Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Victoria hospital Wynberg in adapting to current progress in clinical record keeping has transited from paper to the use of electronic discharge letters. Objectives: To audit the structure and contents of the electronic discharge summaries and find out to what extent they meet universally accepted criteria. Methodology: A retrospective clinical record audit of 60 patient records was conducted, spanning a period of 12 months (January-December) of 2018. Sequential sampling was used to select five folders from each months’ discharge records, making a total study sample of 60 patient records. A checklist of prescribed criteria was developed and used to collect data which was analysed descriptively. Ethical approval was obtained from University of Cape Towns’(UCT) Human Research Ethics Committee (HREC) and the Western Cape Government Provincial Research Committee. Electronic discharge letters compiled in the period 1 January- 31 December 2018 with corresponding folders found properly indexed in the medical records department were included in the sample, while discharge letters where the folders could not be found were excluded, as were the folders of patients who died during the hospital admission. Results: Nearly all clinical records contained biodata (100%), contact details (93%) and clinical details (93%). Only two-thirds of the folders contained information on other diagnoses(67%) and investigations matched clinical issues 63%.). The least compliant category was medication changes(53%), with just under half the folders containing this information. Conclusion: This study found that clinical records met 67% of the standards that define clinical and medico-legal compliance in the internal medicine ward in Victoria Hospital Wynberg. Several areas for future intervention were identified. A useful audit tool was also developed for ongoing quality improvement cycle.

Includes bibliographical references / The use and demand of echocardiography has increased worldwide. In developed countries, this has not been translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of echocardiography over its clinical impact, limiting generalisability to resource constrained settings. Objectives: To assess the impact of an echocardiographic service at district hospital level in Cape Town, South Africa. Methods: A prospective, cross-sectional study was performed. A total of 210consecutive patients, referred to the echocardiography clinic over a five-month period, were recruited. Transthoracic echocardiography was evaluated by its indication, new information provided, correlation with referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation in treatment, as well as usefulness without a change in management. Results: The results show that 84% of the patients' management was impacted by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment post-myocardial infarction. Fifty-six per cent of the echocardiograms confirming the referring doctor's diagnosis still had a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients for referral to tertiary facilities. Conclusion: Echocardiography has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change has been established. This should alert policy makers towards the risk of restricted access and promote training.

Introduction: Tenofovir-Emtricitabine-Efavirenz (TEE) fixed-dose-combination (FDC) has been recommended since 2013 as the first-line antiretroviral therapy (ART) for treating HIV for people living with the virus (PLWH) in South Africa. More evidence has emerged to show long term adverse effects of Efavirenz(EFV). This study assesses the adverse effect profile of TEE by determining the event rate of switching from co-formulation and the reason for such switch. Method: This retrospective cohort study involved the review of the records of HIV infected adults receiving the TEE fixed dose combination ART over a 5-year period. All adult patients 18 years age or above, non-pregnant, previous ART treatment naïve that started TEE during 1 September 2014 and 31 August 2019 were included. Follow-up was censored at first drug change, transfer-out, loss-of-follow-upon deaths. Results: Two-thousand-and-ninety subjects were newly initiated on ART and 1961 met the inclusion criteria. Ninety-four patients (4.8%) had drug-changes prior censor date whereas 1867 remained on TEE. Forty-seven (50%) were single drug changes due to adverse effects and the other 50% were regimen changes as result of virological failure. The median time to change for TDF and EFV were 0,24 and 1,26 person years respectively. The median time to change for virological failure was 1,02 years. Patients with baseline CD4 count less than 200 cells/uL has higher risk of switch event. The proportion of poor outcome (death or loss to follow up) in patients with no drug switches (8,78%) was similar to those of patients with drug changes(8,5%). Conclusion: Tenofovir-Emtricitabine-Efavirenz combination treatment remains an excellent first-line ART option for people living with HIV, with a low rate of substitutions due to toxicity and high virological suppression. With the advent of Tenofovir-Lamivudine-Dolutegravir combination regimen as the preferred first-line, clinicians should remain cognisant of Tenofovir adverse drug effects.

Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.

Includes bibliographical references. / Tenofovir disoproxil fumarate (TDF) is used worldwide for the treatment of HIV-1 infection. Tenofovir has been found to be associated with declines in renal function and chronic kidney disease in HIV-infected patients. There are limited data on how soon after antiretroviral therapy (ART) initiation any loss of renal function can be detected. We studied a cohort of HIV-infected adults initiating TDF-containing ART regimens at the Hannan Crusaid Antiretroviral Treatment Centre in Gugulethu. The centre provides ART to the residents of the Gugulethu and Nyanga districts situated on the outskirts of Cape Town. We described the prevalence and incidence of renal dysfunction in this cohort, the patterns of change in their renal function in the first 12 months on therapy and factors associated with renal dysfunction. We also examined the diagnostic value of early serum creatinine tests in identifying incident renal dysfunction after 12 months.

Includes bibliographical references. / AIM OF THIS STUDY: To describe how doctors are prescribing low dose antidepressants at Heideveld Community Health Centre. OBJECTIVES: 1. To determine how many patients are being prescribed low dose antidepressants at Heideveld Community Health Centre. 2. To see what sort of dosages are being prescribed as low dose most frequently. 3. To see if indications for the use of low dose tricyclic antidepressants are being recorded. 4. To identify the indications for the use of low dose tricyclic antidepressant. METHOD: A total of 500 patient folders were reviewed. 50 patient folders, (10 folders each from five medical officers), were systematically sampled, per day, for ten days over a two week period. Records were reviewed and data was captured on a data capture sheet. Demographic data: age and gender was recorded. The dose of the antidepressant per patient was recorded. The indication for its use was recorded. Where the indication of its use was not recorded, this was also documented. RESULTS: 1. Of the 500 folders reviewed, a total of 153 (30,6%) of the patients were prescribed low dose tricyclic antidepressants at the consultation, during the time that the study took place. 2. The minimum dose used was 10mg and the maximum dose used was 75mg of tricyclic antidepressant. The median dose used was 25mg. 3. 83% of the folders had reasons for the use of low dose tricyclic antidepressant recorded. 17% of the folders had no reason recorded. 4. The reasons for using low dose tricyclic antidepressants, were for chronic pain syndromes, insomnia, somatic symptoms and for psychological or psychiatric reasons (anxiety or depression related symptoms). CONCLUSION: Low dose tricyclic antidepressants were justifiably prescribed for the many non-psychiatric and psychiatric conditions that respond to it, at Heideveld Community Health Centre.

Includes summary. / Booth Memorial Hospital (BMH), situated at the foot of Table Mountain in urban Cape Town, South Africa, is an NGO-run hospital in a Public- Private Partnership with the Western Cape Department of Health. The essential service being offered is sub-acute health care, with state hospitals referring patients needing terminal, rehabilitation or convalescent care for a variety of illnesses. Post-acute stroke rehabilitation forms an integral part of the general service being offered by BMH. This dovetails with the state-run rehabilitation hospital in the sense that younger patients able to undergo intense rehabilitation are sent to the state-run hospital, while BMH generally cares for those patients who may not be able to withstand the rigours of an intense rehabilitation program. In our setting, this means that most of the patients seen at BMH for post-stroke rehabilitation are elderly. The elderly patient who has suffered a stroke is vulnerable in many respects. The most obvious vulnerability refers to the physical, emotional and psychological derangements that follow strokes in this age group. In addition, due to rampant poverty prevalent in the community we serve, social and economic factors place this group of patients at an even greater disadvantage. It is an imperative for social survival and an acceptable quality of life that this group of patients retain as much of their independence and empowerment after the stroke as is possible. The current situation of overflowing old-age homes, increasing prevalence of elder abuse and neglect, and the deficiency of community structures to care for the elderly compel health care providers to ensure that a post-stroke rehabilitation service operates with maximal efficiency, given the paucity of resources endemic in our health system. The above factors provided an impetus for this study. A need arose to assess the quality of the stroke rehabilitation services at BMH, as the starting point to what is hoped will be a continuous Quality Improvement Cycle. An additional factor compelling the examination of the quality of service being offered is that the Geriatric population is underserved in the present health system, competing for scarce resources with other vulnerable groups such as children, Cancer patients, and people living with HIV/AIDS. By focussing on a service that is almost exclusively aimed at the elderly, we hope to be able to advocate for greater resource allocation to this age group, given that receiving good health care is essential to the quality of life of the ageing population. This assessment of the current services looked at the Structure, Process of care and Clinical Outcomes of stroke rehabilitation services being given to patients over the age of 65 years. The findings were evaluated against internationally accepted norms of post-acute stroke care, and are presented in this study.

Includes bibliographical references. / Multi-drug resistant tuberculosis (MDR-TB) was first recognized in the 1990s with an increase in caseload of eighty-two percent between 2000 and 2007. Extensively drug-resistant tuberculosis (XDR-TB), a more difficult and more expensive form of TB to treat with poorer outcomes, emerged in South Africa in 2006. The prevalence of XDR-TB is likely to be underestimated in South Africa as a result of incomplete detection and notification. In peri-urban areas like Khayelitsha where there are high rates of HIV, TB and poverty, the prevalence of MDR-TB is estimated at 51/100 000. A significant proportion of these cases are indeed undetected pre-XDR-TB (MDR and resistance to either a fluoroquinolone or a 2nd line injectable drug) and XDR (MDR and resistance to both fluoroquinolones and any one of the 2nd line injectable drugs) cases with inadequate access to drug sensitivity testing. Treatment outcomes of XDR-TB have been variable with countries like Peru showing a 60% overall cure (or completed treatment) rate, and studies in KwaZulu Natal in South Africa showing much poorer outcomes. The reasons for the poor outcomes in XDR-TB remain unclear. We are continuing to investigate the role of strain-type and several other factors including nutritional status, degree of drug resistance, HIV status and drug regimens in determining outcomes. There is a paucity of literature describing the chest X-ray (CXR) findings in patients with XDR-TB, and whether disease extent is related to treatment outcomes and the evolution of resistance remains unclear. It has been shown that patients with radiological extensive drug-sensitive TB have higher initial sputum mycobacterial loads and take a longer time to sputum conversion than those without . The extent of disease on the CXR at baseline has been used as a tool to inform and predict the need for infection control measures, treatment duration, and outcomes. The time-to-positivity (TTP) of mycobacterium tuberculosis in a liquid medium culture has become a validated indicator of bacterial sputum load and indeed a surrogate bio-marker of treatment response to anti-tuberculosis drugs. The relationships between mycobacterial sputum load, radiological disease and treatment outcomes have been studied in drug-sensitive TB, but little is known about XDR-TB.

Background: Primary care practitioners are at the forefront of the health service and therefore have an opportunity to promote oral health, manage certain oral conditions, or refer appropriately to the closest dental service. In under-resourced areas, patients are more likely to present initially to a primary health care nurse or doctor, with oral or dental needs. Studies abroad have revealed that general practitioners do not always examine the oral cavity, enquire about oral health, or manage oral disease particularly well and have expressed an interest to learn more about oral health. A literature search for similar South African studies did not yield results. This study aims to describe current oral health care practice provided by primary care practitioners in Cape Town and to assess whether this level of service might benefit from interventions to improve the quality of care. Methods: The Nominal Group technique (NGT) was used to identify and achieve consensus among 8 community health centre primary care practitioners regarding the main challenges to providing oral health care and offer suggestions for strengthening oral health care. This assisted the development of a questionnaire, which was then distributed to practitioners at five Community Health Centres in the Cape Town Metropole. The questionnaire aimed to assess the knowledge, attitudes and current practices of practitioners in the area of oral health. Results: The NGT yielded valuable information to inform the questionnaire; two main topics were discussed which helped inform two sections of the 9-part questionnaire. A total of 53 doctors and clinical nurse practitioners completed the questionnaire. Only 17% of participants reported routinely examining the oral cavity, others examined it on request of the patient or suspicion of an abnormality. A minority (13.2%) stated that they routinely promote oral health in the consultation and reported limiting factors to include: insufficient time during consultations, forgetting to include oral health promotion, a limited knowledge of oral disease, and limited access to Oral Health Services. Suggestions for strengthening the oral health care included training clinicians in oral health, motivating clinicians to provide better oral health care, improving patient education on the importance of oral health care, and improving the integration of Primary Care services with Oral Health services. Limitations of this study include a small sample size, studying only urban community health centres in Cape Town, the absence of input from oral health experts, the absence of input from patients and missing data. Conclusion: It is apparent from this study that oral health is inadequately managed, for a number of reasons; including time constraints, limited knowledge of treating clinicians, and limited available oral health services. Possible interventions to improve this clinical area can be posed to relevant authorities and may include examining undergraduate curricula (medicine and nursing) to assess the content and quality of oral health education, provide in-house training to CHC staff by local dentists and oral hygienists, provide information sessions for staff at CHC about the local Oral Health Service available in their areas, and offering education to patients in the waiting room on the topic of good oral health.

Introduction Deaf people experience significant barriers in access to health care as well as poorer health outcomes. While there are many international and South African studies describing the difficulties deaf patients experience when accessing health care, only anecdotal evidence suggests that health care workers (HCW) also experience challenges at these encounters. These difficulties are significant as they may results in errors in medical management with significant impact on mortality and morbidity of the patient as well impacting on future encounters. This study was intended to further the understanding of the dynamics of the encounters between HCW and deaf patient by examining the HCWs experience. In this way we may identify the intrinsic and extrinsic factors contributing to the success of failure of the task, establish if the HCW has the competencies and training to achieve the objectives, how working conditions impact on success and how HCWs adapt their communication strategies. These findings could advocate for changes to formal training HCWs receive and the planning and adaptation of services offered to give deaf patients access to appropriate and effective health care. Methods The study design is a qualitative, descriptive case study. Data was collected using interviews and focus groups of invited staff members at Retreat Community Health Centre (RCHC) in Cape Town. Convenience sampling was used to select participants, and interviews were conducted until saturation was reached. Data was studied and analysed using the phenomenological method. Results HCWs reported that they serve very few Deaf or HI clients. However, themes of language barriers; resilience; preconceptions; improvisation and innovation: interpreters and recommendations emerged. Difficulties in communication were acknowledged, but HCWs insisted that these barriers are not insurmountable. Discussion and conclusion A few preconceptions and gaps in knowledge and awareness were revealed. HCWs also tended to rely on escorts and other interpreters. The dominant recommendations are that HCWs should receive training in sign language (SL) and/or that SL Interpreters be available at facilities. Despite using words and phrases such as “frustrating” and “more effort”, participants concluding remarks reiterate that their experiences are positive, suggesting a notable resilience.