4. Electronic Theses and Dissertations (ETDs) - Faculties submissions

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    A retrospective study on the outcomes of peripartum hysterectomies for puerperal sepsis at Chris Hani Baragwanath Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2024) Olusola, Esther
    Puerperal sepsis is a significant cause of maternal morbidity and mortality, especially4 in developing countries. Hysterectomy is often performed as a measure of source5 control for severe uterine infections when conservative treatment fails. The aim of6 this retrospective study was to examine the outcomes of peripartum hysterectomies7 performed for puerperal sepsis at Chris Hani Baragwanath Academic Hospital,8 Johannesburg, South Africa.9 10 Methods:11 A retrospective cross-sectional study was conducted between 1 January and 3112 December 2019, on all women who underwent hysterectomies for puerperal sepsis.13 Data pertaining to demographics, surgical characteristics, microbiological cultures,14 organ dysfunction scores, and histopathological findings, were extracted from15 medical records. Women with miscarriages or pregnancies less than 24 weeks’16 gestation were excluded. Statistical analysis included descriptive methods and17 comparative tests using Stata 15.0 software. Organ dysfunction scores were18 calculated using MODS, SOFA, and qSOFA systems. Ethical approval was obtained19 prior to conduction of the study.20 21 Results:22 During the study period, 33 hysterectomies were performed for puerperal sepsis,23 representing 0.17% of the 18,458 deliveries at the hospital. The median age of24 women was 28 years of age with a median gestational age at delivery of 38 weeks.25 The majority (88%) underwent total abdominal hysterectomies, while 12% had26 subtotal hysterectomies. Eighty eight percent of women underwent caesarean27 section for a fetal distress. The most common organisms cultured in intra-abdominal28 fluid were Acinetobacter baumannii (26%), Escherichia coli (19%), Klebsiella species29 (14%) and Enterococcus faecalis (14%). A. baumannii was the predominant30 pathogen in all four culture mediums. The most common antibiotics used in this31 hospital for treatment were resistant against most organisms. Women with higher32 MODS and SOFA scores predominantly cultured resistant organisms. A. baumannii33 was strongly associated with worse outcomes. Two women (6%) died due to34 complications of ongoing sepsis. Histological examination revealed that surgeons35 often underestimated the extent of necrosis (30%) and presence of pus (44%),36 highlighting the importance of histopathological evaluation for accurate diagnosis37 and management.38 39 Conclusion:40 This study highlights the rising antibiotic resistance which complicates treatment and41 emphasises the need for revision of antibiotic stewardship in puerperal sepsis42 management. Women with higher MODS and SOFA scores predominantly cultured43 resistant organisms. Further research is required to explore improving surgical44 recognition of uterine sepsis and whether a total abdominal hysterectomy is actually45 superior to a subtotal hysterectomy in women with puerperal sepsis.46 47 Keywords:48 Puerperal sepsis, hysterectomy, antibiotic resistance, maternal mortality, MODS,49 SOFA, Chris Hani Baragwanath Hospital"
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    An Audit of Practice of Neurosurgery at the Klerksdorp Tshepong Hospital, North West Province
    (University of the Witwatersrand, Johannesburg, 2024) Moon, Donjoon; Khohomela, R
    It is difficult to establish a neurosurgery center in a low-income country, particularly in rural Africa. Africa's neurosurgical workforce falls well short of global standards. The current study details the Klerksdorp-Tshepong Hospital Complex (KTHC) neurosurgery unit's five-year audit, which ran from 1 January 2017 to 31 December 2021, at the KTHC in the Northwest province. In all, 1016 patients were treated by the unit during the study period. Out of the 1016 patients, 492 underwent neurosurgical interventions of which 404 were adult patients and 88 were paediatric patients. Of the 492 procedures linked to adults, 45,52% (n = 224) had to do with trauma, 12,60% (n = 62) with spine related conditions, 11,99% (n = 59) with infectious causes, 9,55% (n = 47) with tumours, and 2,43% (n = 12) with vascular disorders. Out of the 88 paediatric related procedures, 68 (or 77,27% of the total) were related to congenital problems, 11 (12,50%) to trauma, and 9 (10,22%) to infection. Overall, most procedures (n = 235) were due to trauma, congenital problems (n = 68), spine (n = 62), infections (n = 68), tumours (n = 47), and vascular conditions (n = 12). Of the total, 59,7% (n=292) were related to emergency procedures. The KTHC neurosurgical unit saw 8884 patients during the course of the study.
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    Incidence, Characteristics, Management and Outcomes of neonates with Patent Ductus Arteriosus (PDA) at Chris Hani Baragwanath Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2024) Naidoo, Delisha; Thandrayen, Kebashni; Nakwa, Firdose L.; Oliphant, Miss Xoli
    Incidence, Characteristics, Management and Outcomes of Very Low Birth Weight Infants with Patent Ductus Arteriosus (PDA) at Chris Hani Baragwanath Academic Hospital Naidoo D1, Nakwa, F.L.1, Thandrayen, K, Thomas R1. 1Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Introduction: Patent Ductus Arteriosus (PDA) accounts for 5-10% of congenital heart disease and is found in 300 per 1000 preterm infants. Significant morbidity and mortality have been associated with PDA. There is limited data available on PDA in low to middle income countries. Methods: This was a retrospective study carried out at Chris Hani Baragwanath Academic Hospital (CHBAH) between January to December 2017. Data on very low birth weight (VLBW) infants were extracted from the neonatal and paediatric cardiology unit’s electronic databases and clinical records of patients with a diagnosis of PDA on echocardiography were retrieved for analysis. Results Of the 859 VLBW infants admitted during the study period, 54(6.2%) had a diagnosis of PDA on echocardiography. PDA was more common in low birthweight (p=0.001) and lower gestational age (p=0.005) infants. Forty (74%) presented with an ejection systolic murmur and 29 (54%) were deemed haemodynamically significant (>1.4mm). Thirty-one infants (57%) were managed with watchful waiting. There were 21(39%) patients managed medically of these, eighteen( 86%) patients were managed using Ibuprofen ( 86%) making it the most common agent used among infants who were managed medically. Infants with a PDA had higher rates of intraventricular haemorrhage (IVH) [37% vs 12.4%; p-0.001], bronchopulmonary dysplasia (BPD) [42.6% vs 11.8%; p-0.001] and had a longer hospital stay (p=0.001). Risk factors for mortality were lower gestational age (OR 0.65, p<0.001, 0.6-0.71) and IVH (OR1.44, p<0.001, CI 1.17-2.18). iv Conclusion PDA is inversely proportional to gestational age and birth weight. Comorbidities in infants with PDA increased the hospital stay. Early identification and appropriate management are important as it may impact on these co-morbidities and length of hospital stay.
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    Treatment outcomes of Lupus Nephritis following the Induction Phase at Chris Hani Baragwanath Academic Hospital from 2010-2019
    (University of the Witwatersrand, Johannesburg, 2024) Dube, Bridget; Mashabane, M.J.; Nqebelele, N.U.
    Background. There is paucity of data from Africa on the treatment outcomes of Lupus Nephritis (LN). Objective. The primary objective of the study was to determine the LN treatment outcomes following the induction phase. Methods. This was a retrospective review of records of 61 patients with proliferative LN at a tertiary institution in Johannesburg, spanning a 10-year period. Results. The mean age at presentation was 30 years (IQR 22-36). The female to male ratio was 5:1. The majority of patients (90%) were black Africans. The commonest comorbidity was hypertension, which was present in 45.9% of the patients. Oedema was the most prevalent symptom at presentation, which was present in 82% of patients. The commonest class was LN class V, occurring in 60.7% of the patients. Most patients (68%) were diagnosed with LN at initial presentation with systemic lupus nephritis . A total number of 32 (52.5%) of the patients received cyclophosphamide (CYC) while 29 (47.5%) received mycophenolate mofetil (MMF). The proportion of patients who achieved complete remission was 44.3%, while 39.3% had partial remission and 16.4% did not respond to treatment. The side-effect profile between the two regimens was similar, with 18% of patients on CYC and 17,2% of patients on MMF reporting side effects. A chronicity score of 4 and above on histology was associated with poor clinical outcomes (p=0.03). Conclusion. The study showed that both mycophenolate mofetil and cyclophosphamide regimens have similar efficacy and side effect profile, which is comparable to the findings of other studies conducted elsewhere.
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    A survey of anaesthesia registrars’ experience and perspectives on epidural training in the WITS Anaesthesia circuit, Johannesburg
    (University of the Witwatersrand, Johannesburg, 2024) Hosking, Brett R; Wagner, Janine; Jooma, Zainub
    Background Insertion of epidurals, in particular thoracic epidurals, is a challenging procedure that is considered one of the most difficult technical skills in which to develop proficiency. Internationally, there is a lack of objective recommendations pertaining to epidural insertion education and skill acquisition. The aim of this study was to describe anaesthetic registrars’ experience and perspectives of epidural training at the University of Witwaterstrand. Method A cross-sectional, contextual, descriptive study was performed using a self-administered electronic questionnaire. A validated questionnaire on this topic developed by Isaacs et al was used with permission as a guide for the development of our questionnaire, which was then adapted to ensure its relevance to the local environment. Results Eighty-nine participants responded to the survey giving a response rate of 80.9%. Despite disagreement with respect to observation and feedback on enough cases to feel confident when performing the procedure alone (47, 52.8%), most participants still perceived they had a good understanding of spinal anatomy (73, 82%) and complications of epidural insertion (70, 78.7%). Participants could easily call for help if struggling (53, 59.5%), and knew when it was appropriate to do so (54, 60.7%). Almost all the participants (87, 97.8%) had never used an epidural simulator before, yet 67 (75.3%) participants indicated that it should be recommended to teach junior colleagues. Regarding the use of ultrasound pre-puncture, a large number of participants (75, 84.3%) had never used it, however, 55 (61.8%) participants recommend it being used as part of a teaching strategy. Conclusion Our study found that a more formal teaching program, as well as a minimum number of supervised epidural insertions has been recommended to improve the current training program, as registrars continue to face challenges in developing th
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    COVID-19: An Evaluation of Predictive Scoring Systems in South Africa
    (University of the Witwatersrand, Johannesburg, 2023) Prim, Brent Tyler Aloysius
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    Ceftazidime-avibactam and Aztreonam susceptibility of Carbapenem Resistant Enterobacterales and Pseudomonas aeruginosa isolates at Chris Hani Baragwanath Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2024) Phooko, Bontle Bessie; Mothibi, Lesego
    Background: The rising resistance of multidrug resistant organisms (MDROs) to currently available last resort antibiotics accompanied by increased mortality, has led to organisms such as Carbapenem Resistant Enterobacterales (CRE) and drug resistant P. aeruginosa becoming a global threat. New antibiotics such as Ceftazidime-Avibactam (CZA) and its use in combination with Aztreonam (ATM), has presented a glimmer of hope to this threat. There is a lack of susceptibility data of these MDROs to CZA and ATM in low to middle income countries such as South Africa. Finding out such information, may assist in motivating for acquisition and usage of these lifesaving antibiotics. Objectives: The aim of the study was to determine the in vitro susceptibility data of CZA and ATM against CRE, Drug resistant P. aeruginosa at Chris Hani Baragwaneth Academic Hospital (CHBAH). Secondarily, we aimed to investigate the invitro synergism of combined CZA and ATM to the CRE and P. aeruginosa isolates that were both CZA and ATM resistant. Methods: This was a prospective laboratory-based study conducted at the National Health Laboratory Services (NHLS), Department of Microbiology, CHBAH. We tested 101 CRE isolates and 32 drug-resistant P. aeruginosa isolates, including multidrug-resistant (MDR) and extremely drug resistant (XDR) strains, against CZA and ATM. Those that were resistant to both CZA and ATM were then tested for synergy using the combination of CZA and ATM. Results: Majority of the CRE isolates were Klebsiella species (84%) with OXA-48 & its variants being the predominant carbapenemase gene detected (67%). The P. aeruginosa isolates were predominantly carbapenem-resistant (88%), with 53% harbouring metallo-β- lactamases (VIM and NDM), and 78% classified as XDR. The overall CZA in vitro susceptibility amongst the serine active (OXA-48 positive) CRE in the study was 100%. The ATM susceptibility was 6% for all the CRE isolates tested. Synergism was seen in 96% of the CRE isolates that were resistant to both CZA and ATM. The activity of CZA and ATM against P. aeruginosa was 34% and 44% respective. Furthermore, the synergistic effect of combined CZA and ATM was seen in only 64 % of the P. aeruginosa isolates qualifying for testing. Conclusion: Local evaluation of CZA and CZA-ATM synergy is important in this era of antimicrobial resistance where there is great need of new treatment options. The high number v of CZA susceptible organisms amongst the OXA-48 isolates is encouraging. Synergistic activity of CZA and ATM presents as a good alternative for the MBL producers. More rigorous studies are needed to determine the clinical impact of usage of these antimicrobials.
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    A 10-year Retrospective Analysis of the Clinical Characteristics and Outcomes of mature B-Cell Non-Hodgkin Lymphoma in children treated in a tertiary South African Hospital.
    (University of the Witwatersrand, Johannesburg, 2024) Lackhoo, Bhavisha
    Background: Mature B-cell Non-Hodgkin lymphoma(B-NHL) is a common childhood malignancy with excellent cure rates in developed countries. There is limited data in Sub-Saharan Africa(SSA) especially with regard to HIV-infected children with B- NHL. Aim: The aim of this study was to compare clinicopathologic characteristics and outcomes in HIV-infected and HIV non-infected children with mature B-NHL. Setting: Chris Hani Baragwanath Academic Hospital, South Africa. Methods: Data were collected for all children diagnosed with mature B-NHL over a 10-year period. This included demographic, clinical, laboratory, radiological, treatment and outcome data. Descriptive statistics, multivariate analysis and a Cox proportional hazard model to determine the hazard ratio were calculated using the statistical programme IBM SPSS version 2. Results: A total of 61 patients were included in this study. The majority of patients were HIV-infected(n=41, 67%). The predominant histological subtype was Burkitt Lymphoma in both groups(40%). The median age of diagnosis in the HIV-infected group was 9.5 years and 5.7 years in the HIV non-infected group (p=0.07). Males were the majority sex in both groups (69%). More HIV-infected patients had a previous history of TB (n=18, p=0.002) and the majority were virally unsuppressed (61%). HIV-infected patients with B-NHL are 19 times more likely to succumb to death compared to HIV non-infected patients with B-NHL (HR=18.8, 95% CI 3.2- 110.3, p=0.001). v Conclusion: This study has shown that HIV-infected patients with B-NHL are 19 times more likely to die compared to their HIV-negative counterparts. Advanced disease at presentation, malnutrition, and treatment toxicity contributed to deaths in the HIV-infected group.
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    The prevalence of SARS-CoV-2 infection in an Academic Department of Anaesthesiology
    (University of the Witwatersrand, Johannesburg, 2024) Daya, Bhavin; Pegu, Kylesh; Mohanadasan, Sujai
    Background Anaesthetists are frontline workers who perform aerosol-generating procedures (AGPs) in enclosed environments which exposes them to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and increases their risk of contracting SARS-CoV-2 infection and Coronavirus disease 2019 (COVID-19). This study describes the prevalence of SARS-CoV-2 infection in the Academic Department of Anaesthesiology of the University of the Witwatersrand prior to vaccination. Methods A cross-sectional, contextual, descriptive research design, using an anonymous, electronic questionnaire, was followed in the study. Consecutive and convenience sampling methods were used. A p-value of <0.05 was considered statistically significant. Descriptive statistics and linear correlations using R 4.0.2 for Windows 1989, 1991 Free Software Foundation, Inc with interface R Studio Version 1.3.959 were used for data analysis. Results A total of 147 participants met the inclusion criteria. There were 90 (61.22%) females and 57 (38.78%) males. The mean age was 35.26 years for the 36 participants who tested positive (26.47%) for SARS-CoV-2. Hospital admission was required by 2.78% participants with COVID-19. Male participants had a higher prevalence of having SARS-CoV-2 infection (p = 0.045). There were no statistically significant associations between SARS-CoV-2 infection and pregnancy (p = 0.09), asthma (p = 0.11), autoimmune disease (p = 0.77), obesity (p = 0.9), diabetes (p = 0.96), hypertension (p = 0.9) and smoking (p = 0.69). Commonly reported COVID-19-like symptoms included fatigue (68.33%), headaches (61.67%) and myalgia (58.33%). Of the participants with a positive SARS-CoV-2 test, 38.46% had reported traveling within 14 days of testing positive (p <0.001). iv Community-exposure to a person with SARS-CoV-2 was associated with participants contracting SARS-CoV-2 infection (p = 0.001). Conclusion AGPs are not a significant risk factor for anaesthetists in the context of work or community transmission of the virus. There was a statistically significant predisposition for contracting SARS-CoV-2 infection among males, participants who travelled and participants who had community-exposure to a SARS-CoV-2 infected person. HCWs need to be protected through this pandemic and measures need to be institutionalised to maintain the functioning of the healthcare system.
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    Assessment of current practices of intrahospital transportation in critically ill patients at an academic hospital in South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Mawjee, Bhavic; Mohanadasan, Sujai; Jooma, Zainub
    Purpose: There is a paucity of guidelines for safe intrahospital transportation(IHT) in a resource-limited setting. The aim of this study was to describe the practices of IHT of critically ill patients perioperatively by anaesthetists. Methods: We conducted a prospective, cross-sectional study including 101 IHTs between theatre and Intensive care unit (ICU) . The most senior anaesthetist completed an adapted questionnaire. Frequency distributions were described, and Chi- square/Fisher's exact tests were performed to identify associations between IHT practices and categorical variables with anaesthetist seniority and first and subsequent IHTs. Results: The majority(72.97%) of the variables investigated were below the expected compliance rate(75%). Only 22.80% of anaesthetists were aware of IHT guidelines. Statistically significant differences were observed in IHT practices between senior and junior anaesthetists for: airway equipment taken(OR 0.25 95% CI 0.08-0.84), emergency drugs taken(inotropes(OR 1.49 95%CI 1.29-1.73), muscle relaxants(OR 5.81 95% CI 1.70-19.83), induction agents(OR 7.23 95% CI 1.86-28.13)) and awareness of IHT guidelines(OR 1.35 95% CI 1.20-1.53); and between first and subsequent transfers for: notification of the current condition(OR 0.23 95% CI 0.08- 0.71), use of manual resuscitation bag(OR 3.64 95% CI 1.21-11.00), and awareness of IHT guidelines(OR 0.14 95% CI 0.04-0.49). Conclusion: The majority of IHT practices interrogated during this study were below the expected compliance level irrespective of the seniority of the anaesthetist or the number of IHTs. Resource limitations and education seem to be the major contributors.