School of Clinical Medicine (ETDs)

Permanent URI for this communityhttps://hdl.handle.net/10539/37930

Browse

Subject: search.filters.subject.SDG-16: Peace, justice and strong institutions

Search Results

Now showing 1 - 10 of 20
  • Thumbnail Image
    Item
    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.
  • Thumbnail Image
    Item
    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.
  • Thumbnail Image
    Item
    Perinatal outcome of all maternal deaths at Chris Hani Baragwanath Academic Hospital from January 2014 to June 2019
    (2024) Afolayan, Nomshado Sthembile
    Background: Maternal death is a tragic event. Out of the total number of maternal deaths, 99% occur in lowand middle-income countries. Perinatal outcome is related to maternal wellbeing. Maternal death has a negative impact on the fetal and neonatal outcome in the short and long term. Objectives: To determine the perinatal outcomes of pregnancies that end in a maternal death at CHBAH over a 5-year period, to describe the causes of maternal death and to determine the stillbirth rate and early neonatal death rate within this population. Methods A retrospective cross-sectional study of the maternal deaths in women with a viable pregnancy from January 2014 till June 2019 at CHBAH. All maternal deaths with gestation > 26 weeks or neonatal weight >500g were included in the study. Data was extracted from maternal and neonatal files. The following information was retrieved; demographics, booking status, antenatal care, pregnancy outcome, fetal and neonatal outcome. The data was analyzed using STATA. Approval from the University of Witwatersrand Human Research Ethics Committee (Protocol number: M1911143) and the CEO was obtained. Results: There was a total of 184 maternal deaths during the study period and 147 were included in this study. The iMMR was 135 deaths per 100 000 live births. Hypertension was the highest direct cause of death at 37% (27/74) followed by pregnancy related sepsis 27.4% (20/74) and then obstetric hemorrhage 20.6% (15/74). Non-pregnancy related infections (NPRI) made up 52.1% (38/73) of indirect causes, with HIV and HIV-related complications contributing 84.2% of the NPRI causes, followed by the medical and surgical disorders respectively. One hundred and thirty-seven neonates were delivered and 14 were undelivered at the time of maternal death. There were also two set of twins and one set of triplets. Ninety-one (61.9%) were born alive and 51 (34.6%) were stillbirths. Of the 91 live births 6 (6.5%) had an early neonatal death. Of the 51 stillbirths, 14 (27.5%) were from undelivered maternal deaths and 11 (21.1%) were from perimortem caesarian sections. The SBR was 347 per 1000 total maternal deaths and an ENND rate was 66 per 1000 live births. The PNMR was high at 388 per 1000 maternal deaths which is12 times higher than the general population. Conclusion: Maternal deaths are associated with very poor perinatal outcomes, resulting in unacceptably high stillbirth rate, early neonatal death rate and perinatal mortality rate. The health of the mother has a significant impact on the perinatal outcomes of the pregnant woman. Most of the causes of death were mostly women with comorbidities , we therefore postulate that prenatal care and stringent antenatal care may assist in optimizing women and thus reducing maternal deaths and ultimately the perinatal outcomes.
  • Thumbnail Image
    Item
    Compliance of medical practitioners with diabetic treatment guidelines at Dr Yusuf Dadoo Hospital, West Rand Health District Gauteng
    (2024) Ohanson, N.J.
    Background: Diabetes (DM) is a common chronic condition. The prevalence is increasing globally and has become a common health care problem associated with multiple complications. Guidelines have been formulated to standardise care among people living with DM, with aim of optimising patient care and thus minimising the complications. Aim: The aim of this study was to assess how well health care practitioners in Dr Yusuf Dadoo Hospital complied with the most recent diabetic treatment guideline, SEMDSA 2017. Setting: This study was conducted in the out-patient department of Dr Yusuf Dadoo hospital in the Westrand Health district of Gauteng. Methods: A retrospective cross-sectional review of patient record living with diabetes was done. Three hundred and twenty-three Record of patients seen from August 2019 to December 2019 were reviewed and some of the basic variables were assessed according to the most recent diabetic treatment guidelines SEMDSA 2017. Results: Files were audited in 4 main categories. Comorbidities, Examinations. Investigations, presence of complications. In terms of monitoring parameters, only 40(12.4%) had HbA1c assessed 6monthly, with annual creatinine assessed in 179(55.4%) and lipogram 154(47.7%) of patients. More than 70% of patients had uncontrolled glycaemia. More than 70% of patients had uncontrolled glycaemia. The most frequently documented target organ screening/examinations were foot related at 8.7% (28) and all of them had established complications. Only 2 people were screened for erectile dysfunction. Conclusion: Adherence to DM treatment guidelines was found to be poor. Monitoring and control parameters were infrequently done as per guideline recommendation. The resultant effect are poor glycaemic control and therefore numerous complications. The study site and thus the West rand needs targeted strategies to improve medical practitioner adherence to guidelines including adequate interpretation of results, timely intervention, when necessary, as a way to improve DM care and thus minimise the risk of complications amongst patients in the district
  • Thumbnail Image
    Item
    Obstetric trauma admissions in a level 1 trauma centre in South Africa: a 5-year retrospective review
    (2024) Moyo, Njaya Bruce
    Background: Trauma is one of the leading causes of morbidity and mortality in pregnancy and remains the most common cause of fetal mortality worldwide. The severity of injury as well as early and aggressive management of injuries are significant factors that determine maternal and fetal outcomes. Objectives: The aim of this study was to describe the characteristics, mechanisms of injury, clinical interventions performed as well as maternal and fetal outcomes of obstetric trauma admissions to our institution. Methods: This was a retrospective review of data of all pregnant patients admitted to Chris Hani Baragwanath Academic Hospital from 01 January 2015 to 31 December 2019 with trauma. Patients were identified from admission registries from the departments of obstetrics and gynaecology, emergency medicine, general surgery, orthopaedics and intensive care. Data collected included demographic data, mechanisms of injury, clinical interventions, as well as maternal and fetal outcomes. Results: Data of 800 patients was included in the study during the five-year period. The median age and gestational ages were 31.00 years and 26.00 weeks respectively. The majority of pregnant trauma patients self-identified as black Africans (n= 713; 89.1%). Five hundred and sixty-two patients were of single marital status (70.3%) and 484 identified as unemployed (60.5%). Assaults were the most frequent cause of trauma (n= 330; 41.3%), followed by falls (n= 265; 33.1%) and motor vehicle accidents (n= 204; 25.5%). Hundred and forty-one patients (18.0%) were documented to have consumed alcohol on the day of the injury. Four patients (0.5%) were admitted to ICU, of these one died in ICU. Ten fetal deaths were recorded, of these three were delivered by patients admitted to ICU. Eleven neonates were delivered before 37 weeks. Conclusion: Trauma in pregnancy is associated with significant morbidity and negative pregnancy outcomes. We identified unemployed pregnant patients of single marital status as being at increased risk of obstetric trauma. Assaults followed by falls and motor vehicle accidents were the commonest causes of maternal trauma in our population. The implementation of strategies aimed at detecting and preventing intimate partner violence as well as road safety may contribute significantly to a reduction of maternal and fetal mortality
  • Thumbnail Image
    Item
    The occurrence of hyponatraemia amongst patients with severe mental illness admitted at Solomon Stix Morewa Memorial Hospital, Johannesburg
    (2024) Nhiwatiwa, Natsai Marjory Sekai
    Background: Morbidity in patients with severe mental illness is known to be higher than in the general population. Numerous factors contribute to this, including the propensity to have comorbid conditions and the effects of long-term treatment with psychotropics. Hyponatraemia is the most common electrolyte abnormality found in hospitalised patients. Patients with severe mental illness are vulnerable to the development of hyponatraemia due to psychogenic polydipsia, comorbid conditions and the long-term use of psychotropics. Aim: To evaluate the occurrence of hyponatraemia in patients with severe mental illness that are admitted at Solomon Stix Morewa Memorial Hospital and to determine the associations between the hyponatraemia and the patients’ demographic and clinical variables. Objectives: To assess and quantify the occurrence of hyponatraemia in patients with severe mental illness. To establish the cases, grades of severity and the trends of hyponatraemia in the study sample. To make possible associations between the development of hyponatraemia and the various clinical profiles. To analyse the trends of sodium testing in the study participants. Results: 32% of the patients had hyponatraemia on admission to Solomon Stix Morewa Memorial Hospital, significantly higher than that of the general population. Female patients and patients on antihypertensive medications were more likely to have hyponatraemia. Other medical conditions such as hypertension, type 2 diabetes mellitus and chronic obstructive pulmonary disease were significant predictors for the development of hyponatraemia. Patients on combination antipsychotics (first- and second-generation antipsychotics) were also more likely to develop hyponatraemia than those not on combination antipsychotics. Conclusion: Hyponatraemia was found in a significant proportion of the study participants. Patients with severe mental illness are more likely to have co-morbid illnesses that can be overlooked. The comorbid illnesses render the patients more likely to develop complications such as hyponatraemia that worsens their outcomes and mortality. More research is required to establish the role of combination antipsychotics as a possible cause of the development of hyponatraemia in psychiatric patients. Definitive monitoring guidelines are required in the long-term management of patients with severe mental illness. More recognition of hyponatraemia as a significant adverse effect of comorbid illness, psychiatric illness and chronic medication is required in patients with severe mental illness.
  • Thumbnail Image
    Item
    Pattern of thyroid disorders in black population referred for thyroid scintigraphy at Chris Hani Baragwanath Hospital, South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Zergoug, Nadia
    Background: Most endocrine disorders are due to thyroid dysfunction with varying etiologies. Different management protocols exist for the different endocrine disorders, and it is crucial to determine the specific cause due to thyroid dysfunction. This study aimed to describe the spectrum of thyroid diseases in patients who undergo thyroid scintigraphy and to assess the agreement with biochemistry and scintigraphy. Methods: This was a retrospective study to assess the pattern of thyroid disorders in the patients referred for thyroid scintigraphy at Chris Hani Baragwanath Hospital (CHBAH). All cases diagnosed with thyroid dysfunction based on biochemical results and referred for 99m Tc scintigraphy to nuclear medicine from January 2017 to December 2018 were reviewed. All records reviewed were >18 years of age and were a total of 780. Result s Of the 780 patients reviewed, 631 (80.9%) were black while the remaining 19.1% comprises White, Indian, and Coloured individuals. Among the Blacks, 84% were females and 16% were males. Graves’ disease was the commonest thyroid disease diagnosed on scintigraphy in the entire population and among the blacks, constituting 72% (n=454/631) of patients. Other thyroid disorders among the black population include toxic multinodular goitre (13%, n=80/631), non-toxic multinodular goitre (7%, n=45/631), toxic adenoma (3%, n=17/631), and thyroiditis (3%, n=21/631). The black patients’ mean age was 47.3 years with a standard deviation (SD) of ±15.1 years. Graves’ disease as well as other thyroid disorders affected all age groups but were most prominent in the 40-59 years age group in both females and males. The median thyroid stimulating hormone (TSH) was 0.001 mIU/L while free thyroxine (fT4) ranged from 7.4 – 160 pmol/L in black population diagnosed with hyperthyroidism. Conclusion: Graves’ disease is the commonest cause of thyroid disorders among individuals referred for thyroid scintigraphy, being most prevalent in Black females in the reproductive age group. Thyroid scintigraphy is useful for aetiological diagnosis in patients presenting with thyroid disorders.
  • Thumbnail Image
    Item
    Evaluation of medical interns’ knowledge and confidence in orthopaedic surgery at the University of the Witwatersrand's academic hospital complex in Johannesburg, South Africa
    (2024) Terreblanche, Michael Harland
    Background Junior doctors’ knowledge and confidence in the assessment and treatment of musculoskeletal disorders and injuries has previously been shown to be limited, both locally and internationally. This has far-reaching consequences, not least of which is sub-optimal patient care. The aim of this study was to evaluate the effectiveness of current undergraduate orthopaedic training in South Africa. Materials and methods Medical interns rotating through the orthopaedic departments of three academic hospitals in Johannesburg, South Africa were surveyed, using a validated questionnaire consisting of twenty-five questions, to assess their knowledge of orthopaedic surgery. Furthermore, they were asked to rate their self-perceived confidence levels relating to various aspects of the care of individuals with musculoskeletal problems using a 5-point Likert scale. The future career interest of the interns was also recorded. Results Seventy-eight completed questionnaires were included in this study for analysis. Ninety six percent (96%) of the medical interns in this study failed to achieve basic cognitive competency concerning knowledge of orthopaedic surgery. Three out of seventy-eight medical interns in this study achieved basic theoretical competency in orthopaedic surgery. The interns’ mean score in the 25-question examination was 40.7% (SD 13.4%) with a range of 17 – 69%. Ninety two percent (92.3%) of participants reported that they were either confident or highly confident in orthopaedic surgery. Future career choice had no influence on the knowledge of orthopaedic surgery. Conclusion The effectiveness of South African undergraduate training of orthopaedic surgery is deficient. Recent South African medical graduates’ knowledge of orthopaedic surgery is inadequate, with a mean score of 40.7% in the Freedman and Bernstein questionnaire, and only 3.8% of interns achieving theoretical competency. The graduates demonstrated inappropriate confidence in orthopaedic surgery with only 7.7% acknowledging a lack of confidence. Interns’ future career interest was not found to have a significant association with knowledge of orthopaedic surgery. This study suggests that, in South Africa, orthopaedic undergraduate training needs reform.
  • Thumbnail Image
    Item
    Comorbidities in a cohort of privately insured South Africans with systemic lupus erythematosus
    (2024) Ntumba, Mbombo Henriette Ngandu
    Background: Comorbidities in systemic lupus erythematosus (SLE) impact negatively health related quality of life and life expectancy. We undertook a retrospective study of the burden of comorbidities in privately insured South Africans with SLE. Methods: Data review of patients insured with Discovery Health Medical Scheme (DHMS), ≥16years at diagnosis, ≥6months follow-up and diagnosed with SLE based on ICD 10 codes. Demographics, drug therapy and comorbidities listed in the Charlson Comorbidity Index (CCI) and other comorbidities occurring commonly in SLE patients were documented. Results: Of 520 patients with SLE ICD 10 codes, only 207 met the other inclusion/exclusion criteria for data analysis. Most were women (90.8%), median (IQR) age and follow-up duration of 39 (30.3-53.0) and 6.1 (3.7-8.1) years, respectively. All patients had at least one comorbidity, the most frequent CCI comorbidities being pulmonary disease (30.9%), congestive heart failure (CHF) (15%) and renal disease (14.5%). Common CCI comorbidities were hypertension (53.1%), mood and anxiety disorders (46.9%), infections (urinary tract infections (UTI) (37.7%) and pneumonia (33.8%)). Independent predictors of 1) CHF were renal disease (OR=855), dyslipidaemia (OR=15.3) and male gender (OR=43.0); 2) hypertension were age at diagnosis (OR=1.03), type 2 diabetes (OR=4.45) and renal disease (OR=4.34); and 3) mood and anxiety disorders were female gender (OR=3.98), cerebrovascular accident (OR=3.18), UTI (OR=2.39) and chloroquine use (OR=1.94). Conclusion: Comorbidities in this cohort of privately insured South Africans with SLE were common, with all patients having at least one comorbidity. Hypertension, infections and mood and anxiety disorders were the leading comorbidities.
  • Thumbnail Image
    Item
    A tale of two sites: an audit of central nervous system metastases in two Johannesburg tertiary centres
    (2024) Molefe, Masechaba
    Background: Literature reports the most common neoplasms of the CNS as metastases. Most studies are from the US and Europe with a paucity of data in the African setting. Objective: To provide information among patients with histologically confirmed CNS metastases treated at the neurosurgical units of the University of the Witwatersrand, namely at CHBAH and CMJAH. Methods: A retrospective record review of patients with histologically confirmed CNS metastases, presenting between 01 January 2015 and 31 December 2019 was conducted. The following data were collected and analysed: demographic, clinical, radiological and histopathological data. Results: 88 patients were included in the study. The frequencies of brain and spine metastases were 13% and 48% respectively compared to all other operated primary tumours. More females were prevalent at 51.7% in the brain metastases cohort, while males were more prevalent in the spine metastases cohort at 57.1%. In brain metastases patients the median age at presentation was 49 and for those with spine metastases the mean age was 47.1. The distribution for brain metastases was: 65% supratentorially; 20% infratentorially; 15% mixed. The distribution for spine metastases was: thoracic 32.1%; lumbosacral 28.5%; cervical 14.3%, mixed 25%. The most prevalent histopathologies for brain metastases were: lung 21.7%; breast 11.7%; melanoma 11.7%. The most prevalent histopathologies for spine metastases were lymphoma and plasma cell neoplasms each comprising 21.4%. Conclusion: More females presented with brain metastases and predominantly more males had spine metastases. There was a younger age of presentation compared to most studies conducted in Africa and globally