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

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    The social contexts of childhood malnutrition in South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Sello, Matshidiso Valeria; Odimegwu, Clifford; Adedini, Sunday
    Background: Childhood malnutrition is a major public health challenge of global importance. It may result from either excessive or deficient nutrients. Despite investments and several efforts made by the South African government and civil society organizations to improve child health, the prevalence of childhood malnutrition remains high in South Africa. South Africa is still lagging in in achieving the sustainable development goals 1-3 (i.e., 1- no poverty, 2 – zero hunger and 3 –good health and wellbeing). This is because the indicators of childhood malnutrition are significantly higher with one in four children being stunted, 13% overweight, and 7.5% underweight. These figures highlight a troubling trend that is echoed in many other African nations, where malnutrition rates are similarly concerning. For instance, while countries like Nigeria and Ethiopia face severe challenges with stunting rates exceeding 30%, South Africa’s rates are comparatively lower but still indicative of a significant public health challenge. In contrast, developed nations such as the United States report much lower stunting rates—around 3.4%—and face different nutritional issues, such as rising obesity rates among children. The current malnutrition status is worrisome in South Africa given that these conditions have not changed much in nearly three decades. Among other factors recognised as the leading causes of poor nutrition outcomes is food insecurity in households -defined as the lack of regular access to safe, sufficient, and nutritious foods, disrupted eating patterns and reduced food intakes. Despite South Africa being a net exporter of food, it is characterised by high poverty, reduced opportunities for higher education, employment challenges, environmental hazards, substandard housing, and health disparities, still have challenges in access to affordable safe nutritious foods. Furthermore, due to the complexity of childhood malnutrition, an integrated multisectoral approach among families, communities, and government systems is critical to ensuring positive child health and nutritional outcomes. Addressing poor nutritional outcomes among under-5 children requires policy-relevant evidence. While the literature shows that childhood malnutrition is a multifaceted issue influenced by poverty and poor socio-economic outcomes, evidence is sparse on how structural and environmental factors operating at different levels influence childhood malnutrition. Therefore, an understanding of social contexts of childhood malnutrition is required to improve children’s health outcomes in South Africa. Hence, this study examined the social context of childhood malnutrition in South Africa with a focus on individual child, 15 caregiver, and household-level characteristics. The study addressed five specific objectives: i) to determine the levels and patterns of childhood malnutrition in South Africa, (ii) to examine the individual child, caregiver, and household factors associated with childhood malnutrition in South Africa, (iii) to investigate the influence of food insecurity on childhood malnutrition, (iv) to explore the extent to which the socio-cultural and childcare practices of caregivers predispose under-5 children to malnutrition in selected low-income communities in South Africa, and (v) to investigate the role of a multi-sectorial approach in improving child nutritional outcomes in SA. This study was guided by the 2020 UNICEF conceptual Framework on Maternal and Child Nutrition as well as the Food and Nutrition Security Theory. Methods: This study adopted an explanatory sequential mixed methods design (i.e., analysis of quantitative data followed by qualitative data collection and analysis). The research methodology was broken into the quantitative and qualitative study. The quantitative study entailed analysing the quantitative secondary data from the 2017 South Africa National Income Dynamics Study (NIDS Wave 5). The NIDS data was nationally representative. The sample was weighted using post-stratified weights. Data of 2 966 children and their mothers were analysed. These children were selected on the basis that they had complete anthropometric measurements (height and weight measurements) and were suitable and selected for the investigation of childhood malnutrition (stunting, overweight, and underweight). We also conducted qualitative in-depth interviews with Early Childhood Development (ECD) practitioners to gain a deeper understanding of their experiences in childcare and perceptions of feeding practices. They were key informants since under-5 children spent a lot of time at ECD centres. Data were analysed at the univariate level to obtain descriptive statistics, and at the bivariate level using the chi-square test of association. At the multivariate level, multi-level binary logistic regression was employed, and odds ratios were reported. The multilevel analysis involved two levels – the individual level (child and mother characteristics) and the household-level characteristics. Data were analysed using Stata software (version 17). The selection of the independent variables was guided by the literature review and conceptual framework of the study. The second part of the study was qualitative and was collected between June and August 2022. Twenty in-depth interviews, and five focus group discussions with mothers of under-5 children, and five in-depth interviews with early childhood development practitioners (ECD practitioners) were conducted. Interviews were conducted using semi-structured questionnaires in selected low-income communities in urban 16 Gauteng (i.e., Thulani in Soweto), and in rural Limpopo (i.e., GaMasemola in Sekhukhune District). These communities were selected based on high poverty and unemployment rates, had substandard houses, insufficient infrastructure and environmental issues. The qualitative data provided deeper understanding about ethe quantitative findings and explored questions that were not available to the researcher in the NIDS dataset. The focus group discussions and key-in- depth interviews further provided a follow-up and an explanation of the quantitative findings. Thematic analysis was used to analyse qualitative data. Key findings from objective 1: In terms of descriptive findings, found that 22.16% of children were stunted, 16.40% were overweight, and 5.04% were underweight. The distribution of children among female and male children in the study population was almost the same. About 40% of the children had a low birth weight (<3 kg), 80.59% relied on the child support grant, and 67.22% were cared for at home during the day. Different patterns of malnutrition were observed. The highest percentage of children ages 12-23 months were stunted (33.43%) and overweight (32.69%), while the highest proportion of children ages 0-11 months and 48-59 months were underweight. Among children with a low birth weight of 1-2.9 kg, the highest percentage of stunting (30.07%) (p = 0.001, χ² = 71.2) and underweight (7.05%) (p = 0.026, χ² = 16.9) was observed. There was a relationship between access to medical aid, access to the child support grant, and childhood stunting (p < 0.05), while being cared for at home during the day was associated with stunting (24.98%) and overweight (18.99%) (p = 0.002, χ² = 36.3). Caregivers’ religion was associated with overweight (p = 0.007, χ² = 25.6) among under-5 children, while caregiver’s ethnicity (p = 0.024, χ² = 18.4) was associated with underweight. Key findings from objective 2: Female children had a lower likelihood (0.63 times) of being stunted compared to males. Children aged 12-23 months face a 60% higher risk of being overweight than those aged 0-11 months (AOR = 1.6). However, the risk of overweight declines steadily as age increases. Children aged 48-59 months are 83% less likely to be overweight compared to the youngest group of 0-11 months (AOR = 0.17). Children with a birthweight of 3 kg are 63% less likely to be underweight compared to those weighing 1-2 kg at birth (AOR = 0.37). Children attending crèches/day moms are 69% less likely to be underweight compared to those cared for at home (AOR = 0.31). Children cared for at home are 1.5 times more likely to be stunted (AOR=1.49) compared to children at a creche/day mom. Caregivers who were Nguni 17 had a 26% lower likelihood of having stunted children. Caregivers of other religions had 2 times higher likelihood of having overweight children compared to Christian caregivers (AOR=1.21). Middle-income households were associated with having overweight children (AOR=1.35) compared to low-income households. Children from structurally sound households had a 54% of high risk of being overweight compared to children from dilapidated household structures. The study found that a significant portion of the variation in child malnutrition (stunting, overweight, and underweight) occurred within communities. This is evident from the intraclass correlation of stunting (ICC) values from 27.9% to 30.2% variation, 34.3% to 38.2% overweight variation and 19.6% to 33,9% underweight variation within communities. The increase in ICC after adding additional variables suggest that these factors explain more of the variation within communities. Key findings from objective 3: The results showed that nearly 30% of the households were below the lower-bound food poverty line of R890 per person per month in South Africa, and just about half of the households did not always have enough available foods all the time. The qualitative findings show that the COVID-19 pandemic exacerbated the food insecurity during the COVID-19 lockdown, when many caregivers lost their income sources due to job losses. Food affordability and availability in the households became a major issue, forcing households to make hard decisions between deciding on foods with high nutrition that should be eaten against diverting financial resources and paying for other household expenses such as rent or electricity. Caregivers understood that they should be feeding their children nutritious foods but due to financial constraints, they were forced to give children the available but less nutritious foods in the households. Key findings from objective 4: Qualitative findings further showed that caregivers had various socio-cultural and childcare practices which influenced children’s nutritional and health outcomes. Socio-cultural practices that influenced childhood malnutrition included dietary choices – these were not necessarily affected by cultural beliefs, but they were rather influenced by the lack of income. Traditional beliefs on food- such as foods like eggs and dairy products such as milk or yoghurts were not given to girls. This was from a belief that this food would make girls more fertile and grow much faster. Traditional healing practices influence the dietary restrictions, limiting access to some nutritious foods, which are based on superstitions and lead to stigma. With regards to the childcare practices, there was also a lack of clarity by caregivers 18 on the duration of exclusive breastfeeding as well as the duration when the children should stop breastfeeding. Caregivers did not have adequate knowledge about when to resume weaning. Some caregivers highlighted that the last time they received nutrition knowledge was when their children were infants, and they had taken the children for vaccinations. Caregivers were not aware of how responsive caregiving such as child feeding frequency and portion sizes could improve children’s nutritional outcomes. Key findings from objective 5: From the qualitative interviews with early childhood development (ECD) practitioners, findings indicated a growing disintegration of childcare systems, including the family, health, and social systems, where a lack of parental support in nutrition programmes, a lack of support in health services and other social services when making referrals. Furthermore, various systems of care were working in silos in childcare service provision, resulting in children facing multiple adversities. Conclusions: The study demonstrated that individual-level child characteristics appear to exacerbate childhood malnutrition more than the mother and household-level characteristics. For example, the child level characteristics showed high significance, with age, sex, and child support grant, compared to the caregiver characteristics such as education, employment, and income. At the household level, variables such as household size and income did not show any significance. While this is the case, it does not necessarily mean that the mother and household-level characteristics were not important. This gap can be explained by the small sample, which can cause challenges of limited statistical power, making it harder to detect statistically significant differences. Furthermore, the qualitative assessment filled some gaps regarding these findings and gave an in-depth understanding on how the income disparities among caregivers and households result from high unemployment rates, highlighting the importance of socio-economic status and food security in child nutritional outcomes. From the ECD practitioners’ interviews, given the disintegration of childcare systems, the coordination and multisectoral collaboration of different sectors of care for children is urgently needed to improve children’s nutritional outcomes. Understanding the social context in which a child is brought up is important for the design of programmes and policies that will be effective in addressing this public health challenge. This understanding will enable efficient and effective service referral and service delivery to improve childhood nutrition in South Africa. This study highlights the need for a good 19 coordination of food, family, health, and social systems to ensure a positive childhood nutritional outcome.
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    Depression Demographic Profiling of Young Adults in South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Bambo, Matsidiso Princess; Hassem, Tasneem
    In young people aged 15 and 29 years, mental illnesses accounted for 23% of Years Lived with Disability (YLD) and among mental disorders, depressive disorders emerged as the second largest worldwide contributor to YLD at approximately 5.6%. In addition, one in every six individuals suffered from depression in South Africa. However, there is limited recent research about the demographic characteristics of South African emerging adults who may be vulnerable to depression. This research aimed to conduct demographic profiling of emerging adults (N=819) in South Africa who present with depressive symptoms. Additionally, using Pearson’s Product-Moment Correlation, T-test, and ANOVA, this cross- sectional research analysed secondary data from the Africa Long Life Study to determine relationships as well as statistical differences among demographic variables and depressive symptoms. Results indicated a low presence of depression in the sample. Significant relationships were found between depressive symptoms and demographic variables (socioeconomic status and religiosity). While no significant differences were found among language groups, a higher presence of depressive symptoms was found among females and those experiencing moderate to great financial difficulties. The findings emphasised the critical need for mental health policies and initiatives that promote prevention or early detection, prevention, and enhanced access to quality mental healthcare, particularly among vulnerable emerging adults like females and individuals who are economically disadvantaged. Mental health interventions should adopt comprehensive approaches that incorporate aspects of religiosity and spirituality to buffer against the presence of depressive symptoms among emerging adults
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    An analysis of the relationship between HIV-testing and cervical cancer screening uptake among females of reproductive age (15-49 years old) in South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Madubye, Koketšo Tholo; Wet-Billings, Nicole De
    Background: Higher income countries (HIC) have threefold testing coverage over lower to middle income countries (LMIC). Cervical cancer is the 4th most prevalent cancer among females globally, and a key contributor to mortality in Southern Africa. In LMIC, including South Africa, only 9% of the eligible screening cohort had ever undergone cervical cancer screening. This study examined the gap in understanding the relationship between HIV testing behaviours and the uptake of cervical cancer screening. Methods: The study was conducted in South Africa, utilising the 2016 South African Demographic and Health Survey (SADHS), as a secondary data source. The sample size of this study was a weighted (n) distribution of 4,199 females. The study design is cross-sectional, the outcome variable of interest in this study was the uptake of cervical cancer screening and the predictor variable is HIV Testing. The data by SADHS (2016) was analysed through the three phases: univariate, bivariate and multivariate. At the bivariate level, contingency tables were employed, using the Pearson chi-square test of association which examined the strength of crude relationships between cervical cancer screening and the study of independent variables. In addition, a multivariate analysis through the employment of a binary logistic regression as the outcome of the study was categorised with ‘yes’ and ‘no’ binary responses. Results: The findings of this study indicated that 33% of females of reproductive age had ever undergone cervical cancer screening, while 62.5% responded affirmatively to having tested for HIV. Females who tested for HIV displayed a higher propensity to having undergone cervical cancer screening, 37.43% female respondents who tested for HIV had undergone screened for cervical cancer, as opposed to those who didn’t test, which only 10.19 % screened for cervical cancer. Conclusions: 37.43% female respondents who tested for HIV had undergone screened for cervical cancer. Among those who did not test for HIV, 10.19 % screened for cervical cancer. There is still much to be done to improve cervical cancer screening among females, while HIV testing remains high, cervical cancer screening is alarmingly low. The 2017 Cervical Cancer Prevention and Control Policy functions as a mediating apparatus, additional supplementations targeting females below the age of 30 remain a necessity
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    Voiding cystourethrography in the renal pre-transplantation workup: an essential investigation?
    (University of the Witwatersrand, Johannesburg, 2022-10) Sofianos, Zelia; Rajkumar, Leisha; Lucas, Susan
    INTRODUCTION: Due to resource constraints in the South African public healthcare sector, patients with End-Stage Renal Disease (ESRD) are eligible for renal replacement therapy only if they are also found to be eligible for renal transplant. AIM: The aim of this study is to document Voiding Cystourethrogram (VCUG) findings in potential renal transplant candidates to assess the contribution of the VCUG as a standard investigation in the renal transplant workup. METHODS: Of the patients who underwent VCUG in Klerksdorp/Tshepong Hospital Complex (North West province, South Africa) from 1 January 2019 to 31 March 2020, 85 patients were included in the study and their VCUG findings retrospectively analysed. RESULTS: The mean age was 40.0 years (range 21-62 years), with males constituting 57.7% of patients and females 42.3%. Lower urinary tract abnormalities were identified in 24.7% of patients, some of whom had more than one abnormality. Of the total abnormalities, VUR (vesicoureteral reflux) accounted for 15.3%, bladder diverticula for 5.9%, urethral strictures for 3.5% and a significant post-void residual volume for 4.7%. No comorbidities were found to have a statistically significant association with the presence of VCUG abnormalities. CONCLUSIONS: To ensure that patients with End-Stage Renal Disease are adequately prepared for renal dialysis and potential renal transplant, and that their comorbidities and lower urinary tract are optimised should abnormalities be identified on VCUG, the VCUG remains an essential investigation in the renal transplant workup.
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    Maternal death at Leratong Regional Hospital: a six-year retrospective review, South Africa
    (University of the Witwatersrand, Johannesburg, 2021-11) Motau, Tumelo Ngaka; Chauke, Lawrence
    Background: The aim of the study was to systematically examine the main causes of maternal deaths and contributing factors at Leratong Regional Hospital in order to recommend strategies that can assist in reducing maternal mortality at this level of healthcare. Objectives: The objectives of the study were to: determine the institutional maternal mortality rate at Leratong Regional Hospital between 2012 to 2017, compare the trend (year on year) in the iMMR over the study period, describe the profile of women who died during the period under study, describe the clinical and surgical management of the women who died, and to determine the leading causes of maternal deaths, contributing factors and avoidable factors. Methods: A hospital based retrospective study based on patient clinical records at Leratong hospital. It included all the maternal deaths that occurred at Leratong Regional Hospital during the six-year study period (2012-2017). Results: There was a total of 78 maternal deaths with 32441 live births giving the MMR of 240 per 100 000 live births. However only 74 files could be analysed. The results showed that there was a rise in the maternal mortality rate over a six years period. The majority (70, 94.5%) of the women who died were African, aged between 20-35 years (56, 76%), multigravida (54,73%) with a parity of three or more (23, 31%). Obstetric haemorrhage was the leading cause of maternal death particularly postpartum haemorrhage (11.14%) followed by non-pregnancy related infections, sepsis and eclampsia. Conclusion: Maternal mortality has decreased according to recent confidential enquiry into maternal death in South Africa (2017-2019) However our study did not demonstrate a decline but rather an increase in the maternal mortality rate at Leratong. It showed that most of the maternal deaths were avoidable and the need for urgent interventions in terms of education, improving access to health care facilities, intensifying health care worker skills training and better transport systems between health care facilities is important.
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    Adherence to the Standard Treatment Guidelines in managing patients with hypertension at Chiawelo Community Health Centre, Gauteng, South Africa
    (University of the Witwatersrand, Johannesburg, 2022-04) Dawduth, Nikkeeta; Torlutter, Michele
    Background: Hypertension is a highly prevalent chronic disease, causing significant morbidity and mortality and is poorly managed and controlled in primary care, with only 24.5 to 56% of patients being controlled. Aim: The aim of the study was to determine health care worker adherence to the Standard Treatment Guidelines in managing hypertensive patients in primary care. Methods: The study was conducted at Chiawelo Community Practice Johannesburg. A retrospective file review was done on 261 hypertensive patients and information extracted to determine whether health care workers performed correct baseline tests at diagnosis; correct investigations were done on ongoing basis; lifestyle modification was addressed; and correct pharmacological therapy was prescribed and titrated. Data analysis included descriptive statistics and bivariate analysis. Results: A total of 77% of participants were female and 23% were male of which 80.5% participants had co-morbidities. Patients were treated by a doctor in 97% of cases; 84.3% by clinical associate, and 0.6% by a nurse only over time. Baseline findings recorded in the file at diagnosis were: weight 65.9%, height 73.2%, potassium 32.2%, BMI 50.2%, abdominal circumference 51.7%, and urine dipsticks 47.9%. Vitals and investigations recorded in the file: BP 99.6%, weight 19.5%, blood glucose 86.6%, creatinine 95.4%, eGFR 94.3% and urine protein 3.4%. Lifestyle modification was recorded for 23.7% and medication adherence was checked and recorded for 36.4% of patients. The correct antihypertensive medications were prescribed in 96.5% of patients but titrated correctly in only 73.5% of patients. 52.8% of patients were controlled on treatment. Conclusion: Adherence to guidelines by health care workers was suboptimal and several aspects of care warrants quality improvement processes.
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    COVID-19 and health care worker exposure at Chris Hani Baragwanath Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2021-12-05) Glatt, Sara Chaya; Menezes, Colin; Winchow, Lai ling; Tsitsi, Merika
    Background: Health care workers (HCWs) are at an increased risk of acquiring coronavirus disease 2019 (COVID-19). Appropriate risk assessments and testing are essential to reduce transmission and avoid workforce depletion. Objective: Investigate the risk of COVID-19 infection among HCWs at Chris Hani Baragwanath Academic Hospital who fulfil the Person Under Investigation (PUI) case definition or had exposure to a confirmed COVID-19 contact. Methods: A retrospective review of HCW records was conducted over a two month period. Data collected included demographics, exposure type, risk level, and COVID-19 test result. Frequency distribution tables, bivariate analyses and univariate and multivariate analyses were conducted. Results: Among the 1111 HCWs reviewed, 643 were tested with 35.6% positive results. PUI’s accounted for 62.4% of positive cases. Symptomatic HCWs with no known contact were at a greater risk of infection than those with a patient exposure (p=0.000). Risk of testing positive was higher after a patient exposure (p=0.000) compared to a co-worker contact. Conclusion: There is a higher positivity rate among HCWs than the general population. The presence of symptoms warrants testing. Nosocomial transmission was derived from patient more than co-worker contacts.
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    The Relationship Between Sensory Disability Status and Contraceptive Use Among Women Aged 15- 49 Years Old In South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Sifora, Kutlwano Katlego Kimberly; De Wet-Billings, Nicole
    Background: Studies suggest that disability significantly hinders access to reproductive health services, particularly family planning, in low- and middle-income countries. Women with disabilities have a low contraceptive use rate, leading to increased risks of unintended pregnancies and health complications. This study examined the relationship between sensory disability status and contraceptive use in South Africa. A sensory disability is a condition that affects one or more of the body's sensory functions like sight, hearing, touch, taste, or smell. In this study, sensory disabilities focused on hearing and visual impairments. Methods: The study employed a cross-sectional design using the 2016 South Africa Demographic and Health Survey. The study focused on women of reproductive age (15–49 years old) in South Africa, who were sexually active and provided information on both their contraceptive use and sensory disability status. The outcome variable of this study was contraceptive use, and the main independent variable was sensory disability status. The control variables included demographic characteristics namely age, race, marital status, province, and place of residence, as well as socioeconomic characteristics such as employment status, wealth status, education, family planning messages, and contraceptive knowledge. The analysis was conducted using Stata 17.0 on a weighted sample of 6 683 sexually active women aged 15–49 years old who answered questions on contraceptive use. The data analysis was done in three phases. For the first phase, cross-tabulations and chi-square analysis were used to demonstrate the levels of contraceptive use as well as all characteristics of women. For the second phase, bivariate binary logistic regression models were used to determine the relationship between each of the independent variables and the outcome variable of contraceptive use. Lastly, for the third phase, a stepwise multivariate binary logistic regression was utilised to determine the relationship between sensory disability status and contraceptive use among women aged 15– 49 years old in South Africa. Results: Among South African women of reproductive age, 55.4% were using contraceptives. Women with sensory disabilities were shown to have lower odds of using contraceptives than those without sensory disabilities, even after adjusting for all other variables [OR: 0.78, CI: 0.63873 - 0.95227]. Significant associations with contraceptive use were observed for factors xi including age, race, marital status, education and province. Compared to women aged 15–24, women aged 35–39 had a much lower likelihood of using contraceptives. [OR: 0.46, CI: 0.38150 - 0.55364]. Women from races other than black were also observed to have lower odds for contraceptive use compared to black women [OR: 0.75, CI: 0.61098 - 0.92237]. Conversely, married women were significantly more likely to use contraceptives than women who were never married [OR: 1.23, CI: 1.05328 - 1.42899]. Additionally, women with secondary [OR: 1.98, CI: 1.28089 - 3.07512] or higher education [OR: 2.40, CI: 1.49931 - 3.83750] exhibited a significantly higher likelihood of contraceptive usage compared to those lacking formal education. Women residing in Western Cape [OR: 1.83, CI: 1.29743 - 2.57637], Eastern Cape [OR: 1.66, CI: 1.27747 - 2.15886], Northern Cape [OR: 1.61, CI: 1.18574 - 2.19087], KwaZulu Natal [OR: 1.51, CI: 1.17797 - 1.92456], North West [OR: 1.43, CI: 1.01266 - 2.01228], and Mpumalanga [OR: 1.50, CI: .15808 - 1.93439] were found to have a higher likelihood of using contraceptives compared to women residing in Limpopo. Conclusions: Low contraceptive use among women with sensory disabilities in South Africa highlights the need for inclusive reproductive health services, addressing communication, information access, and societal attitudes to ensure informed decisions.
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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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    Non-tuberculous mycobacteria (NTM) at Charlotte Maxeke Academic Hospital, 2010-2017
    (University of the Witwatersrand, Johannesburg, 2023-11) Nqwata, Lamla; Feldman, Charles; Black, Marianne
    Rationale: 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.