South African Medical Journal - Volume 106, Issue 1, 2016
Volumes & issues
Volume 106, Issue 1, 2016
Source: South African Medical Journal 106, pp 55 –56 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10166More Less
We investigated the focus of cardiovascular medical device research in South Africa over the 15-year period 2000 - 2014. Information drawn from journal articles was used for the analysis, with attention to articles describing a contribution to the development of a cardiovascular medical device, or a new application of an existing device. The findings suggest that research has focused on diagnostic and monitoring as well as prosthetic cardiovascular medical devices, with specific emphasis on vascular and valvular heart diseases.
Targeting composite treatment of type 2 diabetes in middle-income countries - walking a tightrope between hyperglycaemia and the dangers of hypoglycaemia : reviewSource: South African Medical Journal 106, pp 57 –61 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10284More Less
Middle-income countries need a rational and cost-effective approach to optimise management of type 2 diabetes mellitus (T2DM). There is a paucity of data from such countries on the extent of hypoglycaemia and its consequences for their healthcare systems. This review provides the context for health policy change and evaluates available data on diabetes complications, focusing on hypoglycaemia in T2DM patients in non-Western countries. Suitable guidelines are suggested for these communities, which are in transition from poverty to affluence and in transition from an environment where infectious diseases predominate to one where non-communicable diseases are predominant.
The impact of an electronic clinical decision support for pulmonary embolism imaging on the efficiency of computed tomography pulmonary angiography utilisation in a resource-limited setting : researchSource: South African Medical Journal 106, pp 62 –64 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9886More Less
Background. Pulmonary embolism (PE) is associated with high morbidity and mortality. Effective intervention requires prompt diagnosis. Computed tomography pulmonary angiography (CTPA) is sensitive and specific for PE and is the investigation of choice. Inappropriate CTPA utilisation results in unnecessary high radiation exposure and is costly. State-of-the-art electronic radiology work flow can provide clinical decision support (CDS) for specialised imaging requests, but there has been limited work on the clinical impact of CDS in PE, particularly in resource-constrained environments.
Objective. To determine the impact of an electronic CDS for PE on the efficiency of CTPA utilisation in a resource-limited setting.
Methods. In preparation, a PE diagnostic algorithm was distributed to hospital clinicians, explaining the combined role of the validated modified Wells score and the quantitative D-dimer test in defining the pre-test probability of PE. Thereafter, an automated, electronic CDS was introduced for all CTPA requests. Total CTPA referrals and the proportion positive for PE were assessed for three study phases: (i) prediagnostic algorithm; (ii) post-algorithm, pre-CDS; and (iii) post-CDS.
Results. The proportion of CTPAs positive for PE after CDS implementation was almost double that prior to introduction of the diagnostic algorithm (phase 1 v. 3, 17.4% v. 30.7%; p=0.036), with a correspondingly significant decrease in the proportion of non-positive CTPAs (phases 1 v. 3, 82.6% v. 69.3%; p=0.015) During phases 2 and 3, no CTPAs were requested for patients with a modified Wells score of ≤4and a documented negative D-dimer, indicating adherence to the algorithm.
Conclusion. Implementing an electronic CDS for PE significantly increased the efficiency of CTPA utilisation and significantly decreased the proportion of inappropriate scans.
The relationship between stunting and overweight among children from South Africa : secondary analysis of the national food consumption survey - fortification baseline I : researchSource: South African Medical Journal 106, pp 65 –69 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9839More Less
Background. Globally, in children the prevalence of overweight and obesity is increasing, and this is associated with an increased risk of non-communicable diseases in adulthood. There is a need to examine the growing trends of overweight and obesity in children and their consequences in low- and middle-income countries.
Objectives. To describe the prevalence of, and determine the relationship between, stunting and overweight among children in two provinces of South Africa.
Methods. Secondary data analysis was conducted on anthropometric measurements of 36 - 119-month-old children from Gauteng and Mpumalanga provinces (N=519) participating in the South African National Food Consumption Survey - Fortification Baseline I (2005). The International Obesity Task Force (IOTF) body mass index (BMI) reference percentiles were used to determine overweight and obesity. The World Health Organization standards were used to derive z-scores.
Results. The prevalence of overweight was 12.0% (IOTF BMI ≥25 kg/m2), including 3.7% obesity (IOTF BMI ≥30 kg/m2). The predominantly urban Gauteng Province had a significantly higher prevalence of overweight children (14.1%) compared with Mpumalanga (6.3%) (p=0.0277). The prevalence of stunting was 17.0% (16.5% Gauteng, 18.2% Mpumalanga; p>0.05). There was a significant correlation (r=-0.32) between BMI and height-for-age z-scores (p < 0.0001). In the obese group, 68.4% were stunted, while in the normal and underweight group only 13.6% were stunted.
Conclusions. Stunted children were more likely to be obese. Further research is necessary for clarity on the physiological mechanisms of this relationship. In the interim, prevention of stunting requires priority.
The socio-economic and environmental health situation of international migrants in Johannesburg, South Africa : researchSource: South African Medical Journal 106, pp 70 –75 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10215More Less
Background. Around the world, cities are dealing with growing numbers of international migrants (IMs). Many migrants are likely to have encountered exceptional challenges through the migration process, with implications for their health. Nevertheless, studies conducted in several developed countries point to a pattern of better health in migrant groups - the 'healthy migrant' effect. However, little is known about the health of migrants in poorly resourced destination countries, especially in African settings.
Objectives. To compare living conditions and environmental health status in IMs relative to South African (SA) households, both living in settings of poverty in Johannesburg, SA.
Methods. Data were extracted from a long-term panel study underway in five neighbourhoods of Johannesburg. Cross-sectional studies, undertaken annually from 2006 to 2010, involved the annual administration of questionnaires to around 500 households to obtain information on living conditions and health.
Results. Most of the differences observed through univariate analyses in living conditions and health status between IM and SA households were explained by controlling for socioeconomic and neighbourhood factors.
Conclusion. This study revealed that SA respondents and IMs in settings of urban poverty in Johannesburg had remarkably similar health status, with little evidence of a 'healthy migrant' effect. Nevertheless the authors argue for vigilance and a finer understanding of the unique sociocultural dimensions of health in migrant communities in Johannesburg as they continue to transform the profile of urban health in SA and other African cities.
South African medical schools : current state of selection criteria and medical students' demographic profile : researchSource: South African Medical Journal 106, pp 76 –81 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9913More Less
Background. Selection of medical students at South African (SA) medical schools must promote equitable and fair access to students from all population groups, while ensuring optimal student throughput and success, and training future healthcare practitioners who will fulfill the needs of the local society. In keeping with international practices, a variety of academic and non-academic measures are used to select applicants for medical training programmes in SA medical schools.
Objectives. To provide an overview of the selection procedures used by all eight medical schools in SA, and the student demographics (race and gender) at these medical schools, and to determine to what extent collective practices are achieving the goals of student diversity and inclusivity.
Methods. A retrospective, quantitative, descriptive study design was used. All eight medical schools in SA provided information regarding selection criteria, selection procedures, and student demographics (race and gender). Descriptive analysis of data was done by calculating frequencies and percentages of the variables measured.
Results. Medical schools in SA make use of academic and non-academic criteria in their selection processes. The latter include indices of socioeconomic disadvantage. Most undergraduate medical students in SA are black (38.7%), followed by white (33.0%), coloured (13.4%) and Indian/Asian (13.6%). The majority of students are female (62.2%). The number of black students is still proportionately lower than in the general population, while other groups are overrepresented.
Conclusion. Selection policies for undergraduate medical programmes aimed at redress should be continued and further refined, along with the provision of support to ensure student success.
Implementation of a new 'community' laboratory CD4 service in a rural health district in South Africa extends laboratory services and substantially improves local reporting turnaround time : researchSource: South African Medical Journal 106, pp 82 –87 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10081More Less
Background. The CD4 integrated service delivery model (ITSDM) provides for reasonable access to pathology services across South Africa (SA) by offering three new service tiers that extend services into remote, under-serviced areas. ITSDM identified Pixley ka Seme as such an under-serviced district.
Objective. To address the poor service delivery in this area, a new ITSDM community (tier 3) laboratory was established in De Aar, SA. Laboratory performance and turnaround time (TAT) were monitored post implementation to assess the impact on local service delivery.Methods. Using the National Health Laboratory Service Corporate Data Warehouse, CD4 data were extracted for the period April 2012 - July 2013 (n=11 964). Total mean TAT (in hours) was calculated and pre-analytical and analytical components assessed. Ongoing testing volumes, as well as external quality assessment performance across ten trials, were used to indicate post-implementation success. Data were analysed using Stata 12.
Results. Prior to the implementation of CD4 testing at De Aar, the total mean TAT was 20.5 hours. This fell to 8.2 hours post implementation, predominantly as a result of a lower pre-analytical mean TAT reducing from a mean of 18.9 to 1.8 hours. The analytical testing TAT remained unchanged after implementation and monthly test volumes increased by up to 20%. External quality assessment indicated adequate performance. Although subjective, questionnaires sent to facilities reported improved service delivery.
Conclusion. Establishing CD4 testing in a remote community laboratory substantially reduces overall TAT. Additional community CD4 laboratories should be established in under-serviced areas, especially where laboratory infrastructure is already in place.
Source: South African Medical Journal 106, pp 88 –91 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9571More Less
Background. The large number of population-specific polymorphisms present in the HLA complex in the South African (SA) population reduces the probability of finding an adequate HLA-matched donor for individuals in need of an unrelated haematopoietic stem cell transplantation (HSCT). Next-generation sequencing (NGS) has numerous advantages compared with conventional typing techniques.
Objective.To evaluate whether NGS can provide any additional value over conventional techniques in the SA context for the purpose of HSCT and cord blood banking.Methods. HLA genotyping was performed using NGS on 20 samples that had previously been HLA typed by conventional methods to evaluate whether NGS might provide any additional value over conventional HLA determination techniques.
Results. NGS of routinely sequenced loci and exons yielded accurate genotypes for 98.5% of the five loci of interest, compared with 98%when additional exons were included.
Conclusion. The study shows that the additional value of NGS over conventional techniques is limited, and unless done on a large scale to reduce cost may not be appropriate in SA at this stage in the context of HSCT and cord blood banking.
Time to fibrinolytics for acute myocardial infarction : reasons for delays at Steve Biko Academic Hospital, Pretoria, South Africa : researchSource: South African Medical Journal 106, pp 92 –96 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9801More Less
Background. Fibrinolytic therapy is a time-critical intervention proven to reduce mortality and morbidity in patients with ST-elevation myocardial infarction (STEMI). Limited data exist in South Africa (SA) regarding time to fibrinolytic therapy for STEMI patients and reasons for delayed therapy.
Objectives. To establish the proportion of STEMI patients receiving fibrinolytic agents at Steve Biko Academic Hospital (SBAH), Pretoria,SA, identify any delays to receiving fibrinolytic agents, and uncover reasons for those delays. The number of lives lost as a result of these delays was calculated.
Methods. This prospective, observational study included 100 consecutive patients presenting with a STEMI to SBAH. Using a researcher administered questionnaire, the times from symptom onset to receipt of fibrinolytic therapy and the reasons for delays were documented. The number of lives lost was then calculated.
Results. Only 37% of patients received fibrinolytic therapy and only 3% received the medication within 1 hour. The median total delay inreceiving fibrinolytic therapy was 270 minutes (range 45 - 584). The median time delays from onset of symptoms to call for help, between calling for help and arriving at hospital, and from hospital arrival to fibrinolytic agent administration, were 35 minutes (5 - 1 185), 55 minutes (12.5 - 670) and 62.5 minutes (16.5 - 282), respectively. Numerous delays were identified at all stages, with patient and transport delays being most significant. Strikingly, an additional 32 patients per 1 000 treated could have been saved if a fibrinolytic agent had been administered within 1 hour.
Conclusions. This study highlights the important problem of delayed or non-administration of fibrinolytic therapy at a tertiary hospital. The problems identified will contribute to the implementation of a robust STEMI management network in SA, similar to those in developed countries.
Antenatal screening for hepatitis B virus in HIV-infected and uninfected pregnant women in the Tshwane district of South Africa : researchSource: South African Medical Journal 106, pp 97 –100 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9932More Less
Background. Despite enormous strides in preventing hepatitis B virus (HBV) infection, perinatal transmission still contributes significantly to HBV epidemiology worldwide; this could account for approximately 50% of chronically infected individuals.
Objective. To assess the need for HBV screening in antenatal clinics in the HIV/AIDS era.
Methods. This was a retrospective study conducted at the antenatal clinic of 1 Military Hospital, Tshwane, South Africa. Laboratory data for HBV, HIV and CD4 count were obtained and analysed for the period January 2008 - December 2013.
Results. A total of 2 513 patients' results were retrieved and 2 368 patients were enrolled as both their HBV and HIV serology results were available. The mean age of participants was 29 years (range 14 - 46). HIV prevalence in this study was 20.5% (95% confidence interval (CI) 0.189 - 0.222). The median CD4 count in HIV-infected patients was 522 cells/µL (interquartile range 370 - 711). There was an overall HBV prevalence of 0.8% (95% CI 0.005 - 0.011). The hepatitis B surface antigen (HBsAg) prevalence was significantly higher (2.1%) among HIV co-infected compared with HIV-uninfected patients (0.4%) (p=0.0001). Hepatitis e antigen (HBeAg) positivity was 30% in the HIVco-infected compared with 37.6% in the HIV-uninfected individuals (p=0.7400).
Conclusion. This study showed a significantly higher HBV prevalence in HIV-infected compared with HIV-uninfected patients. The comparable HBeAg prevalence between the two groups indicates that both were at an increased risk of vertical transmission, therefore demonstrating a need for antenatal screening for HBV. Since antenatal screening is often not affordable in low-income countries, administration of HBV vaccine at birth is needed for prevention of vertical transmission.
Source: South African Medical Journal 106, pp 101 –104 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i1.9860More Less
Background. Anaemia is a major global health problem affecting an estimated 42% of pregnant women worldwide. There is a paucity of South African (SA) data on anaemia in pregnancy, despite the fact that parasitic infections are endemic and the nutritional status of sections of the population is poor.
Objective. To determine the prevalence of anaemia among antenatal attendees in a regional hospital in Durban, SA.
Methods. This was a cross-sectional prospective study in a regional health facility in an urban setting serving a population of low socioeconomic status. Venous blood samples to perform a full blood count were obtained from antenatal attendees at their first clinic visit.
Results. Two thousand pregnant women were studied; the mean (standard deviation) age and gestational age at booking was 27.6 (7.6) years and 21.7 (7.1) weeks, respectively. Eight hundred and fifty-four (42.7%) were anaemic (haemoglobin (Hb) levels < 11 g/dL). The majority (81.4%) were mildly anaemic. There were five (0.6%) cases of severe anaemia (Hb < 7 g/dL). The prevalence of anaemia was significantly higher in HIV-positive compared with HIV-negative pregnant women (71.3% v. 28.7%; p< 0.0001). The common morphology was normochromic normocytic (n=588, 68.9%).
Conclusion. The prevalence of anaemia was 42.7%. In the majority (81.4%) the anaemia was mild and normocytic and normochromic (68.9%). Anaemia is a common problem among antenatal attendees in an SA urban population.