School of Clinical Medicine (ETDs)
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Item Surgical aortopulmonary shunts - a thirty-seven year experience in a South African tertiary institution(University of the Witwatersrand, Johannesburg, 2019-11) Dladla-Mukansi, Nontobeko Charity; Cilliers, Antoinette; Mammen, Vijay; Vanderdonk, KathyIntroduction: The surgical aortopulmonary shunt is a valuable palliative procedure in the management of congenital heart diseases. There is a paucity of data regarding aortopulmonary shunts in the developing world, including South Africa. Objectives: The primary objective was to describe the demographic, clinical and echocardiographic characteristics of children between ages 0 and 14 years that underwent surgical aortopulmonary shunts. The secondary objectives were to describe trends in aortopulmonary shunt designs, outcomes in terms of morbidity and mortality, progression to definitive surgery and to assess patency of shunts. Material and Methods: A retrospective clinical audit of patient files who underwent an aortopulmonary shunt between 01 January 1980 to 30 December 2016 was undertaken at Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg. The study period was divided into 3 stages and for descriptive purposes as follows: 1980-1991 refers to period 1, 1992-2003 refers to period 2 and 2004-2016 refers to period 3. Results: A total of 177 aortopulmonary shunts were done over the 37-year study period. Of these 177 patients, 165 (93.2%) patient files were available. Fifty-six percent of the patients included in the study were male. The majority of patients were from the Gauteng Province (76.8%). The four most common diagnoses across the entire study period were tricuspid atresia (26.0%), pulmonary atresia with VSD (23.7%), tetralogy of Fallot (23.2%) and complex cardiac lesions (16.9%), with no particular trend in the proportion of these diagnoses presenting across this study period. There was no statistical difference between period 1 and 2 (p-value a=0,328) and between period 1 and 3 (p-value b=0,548). The total number of all surgeries done over the entire study period was 2145, of which 8.3% were aortopulmonary shunts. Period 1 had the highest percentage [35 (10.9%)] of aortopulmonary shunts compared to the total number of surgeries performed. There was a decline in the number of aortopulmonary shunts performed over the study periods 1-3. With no statistical difference across periods as shown in table 1 with p-value a and b. Of the different types of aortopulmonary shunts, most patients [157 (88.7%)] had a modified Blalock-Taussig shunt (BTS). The remainder of the shunts included 3 (1.7%) classic BTS, 12 (6.8%) central shunts and 5 (2.8%) unknown BTS. The percentage of modified BTS done increased from 80% in period 1 to 87.3% in period 2 and to 95.2% in period 3. Period 1 had the most complications (28.6%) compared to 11.4% in period 2 and 19.1% in period 3. Sepsis as a complication following surgery increased over the study period from 2.9% in period 1 to 3.8% and 7.9% in periods 2 and 3 respectively. Early mortality was 17.1%, 26.6% and 25.4% from periods 1-3 respectively. Late mortality declined from 17.0% in period 1 to 11.4% and 0% in periods 2 and 3 respectively. Only 37 (20.9%) patients were documented to have further surgery after the initial aortopulmonary shunt. Across all three study periods, no blocked shunts were documented. Conclusions: This study describes the characteristics and outcomes of aortopulmonary shunts over a 37-year period in a tertiary care resource limited low to middle income country setting. The commonest cardiac lesions for which aortopulmonary shunts are performed are tricuspid atresia, pulmonary atresia with VSD, tetralogy of Fallot and other complex cyanotic cardiac lesions. The frequency of aortopulmonary shunts compared to total surgeries has corrective surgery for these cardiac lesions. The modified BTS is the most frequently performed aortopulmonary shunt used for palliative surgery in our setting, which is a similar trend in developed countries. The morbidity and mortality in this study is higher than developed countries, with sepsis being the most common complication. Attention to infection control practises need to be emphasized peri- and post-operatively in our hospitals.Item Non-tuberculous mycobacteria (NTM) at Charlotte Maxeke Academic Hospital, 2010-2017(University of the Witwatersrand, Johannesburg, 2023-11) Nqwata, Lamla; Feldman, Charles; Black, MarianneRationale: Diseases due to non-tuberculous mycobacteria (NTM) are difficult to diagnose and are not reportable in South Africa (SA), resulting in the disease burden and trends being under-appreciated. Objectives: To characterize NTM disease occurrence and trends in Johannesburg and to estimate end-of-treatment outcomes. Methods: A retrospective review of all clinical isolates that were positive for NTMs between 1 January 2010 and 30 June 2017 and the corresponding medical records of the patients at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) were analysed. A data collection form was designed, and data was collected based on information listed on the form. This was analysed using Graphpad Instat (Graphpad Inc, 3.1 version, San Diego, California, US) and STATA version 11, College Station, Texas, software. In descriptive analyses, two-tailed Fisher’s exact tests were used to compare categorical variables, while Kruskal-Wallis tests and Student’s T-test were used to compare continuous variables, as needed. Kaplan-Meier curves and log-rank tests were used to compare time-to-death, while Cox regression analyses were used in multivariate analyses of the same. Results: A total of 123 patients with positive NTM isolates were enrolled in this study. In this cohort, positive NTM isolates were found mostly in males (71; 57,7%), with a median age of 39 [Interquartile range 31.5-49.5] years. Mycobacteria avium complex (MAC) was the most common, isolated in 90 (75%) cases. Human immunodeficiency virus (HIV) infection, found in 96(80%) patients, and prior pulmonary tuberculosis (TB), found in 38(30%), were the common comorbidities. Overall, 27(22%) were successfully treated and 28(23%) died. In multivariate Cox regression analysis the adjusted hazard rates were 2.79 (95%CI 1.20 – 6.50) in those with low CD4 cell counts and 4.01 (95%CI 1.17 – 13.77) in those with unknown HIV test results. Receipt of antimicrobials did not significantly improve survival. Conclusion: Non-tuberculous mycobacteria (NTM) appear to be common in our setting and is associated with poor outcomes.Item Public attitudes to corneal tissue donation in an urban South African population(University of the Witwatersrand, Johannesburg, 2023-08) Hajee, Faheema; Hollhumer, RolandBackground: Corneal pathology is the second leading cause of preventable blindness in Sub-Saharan Africa. Corneal disease is the cause of visual loss in 11% of blind or severely visually impaired children and 4% of blind adults in South Africa. In majority of cases, a corneal transplant or keratoplasty can restore or significantly improve vision. South Africa has an immense shortage of donor corneas, causing the burden of corneal disease requiring transplantation to continually rise. Aim: The aim of this study was to determine the public attitude towards corneal tissue donation in an urban South African population. Setting: The study was conducted at St John’s Eye Hospital, Soweto, South Africa. Method and Design: This was an observational, cross-sectional quantitative study of the current attitude of an urban South African population towards corneal tissue donation. A self-designed questionnaire was developed. The participants were asked about reasons for both willingness and unwillingness to donate their corneas. The study population included patients or escorts attending the out-patients clinic at Saint John’s Eye Hospital. Results: A total of 100 participants (60 females and 40 males) completed the questionnaire. The mean age (±SD) of the study participants was 41.26 (±14.7) years. Seventy-six percent of participants did not know about corneal donation. Sixty four percent of participants were willing to donate their corneas, whereas 25% were not willing to do so. The main reason for unwillingness to donate their corneas was cultural reasons. In this study there was no statistically significant correlation between the willingness to donate corneal tissue and age, gender, level of education and employment status. There was a statistically significant difference between the willingness to donate one’s solid organs as compared to the willingness to donate one’s cornea (p-value 0.029). Participants were more willing to donate their solid organs than they were willing to donate their corneas. Conclusion: There is a decreased level of awareness of corneal tissue donation in this urban South African population. However, many of the participants had a positive attitude towards corneal donations. Increasing the awareness of donation and its benefits may help increase the supply of corneal tissue.Item Final-year medical students' experiences and perceptions of integrated primary care learning at decentralised training sites during the COVID-19 pandemic: A mixed-methods study(University of the Witwatersrand, Johannesburg, 2023-09) Ruch, Aviva; George, Ann; Francis, JoelBackground: There is limited data on the effectiveness of online learning to augment theory and clinical knowledge and skills across decentralised training (DCT) sites. This study explored the 2021 cohort of final-year medical students’ experiences and perceptions of the integrated primary care (IPC) online teaching and learning across five DCT sites affiliated with the University of the Witwatersrand in South Africa. This information is essential to determine what online IPC teaching and learning should be retained and what adjustments are needed to enhance and standardise IPC online learning across our DCT sites. IPC is a final-year Bachelor of Medicine and Bachelor of Surgery (MBBCH) subject at Wits University. The subject focuses on primary health care, integrating Internal Medicine, Surgery, Psychiatry, Obstetrics and Gynaecology, Family Medicine, Community Paediatrics and Public Health. Training across different sites poses challenges for standardising learning content and the nature and quality of patient engagement and interaction. The Covid-19 pandemic not only exacerbated the difficulties associated with decentralised teaching and learning, but also decreased student-patient interaction. The rapid shift to emergency remote teaching left teachers with limited time to prepare for online and blended teaching and highlighted shortcomings in some health-professions educators’ ability to create meaningful, authentic learning interactions. The study design was underpinned by the Technology Acceptance Model, the Community of Inquiry Model and the Theory of Self-Regulated Learning. Methods: This explanatory sequential mixed-methods design consisted of a cross-sectional online survey conducted in November 2021, followed by two focus-group discussions in December 2021. The 316 final-year medical students who had completed their IPC block were purposively sampled to participate in this study. Medical students who had not yet completed the IPC block were excluded from the study. Twenty-one closed and four open-ended questions explored the students’ perceptions of how the online materials supported their learning and augmented their clinical skills and management of patients, their challenges with learning online, and ways to improve the online-learning experience. The closed and open-ended survey answers were analysed using descriptive and inferential statistics and content analysis, respectively. The results of the content analysis are presented graphically. The survey findings informed the questions asked in the focus-group discussions (n = 2 and n = 3). The discussions were audio-recorded and transcribed verbatim. The transcripts were analysed inductively in MAXQDA. The findings are presented as thematic maps. Results: The survey response rate was 52% (164/316). The respondents were representative of the study population. Most respondents easily accessed the online content, with more than 70% accessing the online content several times a week. More than 80% found the online content logically organised; the content analysis highlighted three categories of reasons why the online content and interactions influenced their learning. The content analysis also identified three categories of reasons why the online content influenced patient management, but more than a third of respondents remained neutral when asked if the online content introduced them to new clinical skills. Quizzes and tests were the preferred learning method. The features that best supported the respondents’ online learning were grouped into five categories: ‘Range of activities’ (n = 73), ‘Content selection’ (n = 56), ‘Flexible access to content’ (n = 8), ‘Organisation of content’ (n = 4) and ‘Other’ features (n = 7). Respondents highlighted several categories that presented challenges to online learning: ‘Pedagogical issues’ (n = 30), ‘Excessive workload’ (n = 27), ‘Operational issues’ (n = 20), ‘Learning issues’ (n = 17), ‘Technical issues’ (n = 11) and ‘Unclear course expectations’ (n = 50). Participants in the focus-group discussions (FGD) concurred with many of the perceptions and experiences of the questionnaire respondents. Three themes were identified in the thematic analysis of the FGD: ‘Features supporting learning’, ‘Challenges of learning online’, and ‘Ways to improve learning’. Conclusions: The respondents and focus-group participants displayed a positive attitude to the IPC online content and interactions offered to them during the Covid-19 pandemic. Their experiences and perceptions offered insights to better support learning through practical suggestions for students and faculty, especially around faculty competency to design meaningful learning interactions, both online and blended. While this study focused on IPC, the student recommendations may apply to other subjects nationally and internationally, suggesting the need for further research into using online teaching to support clinical teaching.Item An ethico-legal analysis of broad consent for biobank research in South Africa: Towards an enabling framework(University of the Witwatersrand, Johannesburg, 2024) Maseme, Mantombi RebeccaBiobanks preserve collections of human biological material and data for the benefit of medical research. Using and transferring human biological data and materials both inside and outside of South Africa is often a requirement of biobank research. Broad consent is allowed by the South African National Department of Health Ethics Guidelines but appears to be prohibited by section 13(1) of the Protection of Personal Information Act 4 of 2013. Additionally, the Act mandates that all personal data (including biobank sample data) be collected for legitimate, definite, and clearly stated purposes. There is room for several interpretations of the Act because of this discord between the two instruments. Given the connection between the transfer of samples and data, the long-term nature of biobanking, which makes it impractical to provide too much or adequate information because it is simply not available at the time of sample collection, and the various ways that the Protection of Personal Information Act 4 of 2013 have been interpreted, I aim to respond to the following question: How should South Africa’s current regulatory framework appropriately permit broad consent use for biobank research where the transfer of samples and their associated data are contemplated? The research question is addressed by applying ethical principles and theories, as well as analysing and evaluating relevant ethico-legal frameworks and literature. The study involves no research participants and no collection or analysis of any new data. Arguments for and against using broad consent for biobank research are discussed by demonstrating the potential for biobank research to do a great deal of good for humanity; the ambiguity in the current regulatory framework regarding whether broad consent is permissible for personal information/data; and the ethical justifiability of broad consent. In summary, the proposed regulatory framework amendments are those that would be required to allow for ethically justifiable biobank research broad consent use. These include removing regulatory ambiguity regarding broad consent use, ensuring adequate safeguards for research participants by specifying rules for data access and personal information processing, and incorporating consent form information requirements into the national Consent Template as specified in the National Department of Health Ethics GuidelinesItem 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, DeepakBackground 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.Item Anaesthetic nurses’ knowledge and skills in perioperative airway management at Chris Hani Baragwanath Academic Hospital(University of the Witwatersrand, Johannesburg, 2024) Dold, MatthewBackground: Airway management in the peri-operative period carries specific inherent risks, and the benefit of assistance by a skilled anaesthetic nurse cannot be over-stated. The aim of this study was to assess the theoretical and clinical knowledge regarding perioperative airway management in anaesthetic nurses at Chris Hani Baragwanath Academic Hospital (CHBAH). Method: A quantitative, contextual, cross-sectional and descriptive survey was performed by means of a self-administered anonymous questionnaire using convenience sampling. The questionnaire assessed identification of airway equipment, knowledge of the cleaning, maintenance and use of equipment and clinically applicable insight into perioperative airway procedures and emergencies. It’s adequacy and validity were ensured by means of the Angoff standard setting method. Data was analysed in consultation with a biostatistician. Results: A total of 68 nurses took part in the study. By distribution of rank, 78% (n=53) enrolled nurses, 19% (n=13) professional nurses and 3% (n=2) nursing assistants. The incidence of prior airway training was 41% (n=28). The overall mean questionnaire score was 69,8% (SD: 9.6%) with a range of 45% - 97%. Only 19% (n=13) of nurses achieved adequate overall scores. Years of experience was positively associated with overall mean scores (p=0.0009) and adequacy of knowledge (OR 1.28, p=0.004). Airway training showed a small increase mean scores (mean difference=4.63%, p=0.049). There were no statistically significant associations between adequate knowledge and age, prior airway training and nurse qualification. Conclusion: This study found that the theoretical and clinical knowledge of perioperative airway management of many anaesthetic nurses at CHBAH is inadequate. Knowledge adequacy improved with increasing experience but not with current forms of formal training. This may be attributed to the low frequency of training as well as the type of training methods currently employed; both of which should be addressed to improve anaesthetic nurse competence and ultimately patient perioperative safetyItem Glioma histology at charlotte Maxeke Johannesburg academic hospital, a five year retrospective study(University of the Witwatersrand, Johannesburg, 2024) Mohale, Diapo Gerald; Profyris, Christos; Mpanza, Morena NthuseThe epidemiology of gliomas has been described thoroughly by developed countries worldwide but information regarding gliomas is limited in developing countries including in our local setting in South Africa. This study will be describing glioma histology and the demographics of patients with gliomas for patients diagnosed at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) situated in Johannesburg South Africa. The records of 44 patients ages between 12 and 70 years with histologically confirmed glioma from 2015 to 2919 was reviewed and our findings are as follows; In our sector we see more Black population than White, Coloured and Asians combined. Despite that literature commonly report gliomas to be more prevalent in males than females, we found females to be more prevalent than males (ratio 1,3:1) in our study group with males only showing prevalence over females with the advanced age group of 60 to 70 years. Our mean age of glioma diagnosis is younger (43years) than the documented age group and we found the mean age to be even younger with patients confirmed HIV (38 years). The study demonstrated that females were diagnosed at early average age of 40 year and males average age of 47 years. In keeping with literature glioblastoma is the most common glioma in our study population. We also found gliomas to be more prevalent supratentorial in the temporal lobe than infratentorial and other lobes respectively in our study population. Patients with higher grade gliomas presented with varied number of symptoms than lower grade. With regard to biopsy procedures, most of our cases had undergone minimal invasive stereotactic biopsy and about seventy percent of the frozen biopsy cases were of patients who had minimal invasive stereotactic biopsy and only thirty percent had open biopsy. The study found that glioma size increased with increase in glioma grade and patients who are HIV positive. There was no significant relationship found between patients’ age groups and glioma size. We found that immunochemistry is widely done , but molecular testing lacking behind with testing only started late 2017 and improving annually. For patients with HIV it was found that grade III gliomas are the most prevalent. Glioma grade increase with increase in age group and in patients wo are confirmed HIV positive. A formal national registry for gliomas will help to determine disease demographics, distribution, frequencies and associations for early detection and patients management strategies.