South African Medical Journal - Volume 106, Issue 2, 2016
Volumes & issues
Volume 106, Issue 2, 2016
Collaboration is key to strengthening surgical research capacity in sub-Saharan Africa : guest editorialSource: South African Medical Journal 106, pp 125 –126 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10183More Less
Global health research efforts are not being instigated in countries that have the highest burden of disease or the greatest clinical need. The so-called '10/90 gap' is well known, describing an estimated 10% of global health research devoted to conditions that account for 90% of the global disease burden. While much effort has addressed this disparity in the past 25 years, recent research from the Lancet Commission on Global Surgery indicates that high-income countries still account for 85% of published articles from the leading 35 countries undertaking surgical research. This situation needs to change. Disease characteristics and research findings from developed countries are potentially impractical and misleading for clinicians practising in low- and middle-income countries (LMICs) that are less well resourced.
Source: South African Medical Journal 106, pp 129 –130 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10449More Less
It was with mixed emotions that we prepared for our 15-year reunion at the University of Cape Town in November 2015. Certainly the nationwide student protests and shutdowns made administration and organisation quite challenging, but they also gave us a chance to reflect on our own medical education and training. As graduates of UCT in 2000, we started our professional careers as young interns in the middle of the HIV epidemic. As medical students we joked about including HIV or TB on every differential list, but as young doctors it was no longer a joke but a grim reality. With no antiretrovirals to offer our patients, a limited supply of fluconazole and Bactrim and HIV ELISA results that took 6 weeks to return from a tertiary centre, we found ourselves signing piles of death certificates every week and standing helplessly in front of our patients despite having been trained as curative clinicians.
Who will guard the guards? Medical leadership and conflict of interest in South African healthcare : correspondenceAuthor Raymond P. AbrattSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9679More Less
Conflicts of interest (COI) arising from the interaction of the pharmaceutical industry with doctors have been described in an SAMJ editorial. The common interests in patient well-being, shared by doctors and the pharmaceutical industry, will conflict with the pharmaceutical industry's wish to sell their products and influence doctors' behaviour.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10275More Less
Difficult endotracheal intubation commonly results in morbidity and mortality. To overcome such complications, the airway is assessed preoperatively. An intubation is considered difficult if an appropriately trained anesthesiologist needs more than three attempts or more than 10 minutes for successful endotracheal intubation.
Source: South African Medical Journal 106, pp 131 –132 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10523More Less
The ranks of senior public healthcare administrators swelled by 12% over the past 3 years v. a 3.5% growth among all physicians, pharmacists and pathologists over the same period. This previously unpublicised skewed progression has further bolstered appeals by healthcare professional groups to stop the wide-scale, debilitating freezing of clinical posts.
Source: South African Medical Journal 106, pp 132 –134 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10526More Less
A critical mass of key surgeons and anaesthetists met at the University of the Witwatersrand in December last year to start gauging the country's paucity of access to safe, affordable surgical and anaesthetic care, guided by recently crafted global improvement templates.
Source: South African Medical Journal 106, pp 135 –136 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10529More Less
Historically considered an expensive, inefficient and limited public healthcare initiative, the place of surgery as the 'forgotten stepchild' of public health now leaves almost 5 billion individuals worldwide unable to access safe, affordable surgery when needed. In his keynote address at the National Forum on Surgery and Anaesthesia, held at the University of the Witwatersrand in December 2015, Deputy Minister of Health Dr Mathume Phaala stated that the ideal of a long and healthy life for all South Africans cannot be achieved without improved access to safe surgery and anaesthesia, a goal necessitating improvements in existing infrastructure, information systems, financial management and leadership.
Data mining and biological sample exportation from South Africa : a new wave of bioexploitation under the guise of clinical care? : editorialSource: South African Medical Journal 106, pp 136 –138 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10248More Less
In September 2015, the South African (SA) health insurer Discovery announced that, in partnership with Craig Venter's company Human Longevity Inc., it would provide genetic testing to its members for USD250 (approximately ZAR3 400) per person. On the surface, this appears to be innovative and futuristic. However, a deeper look at this announcement reveals considerable problems in the exportation of biological samples and data out of SA, and brings into sharp focus the lack of protection in place for potential donors.
Source: South African Medical Journal 106, pp 139 –140 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10534More Less
Next-generation sequencing (NGS) has truly transformed human genetics and is now an integral discovery tool in the field. Whole-exome sequencing (WES) - an NGS application focused on the proteincoding regions of the human genome - has already bridged the bench-to-bedside divide internationally and is offered as a clinical test by several accredited laboratories. Clinical WES is not currently offered in South Africa (SA) for a number of reasons, including technological constraints, insufficient storage for the resulting large datasets, ethical considerations and limitations of our understanding of the impact of human genetic variants on health and in terms of clinical utility. The historical under-representation of individuals of black African descent in genomics research further complicates the interpretation of results obtained from WES data in black Africans.
Source: South African Medical Journal 106, pp 141 –142 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10408More Less
Healthcare professionals in South Africa (SA) are facing challenging times. As the clinical negligence claims environment in SA deteriorates, the effect is being felt not only by healthcare professionals but also by the wider public as a result of the strain that costs place on the public purse. We look at the current claims environment, and explain why a debate about reform is so important.
Cardiovascular medicine in primary healthcare in sub-Saharan Africa : minimum standards for practice (part 2) : CME - guest editorialSource: South African Medical Journal 106, pp 143 –144 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10454More Less
In the past decades sub-Saharan Africa (SSA) has witnessed urbanisation at unparalleled rates of increase, together with changing lifestyles. The consequence of this epidemiological transition has been a dramatic increase in the incidence of non-communicable diseases (NCDs), in particular cardiovascular disease (CVD). At the same time social disintegration and inequality, compounded by the dwindling economy in many countries in SSA, have seriously hindered a cohesive response to NCDs. Moreover, infections remain rife and many societies in SSA have to contend with the twin epidemics of both communicable diseases and NCDs.
Source: South African Medical Journal 106, pp 145 –150 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10327More Less
Although infective endocarditis (IE) is relatively uncommon, it remains an important clinical entity with a high in-hospital and 1-year mortality. It is most commonly caused by viridans streptococci. Staphylococcus aureus is responsible for a malignant course of IE and often requires early surgery to eradicate. Other rarer causes are various bacilli, including the HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella and Kingella spp.) group of organisms and fungi. The clinical presentation varies. Patients may present with a nonspecific illness, valve dysfunction, heart failure (HF) and symptoms due to peripheral embolisation. The diagnosis is traditionally based on the modified Duke criteria and rests mainly on clinical features and to a lesser extent on certain laboratory findings, microbiological assessment and cardiovascular imaging. Identification of the offending micro-organism is not only important from a diagnostic point of view, but also makes targeted antibiotic treatment possible and provides useful prognostic information. A significant proportion of microbiological cultures are negative, frequently owing to the administration of antibiotics prior to appropriate culture. Blood-culture-negative IE poses significant diagnostic and treatment challenges. The course of the disease is frequently complicated, and sequelae include HF, local intracardiac extension of infection (abscess, fistula, pseudoaneurysm), stroke and intracranial haemorrhage due to septic emboli or mycotic aneurysm formation as well as renal injury. Management includes prolonged intravenous antibiotics and consideration for early surgery with removal of infective tissue and valve replacement in patients who have poor prognostic features or complications. Antibiotic administration for at-risk patients to prevent bacteraemia during specific procedures (particularly dental) is recommended to prevent IE. The patient population who would benefit from antibiotic prophylaxis has become increasingly restricted, and guidelines recommend prophylaxis only for patients with cyanotic congenital heart disease, prosthetic heart valves and a previous episode of IE. The management of a patient with IE is challenging and often requires multidisciplinary input from an IE heart team, which includes cardiologists.
Source: South African Medical Journal 106, pp 151 –155 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10328More Less
Diseases of the pericardium commonly manifest in one of three ways: acute pericarditis, pericardial effusion and constrictive pericarditis. In the developed world, the most common cause of acute pericarditis is viral or idiopathic disease, while in the developing world tuberculous aetiology, particularly in sub-Saharan Africa, is commonplace owing to the high prevalence of HIV. This article provides an approach to the diagnosis, investigation and management of these patients.
Source: South African Medical Journal 106, pp 156 –159 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9928More Less
Very few patients with end-stage kidney disease in South Africa receive renal replacement treatment (RRT), despite the rapidly growing demand, because of resource constraints. Nephrologists who agonise daily about who to treat and who not to, and have been doing so since the inception of dialysis in this country, welcomed the opportunity to interact with the National Department of Health at a recent summit of stakeholders. The major challenges were identified and recommendations for short- to long-term solutions were made. While the renal community can still improve efficiencies, it is clear that much of the responsibility for improving access to RRT and reducing inequities must be borne by the national government. The summit marks the first step in a process that we hope will ultimately culminate in universal access to RRT for all South Africans.
The decolonialisation of medicine in South Africa : threat or opportunity? : in practice - healthcare deliveryAuthor M. De RoubaixSource: South African Medical Journal 106, pp 159 –161 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10371More Less
The South African Traditional Health Practitioners Act 22 of 2007 is now fait accompli. The Act has been promulgated and the Department of Health (DoH) is proceeding with its implementation. An Interim Traditional Health Practitioners Council and a dedicated DoH deputy director have been appointed, the appointment of a registrar is being finalised, and the DoH has conducted a roadshow to introduce the Act and its implications to groups of traditional health practitioners (THPs) countrywide. The objective is eventual formalisation and professionalisation of THP practice to provide appropriate primary healthcare services through co-operation with biomedical service providers. Biomedical practitioners should understand the provisions of Act 22, and how this may affect their own practices.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10512More Less
A multicentre evaluation of emergency abdominal surgery in South Africa : results from the GlobalSurg-1 South Africa study : researchSource: South African Medical Journal 106, pp 163 –168 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10183More Less
Background. GlobalSurg-1 was a multicentre, international, prospective cohort study conducted to address the global lack of surgical outcomes data. Six South African (SA) hospitals participated in the landmark surgical outcomes study. In this subsequent study, we collated the data from these six local participants and hypothesised that the location of surgery was an independent risk factor for an adverse outcome following emergency intraperitoneal surgery.
Methods. Participating hospitals contributed 30-day outcomes data of consecutive emergency intraperitoneal surgical operations performed during a 2-week period between July and November 2014. The six heterogeneous hospital cohorts were compared by categorical confounders. The primary outcome measure was in-hospital mortality; secondary outcome measures were in-hospital morbidity and length of stay of >14 days. The unadjusted association between hospital and adverse outcome and the univariate association between categorical confounders and adverse outcome were tested. Significant associations were further tested by a multivariate stepwise forward logistic regression model built for each outcome of interest.
Results. Six hospitals (designated 1 - 6) contributed outcomes data for 169 operations. The mean age of the patients was 34.9 years (range 9 - 82), 116 (68.6%) were male, and the majority (37.2%) presented as a result of trauma. Hospital 5 was associated with 76-fold increased odds of in-hospital death and 58-fold increased odds of a major in-hospital complication, and hospital 3 was associated with 3-fold increased odds of any in-hospital complication. The final model predicting in-hospital death had a receiver operating characteristic curve statistic of 0.8892.
Conclusion. The hospital is an independent risk factor for risk-adjusted adverse outcomes following emergency intraperitoneal surgery in SA.
South African surgical registrar perceptions of the research project component of training : hope for the future? : researchSource: South African Medical Journal 106, pp 169 –171 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10310More Less
Background. The Health Professions Council of South Africa requires that a research project be submitted and passed before registration as a specialist.
Objective. To describe surgical registrars' perceptions of the compulsory research project.
Method. Ethics clearance was received before commencing the study. A questionnaire was developed to collect feedback from surgical registrars throughout South Africa (SA). Completed questionnaires underwent descriptive analysis using MS Excel. Fisher's exact test and the χ2 test were used to compare perceptions of the research-experienced and research-naive groups.
Results. All medical schools in SA were sampled, and 51.5% (124/241) of surgical registrars completed the questionnaire. Challenges facing registrars included insufficient time (109/124), inadequate training in the research process (40/124), inadequate supervision (31/124), inadequate financial resources (25/124) and lack of research continuity (11/124). Of the registrars sampled, 67.7% (84/124) believed research to be a valuable component of training. An overwhelming percentage (93.5%, 116/124) proposed a dedicated research block of time as a potential solution to overcoming the challenges encountered. Further proposals included attending a course in research methodology (79/124), supervision by a faculty member with an MMed or higher postgraduate degree (73/124), and greater research exposure as an undergraduate (56/124). No statistically significant differences were found between the perceptions of the research-experienced and research-naive groups.
Conclusions. Challenges facing surgical registrars in their efforts to complete their research projects were identified and solutions to these problems proposed. It is heartening that respondents have suggested solutions to the problems they encounter, and view research as an important component of their careers.
Favourable outcomes for the first 10 years of kidney and pancreas transplantation at Wits Donald Gordon Medical Centre, Johannesburg, South Africa : researchSource: South African Medical Journal 106, pp 172 –176 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10190More Less
Background. It is important for centres participating in transplantation in South Africa (SA) to audit their outcomes. Wits Donald Gordon Medical Centre (WDGMC), Johannesburg, SA, opened a transplant unit in 2004. The first 10 years of kidney and pancreas transplantation were reviewed to determine outcomes in respect of recipient and graft survival.
Methods. A retrospective review was conducted of all kidney-alone and simultaneous kidney-pancreas (SKP) transplants performed at WDGMC from 1 January 2004 to 31 December 2013, with follow-up to 31 December 2014 to ensure at least 1 year of survival data. Information was accessed using the transplant registers and clinical records in the transplant clinic at WDGMC. The Kaplan-Meier method was used to estimate 1-, 5- and 10-year recipient and graft survival rates for primary (first graft) kidney-alone and SKP transplants.
Results. The overall 10-year recipient and graft survival rates were 80.4% and 66.8%, respectively, for kidney-alone transplantation. In the kidney-alone group, children tended towards better recipient and graft survival compared with adults, but this was not statistically significant. In adults, recipient survival was significantly better for living than deceased donor type. Recipient and graft survival were significantly lower in black Africans than in the white (largest proportion in the sample) reference group. For SKP transplants, the 10-year recipient survival rate was 84.7%, while kidney and pancreas graft survival rates were 73.1% and 43.2%, respectively.
Conclusion. Outcomes of the first 10 years of kidney and pancreas transplantation at WDGMC compare favourably with local and international survival data.