MPH (Hospital Management), Faculty of Health Sciences, University of the Witwatersrand

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Magister Administrationis - MAdmin / Nursing is a vital part of the health care delivery system, but managers of health care facilities worldwide are increasingly asked to “do more with less”. Nurses are under increasing work pressure and this often manifests in stress and conflict at work and possible absenteeism. Very few researchers have focused on the patterns of absenteeism among different demographics, length of service and occupational strata. The main question this research seeks to answer is: what is the extent and costs of absenteeism amongst nurses and do seniority, length of service and demographic factors matter at Groote Schuur hospital (GSH). Confined to a period of two years, 2012 to 2013, this study draws on a data set of about 1,635 nurses in order to provide a more accurate analysis of sick leave trends showing occupational levels, gender, age, and race. Nurses at GSH are predominantly female and almost 55% of the workforce is classified as “Coloured”. African nurses in general are younger than the Coloured, White and Indian nurses. The research shows that the nurses in age category 60-66 in fact have a better attendance record; but the data shows there is no overall correlation between years of service and absenteeism. The study suggests that contrary to assumed views, absenteeism is well managed at GSH.

Background. Lupus nephritis (LN) can be complicated with requirement for kidney replacement therapy and death. Efficacy of induction therapies using mycophenolate mofetil (MMF) or intravenous cyclophosphamide (IVCYC) has been reported from studies, but there is limited data in Africans comparing both treatments in patients with proliferative LN. Methods. This was a retrospective study of patients with biopsy-proven proliferative LN diagnosed and treated with either MMF or IVCYC in a single centre in Cape Town, South Africa, over a 5-year period. *e primary outcome was attaining complete remission after completion of induction therapy. Results. Of the 84 patients included, mean age was 29.6 ± 10.4 years and there was a female preponderance (88.1%). At baseline, there were significant differences in estimated glomerular filtration rate (eGFR) and presence of glomerular crescents between both groups (p ≤ 0.05). After completion of induction therapy, there was no significant difference in remission status (76.0% versus 87.5%; p = 0.33) or relapse status (8.1% versus 10.3%; p = 0.22) for the IVCYC and MMF groups, respectively. Mortality rate for the IVCYC group was 5.5 per 10,000 person-days of follow-up compared to 1.5 per 10,000 person-days of follow-up for the MMF group (p = 0.11), and there was no significant difference in infection-related adverse events between both groups. Estimated GFR at baseline was the only predictor of death (OR: 1.0 [0.9–1.0]; p = 0.001). Conclusion. This study shows similar outcomes following induction treatment with MMF or IVCYC in patients with biopsy-proven proliferative LN in South Africa. However, a prospective and randomized study is needed to adequately assess these outcomes.

Magister Chirurgiae Dentium - MChD / Mandibular fractures are common facial injuries, occurring twice as frequently as fractures of the bones of the midface. Only the nasal bones are fractured more often as the result of trauma to the face (Olson eta/ 1982; Theriorletal 1987; Shepherd et al 1988; Dodson et al 1990; Lownie et al 1996). In many oral and maxillofacial units, the treatment of fractures of the mandible form the major proportion of the services rendered. Internationally it is accepted that there are two methods of treatment for fractures of the mandible, namely, closed and open reduction. Closed reductions are performed in dentate patients either under local or general anaesthesia. This method entails the placement of eyelet wires between or around teeth in both arches and then placing the patient into intermaxillary fixation. This is the method of choice when treating an undisplaced fracture of the mandible.

Background: Despite advances in techniques and analgesics for pain management, pain remains a major health problem. Regular assessment and reassessment of pain using guidelines with measurable goals is essential for effective pain management in acute hospital settings. Unfortunately, no such guidelines exist in South Africa. To implement appropriate precepts for the South African context, current practice must be understood. Aim: To evaluate pain assessment and management of patients in two surgical wards at Groote Schuur Hospital. Setting: Groote Schuur Hospital is a government-funded tertiary academic institution within the Western Cape Province of South Africa. The patients at this hospital are generally from the low-income strata and live in resource-poor communities. Methods: A cross-sectional, retrospective medical record audit was conducted. The folders of all 215 patients admitted to a specific orthopaedic trauma and urogynaecological ward at Groote Schuur Hospital in June 2015 were targeted for review. Medical folders not available or with missing notes were excluded. Variables evaluated included the number of pain assessments recorded, pain assessor, assessment tool and management plan. Results: 168 folders were available for review. Nearly half of the patients had no documented pain assessment. When pain assessment was conducted, the verbal rating scale was the predominant tool used, and assessments were mostly conducted by the ward doctor. Pain interventions appeared to be primarily based on the professional knowledge and experience of the practitioner and were not evidence-based. Conclusion: Pain assessment and management was a problem in the two wards reviewed, which is similar to the findings of studies referenced in this text. Health professionals need to be empowered to manage pain adequately. An assessment tool, which integrates the biopsychosocial factors that influence the pain experience, should be routinely employed by a multidisciplinary team to facilitate goal-directed therapy.

The advent of intravenous thrombolytic agents has revolutiontzed the management of patients with acute myocardial infarction and has dramatically altered the morbidity and mortality associated with this condition. The aims of this study in patients presenting with acute myocardial infarction and treated with thrombolytic agents are: 1. To evaluate the efficacy of thrombolytic agents used at Groote Schuur Hospital in terms of (a) patency of the infarct related artery; ( b) short and long-term mortality. 2. To assess the feasibility and safety of combining intravenous beta-adrenergic blockade with intravenous thrombolytic therapy in patients presenting with acute nyocardial infarction. 3. To assess the need for coronary angiography in all patients treated with thrombolytic agents for acute myocardial infarction. 4. To assess the effect on mortality of offering coronary angioplasty or coronary artery bypass grafting only to those patients manifesting spontaneous or inducible ischaemia post infarction.

Diagnosis of infectious pericardial disease has been challenging in the developing world despite improvement of treatment modalities. The diagnostic utility of pH in diagnosing infectious pericardial fluid is unknown, yet this concept is well studied in pleural fluid. This cross-sectional diagnostic study evaluated the diagnostic utility of pH in infectious compared to non-infectious pericardial effusions in a high-burden setting. Methods: Patients of 18 years with moderate to large effusion between the 1st February 2016 and 31st May2018 were enrolled at Groote Schuur Hospital in Cape Town, South Africa. After safe pericardiocentesis, pH was measured with a blood gas analyzer. Mycobacterium tuberculosis culture and/or gene Xpert for TB and/or bacteria culture and/or microscopy served as the reference standard for definite infectious pericardial effusions. We calculated sensitivity, specificity, positive and negative predictive values, negative and positive likelihood ratios for an a priori pH cut off of 7.35. Receiver operating characteristic curve analysis was used for selection of ideal pH cut off. RESULTS Using a set sensitivity of 70% we estimated that we needed to recruit a sample size of 149 subjects for a 95% confidence interval and power of 80%. We screened 200 patients, and excluded 60 because they did not meet the appropriate exclusion criteria. The prevalence of infectious pericarditis was 27.1% (n/N=34/140) as confirmed by the reference standard. We found the median pH (IQR) was 7.30(7.20-7.30) for definite infection, 7.30(7.30-7.35) for probable infection and 7.50(7.40-7.55) for non-infectious effusions p value <0.01 (test for trend). At a cut off or <7.35, the sensitivity was 89.5(95%CI: 75%.5-97.1%) and the specificity was 72.5% (95% CI: 62.8%-80.9%). The ideal ROC- determined cut off for pH that would give maximum sensitivity and specificity was ≤7.30 and the maximum sensitivity and specificity at optimum cut off are 86.8% (95% CI:71.9 - 95.6) and 86.8% (95% CI:71.9 - 95.6), respectively. The area under the curve at this cut-off point is 0.86 (95% CI 0.79 to 0.9), p<0. 001. CONCLUSION: In conclusion, pericardial PH offers diagnostic utility for infectious causes of pericardial effusions using both a PH of 7.35 and an ideal cut-off of 7.30. We recommend that given the simplicity of the test it should be adopted in evaluation of patients with pericardial effusions.

Text in English / International studies have demonstrated that Implantable Cardioverter Defibrillators (ICDs) can have a significant impact on the Quality of Life (QOL) of patients. This is often due to factors that cause considerable psychological distress and has not been investigated in South Africa before. This research study thus investigated factors that influence QOL in patients with ICDs who are followed up in the Cardiac Clinic at Groote Schuur Hospital. The objectives were to describe demographic, clinical, ICD and patient support characteristics; to determine the prevalence of anxiety and depression; to assess QOL and to establish factors that influence depression, anxiety and QOL. The method involved a quantitative approach and a descriptive, cross-sectional and correlational design. All eligible patients with ICDs from the Cardiac Clinic were invited to participate. Participants completed a Demographic and Clinical Questionnaire, the Hospital Anxiety and Depression Scale (HADS) and the SF-36v2 Health Survey. A descriptive analysis of frequencies and summary statistics were done, followed by a regression, comparison and correlational analyses. A total of 70 patients (57 years mean, 65% male) participated in the study. The HADS mean score for anxiety was 6.50, SD 4.52 and for depression 4.96, SD 3.36. The SF-36v2 QOL Physical Component Summary (PCS) mean score was 43.83, SD 9.43 and the Mental Component Summary (MCS) was 47.81, SD 10.71. Factors associated with depression, anxiety and poor QOL included having more than 5 ICD shocks (appropriate or inappropriate). Patients who felt that the ICD influenced their lifestyle positively, was 10.46 times more like to have mental well-being. This study showed that patients with ICDs managed in the state sector, is a vulnerable population. They often live far from hospital, have a high unemployment rate and a poor income. The HADS revealed that 21.4% of the patients had depressive symptoms and 28.6% fulfilled criteria for anxiety. The SF-36v2 revealed that the QOL of patients with ICDs was significantly lower than the norm, with regard to their physical and mental well-being. The study highlights the need for psychological and social support of patients living with ICDs. Keywords: quality of life; implantable cardioverter defibrillator; sudden cardiac death; arrhythmia; anxiety; depression; HADS; SF36v2. / Psychology / M.A. (Psychology)