South African Medical Journal - Volume 106, Issue 1, 2016
Volumes & issues
Volume 106, Issue 1, 2016
Using mobile technology to improve maternal, child and youth health and treatment of HIV patients : guest editorialSource: South African Medical Journal 106, pp 3 –4 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10209More Less
Case study: Stock-out of iron supplements in pregnancy
In February 2015, the South African (SA) National Department of Health (NDoH) was notified of a shortage of iron tablets at a clinic in Kenneth Kaunda District in North West Province. Similar reports emerged from two other clinics in the same district around the same time. Iron supplements are routinely provided to pregnant women in SA to prevent maternal anaemia. Maternal anaemia is a risk factor for mortality from obstetric haemorrhage, which accounts for more than 200 maternal deaths annually. These reports resulted in a broader enquiry encompassing the whole of the province, revealing widespread stock-outs. With this insight, the provincial Department of Health met with staff to re-emphasise ordering procedures and what to do if drugs are out of stock. Notably, the earliest reports of iron stock-outs were received not from clinic staff but from pregnant women themselves, using the help desk function of a new mobile phone-based system called MomConnect.
Source: South African Medical Journal 106, pp 5 –6 (2016)More Less
Kangaroo mother care
Treating type 2 diabetes mellitus (DM)
Importance of screening for porphyria
Antenatal screening for hepatitis B virus (HBV) in HIV-infected and uninfected pregnant women in Tshwane
Fibrinolytic therapy for acute myocardial infarction
Source: South African Medical Journal 106, pp 7 –8 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10414More Less
The long-awaited extraction of doctors - and possibly dentists - from the dysfunctional and shockingly administered Health Professions Council of South Africa (HPCSA), the defiant leadership of which face the sack, will not lack a helping hand from the country's largest doctor body.
Source: South African Medical Journal 106, pp 9 –13 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10416More Less
It's hoped that it will take less than a decade, but legal and other reforms urgently needed to address the runaway costs of protecting physicians against clinical negligence - which threaten the very existence of higher risk specialties - now have a starkly clear outline. This emerged after a workshop sponsored by the Medical Protection Society (MPS), in which a review of pertinent global tort reform prompted animated and largely consensual discussion between almost equally represented doctors and lawyers.
Source: South African Medical Journal 106, pp 11 –13 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10416More Less
Author David EedesSource: South African Medical Journal 106 (2016)More Less
Understanding healthcare and population mobility in southern Africa : the case of South Africa : editorialSource: South African Medical Journal 106, pp 14 –15 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10210More Less
The impact of global increases in human mobility on health systems is a little understood but highly political issue in recipient countries. South Africa (SA) is the greatest recipient of migrants from the Southern African Development Community (SADC), a region with high levels of migration, a high communicable disease burden and struggling public healthcare systems. There is a policy of free primary healthcare for all in SA, as outlined in the Constitution and the National Health Act, but its interpretation is less inclusive within implementation guidelines and practice. As a result, non-nationals face access challenges, and healthcare responses have engaged with migration to a limited extent only. Migration provides opportunities for health and economic benefits, and has the potential to positively and negatively affect health systems. To maximise positive impact and mitigate against potential negative consequences requires attention and engagement of policy-makers from health and other sectors, including public health researchers and health workers. We outline our current research and existing responses to migration and health in southern Africa.
Author Solomon R. BenatarSource: South African Medical Journal 106, pp 16 –17 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10417More Less
Much has been written about 'poverty eradication' in recent years. The extent of poverty is of great concern in South Africa (SA) and globally, given the social implications of so many people living under atrocious conditions. Three Carnegie conferences over several decades have addressed poverty in SA. The most recent attracted a large audience, and most of the presentations were on micro-economic approaches to poverty alleviation. Macroeconomic problems and tentative solutions received minimal attention. Despite the complexity and magnitude of the macroeconomic task, there is evidence that 'alleviation of extreme poverty' can be achieved both locally and globally if the goal of doing so is limited to the current parsimonious World Bank (WB) definitions of poverty and economic groups. The swing towards optimism that extreme poverty can be significantly reduced has been boosted by what are (dubiously) deemed by some to be signs of 'global convergence' in wealth and health outcomes. Such optimism was also expressed at the recent Davos meeting, where the goals of 'action 2015' to 'end poverty in all its forms' was discussed.
Source: South African Medical Journal 106, pp 18 –20 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10286More Less
South Africa (SA) remains one of the most unequal societies in the world. Addressing the various challenges we face requires multidisciplinary, multi-pronged approaches, including consideration of strategies for improving the delivery of healthcare. Quality of healthcare can be understood to encompass a number of dimensions, including effectiveness, efficiency, accessibility, patient centredness,equity and safety. SA's call for primary healthcarere-engineering suggests an acute awareness of local challenges. The planned restructuring, including the National Health Insurance initiative, is a means for reducing inequality in the provision of healthcare, which will require new approaches to healthcare delivery, with greater emphasis on health promotion and preventive activities. These changes necessitate a collaborative approach for achieving improvements in key health processes and outcomes, as well as changes in clinician and patient behaviours, all underpinned by innovative interventions. In the changing healthcare system, healthcare providers need clear, trustworthy guidance on how best to care for their patients so that all can reasonably reach the ideals of quality in healthcare. High-quality, evidence-informed clinical practice guidelines (CPGs) are potentially reassuring tools for healthcare providers, as they are a means of bridging the gap between policy, best practice, local contexts and patient choice.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10208More Less
Cardiovascular medicine in primary healthcare in sub-Saharan Africa : minimum standards for practice (part 1) : guest editorialSource: South African Medical Journal 106, pp 21 –22 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10372More Less
Cardiovascular disease (CVD) accounts for approximately30% of deaths worldwide, with 80% of this CVD burden occurring in developing countries. The epidemiological transition occurring in sub-Saharan Africa (SSA) has the consequence of economic and social transformation, resulting in dramatic shifts in the disease spectrum from communicable diseases and malnutrition to CVD and cancer. South Africa (SA) is faced with the challenge of four colliding epidemics: (i) poor child and maternal health; (ii) high rates of interpersonal violence; (iii) infectious diseases including HIV/AIDS and tuberculosis; and (iv) non-communicable diseases (NCDs) including CVD. In SA NCDs are prevalent in both rural and urban areas, most prominently in poor persons living in urban and peri-urban settings, resulting in increasing pressure on acute and chronic healthcare services.
Source: South African Medical Journal 106, pp 23 –31 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10325More Less
Despite medical advances, heart failure (HF) remains a global health problem and sub-Saharan Africa (SSA) is no exception, with de-compensated HF being the most common primary diagnosis for patients admitted to hospital with heart disease. In SSA the in-hospital mortality rate of de-compensated HF is up to 8.3%. HF is a clinical syndrome that is caused by a diverse group of aetiologies, each requiring unique management strategies, highlighting the need for diagnostic certainty and a broad understanding of the complex pathophysiology of this condition. While there are a number of advanced medical, device and surgical interventions being tailored for HF internationally, the fundamental basic principles of HF management, such as patient education, effective management of congestion and initiation of disease modifying medical therapies, remain a challenge on our continent. This review addresses both the epidemiology of HF in SSA and principles of management that focus specifically on symptom relief, prevention of hospitalisation and improving survival in this population.
Source: South African Medical Journal 106, pp 32 –36 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10324More Less
Dyspnoea, also known as shortness of breath or breathlessness, is a subjective awareness of the sensation of uncomfortable breathing. It may be of physiological, pathological or social origin. The pathophysiology of dyspnoea is complex, and involves the activation of several pathways that lead to increased work of breathing, stimulation of the receptors of the upper or lower airway, lung parenchyma, or chest wall, and excessive stimulation of the respiratory centre by central and peripheral chemoreceptors. Activation of these pathways is relayed to the central nervous system via respiratory muscle and vagal afferents, which are consequently interpreted by the individual in the context of the affective state, attention, and prior experience, resulting in the awareness of breathing. The clinical evaluation and approach to the management of dyspnoea are directed by the clinical presentation and underlying cause. The causes of dyspnoea are manifold, and include a spectrum of disorders, from benign to serious and life-threatening entities. The pathophysiology, aetiology, clinical presentation and management of dyspnoea are reviewed.
Source: South African Medical Journal 106, pp 36 –38 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10329More Less
Hypertension is the leading cause of death worldwide. Globally and locally there has been an increase in hypertension in children, adolescents and young adults < 40 years of age. In South Africa, the first decade of the millennium saw a doubling of the prevalence rate among adolescents and young adults aged 15 - 24 years. This increase suggests that an explosion of cerebrovascular disease, cardiovascular disease and chronic kidney disease can be expected in the forthcoming decades. A large part of the increased prevalence can be attributed to lifestyle factors such as diet and physical inactivity, which lead to overweight and obesity. The majority (>90%) of young patients will have essential or primary hypertension, while only a minority (((< 1lt;1lt;10%) will have secondary hypertension. We do not recommend an extensive workup for all newly diagnosed young hypertensives, as has been the practice in the past. We propose a rational approach that comprises a history to identify risk factors, an examination that establishes the presence of target-organ damage and identifies clues suggesting secondary hypertension, and a limited set of basic investigations. More specialised tests should be performed only where there is a clinical suspicion that a secondary cause for hypertension exists. There have been no randomised clinical trials on the treatment of hypertension in young patients. Expert opinion advises an initial emphasis on lifestyle modification. This can comprise a diet with reduced salt and refined carbohydrate intake, an exercise programme and management of substance abuse issues. Failure of lifestyle measures or the presence of target-organ damage should prompt the clinician to initiate pharmacotherapy. We recommend referral to a specialist practitioner in cases of resistant hypertension, where there is severe target-organ damage and when a secondary cause is suspected.
Source: South African Medical Journal 106, pp 39 –42 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10326More Less
Valvular heart disease poses a common yet difficult problem in everyday clinical practice. A thorough clinical evaluation with basic common investigations such as an electrocardiogram (ECG) and a chest radiograph (CXR) remains the cornerstone of diagnosis. Echo-cardiography and more invasive testing, if needed, are usually performed at specialist level to confirm the diagnosis, assess severity and assist in definitive decision-making. The causes and clinical, ECG and CXR features of the common valve lesions are described. Patients with symptomatic valve lesions should be referred for specialist assessment. In most cases, medical therapy serves as a bridge to definitive mechanical or surgical therapy.
Author D.C. StefanSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10400More Less
Epidemiological studies around the world were analysed recently by the International Agency for Research on Cancer, demonstrating a positive correlation between consumption of red meat and processed meat and colorectal cancer. In South Africa (SA) there is a great variation in the incidence of this type of cancer between various ethnic groups, related to diet and other risk factors. Strengthening the SA cancer registry and co-ordinated research on diet and cancer are required to provide specific answers for our population.
Severe porphyric neuropathy - importance of screening for porphyria in Guillain-Barre syndrome : clinical alertSource: South African Medical Journal 106, pp 44 –47 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10118More Less
The hepatic porphyrias are a group of rare metabolic disorders, each of which is associated with a specific enzymatic alteration in the haem biosynthesis pathway. In South Africa (SA), a high incidence of variegate porphyria (VP) is seen as a result of a founder effect, but acute intermittent porphyria (AIP) is also encountered. The development of acute neurovisceral attacks is related to environmental factors, including medications, hormones and diet. A possible manifestation of a severe attack is rapidly progressing quadriparesis, which may mimic Guillain-Barré syndrome. We present four such cases, highlighting that acute porphyria should be considered in the differential diagnosis of Guillain- Barré syndrome. Three patients presented to Steve Biko Academic Hospital, Pretoria, SA, with progressive quadriparesis, and one to a private hospital with acute abdominal pain followed by rapidly progressive quadriparesis. Two patients had started antiretroviral therapy before the development of symptoms, and one had started antituberculosis therapy. All patients had marked weakness with depressed reflexes, andshowed varying degrees of confusion. An initial diagnosis of Guillain-BarrÃ© syndrome led to administration of intravenous immunoglobulins in two patients. On testing for porphyria, it was found that two patients had AIP and two VP. Electrophysiological investigations revealed severe mainly motor axonal neuropathy in all. Two patients deteriorated to the point of requiring mechanical ventilation, and one of themdied due to complications of critical illness. Haemin was administered to three patients, but the process of obtaining this medication was slow, which delayed the recommended early administration. The surviving patients showed minimal recovery and remained severely disabled. Porphyric neuropathy should always be considered as a differential diagnosis in a patient with an acute neuropathy, especially in SA. Absence of abdominal pain does not exclude the possibility of porphyria, and attacks may be precipitated by antiretroviral and antituberculosis medication. The outcome of our patients was not favourable; specifically, obtaining haemin was a challenge in the state hospital setting.
Comparison of two text message (mHealth) campaigns for the deaf : contracted out v. conducted in-house : healthcare deliverySource: South African Medical Journal 106, pp 47 –49 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9640More Less
Cell phone-based health information (mobile health or mHealth) campaigns are an emerging technology. This evaluation focused on the aspect of cost of two health information campaigns, one on hypertension and one on pregnancy. Researchers could either contract out the technical components of the campaigns or attempt to run the campaigns themselves, in-house. The in-house campaigns cost an estimated ZAR13 548.72 v. the private provider quotes which ranged from ZAR27 542.97 to ZAR34 227.59. Running the campaigns in-house was more labour intensive and required more technical expertise, but had a reduced delivery failure rate (9.2% in-house v. 30.0% private provider). Running small to medium SMS (text message) campaigns for evaluative purposes proved advantageous over contracting out to private providers. Larger-scale evaluations and full-scale roll-out will require the services of private providers, but it is still essential that researchers actively engage with and monitor the technical aspects of these campaigns.
Taking kangaroo mother care forward in South Africa : the role of district clinical specialist teams : healthcare deliverySource: South African Medical Journal 106, pp 49 –52 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10149More Less
The global agenda for improved neonatal care includes the scale-up of kangaroo mother care (KMC) services. The establishment of district clinical specialist teams (DCSTs) in South Africa (SA) provides an excellent opportunity to enhance neonatal care at district level and ensure translation of policies, including the requirement for KMC implementation, into everyday clinical practice. Tshwane District in Gauteng Province, SA, has been experiencing an increasing strain on obstetric and neonatal services at central, tertiary and regional hospitals in recent years as a result of growing population numbers and rapid up-referral of patients, with limited down-referral of low-risk patients to district-level services. We describe a successful multidisciplinary quality improvement initiative under the leadership of the Tshwane DCST, in conjunction with experienced local KMC implementers, aimed at expanding the district's KMC services. The project subsequently served as a platform for improvement of other areas of neonatal care by means of a systematic approach.
Diagnosis of iron deficiency anaemia in hospital patients : use of the reticulocyte haemoglobin content to differentiate iron deficiency anaemia from anaemia ofchronic disease : in practiceSource: South African Medical Journal 106, pp 53 –54 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9934More Less
The diagnosis of iron deficiency anaemia in hospital patients with chronic infections and inflammation presents a challenge. Recently laboratory tests such as the reticulocyte haemoglobin content, which are independent of infection and inflammation, have become available for routine diagnostic use.