Groote Schuur Hospital Research Articles

Assessment Criteria to Diagnose Malnutrition (Undernutrition and Overnutrition) in Hemodialysis Patients

This study aimed to determine if adapted Global Leadership Initiative on Malnutrition (GLIM) criteria can diagnose overnutrition, in addition to undernutrition, in hemodialysis patients. Additionally, it compared the adapted GLIM criteria with the Subjective Global Assessment (SGA) for diagnosing undernutrition. A cross-sectional, descriptive study design with an analytical component was utilized. An interviewer-administered questionnaire (IAQ) was completed with 116 adult participants from two public renal units in Cape Town. Data collection included demographic, medical, and anthropometric information, incorporating the established SGA tool and the adapted GLIM criteria. Of the participants, 58% were female, with a mean age of 41.04 years (SD 10.6). The primary causes of renal failure were hypertension (38%) and glomerular disease (33%). The median weight was 64.74 kg (IQR 16.4) and the mean BMI was 25.44 kg/m2 (SD 4.66). The prevalence of obesity was 20%, and undernutrition was 4% by BMI. Participants from Groote Schuur Hospital (GSH) had a higher mean BMI (26.40, SD 4.9) than those from Tygerberg Hospital (TBH) (p=0.0033). Abdominal obesity prevalence was 51%, with a mean waist circumference of 87.06 cm (SD 11.37). Using SGA parameters, undernutrition prevalence was 26%, all classified as SGA-B, compared to 22% by adapted GLIM. Adapted GLIM classified 69.83% as malnourished (overnutrition 47%, undernutrition 22%). For undernutrition, the adapted GLIM had a sensitivity of 75% (CI 64.04, 85.96), specificity of 77.78% (CI 67.26, 88.3), positive predictive value of 69.23% (CI 57.55, 80.91), and negative predictive value of 82.35% (CI 72.71, 92.00). Among those diagnosed with overnutrition by adapted GLIM, 89% were classified as well-nourished by SGA. The adapted GLIM criteria effectively assessed overnutrition as well as undernutrition in hemodialysis patients. It identified a significant proportion of patients misclassified as well-nourished by SGA who were actually overnourished. The adapted GLIM showed good sensitivity and specificity for diagnosing undernutrition in this population.

Cannabis use among hospitalised adolescents before and after decriminalisation in South Africa.

Cannabis is the most widely used substance worldwide, and its use is much higher among adolescents. However, adolescents are at higher risk of negative sequelae secondary to this use, including the possible development of mental disorders. On 31 March 2017, the South African High Court ruled that cannabis use by an adult in a private dwelling should be decriminalised. This study aimed to determine the clinical profile of adolescents who use cannabis, who use, who present to a tertiary hospital in Cape Town, South Africa, before and after the high court ruling in 2017. Folder review of adolescents admitted at Groote Schuur Hospital (GSH) in the Emergency Psychiatric Unit. This study was a retrospective folder review of adolescents admitted from April 2015 to March 2019. Cannabis was the most commonly used substance in the study, with increased use seen post-ruling. The most common frequency of cannabis use reported was daily. A significantly higher proportion of patients who used cannabis pre-ruling had psychotic disorder (p < 0.001) and cannabis use disorder (p = 0.01). Post-ruling, the results were statistically significant (p < 0.001) for both. The study showed an increasing prevalence of cannabis use in adolescents admitted with mental illness after the high court ruling in 2017. This study also demonstrates that adolescents remain a vulnerable population to the effects of cannabis and highlights the need for further research. The findings of this study call for more focussed adolescent interventions and services.

Groote Schuur Hospital neurosurgical intensive care unit: A 2-year review of admission characteristics.

At Groote Schuur Hospital (GSH), the neurosurgical intensive care unit (NsICU) is a 6-bed unit headed by a specialist neurosurgeon with extensive experience in neurocritical care, working in close collaboration with intensivists from the Division of Critical Care. There is currently no detailed analysis of the demographics, diagnosis and management of patients admitted to the NsICU at GSH. To provide a detailed descriptive analysis of the demographics, diagnosis and management of patients admitted to the NsICU at GSH from 1 January 2020 to 31 December 2021. A retrospective descriptive analysis was done of patients who received treatment in the NsICU from 1 January 2020 to 31 December 2021. A total of 685 patients were admitted to the unit over a 2-year period, with a male preponderance (68.2%). The average age was 42.5 (standard deviation (SD) 17.2) years. The most common neurosurgical diagnoses were traumatic brain injuries (39.6%), brain tumours (22.6%) and aneurysmal subarachnoid haemorrhages (9.9%). Emergency admissions comprised 76.6% of the total and 86.7% of patients were admitted postoperatively. Three hundred and seventy-two patients (54.3%) required mechanical ventilation, 132 (19.3%) required both an intracranial pressure (ICP) monitor and brain tissue oxygenation monitor, 86 (12.5%) needed placement of an external ventricular drain, 50 (7.3%) needed placement of a tracheostomy tube and 16 (2.3%) needed placement of an ICP monitor only. The average duration of stay was 5.5 (1.3) days and NsICU mortality over 2 years was 11.1%. The NsICU at GSH manages predominantly male trauma patients and a significant number of admitted patients require specialised invasive intracranial monitoring. This is the first in-depth analysis of patients managed in a dedicated neurosurgical intensive care unit in South Africa. The work defines the patient population, neurosurgical pathologies and service level requirements that would likely be encountered by teams building a similar service.

Neurological manifestations of syphilis-HIV coinfection in South Africa

ObjectiveSyphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa. MethodsWe retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022. ResultsHIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01. ConclusionNeurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

PAEDIATRIC-12 MANAGEMENT OF PAEDIATRIC LOW-GRADE GLIOMA IN CAPE TOWN, SOUTH AFRICA

Abstract OBJECTIVE To assess the management of paediatric low-grade gliomas by the combined neuro-oncology services of the University of Cape Town. METHODS A retrospective analysis was performed on the folders of patients diagnosed at the Red Cross War Memorial Children’s Hospital (RCWMCH) and Groote Schuur Hospital (GSH) between 2000 and 2022. The data includes 2 patient cohorts, the first cohort being patient data collected from 2000-2016 and the second from 2017-2022. RESULTS A total of 127 patients, aged 0.38-13.76 years (mean 5.71) were treated at RCWMCH and GSH. Predisposition syndromes observed included Neurofibromatosis 1 11, Tuberous sclerosis 6, and Trisomy 21 1. The most common sites were the cerebellum 27%, hypothalamus 17%, cerebrum 12%, and optic pathway 13%. Metastatic disease was noted in 12 patients (9%). Gross total resection (or debulking) was performed in 67 (53%) of patients, 40 had biopsy only, and 20 had no surgery (mostly OPGs). Histology was predominantly Juvenile Pilocytic Astrocytoma 70%, Diffuse Astrocytoma 9%, Low-Grade Glioma Nos 8%,5% Subependymal Giant cell Astrocytoma, and 5% Pilomyxoid Astrocytoma. BRAF v600E mutation was tested in 17 patients: all were negative. Forty-four (35%) received chemotherapy and 36 (82%) as first-line therapy with vincristine and carboplatin as the most used agents. Newer therapies Bevacizumab/irinotecan and Trametinib were recently used in 10 patients as third or fourth-line regimens. There was an increase in chemotherapy usage for patients with irresectable tumours between the 2 cohorts, from 27% in the first cohort to 49% in the second. Thirty (23.6%) patients received radiotherapy and of those 8 were in an upfront setting. There was no difference in the 5-year OS between the 2 cohorts, 84% in the first and 85.7% in the second. CONCLUSION Multi-disciplinary treatment of paediatric LGG in LMIC is essential. Patterns of management have changed without affecting outcomes.

Low self-reported penicillin allergy in South Africa-implications for global public health response.

In high-income countries, up to 25% of inpatients have a self-reported penicillin allergy (PA). After testing, 95% of these self-reported PAs are incorrect. These incorrectly labelled PAs increase the use of broad-spectrum antibiotics, and drive bacterial resistance. The epidemiology of PA in low- and middle-income countries is unknown. We aimed to describe the epidemiology and delabelling outcomes of self-reported PA in South African (SA) inpatients. We conducted point prevalence surveys between April 2019 and June 2021 at seven hospitals in Cape Town, South Africa. A team trained in the PEN-FAST allergy decision tool conducted in-person interviews, and reviewed patient notes to identify and risk stratify inpatients with a self-reported PA. These patients were referred to the Groote Schuur Hospital (GSH) allergy clinic for delabelling. A total of 1486 hospital inpatients were surveyed and 3.2% (n = 48) carried a PA label. Importantly, 64.6% (n = 31) were classified by PEN-FAST as low risk for true penicillin hypersensitivity. Overall, 25% of the self-reported PAs received a β-lactam antibiotic in hospital and were directly delabelled. Delabelling attrition was very high, with 6.3% (3/48) of the self-reported PAs attending the GSH allergy clinic, and only one patient proceeding to a negative oral penicillin challenge. Inpatient self-reported PA was lower in South Africa hospitals compared with other upper-middle-income countries, and the majority of patients carried a low-risk PA label. Linkage for delabelling with the allergy clinic was very poor, and thus strategies to improve access and delivery of delabelling remains an urgent public health issue.

Feasibility and safety of interventional electrophysiology and catheter ablation in the South African public sector: Challenges and opportunities for comprehensive cardiac electrophysiology in South Africa.

The spectrum and outcomes of catheter ablation procedures performed in South Africa are unknown, and therefore, the feasibility of interventional electrophysiology in the South African public sector is undetermined. This study was a retrospective review of all patients that underwent invasive electrophysiology procedures and catheter ablation at Groote Schuur Hospital (GSH) and the University of Cape Town Private Academic Hospital (UCTPAH) between 01 January 2013 and 31 December 2020.One thousand one hundred eighty-six invasive electrophysiology procedures were performed during the study period. Of these were 1102 catheter ablation procedures. There were 76 redo catheter ablation procedures, predominantly for atrial fibrillation (AF), which accounted for 39% (30/76) of the repeat procedures. There were only 0.8% (9/1102) catheter ablation related complications which were mostly access related. Atrial fibrillation accounted for most of the ablation procedures, 28.9% (318/1102); these were mainly performed at UCTPAH than at GSH, 300 vs 18 p< .0001. Cavotricuspid isthmus (CTI) dependent atrial flutter ablation was the second most commonly performed catheter ablation procedure, accounting for 21.6% (238/1102) of the catheter ablation procedures. More CTI dependent atrial flutter ablations were performed at GSH than a UCTPAH, 156 vs 82 p< .0001. The overall success rate of catheter ablation was 92%. A broad spectrum of catheter ablation procedures was performed with a high success rate and limited complications, thus demonstrating the feasibility of safe cardiac electrophysiology and catheter ablation in the South African public sector.

Integrating Gestational Diabetes Screening and Care and Type 2 Diabetes Mellitus Prevention After GDM Into Community Based Primary Health Care in South Africa-Mixed Method Study.

Background:Despite high gestational diabetes mellitus (GDM) prevalence in South Africa (9.1% in 2018), its screening and management are not well integrated into routine primary health care and poorly linked to post-GDM prevention of type 2 diabetes mellitus (T2DM) in South Africa’s fragmented health system. This study explored women’s, health care providers’ and experts’ experiences and perspectives on current and potential integration of GDM screening and prevention of T2DM post-GDM within routine, community-based primary health care (PHC) services in South Africa.Methods:This study drew on the Behaviour Change Wheel (BCW) framework and used a mixed method, sequential exploratory design for data collection, analysis and interpretation. Individual semi-structured interviews were conducted with key informants (n = 5) from both national and provincial levels and health care providers (n = 18) in the public health system of the Western Cape Province. Additionally, focus group discussions (FGDs) with Community Health Workers (CHWs n = 15) working with clinics in the Western Cape province. A further four FGDs and brief individual exit interviews were conducted with women with GDM (n = 35) followed-up at a tertiary hospital: Groote Schuur Hospital (GSH). Data collection with women diagnosed and treated for GDM happened between March and August 2018.Thematic analysis was the primary analytical method with some content analysis as appropriate. Statistical analysis of quantitative data from the 35 exit interview questionnaires was conducted, and correlation with qualitative variables assessed using Cramér’s V coefficient.Results:Shortage of trained staff, ill-equipped clinics, socio-economic barriers and lack of knowledge were the major reported barriers to successful integration of GDM screening and postnatal T2DM prevention. Only 43% of women reported receiving advice about all four recommendations to improve GDM and decrease T2DM risk (improve diet, reduce sugar intake, physical exercise and regularly take medication). All participants supported integrating services within routine, community-based PHC to universally screen for GDM and to prevent or delay development of T2DM after GDM.Conclusion:GDM screening and post-GDM prevention of T2DM are poorly integrated into PHC services in South Africa. Integration is desired by stakeholders (patients and providers) and may be feasible if PHC resource, training constraints and women’s socio-economic barriers are addressed.

The University of Cape Town’s paediatric cancer database: Results from the first years (2019–2021)

Background: The paediatric oncology multidisciplinary team at the University of Cape Town (UCT) developed a research-ready data set.Aim: This study aimed to describe the early results detailing the epidemiological profile of childhood cancer patients and evaluated factors associated with presentation and outcome.Setting: The UCT paediatric oncology platform at the Red Cross War Memorial Children’s Hospital (RCWMCH) and Groote Schuur Hospital (GSH).Methods: A REDCap database was developed with a Cancer Association of South Africa (CANSA) grant. A database administrator consented all new patients and recorded demographic and social information.Results: There were 212 children consented from 2019 to 2021: 109 girls and 103 boys. The age range was from 1 day to 15.98 years, with a median of 5.18 years. Only 32 (15%) of these families had medical insurance, 34 (16%) lived in informal housing and 25 (12%) did not have access to piped water. Seventy-four families (35%) reported a relative with cancer, including seven first degree relatives. With a median follow-up of 12.4 months, the estimated 2-year overall survival (OS) and event-free survival (EFS) was 77% and 72%, respectively. Overall survival was significantly different (p = 0.013) by disease group, varying from 100% for Wilms tumour and germ cell tumours to 52% for rhabdomyosarcoma. Most patients with solid tumours (72%) had advanced disease at diagnosis. Outcomes were poorer for children living in informal housing and without piped water.Conclusion: A real-time database can provide a research-ready data set for interrogating cohort-specific factors impacting childhood cancer outcomes.

Morbidity and mortality in small for gestational age very preterm infants in a middle-income country.

ObjectiveTo evaluate the impact of small for gestational age (SGA) on outcomes of very preterm infants at Groote Schuur Hospital (GSH), Cape Town, South Africa.Study designData were obtained from the Vermont Oxford Network (VON) GSH database from 2012 to 2018. The study is a secondary analysis of prospectively collected observational data. Fenton growth charts were used to define SGA as birth weight < 10th centile for gestational age.ResultsMortality [28.9% vs. 18.5%, adjusted risk ratio (aRR) 2.1, 95% confidence interval (CI) 1.6–2.7], bronchopulmonary dysplasia (BPD; 14% vs. 4.5%, aRR 3.7, 95% CI 2.3–6.1), and late-onset sepsis (LOS; 16.7% vs. 9.6%, aRR 2.3, 95% CI 1.6–3.3) were higher in the SGA than in the non-SGA group.ConclusionSmall for gestational age infants have a higher risk of mortality and morbidity among very preterm infants at GSH. This may be useful for counseling and perinatal management.

Impact of COVID-19 on breast cancer diagnostic and surgical services at a South African academic hospital

BACKGROUND: The purpose of the study was to describe the impact of the COVID-19 pandemic on diagnostic and surgical breast cancer services at Groote Schuur Hospital (GSH) and affiliated hospitals. METHODS: All patients, newly diagnosed, awaiting surgery, and listed for neoadjuvant chemotherapy (NACT) by the breast surgical service from 23 March-23 June 2020 were included. A historic control was used where appropriate consisting of patients presenting in the same period in 2019. Clinic attendance records and surgical waiting lists were used to identify patients in the three months and data were extracted from hospital records including hospital admission records and surgical operative notes. RESULTS: The number of patients who presented with a new breast symptom to the diagnostic breast clinic decreased from 1 094 in 2019 to 299 in 2020, representing a 72.6% decrease. Telemedicine use as a function of the total follow-ups increased from 53% (n = 1 350) in 2019 to 75% (n = 735) in 2020. The overall number of new breast cancers diagnosed decreased from 146 in 2019 to 79 in 2020, but the proportion of patients seen with a new breast symptom who were diagnosed with breast cancer increased from 13% (n = 1 094) in 2019 to 26% (n = 299) in 2020. Eighteen per cent (n = 105) fewer breast cancer surgeries were performed in 2020 compared to 2019, with immediate breast reconstructive procedures representing the largest decrease of 40%. CONCLUSION: The impact of COVID-19 on breast cancer services has been both at the diagnostic level and in delays to surgery. A new online referral system improved referral efficacy translating to more cancers being diagnosed as a function of total referrals. The drop in absolute numbers of cancer diagnoses, however, represents an unmet health need. An expansion of our telemedicine service mitigated COVID risk in the outpatient setting. The greatest impact on our treatment decisions was seen in the cohort of patients placed on neo-adjuvant endocrine therapy (NET). We saw a global decrease in breast surgeries performed, with the greatest decrease being in reconstructions.

Patient satisfaction at the Chronic Pain Management Clinic at Groote Schuur Hospital

Background: Chronic pain is a costly and debilitating ailment with an estimated global prevalence of 20%. The evaluation of patients’ satisfaction with pain management is crucial both to ensure that care provided remains fit for purpose and to identify opportunities for improvement. Groote Schuur Hospital (GSH) has one of the few functional interdisciplinary pain clinics in South Africa with more than 900 patients seen per year. To date, there had been no data informing us about patient satisfaction at the clinic. The aim of our study was to survey patients who are being treated at the Chronic Pain Management Clinic to determine their level of satisfaction with the service. Methods: A descriptive cross-sectional study was conducted with a sample of 67 patients who had been attending the Chronic Pain Management Clinic for more than three months. Data were collected telephonically using the patient demographics form and the internationally validated pain treatment satisfaction scale (PTSS). The data were then analysed using descriptive statistics. Results: The mean age of the 67 participants was 56.5 years (SD 12.9; age range: 18–83). In this sample, 81% of the participants are female while 70% of the participants had not completed 12 years of schooling. Most of the participants were referrals from orthopaedics (48%), followed by referrals from day clinics (13.5%). The median pain severity score was 7.5 (IQR 7–9) a week prior to data collection. The majority of participants (70%) reported that they could ask the staff questions and were provided with adequate support and care. Results indicate that six in every ten patients are satisfied with their pain management at the GSH Chronic Pain Management Clinic. One aspect of care which was less than satisfactory related to patients receiving information about their condition and the treatment thereof. In general, participants would have appreciated more information about their illness or injury (51%), causes and treatments of the pain, as well as side effects of the pain medication (60%). Conclusion: Most participants were either somewhat satisfied or very satisfied with all aspects of care they were asked about. It is clear that patient satisfaction is not only driven by pain relief but can also be enhanced by good patient-provider relationships and shared decision-making. It is, therefore, important to continually train healthcare providers to improve their communication skills.

A dosimetric comparison of volumetric modulated arc therapy with three-dimensional conformal radiotherapy in the treatment of cervical cancer

Background: External beam radiotherapy (EBRT) is essential in the management of locally advanced cervical cancer (LACC). Volumetric modulated arc therapy (VMAT) is thought to achieve higher conformity to the planned target volume (PTV) and better sparing of organs at risk (OAR) when compared to three-dimensional conformal radiotherapy (3D-CRT). This study focused on these principles as it applied to treatment and potential toxicity in the management of LACC. Aim: The aim of this study was to compare dosimetric parameters between VMAT and 3D-CRT in the management of LACC. Setting: The study analysed patients treated at Groote Schuur Hospital (GSH) between May and December 2017. Methods: This is a non-randomised comparative retrospective study. Three-dimensional conformal radiation and VMAT plans were generated, and data on treatment parameters for PTV D50%, Dmax, Dmean, conformity index (CI), homogeneity index (HI), treated volume (TV), irradiated volume (IV) and OAR constraints; femoral heads, bladder, bowel bag, rectum and bone marrow were collected. Results: Of the 45 patients assessed, VMAT showed statistically significant, lower treatment parameter values for CI (1.09 vs. 1.49) and TV (1613.1 cm 3 vs. 2230.3 cm 3 ), whereas 3D-CRT showed lower Dmax (48.1 Gy vs. 49.2 Gy) and IV (10652.2 cm 3 vs. 14618.1 cm 3 ). Volumetric modulated arc therapy OAR doses revealed a lower V45 for bowel bag (182.3 cm 3 vs. 411.3 cm 3 ; p &lt; 0.001), lower V40 for bone marrow (19.1% vs. 38.7%; p &lt; 0.001) and rectum (88.5% vs. 96%; p &lt; 0.001). A reduced 3D-CRT dose was noted for bladder Dmax (47.4 Gy vs. 48.3 Gy; p &lt; 0.001). Conclusion: Volumetric modulated arc therapy offered a superior dosimetric option, with better OAR dose sparing and optimal tumour dosimetry.

Comparative Analysis of Kidney Stone Composition in Patients from Ghana and South Africa: Case Study of Kidney Stones from Accra and Cape Town

Background: Kidney stone disease, also termed nephrolithiasis is associated with significant morbidities such as severe colicky flank pain, haematuria, urinary tract infection and kidney failure. Kidney stone disease was perceived as uncommon in developing countries; however, the global prevalence has been rising over the past two decades due to lifestyle changes. There is very limited literature on kidney stone composition in Africa, including Ghana and South Africa. It was based on this evidence that this study was undertaken. Aim: The primary aim of this study was to describe and compare the composition of kidney stone in patients receiving treatment at the Korle-Bu Teaching Hospital (KBTH), Accra (Ghana) and Groote Schuur Hospital (GSH), Cape Town (South Africa). Methods: The study was a retrospective folder review of patients treated for nephrolithiasis at the Korle-Bu Teaching Hospital in Accra (Ghana) and Groote Schuur Hospital in Cape Town (South Africa). Patients who were treated for kidney stone disease between 1st June 2016 and 31st May 2018 were recruited, and their folder numbers were retrieved from theatre logbooks. A total of hundred and sixty-three (n = 163) folders (n = 30 KBTH; n = 133 GSH) were subsequently retrieved from the two facilities’ records department. Demographic data and kidney stone analysis results were analyzed using the R statistical software. Results: The age of KBTH patients ranged from 24 to 75 years and age of 45 years, while that of GSH ranged 19 to 77 years and median age 48 years respectively. Males were the majority stone formers for both hospitals [56.7% KBTH; 59.4% GSH]. There was no statistical difference in gender (p = 0.9447) and age (p = 0.2612) between the two groups. Calcium oxalate (86.7%) and uric acid (90.0%) were the commonest components of the kidney stones analyzed from the KBTH. Calcium oxalate (66.2%) and carbonate apatite (40.6%) were the most common components stones from GSH. Brushite (3.0%), cystine (3.8%) and struvite (19.6%) stones were only found in GSH patients. All kidney stones from the KBTH were mixed stones. Pure kidney stones were only found among the GSH dataset constituting 48.9%, also female patients from GSH formed more mixed stones than their male counterparts (M:F = 40.5%:66.67%) and infection kidney stones were also predominantly found among female patients. Conclusion: The findings indicate that the two facilities’ participants are not different in terms of gender and age. However, the composition of stones was found to be different between participants from both hospitals. This suggests that kidney stone composition may be influenced by patients’ geographical location and or cultural background.

Predictors and Prognosis of HIV-Associated Nephropathy on Kidney Biopsy in South Africa

IntroductionSouth Africa has the highest prevalence of HIV in the world. The epidemiology of kidney disease among people with HIV infections is well-described in the United States. However, there are limited data coming from South Africa, particularly that involve kidney biopsies. The purpose of this study was to determine what, if any, patient factors are predictive of HIV-associated nephropathy (HIVAN) on kidney biopsy in a South African kidney biopsy cohort.MethodsThis study prospectively collected data of all patients infected with HIV referred to the Groote Schuur Hospital (GSH) renal unit for a kidney biopsy from 2002 to 2018.ResultsThere were 419 patients included in the study. Mean age was 36.5 years (SD, 9.4); 219 (52.3%) were women; and all were black. Seventy-nine patients (18.9%) were on dialysis at the time of biopsy; the mean estimated glomerular filtration rate among the remainder was 41.4 ml/min per 1.73 m2 (SD, 39.2). Only 163 patients (47.1%) were known to be taking antiretroviral therapy (ART) at the time of biopsy. There were 246 (58.7%) cases of HIVAN detected, and they were comparable on age, sex, kidney function, and kidney size to those with kidney disease of other causes but were less likely to be taking ART (P < 0.001). Biopsy confirmed HIVAN was associated with mortality (adjusted hazard ratio, 1.77; 95% confidence interval [CI]: 1.07–2.91; P = 0.025), and the use of ART at biopsy was protective (adjusted hazard ratio, 0.52; 95% CI, 0.32–0.84, P = 0.008). The proportion of HIVAN on biopsy decreased and the proportion taking ART increased from 2002 to 2018 (P for trend for both < 0.001).ConclusionIn summary, HIVAN was the most common etiology of kidney disease in this biopsy cohort from South Africa; however, the proportion with biopsy-proven HIVAN declined over time, perhaps in the setting of greater ART availability.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries.

Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Development of a method to determine the cost of breast cancer treatment with chemotherapy at Groote Schuur Hospital, Cape Town, South Africa.

There has been no comprehensive study determining the financial burden of breast cancer in the South African (SA) public sector. To develop a method to determine the cost of breast cancer treatment with chemotherapy per episode of care and to quantify the associated costs relating to chemotherapy at Groote Schuur Hospital (GSH), a government hospital in SA. These costs included costs associated with the management of adverse events arising from chemotherapy. Retrospective patient-level data were collected for 200 patients from electronic databases and patient folders between 2013 and 2015. Direct medical costs were determined from the health funder's perspective. The information collected was categorised into the following cost components: chemotherapy medicines, support medicines, administration of chemotherapy, laboratory tests, radiology scans and imaging, doctor consultations and adverse events. Time-and-motion studies were conducted on a set of new patients and the data obtained were used for the study sample of 200 patients. All the above costs were used to determine the cost of chemotherapy per episode of care. The episode of care was defined as the care provided from 2 months prior to the date of commencing chemotherapy (pre-chemotherapy phase), during chemotherapy (treatment phase) and until 6 months after the date when the last cycle of chemotherapy was administered (follow-up phase). A method was developed to determine the episode-of-care costs for breast cancer at GSH. The total direct medical cost for treatment of breast cancer at GSH for 200 patients was ZAR3 154877, and the average episode-of-care cost per patient was ZAR15 774. The average cost of management of adverse events arising from the various treatment modalities was ZAR13 133 per patient. It was found that the cost of treating a patient with adverse events was 1.8 times higher than the cost of treating a patient without adverse events. Of the patients, 86.5% managed to complete their prescribed chemotherapy treatment cycles, and the average cost of treatment of these patients was 1.3 times more than the average cost for patients who could not complete their treatment, based on the number of treatment cycles received. A comprehensive method to determine the costs associated with breast cancer management per episode of care was developed, and costs were quantified at GSH according to the treatment protocol used at the hospital.

A decade of hepatitis C at the University of Cape Town/Groote Schuur Hospital Liver Clinic, South Africa, in the pre-direct-acting antivirals era.

Hepatitis C virus (HCV) in South Africa (SA) is incompletely characterised and understood. Epidemiological and clinical data will better inform our understanding and assist national policy decision-making. Against the background of more than two decades of clinical challenges in HCV management, the advent of direct-acting antivirals (DAAs) now makes HCV elimination plausible. To better understand the base from which we come, we elected to review and characterise our HCV experience at Groote Schuur Hospital (GSH), Cape Town, SA, in the pegylated interferon (Peg-IFN) and ribavirin (RBV) management era. Patients with chronic HCV infection attending the GSH Liver Clinic from 2002 to 2014 were included in the analysis. Relevant data were extracted from a registry and existing clinical records were accessed. Two brands of Peg-IFN were available, and patients treated with the first-generation add-on protease inhibitor telaprevir were included. A total of 238 patients were included in the analysis (median (interquartile range) 47 (37 - 58) years, 60.5% males). Males were significantly younger than females (43.5 (35 - 52) years v. 55 (42 - 64) years, respectively) (p&lt;0.0001). The majority were white (55.9%) or of mixed ancestry (21.8%), 16.4% were HIV co-infected, 3.7% were hepatitis B virus (HBV) co-infected, and 1 patient (0.4%) was triple-infected with HCV, HBV and HIV. The most likely mode of HCV acquisition was blood or blood product exposure prior to 1992 (32.8%) and injecting drug use (17.6%), while 30.3% of patients had no clear risk factor identifiable. Genotypes (GTs) 1 - 5 were observed, with GT-1 (34.9%) predominating. Of patients who were biopsied (n=90), 30.0% had ≥F3 fibrosis, with 15.6% cirrhotic. With IL28B polymorphisms, the heterozygous CT (23.9%) and CC (15.5%) genotypes were most frequent. Of the patients, 32.6% accessed Peg-IFN/RBV-based therapy, 6.5% (n=5) with add-on telaprevir. GT-1 (35.1%) was most prevalent in the treatment group, followed by GT-3 (26.0%) and GT-5 (18.2%); 10.0% were HIV co-infected. The overall sustained virological response (SVR) rate was 75.3%, with 37.0% of GT-1 patients not achieving SVR. Of the patients treated, 49.4% experienced adverse events, including cytopenias (32.5%) and depression (15.6%), and 23.4% required cell support in the form of erythropoietin and/or granulocyte-macrophage colony-stimulating factor. HCV patients in the Peg-IFN/RBV management era typified the epidemiology of HCV. GT distribution was pangenotypic, and treatment outcomes were encouraging despite treatment challenges. Patient selection, IL28B and sensible support of cytopenias probably accounted for these favourable outcomes. However, numbers treated were limited, and the DAA era of therapy allows for rapid expansion of therapy with now growing numbers of patients and a changing local epidemiology.

Audit of Outcomes of Endoscopic Cholesteatoma Ear Surgery

Background: The objective of cholesteatoma surgery is not only to eradicate disease, but also reduce the risk of recurrence. While the use of the endoscope has been shown to reduce the rate of residual disease, there is currently insufficient data on recidivism and hearing outcomes following exclusive endoscopic use in cholesteatoma ear surgery. Objectives: Auditing outcomes of exclusive endoscopic surgery (EES) for the surgical management of cholesteatoma, with a secondary aim of comparing recidivism and hearing outcomes of 4 different surgical techniques, namely, EES, microscopic canal wall down (CWD), microscopic canal wall up (CWU) and combined endoscopic-microscopic techniques (CEM). Methods: A retrospective chart review was conducted at two tertiary academic hospitals in Cape Town, namely, Red Cross War Memorial Children’s Hospital (RCWMH) for patients below13 years and Groote Schuur Hospital (GSH) for patients above 13 years, over a 5 year period, between January 2012 and December 2016. Results: 128 cholesteatoma surgeries overall; 110 patients were from GSH and 18 from RCWMH. Eight RCWMH patients underwent EES, 7 had CWU, 2 had CWD and 1 underwent CEM. Overall recidivism in the RCWMH population was 33% (6/18), 2 underwent EES, 2 underwent a microscopic CWU, 1 had a CWD and 1 underwent CEM. The mean postoperative hearing in this group was 40 dB from 50.3 decibels (dB) preoperatively. In the GSH group, 23 underwent an EES, 42 had a CWU, 40 underwent CWD and 5 underwent CEM. Overall recidivism for the GSH group was 17% (19/110). Of those, 7 underwent EES, 8 underwent microscopic CWU, 1 underwent CWD and 3 underwent CEM. Mean postoperative hearing was 47.4 dB from 48.4 dB preoperatively. Conclusions: The CWD technique demonstrated superior outcomes. In the GSH group, the EES approach had the same recurrence rate as CWU. Much higher recidivism was observed in the RCWMH group. Management of cholesteatoma requires a highly individualized approach to determine the most appropriate surgical treatment paradigm.

Symptomatic congenital syphilis in a tertiary neonatal unit in Cape Town, South Africa: High morbidity and mortality in a preventable disease.

Despite preventive measures and effective treatment, congenital syphilis continues to impact significantly on neonatal morbidity and mortality. There has been no recent South African (SA) published literature reviewing congenital syphilis, particularly in the context of a tertiary neonatal setting. To describe the clinical features of symptomatic neonates with congenital syphilis and to identify modifiable patient, clinical and health facility factors that contributed to syphilis infection. All positive serological tests for syphilis performed in neonates at Groote Schuur Hospital (GSH), Cape Town, SA, between 1 January 2011 and 31 December 2013 were obtained. Folders were reviewed, and neonates with clinical signs of congenital syphilis were included. Of 50 symptomatic neonates, 19 (38%) died. Twenty-eight mothers (56%) were unbooked and therefore received no antenatal care. Most mothers (98%) were inadequately treated. Health worker-related failures included poor notification and partner tracing as well as failure to recheck syphilis serology after 32 weeks' gestation in mothers who initially tested negative. Thirty-four neonates required intensive care unit admission. Two significant predictors of mortality were 1-minute and 5-minute Apgar scores &lt;5. Hydrops fetalis was an independent risk factor for mortality, as were moderate to severely abnormal cranial ultrasound scan findings. Congenital syphilis in neonates admitted to the GSH neonatal unit was associated with substantial morbidity and mortality. The modifiable factors identified represent inadequate antenatal healthcare and health system failures. These factors are longstanding, highlighting the need to establish governance and audit processes and address the continuing socioeconomic and sociocultural barriers that mothers face as a way forward in ultimately eliminating this entirely preventable disease.