Electronic Theses and Dissertations (Masters)

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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.
Characteristics and Outcomes of HIV-infected Children on Antiretroviral Therapy referred for Vitological failure
(University of the Witwatersrand, Johannesburg, 2024) Magomani, Xitshembiso Confidence; Sipambo, Nosisa
Background: The advent of Anti-Retroviral Therapy (ART) has substantially improved virological outcomes for individuals globally living with Human Immunodeficiency Virus. However, the rates of virological suppression in children and adolescents continue to lag behind those observed in adults. Objectives: This study aims to describe the characteristics and outcomes of children on ART referred to Hariet Shezi Children’s Clinic, Chris Hani Baragwanath Academic Hospital for virological failure. Additionally, the research seeks to identify factors associated with virological failure in this specific population. Methods: Conducted as a retrospective review, this study examined the records of children living with HIV aged 0-14 years, referred to Hariet Shezi Children’s Clinic, for management of virological failure between 01 January 2010 and 31 December 2019. Results: Among the 105 patients meeting the inclusion criteria, the median age at referral was 11 years (IQR 6.7-13 years), with 51.4% being male. Significant proportions (37.3%) of patients above the age of 8 were unaware of their HIV status. At referral, 35.2% were on a Non-nucleoside reverse transcriptase inhibitor-based regimen, and 82% had a VL log 10 exceeding 4. Notably, 86.5% of those on NNRTI were switched to a second-line regimen, compared to 4.4% on Protease inhibitor- based regimens. Despite differences in interventions, virological outcomes were similar at 6 ±3 months. Approximately 56.2% of patients received adherence counselling in conjunction with other interventions, indicating that virological failure in the majority resulted from sub-optimal adherence and additional factors. A significant reduction in median viral load was observed at 6 ±3 months and 12±3 months post-intervention (P <0.001). Conclusion: Viral suppression remains a challenge in the paediatric and adolescent populations. Addressing this challenge necessitates a multifaceted approach involving various interventions. Greater resource allocation towards the optimization of viral suppression rates in children and adolescents living with HIV is imperative
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
Anticoagulation For Nonvalvular Atrial Fibrillation In South Africa
(University of the Witwatersrand, Johannesburg, 2024) Mogashoa, Vanessa; Tsabedze, Nqoba; Mpanya, Dineo
Background: Nonvalvular Atrial fibrillation (NVAF) is a growing epidemic in Africa. Anticoagulation, considered the backbone of NVAF management, is limited to warfarin as the mainstay of available anticoagulation therapy in most low-and-middle-income countries (LMICs). The optimal time in the therapeutic range (TTR) while on warfarin is crucial to avoid bleeding and thromboembolic complications. This study aimed to assess anticoagulation control in patients with NVAF on warfarin in Johannesburg, South Africa. Methods: We conducted a cross-sectional retrospective study on consecutive patients with NVAF managed between the 1st of January 2015 and the 31st of December 2019 at a tertiary- level academic centre in Johannesburg, South Africa. Anticoagulation control for patients with NVAF was assessed by calculating the time in therapeutic range using the Rosendaal method. Results: The study population comprised of 177 patients diagnosed with NVAF. The mean age in the study population was 65.0 ± 13.1 years. The median TTR among patients with NVAF was 46% [interquartile range (IQR): 8.7 – 86.0], and 63 (35.6%) patients with NVAF had a TTR ≥ 70%. Patients with poor anticoagulation control (TTR<70%) were on warfarin for a shorter duration compared with those with optimal anticoagulation control [56 days (IQR: 43 – 84) vs 70 days (IQR: 56 – 140), p=0.0013]. The mean CHA2DS2-VASc score was 4 ± 1.5, and it did not differ between patients with poor or optimal anticoagulation control. Among the 175 patients with calculable HAS-BLED scores, 21 (12.0%), 112 (64.0%) and 42 (24.0%) were at a low, moderate, and high risk for bleeding, respectively. Of the 21 patients in the HAS BLED low risk category, only 4 (19.0%) had a TTR<70% (p<0.001). Warfarin toxicity was documented in 13 (7.3%) patients. Conclusion: In our study, a TTR ≥ 70%, suggesting poor anticoagulation control was found in 35.6% of NVAF patients on warfarin. Larger multicentre trials comparing the occurrence of bleeding, thromboembolic events, as well as the total cost to the healthcare system in patients treated with warfarin compared to direct oral anticoagulation therapy are required to guide oral anticoagulation strategies in Africa
Virological response in children and adolescents switching to dolutegravir based regimens in Johannesburg, South Africa – A Longitudinal Cohort Study
(University of the Witwatersrand, Johannesburg, 2023) Mafora, Tshiamo; Technau, Karl
Introduction: Dolutegravir (DTG) was introduced into South African HIV management guidelines in November 2019, and has since been the mainstay of both adult and paediatric first line antiretroviral treatment (ART) regimens. Following its rapid and widespread introduction we assessed the rate of virological suppression over two years in paediatric patients switching to DTG as part of first line treatment. Methods: We performed a retrospective cohort study at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa. Children and adolescents already on first line ART who switched to DTG (between November 2019 and November 2021) were included. Baseline characteristics (at DTG switch) included age, weight, gender, viral load (VL), CD4, and pre-switch regimen. Past ART exposure and past viraemic periods (years VL >1000 copies/ml) were assessed and VL suppression rates (< 50 copies/ml) were calculated at 6, 12 and 24 months post-switch. Associations with non-suppression were assessed using uni- and multivariate analysis. Results: Of the 747 participants that were switched to DTG, 724 (97%) qualified for a VL and 697 (96%) of those had at least one VL done after switch. Overall, 83% (450/543) were suppressed at 6 months, 86% (434/504) at 12, 91% (487/534) at 24 months. Overall, at a median of 637 days after switch, 90% (624/697) were suppressed at their last VL. Factors associated with not being suppressed at the last VL included: missing a follow-up visit by more than 90 days post-switch to DTG (OR: 3.2 [CI:1.5-6.8], p=0.003), switching to DTG with a VL of 50-1000 rather than <50 copies/ml (OR 2.0 [CI:1.1-3.9], p=0.042), having the blood test done during July December (OR 2.0 [CI:1.2-3.4], p=0.011), and having had exposure to viraemia ≥1000 copies/ml for more than two years between first ART start and DTG switch (OR: 1.9 [CI: 0.9-3.7], p=0.071). Conclusion: In our population, similar to other studies, VL suppression was effectively maintained in the majority of patients after switching to DTG. The switch did however result in a loss of suppression in some patients and caution is needed in children and adolescents with missed visits and extensive prior viraemia
Clinicopathological spectrum of cutaneous malignancies at the skin tumour clinic, charlotte Maxeke Johannesburg academic hospital in Johannesburg, South Africa: a 5-year retrospective review
(University of the Witwatersrand, Johannesburg, 2023) Gwinji, Tapiwa Munyaradzi; Modi, Deepak
Background Skin cancer is the most common malignancy in South Africa, incidence of which continues to rise. This disease remains a consistent problem in South Africa due to a multifactorial risk complex arising mainly from the high levels of year-round Ultraviolet (UV) exposure, high burden of HIV and late health seeking behaviour leading to poly-etiological skin cancers. Despite the ever-present danger that is cancer, the data and literature surrounding skin cancers among different races and ethnic groups remains inadequate as there are few population-based cancer registries in South Africa and only histologically confirmed cancers are logged into the national cancer registry. Objectives To describe the nature, extent and demographic characteristics of patients with histologically confirmed skin cancer seen at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) multidisciplinary skin cancer clinic during the period of January 2015 to December 2019 and to add to the body of literature concerning skin cancers in South Africa. Methods A retrospective chart review identified all patients who were managed for histologically confirmed malignant skin tumours at CMJAH skin tumour clinic. Types, quantity and distribution of common invasive malignancies by population group, age, gender, anatomical site and risk factor were explored. Result A total number of 531 participants with histologically confirmed skin cancers were identified. The most common malignancies were Kaposi’s sarcoma(KS) (53.2%), squamous cell carcinoma (SCC) (27.0%), basal cell carcinoma (BCC) (10.4%), cutaneous melanoma (CM) (7.4%) and mycosis fungoides (MF) (4.2%). SCC and AIDS-associated KS were the most common skin cancer in the white and black population respectively. Conclusion This study provides valuable scientific data on the distribution and patient demographics of skin cancer in the public health system in Johannesburg, South Africa, on which further research can be based. This study highlights the burden of HIV associated skin cancer in this region. There is a need for further research and equitable appropriation of resources and public health awareness efforts towards strengthening UV and HIV-related skin cancer prevention initiatives in SA.
Awareness Factors Affecting Contraceptive Uptake in women attending the Gynaecology Out-Patients Department, at a Tertiary Hospital
(University of the Witwatersrand, Johannesburg, 2023) Ndlovu, Sinegugu
Objectives: The objectives of the study were to assess the knowledge and awareness of contraception in the women seen at Chris Hani Baragwanath Academic Hospital Gynaecology Out-patient department. We also looked at the efficiency of contraceptive counselling from the health care providers and assessed patient satisfaction. Study design: We conducted a prospective, descriptive, cross-sectional study. A survey of 100 women, of reproductive age attending the gynaecology out-patient department, was conducted using a questionnaire over a period of 3 months. Sample size was determined by use of The Survey System, Sample Size Calculator. The survey assessed the women’s knowledge regarding barrier methods as well as hormonal methods (in the form of combined oral contraceptives, injectables, the implant, the intrauterine device, emergency contraception) and permanent forms of contraception. Independent variables were age, level of education, employment, parity. Dependant variables were prevalence of contraceptive uptake, knowledge of available contraception. The association between the prevalence of contraceptive uptake and the knowledge regarding the available methods of contraception was assessed using the Chi square test, as well as the Mann Whitney U test. A p-value of 0.05 was decided upon for statistical significance an odds ratio and 95% confidence intervals were reported. Results: Overall Our study found that the total percentage of women using a method of contraception was 39.79 % while those that were not on any method of contraception was 60.20%. Our study also found that there were high rates of discontinuation of contraception. Overall,there was poor contraceptive awareness and knowledge. There was more awareness than there was intricate knowledge regarding the different forms of contraception. Contraceptive counselling increased the rate of contraceptive uptake; of the women that were initially counselled, and then offered contraception, 82.9% of them were agreeable. Conclusion: Awareness does not equal knowledge. All gynaecology out-patient visits should be seen as an opportunity for contraceptive counselling, regardless of the main complaint. The high rate of discontinuation of hormonal contraception should be further assessed, and women should be counselled prior to discontinuation, and preferably placed on another form of contraception which suits their needs
Presentation and outcomes of children admitted with organophosphate and carbamate poisoning at Rahima Moosa mother and child hospital
(University of the Witwatersrand, Johannesburg, 2023) Dlamini, Sibongile; De Maayer, Tim
BACKGROUND: Children are a vulnerable population for organophosphate and carbamate poisoning (OP/CBM). The World Health Organization reports mortality up to 10%. These agents then cause muscarinic, nicotinic and central nervous system collapse. OBJECTIVES: To describe the demographics and clinical features of OP/CBM poisoning, document the treatment given and the response thereof. Observe the acetylcholinesterase levels in relation to clinical features and assess outcomes of the participants. METHODS: A retrospective cross-sectional record review of patients (<14 years) presenting with OP/CBM poisoning at Rahima Moosa Mother and Child Hospital (RMMCH) from the 1st of February 2016 to the 31st of March 2018. Demographics, poisoning circumstances, clinical features, investigations, management and outcomes were analysed. RESULTS: Over the two-year period, 28 participants were included in the study. Gender distribution was equal, and the median age was 31,5 months (Interquartile range [IQR]: 17.5-32.0). Majority was due to accidental poisoning (85%). On arrival to RMMCH, 42.9% were unconscious, displaying mostly Nicotinic (85.7%) vs Muscarinic (71.4%) symptoms. All the participants received Atropine as part of their initial treatment. Participants that had poor outcomes (i.e., demised, n=6/28, 4.7%) were more likely to require inotropes (p=0.02), suffer seizures (p=0.003) and have metabolic acidosis (p=0.02). CONCLUSION: OP/CBM poisoning can have devastating outcomes. Improvement on trade, storage and legislation of these agents is of importance. Research on long-term effects of poisoning would be beneficial.
The effect of medical castration on lipid levels in black South African men with Prostate cancer
(University of the Witwatersrand, Johannesburg, 2024) Minkowitz, Shaul
Background In South Africa, androgen deprivation therapy (ADT) is commonly given as primary therapy for prostate cancer (PCa) due to many patients presenting with advanced disease. The metabolic adverse effects of ADT on lipid profile and weight gain have been reported mainly in Caucasian populations but few studies have been performed in African populations. Men of African descent generally have favorable lipid profiles compared to other populations and our study looked to analyze the effect of medical castration on lipid levels in black South African men with PCa. Methods The aim of this study is to describe the changes in blood total cholesterol, triglycerides, LDL and HDL at 6 months and at 1 year in men with prostate cancer newly initiated on ADT. Changes to BMI, waist circumference and HbA1c were also measured after 1 year of ADT. Our study was conducted at Chris Hani Baragwanath Academic Hospital which is a teaching hospital affiliated with the University of the Witwatersrand. It is located in Soweto, South of Johannesburg and serves the 1.3 million local residents who are predominantly black and of the lower income bracket. This study enrolled 38 black South African men who were starting to receive ADT for PCa. Subjects were evaluated at baseline and at 6 and 12 months. Lipid profiles and HbA1C levels were measured using blood samples and body composition was measure using BMI and waist circumference. Results In this prospective single center study we found that ADT resulted in a significant rise in triglyceride levels and weight gain in black South African men reaching mean levels of obesity using ethnic specific definitions. High density lipoproteins levels decreased significantly particularly in the first 6 months of treatment and thereafter began to rise. ADT also resulted in an increased HbA1C level which is a marker for insulin resistance. Conclusions Androgen deprivation therapy unfavorably changed the body habitus and lipid profile of men with PCa. It was demonstrated that even black South Africans who generally have favorable lipid profiles compared to their counterparts are at risk of developing metabolic syndrome while being treated with ADT
The feasibility of early chemical thromboprophylaxis in traumatic brain injury patients admitted to a trauma ICU
(University of the Witwatersrand, Johannesburg, 2024) Mathibela, Setoni
Trauma is a disease process that occurs because of man’s interaction with other people and the environment. Trauma is the leading cause of non-natural death, a significant cause of permanent disability, with the economically active population group most affected (1,2). Traumatic brain injury (TBI) characterises a major source of trauma-related mortality and is a leading cause of permanent disability in the young population (3). Traumatic brain injury commonly occurs in the background of polytrauma and remains a major obstacle in improving trauma outcomes. Mortality is directly attributable to TBI in up to one-third of patients who die after multiple injuries (4)
An assessment of the hospital learning environment within the Univesity of Witwatersrand obstetrics and gynaecolgy registrar training programme
(University of the Witwatersrand, Johannesburg, 2023) Masukume, Rumbidzai; Chauke, Lawrence; Odell, Natalie
Background. The hospital educational environment is a critical component of a health professionals’ education. It influences clinicians’ professional development, well-being, academic success and ability to provide high-quality healthcare services. There is limited data on the postgraduate clinical learning environment (CLE) in obstetrics and gynaecology (Obgyn) in South Africa. Research objectives. (1) to evaluate obstetrics and gynaecology registrars’ perceptions of their CLE utilising the modified Postgraduate Hospital Educational Environment Measure (PHEEM) questionnaire, (2) to assess factors influencing these perceptions; (3) to evaluate the impact of the learning environment on academic outcomes, and (4) to use the results to recommend targeted improvements of the registrar training programme in Obgyn at the University of Witwatersrand (WITS). Methods. A prospective cross-sectional study involving a convenience sample of doctors enrolled for the four-year Obgyn training programme at WITS. The modified PHEEM questionnaire was electronically sent to 80 participants between January and April 2022. Categorical variables were described using frequencies and percentages. Continuous variables were summarised by measures of central tendency. Factors associated with the PHEEM scores were evaluated using the Student’s t-test and analysis of variance (ANOVA) tests. A p-value of <0.05 was considered statistically significant. Results. Of the 80 participants, 46 (57.5%) responded to the questionnaire. The mean total modified PHEEM score (SD) was 74.9 (16.4) out of a possible 160. The mean scores in this study were as follows: perception of autonomy 27.4/56 (5.3), perception of teaching 30.2/60 (4.0), and perception of social support 17.3/44 (7.1). The overall perceptions of the educational environment were influenced by sex (p<0.001), supernumerary status (p= 0.0036), and marital status (p=0.001). Only two individuals did not complete the four-year training programme. A total of 81.8% of those who completed the four-year training programme passed their Fellowship of the College of Obstetricians and Gynaecologists (FCOG) of South Africa qualifying exams (FCOG 2) on their first exam attempt, however, 34.1% wrote the FCOG 2 exams after completing the four-year training. Conclusion. During the study period, the educational environment within the Obgyn WITS circuit was perceived to be more negative than positive, indicating that all three domains of the modified PHEEM require attention to enhance the educational environment.
The impact of childhood atopic dermatitis on caregiver quality of life at Rahima Moosa Mother and Child Hospital
(University of the Witwatersrand, Johannesburg, 2023) Makondo, Rulani; Mvulane, Nombuyiselo
Background. Atopic dermatitis (AD) is the most common childhood skin disorder with a rising prevalence in developing countries, likewise South Africa. It is characterized by recurring pruritic cutaneous lesions, the control of which necessitates specific skin care measures and avoidance of triggers. The resultant impact on the quality of life (QOL) of the affected child is well established. Moreover, it places an added burden on caregivers as they have to allocate time and resources in activities aimed at achieving disease control to make the affected child comfortable. Objectives. The primary objective of this study was to determine the psychosocial impact of childhood AD on caregiver QOL at Rahima Moosa Mother and Child Hospital (RMMCH) and to describe the association with disease severity and sociodemographic factors. Methods. This was a cross-sectional study conducted at RMMCH, Coronationville, Johannesburg, South Africa from February to June 2022. Children aged 3 months to 16 years fulfilling the Hanifin and Rajka clinical diagnostic criteria for AD diagnosis presenting to the outpatient dermatology clinic with their primary caregiver were recruited into the study. Caregiver QOL was measured using the Dermatitis Family Impact (DFI) questionnaire which assesses the family impact of atopic dermatitis through a series of 10 lifestyle questions that are scored from 0 to 3. The overall DFI score ranges from 0 (no impact on family life) to 30 (maximum impact on family life). The score was further defined as follows; 0-5 = normal QOL; 6-10 = minor caregiver impact; 11-20 = moderate impact and greater than 20 = high impact. Disease severity was classified as per the scoring atopic dermatitis (SCORAD) index into either mild (score of at least 25), moderate (25-50) or severe (above 50) based on lesion extent, intensity and subjective patient symptoms. Patient demographics (age, gender, race, comorbidities, disease duration and treatment duration) and caregiver sociodemographic characteristics (relationship to the patient, gender, age, marital status, family set-up, other dependents, educational level, source of income and medical history) were recorded on the data collection sheet. Statistical tests were concluded at 5% level of significance. Results. A total of 180 AD patient-caregiver pairs were recruited into the study. The median patient age (interquartile range (IQR)) was 60 months (36, 84) while the caregiver mean age (standard deviation (SD)) was 36 years (9). The mean QOL (SD) was 9.8 (7.3). Based on our suggested classification, 64 (35.6%) had a normal quality of life, 49 (27.2%) suffered a mild impact, 47 (26.1%) had moderate impact and 20 (11.1%) recorded the highest impact on their QOL. Most (72%) of the participants had mild disease while 20% had moderate and 8% had severe disease. There was positive association between the disease severity score and QOL score at 5% level of significance (p<0.001). The QOL perspectives reported by most as worst affected were emotional distress, expenditure, sleep disturbance, food preparation and housework interruption respectively. Patient age, disease duration and treatment duration inversely correlated with QOL scores. Except for marital status, the QOL impact score was independent of caregiver sociodemographic factors. Conclusion. The study showed that childhood AD impacts negatively on caregiver QOL at a tertiary hospital in South Africa. The magnitude of which correlates with disease severity. The effect was independent of all caregiver sociodemographic factors except marital status. Patient treatment outcomes are dependent on the caregiver. Therefore, patient monitoring should incorporate caregiver QOL assessments.
Patterns of liver injury in HIV-positive patients in the medical admissions ward at Chris Hani Baragwanath Academic Hospital (CHBAH)
(University of the Witwatersrand, Johannesburg, 2024) Ndwambi, Rudzani Wendy; Ally , Reidwaan; Chopdat, Nazeer
Background Human immunodeficiency virus (HIV) infection is a major global public health concern, with approximately 37.9 million people living with HIV and acquired immunodeficiency syn- drome (AIDS) as of 2018. There has been an increase in HIV prevalence globally, with the African sub-Saharan region carrying a disproportionate burden, accounting for more than 70% of this burden. In 2018 South Africa had 7.52 million people living with HIV/AIDS (PLWHA), with approximately 115167 AIDS-related illnesses. In PLWHA, liver disease and failure contribute to more significant morbidity, mortality and higher cost of care. Aim And objectives To recognise and categorise the patterns of liver injury in people living with HIV and AIDS (PLWHA). To ascribe an etiology to the pattern of liver injury in PLWHA. Method This was a retrospective cohort, conducted at CHBAH medical admissions ward in Soweto Gauteng province, of patients living with HIV and AIDS with liver injury. All patients admitted to the medical admissions ward were selected and their hospital numbers retrieved from the admission register. Each hospital number was entered into the NHLS labtrack system to retrieve the LFT results. Any patient with abnormal LFT was checked for their HIV status. The two variables (abnormal LFT and HIV test) were matched and confirmed. After ethics approval was obtained, files were recorded and analysed. A data collection sheet was populated with all serological, histological and radio logical investigations documented. Results This study included 208 patients (PLWHA) admitted to the medical admissions ward at CHBAH, with abnormal liver enzymes between January 2019 and March 2020, aged above 18 years. One hundred and five, 50.5% were males with a mean of 43.7 years, and 49.5% (n=103) were females with a mean of 39.9 years. One hundred and forty-three, 81.3% were taking antiretroviral therapy (ART), with the majority, 88.4% (n=107), on the first-line regimen. The most common pattern of liver injury was infiltrative, accounting for 67.8% (n=141), followed by mixed at 22.1% (n=46), hepatocellular at 7.7% (n=16), and lastly was cholestatic with 2.4% (n=5). Irrespective of the pattern of the liver injury, 36.1% (n=75) of the patients had Mycobacterium tuberculosis (MTB) infection, and 22.5% (n=40) of them were on antituberculosis treatment (ATT), 6.3% (n=13) had hepatitis B viral (HBV) infection, 0.5% (n=1 ) had hepatitis C ( HCV) infection, while lymphomas (Hodgkin and non-Hodgkin lymphomas) contributed 1,9%(n=4) and 6,3% (n=13) respectively. Twelve, 5.7% (n=12) had drug induced liver Injury (DILI), and retroviral disease (RVD) cholan giopathy contributed 1.4% (n=3). A significant number of patients, 34.1% (n=71), contributed to at least one-third of patients in the study, wherein the diagnosis was either unknown or not directly related to the liver injury. Those were, Other opportunistic infections accounting for 7.7% (n=16), other diagnoses made up 13% (n=27), and no diagnosis at 13.4% (n=28). Of the infiltrative pattern, 33.13% (n=47) had MTB infection, 5.6% (n=8) had HBV, 0.3% (n=1) had HCV infection, 7.8% (n=11) had non-Hodgkin lymphoma, with Hodgkin lym- phoma, and DILI both accounting for 1,4%(n=2). Only 5.7% (n=12) of PLWHA had liver biopsies done. Conclusion Liver injury is common in PLWHA. The most common pattern of liver injury is an infiltrative pattern, and the most common etiology was MTB infection in this study.
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.
Emergence delirium in children undergoing botulinum toxin injections for strabismus correction
(University of the Witwatersrand, Johannesburg, 2021) Rapuleng, Aletta
Background Emergence delirium is an unpleasant complication that may occur in children after general anaesthesia. Botulinum toxin injections for strabismus correction is a short procedure with rapid recovery from anaesthesia, a risk factor for emergence delirium. The aim of this study was to describe the occurrence of emergence delirium and the associated risk factors in children undergoing botulinum toxin injections for strabismus correction at Chris Hani Baragwanath Academic Hospital. Methods A cross-sectional research study design was followed using convenience sampling. The study included ASA I and II children aged 2 – 6 years. Data collected consisted of the participants characteristics, the intraoperative course and the child’s anxiety level as evaluated at induction using the modified Yale Preoperative Anxiety Scale (mYPAS). The Paediatric Anaesthesia Emergence Delirium (PAED) score was used to diagnose emergence delirium in the recovery room. All children received a standardised anaesthetic. Results Sixty-one children were included in the study and 31 (50.8%) developed emergence delirium. Thirty-nine (63.9%) participants showed signs of anxiety with a mean (SD) mYPAS of 41.2 (17.9) out of 100. There was a very weak negative correlation between the highest PAED score and the highest mYPAS (r =-0.0287, p=0.8260). There was a moderate negative, statistically significant correlation between the highest PAED score and age (r =-4850, p=0.0001). Younger age (p=0.0001) and male sex (p=0.0002) were found to predispose participants to emergence delirium. The length of stay in the recovery room was longer in those who experienced emergence. Conclusion In this study, a high occurrence of emergence delirium was found following sevoflurane anaesthesia for botulinum toxin injections for strabismus correction, a short procedure with rapid awakening. Younger preschool children were more likely to develop emergence delirium. It was, however, self-limiting and seldom required treatment.
A survey of the perceptions and knowledge of anaesthesia and anaesthetists possessed by Grade 12 learners in four Johannesburg districts
(University of the Witwatersrand, Johannesburg, 2022) Talane, Pulane Adelice
Background William J.G Morton (1816-1868) introduced the world to modern anaesthesia when he successfully anaesthetised a patient using Ether at Massachusetts General Hospital in Boston in October 1846. (1) Since then, advances in pharmacology have resulted in the safer use of anaesthetic drugs and technological advances have improved monitoring of patients under anaesthesia. Anaesthetists around the world are now involved in the fields of critical care, trauma and pain management. (2)This has brought a sense professional esprit de corps to the anaesthetic fraternity. Despite this radical growth and development of the speciality, there is still a lack of public knowledge regarding the discipline of anaesthesia, anaesthetists’ expertise, or the role played by the anaesthetist in the chain of health care delivery. (3) Methods A cross sectional study was carried out between June and September 2021 on Grade 12 learners in four Johannesburg districts. A questionnaire consisting of three sections and 26 questions was handed out at pre-selected schools. The first part of the questionnaire acquired demographic data, the second contained questions pertaining to anaesthetists and anaesthesia as a speciality, and the third part pertained to interest in the field of anaesthesia. Results Of the 595 learners that participated in this study, 335 (56.3%) were aware that an anaesthetist administers anaesthesia in the operating room. A considerable number of learners n=344 (57,8%) believed that a nurse monitored and recorded the patient’s vital signs during surgery. Only 95 learners (16%) correctly identified all the duties of the anaesthetist outside of the theatre environment. Overall, learners fared poorly, achieving an average score of 14% for the questionnaire. However, there was a statistically significant correlation between being from a high socioeconomic background and awareness that the anaesthetist administers anaesthesia. A high socioeconomic background was defined as having a suburban residence, a household income comprising a salary instead of social grants and care givers that possessed a university degree. Knowledge regarding the intraoperative duties of the anaesthetist was still poor, regardless of the socioeconomic background of the learner. Previous exposure to anaesthesia did not improve awareness about anaesthesia among the learners. Conclusion This study has shown that awareness regarding anaesthesia and anaesthetists is still lacking despite the radical growth in the field. This lack of awareness cannot be ignored; education of the general public should be intensified in order to empower people to ask the right questions as well as make informed decisions about their perioperative care in the future. More than half of the learners in the study (58.5%) believed that good medical education can reduce the burden of health care costs and medicolegal consequences; and 70% of them would request an anaesthetist to provide them with detailed information about their anaesthetic before the start of surgery. Therefore, despite lack of awareness, the majority of the learners displayed interest and willingness to know more about anaesthesia, and grade 12 learners would be a formidable target group to direct anaesthetic education campaigns
Post caesarean section outcomes of obstetric valvular heart disease patients at Charlotte Maxeke Johannesburg Academic Hospital
(University of the Witwatersrand, Johannesburg, 2022) Mfeka, Ntombizabanguni Glory
Background Valvular heart disease presents a unique set of conditions during pregnancy and delivery with the potential of adverse outcomes complicated by prior interventions and anticoagulation. The aim of this study was to describe the profile and outcomes of obstetric valvular heart disease patients who delivered via caesarean section at Charlotte Maxeke Johannesburg Academic Hospital. Methods A retrospective study was done using patient record files, anaesthetics forms and echocardiogram reports. The study period was a 5-year review from January 2016 to December 2020. Results Sixty-nine patients were included. The mean age ± SD of the patients in this study was 30.1 ± 5.6 years. A total of 83% had gravidity of 1-3 and 90% parity of 0-2. Majority of patients (57%) had elective caesarean section. General anaesthesia was the most common mode used and majority of patients had fixed interval analgesia (FIA) mode of analgesia postoperatively. 40.5% of the patients were on anticoagulants. A significantly higher percentage of those who needed anticoagulation (46%) had poorer outcomes when compared to those who did not (7%), (P<0.001). The was a univariable association between adverse maternal outcome and NYHA class and lack of use of anticoagulants [aOR 3.77, 95%CI 1.45 – 9.79, P=0.006 and aOR 0.11, 95%CI 0.018 – 0.67, P=0.017, respectively]. Low ejection fraction was univariably associated with adverse foetal outcome, uOR 0.94, 95%CI 0.90 – 0.99, P=0.032. One (1%) foetus demised. Conclusion Patients were younger and in relatively good functional status. They carried the pregnancies to term. Patients did experience adverse outcome related to bleeding and arrythmias predominantly, but none demised. One neonate was lost. A structured care plan for these patients, based on a multidisciplinary approach, to afford prehabilitation is necess
Neuroprotective strategies in cardiac surgery: a survey among South African anaesthesiologists
(University of the Witwatersrand, Johannesburg, 2023) Kumalo, Nthabiseng Jacqueline
Background The occurrence of neurological injury and cognitive disorders post cardiac surgery is a known complication that is described in literature. Neuroprotective strategies utilised intraoperatively can significantly improve postoperative neurological outcomes. The current challenge is the lack of standardised practice and protocols for intraoperative neuroprotection during cardiac surgery. This study looks at some of the currently applied neuroprotection strategies by clinicians during cardiac surgery. Methods A cross sectional,descriptive, contextual study was conducted amongst cardiothoracic anaesthetists and registrars in South Africa. A google link survey of the questionnaire consisting of 15 questions and 2 comment sections was sent out. To adhere to the protection of personal information act (POPIA), the questionnaire was centrally distributed via administration by the Cardiac Anaesthesia Society of South Africa (CASSA) and the South African Society of Anaesthesia (SASA), to its members. A link was shared with the members of CASSA during the Joint Peri-Operative Cardiothoracic (JPC) Annual Congress on the 20th of November 2021, and with the SASA members on the weekly online communication platform for the month of February 2022. Results A total of 101 clinicians around South Africa, involved in administering anaesthesia to patients requiring cardiac surgery, participated in this questionnaire. There is lack of standardized care for neuroprotection during cardiac surgery and availability on the stroke rates in most institutions. TTE use was preferred for atheromatous plaque assessment with epiaortic scanning barely used. Conclusion There is lack of standardised guidelines for the anaesthetic management of this high-risk population in academic and private centres across South Africa. This finding exposes a niche to be further explored by researchers to come up with preventative or risk minimising protocols during conduction of anaesthesia during the cardiopulmonary bypass (CPB) period.
Preoperative fasting practices and incidence of hypoglycaemia in patients presenting for caesarean section at a central hospital
(University of the Witwatersrand, Johannesburg, 2023) Prinsloo, Nathalie
Background Prolonged preoperative fasting times have a negative impact on parturients and may have a negative impact on the neonate. This study aimed to describe the preoperative fasting practices and incidence of hypoglycaemia in obstetric patients undergoing caesarean section, as well as the incidence of neonatal hypoglycaemia at Chris Hani Baragwanath Academic Hospital. Methods This prospective, cross-sectional study was conducted in 2021 over six months at Chris Hani Baragwanath Academic Hospital, a tertiary referral hospital in Johannesburg, South Africa. The sample consisted of 213 adult parturients who presented for emergency or elective caesarean section and excluded those who could not provide a history of fasting practices. Maternal blood glucose levels were measured prior to anaesthesia and neonatal blood glucose levels were measured immediately after delivery. Results Mean (SD) fasting times to solids and fluids were 18 h, 19 min (12 h, 4 min) and 13 h, 2 min (8 h, 31 min), respectively. Maternal hypoglycaemia occurred in 24.4% of the parturients and was associated with longer periods of fasting to solids (P=0.049). The incidence of neonatal hypoglycaemia was 1.8% and maternal blood glucose level was significantly positively correlated with neonatal blood glucose level (r=0.59, P<0.001). Conclusion Preoperative starvation times were excessive and should be addressed to avoid maternal hypoglycaemia. The impact of maternal hypoglycaemia on the neonate is less clear and further research is required before a protocol can be developed. It may be prudent to check the blood glucose levels of all parturients prior to caesarean section.
Audit of a surgical booking system for non-elective cases in a tertiary hospital
(University of the Witwatersrand, Johannesburg, 2023) Van Wyk, Natalie Jean
Background South Africa has a particularly large burden of emergency surgical disease, coupled with resource constraints as evidenced by fewer theatres per 100 000 population than the global average. The World Society of Emergency Surgery Study Group Initiative on Timing of Acute Care Surgery (TACS) Classification suggested application of a colour-coded triage system for acute surgical emergencies. TACS developed a ratio of Actual Time to Surgery (aTTS) to Ideal Time to Surgery (iTTS), based on expert opinion for each triage level. It is suggested that each institution examine its aTTS/iTTS ratio as a quality assessment tool, with a target ratio of ≤ 1. Objectives The primary objectives of this study were to describe the time between booking of non- elective operating theatre (OT) cases to the aTTS, denoted by the surrogate of time to theatre, at Chris Hani Baragwanath Academic Hospital and compare it to the iTTS for each colour-coded triage level. The secondary objectives included a description of the total number of non-elective cases per surgical discipline, identification of time differences in preoperative delays between surgical disciplines and age subgroups, and a comparison of preoperative delays for trauma patients against published data from Groote Schuur Hospital. Methods A retrospective clinical audit was conducted in the four dedicated 24-hour theatres of the JD Allen emergency operating theatres (JDA EOTs) over a period of one month. A colour code was added to each booking, at the discretion of the booking surgeon, according to the CHBAH operating theatre triage system (COTTS). The COTTS defined five categories, each with a corresponding iTTS, namely red (immediate), orange (2 hours), yellow (2 to 6 hours), green (24 hours) and blue (72 hours). The aTTS/iTTS ratio was calculated for each triage level. Results The sample size was 435 cases, comprised mostly of general surgery cases (29.7%), followed by orthopaedic surgery (20.1%) and trauma surgery cases (19.5%), respectively. The median aTTS for the red category (with target of immediate aTTS) was 2.1 hours (IQR 1.0 – 4.1 hours). The aTTS/iTTS ratio was 2.75 for the orange category and 2 for the yellow category. The aTTS/iTTS ratio was compliant for the green and blue groups, both with ratios of 0.7. The geriatric group showed the longest aTTS in each triage group and overall. The aTTS for trauma patients at CHBAH was longer for all triage categories than that reported from GSH in 2018. Conclusions This study shows a pattern of prolonged aTTs/iTTs ratios for higher urgency patients and acceptable ratios for lower urgency patients at CHBAH. The geriatric age group showed a longer aTTS for each triage level and overall. Further investigation into reasons for delays and optimal OT utilisation are necessary

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