Browsing by Author "Malan, Jacques"

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    Open Access
    A cross-sectional study of ECG patterns and outcomes of patients thrombolysed for ST-elevation myocardial infarction at a district, public Cape Town hospital
    (2018) Kibamba, Crispin Ngoy; Malan, Jacques; Bruijns, Stevan
    Introduction There is insufficient data to describe ST-elevation myocardial infarction (STEMI) in sub-Saharan African settings using common diagnostic criteria. This study describes the outcomes at discharge (survival, death or transferred) of patients thrombolysed for STEMI at a public hospital without primary percutaneous coronary intervention capability as well as associated ECG changes. Materials and methods A retrospective, cross- sectional study was conducted at an urban, public emergency centre in Cape Town, South Africa that did not have direct access to percutaneous coronary intervention for STEMI. Descriptive statistics for age, length of stay and the various timings surrounding thrombolysis were presented using proportions, mean and standard deviation. Assumptions were tested using the X2 - test or Fishers Exact test. A p-value less than 0.05 was considered significant. Results The study enrolled 104 patients of which 25 were excluded for insufficient data and two for thrombolysis of an incorrect STEMI diagnosis. Of the remaining patients, 56 (64%) survived to discharge, 26 (30%) required transfer and five (6%) died. There was no difference between regions affected and patient outcome (p=0.31). Resolution of ST-segments was seen in 48 (86%) survivors. It was not seen in 21 (81%) who were transferred and in none that died. The difference between resolution of ST-segments between survivors versus those transferred or dead was highly significant (p< 0.001). Conclusion This study described a higher than expected thrombolysis failure rate as well as a higher than expected association of poor outcome with inferior STEMI. It highlights the need for improved health care records to improve health research in low-resourced settings. The creation of a STEMI registry could contribute to research but will need funding. The use of clinical messaging apps to gain senior ECG interpretation may provide an additional layer toward quality care.
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    Open Access
    A descriptive study of the use of troponin I testing at a Cape Town district hospital
    (2018) Gibson, Joshua Glynn; Malan, Jacques; Bruijns, Stevan
    Introduction: Troponin I tests have been shown to be accurate and are relied upon to assist in making critical decisions regarding patient care in patients presenting with chest pain. The tests are expensive, however, and so their rational use becomes extremely important in a budget-constrained public health sector. The aim of this study was to describe how Troponin I tests are used throughout Victoria Hospital, by a range of requesting clinicians, working in different specialties. Methods A cross-sectional, prospective design was employed, using multiple data sources. We collected a consecutive sample over a three-month period from Victoria hospital’s Emergency Centre using a dedicated data collection tool connected to use of the point-of-care troponin I test. We supplemented this prospective sample with outcome data, using the hospital’s electronic admission record. Results Three hundred and sixteen patient entries were included in the final results. The majority of Troponin tests were negative (70%). Discharge directly from Emergency Centre was 10% in Troponin I positive patients, 37,5% in Equivocal Troponin patients, and 65% in Troponin negative patients. Furthermore, patients were twice as likely to be transferred to a tertiary facility if their Troponin was positive (24%), compared to equivocal (10.4%) or negative (12%). Discussion Chest pain was the most common presenting complaint, with Acute Coronary Syndrome being the most common working diagnosis. The clinical management of patients varied considerably when comparing their Troponin I result. Troponin I appears to be used as an effective rule-out tool in the decision-making pathway.
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    Open Access
    Blood cultures taken from patients attending emergency departments in South Africa are an important antibiotic stewardship tool, which directly influences patient management
    (2015-10-06) Boyles, Tom H; Davis, Kelly; Crede, Thomas; Malan, Jacques; Mendelson, Marc; Lesosky, Maia
    Abstract Background Febrile illness with suspected blood stream infection (BSI) is a common reason for admission to hospital in Africa and blood cultures are therefore an important investigation. Data on the prevalence and causes of community acquired BSI in Africa are scarce and there are no studies from South Africa. There are no validated clinical prediction rules for use of blood cultures in Africa. Methods A prospective observational cohort study of patients attending 2 urban emergency departments in Cape Town, South Africa. The decision to take a blood culture was made by the attending clinician and information available at the time of blood draw was collected. Bottles were weighed to measure volume of blood inoculated. Results 500 blood culture sets were obtained from 489 patients. 39 (7.8 %) were positive for pathogens and 13 (2.6 %) for contaminants. Significant independent predictors of positive cultures were diastolic blood pressure <60 mmHg, pulse >120 bpm, diabetes and a suspected biliary source of infection, but not HIV infection. Positive results influenced patient management in 36 of 38 (95 %) cases with the organism being resistant to the chosen empiric antibiotic in 9 of 38 (24 %). Taking <8 ml of blood was predictive of a negative culture. The best clinical prediction rule had a negative predictive value (NPV) of 92 % which is unlikely to be high enough to be clinically useful. Discussion Blood cultures taken from patients attending emergency departments in a high HIV prevalent city in South Africa are frequently positive and almost always influence patient management. At least 8 ml of blood should be inoculated into each bottle. Conclusion Blood cultures should be taken from all patients attending EDs in South Africa suspected of having BSI particularly if diabetic, with hypotension, tachycardia or if biliary sepsis is suspected.