South African Medical Journal - Volume 104, Issue 9, 2014
Volumes & issues
Volume 104, Issue 9, 2014
Author Janet SeggieSource: South African Medical Journal 104 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8766More Less
I write this on the eve of my second anniversary as Editor-in-Chief (E-in-C) of HMPG.
Within six months of my apppointment, I was informed that there would be a restructuring of HMPG. There existed a clear imperative - 'a negative financial result stretching over the previous seven years'. The triumphant result was that 'since starting to implement their financial turnaround strategy with the appointment of a CEO to implement such strategy in September 2013, a negative financial result ... was turned into a net profit of approximately R1.5 million. Although the strategy implemented included drastic cuts in expenses, strategic imperatives implemented created innovative future solutions and a strengthened working relationship between the SAMA subsidiaries, to the benefit of all SAMA members'.
Improved surgical output in district hospitals relies more on softer ingredients than on formal postgraduate training time : correspondenceAuthor Kenneth Beviss-ChallinorSource: South African Medical Journal 104, pp 593 –594 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8599More Less
Mash et al. have suggested that part of the solution to improving surgical and other services at the district hospital may lie in an approach that places full-time specialist family physicians and associate clinicians at district hospitals with periodic outreach from surgical specialists. However, I submit that a solution to district healthcare already exists in the example of Kokstad Medical Centre (KMC), and that it is less reliant on formal specialist family physician training and surgical outreach than on the softer ingredients required to assemble a team of inspired rural practitioners committed to delivering optimal healthcare outcomes.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8559More Less
The South African Dialysis and Transplant Registry issued its last report on renal replacement therapy (RRT) in South Africa (SA) in 1994, followed by an unfortunate hiatus for 20 years. The recent publication of the long-awaited South African Renal Registry Annual Report 2012 should be highly commended. The private sector deserves to be acknowledged for its financial support of this initiative. Since 1994, the SA population has increased from 40.436 million to 52.275 million and the treatment rate for end-stage renal disease (ESRD) per million population (pmp) has improved from 70 pmp in 1994 to 164 pmp in 2012. The treatment rate in 2012 for the public sector is essentially unchanged at 73 pmp, compared with 620 pmp (of insured persons) in the private sector. In contrast, the low national kidney transplant rate of 4.7 pmp highlights the dire need for organs.
Access to flucytosine for HIV-infected patients with cryptococcal meningitis - an urgent need : correspondenceSource: South African Medical Journal 104, pp 594 –595 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8713More Less
The addition of oral flucytosine to an amphotericin B-containing induction regimen for HIV-associated cryptococcal meningitis (CM) is associated with improved fungal clearance and a 39% reduction in 10-week mortality. Owing to the unacceptably high mortality associated with CM, access to flucytosine needs to be prioritised in South Africa (SA), together with interventions such as earlier detection of cryptococcal disease. The World Health Organization (WHO) recommended amphotericin B and flucytosine as the preferred induction regimen in rapid advice guidelines, and in 2013 included these agents in the WHO Model Lists of Essential Medicines as part of the 'core list'. In line with WHO recommendations, the Southern African HIV Clinicians Society has strongly supported efforts to obtain access to flucytosine in updated clinical guidelines.
Source: South African Medical Journal 104, pp 595 –596 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8685More Less
Eric Klug's letter in the June SAMJ is particularly topical, as haemovigilance programmes have extended to include donor health in recent years. Considerable attention has focused on the effects of regular blood donation on iron stores, and consequent risks of iron depletion and iron deficiency anaemia. There is little doubt that frequent blood donation may result in reduced iron stores. It is also important to note that haemoglobin (Hb) levels may remain relatively normal in spite of reduced iron stores, although changes in the red cell indices may be helpful in suggesting iron deficiency. Females of childbearing age are most at risk of iron depletion due to menstruation, pregnancy, a lower body mass and lower oral iron intake.
Source: South African Medical Journal 104, pp 597 –598 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8774More Less
Source: South African Medical Journal 104, pp 598 –600 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8750More Less
The country's top medical scheme administrator, Discovery Health, calculates that far greater use of cheaper, good-quality generic drugs will drive down healthcare inflation, saving as much as R1.5 billion per annum for medical scheme members - while a major hospital group has begun promoting use of these medicines through its hospital pharmacies.
Source: South African Medical Journal 104, pp 600 –601 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8751More Less
National and provincial health departments are failing dismally when it comes to meeting the minimum standards required of them by the Constitution, lacking precise plans to give effect to policy and legislation. They are also treacle-slow in passing laws vital to help them contain virulent diseases such as multidrug-resistant tuberculosis (MDR TB).
Author David MandellSource: South African Medical Journal 104, pp 601 –602 (2014)More Less
My father Bernard Mandell was born in Johannesburg on 22 May 1927. He attended King Edward VII School, matriculating in 1943 at the age of sixteen. He joined the South African Air Force in 1944 as a pupil pilot and graduated from Wits University Medical School in 1952.
Author Noelene BallotSource: South African Medical Journal 104 (2014)More Less
Jean was born in Johannesburg in 1929, the daughter of May and John Sharpe, who became the mayor of Vereeniging in 1934. After matriculating from Parktown High School for Girls at age 16, Jean enrolled at Wits medical school. She was one of very few women studying medicine at the time, and graduated MB BCh in 1951. She completed her housemanship at Baragwanath Hospital and was then invited to take up a registrar post at the Radcliffe Infirmary in Oxford, UK. After qualifying as a specialist obstetrician and gynaecologist (MRCOG) in 1956 she returned to Johannesburg, where she worked in the cardiology department at Baragwanath Hospital. She commenced private practice in Johannesburg in 1961. In 1983 she was awarded the FRCOG.
Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières, Renée C Fox : izindaba - book reviewSource: South African Medical Journal 104 (2014)More Less
Médecins Sans Frontières (MSF) has become the most successful and best-known apolitical, humanitarian endeavour of our time. Founded in 1971 by a small group of French doctors in response to the tragedies and atrocities of the Nigerian Civil War (1967 - 1970), it is now a worldwide movement responding to a wide spectrum of human-made and natural disasters. By 2013 its over 32 500 personnel provided hope and medical assistance to suffering people in more than 67 countries with an annual budget of more than 600 million euros (over 90% from private, non-governmental sources).
Author D. WoodSource: South African Medical Journal 104, pp 604 –606 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8064More Less
South African emergency centres witness high levels of trauma. Successfully managing a compromised trauma airway requires considerable skill and expertise. In the rural healthcare setting, clinics and hospitals are often staffed by junior doctors without formal advanced airway training. Current airway management algorithms tend to ignore lack of resources and skill. We therefore propose a simplified guideline for the rural hospital practitioner. Our algorithm offers a step-by-step approach, with the aim of providing an easy sequence to follow that will ensure successful airway management and patient safety. The paucity of advanced airway equipment in most rural hospitals is taken into consideration.
Source: South African Medical Journal 104, pp 607 –609 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8468More Less
HIV notification enters national debate regularly, often introduced by politicians and supported by many individual healthcare workers. We argue that its proponents advance confused or poorly informed rationales for making HIV notifiable. We present reasons why making HIV notifiable would be inappropriate in South Africa, why the public health benefits of a notification programme are not even likely, and why there are risks of public health and human rights harms.
Preventing hepatitis B and hepatocellular carcinoma in South Africa : the case for a birth-dose vaccine : forum - issues in medicineSource: South African Medical Journal 104, pp 610 –612 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8607More Less
Hepatitis B is a global public health issue, with some 2 billion people having current or past infection. In Africa, 65 million are chronically infected, an estimated 2.5 million of them in South Africa (SA). Hepatitis B and the associated complications of cirrhosis and hepatocellular carcinoma are entirely vaccine preventable. SA was one of the first ten countries in Africa to introduce universal hepatitis B vaccination in April 1995, but has no birth dose or catch-up programme. Although universal infant vaccination in SA has been successful in increasing population immunity to hepatitis B, improvements in terms of implementing protocols to screen all pregnant mothers for hepatitis B surface antigen (HBsAg) and ensuring full hepatitis B coverage, especially in rural areas, is required. The World Health Organization has recommended a birth dose of hepatitis B vaccine in addition to the existing hepatitis B vaccine schedule in order to further decrease the risk of perinatal transmission. We recommend that SA implement a birth-dose vaccine into the existing schedule to attenuate the risk of perinatal transmission, prevent breakthrough infections and decrease HBsAg carriage in babies born to HIV-positive mothers.
Source: South African Medical Journal 104, pp 613 –614 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8608More Less
In the third decade of a new South Africa (SA), major challenges are being faced in almost every aspect of life, ranging from meeting minimum daily subsistence requirements, through providing education and primary healthcare, to the functioning of our legal system and governance at local and national levels. While in this context levels of crime and corruption are reaching new heights, we should not lose sight of the need for humane and accountable approaches to crime and imprisonment. The 37th anniversary on 12 September of Steve Biko's death under inhumane conditions and without adequate medical care in prison provides an opportunity to remember past failings and to reconsider the lessons these hold for our society.
Source: South African Medical Journal 104, pp 615 –618 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.7969More Less
Objective. To describe the use of intravenous (IV) therapy in the South African (SA) prehospital setting, and to determine the proportion of prehospital IV cannulations considered unnecessary when graded against the South African Triage Score (SATS) chart.
Methods. The study was conducted in the prehospital emergency medical care setting in the Western Cape Province, SA. Using a descriptive research design, we looked at the report forms of patients treated and transported by personnel currently employed in the public sector, serving the urban and rural areas stipulated by the municipal boundaries. All medical and trauma cases in which establishment of IV access was documented for the month of April 2013 were included. Interhospital transfers, unsuccessful attempts at IV access and intraosseous cannulation were excluded.
Results. When graded against the SATS, prophylactic IV access was not justified in 42.3% of the total number of cases (N=149) in which it was established, and therefore added no direct benefit to the continuum of patient care. It is worth noting that 18.8% (n=39) of the IV lines were utilised for fluid administration, as opposed to 9.2% (n=19) for the administration of IV medications.
Conclusion. In view of the paucity of studies indicating a direct benefit of out-of-hospital IV intervention, the practice of precautionary, protocol-driven prophylactic establishment of IV access should be evaluated. Current data suggest that in the absence of scientific evidence, IV access should only be initiated when it will benefit the patient immediately, and precautionary IV access, especially in non-injured patients, should be re-evaluated.
The pharmacoeconomics of routine postoperative troponin surveillance to prevent and treat myocardial infarction after non-cardiac surgery : researchSource: South African Medical Journal 104, pp 619 –623 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.7654More Less
Background. A postoperative troponin leak that was previously considered clinically insignificant has been independently associated with 30-day mortality in unselected surgical patients ≥45 years of age following non-cardiac surgery.
Objectives. To determine whether routine troponin surveillance following non-cardiac surgery and initiation of aspirin and statin therapy in troponin-positive patients is cost-effective.
Methods. Pharmacoeconomic analysis to determine the cost-effectiveness of routine postoperative surveillance for patients aged ≥45 years undergoing non-cardiac surgery. We compared the total expected cost of hospital care of patients who received routine troponin surveillance and subsequent introduction of statin and aspirin therapy for 30 days in troponin-positive patients with the cost of hospital care of patients who did not receive troponin surveillance. We estimated a 25% relative risk reduction following statin and aspirin therapy for postoperative vascular mortality and non-fatal myocardial infarction.
Results. Routine troponin surveillance with initiation of aspirin and statin therapy was cost-effective, with an incremental cost of -R16 724 per event avoided.
Conclusion. Routine postoperative troponin surveillance in non-cardiac surgical patients ≥45 years of age requiring a postoperative night in hospital is potentially cost-effective.
Source: South African Medical Journal 104, pp 623 –627 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8111More Less
Background. The burden of cardiovascular disease is expected to escalate in developing countries. However, studies and guidelines concerning atrial fibrillation (AF) are restricted to the developed world.
Objectives. To assess the treatment modalities of AF in South Africa.
Methods. A cross-sectional, observational, multicentre, national registry of the treatment of 302 patients with AF was conducted from February 2010 to March 2011. Specific drug use for rate or rhythm control, as well as drug use for stroke prevention, was surveyed. Events during the 12 months prior to the survey were also characterised, including non-drug treatments, resource utilisation and complications.
Results. The single most prevalent clinical characteristic was hypertension (65.9%). Rhythm control was being pursued in 109 patients (36.1%) with class Ic and class III antiarrhythmic agents, while rate control, mainly with beta-blockers, was pursued in the remainder of the patients. Concomitant use of other cardiovascular drugs was high, and 75.2% of patients were on warfarin for stroke prevention. There was a high burden of AF-related morbidity during the preceding year, with 32.5% reporting a history of heart failure, 8.3% a stroke and 5.3% a transient ischaemic attack. Therapeutic success, as defined by either the presence of sinus rhythm or rate-controlled AF, was achieved in 86.8% as judged clinically by the treating physician, but in only 70.2% according to the electrocardiogram criterion of heart rate ≤80 bpm.
Conclusion. There were no striking differences from previously reported registries worldwide. The lack of application of strict rate control criteria is highlighted.
Investigating hepatitis B immunity in patients presenting to a paediatric haematology and oncology unit in South Africa : researchSource: South African Medical Journal 104, pp 628 –631 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.7952More Less
Background. Hepatitis B is an important public health concern in South Africa (SA). The hepatitis B virus (HBV) vaccine was introduced into the South African Expanded Programme on Immunisation (EPI-SA) in 1995. There is no 'catch-up' programme in place. The duration of protection after hepatitis B vaccination in the SA population is unknown. Waning of vaccine-induced immunity leaves people at risk of acquiring hepatitis B infection in settings where the prevalence of infection is high and horizontal transmission is likely.
Objective. To assess immunity to HBV in patients at presentation to a paediatric haematology and oncology unit.
Methods. An audit of hepatitis profiles was done of all new patients seen in the unit from January 2012 to December 2013. Patients were classified as immune (antibody levels to hepatitis B surface antigen (anti-HBs) >100 mIU/ml), low immune (anti-HBs 10 - 100 mIU/ml) and not immune (anti-HBs <10 mIU/ml).
Results. Of the 210 patients included (median age 6.5 years), 84 (40.0%) had no immunity to hepatitis B despite presumed vaccination as part of the EPI schedule. Six patients tested positive for hepatitis B core antibody (anti-HBc), consistent with previous infection. No patients had active hepatitis B infection (hepatitis B surface antigen-positive). Most human immunodeficiency virus (HIV)-infected patients were not immune to HBV (80.0%).
Conclusion. A significant number of children in SA are not immune to hepatitis B despite vaccination being part of the EPI-SA. Combined passive-active immunisation should be considered for all oncology patients in settings where exposure to HBV is possible. Consideration should also be given to offering booster vaccination to the population as a whole.