South African Medical Journal - Volume 105, Issue 2, 2015
Volumes & issues
Volume 105, Issue 2, 2015
Morbidity and mortality of black HIV-positive patients with end-stage kidney disease receiving chronic haemodialysis in South Africa : researchSource: South African Medical Journal 105, pp 110 –114 (2015) http://dx.doi.org/10.7196/SAMJ.8369More Less
Introduction. There are few published data from South Africa (SA) on the outcomes of black HIV-positive patients receiving chronic haemodialysis.
Methods. This retrospective study compared the incidences of vascular and infectious morbidity and mortality in black HIV-positive patients with those in a group of HIV-negative patients matched for ethnicity, age and gender. All the patients were receiving chronic haemodialysis in the medically insured healthcare sector of SA.
Results. The incidence of tuberculosis and hospital admission rates for vascular access-related infections were significantly higher in the HIV-positive group than the HIV-negative group. The HIV-positive group had significantly lower albumin (p< 0.05) and haemoglobin levels (p< 0.01), but this did not impact on mortality. Survival in both groups was excellent. In the HIV-positive group, viral suppression rates were suboptimal with < 50% of patients on antiretroviral therapy completely virally suppressed.
Conclusion. This study has shown that black HIV-positive patients receiving chronic haemodialysis in a healthcare-funded environment in SA have excellent overall survival in spite of higher hospital admission rates and higher infectious morbidity compared with HIV-negative patients.
The Vaccine and Cervical Cancer Screen (VACCS) project : linking cervical cancer screening to HPV vaccination in the South-West District of Tshwane, Gauteng, South Africa : researchSource: South African Medical Journal 105, pp 115 –120 (2015) http://dx.doi.org/10.7196/SAMJ.8418More Less
Background. Cervical cancer is preventable, but still highly prevalent in South Africa (SA). Screening strategies in the country have been ineffective, and new ways to prevent the disease are needed.
Objectives. To investigate the feasibility of linking cervical cancer screening in adult women to human papillomavirus (HPV) vaccination in schoolgirls.
Methods. Ten primary schools in the South-West District of Tshwane, Gauteng Province, SA, took part in the study. Cervical cancer and HPV vaccine information was provided to schoolgirls and their parents. Consented schoolgirls were vaccinated and their female parents were invited to participate in self-screening.
Results. Among 1 654 girls invited for vaccination, the consented and invited uptake rates were 99.4% and 64.0%, respectively. Vaccine completion rates were higher in schools where the vaccination programme was completed in the same calendar year than in those where it was administered over two calendar years. Of 569 adult females invited, 253 (44.5%) returned screen tests; 169 (66.8%) tested negative and 75 (29.6%) positive for any high-risk HPV (hrHPV). There were no differences in level of education, employment status or access to healthcare between women with positive and those with negative screen results.
Conclusions. Implementation of HPV vaccination in a primary school-based programme was successful, with high vaccine uptake and completion rates. Self-screening reached the ideal target group, and it is possible to link cervical cancer screening to the cervical cancer vaccine by giving women the opportunity of self-sampling for hrHPV testing. This is a novel and feasible approach that would require some adaptive strategies.
Prevalence of gastrointestinal pathogenic bacteria in patients with diarrhoea attending Groote Schuur Hospital, Cape Town, South Africa : researchSource: South African Medical Journal 105, pp 121 –125 (2015) http://dx.doi.org/10.7196/SAMJ.8654More Less
Background. Diarrhoea due to gastrointestinal infections is a significant problem facing the South African (SA) healthcare system.Infections can be acquired both from the community and from the hospital environment itself, the latter acting as a reservoir for potential pathogenic bacteria.
Objectives. To examine the prevalence of a panel of potential diarrhoea-causing bacteria in patients attending a tertiary healthcare facility in Cape Town, SA.
Methods. Polymerase chain reaction (PCR) primers specific for Clostridium difficile, Shigella spp., Salmonella spp., Klebsiella oxytoca, enteropathogenic and enterohaemorrhagic Escherichia coli (EPEC/EHEC), Staphylococcus aureus, enterotoxigenic Bacteroides fragilis and Campylobacter spp. were used to screen total bacterial genomic DNA extracted from stool samples provided by 156 patients with diarrhoea attending Groote Schuur Hospital, Cape Town, SA.
Results.C. difficile was the most frequently detected pathogen (16% of cases) in the 21 - 87-year-old patient range, but was not present in samples from the 16 - 20-year-old range. K. oxytoca (6%), EPEC/EHEC strains (9%) and S. aureus (6%) were also detected. The remaining pathogens were present at low frequencies (0 - 2.9%), and the occurrence of mixed infections was 5%. The majority of non-C. difficile-related diarrhoeas were community acquired.
Conclusion.C. difficile was the main cause of infectious diarrhoea in the sampled patients, while K. oxytoca and EPEC/EHEC strains were present as relatively minor but potentially significant pathogens.
Predictors of in-hospital mortality following non-cardiac surgery : findings from an analysis of a South African hospital administrative database : researchSource: South African Medical Journal 105, pp 126 –129 (2015) http://dx.doi.org/10.7196/SAMJ.8268More Less
Background. Predictors of in-hospital mortality (IHM) following non-cardiac surgery in South African (SA) patients are not well described.
Objective. To determine the association between patient comorbidity and IHM in a cohort of SA non-cardiac surgery patients.
Methods. Data related to comorbidity and IHM for 3 727 patients aged ≥45 years were obtained from a large administrative database at a tertiary SA hospital. Logistic regression analysis was used to determine independent predictors of IHM. In addition, population-attributable fractions (PAFs) were calculated for all clinical factors identified as independent predictors of IHM.
Results. Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were independently associated with IHM (odds ratios (95% confidence intervals) 7.585 (5.480 - 10.50); 2.604 (1.119 - 6.060); 2.645 (1.414 - 4.950); 1.433 (1.107 - 1.853); and 1.646 (1.213 - 2.233), respectively). Ischaemic heart disease, diabetes and hypertension were not identified as independent predictors of IHM in SA non-cardiac surgery patients. Renal dysfunction had the largest contribution to IHM in this study (PAF 0.34), followed by high-risk surgical specialties (PAF 0.15), male gender (PAF 0.08), cerebrovascular disease (PAF 0.03) and congestive heart failure (PAF 0.03).
Conclusion. Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were major contributors to increased IHM in SA non-cardiac surgery patients. Prospectively designed research is required to determine whether ischaemic heart disease, diabetes and hypertension contribute to IHM in these patients.
Source: South African Medical Journal 105, pp 129 –133 (2015) http://dx.doi.org/10.7196/SAMJ.8118More Less
Background. Myiasis is the infestation of live tissue of humans and other vertebrates by larvae of flies. Worldwide, myiasis of humans is seldom reported, although the trend is gradually changing in some countries. Reports of human myiasis in Africa are few. Several cases of myiasis were recently seen at the Mthatha Hospital Complex, Mthatha, Eastern Cape Province, South Africa (SA).
Objective. Because of a paucity of literature on myiasis from this region, surgeons and scientists from Walter Sisulu University, Mthatha, decided to document myiasis cases presenting either at Nelson Mandela Academic Hospital or Umtata General Hospital from May 2009 to April 2013. The objective was to determine the incidence, epidemiology, patient age group and gender, and fly species involved. The effect of season on incidence was also investigated.
Results. Twenty-five cases (14 men and 11 women) were recorded in the 4-year study period. The fly species involved were Lucilia sericata, L. cuprina, Chrysomya megacephala, C. chloropyga and Sarcophaga (Liosarcophaga) nodosa, the latter being confirmed as an agent for human myiasis for the first time. The patients were 3 - 78 years old (median 56). Cases were most numerous during spring and summer, and were associated with underlying pathologies typical of ageing.
Conclusion. Myiasis is a more common medical condition than expected in the Mthatha region. The study shows that human myiasis is still frequently encountered in SA, and there is a need to understand its epidemiology better.
Source: South African Medical Journal 105, pp 134 –138 (2015) http://dx.doi.org/10.7196/SAMJ.8696More Less
Background. Multimorbidity in non-communicable diseases (NCDs) is a complex global healthcare challenge that is becoming increasingly prevalent. In Africa, comorbidity of communicable diseases and NCDs is also increasing.
Objectives. To evaluate the extent of multimorbidity among patients with NCDs in South African (SA) primary healthcare (PHC).
Methods. A dataset obtained from a previous morbidity survey of SA ambulatory PHC was analysed. Data on conditions considered active and ongoing at consultations by PHC providers were obtained.
Results. Altogether 18 856 consultations were included in the dataset and generated 31 451 reasons for encounter and 24 561 diagnoses. Hypertension was the commonest NCD diagnosis encountered (13.1%), followed by type 2 diabetes (3.9%), osteoarthritis (2.2%), asthma (2.0%), epilepsy (1.9%) and chronic obstructive pulmonary disease (COPD) (0.6%). The majority of patients (66.9%) consulted a nurse and 33.1% a doctor. Overall 48.4% of patients had comorbidity and 14.4% multimorbidity. Multimorbidity (two or more conditions) was present in 36.4% of patients with COPD, 23.7% with osteoarthritis, 16.3% with diabetes, 15.3% with asthma, 12.0% with hypertension and 6.7% with epilepsy. Only 1.1% also had HIV, 1.0% TB, 0.4% depression and 0.04% anxiety disorders.
Conclusion. About half of the patients with NCDs had comorbidity, and multimorbidity was most common in patients with COPD and osteoarthritis. However, levels of multimorbidity were substantially lower than reported in high-income countries. Future clinical guidelines, training of PHC nurses and involvement of doctors in the continuum of care should address the complexity of patients with NCDs and multimorbidity.
Prospective analysis of the medicine possession ratio of antidepressants in the private health sector of South Africa, 2006 - 2011 : researchSource: South African Medical Journal 105, pp 139 –144 (2015) http://dx.doi.org/10.7196/SAMJ.8394More Less
Background. Major depressive disorder (MDD) is a disabling mental illness with high morbidity and mortality rates. Inadequate treatment efficacy, unfavourable side-effect profiles and consequent shortfalls in compliance are major stumbling blocks in its treatment. Noncompliance data in low- to middle-income countries are lacking.
Objective. To investigate the prevalence of antidepressant (AD) non-compliance in the private healthcare sector of South Africa (SA).
Methods. We conducted a prospective cohort study analysing AD medicine claims (N=35 175) for 14 135 patients, obtained from a nationally representative pharmaceutical benefit management company, over a 6-year study period (1 January 2006 - 31 December 2011). The medicine possession ratio (MPR) was used as a proxy to determine compliance with AD medication. Only patients >18 years of age whose treatment had been initiated by a psychiatrist following an appropriate International Classification of Diseases (10th edition) (ICD-10) diagnosis of a mood disorder were included. A patient was considered compliant if the MPR was between ≥80% and ≤110% over a >4-month treatment period.
Results. After the first 4 months, only 34% of patients were compliant. A statistically significant association was found between active ingredient consumed and compliance (p< 0.0001). Only 26.2% of patients who received amitriptyline-containing products were compliant, compared with 38.8% and 38.7% for venlafaxine and duloxetine, respectively.
Conclusion. Compliance data collected from pharmacy claims provide a workable estimate of the broader clinical scenario they represent. Although differences between classes of AD were evident, non-compliance was found to be high in the private healthcare environment of SA, comparable with global trends.
Integrated positron emission tomography/computed tomography for evaluation of mediastinal lymph node staging of non-small-cell lung cancer in a tuberculosisendemic area : a 5-year prospective observational study : researchSource: South African Medical Journal 105, pp 145 –150 (2015) http://dx.doi.org/10.7196/SAMJ.8357More Less
Background. Integrated positron emission tomography/computed tomography (PET-CT) is a well-validated modality for assessing mediastinal lymph node metastasis in non-small-cell lung cancer (NSCLC), which determines management and predicts survival. Tuberculosis (TB) is known to lead to false-positive PET-CT findings.
Objectives. To assess the diagnostic accuracy of PET-CT in identifying mediastinal lymph node involvement of NSCLC in a high TB-endemic area.
Methods. Patients who underwent both PET-CT and lymph node tissue sampling for the investigation of suspected NSCLC were prospectively included in this observational study. Results were analysed per patient and per lymph node stage. A post-hoc analysis was performed to test the validity of a maximum standardised uptake value (SUVmax) cut-off for lymph node positivity.
Results. PET-CT had a sensitivity of 92.6%, specificity of 48.6%, positive predictive value of 56.8% and negative predictive value (NPV) of 90.0% in the per-patient analysis. Diagnostic accuracy was 67.2%. Similar values were obtained in the per-lymph node stage analysis. TB was responsible for 21.1% of false-positive results. A SUVmax cut-off of 4.5 yielded an improvement in diagnostic accuracy from 64.0% to 84.7% compared with a cut-off of 2.5, but at the cost of decreasing the NPV from 90.6% to 83.5%.
Conclusion. In a high TB-endemic area, PET-CT remains a valuable method for excluding mediastinal lymph node involvement in NSCLC. Patients with a negative PET-CT may proceed to definitive management without further invasive procedures. However, PET-CT-positive lymph nodes require pathological confirmation, and the possibility of TB must be considered.
Author Bridget FarhamSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9350More Less
February's CME consists of a series of case reports that I have been sent over the past 12 months. Many journals - local and international - feature case reports within their pages, and younger doctors in particular are encouraged to write up their more interesting cases in this format.
The unsuspected killer : liquefied petroleum gas overexposure in South Africa : continuing medical education - case reportSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9267More Less
A 21-year-old woman with no past medical history of note was found unconscious together with five of her family members after prolonged exposure to liquefied petroleum gas. She was admitted to the intensive care unit at Victoria Hospital, Wynberg, Cape Town, South Africa, following resuscitation for pulseless electrical activity. On examination the following was found: coma without focal neurology; shock requiring fluid resuscitation and adrenaline; probable pneumonitis or aspiration pneumonia; acute rhabdomyolysis with severe metabolic acidosis; and raised serum K+. A carboxyhaemoglobin test was unable to confirm or exclude carbon monoxide poisoning.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9263More Less
A 67-year-old woman presented to the Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, South Africa, with an incarcerated umbilical hernia and a history of hypertension and psoriasis. Gastroscopy revealed a prepyloric ulcer. She had generalised plaque psoriasis and arthritis of the small joints of the hands, wrist and feet.
Digoxin therapy in the modern management of cardiovascular disease : an unusual but serious complication : continuing medical education - case studySource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.8638More Less
A 67-year-old woman presented to the Emergency Unit, Groote Schuur Hospital, Cape Town, South Africa, with a 1-week history of poor appetite, vomiting and fatigue. Her background history was notable for infundibular pulmonary stenosis resection, pulmonary embolism and atrial flutter. Two days before, she complained to her general practitioner of recent-onset, recurrent syncope and worsening gastrointestinal upset. Her medical treatment included warfarin 5 mg daily, enalapril 5 mg twice daily, furosemide 40 mg twice daily, atenolol 50 mg twice daily, amiodarone 200 mg daily and digoxin 0.125 mg daily. The digoxin was added to her therapy 8 months earlier to optimise rate control.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9292More Less
A 30-year-old woman presented to Tshepong Hospital, Klerksdorp, South Africa, with a history of rash with papules and pustules, which started on her face and spread to her entire body. There was a typical varicella lesion on the trunk. She was newly diagnosed as HIV-positive and was not yet on antiretroviral therapy.
Author P. MkokoSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9264More Less
Hair dye poisoning is a common problem in West Africa, in North Africa and on the Indian subcontinent. In Morocco, acute hair dye poisoning is the most frequent reason for hospitalisation for attempted suicide. In adults, 70 - 90% of episodes of hair dye poisoning are suicide attempts. The reported mortality rate range for acute hair dye poisoning is 10.6 - 38.7%.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9266More Less
A 35-year-old man presented with symmetrical inflammatory polyarthritis of the small and large joints and associated early-morning stiffness. He was assessed as having features in keeping with Klinefelter's syndrome. It is evident from the literature that there is a relationship between Klinefelter's syndrome and developing rheumatic conditions.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9269More Less
Schistosomiasis (also termed bilharzia, after the tropical disease specialist Theodor Bilharz) is a waterborne parasitic infection. It was first described in the appendix in 1909, but despite awareness of the disease for more than a century, little data on its exact incidence are available.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9262More Less
A 20-year-old man presented with a severely sore throat and myalgia, which were unresponsive to antibiotics. He was admitted to a regional hospital with an ongoing painful throat, generalised myalgia, fever and a transient, recurring, salmon-pink rash on his hands and trunk. He did not respond to ceftriaxone and had a continual significant fever daily.
Wernicke's encephalopathy as a complication of gastroparesis after emergency partial antrectomy : continuing medical education - case reportAuthor N.S. GanieSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9271More Less
Wernicke's encephalopathy is a common complication of malnutrition, alcohol abuse and gastric outlet obstruction. We describe a patient who developed Wernicke's encephalopathy secondary to gastroparesis, with no significant evidence of malnutrition, alcohol abuse, or gastric outlet obstruction.