South Africa is a developing country reliant on selling resources. Its financial health and the health of its citizens are massively dependent on and influenced by its mines. The importance of the mining industry can be gauged from a look at some figures - for example, in 2009 the South African mining industry had over 1 000 mines and 483 212 employees; 168 888 were in platinum, 148 832 in gold, 68 006 in coal, and the rest in other commodities. The 16 August 2012 shooting by police that resulted in the death of 34 striking Lonmin mine workers in what has become known as the 'Marikana massacre', and its aftermath, have cost the country billions in damage to property and lost export income. Miners and their families, especially those who wished to work, have suffered severe hardship.
Nineteenth-century mortality rates?
Deliberate self-harm by ingestion of agricultural insecticides burdens limited critical care facilities
Late termination of pregnancy by intracardiac KCl injection
Lymphoma or tuberculosis?
The intimate examination - chaperone or not?
An update on office spirometry
I was surprised to read that Schoon and Motlolometsi were not able to find any clear job description or scope of practice for advanced midwives (ADMs) in this country. Both were clearly defined in KwaZulu-Natal in 1980, when the first ADM training programme was established at King Edward VIII Hospital, Durban.
In October 2012, Shinya Yamanaka and Sir John Gurdon were awarded the Nobel Prize in Physiology or Medicine for their pioneering research into the reprogramming of mature cells into a pluripotent state. The technology developed by Yamanaka and colleagues allows researchers to turn terminally differentiated somatic cells back into a stem-cell state. These induced pluripotent stem cells (iPSCs) can be cultured indefinitely in the laboratory, and can undergo directed differentiation into any cell type of interest. This is highly beneficial for disease-modelling studies, since researchers are able to culture cells that are not normally obtainable, such as neurons or retinal cells. Furthermore, the differentiated cells can be used to test potential therapies in patient-derived cells, and may even be used for future therapeutic cell transplantation.
I am a specialist in private practice. A patient recently asked for a quotation for an operation, and I supplied her with the relevant codes and pricing structures. As we have no contracts with medical aids she was advised to contact her insurer to ascertain which payments she could expect. Obtaining this information from them was a challenge. She was informed that they could not provide an estimate as to which part of the cost they would cover (thankfully, she was not regaled with the usual 'we refund 100%, 200% and even 300% of the bill'). She was also told that they had not heard of code 0023, which is the anaesthetic modifier for time that must feature on an anaesthetic account and with which most funders are familiar.
David Hall (my previous Professor of Child Health in the UK, who always hoped to make a contribution to child health in South Africa) and others emphasise the importance of the child health approach in delivering healthcare for children.
A Paarl neurosurgeon claims to be on his way to a world first in repairing spinal cord injuries using therapeutic stem cell cloning, having removed 35 mm from the spinal cord of a quadriplegic man and injecting a 'special' matrix of the cells into the defect.
The South African health sector, long-riven by point-scoring across the public/private divide, has crossed its own Rubicon with the R40 million start-up social compact between government and 23 major health corporates aimed at addressing the dual human resource and management crises.
Since the first controversial public showing in Manheim's Museum for Technology and Labour 15 years ago, more than 13 000 people have signed up to donate their bodies for plastination, inspired by Body Worlds - dubbed the most successful touring exhibition ever (35 million viewers).
The phone of attorney Michael Bagraim, who co-ordinated the Abu Dhabi defence of Cape Town's Professor Cyril Karabus on manslaughter and forgery charges has been 'ringing off the hook' as hundreds of now-frightened healthcare professionals seek advice.
In an ironic twist, the absence of clinical notes sufficient to properly rule on manslaughter and forgery charges brought in the United Arab Emirates (UAE) against 77-year-old veteran Cape Town oncologist Professor Cyril Karabus may have led to his acquittal.
Created from adult rather than embryonic cells, induced pluripotent stem (iPS) cells represent a breakthrough in stem cell science, and their pioneers have been recognised with the 2012 Nobel Prize in Medicine. These cells offer new hope in the treatment of pathogenetic diseases, but there is still a way to go on the road to effective therapeutic applications.
To assist our readers in their understanding of ''Pioneer' Paarl neuro sets alarm bells ringing' in Izindaba (p. 8-9), the SAMJ sought the opinions of Professor Susan Kidson (SK), one of SA's foremost stem cell scientists. Based on her insights into the stem cell transplant undertaken on Mr Tommie Prins at the hands of neurosurgeon Dr Adriaan Liebenberg, she offered the following in relation to the stepwise production of suitable stem cells. Dr Gert Jordaan (GJ) was then approached to explain his methodology in raising the stem cells used for the transplant. Dr Jordaan's reply was received in Afrikaans, an English translation of which is supplied. We believe that the debate will continue..
The causes of the poor health status of the South African population are probably multifactorial, but to be socially accountable we must ensure that the education and training of health professionals continue to be aligned with the population's health needs.
The authors of a seminal report published in the Lancet in 2010 provide guidelines for the future training of health professionals. Since November 2010, this report, together with other guiding publications, informed a series of strategic initiatives undertaken by the Undergraduate Education and Training subcommittee of the Medical and Dental Professions Board of the Health Professions Council of South Africa (HPCSA). These initiatives seek to ensure alignment of the training of health professionals in South Africa (SA) with the health needs of the population and with international educational norms and standards. These initiatives are described and the role of the HPCSA in guiding the education and training of SA's health professionals is explored.
Medical management is a recognised specialty in many developing and developed countries, including Australia, India, New Zealand, Pakistan and Sri Lanka. In South Africa it was recognised as a sub-specialty in the 1990s, but this is no longer the case. The South African Society of Medical Managers, in close collaboration with the Division of Medical Management of the College of Public Health Medicine of South Africa, has been working to re-establish the specialty of medical management in South Africa. Well-trained specialist medical managers would play a significant role in the effective and efficient implementation of National Health Insurance and primary healthcare re-engineering through the practice of evidence-based health care, clinical economics and administrative medicine.
The implementation of the National Health Insurance (NHI) scheme will place pathology services under increased pressure. Improvement of access to healthcare will increase demand for diagnostic testing, both for clinical diagnosis in disease states and for screening of healthy people. It is unlikely that the publicly funded budgets for pathology diagnostic services under the National Health Laboratory Service (NHLS) will increase to keep up with the demand. Furthermore, developments in new tests and the introduction of new technology in laboratory medicine will increase the overall costs. Coupled with the progressive decline in the teaching of pathology and laboratory medicine in the undergraduate curriculum, there is likely to be a tendency towards inappropriate usage of laboratory tests in clinical management.
Background. Despite the clear prohibition against sexual relations with one's patients, complaints of a sexual nature against practitioners registered with the Health Professions Council of South Africa (HPCSA) have been increasing. The HPCSA does not provide ethical guidelines regarding the use of a chaperone during intimate examinations.
Aims. (i) To ascertain how a group of medical practitioners felt about the presence of chaperones during the consultation and intimate examination of patients; (ii) to determine whether they currently engage the services of chaperones; (iii) to assess how they felt about consensual sexual relationships between medical practitioners and their patients.
Methods. A self-administered, questionnaire-based survey was distributed to gynaecologists and medical practitioners.
Results. There was a 43% response rate with 72% of practitioners in favour of using a chaperone during an intimate examination, although only 27% always do so. Most practitioners felt that consensual sexual relationships with patients are unacceptable; 83% felt that ethical guidelines on this topic were needed.
Conclusion. The HPCSA should develop guidelines on the use of chaperones to assist practitioners. With medical litigation increasing, using chaperones will benefit patients and practitioners.
Background. Despite the challenges facing healthcare in South Africa, empirical insights into the performance of healthcare services over time are scarce.
Methods. We analysed first admissions of adult medical inpatients to Groote Schuur Hospital, Cape Town, from January 2002 to July 2009. Data included age, sex, medical specialty, and date of admission and discharge. We used population group and hospital billing codes as proxy measures for socio-economic status (SES). We calculated the duration of stay in days from the date of admission to discharge, and inpatient mortality rates per 1 000 patient days. Poisson regression was used to estimate mortality rate ratios (MRR) in unadjusted analysis and after adjusting for potential confounders.
Results. There were 42 582 first admissions. Patient demographics shifted towards a lower SES. Median age decreased from 52 years in 2002 to 49 years in 2009, while patients aged 20 - 39 years increased in proportion from 26% to 31%. The unadjusted proportion of admissions which resulted in in-hospital deaths increased from 12% in 2002 to 17% in 2009. Corresponding mortality rates per 1 000 patient days were 17.0 (95% confidence interval (CI) 15.9 - 18.3) and 23.4 (95% CI 21.6 - 25.4), respectively (unadjusted MRR 1.37; 95% CI 1.23 - 1.53). Annual increases in mortality rates were highest during the first 2 days following admission (increasing from 30.1 to 50.3 deaths per 1 000), and were associated with increasing age, non-paying patient status, black population group and male sex, and were greatest in the emergency ward (adjusted MRR 1.73, comparing 2009 with 2002; 95% CI 1.49 - 2.01).
Discussion. Increasing medical inpatient mortality rates at a large South African academic hospital were most marked during the first 2 days after admission and appeared greatest among emergency medical inpatients.
Background. Since 1970, the incidence of lymphoma, a potentially curable disease, has risen by 80% in the general population and in HIV-positive patients. Given its clinical similarities to tuberculosis (TB), lymphoma may be misdiagnosed and patients treated unnecessarily with potentially harmful TB medication.
Objectives. (i) To identify patients with a histological diagnosis of lymphoma who were previously misdiagnosed with TB; and (ii) to raise awareness of lymphoma as a differential diagnosis when TB has not been confirmed.
Method. A retrospective study was conducted at Ngwelezane Hospital in rural KwaZulu-Natal, which serves an estimated population of 3 million. Using clinic notes and a questionnaire for patients attending the lymphoma clinic, we identified patients who had undergone failed TB treatment in the 12 months before their histological confirmation of lymphoma.
Results. Twenty-one patients were included; 18 had been diagnosed with TB in the 12 months preceding the histological confirmation of lymphoma. All these patients subjectively reported TB treatment failure.
Conclusions. Delay in diagnosing lymphoma or its misdiagnosis is an important clinical problem in South Africa, with the condition often misdiagnosed as TB. This subjects patients to incorrect treatment and potential harm. We propose an algorithm for the work-up of patients presenting with lymphadenopathy +/- constitutional symptoms, to assist diagnosis and management in resource-poor settings.