South African Medical Journal - latest Issue
Volumes & issues
Volume 107, Issue 4, Apr 2017
Author Bridget FarhamSource: South African Medical Journal 107, pp 277 –277 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12460More Less
Towards the end of last year (2016), around 1 300 psychiatric patients were moved over a period of several months from Life Esidimeni, a specialised private facility, to care homes run by charities. Esidimeni means ‘place of dignity’, and the private company delivers healthcare services to indigent patients under contract to national and provincial departments of health and social development, and has done for five decades. The end result reverberated around the country, and indeed the world – at least 100 deaths in truly appalling circumstances.
Source: South African Medical Journal 107, pp 278 –279 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12413More Less
In the era of evidence-based medicine, health authorities are obligated to base policies on solid evidence. The gold standard of evidence-based medicine is the randomised controlled trial (RCT) in which participants fulfil strict criteria for inclusion, and the ecology of care – i.e. factors other than the intervention that could influence the outcome are controlled. However, evidence supporting systems interventions in health services that involve multiple changes in the delivery of services is complex and requires the synthesis of evidence from multiple sources. Not surprisingly, such evidence is scarcest in the resource-constrained settings that need it most, where issues of prioritisation and cost-effectiveness are of paramount importance.
Source: South African Medical Journal 107, pp 280 –280 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12389More Less
To the Editor: South Africa (SA) has witnessed regular protest actions in recent years. These involve major political issues including quality education, service delivery, state capture, and other crucial matters. Despite their large contribution to the national burden of disease, including morbidity and mortality, mental health issues have received much less attention from the public and from the press. And the fate of the most severely impacted, such as those with intellectual disability, appears to be of particularly little interest.
Targeting mothers and selling men what they do not want : a response to ‘Missed opportunities for circumcision of boys’Source: South African Medical Journal 107, pp 281 –281 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12406More Less
To the Editor: Millard et al. state in their editorial in the SAMJ January issue that medical male circumcision (MC) in South Africa (SA) peaked in 2013, only to decline in subsequent years despite improved surgical infrastructure and ‘high-level marketing’. They attach great hope to ‘demand creation’, which they state is supported by the Bill and Melinda Gates Foundation and the Clearinghouse on Male Circumcision. ‘Demand creation is trying to sell something that many men don’t want’, they state.
Author L LondonSource: South African Medical Journal 107, pp 282 –283 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12411More Less
To the Editor: The use, misuse and, sometimes, failure to recognise conflict of interest (CoI) is a growing problem in medical publications. The critique by Harcombe and Noakes published in the December 2016 SAMJ, purporting to find many weaknesses in the so-called ‘Universities of Stellenbosch/Cape Town low-carbohydrate review’ is somewhat disturbing, not specifically because of the content of their critique, to which the authors of the systematic review have replied, but because of how Harcombe and Noakes have recruited questions of bias and implied CoI to support their views.
Author B FarhamSource: South African Medical Journal 107, pp 284 –285 (Apr 2017)More Less
Vitamin D supplementation and acute respiratory tract infections
Acute respiratory tract infections (ARTIs) are responsible for 10% of visits to doctors in the USA and important causes of morbidity and mortality globally. Observational studies report consistent independent associations between low serum vitamin D levels and susceptibility to ARTI. A systematic review and meta-analysis from randomised controlled trials published recently in the BMJ suggests that vitamin D supplementation is safe and protects against ARTI, the effect being particularly marked in those who were very deficient in the vitamin. However, a linked editorial questions the validity of the data, saying that clinical practice should probably not be changed – yet. The authors point out that the primary result is a reduction from 42% to 40% in the proportion of participants experiencing at least one ARTI. Also, the definition of ARTI varied between studies, consisting of a mixture of diverse conditions such as acute otitis media, laboratory-confirmed influenza, self-reported colds or chest infections and radiograph-confirmed pneumonia.
The jury is still out.
Author Graeme CopleySource: South African Medical Journal 107, pp 287 –287 (Apr 2017)More Less
Dr Oliver Raynham was killed in a boating accident in the early evening of 29 December 2016 at the age of 47. He was sailing his Hobie catamaran up the Klein River outside Stanford when its mast hit power lines crossing the river and he was electrocuted. On board with him were three 11-year-old boys, participants in the annual Hermanus Camp, where Oliver was volunteering as the camp doctor (as he had done for several years) and as a group leader. The boys escaped physically unharmed. They reported that just before the accident they had been sharing biscuits and enjoying the beauty of the evening, and Oliver’s last words were about how grateful and blessed they were to share such a wonderful moment. The way he died was typical of him – always living life to the full, out on an adventure, and surrounded by young people, with whom he had a natural affinity.
Source: South African Medical Journal 107, pp 288 –288 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12432More Less
Trauma and violence are major causes of the burden of disease globally, and low- and middle-income countries bear the brunt of this scourge. Unfortunately, in South Africa (SA), attempts to mitigate the devastating effects of trauma and violence on our young population are not a top priority of policy makers and health practitioners.
Source: South African Medical Journal 107, pp 289 –291 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12436More Less
Burn injuries are a persisting challenge in South Africa. Energy poverty, prevalent in under-resourced communities, is a key contributor to the problem. The energy-poor rely on solid fuels and flammable hydrocarbons, such as paraffin, for energy services. The fuels are burntin inefficient, leaky and unstable appliances, leading to health losses from pollutant emissions, burns, and conflagrations. Within crampedinformal home settings, using flammable fuels and risky combustion technologies, the situation can become devastating, especially for youngchildren. Those who survive fiery incidents have to contend with trauma and property losses that may lead to further impoverishment.Proactive intervention strategies are required and should include the broadening of access to safe and sustainable energy. We advocategreater enforcement of home appliance standards and targeted support for the distribution of proven alternative energy technologies, suchas liquefied petroleum gas and solar power. Support and advocacy from professional and citizen groups would be necessary to ensure that government prioritises the safe energy requirements of poor citizens.
Source: South African Medical Journal 107, pp 292 –294 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12433More Less
Road traffic crash (RTC) injuries are the leading cause of child mortality and morbidity in South Africa for children between the ages of 1 and 18 years. The World Health Organization’s Global Status Report on Road Safety 2015 rated the African continent’s roads the world’s most dangerous. After pedestrian injuries, passenger injuries are the most lethal. There is no doubt that a seat belt is the single most effective feature in a vehicle to reduce the severity of injury to the vehicle’s occupants; wearing a seat belt reduces the risk of fatal injury by up to 50% and 75% for front seat and rear seat occupants, respectively. Children have specific anatomical and physiological limitations that render them more vulnerable to serious injury, but the prevention of childhood RTC injuries has unfortunately not received the deserved attention by the medical fraternity. There is currently ample evidence that the use of seat belts and appropriate child restraint seats has led to a significant reduction in RTC fatalities and injuries. It is, therefore, the duty of every healthcare worker to lead by example by using child restraints correctly, and actively encouraging the use of these devices for all their clients and patients.
Source: South African Medical Journal 107, pp 295 –298 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12040More Less
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous condition, which affects multiple organ systems. This study aimed to determine the presenting features of children with TSC in Cape Town, South Africa. A cross-sectional study was conducted at a TSC clinic, and clinical features at presentation were prospectively collected. Thirty-nine children (23 boys; median age 10 (range 1 - 26) years; median diagnosis age 16 (0 - 153) months) were recruited. Twenty-one (54%) children presented with focal seizures. Seven (18%) children had epileptic spasms. Skin manifestations led to a diagnosis in 13 (33%) and neuroimaging in 22 (56%) children. Antenatal screening detected
cardiac rhabdomyomas in 3 children. One child had a positive family history. In the paediatric service, TSC diagnosis usually followed neuroimaging, whereas at the neurology service skin manifestations indicated TSC. In conclusion, most children with TSC presented as emergency cases with seizures. Health practitioner awareness of the common TSC clinical signs was lacking, with the diagnosis often delayed.
Source: South African Medical Journal 107, pp 299 –301 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12053More Less
We report a young woman with systemic lupus erythematosus (SLE) and an acute cerebellar ataxia. A history of poor appetite and vomiting preceded the inco-ordination. Ataxia in SLE has been well described, but is nevertheless uncommon. The clinical triad of mild confusion, ataxia and ophthalmoplegia also raised the possibility of Wernicke’s encephalopathy (WE). The diagnosis of WE was further supported by the magnetic resonance imaging features. Owing to overlapping causal factors, this case illustrates the complexity of diagnosing and managing neuropsychiatric syndromes in a patient with SLE. The limited published literature on SLE-related cerebellar syndromes adds to the challenge. Gastrointestinal manifestations of SLE are described as being common in SLE, with nausea and vomiting occurring in >50% of cases in some series. Poor eating habits and vomiting are well-described causes of non-alcoholic WE. This is the first description of gastrointestinal SLE as a possible cause of WE.
Source: South African Medical Journal 107, pp 302 –303 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12176More Less
Background. Lead exposure constitutes a major public health concern globally. Relative to developed nations, lead exposure is understudied and poorly addressed in Africa, and there is a dearth of information available to inform lead poisoning prevention strategies, even in highrisk groups such as workers in shooting ranges who are potentially exposed to lead daily.
Methods. Two workers at a private shooting range in Gauteng, South Africa (SA), had blood lead levels and exposure histories taken.
Results. Workers had highly elevated blood lead levels and clinical symptoms associated with elevated blood lead levels.
Conclusion. Workers in private SA shooting ranges are vulnerable to lead exposure and poisoning, and scaled-up action is required to protect them and their families, as well as shooting-range users, from lead and the related health risks.
Source: South African Medical Journal 107, pp 304 –306 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12228More Less
Mammary analogue secretory carcinoma (MASC) is a rare and recently described tumour of the salivary glands. MASC has similar histomorphological and immunohistochemical features of secretory carcinoma of the breast. MASC can be mistaken for other salivary gland tumours, especially acinic cell carcinoma. A 28-year-old man was diagnosed with a rare salivary gland tumour in Pretoria, South Africa (SA). To our knowledge, a report of MASC in SA has not previously been published. The surgeons dealing with salivary gland tumours should be aware of the clinical presentation. Current treatment is similar to that of other salivary gland malignancies.
Source: South African Medical Journal 107, pp 307 –317 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12141More Less
Background. Globally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives.
Objective. To assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening.
Methods. Data from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations.
Results. Two-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods.
Conclusion. Contraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women.
Source: South African Medical Journal 107, pp 315 –319 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12084More Less
Background. Snakebites can produce severe local and systemic septic complications as well as being associated with significant overall morbidity and even mortality.
Objective. A prospective audit was undertaken to determine the bacterial causation of wound infection secondary to snakebite, and attempt to quantify the burden of disease.
Methods. The audit was undertaken at Ngwelezane Hospital, which provides both regional and tertiary services for north-eastern KwaZulu-Natal Province, South Africa, over a 4-month period. Records of patients who required surgical debridement for extensive skin and softtissue necrosis were analysed. At the time of ebridement, tissue samples of necrotic or infected tissue were sent for bacteriological analysis as standard of care. Microbiology results were analysed.
Results. A total of 164 patients were admitted to hospital for management of snakebite, of whom 57 required surgical debridement and 42 were included in the final microbiological analysis. Children were found to be the most frequent victims of snakebite; 57.8% of patients in this study were aged ≤10 years and 73.7% ≤15 years. Culture showed a single organism in 32/42 cases, two organisms in 8 and no growth in 2. Eight different types of organisms were cultured, five of them more than once. Thirty-five specimens (83.3%) grew Gram-negative Enterobacteriaceae, the most frequent being Morganella morganii and Proteus species. Thirteen specimens (31.0%) grew Enterococcus faecalis Gram-negative Enterobacteriaceae showed 31.4% sensitivity to ampicillin, 40.0% sensitivity to amoxicillin plus clavulanic acid, 34.3% sensitivity to cefuroxime, 97.1% sensitivity to ceftriaxone, and 100% sensitivity to ciprofloxacin, gentamicin and amikacin. E. faecalis was 92.3% sensitive to amoxicillin, 92.3% sensitive to amoxicillin plus clavulanic acid, 100% sensitive to ciprofloxacin, 92.3% resistant to erythromycin and 100% resistant to ceftriaxone.
Conclusion. Children are particularly vulnerable to snakebite, and the consequences can be devastating. While the majority of patients in this study were shown to have secondary bacterial infection, debridement and subsequent wound management is considered the mainstay of treatment. Common organisms are Enterobacteriaceae and enterococci. There appears to be a role for antibiotics in the management of these patients. A good antibiotic policy is strongly advocated.
Source: South African Medical Journal 107, pp 320 –322 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12158More Less
Background. The association between lung scarring and the subsequent development of cancer remains controversial. South Africa has one of the highest incidences of tuberculosis in the world, and resultant scarring may predispose to malignancy. The country also carries a very high burden of smoking and smoking-related diseases that may be synergistic in malignant transformation. Objective. To assess the frequency of pulmonary scarring in patients with lung cancer.
Methods. All patients with confirmed lung cancer and a staging computed tomography (CT) scan of the chest were included in this 2-year retrospective study. Pulmonary scarring was categorised according to location as present in: (i) the same lobe as the primary tumour, (ii) a different lobe of the same lung, or (iii) the contralateral lung; or (iv) as diffuse. Post-obstructive bronchiectasis and other changes secondary to cancer were considered not to represent scarring.
Results. We identified 435 cases of primary lung cancer. In total, 95 patients (21.8%) had CT evidence of pulmonary scarring. Eighty-three of 85 patients (97.6%) had focal scarring in the same lobe as the primary tumour. Of these, 37 (43.5%) also had scarring involving a different lobe of the same lung, whereas only one (1.2%; p<0.001) had scarring isolated to a different lobe of the same lung. Moreover, 21 patients (24.7%) also had scarring of the opposite lung, but only one patient (1.2%; p<0.001) had scarring isolated to the contralateral lung. Ten patients had diffuse scarring, caused by bronchiectasis (n=5), idiopathic pulmonary fibrosis (n=4) and silicosis (n=1).
Conclusion. At least one in five patients with lung cancer had scarring, which was significantly more likely to be present in the same lobe as the tumour, suggesting a predisposition to malignancy.
Source: South African Medical Journal 107, pp 323 –326 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.12145More Less
Background. Resource-intensive procedures require the use of patient waiting lists in an attempt to increase fairness of access to surgery and improve surgical efficiency. Total hip and knee arthroplasty has waiting lists in excess of years.
Objectives. To analyse our tertiary state institution’s hip and knee arthroplasty waiting list to assess its accuracy.
Methods. At Groote Schuur Hospital, our hospital-maintained database was compared with the surgeons’ personally maintained database. Patients were then telephoned to confirm their contactability, and to discover whether they still wanted the procedure, or if they had already had it. Waiting duration and patient demographics were then calculated.
Results. Of the 655 patients on the hospital waiting list, only 454 were contactable. Three hundred and nine patients still wanted the surgery, 93 had already undergone surgery and 52 no longer wanted surgery. The last group was the oldest and had had the longest waiting time. Those still waiting had waited 451 days (minimum - maximum (standard deviation), 90 - 1 593 (228.5)), those that had had surgery 371 days (0 - 1 728 (296)) and those no longer interested 523 days (138 - 1 881 (260.9)). A total of 429 patients were present on the surgeons’ list but not on the hospital list. They had had longer waiting times than those on the hospital list.
Conclusion. The arthroplasty waiting list is inaccurate due to the existence of two concurrent lists and poor data management, particularly of current contact details. The unfairness of a wide range of waiting times was identified, with patients only on the surgeons’ personal database disadvantaged. These deficiencies have prompted the introduction of a scoring-based prioritisation system incorporating clinical, radiographic and societal parameters, in an effort to improve fair and appropriate access to this high-cost care.
Source: South African Medical Journal 107, pp 327 –330 (Apr 2017) http://dx.doi.org/10.7196/SAMJ.2017.v107i4.10843More Less
Background. Ten percent of patients with a deep-vein thrombosis (DVT) will develop a fatal pulmonary embolism (PE), often initially asymptomatic. The risks and benefits of pharmacological thromboprophylaxis are well documented in respect of total joint arthroplasty and hip fractures, but little is understood about the incidence of venous thromboembolism (VTE) or the potential risks and benefits of chemoprophylaxis in foot and ankle surgery.
Objective. To determine whether prophylactic chemoprophylaxis had any impact on the prevention of VTE in a cohort of foot and ankle surgical patients requiring the combination of below-knee cast immobilisation and non-weightbearing for ≥4 weeks.
Methods. Between March 2014 and April 2015, a prospective cohort study of 142 patients was performed. All completed a thrombosis risk assessment form prior to surgery and were commenced on rivaroxaban (Xarelto) 10 mg/d postoperatively. The primary outcome measure was clinical VTE confirmed by compression ultrasonography (DVT) or a ventilation/perfusion scan (PE).
Results. Three patients (2.1%) developed a clinical DVT. Two did so well beyond the immobilisation and anticoagulation period, and one was non-compliant with therapy. The average risk factor score in this subgroup was 7. No patient had a DVT while on the prescribed regimen of anticoagulant therapy. Five patients (3.5%) developed wound breakdown, two requiring surgical debridement with local skin flap closure. One case of menorrhagia that may have been linked to the anticoagulant therapy was reported. When compared with a previous study, pharmacological thromboprophylaxis significantly reduced VTE risk (p=0.02).
Conclusions. Oral pharmacological thromboprophylaxis significantly reduces the risk of VTE in patients requiring cast immobilisation and non-weightbearing following foot and ankle surgery. The risk/benefit ratio favours this treatment as opposed to the treatment of major
morbidity following non-fatal VTE.