Hospital In Cape Town Research Articles

Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates - A pilot clinical trial.

BackgroundChlorhexidine gluconate (CHG) body washes and emollient application may modulate bacterial pathogen colonization and prevent neonatal hospital-acquired infections.MethodsThis pilot, non-randomized, open-label trial, enrolled preterm neonates (1000-1500g; day 1-3 of life) at a tertiary hospital in Cape Town, South Africa. Participants were sequentially allocated to 4 trial arms (n=20 each): 1% aqueous CHG (CHG), 1% CHG plus emollient (CHG+EM), emollient only (EM) and standard of care (SOC: no antiseptic/emollient). Trial treatment/s were applied daily for 10 days (d) post-enrolment, documenting neonatal skin condition score. Anterior nose, neck, umbilical and perianal swabs for bacterial culture were collected at d1, d3, d10 and d16 post-enrolment, (±1 day), reporting pathogen acquisition rates and semi-quantitative bacterial colony counts. (ClinicalTrials.gov identifier: NCT03896893; trial status: closed).FindingsEighty preterm neonates (mean gestational age 30 weeks [SD 2]) were enrolled between 4 March and 26 August 2019. The bacterial pathogen acquisition rate (comparing d1 and d16 swabs) varied from 33·9% [95%CI 22·9-47·0] at the umbilicus, 39·3% [95%CI 27·6-52·4] at the neck, to 71·4% [95%CI 58·5-81·7] at both the nose and perianal region. At d10, CHG babies had reduced bacterial density detected from neck, umbilicus, and perianal swabs compared to other groups (see Table 3). Following intervention cessation, colonization density was similar across all trial arms, but S. aureus colonization was more prevalent among EM and CHG+EM babies. Neonatal skin condition score improved in babies receiving emollient application (EM: -0·87 [95%CI 0·69-1·06] and CHG+EM: -0·73 [0·45-0·99]), compared to the SOC and CHG arms (Table 2); no CHG-related skin reactions occurred.InterpretationBacterial colonization density was significantly reduced in babies receiving 1% CHG washes but colonization levels rebounded rapidly post-intervention. Emollient application improved skin condition but was associated with higher rates of S. aureus colonization.FundingSouth African Medical Research Council; National Institutes of Health (TW010682).

Fatigue-management strategies among women with endometriosis in South Africa: a qualitative study

Fatigue is a common, secondary symptom of endometriosis that has not been qualitatively explored. We conducted individual, face-to-face interviews with 25 women in South Africa about their experiences of endometriosis-related fatigue. Participants were recruited at a public hospital in Cape Town and through several South African endometriosis organizations. Interviews were conducted in English and Afrikaans and ranged from 30 min to 1 hr 16 min in duration. All interviews were audio recorded and transcribed. Interviews were analyzed using thematic analysis. We found that both the experience of fatigue and fatigue-management strategies were highly personalized. Participants reported using a variety of cognitive strategies, such as planning, pacing, and pushing through their fatigue to reduce the levels of fatigue. Participants also employed physical strategies such as rest, dietary changes, using supplements, and exercise. We found that while participants often tried fatigue-management strategies suggested to them by others, they struggled to maintain these strategies even when they were successful. There are currently no interventions aimed at reducing endometriosis-related fatigue. The findings of this study provide insight into the management of fatigue in women with endometriosis and may be used to develop a psychosocial intervention for fatigue among women with the disease.

The costing of operating theatre time in a secondary-level state sector hospital: A quantitative observational study.

There is no established costing model for operating theatres (OTs) in South Africa (SA), yet both health sectors have existing charges for OT time: in the state sector, Uniform Patient Fee Schedule (UPFS) rates, and in the private sector, rands per minute (ZAR/min) rates. Understanding the cost of providing the separate components of a health service is important for planning and funding purposes. To develop a costing model that would allow calculation of the ZAR/min cost of OT time. To determine the actual costs, in order to establish the comparable costs that would be included in the ZAR/min charges for OTs in the private health sector. The OTs in a secondary-level, state sector hospital in Cape Town were used in this quantitative observational study to develop a top-down costing model for OTs in SA. The inclusive costing model was developed in a consultative process with professionals, managers and experts from the state and private sectors. The model was then populated with costs for the month of August 2018. Costs were considered in the categories of full costs, shared costs, and capital or annualised costs. Owing to uncertainty in costing of OTs, two models - with different annualisation times assigned to the capital costs - were developed to demonstrate the difference. For shared costs, correction factors were determined using either an activity-based (workload) factor or a more generic estimation of workload using theatre nursing staff as a percentage of total hospital nursing staff.To determine a ZAR/min cost of creating a minute of available theatre time, all the annual costs were divided by minutes that the OTs are explicitly available, each year, to provide patient care. The model was then populated with costs using the appropriate correction factors. The longer annualisation model costed OT time at ZAR31.46 per minute, and the shorter annualisation model at ZAR33.77 per minute. In both the longer and shorter capital annualisation models, nursing was the largest contributor to costs at 36% and 33%, respectively, followed by construction costs at 9% and 11%, and then OT equipment at 8% and 11%. An inclusive, top-down costing model for OTs in SA was developed. This costing model will support work to develop costing for individual procedures and the appropriate charge for planned and emergency OT time, and to better determine budgeting for OT services. Meaningful critique of the model will improve its fidelity, and is likely to increase its utility, especially as SA moves towards universal health coverage.

The effectiveness of a performance management system at a South African public hospital in Cape Town

Background: In 1994, South Africa instituted the Public Service Act of 1994 which is presumably applicable and must be adhered to by all public institutions. Because of the adoption of the Public Service Law, all employees employed in the Western Cape Government (WCG) are obligated to participate in the Performance Management System (PMS). Consequently, the authors were interested to know how the PMS performs and how employees respond to this system at a public hospital.Aim: The purpose of this study was to examine the processes of PMS to identify its effectiveness. Of uttermost significance, through the findings of the study, was to make recommendations that contribute to improving the implementation of PMS.Setting: The study is based at a public hospital to examine the effectiveness of a PMS at a South African public hospital. The hospital is situated in Cape Town, South Africa.Methods: In pursuing the study, the authors employed an exploratory research design. Consequently, a qualitative research method was applied.Results: The study discovered that the PMS at the hospital is ineffective to enhance the performance of the employees and achieve organisational goals.Conclusion: The system appears to be a great tool designed to measure the employees’ effectiveness. However, its implementation seems to suggest a need for a thorough investigation of its efficiency.

Serum and cerebrospinal fluid host proteins indicate stroke in children with tuberculous meningitis.

Stroke is a common complication in children with tuberculous meningitis (TBM). Host proteins may give us insight into the mechanisms of stroke in TBM and serve as biomarkers for detection of stroke, however, they have not been widely explored. In this study, we compared the concentrations of cerebrospinal fluid (CSF) and serum proteins between children who had TBM-related stroke and children with TBM without stroke. We collected CSF and serum from 47 children consecutively admitted to the Tygerberg Academic Hospital in Cape Town, South Africa between November 2016, and November 2017, on suspicion of having TBM. A multiplex platform was used to measure the concentrations of 69 host proteins in CSF and serum from all study participants. After classification of study participants, 23 (48.9%) out of the 47 study participants were diagnosed with TBM, of which 14 (60.9%) demonstrated radiological arterial ischemic infarction. The levels of lipocalin-2, sRAGE, IP-10/ CXCL10, sVCAM-1, MMP-1, and PDGF-AA in CSF samples and the levels of D-dimer, ADAMTS13, SAA, ferritin, MCP-1/ CCL2, GDF-15 and IL-13 in serum samples were statistically different between children who had TBM-related stroke and children with TBM without stroke. After correcting for multiple testing, only the levels of sVCAM-1, MMP-1, sRAGE, and IP-10/ CXCL10 in CSF were statistically different between the two groups. CSF and serum protein biosignatures indicated stroke in children diagnosed with TBM with up to 100% sensitivity and 88.9% specificity. Serum and CSF proteins may serve as biomarkers for identifying individuals with stroke amongst children diagnosed with TBM at admission and may guide us to understand the biology of stroke in TBM. This was a pilot study, and thus further investigations in larger studies are needed.

In-depth investigation of turn-around time of full blood count tests requested from a clinical haematology outpatient department in Cape Town, South Africa.

BackgroundThe performance of laboratories can be objectively assessed using the overall turn-around time (TAT). However, TAT is defined differently by the laboratory and clinicians; therefore, it is important to determine the contribution of all the different components making up the laboratory test cycle.ObjectiveWe carried out a retrospective analysis of the TAT of full blood count tests requested from the haematology outpatient department at Tygerberg Academic Hospital in Cape Town, South Africa, with an aim to assess laboratory performance and to identify critical steps influencing TAT.MethodsA retrospective audit was carried out, focused on the full blood count tests from the haematology outpatient department within a period of 3 months between 01 February and 30 April 2018. Data was extracted from the National Health Laboratory Service laboratory information system. The time intervals of all the phases of the test cycle were determined and total TAT and within-laboratory (intra-lab) TAT were calculated.ResultsA total of 1176 tests were analysed. The total TAT median was 275 (interquartile range [IQR] 200.0–1537.7) min with the most prolonged phase being from authorisation to review by clinicians (median 114 min; IQR: 37.0–1338.5 min). The median intra-lab TAT was 55 (IQR 40–81) min and 90% of the samples were processed in the laboratory within 134 min of registration.ConclusionOur findings showed that the intra-lab TAT was within the set internal benchmark of 3 h. Operational phases that were independent of the laboratory processes contributed the most to total TAT.

Cerebral perfusion pressure and autoregulation in eclampsia—a case control study

Dynamic cerebral autoregulation and cerebral perfusion pressure are altered in pregnancies complicated by preeclampsia compared with normotensive pregnancies, but the connections of dynamic cerebral autoregulation, cerebral perfusion pressure, and cerebral complications in preeclampsia remain unclear. This study aimed to assess dynamic cerebral autoregulation and cerebral perfusion pressure after delivery in women with eclampsia, in women with preeclampsia both with and without severe features, and in normotensive women. This was a prospective case control study at a large referral hospital in Cape Town, South Africa. The recruitment of participants was done at diagnosis (cases) or at admission for delivery (controls). Transcranial Doppler examinations with continuous noninvasive blood pressure measurements and end-tidal CO2 monitoring were conducted for cases and controls after delivery. Cerebral perfusion pressure and dynamic cerebral autoregulation index were calculated, and values were compared among groups. We included 16 women with eclampsia, 18 women with preeclampsia with severe features, 32 women with preeclampsia without severe features, and 21 normotensive women with uncomplicated pregnancies. Dynamic cerebral autoregulation was depressed in pregnant women with eclampsia; (autoregulation index, 3.9; interquartile range, 3.1-5.2) compared with all other groups (those with preeclampsia with severe features, autoregulation index, 5.6 [interquartile range, 4.4-6.8]; those with preeclampsia without severe features, autoregulation index, 6.8 [interquartile range, 5.1-7.4]; and normotensive controls, autoregulation index, 7.1 [interquartile range, 6.1-7.9]). Pregnant women with eclampsia had increased cerebral perfusion pressure (109.5 mm Hg; interquartile range, 91.2-130.9) compared with those with preeclampsia without severe features and those with normal blood pressure (84 mm Hg [interquartile range, 73.0-122.0] and 80.0 mm Hg [interquartile range, 67.5-92.0], respectively); furthermore, there was no difference in cerebral perfusion pressure between pregnant women with eclampsia and pregnant women with preeclampsia with severe features (109.5 mm Hg [interquartile range, 91.2-130.9] vs 96.5 mm Hg [interquartile range, 75.8-110.5]). Cerebral perfusion pressure and dynamic cerebral autoregulation are altered in eclampsia and may be important in the pathophysiological pathway and constitute a therapeutic target in the prevention of cerebral complications in preeclampsia.

Palliative care for children with cancer in South Africa

At the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, an innovative psychosocial and spiritual collaboration for children with cancer and their families was established in 2012 from a mixture of public and non-governmental organisations, and private sources. This care service integrates carers and resources to address the dearth of child psychiatrists, psychologists, and other integrated therapists in the South African public health care system, providing an opportunity for more complex psychological support.

A severity-of-illness score in patients with tuberculosis requiring intensive care

Background. We previously retrospectively validated a 6-point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (TB) in the intensive care unit (ICU). Parameters included septic shock, HIV infection with a CD4 count <200 cells/µL, renal dysfunction, a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (P/F) <200 mmHg, a chest radiograph demonstrating diffuse parenchymal infiltrates, and no TB treatment on admission. Objectives. To prospectively validate the severity-of-illness scoring system in patients with TB requiring intensive care, and to refine and simplify the score in order to expand its clinical utility. Methods. We performed a prospective observational study with a planned post hoc retrospective analysis , enrolling all adult patients with confirmed TB admitted to the medical ICU of a tertiary hospital in Cape Town, South Africa, from 1 February 2015 to 31 July 2018. The admission data of all adult patients with TB requiring admission to the ICU were used to calculate the 6-point severity-of-illness score and a refined 4-point score (based on the planned post hoc analysis). Descriptive statistics and χ 2 or Fisher’s exact tests (where indicated) were performed on dichotomous categorical variables, and t -tests on continuous data. Patients were categorised as hospital survivors or non-survivors. Results. Forty-one of 78 patients (52.6%) died. The 6-point scores of non-survivors were higher than those of survivors (mean (standard deviation (SD)) 3.5 (1.3) v. 2.7 (1.2); p =0.01). A score ≥3 v. <3 was associated with increased mortality (64.0% v. 32.1%; odds ratio (OR) 3.75; 95% confidence interval (CI) 1.25 - 10.01; p =0.01). Post hoc , a P/F ratio <200 mmHg and no TB treatment on admission failed to predict mortality, whereas any immunosuppression did. A revised 4-point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors than survivors (mean (SD) 2.8 (1.1) v. 1.6 (1.1); p <0.001). A score ≥3 v. ≤2 was associated with increased mortality (78.4% v. 29.3%; OR 8.76; 95% CI 3.12 - 24.59; p <0.001). Conclusions. The 6-point severity-of-illness score identified patients at increased risk of death. We were able to derive and retrospectively validate a simplified 4-point score with superior predictive power.

Yield of CT angiography in penetrating lower extremity trauma.

CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided. A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined. A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001). There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

Cognitive impairment in preeclampsia complicated by eclampsia and pulmonary edema after delivery.

We aimed to assess cognitive function in women with preeclampsia stratified by severity, before and after onset of disease. Prospective study performed at a referral hospital in Cape Town, South Africa. Pregnant women between 20 and 42weeks of gestation with eclampsia, pulmonary edema and preeclampsia without severe features, and a normotensive pregnancy were approached. Women were included at diagnosis of preeclampsia or at admission for delivery (women with normotensive pregnancies). Two cognitive assessments, the Cognitive Failure Questionnaire to assess the cognitive function subjectively before inclusion in the study, and Montreal Cognitive Assessment to assess the current cognitive function objectively before discharge from the hospital after delivery, were performed. We included 61 women with eclampsia, 28 with preeclampsia complicated by pulmonary edema, 38 with preeclampsia without severe features, and 26 with normotensive pregnancies. There was no difference in cognitive function from early pregnancy between groups. Women with eclampsia and preeclampsia complicated by pulmonary edema scored lower on the Montreal Cognitive Assessment at time of discharge compared with women with normotensive pregnancies. The results were attenuated in pulmonary edema after adjustment for confounders. Women with preeclampsia complicated by pulmonary edema and in particular eclampsia had impaired cognitive function after onset of disease compared with women with normotensive pregnancies. The impairment did not seem to be present before onset of disease. Women with preeclampsia without severe features did not have impaired cognitive function.

A comparison between primary endorectal pull-through and staged procedures for patients with Hirschsprung’s disease

Background: Primary endorectal pull-through is becoming a standard of care across the globe. This study was done to compare the outcome of patients with Hirschsprung’s disease (HD) who underwent primary endorectal pull-through with patients who were treated with a staged approach. Methods: A retrospective data review was done of all patients diagnosed with Hirschsprung’s disease (HD) at Tygerberg Children’s Hospital, a tertiary hospital in Cape Town, during an 11-year period (2007 – 2018). The patients were divided into 2 groups: the primary Endorectal pull-through (ERP) group and the staged group and the two groups were compared. Results: Eighty patients with histologically confirmed Hirschsprung’s disease (HD) were seen at our institution during the study period (2007 – 2018). Four patients did not meet the inclusion criteria and were excluded. Of the remaining seventy-six who were included, forty-six patients (60.5%) had a primary endorectal-pull through (Primary group) and thirty patients (39.5%) had staged procedures (Staged group) with a stoma before the final ERP. The peri-operative complications were subdivided into major and minor complications. Minor perioperative complications in the primary group were less (13%) compared to the staged group (33%) with a p-value of 0.017, making the difference statistically significant. Anastomotic strictures were the most common complication in both groups with abdominal wound infection being more common in the staged group. The late complications were similar in both groups with a p-value of 0.43. Constipation was the most common complication in both groups, followed by soiling. Conclusion: The two groups had a similar outcome without statistically significant differences. We can safely conclude that the primary endorectal pull-through for HD is at least as safe as the staged approach in Sub- Saharan Africa. With this technique, we avoid a stoma and the necessity for two surgical procedures with added potential complications.

Outcomes of Neonates Requiring Neonatal Intensive Care Admission for Necrotizing Enterocolitis in a Resource-Restricted Hospital in Cape Town, South Africa.

The aim of this study is to describe the 30-day mortality, neurodevelopmental outcome and composite outcome (mortality or abnormal neurodevelopmental outcome) of neonates with necrotizing enterocolitis (NEC), requiring neonatal intensive care (NICU) admission, in a resource-restricted environment. All neonates admitted to Tygerberg Hospital, NICU, with a presumptive diagnosis of NEC Bell stage IIB or more, over a 5-year period, were included. One hundred and thirty-five neonates were included with a mean gestational age of 29 ± 2.7 weeks and mean birth weight of 1185 g ± 446 g. The 30-day mortality was 52%, neurodevelopment abnormalities occurred in 35% of survivors and adverse composite outcome in 63%. The 30-day mortality and adverse composite outcome risk were increased by small for gestational age, shock, metabolic acidosis, inotrope requirement and first feed >9 days after surgery. In resource-restricted environments, mortality and abnormal neurodevelopmental outcome of neonates with NEC, remain high. However, outcomes are comparable with international literature. Neonates with NEC, requiring NICU admission and surgery, require neurodevelopmental follow-up.

Motives for deliberate self-harm in a South African tertiary hospital.

BackgroundAlthough there is a growing body of literature on the epidemiology of deliberate self-harm (DSH) in South Africa, comparatively few studies have investigated the motives for self-harm. No studies have investigated the motives for DSH in Cape Town.AimThe objective of the study was to identify the range of motives for DSH in Cape Town, and how these motives are associated with different socio-demographic factors, the severity of self-injury and levels of suicidal intent.SettingGroote Schuur Hospital in Cape Town, South Africa.MethodsData were collected from 238 consecutive patients presenting with DSH to the emergency department. The data were analysed by using bivariate and multivariate analyses.ResultsPatients engaged in DSH for a range of motives. Interpersonal issues were the most common motive (70%), followed by financial concerns (22%). Male patients were twice as likely as female patients to report interpersonal motives for their self-harm. Patients who reported interpersonal issues were more likely to engage in methods of DSH that involved damage to body tissues. Patients without tertiary education were more likely to report academic concerns as a motive, and patients who reported psychiatric illness as motive for DSH were more likely to require medical interventions than those who did not.ConclusionThis study contributes novel insights into the motives for DSH in the Cape Town context and provides the foundation for continued research on the subject. The study also gives impetus to the development of therapeutic interventions focussed on the motives for self-harm.

Outcomes of patients with thoraco-abdominal gunshot wounds operatively managed at a district hospital in Cape Town, South Africa.

AimTrauma is a leading cause of morbidity and mortality in the first four decades of life. Thoracoabdominal gunshot wounds carry a significant risk of mortality. This risk of death is reduced if patients are managed in dedicated units. This study examines the outcome of these patients managed in a district level hospital.MethodIn this retrospective review, patients with thoracoabdominal gunshot wounds were identified from operating room registry for the period of January 2015 to December 2018. Data was collected retrospectively from folders and analysed for the primary outcome of mortality.ResultsSixty-eight thoracoabdominal gunshot wounds were managed operatively over the period described. Only six patients were female. The median age was 29.5 years. Fourteen patients required postoperative transfer to a level 1 trauma unit. Thirteen patients died, nine at the district hospital and four at the level 1 unit. Significant differences in organ injuries were noted in the patients that died compared to the survivors.DiscussionThe in-hospital mortality rate of patients managed at the district hospital was 13.2% which is comparable to international rates of 12–18%. However, the subset of patients that required postoperative transfer to a level 1 trauma unit had a high mortality rate of 28.6%. The DH is committed to managing unstable and unresponsive patients once they present. Improved mortality rates will only occur with better prehospital transport policies and by equipping the DH to manage these patients postoperatively.ConclusionManagement of these patients can be successful at a district hospital. However, significant obstacles exist to their optimal care, as demonstrated by the high mortality patients requiring postoperative transfer.

Biliary cultures of patients with malignant biliary obstruction undergoing pancreaticoduodenectomy and the effect on infectious complications

Introduction: Infective complications are common after pancreaticoduodenectomy and are associated with prolonged hospital stay, delay starting adjuvant therapy and worse disease-free survival. Pre-operative biliary drainage (POBD) is associated with bactobilia and is a risk factor for post-operative infective complications. Indications for POBD include cholangits, severe hyperbilirubinaemia or poor nutritional status at presentation. It is also required to facilitate neo-adjuvant therapy and because of logistical delays to surgery. Methods: We performed a retrospective review of the prospectively maintained pancreatic resection database at an Academic Hospital in Cape Town, South Africa. All patients that had a pancreaticoduodenectomy between the 1st of October 2008 until the 31st of May 2019 were included in the study. Patients were only included if there was an intra-operative biliary culture (IOBC). Patients were divided into those with and without POBD. Perioperative variables including demographic data, microbiology data (microorganisms and antibiotic susceptibility), prophylactic antibody use, POBD, post-operative complications, and mortality, length of ICU and hospital admission. Results: 171 patients had a pancreaticoduodenectomy. 43 patients were excluded as there was no intraoperative culture and/or they had benign pathology. 128 patients were included in the analysis. 89 (69.5%) of these patients had POBD versus 39 (30.5%) without POBD. Patients without POBD were significantly more likely to have sterile intra-operative biliary cultures than patients with POBD (38.6% vs. 6.74%). In 18/45 (40%) of POBD patients and 4/21 (19%) of patients without POBD there was correlation between the IOBC and at least one of the post-operative cultures. Conclusion: This study highlights the importance of institutional specific microbiological reviews to guide appropriate institution specific antibiotic stewardship. The high correlation between IOBC and post-operative cultures favoured prolonged antibiotic therapy in patients with positive IOBC. The high incidence of positive cultures in patients without POBD was a noticeable difference to studies from other regions in the world.

The incidence of maternal hypoglycaemia with prolonged fasting before elective caesarean section

Background: Both national and international guidelines recommend that parturients fast from solids and clear fluids for six and two hours, respectively, prior to a caesarean section (c-section) in order to reduce the risk of pulmonary aspiration. The objective of this study was to evaluate whether fasting times conform to the current American Society of Anesthesiologists’ (ASA) recommendations and whether prolonged fasting times are associated with metabolic sequelae, namely hypoglycaemia and ketonuria. Methods: A total of 56 parturients were enrolled and interviewed at Tygerberg Hospital, a tertiary referral hospital in Cape Town, South Africa. Women who were unable to provide consent (below the age of 18) and/or women who were not scheduled for an elective c-section were excluded from the study. Whole blood glucose and urine ketone levels were measured immediately before anaesthesia. Results: Fasting times for solids and fluids were 15 hours (IQR 12–18; 95% CI 14–17) and 14 hours (IQR 11–16; 95% CI 12–15), respectively. During the preceding week, 32% of the participants were subjected to repeated fasting periods with a median cumulative time (all the fasting periods added) of 40 hours (IQR 35–64; range 28–133). Hypoglycaemia occurred in 39.3% (95% CI 26.8–53.3) and significant ketonuria occurred in 51.8% (95% CI 38.1–65.1) of the participants, with both conditions associated with longer fasting times (p < 0.001). A sigmoid relationship was observed between fasting time and the probability of hypoglycaemia. Hypoglycaemia was unlikely to occur before nine hours of fasting, and thereafter, the risk of hypoglycaemia increased 1.5-fold per hour (95% CI 1.2–1.8). Conclusion: Fasting times before an elective c-section were longer than what is recommended by the ASA guidelines and were associated with statistically and clinically significant metabolic consequences. Maternal glucose should be checked after nine hours of fasting, since the incidence of hypoglycaemia exceeds 5% after nine hours of fasting. Adherence to outdated fasting practices should also be addressed. Fasting time may be a simple, useful healthcare quality indicator.

Juvenile ossifying fibroma of the maxillofacial region: analysis of clinico-pathological features and management.

Background The diagnosis and management of juvenile ossifying fibroma (JOF) remains a highly debated topic with paucity of studies with long-term follow-up, hence the aim of this study was to report on the clinico-pathological features and management of these neoplasms.Material and Methods A retrospective analysis was performed on all histopathologically confirmed JOF presenting at two tertiary hospitals in Cape Town, South Africa over a period of 39 years. Clinical, demographic, histopathological and radiological features were analyzed. Surgical methods were documented and a minimum post-operative follow-up of 12 months was a prerequisite.Results Seventeen patients met the inclusion criteria and were included in this study. Overall, the ages of patients ranged from 3–31 years (mean= 13 years) with male to female ratio of 1.8:1. The ages of patients diagnosed with Trabecular JOF were significantly younger than patients with Psammomatoid JOF (P = 0.01). The majority of patients presented with marked swelling (88.2%). Interestingly, most neoplasms occurred in the mandible (76.5%) with all Psammomatoid JOF uncharacteristically occurring in the mandible. There was only one case of Trabecular JOF occurring in the sinonasal area. Most neoplasms appeared as unilocular (76.5%) and well-defined (82.4%) with mixed radio-density (70.6%) on radiographs and computed tomography. Curettage with peripheral ostectomy was shown to be the least invasive method with an accepTable recurrence rate (10%). Six lesions underwent resection without any recurrences however caused high morbidity to these young patients.Conclusions The high number of lesions occurring in the mandible for both variants of JOF demonstrates that site should not be a major determining factor in the diagnosis of JOF. Moreover, curettage with peripheral ostectomy should be used as the first line of management to minimize morbidity to the patient and that resection should be reserved for large and recurrent lesions. Key words:Juvenile ossifying fibroma, juvenile trabecular ossifying fibroma, juvenile psammomatoid ossifying fibroma, fibro-osseous lesions, maxillofacial region, multi-centre study.

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.

The Evolving Antibiotic Profile of Paediatric Urinary Tract Infections at a Tertiary Hospital in Cape Town

Abstract Background: Urinary tract infection (UTI) is a common problem in infants presenting to hospitals with fever. International data reports that uropathogens and their associated antibiotic susceptibility is evolving. This study describes the organism profile and the respective antibiotic resistance patterns in a paediatric unit at a tertiary hospital in the Western Cape, South Africa. Methods: A retrospective study on urine samples sent to the National Health Laboratory Service from 1 January 2012 to 31 December 2013 was performed. UTI was defined as a single organism growth &gt;105 cfu/ml and leukocytes &gt;1000 cells/ml. The organisms and antibiotic sensitivities were described and stratified into either community, hospital-associated or hospital-acquired infections. Results: Two hundred and eighty-two samples met the study definitions for inclusion in the study. Escherichia coli was cultured most frequently (50.7%) followed by Klebsiella pneumoniae (22.7%) and Proteus mirabilis (4.6%). Extended-spectrum beta-lactamase (ESBL) producing organisms accounted for 26.6% of identified UTI; K. pneumoniae accounted for 54/75 (72%) of those infections. Of ESBL-producing organisms, 6.7% of E. coli were sensitive to piperacillin–tazobactam and 33.3% to amikacin. K. pneumoniae displayed 18.5% and 68.5% sensitivity to piperacillin–tazobactam and amikacin, respectively. E. coli isolates were highly resistant to amoxicillin/ampicillin (90.8%). K. pneumoniae demonstrated high rates of resistance to co-amoxiclavulanate acid (88.7%) and cefotaxime/ceftriaxone (98.2%). Conclusion: The organism population and antibiotic sensitivity profile is evolving in-line with published data. These antibiograms support current hospital policy to treat hospital-associated and acquired infections with piperacillin–tazobactam and amikacin empirically thereby limiting carbapenem drug pressure. Predictors for uropathogen antibiotic resistance require further investigation.