South African Medical Journal - Volume 103, Issue 2, 2013
Volumes & issues
Volume 103, Issue 2, 2013
Source: South African Medical Journal 103, pp 65 –66 (2013)More Less
There are no schools for medical editors. So warned Dan Ncayiayana, editor emeritus of the SAMJ. He is correct. Editorship is learned on the job. I have been fortunate to be the mentee of the retiring, but not-yet-retired, managing editor, J P van Niekerk, as I proudly assume the role of editor of this journal. And there is a plethora of writings on the subject, a distillation of which is offered here.
Source: South African Medical Journal 103, pp 69 –71 (2013)More Less
For Tim Noakes, the University of Cape Town's 'great centenary debate' on what constitutes a healthy diet was a 'kangaroo court', deliberately set up to discredit the 'inconvenient and threatening truths' behind his relatively recent and much-touted high-fat, no sugar, no carbohydrates eating regimen.
Source: South African Medical Journal 103, pp 71 –73 (2013)More Less
Médecins Sans Frontières (MSF) has once again paved the way in local HIV/AIDS treatment, this time piloting ART adherence clubs in Khayelitsha outside Cape Town, improving adherence (and thus sustained virological suppression and immunological recovery) over mainstream care by a full 12%.
Author David WilliamsonSource: South African Medical Journal 103, pp 75 –76 (2013)More Less
Professor Fraser Ross died on 2 October 2012, weeks before his 90th birthday, and after a few years of deteriorating health which he bore with stoicism and dignity. Born in Monifieth, Scotland, Fraser excelled athletically and academically at school and university. On the prestigious Harkness Scholarship, he attended the University of St Andrews, graduating with a BSc and MB ChB in 1946.
Author Eugene MaraisSource: South African Medical Journal 103 (2013)More Less
Jacobus (Cobus) Carolus van Graan is op 10 November 1941 op Swartruggens in Noord-Wes-provinsie gebore. Hy voltooi sy skoolloopbaan op Swartruggens, en doen daarna vir twee jaar diensplig in die Suid-Afrikaanse Lugmag. Daarna studeer hy BA liggaamlike opvoedkunde aan die Universiteit van Pretoria (UP), met die doel om onderwyser te word.
The 2011 United Nations High-Level Meeting on Non-Communicable Diseases : the Africa agenda calls for a 5-by-5 approach : forum - issues in medicineSource: South African Medical Journal 103, pp 77 –79 (2013)More Less
The High Level Meeting of the 66th Session of the United Nations General Assembly was held in September 2011. The Political Declaration issued at the meeting focused the attention of world leaders and the global health community on the prevention and control of noncommunicable diseases (NCDs). The four major NCDs (cardiovascular diseases, cancer, diabetes and chronic respiratory diseases) and their four risk factors (tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol) constitute the target of the '4-by-4' approach, which is also supported by national and international health organisations.
We argue that while preventing these eight NCDs and risk factors is also important in Africa, it will not be enough. A '5-by-5' strategy is needed, addressing neuropsychiatric disorders as the fifth NCD; and transmissible agents that underlie the neglected tropical diseases and other NCDs as the fifth risk factor. These phenomena cause substantial preventable death and disability, and must therefore be prioritised.
Author B.D. SchoubSource: South African Medical Journal 103 (2013)More Less
Here we provide recommendations for the use of viral vaccines in anticipation of the 2013 Southern Hemisphere influenza season. For a review of the 2012 influenza season, please refer to the website of the National Institute for Communicable Diseases of the National Health Laboratory Service (http://www.nicd.ac.za).
'But it's just a spinal' : combating increasing rates of maternal death related to spinal anaesthesia : forum - clinical practiceSource: South African Medical Journal 103, pp 81 –82 (2013)More Less
The number of women dying as a result of spinal anaesthesia during caesarean section in South Africa is steadily increasing in the triennial reports of the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD). This article postulates some of the reasons behind this phenomenon. The concern is raised that spinal anaesthesia is being undertaken inappropriately by poorly trained practitioners. A case is made for the rigorous application of known safety standards and for doctors to be appropriately trained in anaesthesia and to be solely responsible for the care of the mother during caesarean section. The need for doctors to be trained and prepared to administer general anaesthesia when required is noted.
Counting the cost : the consequences of increased medical malpractice litigation in South Africa : editorialAuthor J. MalherbeSource: South African Medical Journal 103, pp 83 –84 (2013)More Less
We live in uncertain times. The recession in Europe and ongoing political instability in the Middle East are each examples of what could legally be termed a 'statement of fact'. The rising cost of healthcare in South Africa is another fact. This phenomenon is accompanied by an even more disturbing trend: a steep rise in medical malpractice litigation. An important question to consider is what effect this increase is having on healthcare provision in South Africa generally.
Analysis of time to regulatory and ethical approval of SATVI TB vaccine trials in South Africa : researchSource: South African Medical Journal 103, pp 85 –89 (2013)More Less
Background. Tuberculosis (TB) vaccine trials in South Africa must be approved by the Medicines Control Council (MCC) and by a human research ethics committee (HREC). Delays in regulatory and ethical approval may affect operational and budget planning and clinical development of the product.
Aim. Our aim was to analyse the time to regulatory and ethical approval for TB vaccine trials conducted by the South African Tuberculosis Vaccine Initiative (SATVI) and to evaluate factors that influence time to final approval.
Method. Sixteen new TB vaccine clinical trials conducted by SATVI between 2004 and 2012 on infants, children, and adults were included. The period between submission and final approval was determined for protocols submitted to the MCC and the University of Cape Town HREC.
Results. Median approval time following first submission to the MCC was 122 days (IQR 112 - 168; range 71 - 350), and for protocol amendments 103 days (interquartile range (IQR) 76 - 141; range 23 - 191; n=30). Median time following first submission for HREC approval was 60 days (IQR 33 - 81; range 18 - 125), and for amendments 6 days (IQR 4 - 13; range 1 - 37; n=30). There was no significant difference in approval time by trial phase, year of submission, revisions required, study population, sample size, or whether a clinical research organisation (CRO) was used.
Conclusion. The time needed for regulatory and ethics approval was highly variable, but MCC approval for first submissions took twice as long as HREC approval and was the primary determinant of time to final approval. National regulatory capacity should be strengthened to facilitate the conduct of new TB vaccine trials in this country with its high burden of TB.
Source: South African Medical Journal 103, pp 89 –93 (2013)More Less
Background. Healthcare has become a major expense. Burnout and its connection with psychological and physical health is well researched, yet little research has been done on the connection between burnout and financial outcomes, specifically as indicated by the costs incurred by medical aid providers as a result of members' claims.
Objective. To investigate the connection between employee burnout and medical aid claims and expenditure data in a sample from the private sector.
Method. A cross-sectional design was used. The sample comprised 3 182 participants. The available objective medical aid expenditure data connected with each participant were: total insured benefits, general practitioner visits, specialist visits, general practitioner insured benefits, and claims for medicine. A low and a high burnout group were extracted, based on comorbidity of the two core components of burnout. Analysis of covariance (ANCOVA) was then applied to investigate the differences in estimated marginal means of the expenditures on the low and the high burnout contrast groups, while controlling for age and gender.
Results. The high burnout group frequented a general practitioner more often, and the medical aid provider expenditure was nearly double that of the low burnout group, on all the variables. Specialist visits did not show a significant result.
Conclusion. High burnout is associated with a higher expenditure by a medical aid provider, compared with low burnout, per member. Stakeholders should therefore address burnout to reduce expenditure and promote health.
Learner-to-learner visual acuity screening : a solution for early identification of visual acuity disabilities : researchSource: South African Medical Journal 103, pp 94 –95 (2013)More Less
Background. The National School Health Policy guidelines (2002) stipulate that primary school learners should have their vision, speech, hearing, mental health, teeth, nutrition and development screened annually. In reality, especially in under-resourced areas such as the Eastern Cape, many learners with disabilities are not identified, with profound consequences for their ability to learn.
Method. This article describes a cost-effective and community-empowering solution, Learner-to-Learner Visual Acuity Screening, whereby secondary school learners were trained to conduct basic visual acuity (VA) eye screening for foundation-phase learners.
Results. Of a group of Grade R learners, 30% were identified as having impaired VA and referred for ophthalmic or optometric evaluation.
Conclusions. This project created greater awareness among learners, parents and teachers regarding abnormal VA and increased interaction between secondary and primary school learners. This simple and cost-effective strategy could be easily and effectively replicated in other schools, helping to address the need for basic eye care.
Prevalence of and risk factors for retinopathy of prematurity in a cohort of preterm infants treated exclusively with non-invasive ventilation in the first week after birth : researchSource: South African Medical Journal 103, pp 96 –100 (2013)More Less
Objectives. To determine the current prevalence of retinopathy of prematurity (ROP) in premature babies treated with non-invasive ventilation at Tygerberg Children's Hospital, Parow, Cape Town, South Africa, and to identify risk factors associated with the development of ROP.
Methods. A retrospective medical records review of infants screened for ROP during a 2-year period (January 2009 - December 2010). Infants who did not receive invasive ventilation during the first week of life were included. Twenty-four previously reported risk factors for the development of ROP were identified for use in a multivariate logistic regression (MLR) analysis.
Results. A total of 356 patients were included. The overall prevalence of ROP was 21.8% and that of clinically significant ROP (CSROP) 4.4%. The risk factors with a statistically significant association with the development of ROP on MLR analysis were severe apnoea (p=0.0005) and decreasing birth weight (p=0.0382).
Conclusions. There is a low prevalence of ROP in the cohort of preterm infants treated exclusively with non-invasive ventilation in the first week of life. The risk factors of importance in our population were severe apnoea and lower birth weight. Birth weight is a practical and reproducible variable that can be used to aid development of ROP screening criteria.
Diagnosing Xpert MTB/RIF-negative TB : impact and cost of alternative algorithms for South Africa : researchSource: South African Medical Journal 103, pp 101 –106 (2013)More Less
Background. Use of Xpert MTB/RIF is being scaled up throughout South Africa for improved diagnosis of tuberculosis (TB). A large proportion of HIV-infected patients with possible TB are Xpert-negative on their initial test, and the existing diagnostic algorithm calls for these patients to have sputum culture (Xpert followed by culture (X/C)). We modelled the costs and impact of an alternative diagnostic algorithm in which these cultures are replaced with a second Xpert test (Xpert followed by Xpert (X/X)).
Methods. An existing population-level decision model was used. Costs were estimated from Xpert implementation studies and public sector price and salary data. The number of patients requiring diagnosis was estimated from the literature, as were rates of TB treatment uptake and loss to follow-up. TB and HIV positivity rates were estimated from the national TB register and laboratory databases.
Results. At national programme scale in 2014, X/X (R969 million/year) is less expensive than X/C R1 095 million/year), potentially saving R126 million/year (US$17.4 million). However, because Xpert is less sensitive than culture, X/X diagnoses 2% fewer TB cases. This is partly offset by higher expected treatment uptake with X/X due to the faster availability of results, resulting in 1% more patients initiating treatment under X/X than X/C. The cost per TB patient initiated on treatment under X/X is R2 682, which is 12% less than under X/C (R3 046).
Conclusions. Modifying the diagnostic algorithm from X/C to X/X could provide rapid results, simplify diagnostic processes, improve HIV/TB treatment outcomes, and generate cost savings.
Correlates of short- and long-term case fatality within an incident stroke population in Tanzania : researchSource: South African Medical Journal 103, pp 107 –112 (2013)More Less
Background. This study aimed to identify correlates of case fatality within an incident stroke population in rural Tanzania.
Methods. Stroke patients, identified by the Tanzanian Stroke Incidence Project, underwent a full examination and assessment around the time of incident stroke. Records were made of demographic data, blood pressure, pulse rate and rhythm, physical function (Barthel index), neurological status (communication, swallowing, vision, muscle activity, sensation), echocardiogram, chest X-ray and computed tomography (CT) head scan. Cases were followed up over the next 3 - 6 years.
Results. In 130 incident cases included in this study, speech, language and swallowing problems, reduced muscle power, and reduced physical function were all significantly correlated with case fatality at 28 days and 3 years. Age was significantly correlated with case fatality at 3 years, but not at 28 days post-stroke. Smoking history was the only significant correlate of case fatality at 28 days that pre-dated the incident stroke. All other significant correlates were measures of neurological recovery from stroke.
Conclusions. This is the first published study of the correlates of post-stroke case fatality in sub-Saharan Africa (SSA) from an incident stroke population. Case fatality was correlated with the various motor impairments resulting from the incident stroke. Improving post-stroke care may help to reduce stroke case fatality in SSA.
Source: South African Medical Journal 103, pp 113 –115 (2013)More Less
Background. There is insufficient research into the state of paediatric oncology in African countries.
Objectives. The purpose of this study was to analyse the state of paediatric oncology between 1995 and 2004 in Côte d'Ivoire.
Methods. This retrospective descriptive study analysed all patients under the age of 18 who were diagnosed with cancer in Côte d'Ivoire over a period of 10 years (January 1995 - December 2004) with regard to demographics, types of pathology, delay in diagnosis and treatment, treatment modalities, abandonment of treatment and survival rate.
Results. Of 405 patients diagnosed with cancer, 331 were included in the study. Burkitt's lymphoma was the most common malignancy (73.6%), followed by nephroblastoma (14.5%) and acute leukaemia (4%). Delay in diagnosis occurred in 38.7% of cases and ranged from 1 to 3 months; the average delay from diagnosis to starting treatment was 18 days. An abdominal mass and swelling of the jaw were the most common clinical presentations. Almost half of the patients (48.6%) were lost to follow-up and over a third (39.3%) died shortly after admission owing to advanced disease. The overall survival rate was 9.4%.
Conclusions. Cancer in children in Côte d'Ivoire was dominated by Burkitt's lymphoma. The rate of loss to follow-up of almost 50% is grounds for concern. The overall survival rate of 9.4% is very low, but such figures are not uncommon for African countries. Collaboration within the Franco-African Group of Paediatric Oncology has contributed to improving the management of children with cancer.