4. Electronic Theses and Dissertations (ETDs) - Faculties submissions
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Item Emergency Department Turnover Intention: Are Job Satisfaction and Burnout Really the Main Culprits?(University of the Witwatersrand, Johannesburg, 2022-11) Jonker, Yvonne Denise; Motara, Feroza; Moolla, MuhammedBackground: Patient presentations to emergency departments (ED) keep increasing. High staff turnover is detrimental to the healthcare worker (HCW), the organisation and the patient. While high levels of burnout (BO) and low levels of job satisfaction (JS) lead to a higher intention to leave (ItL), there are other factors affecting the ItL that need to be evaluated. Objective: To determine the levels of BO, JS and ItL, including when, where and why HCWs want to leave in order to find ways to reduce staff turnover. Methods: This was a prospective observational cross-sectional study conducted in two tertiary-level EDs in Johannesburg, South Africa namely Chris Hani Baragwanath Academic Hospital (CHBAH) and Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Doctors and nurses were invited to complete self-administered questionnaires between 24 November 2020 and 24 March 2021. After analysis the results for doctors and nurses and the two units were compared in order to bring understanding to the different facets affecting staff turnover. Results: A total of 78 respondents (66% of doctors and 58% of nurses) completed questionnaires and were included for analysis. According to the Copenhagen Burnout Inventory 79% of CHBAH doctors, 62% of CHBAH nurses, 79% of CMJAH doctors and 84% of CMJAH nurses suffered from severe personal burnout, while 68% of CHBAH doctors, 62% of CHBAH nurses, 95% of CMJAH doctors and 68% of CMJAH nurses suffered from severe work-related BO and 42% for CHBAH doctors, 24% of CHBAH nurses, 47% of CMJAH doctors and 32% of CMJAH nurses had severe patient-related burnout. Doctors had significantly higher patient-related burnout (p=0.012). JS was average for all staff but nurses were significantly less satisfied (p=0.003). While 42% of staff intended to leave within a year, of which half wanted to leave as soon as possible, a total of 73 % wanted to leave within 5 years. CMJAH staff had higher levels of BO, lower levels of JS and higher levels of ItL. Higher levels of BO and lower levels of JS increased the ItL. The main reasons for leaving were career-related. Conclusion: Burnout levels were higher than similar populations before and during the Covid-19 pandemic, while job satisfaction levels were average. Although burnout and job satisfaction affected intention to leave, the main reasons for wanting to leave were career-related indicating that even when work conditions and burnout could be addressed successfully, the turnover of staff in tertiary level EDs may remain high.Item A Retrospective Review of Bladder Cancer at Charlotte Maxeke Johannesburg Academic Hospital-University of The Witwatersrand - (2010–2020)(University of the Witwatersrand, Johannesburg, 2023-08) Oliver, Trenton Luke; Ayeni, Oluwatosin; Hugo, MiaIntroduction: Bladder cancer is among the most common urological cancers and the leading cause of cancer mortality worldwide. It is particularly prevalent in High-Income Countries (HICs), although its incidence is rising in Low-and-middle -income countries (LMICs). This review describes the profile, clinical presentation, and management of our institution's bladder cancer patients. Method: A retrospective review of patients aged 18 years and above who were diagnosed with bladder cancer and managed at the Radiation Oncology department of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from January 2010 to December 2020. Data were collected on demographics, risk factors, clinic-pathological features, and specific therapies received by these patients. A comparison was made between patients presenting with squamous cell carcinoma and translational cell carcinoma of the bladder. Results: Among 115 patients, the median age ± standard deviation was 60.7 ± 14.9, and 60.9% were males with a male-to-female ratio of 1.6:1. Few patients (4.4%) had a history of schistosomiasis, and 47.8% had a history of smoking. Tumour histology included transitional cell carcinoma (TCC) in 78 (67.8%), squamous cell carcinoma (SCC) in 31 (27.0%), and atypical tumour in 6 (5.2%). Most patients presented with Muscle-Invasive Bladder Cancer (MIBC) (61 (53.0%)) followed by Metastatic Urothelial Cancer (MUC) (n=52, 45.0%), while the remaining 2.0% (n=2) had Non-Muscle Invasive Bladder Cancer (NMIBC). More than half of the patients (59.1% n=68) had palliative treatment, 26 (22.6%) had radical treatment, and 21 (18.3%) patients did not receive radiotherapy. Patients who presented with TCC were more likely to be older (odd ratio (OR): 1.03, 95% Confidence Interval (CI): 1.01–1.06, p=0.029), male (OR: 2.60, 95% CI:1.10–6.04, p=0.030), predominantly of the black population, but white patients are four times more likely to present with TCC than SCC (OR:4.22, 95% CI: 1.43–12.48, p=0.009). Conclusion: The prevalence of TCC is still higher in our centre compared to SCC. Although the burden of bladder cancer is highest in HICs, with increasing exposure to risk factors, a shift is gradually experienced in LMICs.Item Prevalence and spectrum of Cutaneous Tuberculosis in patients at Charlotte Maxeke Johannesburg Academic Hospital(University of the Witwatersrand, Johannesburg, 2023-11) Hargey, Naima; Pillay, Lushen; Ede, ChiomaTuberculosis (TB) is a communicable disease that belongs in the top 10 causes of death worldwide. World Health Organization (WHO) indicated that 90% of the world’s TB cases occurred in 30 countries, with South Africa being one of the countries listed. Cutaneous TB comprises 1-2% of the extrapulmonary TB cases. Cutaneous TB is a chronic skin infection mainly caused by Mycobacterium Tuberculosis. The aim of this study was to investigate the prevalence and spectrum of Cutaneous TB in patients at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). A retrospective study of 69 patients were confirmed on histopathology with cutaneous TB. This was further sub-divided into true TB and tuberculid forms. These forms were correlated with histopathological and clinical findings as well as the patient’s HIV status. The average age (SD) of the 69 patients was 39(12). Females were more common than males in the study (ratio 7.625:1). The average disease duration (SD) of 17(22) months. Tuberculids (81.2%) were the most common form of cutaneous TB with Erythema Induratum (76.8%) being the most common tuberculid. The most common form of true cutaneous TB was that of Lupus Vulgaris (13%). Acid fast bacilli stains were the most common histopathological investigation done on tissue biopsies. Panniculitis (35.4%) was the most common histological feature. The most common clinical manifestation was that of nodules (59.3%). Few patients presented with polymorphic manifestations (20.3%). The lower limbs were the most common affected site in cutaneous TB particularly Erythema induratum (p<0.001). Other key findings for Erythema Induratum were its prevalence in females (p<0.001), histopathological findings of granulomas, vasculitis, panniculitus and AFB negativity (p<0.001). 33 of the 69 patients were HIV positive but the HIV status did not show a relationship with any form of cutaneous TB (p=0.971). Erythema Induratum patients who were HIV positive, were more likely to be on ARV’s (p<0.001). Despite South Africa being at the forefront of the HIV/TB epidemic, cutaneous TB remains uncommon. The advent of ARVs being prescribed to all HIV positive patients may have played a role in these patients presenting in a similar clinical and histopathological manner as HIV negative patients.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 Retrospective audit of the appropriate use criteria for ventilation/perfusion imaging in pulmonary embolism in a South African population cohort(University of the Witwatersrand, Johannesburg, 2023-09) Sibindlana, Amanda Patiswa; Vangu, Mboyo-Di-Tamba; Malan, Nico; Momodu, JaleelatBackground: Venous thromboembolism (VTE) is blood clot formation comprising deep vein thrombosis (DVT) and pulmonary embolism (PE). Stasis, endothelial dysfunction and hypercoagulability place an individual at increased risk for developing DVT. VQ scans are crucial to determine the appropriate treatment in patients. The use of VQ scans is addressed in several clinical scenarios, including pregnancy, renal failure, contrast allergy, haemodynamic instability and abnormal chest X-ray findings. Aim: This study assessed the appropriateness of VQ scan requests received by the nuclear medicine departments at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH). Methods: The appropriateness of referrals and VQ scintigraphy in patients with suspected PE at CMJAH and CHBAH nuclear medicine clinical departments was determined. A retrospective audit was done on the request forms of patients referred for VQ scintigraphy to a diagnose pulmonary embolism over five years from 01 January 2015 to 31 December 2019. The clinical information in the request forms was compared to the appropriate use criteria (AUC) to determine the level of appropriateness and categorised as appropriate, maybe appropriate and rarely appropriate. Statistical software (STATA) was used for data analysis. T-tests were used for continuous variables, and Pearson’s chi-squared tests were used for dichotomous data. A p-value of <0.05 was considered statistically significant. Results: A total of 1167 records were reviewed, and fewer than 50% of the referrals were found to be appropriate overall. There were 440 records that fitted the relevant criteria, 580 were rarely appropriate, and 149 maybe appropriate. The median age of individuals referred was 45 years. Most records were for females, with 321 (73%) falling into the appropriate category. There were 72 (13%) confirmed pregnancies and 17 (24%) were appropriate for a VQ scan. The average D-dimer concentration for these patients was 2.15 mg/L. The average D-dimer concentration was the highest in patients where referrals for VQ scans were considered as maybe appropriate (2.6 mg/L; 1.18 – 6.7) compared to an average D-dimer concentration of 2.5 mg/L (1.35 – 6.78) in patients appropriately referred for VQ scans and 0.68 mg/L (0.41 – 1.51) for patients inappropriately referred for VQ scans. Some patients were still referred for VQ scans to exclude the possibility of PE. Conclusion: The criteria used for referrals in our clinical setting were found insufficient due to the inefficient system and criteria used to refer patients in our clinical setting. This may result from a lack of required information and standardisation of the assessments with which clinicians judge the patient’s risk for PE/VTE. This was the case even in a largely female cohort with many concurrent risk factors.