South African Medical Journal - Volume 105, Issue 12, 2015
Volumes & issues
Volume 105, Issue 12, 2015
Source: South African Medical Journal 105, pp 1014 –1015 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10339More Less
The recent #FeesMustFall protests by students seeking better access to tertiary education remind us how politically and socially explosive inequitable access to social services can be. The protests have effectively highlighted government underfunding of tertiary education and surfaced dissatisfaction with persistent income and service disparities more generally. As we approach the second Universal Health Coverage Day on 12 December, and with the reportedly imminent release of the National Health Insurance White Paper in South Africa (SA), we need to reflect as a society on our commitment to equitable access to good-quality health services.
Author Michele RamsaySource: South African Medical Journal 105, pp 1016 –1017 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10281More Less
Africa is disproportionately burdened by communicable and non-communicable diseases and their consequences. The 2010 - 2015 life expectancy at birth is 58.2 years for people born in Africa compared with 77.7 years in more developed regions, with a world average of 70.0 years (United Nations, World Mortality Report 2013). The Human Heredity and Health in Africa (H3Africa) Consortium is unique in its objective to promote human genomic research and health in Africa, led and managed by African investigators and their collaborators. In line with the vision articulated in the H3Africa White Paper published in 2011, the H3Africa Consortium aims to build capacity for genomic research in Africa, promote research on both communicable and non-communicable diseases and improve our understanding of the complexities of their coexistence in African populations, generate data and knowledge to promote an understanding of the health and epidemiological transition across the continent, and improve the health of its people. It provides a platform of integrated resources for biomedical research on the continent and is developing an extraordinary wealth of data. In addition it will host biorepositories with samples from over 75 000 African participants, many of whom have provided broad consent for sharing their data and samples through a managed access approach, to the benefit of the African and international research community.
Source: South African Medical Journal 105, pp 1018 –1023 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10332More Less
Concern and general awareness about the impacts of climate change in all sectors of the social-ecological-economic system is growing as a result of improved climate science products and information, as well as increased media coverage of the apparent manifestations of the phenomenon in our society. However, scales of climate variability and change, in space and time, are often confused and so attribution of impacts on various sectors, including the health sector, can be misunderstood and misrepresented. In this review, we assess the mechanistic links between climate and infectious diseases in particular, and consider how this relationship varies, and may vary according to different time scales, especially for aetiologically climate-linked diseases. While climate varies in the medium (inter-annual) time frame, this variability itself may be oscillating and/or trending on cyclical and long-term (climate change) scales because of regional and global scale climate phenomena such as the El-Niño southern oscillation coupled with global-warming drivers of climate change. As several studies have shown, quantifying and modelling these linkages and associations at appropriate time and space scales is both necessary and increasingly feasible with improved climate science products and better epidemiological data. The application of this approach is considered for South Africa, and the need for a more concerted effort in this regard is supported.
Source: South African Medical Journal 105, pp 1024 –1029 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10120More Less
Background. The Global Solar Ultraviolet Index (UVI) is a health communication tool used to inform the public about the health risks of excess solar UV radiation and encourage appropriate sun-protection behaviour. Knowledge and understanding of the UVI has been evaluated among adult populations but not among school students.
Objectives. To draw on previously unpublished data from two school-based studies, one in New Zealand (NZ) and the other in South Africa (SA), to investigate and compare students' knowledge of the UVI and, where possible, report their understanding of UVI.
Methods. Cross-sectional samples of schoolchildren in two countries answered questions on whether they had seen or heard of the UVI and questions aimed at probing their understanding of this measure.
Results. Self-report questionnaires were completed by 1 177 students, comprising 472 NZ (264 year 8 (Y8), 214 year 4 (Y4) students) and 705 SA grade 7 primary-school students aged 8 - 13 years. More than half of the NZ Y8 students answered that they had previously heard about or seen the UVI, whereas significantly more SA students and NZ Y4 students replied that they had neither seen nor heard about the UVI. Among the NZ students who had seen or heard of the UVI, understanding of the tool was fairly good.
Conclusion. The observed lack of awareness among many students in both countries provides an opportunity to introduce an innovative and age-appropriate UVI communication method that combines level of risk with behavioural responses to UVI categories and focus on personal relevance to the UVI message.
Molecular characterisation and epidemiological investigation of an outbreak of blaOXA-181 carbapenemase-producing isolates of Klebsiella pneumoniae in South Africa : researchSource: South African Medical Journal 105, pp 1030 –1035 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9926More Less
Background. Klebsiella pneumoniae is an opportunistic pathogen often associated with nosocomial infections. A suspected outbreak of K. pneumoniae isolates, exhibiting reduced susceptibility to carbapenem antibiotics, was detected during the month of May 2012 among patients admitted to a haematology unit of a tertiary academic hospital in Cape Town, South Africa (SA).
Objectives. An investigation was done to determine possible epidemiological links between the case patients and to describe the mechanisms of carbapenem resistance of these bacterial isolates.
Methods. Relevant demographic, clinical and laboratory information was extracted from hospital records and an observational review of infection prevention and control practices in the affected unit was performed. Antimicrobial susceptibility testing including phenotypictesting and genotypic detection of the most commonly described carbapenemase genes was done. The phylogenetic relationship of all isolates containing the blaOXA-181 carbapenemase gene was determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing.
Results. Polymerase chain reaction analysis identified a total of seven blaOXA-181-positive, carbapenem-resistant K. pneumoniae isolates obtained from seven patients, all from a single unit. These isolates were indistinguishable using PFGE analysis and belonged to sequence type ST-14. No other carbapenemase enzymes were detected.
Conclusion. This is the first documented laboratory-confirmed outbreak of OXA-181-producing K. pneumoniae in SA, and highlights the importance of enforcing strict adherence to infection control procedures and the need for ongoing surveillance of antibiotic-resistant pathogens in local hospitals.
Measurement of viral load by the automated Abbott real-time HIV-1 assay using dried blood spots collected and processed in Malawi and Mozambique : researchSource: South African Medical Journal 105, pp 1036 –1038 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9673More Less
Background. The use of dried blood spots (DBS) for HIV-1 viral load quantification can greatly improve access to viral monitoring for HIV-infected patients receiving treatment in resource-limited settings.
Objectives. To evaluate and validate HIV viral load measurement from DBS in sub-Saharan Africa, with a reliable, all-automated, standard commercial assay such as the Abbott m2000.
Methods. A total of 277 DBS were collected in different health centres in Malawi and Mozambique and analysed for viral load determinationusing the Abbott m2000 assay with the corresponding plasma samples as gold standard. Samples were extracted using the m2000SP automatic extractor and then processed as the plasma samples using the specific 1.0 mL HIV-RNA DBS protocol.
Results. Among samples with detectable HIV-RNA the correlation between viral load obtained from the paired 131 plasma and DBSsamples was high (r=0.946). Overall, viral load values between DBS and plasma differed by less than 0.5 log unit in 90.1% of cases and by less than 1 log unit in 100% of cases. Using a threshold of 1 000 copies/mL (defining virological failure in resource-limited settings), sensitivity was 94.2% and specificity 98.6%, and both positive and negative predictive values were high (98.5% and 94.5%, respectively).
Conclusion. DBS extracted and processed using the Abbott automated system can be reliably used in resource-limited setting to diagnose virological failure.
Time for a culture change? Suboptimal compliance with blood culture standards at a district hospital in Cape Town : researchSource: South African Medical Journal 105, pp 1039 –1043 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9442More Less
Background. The benchmark for contaminated blood cultures (BCs) is 3%. The South African (SA) guideline aims to optimise BC yield and reduce contamination. Data on BC collection practices in SA since the publication of the 2010 SA guideline are lacking.
Objective. To evaluate compliance with the national guideline for the optimal use of BCs and determine the BC contamination rate at a local district hospital.
Method. An audit of compliance with 22 BC standards was conducted at a district hospital in Cape Town, SA. Standards were evaluated by reviewing clinical and laboratory data and by a clinician questionnaire.
Results. Of the 425 BCs reviewed, 12.5% had positive growth, and 4.5% grew contaminants. Only 33% of BC bottles contained the recommended fill volume of 8 - 10 mL, and 96.9% of patients had a single BC within a 24-hour period. Of all the BCs, only 7.8% had a combined blood volume of at least 20 mL. The yield of pathogens in BCs collected after antibiotic exposure was 4.9% compared with7.5% for those cultures with no prior antibiotic exposure (p=0.3). The overall median needle-to-incubator transport time was 11 hours 25 minutes.
Conclusion. The BC contamination rate was high and compliance with most standards was variable or not met. The findings may not be generalisable to other hospitals, and we recommend that each institution reviews its own BC practices. Recommendations made to hospital staff included a re-audit following implementation of these recommendations.
Diagnosing childhood pulmonary tuberculosis using a single sputum specimen on Xpert MTB/RIF at point of care : researchSource: South African Medical Journal 105, pp 1044 –1048 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.8585More Less
Background. The GeneXpert MTB/RIF (Cepheid, USA) (Xpert) has proved successful for pulmonary tuberculosis (TB) diagnosis on decontaminated/concentrated induced sputum specimens from children. Capacity to perform induction in many settings is limited.
Objective. To assess: (i) volumes of 'routinely obtained' sputum in a district-level academic hospital; (ii) whether sputum specimens not meeting Xpert-required testing volumes could still be tested; and (iii) performance of Xpert on a single paediatric sputum specimen at point of care (POC).
Methods. Two sputa were collected from paediatric TB suspects (≤14 years) at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa. One specimen was weighed at POC; if the volume was ≥0.1 mL but < 0.5 mL, it was increased to 0.5 mL using saline. On-site Xpert testing (G3 cartridge) was performed by a dedicated laboratory technician. The second specimen was referred for TB smearmicroscopy and culture as per standard of care (SOC).
Results. A total of 484 patients presumed to have TB (median age 24 months) were eligible for this study, performed between June 2011 and May 2012. Xpert could not be used on 4.1% of specimens because of volumes < 0.1 mL, and 62.8% required addition of saline prior to Xpert testing. Xpert generated a 2.2% error and 3.7% invalid rate, compared with the SOC that rejected 2.3% because of insufficient volume and 2.3% that were contaminated. The diagnostic performance compared with culture was 62.5% (95% confidence interval (CI) 24.7 - 91) and 99.1% (95% CI 97.4 - 99.8) sensitivity and specificity, respectively, for Xpert (n=345) and 33.3% (7.9 - 69.9) and 99.5% (98.1 - 99.9)sensitivity and specificity, respectively, for smear microscopy (n=374).
Conclusions. Up to 67% of 'routinely obtained' sputum specimens from children (≤14 years) are below the required volume for Xpert testing but can be 'topped up' with saline. Xpert MTB/RIF performed better than microscopy and generated clinically relevant, timeous results, but sensitivity did not reach the same levels as culture in children.
The diagnostic accuracy of integrated positron emission tomography/computed tomography in the evaluation of pulmonary mass lesions in a tuberculosis-endemic area : researchSource: South African Medical Journal 105, pp 1049 –1052 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10300More Less
Background. Integrated positron emission tomography/computed tomography (PET-CT) is a well-validated modality for assessing pulmonary mass lesions and specifically for estimating risk of malignancy. Tuberculosis (TB) is known to cause false-positive PET-CT findings.
Objective. To investigate the utility of PET-CT in the evaluation of pulmonary mass lesions and nodules in a high TB prevalence setting.
Methods. All patients referred for the evaluation of a solitary pulmonary nodule or mass and who underwent PET-CT scanning over a 3-year period were included. The PET-CT findings, including maximum standardised uptake value (SUVmax), were compared with the gold standard (tissue or microbiological diagnosis). The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy for malignant disease were calculated according to the SUVmax cut-off of 2.5 and a proposed cut-off obtained from a receiver operatingcharacteristic (ROC) curve.
Results. Forty-nine patients (mean (standard deviation) age 60.1 (10.2) years; 29 males) were included, of whom 30 had malignancy. Using an SUVmax cut-off of 2.5, PET-CT had a sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for malignancy of 93.3%, 36.8%, 70.0%, 77.8% and 71.4%, respectively. After a ROC curve analysis, a suggested SUVmax cut-off of 5.0 improved the specificity to 78.9% and the diagnostic accuracy to 86.7%, with a small reduction in sensitivity to 90.0%.
Conclusions. The diagnostic accuracy of PET-CT in the evaluation of pulmonary mass lesions using the conventional SUVmax cut-offof 2.5 was reduced in a TB-endemic area. An SUVmax cut-off of 5.0 has a higher specificity and diagnostic accuracy for malignancy, with a comparable sensitivity.
Diabetes mellitus and non-traumatic lower extremity amputations in four public sector hospitals in Cape Town, South Africa, during 2009 and 2010 : researchSource: South African Medical Journal 105, pp 1053 –1056 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9276More Less
Background. Diabetes mellitus (DM) is the most commonly reported cause of non-trauma-related lower extremity amputations (LEAs) worldwide, but there is a dearth of such information for South Africa (SA).Objectives. To examine the proportion of LEAs due to diabetes and to describe the associated characteristics of these patients.
Methods. A retrospective analysis of all LEAs was performed in four public sector hospitals in Cape Town, SA, for 2009 and 2010. Operating theatre records were reviewed to identify all patients who had an LEA. Patient records were perused and information extracted using a structured questionnaire.
Results. Records for 941 of 1 134 patients identified as having an LEA were found (recovery rate 82.9%). Of the 867 patients with 1 280 LEAs included in the study, 925 LEAs were in 593 patients with DM and 355 LEAs in 274 non-DM patients. Therefore 72.3% (95% confidenceinterval (CI) 69.8 - 74.7) of LEAs were in people with DM, while 68.4% (95% CI 65.2 - 71.4) of the total patients had DM. The DM group underwent more multiple LEAs (42.0% v. 23%; p< 0.001) and had more multiple admissions (14.3% v. 7.7%; p< 0.005) than the non-DMgroup. Infection (85.7% v. 63.5%,; p< 0.001) and ulcer (25.3% v. 15.3%; p=0.001) were the leading causes for LEA in the DM group compared with the non-DM group. Ischaemia was the dominant cause in the non-DM patients (49.3% v. 23.3%; p< 0.001), as was smoking (69.7% v.43.5%, p< 0.001), compared with the DM patients.
Conclusions. These data demonstrate an alarming burden of LEAs due to DM in the public sector in Cape Town. Given that the majority of LEAs are preventable with adequate education, screening, treatment and follow-up, effective interventions are needed.
Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers : researchSource: South African Medical Journal 105, pp 1057 –1060 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9843More Less
Background. Diabetes mellitus (DM) may increase the risk of depression as a result of a sense of threat of debilitating complications or because of associated lifestyle changes. Depression may increase the risk of type 2 diabetes as a result of poor health behaviours.
Objective. To determine the association between diabetes mellitus, depression and psychological distress in a cohort of South African (SA) teachers.
Methods. Teachers from 111 public schools in the Metro South District of the Cape Metropolitan area, SA, were invited to participate in this study. The Center for Epidemiologic Studies Depression Scale (CES-D) and the Kessler Psychological Distress Scale (K10) were used to assess depression and psychological distress, respectively. A professional nurse completed a physical examination and collected blood formeasurement of glucose, cholesterol and serum creatinine.
Results. Of the 388 teachers who completed the questionnaires, 67.5% were female and the average age was 46.2 years (standard deviation8.7). Psychological distress was identified in 28.1% of the cohort and depression in 15.5%, and 7.7% were found to fulfil criteria for DM. A diagnosis of DM was associated with an increased risk of depression (adjusted odds ratio (AOR) 3.90; 95% confidence interval (CI) 1.33 - 11.37) and psychological distress (AOR 3.62; 95% CI 1.31 - 10.00).
Conclusion. The high prevalence of obesity and DM in this cohort of SA teachers is of concern. A diagnosis of DM was strongly associated with an increased risk of depression and psychological distress.
An electronic colonoscopy record system enables detailed quality assessment and benchmarking of an endoscopic service : researchSource: South African Medical Journal 105, pp 1061 –1063 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10115More Less
Background. Competence in colonoscopy, which is a technically difficult procedure, requires adequate exposure to it and the maintenance of a detailed logbook. Without an electronic record this is difficult to achieve. By implementing an electronic medical record system we aimed to perform a detailed quality assessment audit of colonoscopy, to benchmark our results and generate accurate logbooks for individual endoscopists.
Methods. We reviewed the prospectively maintained Hybrid Electronic Medical Registry (HEMR). Colonoscopies performed between March 2013 and March 2014 were reviewed, and for competency, quality metrics were derived from the guidelines of the American Society of Gastroenterology.
Results. A total of 843 colonoscopies were performed. Seven hundred and seventy procedures were performed by three staff endoscopists who each performed over the required 150 procedures annually (n=197, 338 and 235). The remaining 73 (8.7%) were performed by other staff. In 105 cases (12.5%), bowel preparation was deemed to be inadequate, which caused the procedure to be abandoned in 34 cases.A total of 64 cases were deemed to be incomplete because of obstructing lesions (n=26), extensive diverticulosis (n=4), technical difficulty(n=31) and patient discomfort (n=3). There were two complications recorded: perforation (n=1) and bleeding (n=1).
Conclusions. The HEMR system enabled the audit of experiences with colonoscopy in our institution. Our results are broadly compatible with the international literature and with a number of guidelines. The development of an electronic record system is a major advance, as it enables meaningful benchmarking and the generation of accurate procedural logbooks.
Dyspepsia prevalence and impact on quality of life among Rwandan healthcare workers : a cross-sectional survey : researchSource: South African Medical Journal 105, pp 1064 –1069 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9482More Less
Background. Dyspepsia has been demonstrated worldwide to have major personal and societal impacts, but data on the burden of this disease in Africa are lacking.
Objective. To document the prevalence of dyspepsia and its quality-of-life impact among healthcare workers (HCWs) at Butare University Teaching Hospital (BUTH), Rwanda.
Methods. A cross-sectional survey among consenting HCWs at BUTH was conducted. Multilingual interviewers guided participants through validated questionnaires, including the Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ), to detect the presence and frequency of dyspeptic symptoms, and the Short-Form Nepean Dyspepsia Index (SF-NDI), to examine the impact of dyspepsia on quality of life.
Results. The study included 378 enrolled HCWs, all of whom provided responses to the SF-LDQ and 356 of whom responded to the SF-NDI. The prevalence of dyspepsia in the study population was 38.9% (147/378). Of these 147 HCWs, 79 (53.7%) had very mild dyspepsia, 33 (22.4%) had mild dyspepsia, 20 (13.6%) had moderate dyspepsia and 15 (10.2%) had severe dyspepsia. Females were more likely to complain of dyspepsia than males (98/206 v. 49/172; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.5 - 3.5; p< 0.001). Participants with dyspepsia of at least mild severity had SF-NDI scores reflecting reduced quality of life when compared with non-dyspeptic participants (OR 17.0; 95% CI 5.0 - 57.1; p< 0.001), with most marked effects on the 'tension' and 'eating and drinking' subdomains of the SF-NDI.
Conclusion. The prevalence of dyspepsia among HCWs in Rwanda is high and is associated with lowered quality of life.
Musculoskeletal disorders - disease burden and challenges in the developing world : CME - guest editorialSource: South African Medical Journal 105, pp 1070 –1071 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10260More Less
Recent advances in rheumatology have contributed to elucidate the complex pathogenic processes that underlie the development and progression of rheumatic diseases. This has led to the advent of new therapies to treat these conditions, including the biologic therapies. The use of synthetic disease-modifying anti-rheumatic drugs (DMARDs) together with biologic therapies has increased dramatically across a range of diseases, and resulted in improved outcomes for patients. In a study done in Spain, the overall age-standardised mortality rate for systemic lupus erythematosus (SLE) increased during 1981 - 1999 and stabilised during 2000 - 2010. The mean age at death increased with time, from 42 years in 1981 to 61 years in 2010. Similar mortality trends have been observed in patients with rheumatoid arthritis (RA), even though mortality still remains higher in RA patients compared with the general population. The overall SLE survival rates have increased significantly between the 1950s and 2000s, from 74.8% to 94.8% and 63.2% to 91.4% for the overall 5-year and 10-year survival, respectively. These improved outcomes are thought to be due to a combination of earlier recognition of mild disease and better approaches to therapy.