Browsing by Author "Vallabh, Kamil"

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    Clinical presentation and diagnostic work up of suspected pulmonary embolism in a district hospital emergency centre serving a high HIV/TB burden population
    (2018) Bulajic, Bojana; Welzel, Tyson; Vallabh, Kamil
    Introduction: The diagnosis of Pulmonary Embolism (PE) is challenging to make and is often missed in the Emergency Centre. The true incidence of PE in South Africa is unknown. The diagnostic work-up of PE has been improved by the use of Clinical decision rules (CDRs) and CT Pulmonary Angiography (CTPA) in high-income countries. Currently used CDRs have not been validated in the South African environment, where HIV and TB are highly prevalent. Both conditions are known to induce a hyper-coagulable state. Methods: This study was a retrospective chart review of patients with suspected PE that had CTPAs performed from October 2013 to October 2015 at Mitchell’s Plain Hospital in South Africa. Data was collected on demographics, presenting symptoms and signs, vitals, bedside investigations, HIV and TB status, use of CDRs and CTPA result. A Revised Geneva Score was calculated retrospectively and compared to the CTPA result. Results: The median age of patients with confirmed PE was 45 years and 68% were female. The CTPA yield for PE in our study population was 32%. The most common presenting complaint was dyspnoea (83%), followed by cough and chest pain. 29% of patients also had clinical features of DVT. No sign or symptom was seen to be markedly different in those with confirmed PE compared to those without. Among patients with confirmed PE, 37% were HIV positive and 52% had current TB. The retrospective revised Geneva Scores compared poorly with the CTPA results. Discussion: PE remains a diagnostic challenge. Worldwide, the use of CDRs has shown to improve the utilization of CTPA. In our study, the retrospectively calculated CDR was not predictive of PE in a population with a high prevalence of HIV and TB. Emergency physicians should be cautious when making a clinical probability assessment of PE in this setting. However, further studies are needed to determine whether HIV and TB could be independent risk factors for PE.
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    Computed tomography (CT) head studies in a district emergency department: a focused study of CT related imaging and analysis of current practice
    (2022) Lesar, Ursula; Hendrikse, Clint; Vallabh, Kamil
    Introduction: The South African population has a significant emergency burden of disease. In South Africa, immediate access to computed tomography (CT) imaging may not always be available. Globally, the number of all imaging studies is increasing annually. Due to access challenges patients requiring CT head imaging needs to be carefully selected to ensure safe management and discharge. Patient demographics, clinical presentation and type of expected emergency pathology known about this population will assist the emergency physician in making appropriate management decisions. Methodology: This study was conducted in two parts: a literature review and a retrospective, descriptive analysis conducted at Mitchells Plain Hospital, Cape Town, exploring the type and prevalence of pathology identified by CT head imaging in the emergency department. Data for the descriptive study was collected over a one-year period and the demographics, indications and reported pathology were described for all CT head requests in the emergency department. Statistically significant differences between groups were calculated using the Chi-squared test, depending on the sample characteristics. Statistical significance was defined as p-value <0.05. Results: There was a male predominance (57%) in this study with the most common comorbidity being hypertension. The cumulative yield of pathology was identified at 58% on imaging (new pathology 40% and existing pathology 18%). Stroke (32%), trauma (30%) and seizures (16%) were the most common indications for imaging with a yield per indication of 54%, 48% and 20% respectively. The most common imaging finding across all categories was an ischaemic stroke. Stroke indicated CT head imaging pathology demonstrated ischaemic (19%) to haemorrhagic (3%) stroke pathology. The most common finding on a trauma indicated CT head was an ischaemic stroke (13%). Seizure indicated CT head imaging demonstrated 18% with new pathology and 36%that had existing pathology. Emergency imaging was performed on average under seven hours post consultation. Conclusion: Acquiring CT head imaging in a resource limited setting requires appropriate clinical history, examination as well as awareness of the most prevalent pathology of the community the doctor is treating. Even though yield of pathology was considered high when compared to HIC there was similarity in yield to local and international LMICs. Stroke, trauma and seizures are common indications for imaging in the South African setting with the most common pathology identified to be an ischaemic stroke.
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    The prevalence of atrial fibrillation in patients with ischaemic stroke in a district hospital in the Western Cape
    (2019) Mayet, Mohammed; Hendrikse, Clint; Vallabh, Kamil
    Background Cerebrovascular disease remains one of the leading causes of morbidity and mortality globally. In South Africa, cerebrovascular disease was the fourth leading cause of death in 2016, responsible for 5.1 % of all deaths - the leading cause of death in individuals 65 years and older. Atrial fibrillation accounts for 15% of all strokes and a 25% of patients with AF-related stroke have this arrhythmia diagnosed at the time of the stroke. Objectives This study sets out to determine the prevalence of atrial fibrillation in patients with ischaemic stroke, as confirmed on CT scan, at a district level hospital in the Western Cape, South Africa. Methods This descriptive study was conducted at Mitchell’s Plain Hospital in Cape Town and data was collected over a year. Patients diagnosed with a stroke were identified from an electronic patient register and relevant radiology and clinical data was sourced retrospectively. The diagnosis of ischaemic stroke was confirmed by a CT scan report and ECGs were independently screened by two Emergency Physicians. Categorical data was described in percentages and descriptive statistics. Continuous variables were described by median and interquartile range (IQR). Statistical significance is defined as a p< 0.05. Categorical data was compared using the Fisher’s exact test. This project has been approved by UCT Human Research Ethics Committee [790/2018]. Results The proportion of adult patients with a diagnosis of stroke was 2%. Of those, 64% had ischaemic strokes, 9% had intracranial bleeds, 20% did not have a CT scan and 7% had stroke mimics. 11% of all participants with ischaemic stroke had atrial fibrillation, 67% of those presumed new. A total of 90 (22%) of all participants with ischaemic stroke was less than 51 years of age. The mortality rate was statistically higher in patients who had AF. Conclusion The results from this study suggests that screening practices to detect both Atrial Fibrillation in asymptomatic patients, as well as in those with an ischaemic stroke, are not effective. With the increasing population life expectancy, and prevalence of cardiovascular disease, the prevalence of AF and its complications will increase. Since the risk of stroke related to AF can be reduced significantly by oral anticoagulation, further studies should aim to explore barriers and challenges to effective screening.