South African Medical Journal - Volume 104, Issue 12, 2014
Volumes & issues
Volume 104, Issue 12, 2014
Author Bridget FarhamSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.9063More Less
In May this year, the Lancet published an analysis of global, regional and national prevalence of overweight and obesity in children and adults during 1980 - 2013, for the Global Burden of Disease Study 2013. The findings are salutary. Worldwide, the proportion of adults with a body mass index of ≥25 kg/m2 increased between 1980 and 2013 from 28.8% to 36.9% in men, and from 29.8% to 38.0% in women. The prevalence of obesity has also substantially increased among children and adolescents in both developed and developing countries.
Source: South African Medical Journal 104, pp 836 –837 (2014)More Less
CME: Tuberculosis and HIV
Recommendations for amniocentesis in HIV-positive women
Premedication for newborns before elective intubation
Retinoblastoma - early detection improves outcome
Unwanted pregnancies in Gauteng and Mpumalanga
Risks associated with pregnancy in young HIV-infected women
Venous thromboembolism (VTE) risk assessment
Author Viroj WiwanitkitSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8922More Less
In their article, Vergotine et al. concluded that 'the Gly972Arg variant may not aid diabetes risk evaluation in this setting'. In fact, the insulin receptor substrate-1 Gly972Arg variant is widely studied in terms of its relationship to diabetes mellitus. Different observations have been made in different settings.
Source: South African Medical Journal 104, pp 838 –839 (2014) http://dx.doi.org/10.7196/SAMJ.9129More Less
HIV research for prevention has so far produced a mixed bag with no magic bullet, but results for an anti retroviral (ARV)-infused vaginal ring that stays in place for 30 days, potentially offering women up to 50% (or more) protection against HIV and theoretically saving millions of lives over time, will be reported in 2016.
Source: South African Medical Journal 104, pp 839 –840 (2014) http://dx.doi.org/10.7196/SAMJ.9118More Less
While South Africa (SA) will almost certainly fail to meet next year's Millennium Development Goals (MDGs) of reducing deaths of children under 5 by two-thirds and the maternal mortality rate by three-quarters, one brilliantly simple technological innovation is accelerating progress.
Source: South African Medical Journal 104, pp 841 –842 (2014) http://dx.doi.org/10.7196/SAMJ.9119More Less
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.9120More Less
The new board of the Hospital Association of South Africa (HASA), elected at its annual general meeting shortly after the association's annual conference in Sandton this October, brings added depth and a wide variety of skills to the seismic shifts changing the face of healthcare delivery in South Africa.
Author John PettiforSource: South African Medical Journal 104 (2014)More Less
Prof. Lorna Macdougall was one of the pioneers in paediatric oncology/haematology in Johannesburg and South Africa and a founder of CHOC (Children's Haematology and Oncology Clinics), an NGO to support the families and children with cancer that has blossomed from being a local Johannesburg organisation to a national one over the years.
Source: South African Medical Journal 104, pp 844 –845 (2014) http://dx.doi.org/10.7196/SAMJ.8660More Less
There is limited literature on the known risk of HIV transmission during amniocentesis. Before the introduction of highly active antiretroviral therapy (HAART), amniocentesis was avoided owing to the increased risk of HIV transmission. Recent literature suggests that it is safe to perform amniocentesis in women on HAART with undetectable viral loads. In South Africa (SA), many women access antenatal care late in pregnancy and there is often insufficient time to attain undetectable viral loads within a pre-viability period. Guidelines and recommendations for invasive testing in HIV-positive women in the SA setting are lacking. This article provides recommendations to healthcare practitioners who are faced with an HIV-positive patient requiring amniocentesis.
Source: South African Medical Journal 104, pp 846 –849 (2014) http://dx.doi.org/10.7196/SAMJ.8305More Less
Background. Intubation is a common neonatal procedure. Premedication is accepted as a standard of care, but its use is not universal and wide variations exist in practice.
Objective. To evaluate current practices for premedication use prior to elective neonatal intubation in South Africa (SA).
Method. We invited 481 clinicians to participate in a cross-sectional web-based survey.
Results. We received responses from 28.3% of the clinicians surveyed; 54.1% were from the private sector and 45.9% from the state sector. Most respondents worked in medium-sized neonatal units with six to ten beds. Most paediatricians (76.0%) worked in the private sector, and 78.6% of neonatologists in the state sector. Premedication was practised by 71.9% of the respondents, but only 38.5% of neonatal units had a written policy. Sedatives were used for premedication by 63.2% of the respondents. Midazolam (41.5%), morphine (34.0%) and ketamine (20.8%) were most commonly used. Muscle relaxants and atropine were not routinely administered. Suxamethonium was the muscle relaxant of choice. Varied combinations of agents or single agents were used. Midazolam used alone was the preferred option.
Conclusion. This first survey of premedication for neonatal intubation in SA revealed variations in practice, with a minority of clinicians following a written policy. The findings can be used to benchmark practice and inform the design of local collaborative trials aimed at determining optimal premedication prior to neonatal intubation. The survey demonstrates clinicians' reluctance to participate in surveys, suggesting a need for a national collaborative network to obtain representative data.
The structured communication tool SBAR (Situation, Background, Assessment and Recommendation) improves communication in neonatology : forum - clinical practiceSource: South African Medical Journal 104, pp 850 –852 (2014) http://dx.doi.org/10.7196/SAMJ.8684More Less
Background. Effective communication, co-operation and teamwork have been identified as key determinants of patient safety. SBAR (Situation, Background, Assessment and Recommendation) is a communication tool recommended by the World Health Organization and the UK National Health Service. SBAR is a structured method for communicating critical information that requires immediate attention and action, contributing to effective escalation of management and increased patient safety. To our knowledge, this is the first study showing use of SBAR in South Africa (SA).
Objective. To determine the effectiveness of adopting the SBAR communication tool in an acute clinical setting in SA.
Methods. In the first phase of this study, neonatal nurses and doctors at Groote Schuur Hospital, Cape Town, were gathered in a focus group and given a questionnaire asking about communication in the neonatal department. Neonatal nurses and doctors were then trained to use SBAR.
Results. A telephone audit demonstrated an increase in SBAR use by registrars from 29% to 70% when calling consultants for help. After training, the majority of staff agreed that SBAR had helped with communication, confidence, and quality of patient care. There was qualitative evidence that SBAR led to greater promptness in care of acutely ill patients.
Conclusions. Adopting SBAR was associated with perceived improvement in communication between professionals and in the quality and safety of patient care. It is suggested that this simple tool be introduced to many other hospitals in SA.
Tricuspid valve endocarditis associated with intravenous nyoape use : a report of 3 cases : forum - clinical alertSource: South African Medical Journal 104, pp 853 –855 (2014) http://dx.doi.org/10.7196/SAMJ.8291More Less
We report three cases of tricuspid valve infective endocarditis associated with intravenous nyoape use. Nyoape is a variable drug combination of an antiretroviral (efavirenz or ritonavir), heroin, metamphetamines and cannabis. Its use is becoming increasingly common among poor communities in South Africa. All our patients were young HIV-positive men from disadvantaged backgrounds. They all presented with tricuspid regurgitation and septic pulmonary emboli. They were treated with prolonged intravenous antibiotic courses, and one required referral for surgery.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8741More Less
Source: South African Medical Journal 104, pp 857 –858 (2014) http://dx.doi.org/10.7196/SAMJ.9133More Less
Many women in South Africa (SA) risk their lives to end an unwanted pregnancy. Despite the liberalisation of laws and formalisation of services dedicated to abortions, women continue to resort to illegal and unsafe solutions that render them vulnerable to health and social risks, serious morbidity and even death.
Source: South African Medical Journal 104, pp 859 –863 (2014) http://dx.doi.org/10.7196/SAMJ.8255More Less
Introduction. Retinoblastoma (RB) is the most common eye cancer in children. Early detection is necessary for cure.
Objective. To compare stage and outcome of children with RB treated at Kalafong Hospital, Pretoria, South Africa (SA), during two time periods (1993 - 2000 and 2001 - 2008, after outreach interventions in 2000 and introduction of compulsory community service for doctors in 1998).
Methods. Data collected included demography (age, gender, date of birth), stage and treatment received. The main outcome measure was disease-free survival and the study end-point was 60 months after diagnosis.
Results. There were 51 patients during the time period 1993 - 2000 (group 1) and 73 during 2001 - 2008 (group 2), with median ages of 32 and 26 months, respectively (marginally significantly younger in group 2; p=0.046). In group 1, the majority (57%) presented with advanced disease (stages III and IV), with a decline in this proportion in group 2 (40%) indicating a downward but not significant trend (p=0.075). Bilateral disease was diagnosed in 22% of patients in group 1 and 33% in group 2. Overall survival was 33% and 43% for groups 1 and 2, respectively. Excluding absconding patients, event-free survival was 50% in group 1, improving to 68% in group 2 (not statistically significant; p=0.18). Fewer patients needed radiotherapy during the second period (statistically significant; p=0.04), probably because of less advanced disease.
Conclusion. Poor outcome is probably a result of late diagnosis. It is important to implement a strategy that will ensure early diagnosis and optimal management of RB in SA.
Unwanted pregnancies in Gauteng and Mpumalanga provinces, South Africa : examining mortality data on dumped aborted fetuses and babies : researchSource: South African Medical Journal 104, pp 864 –869 (2014) http://dx.doi.org/10.7196/SAMJ.8504More Less
Background. Across the world, millions of women unintentionally become pregnant and decide to terminate the pregnancy. Despite progressive abortion laws in South Africa (SA), evidence suggests that many women of all ages still resort to unsafe terminations outside legal, designated facilities. Media reports alert the public to an increase in the illegal dumping of fetuses and abandoned babies, suggesting an increase in unsafe termination practices as well as concealed births.
Objective. To examine mortality data to identify trends in the dumping of aborted fetuses and abandoned babies in SA.
Method. This study utilised data from the National Injury Mortality Surveillance System in two provinces, namely Gauteng and Mpumalanga. A total sample of mortality data was used to analyse trends associated with this phenomenon from 2009 to 2011. Descriptive, exploratory statistics were used and included the calculation of crude population incidence rates for abortions and abandoned babies as well as figures (n) and percentages (%) for each category under investigation.
Results. An increase in the rate of discovery of non-viable fetuses was noted for both provinces over the 3-year period, while there was a significant decrease in the discovery of deceased abandoned babies in Gauteng only.
Conclusion. The illegal dumping of fetuses and babies is a very real public health concern in both Gauteng and Mpumalanga. Information is insufficient for adequate surveillance, and improved data collection systems should be prioritised.
Blood pressure measurements in the ankle are not equivalent to blood pressure measurements in the arm : researchSource: South African Medical Journal 104, pp 869 –873 (2014) http://dx.doi.org/10.7196/SAMJ.8102More Less
Background. Blood pressure (BP) is often measured on the ankle in the emergency department (ED), but this has never been shown to be an acceptable alternative to measurements performed on the arm.
Objective. To establish whether the differences between arm and ankle non-invasive BP measurements were clinically relevant (i.e. a difference of ≥10 mmHg).
Methods. This was a prospective cross-sectional study in an urban ED making use of a convenience sample of 201 patients (18 - 50 years of age) who were not in need of emergency medical treatment. BP was measured in the supine position on both arms and ankles with the correct size cuff according to the manufacturer's guidelines. The arm and ankle BP measurements were compared.
Results. There was a clinically and statistically significant difference between arm and ankle systolic BP (SBP) and mean arterial pressure (MAP) (-13 mmHg, 95% confidence interval (CI) -28 - 1 mmHg and -5 mmHg, 95% CI -13 - 4 mmHg, respectively), with less difference in diastolic BP (DBP) (2 mmHg, 95% CI -7 - 10 mmHg). Only 37% of SBP measurements and 83% of MAP measurements were within an error range of 10 mmHg, while 95% of DBP measurements agreed within 10 mmHg. While the average differences (or the bias) were generally not large, large variations in individual patients (indicating poor precision) made the prediction of arm BP from ankle measurements unreliable.
Conclusion. Ankle BP cannot be used as a substitute for arm BP in the ED.
Adolescent and young pregnant women at increased risk of mother-to-child transmission of HIV and poorer maternal and infant health outcomes : a cohort study at public facilities in the Nelson Mandela Bay Metropolitan district, Eastern Cape, South Africa : researchSource: South African Medical Journal 104, pp 874 –880 (2014) http://dx.doi.org/10.7196/SAMJ.8207More Less
Background. South Africa (SA) has the highest burden of childhood HIV infection globally, and has high rates of adolescent and youth pregnancy.
Objective. To explore risks associated with pregnancy in young HIV-infected women, we compared mother-to-child transmission (MTCT) of HIV and maternal and infant health outcomes according to maternal age categories.
Methods. A cohort of HIV-positive pregnant women and their infants were followed up at three sentinel surveillance facilities in the Nelson Mandela Bay Metropolitan (NMBM) district, Eastern Cape Province, SA. Young women were defined as ≤24 years old and adolescents as ≤19 years. The effect of younger maternal age categories on MTCT and maternal and child health outcomes was assessed using log-binomial and Cox regression controlling for confounding, using women aged >24 years as the comparison group.
Results. Of 956 mothers, 312 (32.6%) were young women; of these, 65 (20.8%) were adolescents. The proportion of young pregnant women increased by 24% between 2009/10 and 2011/12 (from 28.3% to 35.1%). Young women had an increased risk of being unaware of their HIV status when booking (adjusted risk ratio (aRR) 1.37; 95% confidence interval (CI) 1.21 - 1.54), a reduced rate of antenatal antiretroviral therapy (ART) uptake (adjusted hazard ratio 0.46; 95% CI 0.31 - 0.67), reduced early infant HIV diagnosis (aRR 0.94; 95% CI 0.94 - 0.94), and increased MTCT (aRR 3.07; 95% CI 1.18 - 7.96; adjusted for ART use). Of all vertical transmissions, 56% occurred among young women. Additionally, adolescents had increased risks of first presentation during labour (aRR 3.78; 95% CI 1.06 - 13.4); maternal mortality (aRR 35.1; 95% CI 2.89 - 426) and stillbirth (aRR 3.33; 95% CI 1.53 - 7.25).
Conclusion. An increasing proportion of pregnant HIV-positive women in NMBM were young, and they had increased MTCT and poorer maternal and infant outcomes than older women. Interventions targeting young women are increasingly needed to reduce pregnancy, HIV infection and MTCT and improve maternal and infant outcomes if SA is to attain its Millennium Development Goals.
Source: South African Medical Journal 104, pp 880 –884 (2014) http://dx.doi.org/10.7196/SAMJ.8456More Less
Background. The TUNE-IN (The Use of VTE prophylaxis in relatioN to patiEnt risk profiling) study evaluated venous thromboembolism (VTE) risk assessment and prophylaxis in private medical and surgical inpatients in Gauteng Province, South Africa. The study concluded that of the 608 patients enrolled, 54.1% were clinically evaluated to be at risk for VTE. A VTE risk assessment model (RAM), the Caprini score, increased the rate to 74.6%.
Objectives. TUNE-IN Wave 2, an extension of TUNE-IN, was conducted on a national level including the public sector, focusing on surgical in-patients.
Methods. The study was a national, prospective, non-interventional, multisite, epidemiological disease registry enrolling 453 surgical inpatients. The perceived clinical VTE risk, VTE risk score on Caprini RAM, VTE prophylaxis and clinical details were documented during a baseline visit. A bleeding risk score was provided.
Results. Of the cohort, 269 patients (59.4%) were assessed to be at risk for VTE before applying the RAM. All patients (100%), however, were at risk on the RAM score. Early mobilisation and assessment of the VTE risk as low were the most frequent reasons for non-prescription of prophylaxis. Only 15 patients in the private and 2 in the public sector were assessed as having a bleeding risk. Chemoprophylaxis differed between the healthcare sectors, with low-molecular-weight heparin predominating in the private sector and unfractionated heparin being prescribed only in the public sector.
Conclusion. VTE risk assessment and prophylaxis need to improve in both the public and the private sectors. A formal RAM will improve identification of patients at risk of VTE.
Author Graeme MeintjesSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.9121More Less
Globally, South Africa (SA) is disproportionately affected by the epidemics of tuberculosis (TB) and the human immunodeficiency virus-1 (HIV-1). The intersection of these two diseases has resulted in an unprecedented disease burden. It is estimated that 12.2% of South Africans are HIV-infected - a total of 6.4 million people, the largest number in any country in the world. SA has the second highest annual incidence of TB after Swaziland - approximately 1% of the population develop active TB disease each year (an estimated 530 000 people in 2012). While SA comprises 0.7% of the world's population, it is estimated that of all cases of HIV-associated TB that occur worldwide annually, 30% are in SA.