South African Medical Journal - Volume 103, Issue 10, 2013
Volumes & issues
Volume 103, Issue 10, 2013
Source: South African Medical Journal 103, pp 736 –742 (2013)More Less
Background. Voluntary medical male circumcision (VMMC) is a priority HIV preventive intervention. To facilitate male circumcision scale-up, the World Health Organization is actively seeking circumcision techniques that are quicker, easier, and safer than open surgical methods.
Objective. To compare conventional open surgical circumcision with suturing with a minimally invasive technique using the Gomco circumcision clamp plus tissue adhesive.
Methods. We conducted a non-blinded randomised controlled trial comprising 200 male volunteers >18 years of age, seen at the outpatient university teaching clinic of the Catholic University of Mozambique. We compared two interventions - open surgical circumcision with suturing v. Gomco instrument plus tissue adhesive. Our primary outcome was intraoperative time and our secondary outcomes included: ease of performance, post-operative pain, adverse events, time to healing, patient satisfaction and cosmetic result.
Results. The intraoperative time was less with the Gomco/tissue adhesive technique (mean 12.8 min v. 22.5 min; p<0.001). Adverse events were similar except that wound disruption was greater in the Gomco/tissue adhesive group, with no difference in wound healing at 4 weeks. Levels of satisfaction were high in both groups. The cosmetic result was superior in the Gomco/tissue adhesive group.
Conclusions. This study has important implications for the scale-up of VMMC services. Removing the foreskin with the Gomco instrument and sealing the wound with cyanoacrylate tissue adhesive in adults is quicker, is an easier technique to learn, and is potentially safer than open surgical VMMC. A disposable plastic, Gomco-like device should be produced and evaluated for use in resource-limited settings.
Quantifying the disparity in outcome between urban and rural patients with acute appendicitis in South Africa : researchSource: South African Medical Journal 103, pp 742 –745 (2013)More Less
Background. Acute appendicitis in South Africa is associated with higher morbidity than in the developed world.
Objective. To compare outcomes of urban and rural patients in KwaZulu-Natal and to determine whether there are disparities in outcome.
Methods. We conducted a prospective study from September 2010 to September 2012 at Edendale Hospital in Pietermaritzburg, South Africa. All patients who presented with acute appendicitis were included. The operative and clinical course of urban and rural patients was compared.
Results. A total of 500 patients were included, with 200 patients in the rural group and 300 in the urban group. Those from the rural group had a significantly longer duration of symptoms prior to presentation. All septic parameters were significantly worse in the rural group. Significantly more patients from the rural group required a laparotomy (77% v. 51% urban; p<0.001). Inflamed, non-perforated appendicitis was more commonly seen in the urban group (52.3% v. 21% rural; p<0.001), while perforated appendicitis was much more common in the rural group (79% v. 47.7% urban; p<0.001). Perforation associated with generalised, four-quadrant intra-abdominal contamination was significantly higher in the rural group than the urban group (60.5% v. 21%, respectively; p<0.05). Significantly more patients from the rural group required an open abdomen (46% v. 12% urban; p<0.001) and ≥1 re-laparotomies to control severe intra-abdominal sepsis (60.5% v. 23.3% urban; p<0.001).
Conclusion. We have identified rural origin as an independent indicator of poor outcome. Possible reasons may include difficulty in accessing the health system or delay in transfer to a regional hospital. These need to be investigated further.
The South African Vascular Surgical Cardiac Risk Index (SAVS-CRI) : a prospective observational study : researchSource: South African Medical Journal 103, pp 746 –750 (2013)More Less
Background. Recent evidence suggests that application of the Revised Cardiac Risk Index (RCRI) for peri-operative cardiovascular risk stratification in vascular surgery patients may be inappropriate, necessitating the development of risk indices specific to vascular surgery patients.
Objectives. To identify risk factors for cardiovascular morbidity and mortality in South African patients undergoing major vascular surgery, and to develop an appropriate cardiovascular risk stratification index, the South African Vascular Surgical Cardiac Risk Index (SAVS-CRI), which could be used to predict the risk of peri-operative major adverse cardiovascular events (MACEs) in South African vascular surgery patients.
Methods. We prospectively collected data related to peri-operative MACE occurrence and established risk factors for peri-operative MACEs from adult patients who underwent elective vascular surgery at a tertiary hospital in Durban, South Africa, between February 2008 and March 2011. We determined independent predictors of peri-operative MACEs in our cohort by binary logistic regression and used the identified predictors to create a risk index that stratified patients into low-, intermediate- or high-risk groups.
Results. Six independent predictors of peri-operative MACEs were identified in the vascular surgery cohort: age >65 years, a history of ischaemic heart disease, a history of diabetes, chronic β-blockade, prior coronary revascularisation, and the vascular surgical procedure. The risk model derived from these risk factors appeared to discriminate between the three risk groups more accurately than the RCRI.
Conclusion. The RCRI is not appropriate for peri-operative cardiovascular risk stratification in vascular surgery patients. The SAVS-CRI may be preferable for risk stratification in South African vascular surgery patients, although independent validation is required.
Source: South African Medical Journal 103, pp 751 –753 (2013)More Less
Objective. To determine the national distribution of intensive care unit (ICU)/high care (HC) beds and the implications for ICU bed availability in the envisaged national health insurance (NHI) scheme.
Methods. A descriptive, non-interventional, observational study design was used. A desk-top audit of all public and private sector ICUs, including ICU/HC beds, in South Africa was undertaken for the period 2008 - 2009. For this study, both categories were analysed and referred to as ICU beds, as they reflect the critical care component of the health service in South Africa.
Results. In 2008 - 2009, there were 4 719 ICU beds in the private and public sectors in South Africa, with 75% (3 533) in the former and 25% (1 186) in the latter. The majority of ICU beds in the two sectors were located in three provinces: Gauteng (49%), KwaZulu-Natal (14%) and Western Cape (15%), representing 78% of ICU beds (3 703/4 719) and catering for 54% of the country's population. Eastern Cape had fewer than 300 beds, North West and Mpumalanga had fewer than 150 beds, and Limpopo and Northern Cape had 66 and 47 beds respectively. With the proposed NHI scheme, the number of ICU beds available would be 4 719, which would translate into a bed:population ratio of approximately 1:10 000. However, there are large variations across the provinces, which makes the availability of this level of care in some provinces non-existent.
Conclusion. While increasing the number of ICU beds in the public sector will open critical care services to more users, the NHI scheme would not solve the huge discrepancies of access to ICUs, and availability of critical care staff, across the provinces.
Source: South African Medical Journal 103, pp 754 –757 (2013)More Less
Background. Healthcare services in KwaZulu-Natal (KZN) frequently experience shortages of blood products. Alternatives to traditional blood sources are needed. One possibility is cell salvage and autologous blood transfusion. Few data exist relating to their use in the South African context.
Objectives. To ascertain whether cell salvage (CS) is beneficial, feasible and economical in our setting, with the anticipation that results would excite further studies and potentially change current practice and improve existing protocols.
Methods. This study reviewed current intraoperative Cell Saver use at Grey's and Edendale hospitals in Pietermaritzburg, KZN. Current practices were observed and compared with the costs of the equivalent amount of red cell concentrate (RCC) purchased from the South African National Blood Service (SANBS). All cases of Cell Saver usage over a 1-year period from July 2012 to June 2013 were analysed.
Results. The total volume of blood transfused from CS was 55 735 ml, approximately equivalent to 186 RCC units. The comparative cost of equivalent units of RCC from SANBS was R258 445. The total cost of Cell Saver disposables during the study period was R206 047, or R263 478 when Cell Saver machine depreciation costs were included. More than one CS blood unit was available for transfusion in 66% of cases. No additional staff were required to operate the Cell Saver, which was successfully used by medical officers.
Conclusions. This study showed that intraoperative CS use is feasible, has potential patient benefit by reducing blood bank blood transfusion, and is financially comparable to purchasing the equivalent number of SANBS RCC.
HIV-associated neurocognitive disorders : antiretroviral regimen, central nervous system penetration effectiveness, and cognitive outcomes : researchSource: South African Medical Journal 103, pp 758 –762 (2013)More Less
Background. The human immunodeficiency virus (HIV) can give rise to a spectrum of neuropsychological impairments known collectively as HIV-associated neurocognitive disorders (HAND). Although antiretroviral therapy (ART) has reduced the incidence of HIV dementia, the prevalence of milder forms of HAND has increased. It has been postulated that incomplete central nervous system (CNS) viral suppression or potential drug toxicity, both of which could be related to the CNS penetration effectiveness (CPE) of ART regimens, may contribute to this phenomenon.
Objective. This study compared cognitive outcomes in clade C-infected HIV patients in South Africa treated for 1 year with ART regimens with differing CPE scores.
Methods. We assessed 111 HIV-positive patients with varying levels of cognitive function at baseline (pre-ART) and then a year later. A neuropsychological battery was administered at both visits to derive global deficit scores. ART regimen data were collected at the follow-up visit. Some participants remained ART-naïve during this period, thus providing a non-treatment control group.
Results. Significantly more ART recipients maintained or improved cognitive function compared with patients not on ART (p=0.017). There was no significant difference in cognitive outcomes between higher and lower CPE regimen groups (p=0.473).
Conclusions. ART preserves or improves cognition in HIV-infected patients after 1 year, irrespective of the regimen's CPE. South Africa's current low CPE-scored first-line regimen performed as well as higher CPE-scored regimens. These findings are reassuring for South Africa, but larger, longer-term studies would be more definitive.
Source: South African Medical Journal 103, pp 763 –766 (2013)More Less
Current South African Road Accident Fund (RAF) legislation requires a medical determination of the seriousness of injuries sustained in motor vehicle accidents to determine whether the claimant is entitled to a claim for general damages. Such medical assessments are submitted in the form of RAF 4 Serious Injury Assessment Reports. Contested claims for serious injury are referred to the Health Professions Council of South Africa (HPCSA) Appeal Tribunals for final determination. The legislation prescribes 2 instruments, namely the American Medical Association (AMA) Guides (6th edition) and the Narrative Test for this purpose. Whereas the AMA Guides are published in a comprehensive book, and training courses are provided in their use, existing legislation does not provide any indication of the required structure, content or criteria of a Narrative Test report. This document is published by the HPCSA Appeal Tribunals as a guideline to the performance of the Narrative Test; what it is, reasons for applying it and who should compile it, as well as the required structure, content and criteria thereof. A Narrative Test Report should include relevant and meaningful comment in relation to each of the 6 sections described in the article.
Source: South African Medical Journal 103 (2013)More Less
South Africa (SA) is one of 34 malaria-endemic countries that are currently targeting elimination of the disease. This supplement of the SAMJ documents SA's remarkable public health achievement in moving from malaria control to the threshold of elimination (zero local transmission in a defined geographical area). Nevertheless, SA's malaria programme still needs to travel some distance before it attains its goal of elimination by 2018. The articles in this supplement pay tribute to sterling efforts by dedicated persons who contributed and guided policies and interventions, not only in SA, but also elsewhere on the African continent and globally. These pioneering efforts deserve high-level recognition. The key lesson from early malaria control is that hard-won gains are rapidly lost when important control measures are curtailed, especially in low-transmission settings. Progress on every front, and at every level, is fragile. Malaria is a disease that can take full advantage of any lapse in investment, vigilance or control.
Source: South African Medical Journal 103, pp 770 –778 (2013)More Less
In Africa today, the drive towards controlling malaria is comparable with efforts made in the 1950s and 1960s during the World Health Organization's Global Malaria Eradication Campaign. Unlike the Eradication Campaign that 'covered' the globe but excluded Africa, the current endeavours focus on Africa, but not to the exclusion of the rest of the tropical and sub-tropical world. Major donor agencies are partnering with African governments in an attempt to curb transmission of malaria parasites, and in some countries on the edges of the distribution of malaria, there is talk of eliminating the disease. South Africa is at the very southernmost fringe of malaria distribution on the African continent and has a long history of intense malaria control activities. This article looks at what South Africa has achieved in the past and where it needs to go in the future, not only to maintain the status quo, but hopefully to eliminate transmission of the disease within its borders.
Source: South African Medical Journal 103, pp 779 –783 (2013)More Less
Locally specific epidemiological understanding is pivotal to the success of malaria elimination in South Africa. Here, we focus on how the host, vector, parasite and environment and their interactions have influenced malaria incidence in South Africa between 1995 and 2012. Broad environmental considerations are necessary, including the physical (temperature and humidity), social (migration patterns), economic (quality of housing stock) and political (regional collaboration).
Source: South African Medical Journal 103, pp 784 –788 (2013)More Less
Malaria vector control is primarily insecticide based and relies on indoor residual spraying (IRS) and the distribution of long-lasting insecticide-treated bednets (LLINs). These interventions have generally proved effective where appropriately implemented. However, the increasing incidence of insecticide resistance in target vector populations can, and in several cases already has, undermined the effectiveness of IRS and LLINs. Today there are very few localities on the African continent where populations of vector mosquitoes are still susceptible to the approved classes of insecticides. If elimination is to be achieved, SA needs to invest more resources into malaria control.
Source: South African Medical Journal 103, pp 789 –793 (2013)More Less
Laboratory diagnosis of malaria in South Africa has traditionally relied on microscopic examination of stained blood films. More recently, rapid diagnostic tests (RDTs) have been introduced into routine use, and molecular methods like polymerase chain reaction are useful in certain situations. As with all laboratory tests, each technique has its advantages and disadvantages. Microscopy and RDTs, if appropriately quality assured, are adequate for clinical case management. For elimination, active surveillance will need to be expanded substantially, with wider use of more sensitive diagnostic nucleic acid amplification techniques, and/or serology. To facilitate surveillance activities, techniques suitable for field or near-field use would be ideal. A long-running external quality assessment programme in South Africa has shown some deficiencies in the quality of malaria diagnosis in routine laboratories. Quality systems across the spectrum of diagnostic facilities in South Africa need strengthening, to ensure progress towards elimination.
Source: South African Medical Journal 103, pp 793 –798 (2013)More Less
Malaria case management is a vital component of programmatic strategies for malaria control and elimination. Malaria case management encompasses prompt and effective treatment to minimise morbidity and mortality, reduce transmission and prevent the emergence and spread of antimalarial drug resistance. Malaria is an acute illness that may progress rapidly to severe disease and death, especially in non-immune populations, if not diagnosed early and promptly treated with effective drugs. In this article, the focus is on malaria case management, addressing treatment, monitoring for parasite drug resistance, and the impact of drug resistance on treatment policies; it concludes with chemoprophylaxis and treatment strategies for malaria elimination in South Africa.
Source: South African Medical Journal 103, pp 799 –800 (2013)More Less
Source: South African Medical Journal 103, pp 801 –806 (2013)More Less
In this supplement, several authors have shared lessons from the past and identified factors that led to the significant reductions in malaria morbidity and mortality during the past half-century in South Africa. In addition, strategies for achieving malaria elimination have been proposed. Here, we highlight the gaps that have been identified and make proposals for taking South Africa from malaria control to elimination.