South African Medical Journal - Volume 105, Issue 6, 2015
Volumes & issues
Volume 105, Issue 6, 2015
Author Pieter CarstensSource: South African Medical Journal 105, pp 425 –426 (2015)More Less
Healthcare professionals should accept that mistakes are an inevitable part of clinical practice. Despite what patients may think - and many expect doctors to be infallible, and the healthcare system to be flawless - medicine by its very nature is risky. Accepting that things will not always go to plan, and that patients will complain, should make doctors think about developing their own system for handling complaints.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9376More Less
To the Editor: The National Department of Health clearly states its mission objective 'to improve quality of care of all levels of the health system is a priority'. The Department also aims to 'improve the overall efficiency of the health care delivery system'. The key word are improvement, quality and efficiency. So, are we all striving towards this objective? Are we all constantly trying to improve the level of service we offer to our patients and to improve their level of satisfaction?
Source: South African Medical Journal 105, pp 430 –431 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9748More Less
Stellenbosch University (SU)'s Centre for Medical Ethics and Law became Africa's first World Health Organization (WHO) Bioethics Collaborating Centre in April this year, after several years of working with the global body in vital areas such as vaccine policies, bio-banking and research ethics.
Source: South African Medical Journal 105, pp 431 –432 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9749More Less
Source: South African Medical Journal 105, pp 432 –433 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9789More Less
A terminally ill Cape Town advocate who died of natural causes hours before a Gauteng High Court judge granted him the locally unprecedented right to end his life (or have a doctor help him end it) may have speeded up long-recommended progressive law more in line with provisions of the Constitution.
The Fabricius decision on the Stransham-Ford case - an enlightened step in the right direction : izindabaAuthor Keymanthri MoodleySource: South African Medical Journal 105, pp 434 –435 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9790More Less
Many diseases are associated with incredible pain and suffering. Others impair function and independence to the extent that human dignity is eroded. In many instances the natural history of such conditions often leads to death within a reasonable period of time. In some cases, protracted ill health, pain, suffering and indignity ensue. Such circumstances have since time immemorial triggered the debate on euthanasia - a debate on what it means to have a good death. Acting compassionately, many South African (SA) doctors have, to some extent, either passively or actively assisted patients in achieving a good death.
Source: South African Medical Journal 105, pp 435 –436 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9464More Less
Just 15 months after four highly sophisticated robot-assisted da Vinci Surgical Systems were introduced to South Africa (SA), nine local urologists are now 'flying' the ZAR23 million devices 'solo', while another ten are being mentored on the revolutionary robotic-assisted laparoscopic tool.
Source: South African Medical Journal 105, pp 437 –439 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9307More Less
Pulmonary arterial hypertension (PAH) is a potentially lethal disease mainly affecting young females. Although the precise mechanism of PAH is unknown, the past decade has seen the advent of many new classes of drugs with improvement in the overall prognosis of the disease. Unfortunately the therapeutic options for PAH in South Africa are severely limited. The Working Group on PAH is a joint effort by the South African Heart Association and the South African Thoracic Society tasked with improving the recognition and management of patients with PAH. This article provides a brief summary of the disease and the recommendations of the first meeting of the Working Group.
Rural district hospitals - essential cogs in the district health system - and primary healthcare re-engineering : forum - healthcare deliverySource: South African Medical Journal 105, pp 440 –441 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9284More Less
The re-engineering of primary healthcare (PHC) is regarded as an essential precursor to the implementation of National Health Insurance in South Africa, but improvements in the provision of PHC services have been patchy. The authors contend that the role of well-functioning rural district hospitals as a hub from which PHC services can be most efficiently managed has been underestimated, and that the management of district hospitals and PHC clinics need to be co-located at the level of the rural district hospital, to allow for proper integration of care and effective healthcare provision.
Encephalopathy after persistent vomiting : three cases of non-alcohol-related Wernicke's encephalopathy : forum - clinical alertSource: South African Medical Journal 105, pp 442 –443 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9299More Less
Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration.
Author M. TshifularoSource: South African Medical Journal 105, pp 444 –445 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9404More Less
There are limited data on grading of parotid gland mass, and currently no bedside clinical grading system is available. Parotid enlargement is common in patients with HIV/AIDS, and the size of the gland can change depending on the progression of disease, with or without treatment. This needs to be recorded accurately and communicated properly. A novel system for bedside clinical grading of parotid gland enlargement using a soft tape measure is proposed.
Reflections of a retiree : 40 years in public service at Chris Hani Baragwanath Academic Hospital : forum - personal viewAuthor K.R.L. HuddleSource: South African Medical Journal 105, pp 446 –450 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9354More Less
Source: South African Medical Journal 105, pp 451 –452 (2015)More Less
Laparoscopic cholecystectomy entered into the surgical treatment of gallbladder disease in 1985. This was at a time when innovation rather than evidence was the driving force for the operation. It became evident that the persistent Achilles heel of this operation was bile duct injury (BDI), the incidence of which has remained twice that of open cholecystectomy.
Author Darryl WoodSource: South African Medical Journal 105 (2015)More Less
Burn injuries remain a significant cause of trauma, especially in low- to middle-income countries. The start point for reducing burn injuries lies in prevention, and education on risk factors for burn injuries begins in peoples' homes. The World Health Organization (WHO) in collaboration with various burns societies has prioritised prevention of burns and support for burns control measures. Fire-related burns are responsible for an estimated mortality rate of 6.1/100 000 population per year in Africa, much higher than the 1.0/100 000 in high-income countries. Worldwide, burns account for 10 million disability-adjusted life years. The WHO and burns organisations are aware that in low-income countries, rural and poor urban communities, lacking access to electricity, face a mix of risk factors such as ground-level cooking pots, open wood fires, candles and paraffin (kerosene) stoves of questionable safety. Efforts have been made to introduce safer paraffin lamps into South Africa (SA) in the hope that the number of burn injuries will be reduced.
Author B.J.S. DiedericksSource: South African Medical Journal 105 (2015)More Less
Sedation is widely used to reduce the fear and anxiety associated with dental procedures. In South Africa (SA), this is frequently done in consultation rooms rather than a theatre environment, with the aim of reducing cost and improving patient comfort, particularly in the case of children. Both local and systemic analgesia are combined with sedation. While severe complications are rare, critical incidents such as dysrhythmias or respiratory depression are common. Adverse events occur more frequently and have worse outcomes in the younger age group (((< 7lt;7lt;7 years of age). Such events include undersedation (with movement and possible injury), oversedation, oxygen desaturation, airway obstruction, laryngospasm, respiratory and cardiovascular depression or respiratory or cardiac arrest, seizures, unresponsiveness, allergic reactions, vomiting or excessive secretions, with risk of aspiration, and death.
Source: South African Medical Journal 105, pp 454 –457 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9038More Less
Background. Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury.
Objective. To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries.
Methods. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013.
Results. Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury.First-time repairs were performed at a median of 24.5 days (range 1 - 3 662) after initial surgery. Median hospital stay was 15 days (range 6 - 86). Mean cost of repair was ZAR215 711 (range ZAR68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance.
Conclusions. The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgical intervention and intensive imaging requirements.
Prehospital cooling of severe burns : experience of the Emergency Department at Edendale Hospital, KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 105, pp 457 –460 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8705More Less
Background. Early cooling with 10 - 20 minutes of cool running water up to 3 hours after a burn has a direct impact on the depth of the burn and therefore on the clinical outcome of the injury. An assessment of the early cooling of burns is essential to improve this aspect of burns management.
Objectives. To assess the rates and adequacy of prehospital cooling received by patients with severe burns before presentation to the Emergency Department (ED) at Edendale Hospital, Pietermaritzburg, South Africa. Patients with inadequate prehospital cooling who presented to the ED within 3 hours were also identified.
Methods. A retrospective review of the burns database for all the patients with severe burns admitted from the ED at Edendale Hospital from September 2012 to August 2013 was undertaken. Demographic details, characteristics and timing of the burns, and presentation were correlated with burn cooling.
Results. Ninety patients were admitted with severe burns. None received sufficient cooling of their burns, 25.6% received cooling of inadequate duration, and 32.3% arrived at the ED within 3 hours after the burn with either inadequate or no cooling. The median time to presentation to the ED after the burn was 260 minutes.
Conclusion. Appropriate cooling of severe burns presenting to Edendale Hospital is inadequate. Education of the community and prehospital healthcare workers about the importance of early appropriate cooling of severe burns is required. Many patients would benefit from cooling of their burns in the ED, and facilities should be provided for this vital function.
Source: South African Medical Journal 105, pp 461 –464 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.8788More Less
Background. Procedural sedation and analgesia (PSA) is often required to perform dental procedures in children. Serious adverse outcomes, while rare, are usually preventable.
Objectives. To determine the proportion of dental practitioners making use of paediatric dental chair PSA in Gauteng Province, South Africa, describe their PSA practice, and determine compliance with recommended safety standards.
Method. A prospective, contextual, descriptive study design was used, with 222 randomly selected dental practitioners contacted to determine whether they offered paediatric dental chair PSA. Practitioners offering PSA were then asked to complete a web-based questionnaire assessing their practice.
Results. Of the 213 dental practitioners contacted, 94 (44.1%; 95% confidence interval 37 - 51) provided PSA to children. Most patients were 1 - 5 years old, although there were practices that offered PSA to infants. While most procedures were performed under minimal to moderate sedation, deep sedation and general anaesthesia were also administered in dental rooms. Midazolam was the most frequently used sedative agent, often in conjunction with inhaled nitrous oxide; 28.1% of PSA providers administered a combination of three or more agents. Presedation patient assessment was documented in 83.0% of cases, and informed consent for sedation was obtained in 75.6%. The survey raised several areas of concern regarding patient safety: 41.3% of dental practices did not use any monitoring equipment during sedation; the operator was responsible for the sedation and monitoring of the patient in 41.3%; 43.2% did not keep any recommended emergency drugs; and 19.6% did not have any emergency or resuscitation equipment available. Most respondents (81.8%) indicated an interest in sedation training.
Conclusion. Paediatric dental chair PSA was offered by 44.1% of dental practitioners interviewed in Gauteng. Modalities of PSA provided varied between practices, with a number of safety concerns being raised.