South African Medical Journal - Volume 101, Issue 10, 2011
Volumes & issues
Volume 101, Issue 10, 2011
Author Steve ReidSource: South African Medical Journal 101 (2011)More Less
This pocket handbook is an essential guide for general practitioners, medical officers, registrars, emergency care practitioners, and all trauma unit staff in South African hospitals. Following the well-established format of pocket handbooks that can be carried around and referred to at the moment when they are needed, this handbook sets out all the major issues in trauma management in an accessible and comprehensive way.
Author Peter FolbSource: South African Medical Journal 101 (2011)More Less
The essential requirement for an autobiography is truthfulness. In that regard, Marius Barnard in his book written in conjunction with family friend and author Simon Norval, has met the challenge with distinction. With complete candour he describes, in sequence, his early days in Beaufort West, his devotion to and esteem for his parents who served the religious needs of the disadvantaged and disenfranchised community of the Karoo town, his days as a medical student at the University of Cape Town and society doctor in Salisbury, Southern Rhodesia (that was), his training as cardiac surgeon at Groote Schuur Hospital and in the USA, his participation in the world's first heart transplant on 3 December 1967 under the direction of his brother Chris, his contribution to the development of cardiac surgery in Romania (then part of the Soviet Union), his work as member of Parliament for Parktown while at the same time conducting private practice in Johannesburg, and in the latter part of his long career his work in developing and promoting critical illness insurance.
Authors: Peter Collins, Dan J Stein, Adele Pretorius, Heidi Sinclair, Don Ross, Graham Barr, Andre Hofmeyr, Carla Sharp, David Spurrett, Jacques Rousseau, George Ainslie, Andrew Dellis, Harold Kincaid, Nelleke Bak, Peter Collins, Dan J Stein, Adele Pretorius, Heidi Sinclair, Don Ross, Graham Barr, Andre Hofmeyr, Carla Sharp, David Spurrett, Jacques Rousseau, George Ainslie, Andrew Dellis, Harold Kincaid, Nelleke Bak, Peter Collins, Dan J Stein, Adele Pretorius, Heidi Sinclair, Don Ross, Graham Barr, Andre Hofmeyr, Carla Sharp, David Spurrett, Jacques Rousseau, George Ainslie, Andrew Dellis, Harold Kincaid and Nelleke BakSource: South African Medical Journal 101, pp 722 –723 (2011)More Less
In the English-speaking world and some parts of Europe, problem and pathological gambling are treated as a significant public health problem. At the same time, these jurisdictions recognise that for most of those who engage in it, gambling is a harmless leisure activity that may yield public benefits by contributing more in taxation than other leisure industries and/or contributing to out-of-town tourism. Strategies that combine minimising the harm caused with maximising the benefits of gambling are therefore crucial for good public policy. Such lessons may also be relevant to other legal and illegal industries, such as those involving the production and sales of alcohol, where analogous harms and benefits exist.
Childhood behavioural and developmental disorders - association with maternal alcohol consumption in Cape Town, South Africa : scientific letterSource: South African Medical Journal 101, pp 724 –727 (2011)More Less
Current maternal alcohol consumption, especially binge drinking, is strongly associated with childhood behavioural and/or developmental disorders (BDDs) in a population attending tertiary hospital ambulatory services. BDDs were also associated with maternal alcohol use 6 months before pregnancy. An association with BDDs could not be conclusively demonstrated for drinking during pregnancy, but this may have been influenced by under-reporting and reduced study power due to misclassification of exposure. We cannot rule out the a priori suspicion that some mild BDDs in children in the Western Cape could be undiagnosed fetal alcohol spectrum disorder. Nonetheless, the study highlighted the important impact of current maternal alcohol use on behaviour and development of children. Future research on the impact of maternal alcohol use on childhood development should include examination of environmental and social factors contributing to this increased risk. Upstream interventions aimed at reducing alcohol-related harms may also contribute to reducing the burden of BDDs.
Treatment of paediatric burns with a nanocrystalline silver dressing compared with standard wound care in a burns unit : a cost analysis : scientific letterSource: South African Medical Journal 101, pp 728 –731 (2011)More Less
Burns are a leading cause of non-natural death in South African infants and children. Conventional care of partial-thickness burns often requires painful, time consuming and costly twice-daily dressing changes to clean the wound and apply antimicrobial topical agents. A new topical nanocrystalline silver-coated (NS) dressing (Acticoat; Smith & Nephew) has been developed and is the first-line treatment of choice in many burn centres. However, because of its cost the Department of Health has been reluctant to introduce it as a standard of care.
We retrospectively studied 4 randomly selected paediatric burn patients, calculating the cost associated with the use of NS dressings and comparing this with the projected costs of three previously standard burn wound treatment regimens. NS dressings were changed every 3 days based on their sustained and slow release of silver ions over 72 hours. Using NS clearly saved costs compared with the three other regimens. The demonstrated cost savings resulted primarily from the decreased number of dressings, and the presumed shorter hospital stay.
Clinically significant anaerobic bacteria isolated from patients in a South African academic hospital - antimicrobial susceptibility testing : scientific letterSource: South African Medical Journal 101, pp 732 –734 (2011)More Less
Background. Increasing resistance to some antimicrobial agents among anaerobic bacteria has made susceptibility patterns less predictable.
Method. This was a prospective study of the susceptibility data of anaerobic organisms isolated from clinical specimens from patients with suspected anaerobic infections from June 2005 until February 2007. Specimens were submitted to the microbiology laboratory at Charlotte Maxeke Johannesburg Academic Hospital, where microscopy, culture and susceptibility testing were performed the using E test® strip minimum inhibitory concentration method. Results were interpreted with reference to Clinical and Laboratory Standards Institute guidelines for amoxicillin-clavulanate, clindamycin, metronidazole, penicillin, ertapenem, cefoxitin, ceftriaxone, chloramphenicol and piperacillin-tazobactam.
Results. One hundred and eighty anaerobic isolates were submitted from 165 patients. The most active antimicrobial agents were chloramphenicol (100% susceptible), ertapenem (97.2%), piperacillin-tazobactam (99.4%) and amoxicillin-clavulanic acid (96.7%). Less active were metronidazole (89.4%), cefoxitin (85%), clindamycin (81.7%), ceftriaxone (68.3%) and penicillin (33.3%).
Conclusion. Susceptibility testing should be performed periodically to identify emerging trends in resistance and to modify empirical treatment of anaerobic infections.
Source: South African Medical Journal 101, pp 736 –738 (2011)More Less
We report on 13 patients diagnosed with meningococcal infections in patients attending state-owned hospitals serving an indigent population in Pretoria in 2009. The case fatality rate was 27%. Ceftriaxone was the main antibiotic (9 out of 13 patients) for therapy. Five isolates (39%) were serogroup B and 4 (31%) serogroup W135. Most isolates (12/13) were fully susceptible to penicillin (MIC range 0.016 - 0.047 µg/ml). A single isolate was intermediately resistant to penicillin (MIC, 0.125 µg/ml) while all isolates were uniformly susceptible to ceftriaxone, ciprofloxacin and rifampicin. This pattern reveals a shift in serogroups with an increase of serogroup B disease in the Pretoria region, and the need for ongoing monitoring of antimicrobial susceptibility profiles and the value of ceftriaxone for favourable therapeutic outcome.
Source: South African Medical Journal 101, pp 740 –742 (2011)More Less
Objectives. The aim of this study was to determine the success rate of myringoplasty surgery performed at Groote Schuur Hospital and to evaluate some of the presumed prognostic factors.
Design. The study design was a retrospective analytical cohort.
Setting. Groote Schuur Hospital (tertiary medical centre), Cape Town.
Subjects. This study assessed the success rate of 341 myringoplasty operations performed by surgeons in the Department of Otolaryngology from January 2005 to December 2009.
Outcome measures. An unsuccessful operation was classified as a residual perforation seen at the 3-month follow-up visit that remained present at all subsequent visits. Presumed prognostic factors such as the rank of the surgeon, size of the perforation, location of the perforation, graft used and whether it was a revision procedure, were also evaluated. Where possible, the audiometric gain following surgery was calculated.
Results. The overall success rate in terms of an intact tympanic membrane following myringoplasty was 71%. The average improvement in pure tone average following myringoplasty was 12.4 dB. In 64% of patients, socially acceptable hearing levels were present postoperatively (air-conduction of less than 30 dB). None of the presumed prognostic factors was a statistically significant determinant (p>0.05).
Conclusion. The success rate for myringoplasty (in terms of perforation closure) of 71% at Groote Schuur Hospital compares well with that quoted in the literature. There is no ethical dilemma from a surgical outcomes perspective of registrars performing myringoplasties.
Source: South African Medical Journal 101 (2011)More Less
Pregnancy, with or without additional complications, constitutes a high-risk condition for complications of influenza infection and warrants early intervention with neuraminidase inhibitors such as oseltamivir, if influenza is suspected. Treatment should not be delayed for laboratory confirmation. In South Africa, the high burden of HIV infection is a further complication.
Providing clinicians with information on laboratory test costs leads to reduction in hospital expenditure : original articleSource: South African Medical Journal 101, pp 746 –748 (2011)More Less
Objectives. We aimed to ascertain the efficacy of an intervention in which laboratory test costs were provided to clinicians as a pocketsized brochure, in reducing laboratory test costs over a 4-month period.
Methods. This was a non-randomised intervention study in the Internal Medicine wards at Steve Biko Academic Hospital, Pretoria, in which the intervention was laboratory test costs provided to clinicians as a pocket-sized brochure. The intervention period was the winter months of May - August 2008 and the pre-intervention period was the same months of the preceding year. In the two 4-month periods (2007 and 2008), the number of days in hospital and the laboratory tests ordered were computed for each patient admitted. For the intervention and control groups, pre- and post-intervention cost and days in hospital were estimated.
Results. The mean cost per patient admitted in the intervention group decreased from R2 864.09 to R2 097.47 - a 27% reduction. The mean cost per day in the intervention group as a whole also decreased, from R442.90 to R284.14 - a 36% reduction.
Conclusion. Displaying the charges for diagnostic tests on the laboratory request form may significantly reduce both the number and cost of tests ordered, and by doing so bring about considerable in-hospital cost savings.
Is the attendance of paediatricians at all elective caesarean sections an effective use of resources? : original articleSource: South African Medical Journal 101, pp 749 –750 (2011)More Less
Objectives. To determine the need for resuscitation at the birth of babies delivered by elective caesarean section (CS) and to record the time spent by doctors attending such deliveries.
Methods. Data were collected prospectively on all elective CSs performed at Groote Schuur Hospital over a 3-month period. Data collected included: total time involved for paediatrician from call to leaving theatre, management of infant (requiring any form of resuscitation), Apgar scores and neonatal outcome (e.g. admission to nursery). The CSs were classified as low-risk or high-risk (multiple pregnancy, prematurity, growth restriction, abnormal lie, general anaesthetic or known congenital abnormality).
Results. Data were recorded for 138 deliveries. Three were excluded as they were not elective CS. One hundred and fifteen deliveries were classified as uncomplicated and 20 as high-risk. Only 1 of the babies born from the 115 low-risk CSs needed brief resuscitation, whereas 9 of the 20 high-risk deliveries resulted in newborn resuscitation. The reasons for low-risk CS were: previous CS (81); infant of diabetic mother (IDM) and previous CS (16); IDM alone (6); estimated big baby (10); and other (2).The average time spent at each elective CS by the paediatrician was 37 minutes.
Conclusion. For low-risk CS, the same medical attendance (i.e. a midwife) as for an uncomplicated normal vaginal delivery (NVD) would be appropriate; this can free a doctor for other duties, and assist in de-medicalising a low-risk procedure.
Mental health service delivery in South Africa from 2000 to 2010 : one step forward, one step back : original articleSource: South African Medical Journal 101, pp 751 –757 (2011)More Less
Objectives. To identify progress and challenges in mental healthcare in South Africa, as well as future mental health services research priorities.
Method. A systematic review of mental health services research. Literature searches were conducted in Medline, PsychInfo and Sabinet databases from January 2000 to October 2010 using key phrases. Hand searches of key local journals were also conducted. Of 215 articles retrieved, 92 were included. Data were extracted onto a spreadsheet and analysed thematically.
Results. While progress in epidemiological studies has been good, there is a paucity of intervention and economic evaluation studies. The majority of studies reviewed were on the status of mental healthcare services. They indicate some progress in decentralised care for severe mental disorders, but also insufficient resources to adequately support community-based services, resulting in the classic revolving-door phenomenon. Common mental disorders remain largely undetected and untreated in primary healthcare. Cross-cutting issues included the need for promoting culturally congruent services as well as mental health literacy to assist in improving help-seeking behaviour, stigma reduction, and reducing defaulting and human rights abuses.
Conclusion. While there has been some progress in the decentralisation of mental health service provision, substantial gaps in service delivery remain. Intervention research is needed to provide evidence of the organisational and human resource mix requirements, as well as cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.
Source: South African Medical Journal 101, pp 758 –759 (2011)More Less
Objective. Sexual assault evidence collection kits (SAECKs) are used to collect evidence for DNA recovery after rape. The aim of this study was to assess the extent of completion of the kits by health care workers in 6 provinces of South Africa.
Methods. A cross-sectional study was conducted to code SAECKs that were analysed at one forensic science laboratory in South Africa.
Results. The findings from 204 SAECKs that were analysed are presented. The study found that none of the SAECKs complied fully with administrative quality requirements. Almost all of the specimens that were collected were analysed, except for pubic and head hair specimens that were rarely collected and analysed. A quarter of SAECKs did not have one of the three genital specimens collected. The presence and availability of all three genital swabs for forensic DNA analysis were found to be significant as this increased the chance of evidence recovery and obtaining a foreign forensic DNA profile. In 80% of cases, the DNA matched the suspect.
Conclusions. The importance of administrative quality and the significance of collecting all three genital specimens should be emphasised in training programmes for health care workers. The study raises questions related to other aspects of sexual assault services and has implications regarding the overall quality of care that survivors receive.
Acute hospitalisation needs of adults admitted to public facilities in the Cape Town Metro district : original articleSource: South African Medical Journal 101, pp 760 –764 (2011)More Less
Introduction. Public health care delivery in South Africa aims to provide equitable access at the most appropriate level of care. We studied to what extent the acute health care needs of adults admitted to public hospitals in the Cape Town Metropole were being appropriately met.
Methods. A retrospective study was conducted of the hospital records of adults admitted to medical beds in public hospitals in Cape Town between August and November 2008. Intensive care unit patients were not included.
Results. Of 802 beds in use, the estimated occupancy was at least 95%. The average time elapsed since admission was 7.9 days; 94.3% of medical admissions were acute; 45% were severely to critically ill on admission; and co-morbid disease was present in 78.1%. Of all admissions, 31.9% were HIV-positive, and 17% had active tuberculosis. At least 396 (51.6%) patients were deemed to have required specialist or subspecialist consultation to expedite appropriate care; 386 (50.3%) accessed the appropriate level of medical care required; 339 (44.2%) accessed a more sophisticated level of care than required; and 42 (5.5%) did not access an adequate level of care. CT scan and ultrasound accounted for 59% of all restricted tests done.
Conclusions. Our findings support the plan to provide more primary care hospital facilities in the metropolitan area. Most patients needing specialised care are accessing such care, and most patients accessing a higher level of care than needed can be addressed by ensuring that they first access primary care and are referred according to protocols.
Family-witnessed resuscitation in emergency departments : doctors' attitudes and practices : original articleSource: South African Medical Journal 101, pp 765 –767 (2011)More Less
Background. Resuscitation of patients occurs daily in emergency departments. Traditional practice entails family members remaining outside the resuscitation room.
Objective. We explored the introduction of family-witnessed resuscitation (FWR) as it has been shown to allow closure for the family when resuscitation is unsuccessful and helps them to better understand the last moments of life.
Results. Attending medical doctors have concerns about this practice, such as traumatisation of family members, increased pressure on the medical team, interference by the family, and potential medico-legal consequences. There was not complete acceptance of the practice of FWR among the sample group.
Conclusion. Short-course training such as postgraduate advanced life support and other continued professional development activities should have a positive effect on this practice. The more experienced doctors are and the longer they work in emergency medicine, the more comfortable they appear to be with the concept of FWR and therefore the more likely they are to allow it. Further study and course attendance by doctors has a positive influence on the practice of FWR.
A novel CYBB mutation with the first genetically confirmed case of chronic granulomatous disease in South Africa : original articleSource: South African Medical Journal 101, pp 768 –769 (2011)More Less
A case of a child with chronic granulomatous disease (CGD) presenting with recurrent mycobacterial infections and invasive Aspergillus fumigatus disease is described. Genetic analysis confirmed X-linked CGD with a novel mutation in exon 10 of the CYBB gene - the first South African report of genetically confirmed CGD.