Browsing by Author "Raubenheimer, Peter"

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    Delirium amongst HIV-infected general medical admissions in Cape Town, South Africa
    (2021) Day, Cascia; Peter, Jonathan; Raubenheimer, Peter
    Background Delirium is associated with increased mortality and hospital length of stay. Limited data are available from HIV-infected acute hospital admissions in developing countries. We conducted a prospective study of delirium amongst acute medical admissions in South Africa - a developing country with universal ART access and high burdens of TB and noncommunicable disease. Methods Three cohorts of adult acute medical admissions to Groote Schuur and Victoria Hospitals, Cape Town, South Africa were evaluated for prevalent delirium within 24 hours of admission. Reference delirium testing was performed by either consultant physicians or neuropsychologists, using the Confusion Assessment Method (CAM). Findings The study included 1182 acute medical admissions; with 318 (26·9%) HIV-infected Median(IQR) age and CD4 count was 35(30-43) years and 132(61-256) cells/mm3 respectively, with 140/318(44%) using ART on admission. Delirium prevalence was 17·6%(95% CI 13·7-22·1%) amongst HIV-infected patients and was an independent risk factor for inpatient mortality. In multivariable logistic regression, factors associated with delirium were age ≥55 years(AOR 6·95[2·03-23·67], p=0·002) and urea ≥15(AOR 4·83[1·7- 13·44], p=0·003), while ART use reduced risk (p=0·014). Low CD4 count, unsuppressed viral load, and active TB were not predictors of delirium; nor were other traditional risk factors such as non-opportunistic, acute infections or polypharmacy. Interpretation Delirium is common and predicts poor outcome in HIV-infected acute medical admissions in endemic settings despite increased ART use. Older HIV-infected patients with renal dysfunction are at high risk for inpatient delirium while those using ART on admission are protected.
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    Evaluation of adherence to an evidence-based bundle of care for the treatment of staphylococcus aureus bacteraemia at Groote Schuur Hospital
    (2022) Gatley, Elizabeth M; Raubenheimer, Peter
    Background Staphylococcus aureus bacteraemia (SAB) is associated with high hospital mortality. Improvements in outcome have been described with standardised bundles of care. Objectives To study adherence to a standardised bundle of care (BOC) recommendations using a consultation proforma, for all patients admitted with SAB to Groote Schuur hospital over a year. To describe in-hospital and 90-day mortality in these patients Methods A retrospective audit of all unsolicited infectious disease consultations for patients with SAB admitted to Groote Schuur hospital during 2018. Adherence to recommendations of a standard care bundle were audited. Results Eighty six patients were included; 61 (71%) with healthcare-associated infection and 25 (29%) with community associated infection. Over 80% of adherence to treatment recommendations was achieved regarding antibiotic (including vancomycin) usage, source control and use of echocardiography as required. In-hospital mortality was 16% while overall 90-day mortality was 18%, with only age an independent predictor of mortality. No association with adherence to the recommendations and outcome was seen. Conclusion Adherence to a simple BOC is good, when using standardised a proforma as a communication tool. SAB mortality may be reduced by such an approach.
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    One year mortality after hospital admission as an indicator of palliative care need in the Western Cape, South Africa: an incident cohort study
    (2020) Frankenfeld, Petronella; Raubenheimer, Peter
    Background: Globally there is an increasing awareness of the need for end-of-life care and palliative care in hospitalized patients that are in their final year of life. However, limited data are available in low and middle income countries which hinders the design and implementation of effective policies and health services for this patient group. Aim: To determine the proportion of patients who die within one year from their date of admission to hospital in public hospitals in South Africa. Design: Retrospective incident cohort study using record linkage of admission and mortality data. Setting: 46 acute care public hospitals in the Western Cape Province of South Africa. Results: Of the 10 761 patients (median age 44 years; IQR: 31 - 60) admitted to 46 hospitals over a 2 week period in March 2012, 1570 (14.6%) died within one year, the majority of the deaths occurring within the first 3 months. Mortality rose steeply with age as expected. The median age of death was 57.5 years; IQR: 45 - 70. A greater proportion of patients admitted to medical beds died in one year (21.3%) as compared with surgical beds (7.7%). Conclusion: Despite a median age under 60 years at admission, a large percentage of patients admitted to public sector hospitals in South Africa, an upper-middle income country with a high HIV and non-communicable disease burden, are in the final year of their lives. This finding highlights the need for planning and implementation of end-of-life and palliative care strategies for hospitals and patients.
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    Overt hypoadrenalism is uncommon in patients with stage 3 and 4 bronchogenic carcinoma
    (Health & Medical Publishing Group, 2003) Ross, Ian L; Marais, Suzaan; Raubenheimer, Peter; Abratt, Raymond; Isaacs, Sedick; Soule, Steven
    Introduction. Lung cancer is the leading cause of cancer mortality in most countries. The adrenal glands are common sites of metastatic lung cancer as approximately 40% of subjects with stage 4 bronchogenic carcinoma have adrenal metastases. The prevalence of biochemical hypoadrenalism is, however, remarkably poorly documented. Objectives. Our study aimed to determine the prevalence of primary hypoadrenalism, as defined by a subnormal cortisol response to the 250 µg adrenocorticotrophic hormone (ACTH) stimulation test, in patients with stage 3 and 4 lung cancer. Methods. Thirty patients with stage 3 and 4 bronchogenic carcinoma were prospectively recruited from the bronchus clinic. Demographic data and electrolytes were recorded and each patient had a 250 µg ACTH stimulation test to determine the prevalence of overt adrenal insufficiency, defined as a +30 minute cortisol of less than 550 nmol/l. Results. The median age and quartile deviation was 62 (10) years and the median basal cortisol was 429.5 (321) nmol/l. The median peak cortisol was 828.5 (342) nmol/l (range 536 - 1 675 nmol/l). Twenty-eight patients (93.3%) had an appropriate rise of cortisol to greater than 550 nmol/l following 250 µg ACTH stimulation. Two patients (6.7%) had mild primary adrenal failure with a peak cortisol between 500 and 550 nmol/l associated with a raised plasma ACTH concentration (131.4 and 10.5 pmol/l, normal 2.2 - 10 pmol/l). Twenty-eight patients (92.9%) were normonatraemic, while the two hyponatraemic patients had biochemical evidence of the syndrome of inappropriate antidiuretic hormone secretion. Conclusion. In conclusion, despite evidence that the adrenal glands of patients with disseminated bronchogenic carcinoma are frequently affected by metastatic disease, biochemical evidence of clinically significant hypoadrenalism is relatively uncommon and is not accurately predicted by electrolyte abnormalities.
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    Prevalence and outcome of delirium amongst acute general medical inpatients in Cape Town, South Africa
    (2019) Du Plooy, Daniël Francois; Raubenheimer, Peter; Peter, Jonathan
    Objectives Delirium is a common, serious, underdiagnosed condition in acute medical and surgical inpatients. It is associated with increased risk of mortality and morbidity. Data are largely limited to developed countries in geriatric cohorts. Here we describe prevalence, risk factors and outcomes of delirium amongst general medical patients admitted to two hospitals in Cape Town, South Africa. Design and Setting Prospective cohort study of patients admitted acutely to a general medical inpatient service, in a secondary and tertiary-level public hospital serving the Metro West area of Cape Town, South Africa. Participants Patients ≥ 18 years old were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or had Glasgow Coma Scale < 12/15. In total, 808 patients were included. Main outcome measures Delirium was diagnosed using the validated confusion assessment method (CAM) tool performed by trained neuropsychologists. Demographic data was collected by a clinical team and short and long-term mortality data were obtained using linkage analysis of hospitalised patients to routinely collected provincial death certification records. Results: The median age of inpatients was 51 (36-65) years. Twenty nine percent were proven HIV-infected. The overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included: the presence of an indwelling urinary catheter (OR 4.37, CI 2.36-8.03), admission with a central nervous system disease (OR 4.37, CI 2.39-7.98), pre-existing cognitive impairment (OR 2.72, CI 1.11-6.64) and admission with a terminal disease (OR 3.11, CI 1.09-8.89). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk for in-hospital (delirium vs. no delirium: 29% vs 12%; p<0.01) and 12-month mortality (30% vs 20%; p < 0.01), as well as increased length of hospital stay (7 days vs 5 days, p < 0 .01). Conclusion: In this cohort of medical in-patients (with a relative young age and high HIV prevalence,) one in eight (12.3%) are delirious.. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort are similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.