Browsing by Subject "Hospital"

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    Caregiver experiences of public services following child trauma exposure: a qualitative study
    (BioMed Central, 2018-04-10) Williamson, Victoria; Halligan, Sarah L; Coetzee, Bronwyne; Butler, Ian; Tomlinson, Mark; Skeen, Sarah; Stewart, Jackie
    Background: Many children in low and middle income countries (LMIC) are exposed to trauma. Contact with public services are a potential infuence on parent–child reactions and coping post-trauma. Little is known about how caregivers perceive these interactions. Methods: The aim of this study was to explore caregivers’ experiences of accessing and interacting with public services post-trauma and perceptions of needed improvements to public services in a LMIC context. Qualitative interviews were conducted with 20 female caregivers from a high-risk settlement in South Africa after child trauma exposure. Results: Three themes and seven sub-themes were identifed regarding caregivers’ perceptions of interactions with public services post-trauma. The key themes identifed related to (1) communication and exchanges with law enforcement, (2) consequences of an under-resourced justice system and (3) importance of communication and empathy in the healthcare system. Interactions with police were often positive. However, caregivers explained that police-family communication post-trauma could be improved and may help to lessen caregiver anxiety and concerns for the child’s safety post-trauma. Caregivers perceived the judicial system to be under-resourced as contact with the judicial system was often protracted and caused child anxiety and distress. Medical treatment was reportedly rushed, with extensive waiting times and little information provided to caregivers regarding the child’s injuries or treatment. Some medical staf were perceived as unsympathetic during the child’s treatment which was found to exacerbate caregiver and child distress post-trauma. Conclusions: This study provides insight into caregiver experiences of accessing public services following child trauma exposure in a high-risk LMIC context. Public services were perceived as oversubscribed and under-resourced and negative interactions often infuenced caregiver responses and appraisals of child safety. Given the impact of poor interactions with public services on families post-trauma, additional research is needed to investigate feasible improvements to public services in LMIC.
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    Open Access
    Diagnostic accuracy, incremental yield and prognostic value of Determine TB-LAM for routine diagnostic testing for tuberculosis in HIV-infected patients requiring acute hospital admission in South Africa: a prospective cohort
    (2017) Lawn, Stephen D; Kerkhoff, Andrew D; Burton, Rosie; Schutz, Charlotte; Boulle, Andrew; Vogt, Monica; Gupta-Wright, Ankur; Nicol, Mark P; Meintjes, Graeme
    Abstract Background We previously reported that one-third of HIV-positive adults requiring medical admission to a South African district hospital had laboratory-confirmed tuberculosis (TB) and that almost two-thirds of cases could be rapidly diagnosed using Xpert MTB/RIF-testing of concentrated urine samples obtained on the first day of admission. Implementation of urine-based, routine, point-of-care TB screening is an attractive intervention that might be facilitated by use of a simple, low-cost diagnostic tool, such as the Determine TB-LAM lateral-flow rapid test for HIV-associated TB. Methods Sputum, urine and blood samples were systematically obtained from unselected HIV-positive adults within 24 hours of admission to a South African township hospital. Additional clinical samples were obtained during hospitalization as clinically indicated. TB was defined by the detection of Mycobacterium tuberculosis in any sample using Xpert MTB/RIF or liquid culture. The diagnostic yield, accuracy and prognostic value of urine-lipoarabinomannan (LAM) testing were determined, but urine-LAM results did not inform treatment decisions. Results Consecutive HIV-positive adult acute medical admissions not already receiving TB treatment (n = 427) were enrolled regardless of clinical presentation or symptoms. TB was diagnosed in 139 patients (TB prevalence 32.6%; median CD4 count 80 cells/μL). In the first 24 hours of admission, sputum (spot and/or induced) samples were obtained from 37.0% of patients and urine samples from 99.5% of patients (P < 0.001). The diagnostic yields from these specimens were 19.4% (n = 27/139) for sputum-microscopy, 26.6% (n = 37/139) for sputum-Xpert, 38.1% (n = 53/139) for urine-LAM and 52.5% (n = 73/139) for sputum-Xpert/urine-LAM combined (P < 0.01). Corresponding yields among patients with CD4 counts <100 cells/μL were 18.9%, 24.3%, 55.4% and 63.5%, respectively (P < 0.01). The diagnostic yield of urine-LAM was unrelated to respiratory symptoms, and LAM assay specificity (using a grade-2 cut-off) was 98.9% (274/277; 95% confidence interval [CI] 96.9–99.8). Among TB cases, positive urine-LAM status was strongly associated with mortality at 90 days (adjusted hazard ratio 4.20; 95% CI 1.50–11.75). Conclusions Routine testing for TB in newly admitted HIV-positive adults using Determine TB-LAM to test urine provides major incremental diagnostic yield with very high specificity when used in combination with sputum testing and has important utility among those without respiratory TB symptoms and/or unable to produce sputum. The assay also rapidly identifies individuals with a poor prognosis.
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    Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital
    (2010) Decloedt, Eric; Leisegang, Rory; Blockman, Marc; Cohen, Karen
    BACKGROUND: Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers. METHODS: We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) < or = 50 ml per minute per 1.73 m2, were identified. In-patient prescriptions were captured if they were written after clinical notes indicated impaired renal function, or > or = 1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted. RESULTS: We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted. CONCLUSION: Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment.
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    Informed consent for peripheral nerve blocks at a tertiary level hospital in South Africa: a quality improvement project
    (2025) Burger, Roxanne; Gibbs, Matthew; Plenge, Ulla
    Background: In South Africa, the doctrine of informed consent (introduced by the South African courts, Cape Provincial Division) dictates that all reasonable patients be told of material risks and alternative options before consenting to medical treatment or procedural interventions. The reasonable patient standard requires that a patient be told of all material risks that would influence a reasonable person in determining whether or not to consent to the treatment. Regional anaesthesia, including peripheral nerve blocks (PNBs), provides a plethora of benefits to patients undergoing surgery but, due to potential risks involved, also requires informed consent. Studies have shown that South African anaesthetists do not regularly obtain adequate informed consent for these procedures. We implemented a quality improvement project to facilitate and enhance documented informed consent in our setting. Methods: A prospective quality improvement project was established at Groote Schuur Hospital, Cape Town, including all PNBs performed in two-week blocks before and after the introduction of a standardised regional anaesthesia informed consent form. The primary outcome, comparing the incidence of documented informed consent between the two groups, was assessed with the McNemar paired-sample test for differences in proportions. Regression analysis was used to explore the effect of prespecified confounders (such as documented consent taken, benefits discussed, alternatives discussed, complications discussed and whether autonomy was documented). Results: In total, 39 and 43 patients were included in the pre- and post-intervention groups, respectively. In our setting, anaesthetists were 4.16 times (95% confidence interval (CI) -6.67 to -2.98, p < 0.001) more likely to take documented informed consent when provided with a standardised form. The incidence of documented informed consent improved from 7.7% to 60.5%. Regression analysis showed that these confounders influenced the recall of the PNB consent and discussed benefits and complications. Overall, recall was mostly influenced when benefits were discussed with patients (95%CI -20.023 to -14.64, p < 0.001). Conclusion: Documentation of informed consent for PNBs in our setting is poor. A standardised consent form can facilitate the documentation of consent significantly. Patient recollection of the consent process also improved, specifically when benefits were discussed.
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    Neurocysticercosis : experience at the teaching hospitals of the University of Cape Town
    (1993) Thomson, AJG
    In the 15 years 1975-1989, 239 patients attending the associated teaching hospitals of the University of Cape Town have been identified retrospectively as having neurocysticercosis. One hundred and twenty-three (51,46%) were children 12 years of age or younger, 14 (5,86%) were adolescents aged 13-19 years, and 102 (42,68%) were adults 20 years of age or older. Two hundred and twelve (88,7%) of these patients were black, almost exclusively Xhosa-speakers originating from the eastern Cape homeland regions of Transkei and Ciskei. Although the clinical features of neurocysticercosis are protean, these patients could be divided into three clinicoradiological groups - a group with seizures, a group with raised intracranial pressure, and an asymptomatic group.In the 15 years 1975-1989, 239 patients attending the associated teaching hospitals of the University of Cape Town have been identified retrospectively as having neurocysticercosis. One hundred and twenty-three (51,46%) were children 12 years of age or younger, 14 (5,86%) were adolescents aged 13-19 years, and 102 (42,68%) were adults 20 years of age or older. Two hundred and twelve (88,7%) of these patients were black, almost exclusively Xhosa-speakers originating from the eastern Cape homeland regions of Transkei and Ciskei. Although the clinical features of neurocysticercosis are protean, these patients could be divided into three clinicoradiological groups - a group with seizures, a group with raised intracranial pressure, and an asymptomatic group.
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    Risk factors for unsuccessful induction of labour at Mowbray Maternity Hospital
    (2025) Mfutila, Tsitukenina Ruffine; Fawcus, Susan; Petro, Gregory
    BACKGROUND: Induction of labour (IOL) is a commonly performed obstetrical procedure. Over time, the rate of IOL has varied from region to region, with a progressive increase and almost doubling of the incidence in some developed countries.1 According to the World Health Organization (WHO), IOL may account for up to 25% of all term deliveries in developed countries and account for only 4.4% of deliveries on average in African countries.2 Major concerns associated with IOL are the potential for increased risk of emergency caesarean delivery (CD), iatrogenic prematurity and cost. The increasing IOL rates worldwide have resulted in debates on the cost benefit ratio of this procedure. There is no consensus on what constitutes unsuccessful IOL (USIOL). Some studies consider failure to achieve vaginal delivery as USIOL. Another view is that, since the purpose of IOL is to cause a non-labouring woman to go into labour, failure to achieve active labour should be the definition of USIOL. More accurate prediction of USIOL would provide useful information for the obstetrician and the women being counselled for IOL. For this study, unsuccessful IOL was defined as failure to achieve 5 cm cervical dilation (onsetof active labour) despite IOL methods. The main aim of this study was to identify factors associated with USIOL at the Mowbray Maternity Hospital (MMH), a regional referral hospital in Cape Town. METHODS: This was a retrospective observational study. We identified women undergoing IOL in MMH labour wards between 01/01/2019 and 31/03/2019 and reviewed their medical records. Women having IOL with preterm gestations less than 34 weeks, with intra-uterine fetal death, with multiple pregnancy and prior caesarean delivery were excluded. Data was collected on background factors, indications for IOL, obstetric factors and outcomes. It was hypothesised that hypertension as the indication for IOL would be a significant risk factor for USIOL, and a sample size of 240 was estimated to be appropriate. Ethics approval was obtained from the Human Research Ethics Committee of the faculty of Health Sciences of the University of Cape Town (UCT). RESULTS: Of the 240 women who commenced IOL during the study period, 223 were eligible for inclusion. SIOL (achieving active labour; ≥5 cm cervical dilatation) occurred for 169 (75.8%) women and USIOL occurred for 54 (24.2%). The study revealed two factors statistically associated with USIOL: nulliparity, and low birthweight. In the USIOL group, 51.9% were nulliparous compared to 33.1% of SIOL (p=0.013). In the USIOL group, 18.5% of babies weighed less than 2.5 kgms compared to 8.3% in SIOL (p=0.006). Hypertension as an indication for IOL, as hypothesised in the sample size estimation, was not a determinant for USIOL. The most frequent indications for IOL were Prolonged pregnancy (31.8%), Hypertension (26%), Pre-labour rupture of membranes (13.5%), and ‘Other' category (29%) which was a composite of several less common indications. There were no significant differences in IOL indications between SIOL and USIOL groups. The USIOL group had a higher proportion of IOLs performed that were late preterm (34 to 36+6 weeks) compared to SIOL which correlates with the significantly lower birthweight in this group. Body Mass Index of the total study population was ≥ 30 kgms/m² (obesity) for 134 women (60%), yet this study did not show an association between body mass index and USIOL (p=0.864). For the method of IOL, a higher proportion of the USIOL group had misoprostol (66.7%) compared to SIOL (58.6%); whereas a higher proportion of the SIOL group had intracervical catheter (40.2%) than the USIOL group (31.5%), but these differences were not statistically significant. The mean Induction to Delivery (I-D) intervals, was 18h43min for the whole study group; 18h19min for SIOL and 19h57min for USIOL. The caesarean delivery rate for the whole study group was 35%. By definition, it was 100% in the US IOL group. Of the 169 women with SIOL, 26 (15.4%) had emergency caesarean delivery, of which 46.1% were for an abnormal CTG, 34.6% for failure to progress into active labour, and 15.4% for an undiagnosed breech in labour. In the USIOL group, the majority of CD, 37 (68.5%) were performed for an abnormal CTG with only 14 (26%) being done for a truly failed IOL that did not progress into active labour despite receiving IOL methods. There were no major adverse maternal or perinatal outcomes in SIOL or USIOL groups, with 7 babies (3% of the whole study group) requiring admission to the neonatal unit. DISCUSSION AND CONCLUSION: The study revealed two factors statistically associated with USIOL: nulliparity, and low birthweight. The higher proportion of low birthweight babies in the USIOL group, suggests undetected intrauterine growth restriction that may have been associated with the higher rate of CTG abnormalities in this group requiring CD, and/or the non-significant increase in the proportion of late preterm gestations. Hypertension, as hypothesised in the sample size estimation was not a risk factor for USIOL. The majority of women with USIOL had CD for an abnormal CTG during the process of IOL, rather than failure to progress into active labour, related possibly to high-risk fetuses or the IOL method employed. Of note, the success rate for IOL was 75.8%, the overall CD rate of 35% in women commencing IOL was less than the average for MMH; and there were few maternal and perinatal complications. This information is valuable when counselling women for IOL at MMH.
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    Social and cultural determinants of psychiatric illness : presenting in an urban general hospital
    (1961) Sakinofsky, Isaac
    In spite of these words to Martha Bernays, at that time his fiancee, Freud was for very long preoccupied with the analysis of patients from a Viennese middle- class practice a lone. It was out of this experience that he evolved his views of the origin of psychological symptoms from repression of stereotyped instinctual urges of childhood . These instinctual demands arose out of the patriarchal Viennese society.