McCord Hospital

Background: Ventral incisional hernia repair commonly utilizes onlay or retro-rectus sublay mesh placement. Comparative evidence on early postoperative outcomes remains limited in low-resource surgical settings. Objective: This investigation aims to evaluate one-year postoperative outcomes, complication profiles, operative characteristics, and recurrence patterns following open onlay versus retro-rectus sublay mesh repair among patients with ventral incisional hernia. Methods: A quasi-experimental study was conducted from July 2022 to June 2024 at Rajshahi Medical College Hospital, enrolling 60 patients randomized into onlay (n=30) and sublay (n=30) groups. Data on demographics, BMI, defect size, operative duration, postoperative complications, hospital stay, and recurrence were collected. Statistical analyses employed the Student’s unpaired t-test for continuous variables and Chi-square tests for categorical outcomes with significance at p<0.05. Results: Mean age was slightly higher in the sublay group (52.3 ± 7.9 years) than the onlay group (51.1 ± 6.8 years, p=0.42). Normal BMI distribution differed significantly (56.6% vs. 83.3%, p=0.018). Larger defects (>2 cm) were more frequent in sublay repairs (80.0% vs. 66.6%, p=0.21). Operative duration was significantly longer for sublay (132 ± 14 minutes) versus onlay (104 ± 11 minutes, p<0.001). Postoperative seroma (43.3% vs. 6.6%, p<0.001), wound infection (30% vs. 6.6%, p=0.012), sepsis (13.3% vs. 3.3%, p=0.04), and mesh extraction (10% vs. 0%, p=0.041) were markedly higher in the onlay group. Recurrence rates favored sublay repair (3.3% vs. 6.6%, p=0.55). Conclusion: Sublay mesh repair demonstrates lower complication rates, reduced infectious morbidity, and improved recurrence outcomes compared with onlay repair, supporting its preferential use when surgical expertise and operative resources permit.

BackgroundLittle is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa.MethodsWe used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health).ResultsAmong 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60.ConclusionsIndependent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus.Trial registrationClinical Trials.gov Identifier NCT01188941. Registered 26 August 2010.

IntroductionChanges to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source.MethodsAll adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models.ResultsOf the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (<3 months, aHR 3.80, 95% CI 2.77 to 5.21; three months to one year, aHR 1.32, 95% CI 1.15 to 1.51, each compared with >1 year) were associated with not having a post‐transfer record.ConclusionsUsing data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories.

Introduction: High sensitivity cardiac troponin (hs-cTn) assays are able to quantitate low concentrations of cTn and provide an opportunity to rule out acute myocardial infarction (MI) at an early stage following a patient’s presentation to an emergency department. Hypothesis: The objectives of the current study were to examine the performance of single hs-cTnI measurement strategy to rule out acute MI and predict 30-day safety outcomes at presentation in these patients. Methods: This was a prospective, observational study of patients (n = 2342) presenting to US emergency departments with suspected acute coronary syndrome in whom cTnI measurements were obtained using the Siemens Atellica IM High Sensitivity Troponin I Assay (Siemens Healthcare Diagnostics). Clinical data and hs-cTnI results were analyzed to determine: 1) clinical sensitivity and negative predictive value (NPV) for ruling out acute MI and 2) safety outcomes of acute MI and death at 30 days, using the hs-cTnI limit of detection (LoD) 1.6 ng/L concentration. Results: Acute MI occurred in 306 patients (13.1%). In patients with a hs-cTnI &lt;LoD (n=421, 18.0%), the clinical sensitivity and negative predictive value (NPV) for acute MI were 100% (95% CI 99.0,100) and 100% (CI 99.3,100), respectively. Further, the sensitivity and NPV for the safety outcome of acute MI or death within 30 days for hs-cTnI &lt;LoD were 99.4% (CI 98.5, 99.9) and 99.5% (CI 98.9, 99.9), respectively. Only 2 patients (0.85%) had an event. Conclusion: A strategy of using a single hs-cTnI &lt;LoD at presentation allowed the immediate identification of 18.0% of patients highly unlikely to have acute MI and who were at very low risk for events at 30 days. Additional studies to understand the clinical utility and cost-savings of this strategy are needed.

Analyzing factors associated with virological failure (VF) may improve antiretroviral therapy (ART) outcomes for individuals living with HIV. The Risk Factors for Virological Failure (RFVF) study compared 158 cases with VF (viral load, VL, >1,000 copies/mL) and 300 controls with virological suppression (VL ≤1,000 copies/mL) after ≥5 months on their first ART regimen at McCord Hospital in Durban, South Africa between October 2010 and June 2012. RFVF participants completed a battery of various psychosocial measures. Using multivariate logistic regression stratified for gender, the association of various psychosocial factors with VF was assessed. It was found that not all factors were equally significant for both genders. The factors that were significantly associated with VF for both genders were younger age, shorter treatment duration and reporting depressive symptoms. The factors associated with VF that differed by gender were religious inactivity, having HIV+ family members, and status disclosure to friends.

BackgroundHIV-exposed uninfected (HEU) infants are a growing population in sub-Saharan Africa especially with the increasing coverage of more effective prevention of mother-to-child transmission (PMTCT) antiretroviral therapy regimens. This study describes the characteristics of South African HEU infants, investigates factors impacting birth weight and assesses their growth within the first 28 weeks of life.MethodsThis is a retrospective cohort based on routine clinical data from two South African PMTCT programmes. Data were collected between 2007 and 2013. Linear regression assessed factors affecting birth weight-for-age z-scores (WAZ) while growth (longitudinal WAZ) was assessed using mixed effects models.ResultsWe assessed the growth of 2621 HEU infants (median birth WAZ was -0.65 (IQR -1.46; 0.0) and 51% were male). The feeding modalities practised were as follows: 0.5% exclusive breastfeeding, 7.9% breastfeeding with unknown exclusivity, 0.08% mixed breastfeeding and 89.2% formula feeding. Mothers with CD4 <200 cells/μl delivered infants with a lower birth WAZ (adjusted ß -0.253 [95% CI -0.043; -0.072], p = 0.006) compared to mothers with aCD4 ≥500 cells/μl. Similarly, mothers who did not receive antiretroviral drugs delivered infants with a lower birth WAZ (adjusted ß -0.39 [95% CI -0.67; -0.11], p = 0.007) compared to mothers who received antenatal antiretrovirals. Infants with a birth weight <2 500g (ß 0.070 [95% CI 0.061; 0.078], p <0.0001) experienced faster growth within the first 28 weeks of life compared to infants with a birth weight ≥2 500g. Infants with any breastfeeding exposure experienced slower longitudinal growth compared to formula fed infants (adjusted ß -0.012 [95% CI 0.021; -0.003], p = 0.011).ConclusionLess severe maternal disease and the use of antiretrovirals positively impacts birth weight in this cohort of South African HEU infants. Formula feeding was common with breastfed infants experiencing marginally slower longitudinal growth.

Background: Red cell distribution width (RDW) is a measure of the variability in size of erythrocytes. A high RDW value indicates greater variation in size between individual erythrocytes and has been shown to be an independent predictor of mortality in patients with coronary artery disease, heart failure and in patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to evaluate the prognostic value of RDW in predicting clinical outcomes in patients with hypertensive crisis. Methods: We performed a retrospective study of 465 consecutive patients from January 2007 to March 2010 who presented with hypertensive crisis. Hypertensive crisis was defined as systolic BP &gt;180 and/or diastolic BP &gt;110mmHg with impending or progressive end organ dysfunction requiring inpatient hospitalization. The study sample consisted of 465 patients (38.9% men (181 of 465); mean age 59.6 ± 15.9). Baseline levels of RDW were measured at time of admission and analyzed as continuous and categorical variables (elevated RDW was defined as &gt;14.5%). Multivariable regression analysis was performed for development of all-cause mortality, myocardial infarction, new-onset heart failure (defined as first time hospital admission for heart failure), stroke and MACE (MI, new-onset heart failure and stroke) at 2 years. Results: RDW &gt; 14.5% was a strong independent predictor of all-cause mortality at 2 years (OR: 1.90, 95% CI: 1.1-3.3, p &lt;0.05). Elevated RDW was also found to be an independent predictor of new-onset heart failure at 2 years (OR: 1.97, 95% CI: 1.1-3.7, p &lt;0.05). Elevated RDW was not a predictor of MI, PCI or stroke at 2 years. Conclusions: Elevated RDW level in patients with hypertensive crisis was an independent predictor of all-cause mortality and new-onset heart failure in patients with hypertensive crisis.

Poor social support and mental health may be important modifiable risk factors for HIV acquisition, but they have not been evaluated prior to HIV testing in South Africa. We sought to describe self-perceived mental health and social support and to characterize their independent correlates among adults who presented for voluntary HIV testing in Durban. We conducted a large cross-sectional study of adults (≥18 years of age) who presented for HIV counseling and testing between August 2010 and January 2013 in Durban, South Africa. We enrolled adults presenting for HIV testing and used the Medical Outcomes Study’s Social Support Scale (0 [poor] to 100 [excellent]) and the Mental Health Inventory (MHI-3) to assess social support and mental health. We conducted independent univariate and multivariable linear regression models to determine the correlates of lower self-reported Social Support Index and lower self-reported MCH scores. Among 4874 adults surveyed prior to HIV testing, 1887 (39%) tested HIV-positive. HIV-infected participants reported less social support (mean score 66 ± 22) and worse mental health (mean score 66 ± 16), compared to HIV-negative participants (74 ± 21; 70 ± 18; p < 0.0001). In a multivariable analysis, significant correlates of less social support included presenting for HIV testing at an urban hospital, not having been tested previously, not working outside the home, and being HIV-infected. In a separate multivariable analysis, significant correlates of poor mental health were similar, but also included HIV testing at an urban hospital and being in an intimate relationship less than six months. In this study, HIV-infected adults reported poorer social support and worse mental health than HIV-negative individuals. These findings suggest that interventions to improve poor social support and mental health should be focused on adults who do not work outside the home and those with no previous HIV testing.

We assessed the role of urine lipoarabinomannan (LAM) grade and a second LAM test for HIV-associated pulmonary tuberculosis (TB) screening in outpatient clinics in South Africa. We enrolled newly diagnosed HIV-infected adults (≥18 years) at 4 clinics, excluding those on TB therapy. Participants provided sputum for acid-fast bacilli (AFB) microscopy and culture. Nurses conducted 2 rapid urine LAM tests at the point-of-care and graded positive results from low (faint) to high (5+). Culture-confirmed pulmonary TB was the gold standard. We used area under receiver operating curves (AUROC) to compare screening strategies. Among 320 HIV-infected adults, median CD4 was 248 cells per cubic millimeter (interquartile range, 107-379/mm); 54 (17%) were TB culture positive. Fifty-two (16%) of all participants were LAM positive by either test; correlation between LAM tests was high. Among 10 "faint" positive results, 2 (20%) had culture-positive TB. Using ≥1+ LAM grade as positive, 1 LAM test had sensitivity of 41% [95% confidence interval (CI): 28% to 55%] and specificity of 92% (95% CI: 88% to 95%). A 2 LAM test strategy had a sensitivity of 43% (95% CI: 29% to 57%). One LAM test ≥1+ grade (AUROC = 0.66; 95% CI: 0.60 to 0.73) was significantly better than sputum AFB alone. The optimal strategy was sequentially performing 1 LAM test followed by sputum AFB if LAM grade <1+ (AUROC = 0.70; 95% CI: 0.63 to 0.77), which had sensitivity of 48% (95% CI: 34% to 62%) and specificity of 91% (95% CI: 87% to 94%). In this clinic-based study, "faint" line was a false-positive second urine LAM test added no value, and an optimal screening strategy was 1 LAM test followed by sputum AFB microscopy for urine LAM-negative people.

Purpose – This study aimed to provide an examination of the extent to which different leadership styles impact employee motivation, performance and absenteeism at four selected hospitals in Eastern Free State, South Africa. Design/methodology/approach – Quantitative; descriptive survey design was used with a structured questionnaire as data collection instrument. The useable survey comprised 180 individual responses from 250 distributed, giving a response rate of 72 percent. Findings – The findings show that autocratic, participative, and democratic and laissez- faire leadership styles are prevalent in the hospitals under study. Further, it was found that employees’ motivation, performance was decreased while absenteeism was increased as a result of the autocratic and laissez – faire leadership styles prevalent in the hospitals. Recommendations - Recommendations were made for improvement of leadership styles in order to increase motivation and performance whilst reducing absenteeism. Further research, specifically relating to impact of leadership styles in hospitals and the impact of human capital factors were recommended