Theses and dissertations (Health Sciences)

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An analysis of inter-healthcare facility transfer of neonates within the eThekwini Health District of KwaZulu-Natal
(2013-01-18) Ashokcoomar, Pradeep; Adam, Jamila Khatoon
Introduction The safe transfer of neonates from one healthcare facility to another is an integral component in the process of neonatal care. Neonates, a term applying specifically to infants during the first 28 days of life, are transferred from medical healthcare facilities which do not have specialist care or intensive care management to more specialised facilities in order to improve their clinical outcome and chance of survival. The transfer system is thus an important aspect of the overall care provided to neonates. The transfer process, however, poses a threat of aggravating the clinical condition of the neonate. Inter-healthcare facility transfer of a neonate requires careful planning, skilled personnel and specialised equipment to maintain the continuum of care, as this directly impacts on the morbidity and mortality of the neonate. Purpose of the study The purpose of the study was to undertake a descriptive analysis of the current neonatal inter-healthcare facility transfer system in the eThekwini Health District of KwaZulu-Natal (KZN). This service is provided by the public sector ambulance service known as the Emergency Medical Rescue Service (EMRS). The study, based on 120 consecutive transfers, assessed the clinical demographics of the neonates, the time taken to complete the transfers, including time sub-intervals, the equipment that was necessary for the transfers and the qualifications and procedures performed by the transfer team. The study also identified any adverse events that were encountered during the transfers. Methodology The study was conducted from 19 December 2011 to 30 January 2012. It used quantitative methodology and a non-experimental prospective design to undertake a descriptive analysis of 120 inter-healthcare facility transfers of neonates within the eThekwini Health District of KwaZulu-Natal. Data collection relied upon two types of questionnaires. A descriptive survey method incorporated logistic and deductive reasoning to evaluate the objectives of this study. Frequency distributions were generated to describe data categories. Bivariate analysis was conducted using chi- square. Results During the study period there were a total of 120 neonatal inter-healthcare facility transfers. All referrals were undertaken by road ambulances. Eighty-three (62.2%), transfers were undertaken by the operational ambulance units, 35 (29.2%) by the obstetric unit and 2 (1.7%) by the planned patient transport units. Thirty one (28.5%) transfers were on Fridays, followed by 24 (20.8%) on Mondays and 20 (16.6%) on weekends. Ninety seven (80.8%) were during the hours of dayshift (07h00-19h00) and 23 (19.2%) were during nightshift (19h00-07h00). Of the 120 neonatal transfers, 29 (24.2%) were specialised transfers, of which 22 (75.9%) were ventilated. With reference to the gestational ages of the neonates being transferred 90 (76.7%), were pre-term, 26 (21.7%) were term and 2 (1.7%) were post-term. There were 11 (9.2%) newborns (from birth to 4 hours), 56 (46.7%) early neonates (from 4 hours to 7 days) and 53 (44.2%) late neonates (from 7 days to 28 days). Of the 120 neonatal transfers, 90 (75.0%) were pre-term having associated co-morbidities and 49 (40.8%) had respiratory problems. The mean time ± standard deviation (SD), taken by EMRS eThekwini to complete an inter-healthcare facility transfer was 3h 49min ± 1h 57min. The minimum time to complete a transfer was 55min and the maximum time was 10h 34min. The mean time ± SD from requests to dispatch was 1h 20min ± 1h 36min. The delays in dispatch were associated with no ambulances being available 70 (58.3%), no ALS personnel available 48 (40.0%), no equipment available 23 (19.2%) and no ILS personnel available 7 (5.8%) to undertake the transfers. Junior or inexperienced personnel in the communication centre also contributed to the time delays by dispatching ALS personnel for non-specialised transfers and requesting neonatal equipment when it had not been requested by the referring personnel for the transfer. The mean time ± SD from the referring hospital to the time mobile to the receiving hospital was 43min ± 26min. Six (5.0%) neonates were clinically unstable at the referring facility for transfer. For 15 (12.5%) transfers, neonates had been inappropriately packaged for transport by the hospital staff, which added to the delays, p. value = 0.018. The necessary equipment was unavailable for 37 (30.8%) of the transfers. The lack of equipment was due to problems such as poor resource allocation, and malfunctioning, inappropriate, insufficient and unsterile equipment. The pre- departure checklist had not been completed in 50 (41.67%) of the transfers. The study identified 10 (8.3%) adverse events related to the physiological state of the neonate and included 1 (0.8%) mortality. Nine (7.5%) neonates suffered serious life threating complications during transportation, 8 (6.7%) of which were due to desaturation, 6 (5.0%) due to respiratory deterioration, 3 (2.5%) due to cardiac deterioration and 1 (0.8%) due to temperature related problems. Eighteen (15.0%) of 120 transfers experienced equipment related adverse events of which 9 (7.5%) were associated with ventilators, 9 (7.5%) with incubators, 3 (2.5%) with the ambulance, 2 (1.7%) with the oxygen supply and 1 (0.8%) with arterial cannulation. Five (33.3%) of the 15 equipment related adverse events contributed directly to life threatening physiologically related adverse events, p. value = 0.007. Conclusion and recommendation The Emergency Medical Rescue Service (EMRS) is involved in the transportation of a significant number of neonates between various healthcare facilities in the eThekwini Health District, some requiring intensive care and some not. This descriptive, prospective study has identified numerous shortfalls in the service provided by the EMRS in the eThekwini District. Inter-healthcare facility transfer of neonates can be safely performed by the transport services if the operations are well co-ordinated and there are dedicated, specialised and trained transport teams armed with appropriate equipment and medication, together with the guidance of policies and quality assurance. Transport teams must be trained to provide this specialised care in various environments, including ground and air ambulances and understand the multiphase neonatal transfer processes. There must be good communication and co-ordination by all role players, which is underpinned by good team work to improve the standards of neonatal care and monitoring. Only then can clinical excellence be achieved when transporting neonates between healthcare facilities.
Assessing infection control knowledge and compliance in theatre at a private hospital in KwaZulu-Natal, South Africa
(2022-09-29) Naidoo, Elizabeth Laura; Adam, Jamila Khatoon
Infections acquired in a hospital (HAI) often referred to as nosocomial infections are related with increasing morbidity and death among patients that are hospitalised and are predisposed to an elevated risk of infection by health workers (HCWs). The need to maintain an effective infection prevention and control program is therefore essential for quality health care. This study sought to assess the knowledge and compliance of infection control practices of Cardiovascular Perfusionists in theatre at a private healthcare facility in KwaZulu-Natal (KZN) in the city of Durban. A qualitative, research design was used to explore the knowledge and compliance of infection control practices of Cardiovascular Perfusionists by conducting online semi structured interviews. The interviews were conducted online due to the current pandemic of COVID-19, where much consideration was given to social distancing and modes of virus transmission. Duration of the interviews lasted no more than 20 minutes. Prior to conducting the main study, a pilot study was pursued in order to ensure that the interview questions were relevant and that the participants had clear engagement with the questions and no modification nor questions were added to the interview guide. The researcher found that the actual description of the professions differed in the procedures carried out, however, the theatre environment is the same, and only a few questions pertaining to the difference in practice of the participants had to be slightly rephrased in order to be more applicable to the main study. The study was conducted by means of a purposive sample of Cardiovascular Perfusionists. The interviews conducted were limited to only those that practice in the private sector. Participants were chosen based on their ability to provide the necessary information. The interviews were transcribed and then coded by a statistician. The rationale for selecting this strategy was that the researcher was seeking knowledge about the factors that influence the knowledge and compliance of Cardiovascular Perfusionists in the private sector regarding infection prevention and control techniques. Subsequently, these participants would be therefore able to contribute valuable information. The major themes which emerged where namely., infection control and prevention, knowledge of healthcare associated infections, awareness of healthcare acquired infections, cardiovascular perfusionists procedures and precautions followed in cardiovascular surgery. The study found that there is a need for Clinical Technologist specialising in Cardiovascular Perfusion to undergo training in infection control and prevention practices at the higher education and training level. Subsequently, the study reveals that Cardiovascular Perfusionists have a good overall understanding of pathogens and the implications thereof. The study also notes that there is considerable compliance to infection control practices in theatre irrespective of the knowledge pertaining to infection control and prevention policies.
Assessment of technical competence of candidates within a clinical pathology discipline
(2017) Baruth, Melini; Adam, Jamila Khatoon
Background Medical laboratories play a crucial role in patient care and require a competent skilled workforce to deliver this essential service. The current process of Medical Technologist training is a summative assessment consisting of two written 3 hour papers that correlates theoretical knowledge acquired at a tertiary level with the practical internship. Currently there is no assessment of technical competence of Intern Medical Technologists (candidates) by the HPCSA. Aim: This study aims to determine how technical competence was assessed for Intern Medical Technologists who are eligible to write the National Board Examination in the Clinical Pathology discipline. Methods: A quantitative design was used for assessing the technical competence of the candidates that were eligible to write the National Board Examination by using an adapted SANAS witnessing tool across ten Clinical Pathology test procedures by direct observation as well as to determine how technical competence is assessed in HPCSA registered training laboratories using a survey administered to Laboratory managers and trainers. The data was collected and analysed using the statistical software SPSS version 24.0. Results Some candidates that were directly observed in each of the Clinical Pathology test procedures were deemed not yet competent in compliance and adherence to SOP’s, acceptability of results, internal quality control procedures and the acceptability of the outcome and availability of signed training and competency records on the direct observation checklist. These results of the assessment of technical competence were compared to the results of the National Board examination that candidates wrote and there was no correlation between the two except for the Microbiology sub-discipline and the general section. Results of operations of competency assessment in 9 HPCSA registered Training Laboratories revealed that 100% of respondents have a technical competence laboratory policy, 90% identified the Laboratory Manager as having responsibility for ensuring assessment of staff competency, 100% stated that frequency of competency testing was upon initial employment and once in two years thereafter, 90% had clear criteria to define competency assessment and 100% indicated that the remedial process used in their laboratories was documented corrective action which included re-training and re-assessment. Conclusion: From this study it can be concluded that assessment of technical competency for Intern Medical Technologists in the Clinical Pathology could augment current assessment systems of Intern Medical Technologists for conferment of professional designation and a policy review is recommended.
Assessment of the antibacterial activity of Artemisia afra, Erythrina lysistemon and Psidium guajava
(2013-11-13) Nsele, Nhlanhla Wiseman; Mtshali, Joyce Nonhlanhla; Botha, Izel; Adam, Jamila Khatoon
Introduction Medicinal plants have been used for centuries as remedies for human diseases because they contain components of therapeutic value. Recently, the acceptance of traditional medicine as an alternative form of health care and the development of microbial resistance to the available antibiotics have led scientists to investigate the antimicrobial activity of medicinal plants Aim The aim of this study was to investigate the antimicrobial activity of extracts obtained from medicinal plants used in traditional medicine. A comparative study was carried out on the antimicrobial properties of extracts obtained by two different methods in order to choose that which extracts the most effective antimicrobial compounds. Methodology The plants used in this study Artemisia afra, Erythrina lysistemon and Psidium guajava were harvested from the Silverglen Nature Reserve (Chatsworth) early in the morning (8 a.m.). The leaves of A. afra and P. guajava extracts and the bark of E. Lysistemon were used to prepare the extracts. All plant extracts were prepared according to modified method of the German Homeopathic Pharmacopoea. Two solvents, water and 60 percent ethanol were used to extract the antibacterial compounds from plant material. The extracts were then assessed for their antibacterial activity against Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. The effect of the plant extracts on these bacteria was determined by the disk diffusion test, which was used as the screening test. Positive results were further subjected to the minimum inhibitory concentration and minimum bactericidal concentration assays. Tubes that showed no turbidity were then sub-cultured onto non-selective plates. Bacterial sensitivity testing was carried out in accordance with modified Kirby-Bauer Antimicrobial Sensitivity Test. An attempt was made to identify some antibacterial compounds using Thin Layer Chromatography and High Pressure Liquid Chromatography. Results None of the gram negative organisms were inhibited by Artemisia afra, Erythrina cafra and Psidium guajava. Only the ethanol extracts of all three plants were able to inhibit Staphylococcus aureus but not Escherichia coli and Pseudomonas auruginosa. None of the test organisms were inhibited by the aqueous extracts of all three plants used in this study. In the screening test, the zones of inhibition for ethanol extracts against Staphylococcus aureus ranged from 3mm – 7mm. The minimum inhibitory concentration ranged from 16.67 percent – 83.3 percent inhibition depending on the dilution of the extract. Quercetin and Catechin were identified as some of the antibacterial compounds present in the leaves of Psidium guajava. These two compounds were not identified on Erythrina lysistemon and Artemisia afra. Conclusion The results obtained in this study have proven that Artemisia afra, Erythrina cafra and Psidium guajava ethanol extracts contain antibacterial substances. The ethanol extracts of all plants in this study inhibited the growth of Staphylococcus aureus but had no effect on the gram negative bacteria. Aqueous plant did not inhibit the growth of any bacteria in this study. This study has also shown that antibacterial effect of these extracts may be considerably enhanced in traditional treatment if traditional healers can include ethanol as one of the extraction solvents. The results obtained in this study might be considered sufficient for further studies aimed at isolating and identifying the active compounds and evaluating possible synergism of antimicrobial activity among these extracts. Investigations on toxicity of these extracts should also be carried out.
The assessment of the facilitation of the clinical training component of an undergraduate nursing programme at a University of Technology
(2015) Xaba, Nompumelelo Pearl; Mkhize, B.T.; Adam, Jamila Khatoon
Background All nursing students need to undergo clinical training for them to be competent practitioners when they qualify. According to the South African Nursing Council (SANC) training facilities are accredited only if the clinical training component is effective. Therefore, it is important that students are accompanied in order for them to grow professionally and have values as future health care professionals. In nursing education, a student throughout the nursing training course receives instruction both theoretically and clinically in the subjects prescribed in the curriculum by the SANC. Clinical instruction is effected through clinical teaching and learning, which is a requirement by the nursing regulatory body, the SANC. For an undergraduate programme a student has to spend a minimum of 1000 hours per year in clinical placement to meet programme outcomes. It is the responsibility of all nursing schools, colleges and universities to ensure that each student meets these requirements. For this to be effective it has to be facilitated by lecturers and clinical instructors, through teaching and learning strategies to enable students to perform the clinical skill with knowledge and eventual competence. Therefore, clinical instructors are there to ensure that the students are competent in all skills, such as cognitive, affective as well as psychomotor skills. This will be beneficial to the programme in reduction of rates of failure and dropout and again by producing competent practitioners. A positive relationship and collaboration between the clinical training institutions and clinical placement facilities is vital for student achievement, especially because the clinical instructors assist students in correlating theory and practice. This study sought to assess the clinical training component of an undergraduate programme at this UoT in KwaZulu Natal. Findings may inform an improved clinical instruction programme as no such study had been undertaken. Methods A qualitative and quantitative design was used to explore feelings, perceptions as well as experiences of staff and student nurses with regard to clinical training component. Stratified random sampling was used to select student nurses according to levels of training and questionnaires were used to collect data. All permanently employed staff who had been working over six months were selected since they were directly or indirectly involved in the clinical facilitation. A focus group interview was conducted for the clinical instructors and questionnaires were used for the lecturers to collect data. Themes and sub-themes emerged and on analysis they were compared to the findings from the quantitative survey. Results and discussion The results revealed that collaboration of clinical placement facilities and training institutions is important for student’s support since all parties are able to communicate freely and students benefit. Students stated that they did not get enough support since the clinical facilitators were short staffed and they were also allocated to facilities that were far from the campus. The respondents cited problems during clinical accompaniments as there were very high expectations by staff members in the placement areas regarding student support. Lecturers were also expected to involve themselves in clinical accompaniment to bridge theory-practice gap. The employment of mentors will assist in student support as the mentors will be at placement areas and the staff and students easily contact them. Conclusion From the interviews the researcher managed to come up with important aspects that should be included in an accompaniment tool when developed, which should be user friendly to both lecturers and clinical facilitators. It will thus assist students with critical skills including critical thinking when performing any patient related nursing skill. It was recommended that the UoT management support staff by attending to their concerns including finding more clinical placement facilities close to the campus.
The assessment of two year clinical outcomes after stent implantation for the treatment of coronary artery disease
(2013-01-18) Harrypaul, Ashika; Adam, Jamila Khatoon; Dyer, Robby B.
The sirolimus-eluting stent (Cypher) was the first approved drug- eluting stent by the Food and Drug Administration in April 2003. This is a stent that is based on a bare-metal stent and is coated with a layer of polymer incorporating sirolimus and releasing it by diffusion. Drug-eluting stents reduced risk of restenosis and repeat revascularization as compared with bare-metal stents. Clinical data has raised concerns that drug-eluting stents are associated with late untoward events. Objectives: The objective of this study was to test the hypothesis that stenting is safe and effective treatment for coronary artery disease. Methods and Results: Sirolimus-eluting stenting was performed in 30 patients with 34 coronary lesions. Detailed clinical follow-up data was collected by personal interview or telephone contact at 1, 6, 12 and 24 months. Patients were followed for 2 years for the occurrence of angina and cardiovascular events namely death, myocardial infarction, stent thrombosis and target lesion revascularization. The mean age of the cohort was 62.33±10.99 years; 83 percent were male, 6 percent were diabetic, 53 percent had hypertension. In spite of the overall patient and lesion complexity there were no incidences of major adverse cardiac events and all patients remained angina free out to two years. Dual antiplatelet therapy with aspirin and plavix varied from at least four weeks to one year. One patient had a bleeding event. Conclusions: Treatment of lesions with sirolimus-eluting stents is associated with a sustained clinical benefit two years after device implantation.
Case based learning in the undergraduate nursing programme at a University of Technology : a case study
(2015-03) Sinqotho, Thembeka Maureen; Adam, Jamila Khatoon
Background The current health care system in South Africa and its diverse settings of health care delivery system require a nurse who can make decisions, think critically, solve problems and work effectively in a team. Traditional nursing education teaching strategies have over the years relied on didactic and often passive approaches to learning. In pursuit of quality, academics and students must be continually engaged in a process of finding opportunities for improving the teaching and learning process. Purpose of the study The purpose of this study was to evaluate the structure and the process in case based learning at the University of Technology. Methodology This study is qualitative in nature, governed by an interpretive paradigm. This is a case study, which enabled the researcher to merge student interview data with records in order to gain insight into the activities and details of case based learning as practised at the University of Technology under study. Most importantly, the case study method was deemed appropriate for the current study, since case-based learning as a pedagogical approach (and a case) cannot be abstracted from its context for the purposes of study. Case based learning is evaluated in its context namely, the undergraduate nursing programme, using the Donabedian framework of structure, process and product. Results The study recorded that students were positive towards case based learning though some identified dynamics of working in groups as demerits of case based learning. The structures that are in place in the programme and the CBL processes are adequate and support CBL. There are however areas that need attention such as the qualification of the programme coordinator, the size of the class-rooms and the service of the computer laboratory. Conclusion The study found that apart from a few minor discrepancies, case based learning is sufficiently implemented, and experienced as invaluable by students, at the University of Technology under study.
Colour stability of three modern ceramic materials after repeated firing
(2017) Naidoo, Ansuya; Adam, Jamila Khatoon; Zondi, M.P.P.
Background Shade matching is a challenging aspect of aesthetic dentistry (Vichi et al., 2011). For a long time, aesthetically pleasing prostheses have been achieved using the porcelain-fused-to-metal crown whereby the metal is masked with an opaque layer and then consecutive layers of veneering ceramic are built up (McLean, 1979). The growing popularity of all-ceramic restorations has created a need for an understanding of its colour characteristics in preference to porcelain fused to metal restorations. The study aims to assist dental technicians in making a more informed decision when choosing an all-ceramic system in terms of colour stability. Objectives The objectives were to identify colour changes of the zirconia after each firing cycle and defining if there are any microstructural changes in the zirconia cores after subsequent firing. Methods This is a quantitative study with a sample size of eighteen which was used for each experimental group. Green state zirconia blocks from Cercon (Dentsply DeguDent, USA), Lava (3M ESPE,USA), and Zirkon Zahn (Zirkonzahn Gmbh, Bruneck, Italy) were trimmed, finished and sintered to a final thickness of 0.5mm according to the manufacturers’ instructions. Each sample group was obtained directly from the manufacturer. In each group, nine specimens were shaded and nine were unshaded. The colour of each specimen was recorded before being exposed to firing cycles. This data formed the control group. All specimens were subjected to three firings and spectrophotometer reading. After each firing, SEM analysis was done after one and three firings. There was a total of thirty six specimens x three firings; n = 108. The raw data for the statistical analysis was obtained from the spectrophotometer readings recorded after the firings (n=108). The data of the study was analyzed using the SPSS version 22.0. The data were compared among the three groups using Pearsons chi square tests, where the data of the firings were measured as a binary or nominal variable, and using t-tests where a measured normally distributed variable was compared. The general linear model (GLM) looked at combinations of the variables and their effects on the dependant variable. The Multivariate tests table indicates the actual result of the one-way MANOVA. Results The Cercon results for both the control and experimental groups reveal the same result patterns and was maintained before and after firing. Lava also revealed the same results before and after firing, however, the cores in the control group differed in colour. The Zirkon Zahn system proved to be the least stable in colour. Conclusion This study supports the hypothesis that colour differences would occur relative to the number of firings for shaded zirconia. It can be concluded that Cercon displayed the most stable results in terms of colour. The acumen gained in this study may better assist dental technicians in their selection of an all-ceramic zirconia system.
Comparative in vitro analysis of a balanced electrolyte solution versus an unbalanced electrolyte solution, for processing of residual pump blood using cell saver for patients undergoing elective cardiac surgery
(2016) Pillay, Krishnan; Adam, Jamila Khatoon; Mohapi, M.J.
Introduction: A large volume of residual haemodilute blood remains in the cardiopulmonary bypass (CPB) circuit after termination of the bypass. It is common practice in many centres to process residual pump blood with an autologus cell salvage system (ACSS), thereby producing a re-suspended red blood cell (RBC) concentrate and attenuating the need for donor blood RBC concentrate. It has also become standard practice to wash donor pack red blood cells (PRBC) before adding it to neonate cardiopulmonary circuits (Swindell et al., 2007). Manufactures of ACSS recommend 0.9% sodium chloride (NaCl) as a wash solution for processing salvaged blood. Previous studies have demonstrated that washing PRBC with normal saline results in acid-base (Huber et al., 2013) and electrolyte derangements (Varghese et al., 2007). Infusion of normal saline in healthy volunteers also results in significant changes in osmolality (Williams et al., 1999). The use of normal saline as a wash solution in processing residual CPB blood requires investigation. Aims and Objectives: This was a prospective, quantitative in vitro investigation to analyze and compare the quality of residual pump blood post CPB that had been washed with either an unbalanced electrolyte solution (0.9% normal saline) or a balanced electrolyte solution (Balsol®). Both are crystalloid solutions. The primary objective of the present study was to measure and compare the pH, electrolytes, metabolites, osmolality and strong ion difference (SID) of residual pump blood to the pH, electrolytes, metabolites, osmolality and SID of processed cell saver blood, which was washed with either 0.9% normal saline or Balsol® solution. The secondary objective was to measure and compare protein levels (albumin and total protein) in residual pump blood to protein levels in processed cell saver blood, that is washed with either 0.9% normal saline or Balsol® solution. The final objective was to determine the volume, haematocrit and haemoglobin yield post cell saver processing, from the input volume of residual pump blood when washed with either 0.9% normal saline or Balsol® solution. This was the first study of this nature done in the South African population group. Methodology: In this investigation in a series of forty patients (n=40) undergoing elective cardiac surgery with CPB, the first twenty patients were allocated to the NaCl control group (n=20) and the second twenty patients were allocated to the Balsol® interventional group (n=20). The extracorporeal circuit consisted of a standard integral hollow fibre membrane oxygenator and tubing that was primed with 1500-1800 millilitres of balanced crystalloid solution (Balsol®), for both the control group and the interventional group, and addition of 5000 iu heparin. The balanced crystalloid solution (Balsol®) is the approved standard CPB priming solution for all cardiac procedures at Inkosi Albert Luthuli Central Hospital. This setup was used with the Stockert S5 roller pump heart lung machine. The operations were performed as per protocol with standard non-pulsatile CPB and hypothermia was maintained at 28 – 32 ºC (core) and haemodilution (haematocrit 20 % to 30 %). A standard flow rate of 2.4 L/min/m² was used. Cardio protection consisted of either cold Blood Cardioplegia using the Buckberg 4:1 ratio, being four parts blood to one part cardioplegia (with the 35ml of 20 % Dextrose + 1 gram Magnesium Sulphate added per 500ml), or 20ml/kg cold St Thomas II cardioplegia (with addition of 10ml of 8.5% NaHCO3 + 100mg lignocain per litre). Topical cooling was achieved with ice cold 0.9 % saline. Maintenance fluid used during CPB was Balsol® for both the control and the interventional groups. Calcium, potassium and sodium bicarbonate was administered as required during CPB to correct deficits for both groups. Weaning of CPB was performed after re-warming to a rectal temperature of at least 35 ºC for both study groups. Immediately on termination of CPB a blood sample was taken from the sampling manifold of the CPB circuit for pre wash analysis. Residual pump blood was then flushed out with one litre of Balsol® solution for both groups and collected into the Medtronic autolog cell saver reservoir to be processed. In the control study group 0.9% NaCl was used as the wash solution and in the interventional study group Balsol® solution was used as the wash solution. After processing of the salvaged blood is complete, a blood sample was taken for post wash analysis. Clinical data recorded for pre and post wash samples included: pH, pCO2, pO2, [K+], [Na+], [Cl-], [Ca2+], lactate, glucose, [HCO3-], TCO2, haematocrit, haemoglobin (GEM 4000® premier™ blood gas analyser) blood volume (Medtronic autolog) and SID (calculated as per equation). Inorganic phosphate, total magnesium, albumin, total protein (Siemens Advia 1800 blood gas analyser) and osmolality (Gonotech osmometer) were also measured. Results: There was a highly significant decrease (p < 0.05) within the NaCl group after washing with pCO2 (28.3 ± 2.9 vs. <6.0 ± 0.0), [K+] (4.5 ± 0.5 vs. 1.0 ± 0.7), total magnesium (1.7 ± 0.7 vs. 0.29 ± 0), ionized calcium (1.0 ± 0.09 vs. 0.1 ± 0.03), inorganic phosphate (0.9 ± 0.4 vs. 0.09 ± 0.04) and SID (27.1 ± 2.1 vs. 18.4 ± 2.2). There was a highly significant increase (p < 0.05) within the NaCl group after washing with pH (7.5 ± 0.1 vs. 7.7 ± 0.1), [Na+] (132.9 ± 3.2 vs. 146.3 ± 1.9), [Cl-] (107.8 ± 3.1 vs. 127.4 ± 2.1) and osmolaltity (256.9 ± 38.4 vs. 296.2 ± 57.5). There were highly significant decrease (p < 0.05) within the Balsol® group after washing with pCO2 (30.15 ± 6.0 vs. 18.9 ± 4.9), [Na+] (134.7 ± 2.2 vs. 125.6 ± 1), [Cl-] (108.8 ± 2.7 vs. 100.2 ± 1.4), ionized calcium (0.9 ± 0.1 vs. 0.02 ± 0.04), inorganic phosphate (0.8 ± 0.2 vs. 0.1 ± 0.024) and osmolality (288.8 ± 20.6 vs. 272.8 ± 19.9). There were highly significant increase (p < 0.05) within the Balsol® group after washing with pH (7.5 ± 0.1 vs. 7.7 ± 0.1), [K+] (4.2 ± 0.4 vs 4.6 ± 0.3). Total magnesium and SID were similar after washing within the Balsol® group. Albumin and total protein revealed similar significant decreases within both groups after washing. There was a highly significant difference (p < 0.05) in the change between groups after washing in all the variables measured, except for pH, inorganic phosphate, lactate, glucose, albumin, total protein, haematocrit, haemoglobin, and blood volume. Total carbon dioxide and [HCO3-] were not compared because they were incalculable by blood gas analyser in the NaCl group. Conclusion: This investigation concluded that the balanced electrolyte solution Balsol® used for washing residual CPB blood results in a re-suspended RBC concentrate, with an osmolality and electrolyte profile that is superior compared to washing residual CPB blood with 0.9% NaCl solution.
Contributing factors affecting erythropoiesis and analysis of erythropoiesis bioassay in renal patients in KwaZulu-Natal
(2016) Benjamin, Sherilene Cheryl; Adam, Jamila Khatoon; Assounga, A.G.
Erythropoietin (EPO) is widely used in patients with chronic renal failure and is a necessity. However, due to the cost implications and the medical complications in our population it is imperative to review the factors affecting the process of erythropoiesis and the analysis of cell proliferation and cell viability in the bioassay. Complications such as hypertension and risk of worsening a malignancy cannot be ignored. We had previously analysed variations of erythropoietin levels in haemodialysis patients over a six month period. This study aims to evaluate erythropoiesis in conjunction with various laboratory, demographic, clinical parameters and inflammatory markers, in the population of haemodialysis patients. EPO, antibody level and antibody activity were analysed in the population groups as EPO responsive and EPO sensitive patients. This is a prospective, experimental and controlled study. Fifty nine patients were randomly selected from haemodialysis units of Addington and King Edward VIII Hospitals following an informed consent and 15 healthy individuals were also selected as controls. Demographic parameters (age, sex), clinical parameters (weight, height, skin folding, EPO doses and blood pressures (BP) were recorded. Pre-dialysis serum was used to measure laboratory markers (haemoglobin, transferrin, ferritin, albumin, ESR, C reactive protein, creatinine and urea). EPO levels and antibody levels were measured by ELISA, the optical density of each well was determined within fifteen minutes using the microplate reader set at 450 nm. All results were statistically analysed using SPSS statistical package version 21 (IBMR). Patients requiring very high doses of EPO to reach Hb of 11g/dL, and they remained anaemic after at least three months of adequate EPO doses were considered to be EPO resistant. Those who responded to the usual EPO doses were labelled EPO sensitive. The bioassay was used to quantify cell proliferation and cell viability in the presence of EPO. The UT 7 cells were cultured in medium, in the presence of serum from the EPO resistant, EPO sensitive patients and the healthy, control subjects. Luminescence was read with the Glorunner Microplate Luminometer and was recorded in relative light units (RLU). The analysis revealed: a non-significant positive correlation between haemoglobin and erythropoietin levels. However, a strong negative correlation was found between CRP and albumin level (R= -0.591; (p=0.001), which was not significant. No correlation was found between haemoglobin or erythropoietin levels and CRP or albumin. There was a positive correlation with systolic and diastolic blood pressures and mean arterial pressures which was statistically significant (p <0.05). EPO dosages and Hb levels were correlated significantly (p < 0.05). No correlation of EPO levels and Hb; age and Hb was found to be significant (p = 0.08). The UT 7 cells cultured in serum in medium alone with RHuEPO containing cells were statistically significant (p <0.01)). Reduction of ATP stimulation between medium and serum was observed. However, mean arterial pressures had a significant association with EPO resistance (p = 0.041) odd ratio- 1.066. In conclusion, EPO level is not a useful tool for the monitoring of its use as it does not correlate with EPO goal of red blood production in our patients. The neutralizing antibodies did not correlate with any of our variables contributing to erythropoiesis, and are therefore not confirmed as playing a major role in erythropoiesis. From the analysis of our results the key contributing factors of EPO doses, malnutrition and age were more significant in erythropoiesis. However the higher doses of EPO significantly increased the blood pressures and the mean arterial pressures (MAP). The analysis of the bioassay showed lack of difference between EPO responsive and EPO sensitive patients. This observation warrants further studies to clarify the role of serum of haemodialysis patients in erythropoiesis.
Correlation between cerebral tissue oxygen saturation and central venous oxygen saturation during off-pump coronary artery bypass graft surgery
(2009) Harilall, Yakeen; Adam, Jamila Khatoon; Reddi, A.
Currently, off-pump coronary artery bypass surgery (OPCAB) is a selectively employed technique for myocardial revascularization used in the majority of heart units worldwide. This strategy obviates the documented deleterious effects of cardiopulmonary bypass. However the occurrence of neurological sequelae associated with OPCAB ranges from minor cognitive dysfunction to major stroke. Haemodynamic instability throughout the positioning, stabilization and interruption of coronary blood flow are regarded as important factors that affect the performance of off-pump surgery. Fluctuations during the perioperative period, in particular manipulation of the heart could result in temporary brain hypoperfusion and neurological sequelae. To predict those patients that are predisposed to cerebral complications, investigators have used neurological monitoring, in particular Near-infra red spectroscopy (NIRS) during cardiac surgery. Aims and Objectives of the study This prospective, observational study was carried out to assess the correlation between cerebral oxygen saturation and central venous saturation during OPCAB surgery. Central venous saturation is an important variable used to assess global tissue perfusion and could therefore be advocated as a surrogate measure of cerebral oxygen saturation. In addition variables such as mean arterial (MAP) pressure, heart rate (HR), patient oxygen saturation (SpO2), partial pressure of carbon dioxide (PcvCO2), haematocrit (Hct) and lactate were also measured to determine if they were independent predictors of cerebral desaturation. This study is one of the first done in the South African population group. iv Methodology Twenty patients undergoing OPCAB surgery from the Cardiothoracic unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa were recruited in the trial. Cerebral somasensors were placed on the patients forehead to measure left and right cerebral saturations. These sensors were linked by cables to the cerebral monitor (NIRS), INVOS model 5100C. Eight time periods throughout the surgical procedure whereby patients would be haemodynamically unstable were identified. These time periods included, post induction and pre sternotomy, pre and post placement of swabs beneath the heart, pre and post placement of the stabilizer device (Octopus), pre and post snaring of the LAD (left anterior branch of the coronary arteries), pre anastomosis and during anastomosis of the coronary arteries, second sample during anastomosis and post anastomosis, pre and post removal of swabs from beneath the heart, pre and post transfer of the patient to the ICU bed. These time periods constituted the sampling period pre and post manoeuvres. Eight paired measurements, i.e., MAP, PaCO2, HR, Hct, lactate, SpO2, central venous saturation (ScvO2) and cerebral oxygen saturation (rSo2) per patient were taken during these time periods. Recording of cerebral saturations and blood samples from the central venous line were taken during these eight time periods in order to determine the correlation between central venous and cerebral oxygen saturations. Results Strong positive correlations between central venous saturation and cerebral saturation presented in majority of the sampling time periods throughout the study (post induction and pre sternotomy, post placement of swabs beneath the heart, post snaring of the LAD (left anterior branch of the coronary arteries, pre anastomosis and during anastomosis of the coronary arteries, second sample during v anastomosis, pre and post transfer of the patient to the ICU bed). The positive correlation indicates that central venous saturation can be used as a surrogate measure of cerebral oxygen saturation during OPCAB surgery. Conclusion The absence or poor correlation of MAP, HR, PcvCO2, heamatocrit, lactate, and patient saturation to cerebral saturation in this study suggests that insertion of a central venous line (CVP) during OPCAB should be a fundamental clinical requirement.
The effect of exercise on solute removal during haemodialysis in end-stage renal disease
(2009) Singh, Shakthi; Adam, Jamila Khatoon
Exercise assessment, counseling and training are not widely offered to patients with chronic kidney disease. Haemodialysis patient’s participation in exercise and an adequate assessment of exercise effects on haemodialysis outcome are needed so that more interventions can be developed to improve the well being of those patients with chronic kidney disease. Exercise is not routinely advocated in patients with end-stage renal disease receiving maintenance haemodialysis. Lack of widespread awareness of exercise in haemodialysis literature may be contributing to these shortcomings in clinical practice. Purpose of the study This study was aimed to establish the effect of exercise during haemodialysis on pedal oedema and solute removal. This is the first time that such a study was undertaken in dialysis units in South Africa. Methodolgy In a quasi-experimental design, thirty-four end-stage renal failure patients on three times weekly haemodialysis program from Bloemfontein and Newcastle MediClinic Renal Units participation in the study. Ethical approval for the study was obtained from Durban University of Technology Ethics Committee. Seventeen patients were in the intervention group (aged between 25 and 60) and seventeen in the control group (aged between 18 and 60). The intervention group did not exercise for the first three months of the study in order to establish a baseline period. Thereafter, exercising took place from the fourth to the ninth month. Patients pedaled on an exercise cushion for fifteen minutes every hour to achieve a total of sixty minutes of exercise over a four-hour dialysis session. Patients in the control group did not pedal on the exercise cushion during the nine-month study period. Pre and post haemodialysis measurements of creatinine, urea and potassium using the Alkaline Picrate, Urease and Ion Selective Electrode methods respectively were done for each patient monthly over the nine month period. Oedema of the lower limb was evaluated by measuring the right and left ankle circumference, in centimeters before and after dialysis. Urea Kt/V was also measured before and after haemodialysis for each patient over the study period. Results Statistical analysis of results showed a significant 30% reduction in urea levels and a 46% reduction in creatinine levels in the intervention group at the end of the nine month period, a 12% reduction in the potassium levels in the intervention group which was 4% more than the control group. The urea Kt/V in the intervention group showed a 9% greater reduction than the control group. There was a significant improvement in oedema of 45% of the right ankle for the first three months of exercise and thereafter there was a an increase in ankle size in the last three months which was a 13% reduction in oedema compared to baseline. There was a significant improvement in oedema of 60% of the left ankle for the first five months of exercise and thereafter there was an increase in ankle size in the last month which showed a 25% reduction compared to baseline. The reason for the increase in ankle size in both ankles in the last three months in inconclusive and future investigation is recommended. Conclusion The results of this study demonstrated benefits of exercise during haemodialysis on solute removal and oedema perhaps due to the acute increases in blood flow and therefore increasing perfusion of skeletal muscles.
The effect of optimizing cerebral tissue oxygen saturation on markers of neurological injury during coronary artery bypass graft surgery
(2011) Harilall, Yakeen; Adam, Jamila Khatoon; Reddi, A.
Surgical revascularization of the coronary arteries is a cornerstone of cardiothoracic surgery. The enduring nature of coronary artery bypass grafting (CABG) bespeaks of its history and proven efficacy. However, cerebral deoxygenation during on-pump coronary artery bypass graft surgery may be associated with adverse neurological sequelae. Advanced age and the incidence of preoperative co-morbidity in patients presenting for coronary artery bypass graft surgery increases the potential for stroke and other adverse perioperative outcomes (Murkin, Adams, Quantz, Bainbridge and Novick, 2007). It is hypothesized, that by using the brain as an index organ, interventions to improve cerebral oxygenation would have systemic benefits for cardiac surgical patients. In an attempt to predict those patients that are predisposed to cerebral complications, investigators have used neurological monitoring ie, Near infrared spectroscopy (NIRS) to enhance detection of hypoxic conditions associated with neurological injury (Hoffman, 2006). Serum S100B protein has been used as a biochemical marker of brain injury during cardiac surgery. Elevated levels serve as a potential marker of brain cell damage and adverse neurological outcomes (Einav, Itshayek, Kark, Ovadia, Weiniger and Shoshan, 2008). Aims and Objectives of the study This prospective, quantitative, interventional study was carried out to maintain cerebral tissue oxygen saturation during cardiopulmonary bypass above 75% of the baseline level by implementation of a proposed interventional protocol. The analysis of S100B which is a marker of neurological injury and optimization of regional cerebral oxygen saturation would allow for the formulation of an algorithm which could be implemented during on-pump coronary artery bypass graft surgery as a preventive clinical measure further reducing the risk of neurological injury. Central venous lines (CVP) are inserted routinely during cardiac surgery. Central venous oxygen saturation is a global marker of tissue oxygenation. A secondary aim of the study was to determine if a correlation existed between central venous and cerebral tissue oxygen saturations. If a positive correlation existed then central venous oxygen saturation could be used as a surrogate measure of cerebral tissue oxygen saturation during on-pump coronary artery bypass graft surgery. This study is one of the first done in the South African population group. Methods Forty (40) patients undergoing on-pump coronary artery bypass graft surgery were recruited at Inkosi Albert Luthuli Central Hospital. Patients were randomized into a control group (n=20) and interventional group (n=20) using a sealed envelope system. The envelope contained designation to either group. Envelopes were randomly chosen. Intraoperative regional cerebral oxygen saturation (rSO2 ) monitoring with active display and treatment intervention protocol was administered for the interventional group. In the control group regional cerebral oxygen saturation monitoring was not visible to the perfusionist operating the heart lung machine during cardiopulmonary bypass (blinded). Recording of regional cerebral saturation was conducted by an independent person (another perfusionist) who was not involved in the management of the case so as to ensure that no interventions were carried out on the control group. Arterial blood samples for the measurement of serum S100B were taken pre and postoperatively. An enzyme immunoassay (ELISA) was used for the quantitative and comparative measurement of human S100B concentrations for both groups. Central venous oxygen saturation was monitored from the CVP using the Edwards Vigileo monitor. Cerebral monitoring constituted the use of Near infrared spectroscopy monitoring using the Invos 5100c, Somonetics Corp, Troy MI monitor. Adhesive optode pads were be placed over each fronto- temporal area for cerebral oxygen measurement. During cardiopulmonary bypass, eight time period measurements of mean arterial pressure (MAP), heart rate, temperature, activated clotting time (ACT), patient oxygen saturation (SpO2), partial pressure of carbon dioxide (pCO2), haematocrit, lactate, pH, haemoglobin (Hb), base excess (BE), potassium (K+), sodium (Na+), glucose, calcium (Ca2+), central venous oxygen saturation (ScvO2), cerebral tissue oxygen saturation (rSO2), fraction inspired oxygen (FiO2 ), sweep rate, pump flow rate (cardiac index), and percentage isoflurane per patient were taken. The time periods when data was recorded included: 5 minutes after onset of cardiopulmonary bypass, aortic cross clamping, after cardioplegic arrest, during distal anastomosis, during proximal anastomosis, during rewarming, after aortic cross clamp release and before termination of cardiopulmonary bypass. Baseline measurements were also taken. Clinical data recorded for both groups included: the number of grafts performed, cardiopulmonary bypass time, cross clamp time, red blood cells administered (packed cells), amount of adrenalin infused and total cerebral desaturation time. A prioritized intraoperative management protocol to maintain rSO2 values above 75% of the baseline threshold during cardiopulmonary bypass was followed. Cerebral desaturation was defined as a decrease in saturation values below 70% of baseline for more than one minute. Interventions commenced within 15 seconds of decrease below 75% of baseline value. Results The results of the study show that there was a highly significant difference in the change in S100B concentrations pre and post surgery between the interventional and control groups. The intervention vii group showed a smaller increase in S100B concentration of 37.3 picograms per millilitre (pg/ml) while the control group showed a larger increase of 139.3 pg/ml. Therefore, the control group showed a significantly higher increase in S100B concentration over time than the intervention group (p < 0.001). Maximizing pump flow rates was the most common intervention used (45 times) followed by maintaining partial pressure of carbon dioxide to approximately 40 mmHg (28 times), increasing mean arterial pressure by administration of adrenalin (11 times) and administration of red blood cells to increase haematocrit (11 times). There was a highly statistically significant treatment effect within the intervention group for each of the above interventions compared with no intervention. The above mentioned interventions significantly affected right and left cerebral oxygen saturations. However, administration of red blood cells was not found to significantly increase right (p = 0.165) and left (p = 0.169) cerebral oxygen saturation within the intervention group. The study highlighted a significant difference between the intervention and control groups in terms of cerebral desaturation time (p <0.001). The mean desaturation time for the control group was 63.85 minutes as compared to 24.7 minutes in the interventional group. Cerebral desaturation occurred predominantly during aortic cross clamping, distal anastomosis of coronary arteries and aortic cross clamp release. Predictors of cerebral oxygen desaturation included, partial pressure of carbon dioxide (pCO2), temperature, pump flow rate (LMP), mean arterial pressure (MAP), haematocrit, heart rate (HR) and patient oxygen saturation (SpO2). Central venous oxygen saturation was not significantly related to right (p = 0.244) or left (p = 0.613) cerebral oxygen saturations. Therefore central venous oxygen saturation cannot be used as a surrogate measure of cerebral tissue oxygen saturation during on-pump coronary artery bypass graft surgery. viii Conclusion These findings demonstrate the positive effect of optimizing cerebral oxygen saturation using an interventional protocol on markers of neurological injury (S100B). Optimization of pump flow rate, partial pressure of carbon dioxide and mean arterial pressure would result in increased cerebral oxygen saturation levels and a reduction in neurological injury. Therefore, an algorithm incorporating these interventions can be formulated. Monitoring specifically for brain oxygen saturation together with an effective treatment protocol to deal with cerebral desaturation during on-pump CABG must be advocated.
The efficacy of an instructional model on the quality of teaching and learning using assessment
(2017) Mohapi, Mogapi Jeremia; Adam, Jamila Khatoon; Ngwenya, Thengamehlo Harold
The key aim of this study was to investigate the efficacy of the student-centric Integrated Teaching and Learning Model Using Assessment (ITLMUA) to enhance the effectiveness, efficiency and quality of student learning and teaching in a Clinical Technology programme. The ITLMUA provides a pragmatic theoretical framework for developing and enhancing perceptions and conceptions of pedagogics and associated educational and psychological theories, particulary assessment information to review, reflect and improve educational constructs of teaching, learning, assessment and educational research. The efficacy of ITLMUA uses effectiveness, usability and participants’ satisfaction as the key criteria in evaluating the impact of ITLMUA on the quality of student learning. The ITLMUA’s efficacy is judged in terms of participants finding it academically beneficial, valuable, suitable, useful and meaningful to instructional strategies and practices in higher education (HE). The motivation for the study is premise on lecturers’ adherence to conventional instructional strategies and practices and lack of instructional model that guides and measures the effectiveness and the quality of student learning and teaching. Increased workloads and superfluity of academic gatherings are some of the factors that exacerbate adherence to conventional instructional practices, including lack of academic qualification to understand the princples of educational practice in HE. This study promote and encourage integrated, authentic, dynamic and innovative instructional practices that demonstrate theoretical interest and practical relevance, such as active learning (AL) that is underpinned by learning theories and pedagogical principles. Furthermore, the study analyzed and identified some of the implementation challenges in introducing the integrated instructional model in a conventional learning environment in order to justify how and why it is imperative to adopt an integrated performance-based instructional model in the face-to-face (F2F) learning environment. The study proposed to provide an instrument that can be utilized to enhance the quality of student learning and teaching. The integrated instructional model can assist lecturers to reflect on their pedagogical practices with the intention of enhancing their subsequent pedagogical practices and strategies. The theoretical and conceptual framework of ITLMUA offered the lecturers an opportunity to integrate conventional and contemporary instructional practices. These frameworks have previously been underpinned by learning theories and pedagogical principles to enhance the quality of learning and teaching. Design-based research (DBR) methodology was utilized as it offered a systematic, flexible methodology that is theory-driven, and involves contextually-sensitive design principles and theories of the learning environment. It also offers the opportunity to review and redesign the ITLMUA as the research process develops, and new theoretical and conceptual framework information emerges. In addition, the DBR integrates research, design and practice into a single useful process which results into a usable product that is supported by a theoretical framework. Active learning is one of the teaching strategies that is supported and promoted by this study to improve quality learning and teaching in order for students to comply with and satisfy the academic quality standards and learning outcomes expected of them. This is can be achieved through meaningful engagement and active involvement in academic activities that promote critical analytical skills and competencies through collaborative and cooperative learning, and within a structured, supportive and facilitated learning environment. The learning environment should be characterized by student-centered and lecturer-facilitated instructional practices such as active learning teaching strategies. To enhance the quality of learning and teaching, lecturers attempt to match and modify their teaching strategies to accommodate the wide range of students in their classes, all of whom have different needs and expectations. Qualitative and quantitative research methods were used to gather data. Data analysis techniques included content analysis, the constant comparative method, factor analysis (FA) to reduce data in order to correlate and relate variables to components. Cronbach’s alpha was used to determine reliability of items. The study has demonstrated the utility, usability and efficacy of the ITLMUA as indicated, in the main, by participants’ satisfaction with the instructional model. The study reports on some of the enablers and barriers in the implementation and evaluation of the integrated instructional model and articulated the lessons that have been learned in this academic journey.
An evaluation of the effectiveness of the sonogram and the clinical determination of the arterio-venous fistula site in the diabetic population entering the chronic haemodialysis program
(2013) Ramnarain, Rakhee; Haffejee, A. A.; Adam, Jamila Khatoon
Diabetic nephropathy is a serious complication of diabetes that can lead to end stage renal failure (ESRF). It is now the most common cause of ESRF in patients accepted onto renal replacement therapy (RRT) programmes. Kidney disease is common in South Africa. 60-65% is due to inherited hypertension and 20-25% due to Type 2 diabetes (National Kidney Foundation of South Africa, 2002). The renal replacement therapies include haemodialysis, peritoneal dialysis and transplantation. Successful long-term haemodialysis in patients with end stage renal disease (ESRD) depends to a large extent upon a trouble- free vascular access. Achieving a successful vascular access remains a challenge especially in the diabetic population. Current Kidney Dialysis Outcome Quality Initiative (KDOQI) guidelines encourage placing Arterio-Venous Fistula (AVF) in more haemodialysis patients. While the upper limb is the preferred site for AVF creation, researchers are undecided on which is the ideal location (distal or proximal arm) in the diabetic population. Many new fistulae fail to mature sufficiently to be usable for haemodialysis. Pre-insertion work-up with regard to haemodialysis access is important in maintaining the most appropriate access in the growing diabetic population requiring haemodialysis. Pre-operative vascular mapping to identify suitable vessels has been reported to improve vascular access outcomes . In South Africa, duplex scanning is not routinely done, and a clinical judgement by the surgeon remains in most instances the deciding factor on the site of the AVF. Whilst conducting this research, it has been found that while diabetic patients may have AVF created, the maturation time is of a much extended period, and a challenge to achieve the desired dose of dialysis. This is a prospective, quantitative and qualitative study of 21 diabetic patients. These included patients that were starting on the chronic haemodialysis program and limited to patients that were having first attempt of AVF creation and aims to establish if sonogram testing provides a more accurate measure of the ideal location for the AVF, or if a clinical evaluation alone by the surgeon is sufficient. Surgical techniques are different amongst surgeons and clinical evaluation is more a subjective decision. By limiting the surgeons performing the AVF, a standardized surgical procedure was established. If an ideal AVF access for the patient is created, haemodialysis efficiency is increased and ultimately patient outcome improved. The AVF was created according to the clinical evaluation as is the current process, and the surgeons were not aware of the duplex sonogram results. Failure and success of AVF were analysed according to primary patency and functional success. A primary patency success of the AVF does not guarantee functional success. If an AVF is not able to complete an entire haemodialysis session trouble free at the prescribed dialysis dose, the AVF is considered a failure irrespective of primary patency success. This was evident with 10% of patients who had primary patency but functional success was not achieved. With a 55% functional success in this study with AVF created on clinical evaluation, there was no significance difference (p=0.795) if AVFs were based on duplex sonogram findings. However, there was evidence of increased AVF success in 33% of the failed AVFs when the new AVFs were created at the duplex sonogram site. 95% of patients in this study had commenced haemodialysis with a Central Venous Catheter (CVC). AVF success could be increased if early referral of diabetic patients for permanent access to the surgeon occurred. Maturation rate of AVF differed from KDOQI guidelines with AVF first cannulation only after 17 weeks, and not after the recommended time of 6 weeks. Blood flow rates on dialysis also varied with international standards, with only maximum of 400mls/min reached after one year. With distal arm AVF, diameter of radial artery of less than 2mm and cephalic vein less than 3mm was associated with AVF failure. This research study represents the first of its kind in Kwazulu Natal looking at vascular access sites in diabetic patients with End Stage Renal Disease on haemodialysis.
The impact of dialysis therapy on metabolic syndrome traits at the Groote Schuur Hospital
(2015-03-03) Maree, Marilyn Jacqueline; Adam, Jamila Khatoon
Background The metabolic syndrome (MS) is a clustering of cardiovascular (CV) risk factors and is noted to be increasing globally. Several studies have shown a link between the MS, chronic kidney disease (CKD) and end-stage renal disease (ESRD) possibly through a process of inflammation. Dialysis therapy may increase inflammation and could worsen MS and increase CV risk and diseases in ESRD patients. ESRD has been associated with increased CV disease in dialysis patients. Although there have been several reports on the prevalence of MS from the general population as well as from other specific groups, there are no known studies in South Africa on the prevalence of MS in ESRD patients on chronic dialysis therapy. The prevalence and risk factors for CV diseases are also currently unknown in the dialysis population in Cape Town. Aim The aim of this study was to determine the prevalence of MS in the dialysis population at Groote Schuur Hospital in Cape Town, to determine the effect of dialysis on MS and its traits and to evaluate CV risk in this patient group. Methods A total of 143 prevalent chronic dialysis patients who consented were used for this study. Demographic and relevant clinical details including systolic and diastolic blood pressures, waist and hip circumference and body mass index were obtained from all patients. Blood was drawn in the fasting state for assessment of full lipogram, glucose, ferritin, iron, calcium and phosphate. The metabolic syndrome was defined using the Adult Treatment Panel III (ATPIII) criteria. To determine the impact of dialysis on MS and its traits in our patients, only incident (new) patients starting dialysis were followed up for assessment of MS traits at timed intervals (at baseline, at 6 months and at 12 months) following initiation of chronic dialysis. To evaluate CV risk in this study, common traditional CV risk factors were assessed and were stratified according to number of risk factors as low ( ≤ 1), moderate (2 – 4) or high ( ≥ 4). Relevant statistical methods were used for analysis. Results Of the 143 patients in the study, 67.8% were on haemodialysis (HD) and 32.2% were on peritoneal dialysis (PD). The mean age of all the patients was 38.5 ± 10.4 years. The MS was present in 37.1% of all patients (PD – 52.2%, HD 29.9%; p = 0.015) and the frequency of increased waist circumference and hypertriglyceridaemia were significantly higher in PD patients than HD patients (p < 0.0001 and p = 0.006 respectively). Hypertension was the most prevalent MS trait in all the patients (89.5%) and was also the most prevalent trait in males (92.4%), females (85.9%) and in HD and PD patients (91.3% and 88.7% respectively). The frequency of CV risk was 3.5, 75.5 and 21.0% respectively for low, moderate and high CV risk and there was no difference in CV risk in HD and PD patients. High CV risk correlated with body mass index (BMI), increased waist circumference (WC), hyperphosphataemia, raised calcium – phosphate product, raised parathyroid hormone (PTH) and elevated C-reactive protein (p < 0.05). There was no significant change in MS prevalence or prevalence of MS traits in patients who were followed up irrespective of gender or modality of dialysis (p > 0.05) Conclusion The prevalence of the MS is higher in dialysis patients compared to the general population in South Africa and among dialysis patients, the prevalence is higher in PD than HD patients. Patients with MS have significantly higher CV risk factors than those without MS. Although dialysis therapy appear to have no significant effects on the prevalence of the MS or its traits in this study, the increased prevalence of the MS and CV risk factors may be related to the underlying disease process associated with ESRD. There is therefore an urgent need to identify and treat dialysis patients with the MS in order to reduce CV morbidity and mortality in this group of patients. Further prolonged prospective studies are needed to clarify the impact of dialysis on the MS and its traits in the ESRD population.
Infective endocarditis at Dr George Mukhari Hospital : correlating echocardiography findings with intraoperative findings
(2015-03) Henema, Musawenkosi; Adam, Jamila Khatoon; Mntla, P.S.
Introduction Infective endocarditis is a serious disease that needs rapid diagnosis and accurate risk stratification to offer the best therapeutic strategy. Echocardiography plays a key role in the management of the disease but may be limited in some clinical situations. Moreover, this method is insensitive for very early detection of the infection and assessment of therapeutic response because it does not provide imaging at the molecular and cellular levels. Recently, several novel morphological, molecular and hybrid imaging modalities have been investigated in infective endocarditis and offer new perspectives for better management of the disease. Aims and Objectives of the Study This prospective, quantitative and observational study was investigated at Dr George Mukhari Hospital in Pretoria, South Africa. Infective Endocarditis is a serious disease associated with poor prognosis despite improvements in medical and surgical therapies. Infective Endocarditis results in complex pathogenesis that involves many host-pathogen interactions. Indeed, previous endocardial lesions can lead to the exposure of the underlying extracellular matrix proteins, local inflammation and then thrombus formation, which is termed ‘non-bacterial vegetation’. The project aims to compare the echocardiographic findings (transthoracic echocardiographic-TTE) with intraoperative findings on patients with infective endocarditis. If the correlation existed then the echocardiogram findings were accurate when performed in patients with infective endocarditis. Methodology The research participants consisted of forty (40) patients with infective endocarditis at Dr George Mukhari Hospital in Pretoria, South Africa. A cardiologist examined the patient’s clinically for features of infective endocarditis. Two techniques were used to assess the infective endocarditis. These included echocardiography and Intraoperative findings (visual and histology). Bloods were cultured to demonstrate the presence of micro-organisms. Blood was sent to the laboratory for culture in order to detect the presence of micro-organisms. The researcher performed an Echocardiogram to assess which valve was affected, the left ventricular endiastolic diameter (LVED), the left ventricular ensystolic diameter (LVES), the shortening fraction (SF), the ejection fraction (EF) and the size of the vegetation/mass or abscess. For patients requiring a heart surgery, the cardiac surgeon performed the valve replacement, and the intra-operative findings was assessed visually to confirm the presence of vegetation or abscess and leaflets destruction. During the operation, which was performed by the same cardiac surgeon, a biopsy sample was taken for histological examination to confirm the presence of vegetation or abscess. Thereafter, the cardiac surgeon performed the valve repair/ replacement/ bioprosthesis. The researcher was blinded to the findings in the theatre as the researcher was not present in the theatre. The results from the laboratory was sent to the researcher. The researcher was then able to confirm the presence of vegetation or mass/ abscess and leaf destruction. Results The histology confirmed what was seen on echocardiographical findings and intraoperative findings (visual). The intraoperative and echocardiography findings showed thirty two of 40 (80%) vegetation, two of 40 (5%) perforation, four of 40 (10%) pseudoaneursym and two of 40 (5%) abscesses. The prognosis of patients with poor ejection fraction (40-50% EF) was poorer than those with good ejection fraction (60-75%). The clinical findings of all patients confirmed infective endocarditis and thirty two of 40 (80%) blood cultures were positive and eight of 40 (20%) were negative. There were seven of 40 (17,5%) patients who showed poor correlation 40- 50% between echocardiographical findings and post-operative findings. The results of thirty three of 40 (82%) patients showed moderate correlation 69% between the echocardiographical findings and post-operative findings. Conclusion My findings of the study was that eight of 40 (20%) had stenosis and thirty two of 40 (80%) had regurgitation in patients who had infective endocarditis. There was an overall moderate association (r=0.68) between echocardiography and the intraoperative findings in all patients for LVES.
An investigation of the rate of change of CD4 and CD8 T lymphocyte counts and viral loads in HIV infected patients on immune boosters
(2007) Mkhize, Brenda Thabisile; Madurai, S.; Adam, Jamila Khatoon
In 2004, it was reported that KwaZulu-Natal had the greatest number of HIV infected people, approximately 1.8 million people, of whom an estimated 450 000 were in need of antiretroviral drug therapy based on their Cluster of Differentiation 4 (CD4) counts and clinical status. Studies on the success of antiretroviral drugs in improving the quality of life in HIV infected individuals have been extensively performed and published. However, there are no published data on the effect that immune boosters have in improving the quality of life in such persons. Considering the side effects, toxicity, multi-drug regimens and drug resistance problems associated with antiretroviral therapy, alternative or supplementary therapies may play an important role in improving the quality of life in HIV infected people. Such therapy might help in situations where some patients who qualify for antiretroviral treatment are unable to access them because of several reasons such as long waiting lists, travelling costs, unwilling to take antiretroviral drugs, etc. Some patients have reservations in taking antiretroviral drugs. The stigma associated with the disease may be a major factor. The aim of this study was to investigate the change in the immune status of HIV infected patients that were on the Inochi New Medicine immune booster, as well as, to assess the safety and efficacy of this immune booster in improving the patients’ quality of life.
The occurrence of effusive constrictive pericarditis (ECP) of tuberculosis origin in a cohort of patients with large effusions
(2014-07-23) Motete, Agnes Lerato; Adam, Jamila Khatoon; Ntshekhe, M.
Introduction : Effusive constrictive pericarditis (ECP) is a clinical syndrome characterized by concurrent pericardial effusion and pericardial constriction where constrictive haemodynamics are persistent after the pericardial effusion is removed. Although first observed in the 1960s, it was not until the publication of a 13 patient-case series by Hancock in 1971, and the prospective cohort publication by Sagrista-Sauleda in 2004, that more information about the aetiology, incidence, and prognosis of effusive-constrictive pericarditis became known (Sagrista-Sauleda, Angel, Sanchez, Permanyer-Miralda, and Soler-Soler 2004). Hancock (1971) first recognized that some patients presenting with cardiac tamponade did not have resolution of their elevated right atrial pressure after removal of the pericardial fluid. In these patients, pericardiocentesis converted the haemodynamics from those typical of tamponade to those of constriction. Thus, the restriction of cardiac filling was not only due to the pericardial effusion but also resulted from pericardial constriction (predominantly the visceral pericardium). The hallmark of effusive-constrictive pericarditis is the persistence of elevated right atrial pressures after the intrapericardial pressure has been reduced to normal levels by the removal of the pericardial fluid. Aims and Objectives : This study was carried out to determine the prevalence of ECP in a cohort of patients with large effusions of Tuberculosis origin. The primary objective was to measure pre and post- pericardiocentesis intrapericardial and right atrial cardiac pressures in all patients undergoing pericardiocentesis in order to determine the relative proportion of effusive constrictive pericarditis in these patients. The secondary objective was to determine if any echocardiographic features can help predict the presence of ECP by studying the three parameters two-week post-pericardiocentesis. Methodology : Fifty consecutive patients with pericarditis presenting to Groote Schuur Hospital and surrounding hospitals referred for pericardiocentesis, who met the inclusion criteria were recruited to participate in the study. All patients had the right atrial and intrapericardial pressures simultaneously measured and recorded, before and after pericardiocentesis. The pressures were analyzed to determine the presence of ECP, which was defined as failure of the right atrial pressure to fall by 50% or to a new level of ≤12 mmHg after the intrapericardial pressure is lowered to below 2 mmHg. Participants also had an echocardiogram done two weeks post pericardiocentesis. Three echocardiographic features of constriction were studied, to determine if they can predict the presence of ECP. The parameters studied were 1) Thickened pericardium, 2) Dilated inferior vena cava (IVC) and 3) Septal bounce. Results : This study showed a 34% (17 0f 50) prevalence of ECP in patients with TB pericarditis. It also showed a statistically difference in the right atrial and intrapericardial pressures pre and post pericardiocentesis, between patients with ECP and those without. The echocardiographic parameters studied showed no difference between ECP and non ECP, and also did not predict the presence of ECP. Discussion : In the cohort of patients (n=50), the prevalence of ECP was found to be 34%. This is much higher than that observed in the Sagrista-Sauleda et al., (2004) study. They found a prevalence of 1.3% amongst patients with pericardial disease of any type and 6.95% amongst patients with clinical tamponade. The authors did state that they expected the true prevalence to be higher than estimated as not all patients underwent catheterization. Pre-pericardiocentesis pressures, both right atrial and intrapericardial, were found to be higher in patients with ECP than in those without. This is in keeping with published results, such as the study of Hancock (1971) The echocardiographic parameters studied were two weeks post pericardiocentesis, because the diagnostic accuracy of echocardiogram has been shown to be very poor at the time of tamponade. The presence of these parameters (thickened pericardium, dilated IVC and septal bounce), did not predict the presence of ECP. This could be due to the fact that less than 50% of participants had an echocardiogram two weeks post pericardiocentesis. Conclusions : The results of this study show that ECP is actually more common than thought in a population with TB pericarditis. This syndrome may be missed in most patients due to the fact that not all centres measure right atrial and intrapericardial pressures at the time of pericardiocentesis. Echocardiography is not able to predict the presence of ECP. Other non-invasive imaging techniques such is computerized tomography (CT) and cardiac magnetic resonance imaging (CMRI) have shown good results in diagnoses of ECP. The importance of early diagnosis of ECP lies in recognition that removal of pericardial fluid alone may not be enough; patients may need to have surgery. Given the high prevalence shown by the study, ideally all patients with pericardial effusion should have haemodynamic monitoring at the time of pericardiocentesis.
Pain management of patients with chronic renal failure :|ba case study of patients in a private renal facility
(2018) Govender, Shamanie; Adam, Jamila Khatoon; Khan, A. A.
Introduction At least 82% of patients with chronic kidney disease (CKD) report pain of moderate to severe intensity (Davison, 2006: 1). Despite this high prevalence, a growing body of literature has shown that pain in the CKD population is under-recognised and ineffectively treated (Weisbord, 2016; Harris et al., 2012; Davison, 2007). There are multidimensional causes of pain, for example, from the kidney disease itself, the dialysis procedures or diabetic neuropathy (Curtin et al., 2002: 569). Pain has consistently shown to negatively impact health-related quality of life (Koncicki et al., 2015; Barakzoy and Moss, 2006). Pain also causes other symptoms, such as, depression, cramps, aching bones and headaches and pain is associated with sleep disturbances and may adversely affect dialysis treatment such as non-compliant behaviour. (Brkovic et al., 2016; Davison, et al., 2014; Danquah, 2009). Pain management is highly complex in patients with CKD because there is a very narrow margin between pain relief and toxicity. Opioids can accumulate in the body and cause adverse effects, such as, respiratory distress, sedation and myoclonus (Davison, 2003; Kurella et al., 2003). In the last decade research has demonstrated that the implementation of the World Health Organisation (WHO) three-step analgesic ladder significantly reduces pain in CKD patients (Barakzoy and Moss, 2006; Davison, 2005; Kurella et al., 2003). Non- pharmacological strategies to relieve pain symptoms such as psychological and cognitive behavioural therapy, for example, relaxation techniques, and spiritual counselling should also be recommended and supported by the renal professional team (Santoro et al., 2013; Davison, 2005). Nephrologists and dialysis nursing staff are often inadequately prepared to recognize and treat pain, primarily due to the fact that pain management is not part of the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines (Patel, 2013:270). With the increase in the number of patients with CKD, it is increasingly relevant that measures should be implemented to identify, assess and provide appropriate analgesia and / or non-pharmacological therapies to reduce pain and bring comfort to patients experiencing debilitating types of pain. Aims and objectives of the study The overall aims and objectives of this study was to investigate the types, frequency and severity of pain experienced by patients with chronic kidney disease and to suggest strategies that patients and staff could use to manage the patients’ pain that was experienced. Methodology A total of 60 patients and 22 renal staff participated in the study. Questionnaires were administered to staff and patients at the Durban Kidney and Dialysis Centre. Inclusion and exclusion criteria were applied to the participants. Medical records of the patients were analysed. Minutes of staff meetings and the protocols of the Centre were scrutinised in terms of pain management strategies. The study was conducted between September 2017 and March 2018. Relevant statistical methods were used for analysis. Results Patients were on average 57 years of age and all were on haemodialysis. Results for this study show that 98.3% of patients reported pain symptoms during dialysis and for 72.3% of the patients, the pain experienced was moderate to severe indicating that pain is a major symptom burden in this patient population. The most frequently reported symptoms were lower back pain (80%), lower leg pain (51,7%) and upper chest pain (46,7%%). Pain was frequently experienced by patients following the dialysis session (78,35%). Between 53, 3% and 65% of patients reported that pain affected them mostly, for example, when climbing stairs or walking. Patients in this study had substantial co-morbid diseases with 26,7% reporting hypertension, diabetes and cardiac stent. Thus, the causes of pain are multi- factorial and make management thereof challenging. There was a significant association with pain and older age, long years of being on dialysis and the period at the end of the haemodialysis (HD) treatment session itself (p< 0.0 5). Patients (72,7%) shortened their time on dialysis because of severe pain experienced. Thus, this study shows that there is significant relation between compliance and pain. In this study, pain was not related to gender or race. Depression was experienced by a large percentage (85%) of patients in this study. The severity of pain experienced caused 66,6% of the patients to be hospitalised and 86,6% stated that pain affected their ability to have a restful sleep. When this is seen in conjunction with the fact that 78% of patients responded that their pain impacted on their ability to work, one can see the distinct link that pain adversely impacts their functional status. The pain medication that was primarily used by patients was Panado (53%) and nearly 60% of the patients reported using alternative means of pain relief such as a physiotherapist. Non- steroidal anti-inflammatory drugs (NSAIDs) use appears to be high and there is a low use of opioids. In addition, there was no indication that adjuvants were prescribed or used. Thus, the patterns of pain medication recommended and / or taken by the patients in this study show a simple, generalised pharmacological approach rather than a targeted therapeutic intervention specifically tailored to the type of pain experienced by the patient; an approach which has also been reported by Davison et al., (2014). Several international studies have shown that analgesic use is not high in CKD patients despite the high prevalence of pain (Murtagh et al., 2007; Dean, 2004; Kurella et al., 2003). Interesting to note that 90,9% of staff reported that Lyrica was recommended for muscle pain, joint pain and numbness but patients reported high usage of only Panado (53%). This could possibly indicate under-education of patients with regard to analgesics; under-recognition of the type of pain or lack of follow-up by staff. High cost of medication for the patients (68%) and unawareness of pain management strategies (72%) are also barriers to use of analgesics. It is evident that all patients in this study do not do any form of exercise. It would, therefore, be important for these patients to be referred to a physiotherapist or bio-kinesthesis so that they receive appropriate physical training to help alleviate their pain symptoms. The renal staff in the Centre are highly qualified to perform their duties. However, they did not offer analgesics for pain relief at the end of the dialysis session when many patients complained of pain and terminated their session early (72,7%). 100% of the staff ensured that patients were comfortable rather than offer analgesics to relieve pain (54,5%) during or after dialysis. However, there were no pain assessment instruments for staff to clinically assess types, frequency and severity of pain that was experienced by the patients. There was a lack of guidelines to assist staff to make decisions about analgesic use. Conclusion It is evident from the results of this study that pain management was neither done in a strategic manner nor was it tailored to the patient’s specific needs. For staff, there were no formal, clinical pain management assessment instruments or follow-up regarding adherence to the recommendations for pain analgesics. The patients (72%) revealed that they did not have in-depth knowledge of pain management treatments and associated with the fact that many did not comply with the full duration of the dialysis session, indicating that focused attempts must be made to instil patient education about pain management therapies in this vulnerable group. Both patients and staff would benefit from awareness about different types of pain management therapies, (both pharmacological and non-pharmacological) and the long term impact if pain continues to be under-diagnosed and under-treated. The development of guidelines by the Centre to assist the staff to make decisions about analgesic use for the patients is essential. The specialist nephrologists should investigate and implement a combination of analgesics tailored to the needs of the patient. Future decisions can be based on the WHO three-step ladder on analgesic use. The patients would benefit from appropriate interventions to manage their pain.