4. Electronic Theses and Dissertations (ETDs) - Faculties submissions
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Item In-hospital Mortality Outcomes of ST-segment Elevation Myocardial Infarction(University of the Witwatersrand, Johannesburg, 2023-04) Ndaba, Lindokuhle; Mutyaba, Arthur; Tsabedze, NqobaBACKGROUND: ST-segment elevation myocardial infarction (STEMI) is a common malignant complication of ischaemic heart disease. Despite optimal treatment, STEMI is often associated with significant morbidity and mortality. In high-income countries (HICs), STEMI-related morbidity and mortality incidence have decreased. However, in sub-Saharan Africa (SSA), there is an increasing burden of non-communicable diseases driven by atherosclerotic cardiovascular disease. Similarly, the incidence of STEMI is increasing. However, despite the growing burden of STEMI in SSA, there is still a paucity of data reporting on the regional morbidity and mortality associated with this disease. AIM: Hence, this study aims to provide a comprehensive description of the clinical profiles, determine the in-hospital all-cause mortality rate, and identify predictors of mortality for STEMI patients treated at the Division of Cardiology in Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa. METHODS: We conducted a retrospective review of the medical records of 815 consecutive patients diagnosed with ST-elevation myocardial infarction (STEMI), with confirmatory angiography findings, between January 1, 2015, and December 31, 2019. All participants underwent diagnostic coronary angiography, with or without percutaneous coronary intervention (PCI). As our institution is a PCI-capable centre, all patients underwent angiography either during the index admission or at a later date, and this removed ambiguity regarding the diagnosis of STEMI. The study included patients who met the third and fourth universal definitions of myocardial infarction. Data on demographics, clinical presentation, electrocardiogram (ECG) changes, biochemical parameters, coronary angiographic findings, coronary interventions, STEMI-related complications, and ongoing medical management were extracted from these sources. We compared socio-demographic characteristics, comorbidities, clinical parameters, biochemistry investigation findings, treatment, and complications between the patients who survived in-hospital and those who died. To identify predictors of in-hospital all-cause mortality in patients with STEMI, we developed a multivariable logistic regression model. RESULTS: Among 677 participants with a mean age of 55.5 ± 11.3 years, 533 (78.7%) were males. The in-hospital all-cause mortality rate was 6.2%. Co-morbidities in STEMI patients included smoking (56.1%), hypertension (52.8%), dyslipidaemia (40.0%), a family history of coronary artery disease (32.7%), and diabetes mellitus (28.3%). The median duration from the onset of chest pain to arrival at the catheterisation laboratory was two days [interquartile range (IQR): 1-3] for survivors and one day (IQR: 0-2) for non-survivors (p=0.010). Pharmaco-invasive treatment was the pre-dominant management strategy, with 61.4% of patients receiving thrombolysis and 53.9% undergoing PCI. On the age and sex-adjusted multivariable logistic regression model, the use of inotropes (OR: 4.04; CI: 1.14-14.34, p=0.031) and an increase in heart rate (OR: 1.02; CI: 1.01-1.04, p=0.010) independently predicted in-hospital all-cause mortality, while thrombolytic therapy (OR: 0.27; CI: 0.10-0.75, p=0.012), and PCI to the right coronary artery (OR: 0.03; CI: 0.00-0.46, p=0.011) reduced the risk of all-cause mortality. CONCLUSION: Our study's all-cause mortality rate among STEMI patients is comparable to rates reported in other countries globally.Item The experiences and impact of workplace violence on doctors and nurses working in Emergency Departments in the Gauteng Province, South Africa(University of the Witwatersrand, Johannesburg, 2023-10) Kobe, Lerato; Saffy, Patricia; Bentley, AlisonObjectives: Workplace violence (WPV) remains grossly under-reported preventing a true appreciation of the problem. With South Africa currently rated in the top three in the world for crime, it is likely that such crime correlates with WPV experienced by health care workers. This study investigates the range of WPV experienced in the Emergency Department (ED), the demographics of the perpetrator, the impact of WPV on ED staff, and reporting behaviour. Study design: prospective, quantitative, observational, cross-sectional study of five public hospitals in Gauteng. Methods: During the period October 2020-March 2021 data was collected through the completion of a self-administered questionnaire. Nursing staff and doctors, with the exclusion of those in training, were enrolled. The questionnaire included questions on demographics, experience of physical and non-physical WPV over the last 12 months as well as responses and effects of those events. Results: There were 211 respondents. Seventy percent of respondents had experienced at least one physical WPV event and 84% had experienced at least one non-physical WPV event. In both types of violence most did not require treatment. The incidents, mainly perpetrated by patients or their relatives/visitors, left 42% of victims very worried about violence in their workplace and some with symptoms of post-traumatic stress disorder however reporting of events was severely lacking. Respondents indicated that there were no clear reporting procedures available to them. Conclusions: Workplace violence is a problem in the ED and more needs to be done in encouraging reporting of incidents but most importantly methods of preventing violence need to be prioritized.Item An audit of anaesthetic charts at Chris Hani Baragwanath Academic Hospital(University of the Witwatersrand, Johannesburg, 2022-04) Nkadimeng, Lebohang Matau; Gilliland, Lizil; Nel, Dorinka; Mashinini, MduduziBackground: The anaesthetic chart is an important component of a patient’s health record in the perioperative period. Studies have shown that anaesthetic charts are often incomplete. The adequacy of chart completion in the anaesthetic department at Chris Hani Baragwanath Academic Hospital (CHBAH) has never been quantified. An audit was done, and the charts were assessed for adequacy of completion. Methods: A retrospective audit of anaesthetic charts was done for the year 2019. Using a peer reviewed checklist adapted from the Australian and New Zealand College of Anaesthetists (ANZCA) and the South African Society of Anaesthesiologists (SASA) guidelines, a sample of 333 charts was audited to assess adequacy of completion. To eliminate sampling bias, a stratified sampling method was used. Results: Completeness was defined as a chart scoring 100%. None of the charts scored 100%. The overall median score of the charts was 77%. Charts were subdivided into three groups. Charts scoring between 75-99% (n=212), 50-74% (n=121) and charts less than 50% complete (n=0). Patient category (adult versus paediatrics), time of shift (day versus night) and type of anaesthetic were audited and compared as factors that could affect chart completeness. The only factor that had a statistically significant difference in chart completeness was the patient category, where adult chart completion scored higher compared to paediatric charts with a p-value <0.0074. Conclusion: In conclusion the charts audited scored higher than previous audits done both locally and internationally. Some important aspects of the charts were poorly documented. Ongoing audits and training on chart completion can potentially improve the adequacy of completion and should be part of the academic program. Better documentation has the potential to improve perioperative patient care and mitigate medicolegal risks.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 Prevalence and risk factors of intraventricular hemorrhage in Very low birth weight infants at Chris Hani Baragwanath academic hospital(University of the Witwatersrand, Johannesburg, 2023-11) Mabasa, Kulani; Nakwa, Firdose L.; Ntuli, NandiBackground: Intraventricular hemorrhage (IVH) is the commonest form of bleeding in the central nervous system (CNS) of premature neonates. Pathogenesis is attributed to germinal matrix fragility. Risk factors are multifactorial and related to various events that may happen in utero, peri-partum and postnatally. Methods: This was a retrospective descriptive study in the neonatal unit of CHBAH. 529 VLBW infants of <1500g admitted between January 2017 to December 2018 were studied. Those with IVH were cases and those without IVH were controls. Results: Of the 529 infants studied, 33%(n=176) had IVH, 56% (n=99) were mild IVH (grade 1 and 2) and 44% (n=77) were severe IVH (grade 3 and 4). Median gestational age (28 vs 30, p<0.001) and birthweight (1059g vs 1220g, p<0.001) were lower in those with IVH. More neonates with no IVH received steroids (40.5% vs 30.1%, p=0.020) and magnesium sulphate (11.9% vs 2.8%, p<0.001). Neonates with an Apgar score < 6 at 5 minutes (OR 8.17, 95%CI: 2.54-26.3), intubated (OR 8.822, 95%CI: 1.34-56.41) and had meningitis (OR 104.92, 95%CI: 40.10 -274.5) were more likely to have IVH. Those with IVH had a 20-fold chance of having PHHC (OR 20.25, 95%CI: 1.21 -338.84) and a higher likelihood of dying (3.70 95% CI 1.50-9.15). PHHC was observed in neonates who had severe IVH (grade 3 and 4). Of the neonates who died IPPV (2.20, 95% CI 1.117-4.34), hypotension (10.46, 95% 2.32-47.11) and meningitis (1.13, 95% 1.016-1.26) were associated with death. Conclusion: Incidence of IVH is consistent with those of LMIC. The significant risk factors for IVH were low Apgar score at 5 minutes, those who were intubated, and had meningitis. Steroids and magnesium sulphate were protective against developing IVH. More studies are needed to analyze risk factors associated with severe IVH (grade 3 and 4). Identifying pharmacological neuroprotective agents may be beneficial in future.Item A Retrospective Observational Study of The Impact of HIV Status on The Outcome of Paediatric Intensive Care Unit Admissions(University of the Witwatersrand, Johannesburg, 2022-12) Whitehead, Kim; Ballot, DayniaBACKGROUND: Previously it was thought futile to offer HIV infected children ICU care, however this has changed with the availability of Antiretroviral Therapy (ART). Improved Prevention of Mother to Child Transmission (PMTCT) has led to a larger population of HIV exposed uninfected (HEU) children with unique health risks. Our study looked at how HIV exposure and infection impact presentation and outcomes in PICU in an era of improved access to ART and PMTCT. METHODS: A retrospective analysis of children admitted to PICU at a tertiary/quaternary hospital between 2015 and 2019 was conducted. De-identified data was obtained from an existing database and analysed using SPSS software. Medians and interquartile ranges were used to analyse continuous variables and frequencies and percentages to analyse categorical variables. The sample was then divided into three groups (HIV negative, HEU and HIV infected) and their presentation and outcomes compared using Chi-Squared and Kruskall-Wallis tests with a significance level set at p < 0.05. RESULTS: Our study showed that 16% (109/678) of children admitted to PICU were HEU and 5.2% (35/678) HIV infected. HIV infected children were admitted at a younger age (median two months) and had an increased incidence of lower respiratory tract infections than HIV negative children (p < 0.001). HIV infected children required longer ventilation and admission than HIV negative and HEU children (p < 0.001). HIV infected children had a higher mortality (40%) (p = 0.02) than HIV negative children (mortality 22.7%); when comparing children admitted with a medical diagnosis however the difference in mortality was not statistically significant (p = 0.273). HEU children were admitted at a younger age (median three months) with a higher incidence of lower respiratory tract conditions than HIV negative children (p < 0.001). HEU children had similar outcomes to HIV negative children with no statistically significant difference in duration of ICU stay (p =0.163); ventilation (p = 0.443) or mortality (p=0.292). CONCLUSION: HIV infected children presented with more severe disease requiring longer ventilation and admission. HEU had similar outcomes to HIV negative children.Item Diagnostic Coronary Angiography Access In Johannesburg(University of the Witwatersrand, Johannesburg, 2023-10) Ntaka, Khulasande Liso Sifiso; Tsabedze, Nqoba; Kalk, Thomas; Mpanya, DineoBackground: Contemporary interventional cardiology guidelines prefer radial over femoral artery access when performing diagnostic coronary angiograms (DCA). There is a paucity of data on the safety and efficacy of radial and femoral DCA in low-and-middle-income countries. Methods: We retrospectively reviewed inpatient medical records and DCA reports of patients referred for DCA and evaluated the safety and efficacy of the femoral versus radial artery access route. Results: There were 653 patients with a mean age of 58.2 ±12.6 years. Radial access was used in 318 (48.7%) patients. The median duration of the DCA was slightly longer with radial access and was 50 minutes (Interquartile range (IQR): 40–60), while the median procedural duration for femoral artery access was 45 minutes (IQR: 35–60) (P = 0.010). The median total radiation dose in the femoral artery access group was 3511 µGym2 (IQR: 2154–5821), and patients in the radial artery access group were exposed to a median radiation dose of 4011 µGym2 (IQR: 2298–6411) (P = 0.0661). A total of 639 (97.9%) DCA were performed without crossover, and 99.0% (95% CI: 97.2 – 99.8) of DCA performed via the radial artery did not require crossover to transfemoral access, and 96.1% (95% CI: 93.4 – 97.9) of the DCA done via the femoral artery did not require crossover to transradial access (P = 0.009). Conclusion: Almost half of all diagnostic angiograms were performed via the radial artery. Both radial and femoral artery access were equally safe and efficacious in patients with coronary artery disease.Item Diversity Management in the Ghanaian Health Sector: A Case Study of the NHIA(University of the Witwatersrand, Johannesburg, 2024) Inweregbu, Cynthia Ngozi; Maier, ChristophDiversity management has become a critical tool in ensuring efficiency and productivity in organisations and societies. Research has recognized several conceptualisations of diversity and provided direction for effective and better ways of implementing diversity management at an organisational and national level. However, it has been contended that emphasis on conceptualising diversity management has mainly been within the context of the western perspective. Diversity management is an emerging aspect of management, which embodies on disciplines such as sociology, psychology, and human resource. The concept of diversity management has assumed global dimension and a context specific approach is required to make it effective. In this regard, it has been established by scholars to be a potent management tool in the globalised world. This call for an approach which suits the African and for that matter the Ghanaian context. To this effect, this research explores the concept, policies, and challenges of diversity management from Ghanaian perspective to assist in fashioning out a context specific strategy to diversity management. A qualitative methodology (case study approach) was employed to answer the research questions and realise the objectives. In line with the tenets of the chosen methodology, which requires data absoluteness, the interviewees and focus group members were selected through purposively sampling. There were thirty-four in-depth interviews and two focus group discussions conducted at the NHIA head office and regional office. Coding and thematic analysis were employed to identify the conceptualisation of diversity, policies in place for diversity management and challenges encountered in relation to diversity management at the NHIA. The results suggests that diversity can be described as differences in ethnic background, political affiliation, gender, religious belief, languages, and age. Further, the result points to the fact that an individual cannot be only identified by one characteristic but several of them. ii Additionally, this study identified couple of areas that needs attention to ensure an effective diversity management at the NHIA. The work environment in NHIA is very diverse and drives the complexity therein. The socio-cultural, religious, and political differences are very entrenched and require an effective diversity framework that ensures the presence of critical elements such as appreciation of uniqueness and the sense of belonging. Subsequently, a model was developed from the findings of the study to highlight the critical elements driving the dynamics of diversity management in NHIA. Additionally, the identified elements serve as tools which can be employed to allay the challenges encountered in ensuring effective management of diversity in NHIA and similar environments. Future studies may be conducted to validate the framework developed in this study and establish generalisabilty in the health industry and in other public organisations. A comparative case study research focusing on a private and public sector could also enrich the frameworkItem Validation of Roche immunoassay for severe acute respiratory virus 2/SARS-COV-2 in South Africa(University of the Witwatersrand, Johannesburg, 2023-01) Grove, Jurette Simone; George, Jaya; Mayne, ElizabethBackground: Serology testing is an important ancillary diagnostic to the reverse transcriptase polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to evaluate the performance of the Roche Elecsys™ chemiluminescent immunoassay (Rotkreuz, Switzerland), that detects antibodies against the SARS-CoV-2 nucleocapsid antigen, at an academic laboratory in South Africa. Methods: Serum samples were collected from 312 donors with confirmed positive SARS CoV-2 RT-PCR tests, with approval from a large university’s human research ethics committee. Negative controls included samples stored prior to December 2019 and from patients who tested negative for SARS-CoV-2 on RT-PCR and were confirmed negative using multiple serology methods (n = 124). Samples were stored at –80 °C and analysed on a Roche cobas™ 602 autoanalyser. Results: Compared with RT-PCR, our evaluation revealed a specificity of 100% and overall sensitivity of 65.1%. The sensitivity in individuals > 14 days’ post-diagnosis was 72.6%, with the highest sensitivity 31–50 days’ post-diagnosis at 88.6%. Results were also compared with in-house serology tests that showed high agreement in majority of categories. Conclusions: The sensitivity at all-time points post-diagnosis was lower than reported in other studies, but sensitivity in appropriate cohorts approached 90% with a high specificity. The lower sensitivity at earlier time points or in individuals without symptomatology may indicate failure to produce antibodies, which was further supported by the comparison against in-house serology tests.Item Microbiological epidemiology at Chris Hani Baragwanath Academic Hospital: Poly-microbial osteomyelitis analysis(University of the Witwatersrand, Johannesburg, 2023-10) Hlapolosa, Josiah Tiego; Kgagudi, Paul Marule; Jingo, MaxwellBackground: The majority of the patients seen and treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following high-energy trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit. Methods: This was a retrospective study of patients treated for osteomyelitis from 1st of June 2016 to 30th of May 2021. Medical records of eligible patients were retrieved for examination. Demographic data such as age, sex and race were recorded. Clinical presentation, and organisms cultured, including their anti-microbial sensitivities were documented. Results: There were 63 participants in the study. Thirty-one (49.21%) participants had mono-microbial osteomyelitis with 32 (50.79%) participants having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a draining sinus (68.75%) and most was located in the tibia (50%). Multiple mixed pathogens (both gram-positive and gram-negative) were cultured in combination in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii at 7%. Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime. Conclusion: A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod shaped bacteria. Cephalosporins were not shown to be valuable as broad-spectrum cover drugs, and most bacteria cultured were found to be insensitive to them. What we suggest is tailoring antibiotics to the specific cultured bacteria and sensitivity. Prompt management of patients with open fractures with early administration of intravenous antibiotics and adequate surgical management may lead to a reduction in the prevalence of chronic osteomyelitis.