South African Medical Journal - Volume 105, Issue 4, 2015
Volumes & issues
Volume 105, Issue 4, 2015
Source: South African Medical Journal 105, pp 275 –276 (2015) http://dx.doi.org/10.7196/SAMJ.9338More Less
The authors present the case for collaborative cohort supervision (CCM), including both master's students and novice supervisors, as a possible way to rapidly increase the number of supervisors needed to address the recent implementation of a compulsory research component to specialist registration with the Health Professions Council of South Africa. Different models of CCM are discussed and possible pitfalls highlighted.
Resuscitating an ethical climate in the health system : the role of healthcare workers : forum - opinionAuthor P. PillaySource: South African Medical Journal 105, pp 277 –278 (2015) http://dx.doi.org/10.7196/SAMJ.9397More Less
South Africa boasts a proud tradition of healthcare professionals speaking out against injustice in line with the medical doctrine of beneficence (to do good) and maleficence (do no harm). There are many who play a part in making the health system better, including the state, managers, patients and healthcare workers (HCWs). This article looks at the role of HCWs beyond providing medical care to individual patients. HCWs often face a lack of resources enabling them to adequately provide care and treatment and respond to life-threatening emergencies. As a result, they are forced to make difficult decisions when it comes to allocating those scarce resources. These decisions are not purely fiscal in nature, but also ethical. Deciding who to bump off a theatre list because there is no linen is a choice most HCWs did not imagine they would ever have to make. In order to circumvent a sense of hopelessness, HCWs need to empower and motivate themselves (and others) with knowledge of how to make things better.
Author B. TshehlaSource: South African Medical Journal 105, pp 279 –280 (2015) http://dx.doi.org/10.7196/SAMJ.9217More Less
The Interim Traditional Health Practitioners Council was inaugurated in February 2013, and in May 2014 the sections of the Traditional Health Practitioners Act that give it full powers came into effect. The Council, as a professional body established by Parliament, gives traditional health practitioners registered with it the authority to issue medical certificates in line with the provisions of the Basic Conditions of Employment Act. However, the Council does not seem to be in a position to perform this function yet. Moreover, the field itself seems almost impossible to regulate because the practitioners cannot be subjected to objective assessment measures. While registered traditional health practitioners have the authority to issue medical certificates, it remains a moot point whether the certificates should be given full credibility before specific requirements for registration have been formulated and are implementable, and the envisaged code of conduct is in force.
Source: South African Medical Journal 105, pp 281 –282 (2015) http://dx.doi.org/10.7196/SAMJ.8907More Less
Worldwide an estimated 240 million people are chronically infected with chronic hepatitis B virus (CHB), of whom an estimated 3.4 million are coinfected with HIV. Chronic liver disease has emerged as an important cause of morbidity in the HIV-infected population. It is, after opportunistic infections, the second most common cause of death among some populations of HIV-infected patients on antiretroviral therapy (ART). In resource-limited settings (RLSs), infection with HIV and hepatitis B virus (HBV) is associated with poorer outcomes than HBV mono-infection. Co-infection is associated with higher rates of HBV persistence after acute infection, and among individuals with CHB, higher HBV DNA levels, a higher prevalence of HBV e antigenaemia, and an increased risk of progression to fibrosis, cirrhosis and possibly hepatocellular carcinoma (HCC). Identifying patients who are chronically infected and providing specific management improves outcomes. However, screening for active HBV infection before starting ART is not currently part of HIV guidelines in many countries in sub-Saharan Africa (SSA).
Of ambivalence, shame and guilt : perceptions regarding termination of pregnancy among South African women : editorialSource: South African Medical Journal 105, pp 283 –284 (2015) http://dx.doi.org/10.7196/SAMJ.9419More Less
Termination of pregnancy (TOP) for health or other reasons is an emotive and contentious issue, steeped in the context of a political, moral and religious climate. For most women, the decision to have a TOP is not easy, regardless of the reason. While early literature supported the notion that that there is little in the way of negative sequelae following TOP, more recent long-term studies have suggested that negative sequelae may be more common than was previously thought. Risk factors for the development of negative sequelae include the attitude projected by those providing the procedure (negative attitudes of providers tend to promote emotional sequelae in women undergoing TOP), previous psychological/psychiatric history (associated with higher rates of post-traumatic stress disorder (PTSD) and depression following TOP), and low income (with women from low-income groups having higher admission rates for depression and PTSD after TOP).
Abuse in South African maternity settings is a disgrace : potential solutions to the problem : editorialSource: South African Medical Journal 105, pp 284 –286 (2015) http://dx.doi.org/10.7196/SAMJ.9582More Less
Abuse of patients by healthcare staff in maternity settings has been reported globally, in high- and low-income settings. Such behaviours include verbal abuse, physical abuse, non-consensual care, non-confidential care, neglect, abandonment of care and bribery. Review articles suggest that the causes are multifactorial, including lack of professional support for healthcare workers, hierarchical work relationships, excessive workload, inadequate staffing levels and poor infrastructure. A World Health Organization statement in 2014 emphasised that the problem of disrespect and abuse of women during facility-based childbirth is a global phenomenon requiring urgent attention.
Author Norman David GoldstuckSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9480More Less
There are about 7 billion people living on our planet. In many countries resources are strained and we seek to slow down the rate of population growth. There are obviously many factors that lead to rapid population growth. Contraceptive methods are an important means of slowing population growth by helping people limit and/or space their families. While the cost of older methods such as the oral contraceptive pill, injectable progestogens and copper intrauterine contraceptive devices (IUCDs) has come down considerably, the cost of the newer hormone-based long-acting reversible contraceptive (LARC) methods has not.
Maternal death and caesarean section in South Africa : results from the 2011 - 2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths : researchSource: South African Medical Journal 105, pp 287 –291 (2015) http://dx.doi.org/10.7196/SAMJ.9351More Less
Background. In the latest (2011 - 2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10 000 CSs performed.
Objective. To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011 - 2013 national data.
Methods. Data from the 2011 - 2013 triennial review were entered into an Excel database and analysed on a national and provincial basis.
Results. There were 1 243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism.
Conclusion. This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are made to this effect.
Utility of the Robson Ten Group Classification System to determine appropriateness of caesarean section at a rural regional hospital in KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 105, pp 292 –295 (2015) http://dx.doi.org/10.7196/SAMJ.9405More Less
Background. High caesarean section (CS) rates are not only costly but associated with significant perinatal and maternal morbidity and mortality. It has recently been suggested that structured auditing of CSs may identify those groups in the obstetric population that contribute substantially to the high rates and for which focused interventions may bring about change.
Objective. To evaluate the utility of the Robson Ten Group Classification System (RTGCS) in determining appropriateness of CS at a regional rural hospital in KwaZulu-Natal Province, South Africa.
Methods. A retrospective review of the hospital records of women delivered by CS over a 3-month period was performed. The RTGCS was used to categorise women according to parity, age, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery.
Results. There were 2 553 hospital births over the 3-month study period. The CS rate was 42.4% (1 082/2 553). According to the RTGCS, groups 1 (n=296, 27.4%), 5 (n=186, 17.2%) and 10 (n=253, 23.4%) were substantial contributors to the overall CS rate. The main indications for CS were fetal distress (36.5%) and cephalopelvic disproportion (26.8%).
Conclusion. The RTGCS is a useful tool with which to identify patient groups warranting interventions to reduce high CS rates in a rural regional hospital setting. Group 1 (nullipara: single cephalic term pregnancy; spontaneous labour) warrants the most attention. Applying stricter criteria and due diligence in decision-making for primary CS may decrease the high CS rates.
Office-based sperm concentration : a simplified method for intrauterine insemination therapy : researchAuthor D.R. FrankenSource: South African Medical Journal 105, pp 295 –297 (2015) http://dx.doi.org/10.7196/SAMJ.8944More Less
Background. Intrauterine insemination (IUI) could become preferred to more invasive and expensive techniques of assisted reproduction therapy (ART) and should be offered as the first choice in cases with no female factors and mild male factor subfertility. However, developing countries and especially their rural areas often lack the necessary equipment and laboratory facilities.
Objective. To describe a simplified one-step method to determine the sperm concentration range for IUI therapy.
Methods. Semen samples from 51 sperm donors were used. Following swim-up separation, the sperm concentration of the retrieved motile fraction was counted, as well as progressive motile sperm using a standardised wet preparation. The number of sperm in a 10 µL droplet covered with a 22 × 22 mm coverslip was counted under 400 × total magnification. The observed numbers of retrieved motile sperm were divided into three groups: < 40, 40 - 100 and >101 spermatozoa as recorded per initial estimation on the wet preparation.
Results. The mean (standard deviation) estimated sperm concentration for each group compared with actual counts per Neubauer counting chamber were: estimated < 40 sperm (n=14), mean 20 (8), Neubauer count 2.5 × 106/mL; estimated 40 - 100 sperm (n=14), mean 71 (15), Neubauer count 16 × 106/mL; and estimated >100 sperm (n=23), Neubauer count 48.3 (21.7) × 106/mL.
Conclusion. The results with IUI in male subfertility cases reported by Ombelet et al. in 1995 support the concept of first-line treatment of infertility by three to four cycles of IUI therapy in selected cases.
Intrapartum asphyxia and hypoxic ischaemic encephalopathy in a public hospital : incidence and predictors of poor outcome : researchSource: South African Medical Journal 105, pp 298 –303 (2015) http://dx.doi.org/10.7196/SAMJ.9140More Less
Objective. To determine the incidence of asphyxia and hypoxic ischaemic encephalopathy (HIE) and predictors of poor outcome in a hospital in a developing country.
Methods. Neonates of birth weight ≥2 000 g who required bag-and-mask ventilation and were admitted with a primary diagnosis of asphyxia from January to December 2011 were included. Medical records were retrieved and maternal and infant data collected and analysed. Infants who had severe HIE and/or died were compared with those who survived to hospital discharge with no or mild to moderate HIE.
Results. There were 21 086 liveborn infants with a birth weight of ≥2 000 g over the study period. The incidence of asphyxia ranged from 8.7 to 15.2/1 000 live births and that of HIE from 8.5 to 13.3/1 000, based on the definition of asphyxia used. In 60% of patients with HIE it was moderate to severe. The overall mortality rate was 7.8%. The mortality rate in infants with moderate and severe HIE was 7.1% and 62.5%, respectively. The odds of severe HIE and/or death were high if the Apgar score was < 5 at 10 minutes (odds ratio (OR) 19.1; 95% confidence interval (CI) 5.7 - 66.9) and if there was no spontaneous respiration at 20 minutes (OR 27.2; 95% CI 6.9 - 117.4), a need for adrenaline (OR 81.2; 95% CI 13.2 - 647.7) and a pH of < 7 (OR 5.33; 95% CI 1.31 - 25.16). Predictors of poor outcome were Apgar score at 10 minutes (p=0.004), need for adrenaline (p=0.034) and low serum bicarbonate (p=0.028).
Conclusion. The incidence of asphyxia in term and near-term infants is higher than that reported in developed countries. Apgar score at 10 minutes and need for adrenaline remain important factors in predicting poor outcome in infants with asphyxia.
Early sexual debut : voluntary or coerced? Evidence from longitudinal data in South Africa - the Birth to Twenty Plus studySource: South African Medical Journal 105, pp 304 –307 (2015) http://dx.doi.org/10.7196/SAMJ.8925More Less
Background. Early sexual debut, voluntary or coerced, increases risks to sexual and reproductive health. Sexual coercion is increasingly receiving attention as an important public health issue owing to its association with adverse health and social outcomes.
Objective. To describe voluntary and coerced experience at sexual debut.
Methods. A longitudinal perspective among 2 216 adolescents (1 149 females, 1 067 males) in a birth cohort study in South Africa, analysing data collected on six occasions between 11 and 18 years.
Results. The median age of sexual debut was 16 years for females and 15 for males. Reported coerced sexual debut included children < 11 years of age. Males reported earlier sexual debut, with both voluntary and coerced sexual experience, than females (p< 0.0001). Sexual coercion at early sexual debut among both male and female adolescents occurred mostly through sexual intercourse with older adolescents and partners of the same age.
Conclusion. The identified time periods and age groups need to be targeted for interventions to delay sexual debut and prevent sexual coercion among young people. More research is needed to understand underlying predisposing risk factors for sexual coercion at sexual debut, both early and not early.
Source: South African Medical Journal 105, pp 308 –311 (2015) http://dx.doi.org/10.7196/SAMJ.9108More Less
Background. Preoperative, intraoperative and follow-up guidelines for managing occult carcinoma in reduction mammoplasty specimens are scant.
Methods. We retrospectively analysed the records and pathology reports of 200 patients who had undergone reduction mammoplasty at two major public hospitals in Johannesburg, South Africa, during 2009 - 2014. Demographic data, their history of breast cancer and preoperative screening, the surgical techniques used and pathological reports were included. In all cases preoperative screening for breast cancer had been negative.
Results. All the patients were female, mean age 37.1 years, range 20 - 84 (standard deviation 11.9). All reductions were performed using standard techniques. Benign pathology was observed in 98 patients (49%) and malignant pathology in four (2%). The most common benign pathology observed was fibrocystic disease, and the most common malignant pathology ductal carcinoma in situ. Patient age correlated significantly with benign or malignant disease.
Conclusions. Reduction mammoplasty produces tissue that should always be sent for pathological assessment. Patients should be stratified by risk, as doing so helps in selecting both the surgical setting and the approach to pathological analysis of the specimen. While the incidence of occult carcinoma in reduction mammoplasty specimens is low, all patients undergoing the procedure should be informed that tissue will be sent for pathological examination, allowing them to prepare to receive possible news of breast cancer and be adequately equipped for subsequent decision-making.
Comparison of findings using ultrasonography and cystoscopy in urogenital schistosomiasis in a public health centre in rural Angola : researchSource: South African Medical Journal 105, pp 312 –315 (2015) http://dx.doi.org/10.7196/SAMJ.8564More Less
Background. Schistosomiasis is a chronic disease caused by infection with parasitic worms of the genus Schistosoma. In sub-Saharan Africa, infections with S. haematobium are most common. Cystoscopic examination (CE) has been accepted as the gold-standard test for detecting the late manifestations of schistosomiasis, including urothelial cancer of the bladder. However, this procedure is invasive and 10 - 40% of tumours may remain undetected. A non-invasive examination and a new generation of biomarkers are needed for better monitoring of the disease.
Objective. To assess the usefulness of ultrasound (US) scans for monitoring of structural urinary tract disease by local public health services in areas of Angola in which urogenital schistosomiasis is endemic.
Methods. A cohort of 80 S. haematobium-infected patients was selected in order to compare changes in the bladder wall detected by US with those observed on CE.
Results. There was a notable correlation between the findings observed on CE and US. Patients with lesions of the bladder mucosa such as neoplasms, ulcers or granulomas detected by CE also had changes in bladder wall thickness on US. The results support increased use of portable US machines for non-invasive examination of the bladder by local general practitioners.
Conclusion. US examination should be an integral part of the investigation of haematuria and used in all S. haematobium control programmes. General practitioners may find it useful for more accurate diagnosis of haematuria and to identify bladder wall alterations in both adults and children in schistosomiasis-endemic regions.
Author I. Van BiljonSource: South African Medical Journal 105, pp 316 –319 (2015) http://dx.doi.org/10.7196/SAMJ.9532More Less
Doctors use various guidelines on paediatric chronic kidney disease (CKD) for managing their patients according to the availability of resources. As with adolescent and adult patients, CKD in children can also progress to end-stage renal failure - the time course being influenced by several modifiable factors. Decline in renal failure is best categorised in stages, which determine management and prognosis. Staging is based on three categories, i.e. cause, glomerular filtration rate and proteinuria. Early diagnosis of CKD allows for the institution of renoprotective treatment of modifiable factors and treatment to prevent the development of complications. The two most important modifiable factors that can be treated successfully are hypertension and proteinuria. The objective of this article is to provide information on the diagnosis and treatment of CKD in children. Early identification and treatment of modifiable risk factors of CKD decreases the burden of disease and delays or prevents the need for renal replacement therapy.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9535More Less
In hypertensive patients without chronic kidney disease (CKD) the goal is to keep blood pressure (BP) at ≤140/90 mmHg. When CKD is present, especially where there is proteinuria of ≥0.5 g/day, the goal is a BP of ≤130/80 mmHg. Lifestyle measures are mandatory, especially limitation of salt intake, ingestion of adequate quantities of potassium, and weight control. Patients with stages 4 - 5 CKD must be carefully monitored for hyperkalaemia and deteriorating kidney function if angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are used, especially in patients >60 years of age with diabetes or atherosclerosis. BP should be regularly monitored and, where possible, home BP-measuring devices are recommended for optimal control. Guidelines on the use of antidiabetic agents in CKD are presented, with the warning that metformin is contraindicated in patients with stages 4 - 5 CKD. There is a wide clinical spectrum of renal disease in the course of HIV infection, including acute kidney injury, electrolyte and acid-base disturbances, HIV-associated glomerular disease, acute-on-chronic renal disease and side-effects related to the treatment of HIV.
Author C.R. SwanepoelSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9536More Less
The complications of chronic kidney disease (CKD) are dyslipidaemia, hyperkalaemia, metabolic acidosis, anaemia, and bone and mineral disorders. Dyslipidaemia may be treated with low-density lipoprotein-lowering agents. Statins are ineffective in stages 4 and 5 CKD, but are indicated for preventing the progression of disease in the earlier stages. Chronic acidosis has recently been shown to be a risk factor in the progression of CKD renal dysfunction. Therefore, treatment is mandatory. Practically, this should consist of 1 - 2 heaped teaspoons of sodium bicarbonate 2 - 3 times per day, which is an inexpensive and safe therapy that does not raise the blood pressure in spite of the increased sodium level. Target levels of haemoglobin, according to international guidelines, are between 10 g/dL and 12 g/dL. The serum phosphate level is raised in stage 4 CKD, and especially in stage 5 CKD, which is associated with coronary carotid and other vascular calcifications and may result in ischaemic heart disease, myocardial infarction and stroke. A raised parathyroid hormone level (secondary hyperparathyroidism) is also a major risk factor for cardiovascular disease and is associated with increased hypertension and resistance to the treatment of CKD-associated anaemia.
Author S. NaidooSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9537More Less
This article on drug nephrotoxicity is detailed, as it is important to be fully aware of renal side-effects of drugs with regard to prevention and early diagnosis in order to manage the condition correctly. Many therapeutic agents are nephrotoxic, particularly when the serum half-life is prolonged and blood levels are raised because of decreased renal excretion. Distal nephrotoxicity is markedly enhanced when the glomerular filtration rate (GFR) is reduced and is a particular threat in elderly patients with so-called 'normal' creatinine levels. In patients of 45 - 55 years of age the GFR is reduced by about 1 mL/min/year, so that an otherwise healthy person of 80 may have an estimated GFR (eGFR) of < 60 mL/min or < 50 mL/min, i.e. stage 2, 3 or 3b chronic kidney disease (CKD). Furthermore, other effects related to kidney dysfunction may be seen, e.g. worsening of hypertension with the use of non-steroidal anti-inflammatory drugs, increased bruising or bleeding tendency with aspirin, and hyponatraemia hypertension acidosis with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Digoxin is contraindicated in stage 3 CKD, even in a reduced dosage. Other drugs can cause the direct formation of kidney stones, e.g. topiramate (used in the prophylaxis of resistant migraine). Levofloxacin (Tavanic) can cause rupture of the Achilles tendon and other tendons. Radiocontrast media must be used with care. Occasionally, strategies to prevent acute kidney insufficiency cause irreversible CKD, especially in patients with diabetes and those with myeloma who have stage 4 - 5 CKD. Gadolinium in its many forms (even the newer products) used as contrast medium for magnetic resonance imaging is best avoided in patients with stages 4 and 5 CKD.