Faculty of Health Sciences (ETDs)

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    An assessment of the hospital learning environment within the University of Witwatersrand obstetrics and gynaecology registrar training programme
    (University of the Witwatersrand, Johannesburg, 2023-11) 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 <0.05was 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.
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    Post-COVID Syndrome in Otorhinolaryngology: A Systematic Review
    (University of the Witwatersrand, Johannesburg, 2023-07) Chiware, Rumbidzai; Maharaj, Shivesh
    Background: The novel virus SARS-CoV-2 which is the cause for coronavirus-19 disease (widely known as COVID-19), has shifted health and healthcare worldwide. With the majority of COVID-19 cases having mild to moderate symptoms, and with improvement in treatment and survival of severe disease, there has been a rise in the number of patients presenting with prolonged, recurrent or new symptoms long after the time frame of active disease. This phenomenon has been given various terms which include post-COVID syndrome. Post-COVID syndrome like acute disease has various clinical presentations that involve multiple systems in the body which include the ear, nose and throat. Due to the substantial increase in this population of patients with ongoing COVID-19 symptoms, the current focus is towards identifying and managing these patients early so as to improve outcomes and quality of life. Objectives: The aim of this systematic review was to bring awareness to post-COVID syndrome in the context of otorhinolaryngology with a description of the demographics, clinical manifestations and identifiable predisposing factors. The secondary objectives were to describe special investigations used for diagnosis and management of patients with post-COVID syndrome in otorhinolaryngology. Methods: A systematic review of all the available published literature (systematic reviews, cohort studies, case series and case studies) was conducted. The databases searched were PubMed, The Cochrane Database of Systematic Reviews, EMBASE, and Google Scholar. The search terms used were “post-COVID syndrome” OR ‘’post-acute COVID-19’’ OR ‘’long COVID’’ AND “chemoreceptor dysfunction” OR “Otology” OR “Rhinology” OR “Laryngology”. The search included articles from January the 1st 2020 to the 31st of July 2021. A total number of 13 561 articles were found of which 25 articles met the inclusion criteria. The systematic review was a retrospective study of information already available in the public domain. Ethics clearance was received from the University of the Witwatersrand Human Research Ethics Committee (medical). Results: A total of 25 studies were included in the systematic review with a total of 1041 patients presenting with otorhinolaryngological symptoms associated with COVID-19. Patients who presented with symptoms in the post-acute COVID-19 period (more than 4 weeks) were 383 in total. The vast majority presented with chemosensory dysfunction (olfactory +/- gustatory) accounting for 82,5% (n=316). Patients with audiovestibular symptoms (sensorineural hearing loss, tinnitus and/or vertigo) accounted for 7,6% (n=29) and patients with dysphonia 9,9% (n=38). Fifteen percent of cases (152/1041) presented with otorhinolaryngological symptoms beyond 12 weeks (post-COVID syndrome). Chemosensory dysfunction still accounted for most cases in this group with 80,9% (n=123), 8,6% (n=13) had persistent or residual audiovestibular symptoms (sensorineural hearing loss, tinnitus, vertigo) and 10,5% (n=16) had persistent dysphonia. The limitations of the systematic review were the lack of high-quality data due to the novelty of COVID-19, the risk of bias of individual studies and the heterogenous findings and outcomes. Conclusion: Post-COVID syndrome like acute COVID-19 manifests in multiple systems in the body which include the ear, nose and throat. Otorhinolaryngological symptoms that this population presents with include chemosensory dysfunction, audiovestibular dysfunction and dysphonia. Olfactory dysfunction is the dominant presentation with more data available in the literature as it presents more commonly. There is need for larger and more detailed future studies with focus on identification of specific risk factors that predispose individuals to post-COVID syndrome with the goal of improving outcomes and preventing long-term disability.
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    The role of prophylactic antibiotics in zone II and zone V acute flexor tendon injury
    (University of the Witwatersrand, Johannesburg, 2023-11) Tshisikule, Rihangwele Christopher; Sathekga, Mokgopo Cynthia; Sekeitto, Allan Roy
    Background: In the literature, there is no universal consensus on the role of antibiotic prophylaxis in patients presenting with simple hand lacerations that has no macroscopic wound contamination. Our study sought to establish the necessity of prolonged pre-operative antibiotic prophylaxis in patients presenting with zone II and zone V acute flexor tendon injuries (FTI) at Chris Hani Baragwanath Academic Hospital (CHBAH). Methods: This was a prospective study of 116 patients who presented with zone II and zone V acute FTI. The study period was between 01 November 2020 and 31 August 2021. Patients were randomised into a group receiving a single dose of prophylactic antibiotic in casualty and another group receiving a single antibiotic dose plus a continuous 8 hourly dose until the day of surgery. Each group was subdivided into occupational and non-occupational injuries. Their post-operative wound outcomes were documented 10 ‒ 14 days after surgery. The wound outcome was reported as no infection, superficial infection (treated with wound dressings), and deep infection (requiring surgical debridement). Results: There was 0.9% rate of deep post-operative wound infections, which was a single zone V acute FTI case in a single dose prophylactic antibiotic group. There was a 7.8% superficial post-operative wound infection rate, which was mainly zone II acute FTI in both antibiotic groups. There was a strong association between zone II acute FTI and post-operative wound infection (p < 0.05). There was no association between (antibiotic dosage or place of injury) with post-operative wound infection (p > 0.05). Conclusion: There is no benefit in prescribing prolonged pre-operative antibiotic in patients with acute, simple lacerations to zone II and zone V FTI if there is no macroscopic wound contamination.
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    Comparison of the success of medial patellofemoral ligament reconstruction techniques
    (University of the Witwatersrand, Johannesburg, 2023-11) Almeida, Peter Richard; Gelbart, B.R.; Firer, P.
    Introduction: Recurrent lateral patella instability is multifactorial, with the current emphasis of treatment being to restore the medial stabilising structures to prevent further dislocations and complications. Many treatment options have been documented and Medial Patella Femoral Ligament (MPFL) reconstruction has become the most common surgical method, yet there is no gold standard technique reported for MPFL reconstruction. The aim of this study was to compare the success of different MPFL reconstruction techniques especially double bundle technique (DBT) versus single bundle technique (SBT). Methods: A retrospective review of the records of patients who had MPFL reconstructions performed over a 10-year period at a single orthopaedic practice was conducted. Patient demographic details, including Body Mass Index (BMI) and the surgical technique used, including DBT or SBT, and graft choice were recorded. Outcome measures included re-dislocation rate, Kujala knee questionnaire, Tegner activity scale and visual analogue scale (VAS) assessing satisfaction. Results: One hundred and thirty-three patients underwent MPFL reconstruction, 17 patients were excluded. Thirty-one patients were lost to follow up. A total of 85 (73.28%) patients were assessed. Mean age was 23.9 years and 63.53% (n = 54) were female. The average follow up was 80.6 months, with 3.5% (n = 3) patients that re-dislocated requiring revision surgery. The mean Kujala knee score was 85, the mean Tegner activity scale was 5.6 and the mean VAS satisfaction score was 9. DBT reconstructions accounted for 45.9% (n = 39) of procedures, while 54.1% (n = 46) of patients underwent SBT reconstruction. Of the SBT group 19.57% (n = 9) utilised allograft. No statistical significance between dislocation rate (p = 0.810), Tegner activity score (p = 0.155), Kujala knee score (p = 0.265) or patient VAS satisfaction scores (p = 0.989) between the DBT and SBT groups was found. No significant difference was found in the outcomes between allograft and autograft. Sixty-nine percent of patients completed rehabilitation, with significantly higher Kujala knee scores noted in those patients (86.8 ± 10.586) compared to than those who did not complete rehabilitation (81.04 ± 14.05) (p = 0.040). Conclusion: The use of either SBT or DBT in MPFL reconstruction, as well as the use of allograft or autograft, resulted in similar favourable outcomes. This follows the trend reported in previous literature. Other factors such as rehabilitation and articular damage noted at the time of surgery may influence outcomes more. Higher-powered prospective studies are required to better determine which techniques may be superior.
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    Secondary prevention and management of dyslipidaemia in patients with coronary artery disease on statin therapy in a tertiary academic centre in Johannesburg
    (University of the Witwatersrand, Johannesburg, 2023-11) Ntila, Patience Mtwakazi; Tsabedze, Nqoba; Mpanya, Dineo
    Background and aims: Low-density lipoprotein-cholesterol (LDL-C) is essential in initiating atherosclerosis, and its control is paramount in reducing future major adverse cardiovascular events. New guidelines recommend an LDL-C target of <1.4 mmol in patients with atherosclerotic cardiovascular disease. However, whether patients on statin therapy achieve these LDL-C targets in South African public hospitals is unknown. Therefore, this study aimed to determine the achievement of LDL-C targets in patients with coronary artery disease (CAD) on statin treatment at a public tertiary academic hospital. Methods: We analysed data from 458 patients with angiographically confirmed CAD on statin therapy, comparing index admission to the most recent follow-up LDL-C level. Results: After a median duration of 17 months (interquartile range: 7 - 31), 93 (20.3%) patients achieved the LDL-C target. Among the 329 (71.8%) patients on a high-potency statin, 76 (23.2%) achieved the LDL-C target. On univariable logistic regression analysis, a history of previous CAD or stroke [odds ratio (OR):1.73; 95% confidence interval (CI): 1.05 - 2.85; p value= 0.031], presentation with non-ST-elevation myocardial infarction [OR:0.55; 95% CI: 0.34 - 0.90; p = 0.017] and unstable angina [OR: 2.25; 95% CI: 1.08 to 4.70; p = 0.030] were related with failure to attain LDL-C targets. Conclusions: Only 20.3% of all patients with atherosclerotic CAD and 23.2% on high-intensity statins achieved the guideline-recommended LDL-C target.
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    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, Kathy
    Introduction: 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.
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    Comparison of second and third generation parathyroid hormone (PTH) assays performed at Charlotte Maxeke Johannesburg Academic Hospital – Are they fit for purpose?
    (University of the Witwatersrand, Johannesburg, 2023-11) Nhlapo, Nokuthula; Jacob, Doreen; Maphayi, Mpho
    Background: Parathyroid hormone (PTH) measurement is crucial in the investigation of calcium and phosphate disorders and in the management of chronic kidney disease (CKD). Available PTH assays include second (intact PTH) and third generation (PTH 1-84) assays. Intact PTH assays are widely available and used for clinical guidelines but overestimate PTH in CKD. PTH 1-84 assays are more specific, but lack of standardisation has complicated clinical interpretation. The study aimed to compare the second and third generation assays to determine the difference in analytical performance and the effect on clinical interpretation. Methods: A method comparison was done on 481 patient samples with PTH requested at Charlotte Maxeke Johannesburg Academic Hospital. PTH was measured in each sample using both intact PTH and PTH 1-84 assays. Passing Bablok regression and Bland Altman plots were performed to determine method agreement and bias. Analytical performance was assessed using the European Federation of Clinical Chemistry and Laboratory Medicine biological variation specifications. Clinical performance was compared in the diagnosis of hypo- and hyperparathyroidism, and in predialysis and dialysis CKD based on current Kidney Disease Improving Global Outcomes guidelines. Results: Intact PTH had a higher median concentration than PTH 1-84 (9.93 vs 8.60 pmol/L, p<0.0001) but showed good correlation (r = 0.994 and p<0.0001). Regression analysis revealed significant systematic and proportional differences, with increased deviations at higher concentrations. The average bias was above allowable bias of 7.1%. Clinical interpretation of hypo- and hyperparathyroidism and predialysis and dialysis groups was unchanged. Conclusions: There was significant bias observed between the two PTH assays thus, they should not be used interchangeably. However, no significant changes in clinical interpretation were found when one assay was used over the other. The decision to use third over second generation PTH assay should consider the impact on clinical interpretation in the population.
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    The clinical spectrum of viridans group streptococcus bacteraemia in paediatric patients at Chris Hani Baragwanath Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2023-11) Shongwe, Nkosinathi Sifiso; Petersen, Karen L.; Mabena, Fikile C.
    Background: Viridans group streptococci (VGS) are often considered organisms of low virulence; however, infection can result in clinically significant sepsis and life-threatening complications in paediatric patients. Objectives: To describe the spectrum of clinical presentation of VGS bacteraemia in paediatric patients, to analyse risk factors, and to describe the antibiotics resistance patterns of VGS. Methods: Cultures of VGS in paediatric patients admitted to Chris Hani Baragwanath Academic Hospital in 2019 were retrieved from NHLS data base. Data was extracted from archived clinical records and analysed. Sepsis scores were calculated at the time of bacteraemia. Results: 133 cultures were identified; 64 (48.1%) polymicrobial cultures (64) and no records 4 (0.03%) were excluded; 65 (48.9%) were analysed. The median age was 1.5 months (range 0.03 to 168, Interquartile range (IQR) 0.2 to 13.25), 27/65 (42%) were neonates. The median duration of hospitalisation was seven days (IQR 3 to 21). The commonest diagnoses were neonatal sepsis 30.8% (n=20) and pneumonia 28% (n=18). The systemic inflammatory response syndrome (SIRS) score was ≥2 in 57% (16/28) patients; paediatric sequential organ failure assessment (pSOFA) score was >2 in 10/24 (42%). Fifty-seven (88%) patients were discharged; three (5%) required ICU admission and 8/65 (12.3%) died. Malnutrition was present in 50% of patients who died. Cephalosporins and penicillin had susceptibility of 89% and 55% respectively. Conclusion: VGS bacteraemia was common in neonates, and pneumonia was a common presentation in this cohort outside the neonatal period. VGS bacteraemia was associated with morbidity and deaths in this cohort. Contribution: VGS should be considered a significant organism when cultured and routine antibiotic susceptibility testing should be performed. Prospective studies are recommended.
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    Epidemiology of laboratory-confirmed SARS-CoV-2 hospitalized cases in a tertiary hospital, Gauteng Province, South Africa, 1 April 2020 to 31 March 2021
    (University of the Witwatersrand, Johannesburg, 2021-12) Sikhosana, Mpho Lerato; Makatini, Zinhle
    Gauteng Province (GP) was the most affected province in South Africa during the first year of the COVID-19 pandemic. We aimed to describe the epidemiology of COVID-19 cases admitted in one of the largest quaternary hospitals in the province during the two pandemic waves. We used data from the national hospital surveillance system, DATCOV, that recorded COVID-19 admissions at Charlotte Maxeke Johannesburg Academic Hospital in (GP) from 5 March 2020 to 27 March 2021. We used multivariable logistic regression to determine a) factors associated with hospitalization in the second compared to the first pandemic wave, and b) factors associated with in-hospital mortality. There were 1861 cases admitted during the study period. The mean age of the cases was 50 (IQR 37-61), 51.80% were females, and 58.68% were black. Of the total number of admissions, 2.10% were healthcare worker, 53.85% of whom were nurses. On admission, 91.99% of cases were admitted at a general ward while 5.86% were admitted at an intensive care unit. Overall, 10.59% of the cases required intensive care during their hospital stay. The case fatality ratio was the highest (28.54%) during wave 2 and lowest during pre-wave (11.49%). Compared to the first wave, factors associated with hospitalization during the second wave included age >80 years (adjusted odds ratio [aOR] 3.43, 95% CI 1.07-10.98) compared to ages 0-19 years, as well as being of other race (aOR 5.63, 95%CI 1.84-17.20) compared with White race. Regarding in-hospital mortality, associated factors included age groups 60-79 (aOR 4.53, 95%CI 1.03-19.86) and >80 (aOR 9.63, 95%CI 1.93-48.01) compared to ages 0-19 years; male sex (aOR 1.55, 95%CI 1.16-2.08); presence of an underlying comorbidity (aOR 1.99, 95%CI 1.45-2.71) 106 as well as being admitted during the second wave (aOR 1.54, 95%CI 1.12-2.10). Our study found that there was a higher risk of mortality during the second compared to the first wave, and other factors associated with mortality included older age, being male as well as having an existing comorbidity. These findings will help inform prevention strategies required to prevent high mortality rates during future waves of infection.
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    A retrospective study of the biochemical and radiological profile of children with genetic hypophosphatemic rickets and their response to conventional treatment
    (University of the Witwatersrand, Johannesburg, 2023-11) Isaac, Nikhila; Thandrayen, Kebashni
    Objectives: Assessing the biochemical and radiological profile of children with genetic hypophosphatemic rickets and their response to conventional treatment. Design: Retrospective descriptive study. Setting: Metabolic Bone clinic at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. Subjects: Children less than 18 years, attending the Metabolic Bone clinic from 1st January 2006 to April 2020, with genetic hypophosphatemic rickets, commenced on conventional treatment. Results: Seventy patients met the inclusion criteria. Majority of patients were black South African (n=54 (77%)). Positive family history seen in 32 (46%) patients. The patients were short statured with a mean height for age z score (HAZ) of - 3.4 ± 1.79. The mean calcium, phosphate, alkaline phosphatase, parathyroid hormone levels and median Thacher score was 2.3 ± 0.16 mmol/L, 0.84 ± 0.19 mmol/L, 776.6 ± 531 IU/L, 7.15 ± 4.8 pmol/L and 8 (4-8) respectively. Improvement on last follow up on treatment was seen in ALP (776 ±531 vs 525±232; p <0.001) and Thacher scores (8 (4-8) vs 2 (1-3.5); p =0.01) after 5 years, but no change in phosphate or HAZ. Conclusion: Conventional therapy for treatment of hypophosphatemic rickets is not associated with an improvement in HAZ despite an improvement in radiology and ALP. Adherence is a major challenge for the majority of patients.