD (odds ratio: 4.9; 95% Confidence interval 1.93 – 5.424) and PDA (odds ratio: 2.702; 95% Confidence interval:0.33 – 5.424) a were associated with PHS. Discussion: This study showed that 11.8 % of VLBW preterm infants at CMJAH have PHS. Prematurity is an independent risk factor for PHS. Complications associated with the latter, such as NOS, BPD, PDA and lower gestational age, prolongs the hospital stay further. However, an association between PHS with PDA was unique to our current study. Conclusion: It is critically important to modify risk factors and morbidities associated with PHS.Prevention of BPD and PDA are required to reduce PHS in our setting. This will ultimately maximize the resource and reduce financial burden in our hospitals.

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