South African Medical Journal - Volume 104, Issue 7, July 2014

I have been fortunate to have had powerful mentors and role models throughout my career. Echoing the quotes above, none ever knew that I had chosen them! By their presence and performance in my daily working life (in and out of working hours), I judged them to be worthy mentors and my career was undoubtedly shaped by that observance.

Can tuberculosis be cured? Yes. Can we eradicate polio? Definitely. So why are these diseases still out there, causing suffering and hastening death? Why do proven, effective interventions stop short of achieving their potential? Because weak health systems - the combination of actors, institutions, policies and resources that strive to improve population health - prevent well-intentioned policies from being translated into population benefits. The problem is that there is little useful evidence to help policy makers decide how to make their health systems stronger - or even to gauge what 'stronger' really means.

CME: Paediatric palliative care

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National expenditure on health research in SA

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Smoking cessation after acute coronary syndrome

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Traumatic brain injury

In their recent article, Apffelstaedt et al. analysed 16 105 mammograms performed at Tygerberg Hospital (TBH), Cape Town, South Africa (SA), between 2003 and 2012. The summary reported that 'mammograms were read by experienced breast surgeons', while the discussion stated: 'A further noteworthy fact is that this TBH series was based exclusively on mammography interpretation by surgeons with a special interest in breast health.' The suggestion that mammograms were exclusively interpreted by breast surgeons does not reflect the mammography workflow at our institution.

In William Shakespeare's Romeo and Juliet, Juliet says: 'What's in a name? that which we call a rose By any other name would smell as sweet.'

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She is arguing that the name of something does not matter, only the thing itself matters. This is not always true. A name can determine destiny. Misnaming something can have negative implications. This is why it is so crucial that leaders in the specialty of emergency medicine unite in choosing the name of the department in which we work - the Emergency Department. We are still fighting the demons of 'Casualty', and now another misnomer has arisen: that of 'Emergency Centre'.

Fluorescent lamps are regarded as hazardous waste because of their mercury content. Mercury has toxic properties that may have acute or chronic detrimental impacts on human health and the environment. A study was recently undertaken with the objective of determining the availability of guidelines for the handling of fluorescent lamps in selected public schools in Johannesburg, South Africa. The study was undertaken under the umbrella of the World Health Organization Collaborating Centre for Urban Health's Health, Environment and Development (HEAD) study. The sample included 22 public schools from within and in the immediate vicinity of the five HEAD study sites, Hillbrow, Bertrams, Riverlea, Braamfischerville and Hospital Hill. A structured questionnaire and observation checklist was administered, typically to the school principal.

Telling healthcare providers where they may or may not practice, based purely on creating an equitable spread of healthcare services across the country (i.e. the newly promulgated Certificate of Need (CoN) law), may prove a legal nightmare, ultimately undermining healthcare delivery.

The government has categorically denied that there is any danger of antiretroviral (ARV) drug supplies running short or drying up following a claim from one of their three suppliers, Aspen Pharmaceuticals, that insufficient relief on the dismal rand exchange rate and single exit price (SEP) is creating a net loss.

Medicine in South Africa (SA) is replete with women doctors at an advanced stage of their careers who were actively dissuaded from specialising or baulked at the demands of registrarship combined with potential motherhood, while hundreds of their younger colleagues daily brave security threats and discrimination.

With Ron Tucker's passing, South Africa has lost one of her most distinguished physicians. Ron matriculated at Germiston High School in 1946 and, passionate about medicine but lacking the means to go straight to medical school, trained as a medical technologist at the South African Institute for Medical Research. He went to work on the Copperbelt in what was then Northern Rhodesia, and after four years had saved enough to enrol at the University of the Witwatersrand, where he graduated in 1959.

Manilal Damodar Daya was born in South End, Port Elizabeth, in June 1941 of parents who had immigrated to South Africa from Gujarat State in India. He did his schooling in Port Elizabeth, matriculating at South End High School, and completed his MB ChB at the University of Cape Town in 1967. After doing his internship at Somerset Hospital he started work as a medical officer at Livingstone Hospital, Port Elizabeth, in 1969. He married his wife Hemkala in 1971 and they had four boys, two of whom followed in their father's footsteps to become medical doctors.

The question of whether a child aged 12 years or more who is sufficiently mature and has the necessary mental capacity may refuse to consent to life-saving treatment without consent from a parent, guardian or caregiver or without the assistance of a parent or guardian is governed by the Constitution, the Children's Act, the National Health Act and the common law. The best interests of the child are paramount, and should the child unreasonably refuse to consent to life-saving treatment, the Minister of Social Development may give consent for such treatment in terms of the Children's Act. Otherwise, should a parent, guardian, caregiver or healthcare provider believe that such a refusal is not in the best interests of the child, he or she may approach the High Court for an order to provide such treatment.

The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors, was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure.

Remunerated work outside of public service (RWOPS) has largely been seen in a negative light. This is partly a result of the Public Service Commission review undertaken in 2004, but attitudes are also shaped by unsubstantiated reports of abuse. There are, however, potential advantages for both patients and doctors if RWOPS is done without neglecting public sector service and academic commitments. We explore some of the issues around controlling RWOPS, and the experience with this in the Department of Surgery at the University of Cape Town, South Africa.

On 17 May 2014, the World Health Assembly adopted World Health Organization (WHO) resolution WHA67.25 'Combating antimicrobial resistance including antibiotic resistance'. Among other directives, the nine-point call to action urges member states 'to develop or strengthen national plans, strategies and international collaboration for the containment of antimicrobial resistance'. Such calls have been heard before. So what is different this time, how do we break the mould to ensure that significant international change occurs, and how is South Africa (SA) positioning itself to respond to the call?

Professional life has long been fraught with many difficulties, and the literature is replete with valid criticisms of individuals and the professions (see, for example, Freidson and Kronman). With advancing complexity in medical knowledge and skills and in providing healthcare, maintaining high professional standards is an increasingly recognised challenge in all societies. Enhanced educational efforts to sustain professionalism, improved methods of vigilance, and robust methods of reporting complaints and dealing with offenders are essential.

Background. Good evidence exists to support the use of secondary prevention medications (aspirin, statins, beta-blockers and angiotensinconverting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs)) and smoking cessation in patients after acute coronary syndromes (ACSs). Little is currently known about adherence to medication and smoking behaviour after discharge in South Africa.

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Methods. We conducted a cross-sectional analysis of all patients with a diagnosis of ACS discharged from the Coronary Care Unit at Groote Schuur Hospital, Cape Town, between 15 November 2011 and 15 April 2012. Patients were telephoned 6 - 9 months after discharge and completed a standardised questionnaire detailing current medication use, reasons for non-adherence and smoking status.

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Results. Prescribing of secondary prevention medications at discharge was high (aspirin 94.5%, statins 95.7%, beta-blockers 85.4%, ACEIs/ARBs 85.9%), and 70.7% of patients were discharged on a combination of all four drugs. At 6 - 9-month follow-up, the proportion using these medications had dropped by 8.9% for aspirin, 10.1% for statins, 6.2% for beta-blockers and 17.9% for ACEIs/ARBs. Only 47.2% remained on all four drugs, a reduction of 23.5%. Of the 56.0% of patients who were smokers, 31.4% had stopped smoking.

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Conclusions. A significant decline in adherence to recommended therapy 6 - 9 months after discharge and a poor rate of smoking cessation suggest that efforts to educate patients about the importance of long-term adherence need to be improved. Furthermore, more effective interventions than in-hospital reminders about the hazards of smoking are needed to improve smoking cessation.

Background. Injuries and deaths from road traffic collisions present an enormous challenge to the South African (SA) healthcare system. The use of restraining devices is an important preventive measure.

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Objective. To determine the relationship between seatbelt use and injury severity in vehicle occupants involved in road traffic collisions in Cape Town, SA.

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Methods. A prospective cohort design was used. Occupants of vehicles involved in road traffic collisions attended to by EMS METRO Rescue were included during the 3-month data collection period. Triage categories of prehospital patients were compared between restrained and unrestrained groups. Patients transferred to hospital were followed up and injury severity scores were calculated. Disposition from the emergency centre and follow-up after 1 week were also documented and compared.

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Results. A total of 107 patients were included in the prehospital phase. The prevalence of seatbelt use was 25.2%. Unrestrained vehicle occupants were five times more likely to have a high triage score (odds ratio (OR) 5.4; 95% confidence interval (CI) 1.5 - 19.5). Fifty patients were transferred to study hospitals. Although seatbelt non-users were more likely to be admitted to hospital (p=0.002), they did not sustain more serious injuries (OR 0.44; 95% CI 0.02 - 8.8).

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Conclusion. The prevalence of seatbelt use in vehicle occupants involved in road traffic collisions was very low. The association between seatbelt non-use and injury severity calls for stricter enforcement of current seatbelt laws, together with the development and implementation of road safety interventions specifically focused on high-risk groups.

Background. Several studies have made it possible to predict outcome in severe traumatic brain injury (TBI) making it beneficial as an aid for clinical decision-making in the emergency setting. However, reliable predictive models are lacking for resource-limited prehospital settings such as those in developing countries like South Africa.

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Objective. To develop a simple predictive model for severe TBI using clinical variables in a South African prehospital setting.

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Methods. All consecutive patients admitted at two level-one centres in Cape Town, South Africa, for severe TBI were included. A binary logistic regression model was used, which included three predictor variables: oxygen saturation (SpO2), Glasgow Coma Scale (GCS) and pupil reactivity. The Glasgow Outcome Scale was used to assess outcome on hospital discharge.

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Results. A total of 74.4% of the outcomes were correctly predicted by the logistic regression model. The model demonstrated SpO2 (p=0.019), GCS (p=0.001) and pupil reactivity (p=0.002) as independently significant predictors of outcome in severe TBI. Odds ratios of a good outcome were 3.148 (SpO2 ≥90%), 5.108 (GCS 6 - 8) and 4.405 (pupils bilaterally reactive).

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Conclusion. This model is potentially useful for effective predictions of outcome in severe TBI.

Background. HIV research is a therapeutic area for which well-defined population-specific treatment and prophylaxis guidelines exist. However, there are limited objective, evidence-based data for assessing adherence to these guidelines.

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Objective. To conduct a retrospective, cross-sectional study of adult HIV-infected patients receiving treatment at the antiretroviral (ARV) roll-out clinic of the Infectious Diseases Clinic Pharmacy at 1 Military Hospital (1MH) over a period of 3 years to assess clinicians' adherence to the 2010 ARV guidelines.

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Methods. Pharmacy files from the pool of adult patients receiving treatment at the ARV roll-out clinic between 1 April 2009 and 31 March 2012 were selected. Variables used to establish adherence were assessed through evaluation of pharmacy scripts and laboratory tests.

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Results. In accordance with the ARV guidelines, we found a switch in the first-line regimen from stavudine to tenofovir during the period following implementation. There was no difference in baseline blood tests conducted, suggesting that clinicians were recommending a standardised test panel. Notably, similar blood tests were routinely done during follow-up visits, despite no indication for doing so. While the number of blood tests was found to decrease over time, the type of blood tests requested for specific treatment regimens was not in accordance with the ARV guidelines.

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Conclusion. We used an evidence-based approach to critically assess variations from the delineated ARV guidelines. Adherence to clinical guidelines at 1MH, while demonstrating improvement in patient outcomes, highlighted the need for increased vigilance in monitoring failure of prescribers to comply with ARV guidelines.