South African Medical Journal - Volume 106, Issue 2, 2016
Volumes & issues
Volume 106, Issue 2, 2016
Factors determining clinical outcomes in intussusception in the developing world : experience from Johannesburg, South Africa : researchSource: South African Medical Journal 106, pp 177 –180 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9672More Less
Background. Rates of open reduction of intussusception were noted to be unacceptably high during an institutional internal audit.
Objectives. To determine the impact of revised protocols to better select patients for pneumatic reduction (PR), and document associated morbidity and mortality, and the factors that affect the above.
Methods. Medical records of patients between 3 months and 3 years of age presenting to the Department of Paediatric Surgery at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 2007 to 2010 were reviewed. Determining factors, including duration of symptoms, admission C-reactive protein (CRP) level and weight, were analysed against clinical outcomes, notably PR, bowel resection, relook laparotomy and death.
Results. A total of 97 cases were suitable for inclusion. In 62 of these (63.9%), PR was attempted; this was successful in 32 cases (51.6%), giving an overall successful PR rate of 33.0%. In 7 of the 62 patients, a pneumoperitoneum was documented during the reduction attempt. Of the 65 patients who underwent surgery, 53 required intestinal resection and 12 had spontaneous or manual reduction. Ileostomy was necessary in 9 patients, and 7 required relook laparotomy. The overall mortality rate was 9.1%. Averages of 'determining factors' assessed against clinical outcome were as follows: mean weight (standard deviation (SD)) 7.4 (4.3) kg, mean duration of symptoms (DOS) 3.0 (SD 2.2) days, and admission CRP level 50.9 mg/L (range 1 -â??249.3). Prolonged DOS and a raised CRP level predicted a poor outcome.
Conclusions. Despite marked improvements in management and PR outcomes, intussusception remains associated with significant morbidity and mortality. Prolonged DOS and an elevated CRP predict worse outcomes. The use of these markers in association with clinical factors may assist management decisions, specifically with regard to operative or non-operative management. Awareness and education are key to prompt presentation and early diagnosis. Well-defined protocols introduced at all points of contact ensure early recognition and resuscitation as well as prompt referral for definitive management.
Are central hospitals ready for National Health Insurance? ICD coding quality from an electronic patient discharge record for clinicians : researchSource: South African Medical Journal 106, pp 181 –185 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10079More Less
Background. South Africa (SA)'s planned National Health Insurance reforms require the use of International Statistical Classification of Diseases (ICD) codes for hospitals to purchase services from the proposed National Health Authority. However, compliance with coding at public hospitals in the Western Cape Province has been challenging. A computer application was developed to aid clinicians in integrating ICD coding into the patient hospital discharge process.
Objectives. To evaluate the quality of ICD codes captured using the application and predictors thereof in a single hospital department.
Methods. After 6 months, the quality of ICD codes was determined by comparing ICD code descriptors with medical concepts in a random sample of original patient records selected over a 6-week period. Patient and personnel characteristics influencing quality of coding, derived from a theoretical framework, were collected.
Results. Of 223 patient records, 45.3% (95% confidence interval (CI) 38.8 - 51.9) had complete ICD codes. Primary ICD code accuracy was 74.0% (95% CI 67.8 - 79.5). Patient characteristics such as female gender, younger age group and fewer comorbidities, as well as seniority of clinician rank, were significantly associated with ICD coding being complete on adjusted analysis.
Conclusions. The results of this study describe ICD coding quality at a central hospital in SA supported by a computer application and the factors influencing this. More interventions are required to achieve reliable coding data, such as additional ICD coding validation tools, training and oversight of junior clinicians.
Source: South African Medical Journal 106, pp 186 –191 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9954More Less
Background. The high burden of burn injuries in South Africa (SA) requires surgeons skilled in burn care. However, there are few dedicated burn surgeons and properly equipped units or centres.
Objectives. To quantify the involvement of surgeons in burn care in SA hospitals, identify factors that attract surgeons to pursue burn care as a career and deter them from doing so, and understand the challenges of hospitals treating burn patients around the country.
Methods. This was a prospective, qualitative study. Questionnaires were handed out at the South African Burn Society Congress in September 2013 and a trade symposium in March 2014.
Results. One hundred questionnaires were handed out, and there was a 70% response rate. Twenty-six (39%) of the respondents had a specialist surgical qualification. Only half the units had registrars (48%) and interns (51%) on their staff. Only 30% of the respondents were dedicated to burn care alone, the majority being involved on a part-time basis. The most common factor respondents suggested was needed to recruit future burn care providers, cited by 76%, was better facilities and resources. Other factors included training and skills development (59%), subspecialist training (55%), development of a diploma in burn care (52%), development of research (52%) and healthcare worker psychological support (45%).
Conclusion. We have demonstrated that current workforce resources for burn care are inadequate, the major deficit being lack of training and the resource-restricted environment. This survey provides basic information towards workforce planning, which can be used to inform the necessary strategic decisions.
Mortality in paediatric burns victims : a retrospective review from 2009 to 2012 in a single centre : researchSource: South African Medical Journal 106, pp 189 –192 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.8942More Less
Background. Childhood mortality is high in low- and middle-income countries. Burns are one of the five leading causes of childhood injury mortality in South Africa (SA). While there is an abundance of literature on burns in the developed world, there are far fewer publications dealing with childhood mortality related to burns in Africa and SA.
Objective. To describe the mortality of children admitted to a dedicated paediatric burns unit, and investigate factors contributing to reducing mortality.
Methods. A retrospective review was performed of patients admitted to the Johnson & Johnson Paediatric Burns Unit, Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, between May 2009 and April 2012.
Results. During the study period, 1 372 patients aged ≤10 years were admitted to the unit. There were 1 089 admissions to the general ward and 283 admissions to the paediatric burns intensive care unit (PBICU). The overall mortality rate was 7.9% and the rate for children admitted to the PBICU 29.3%; 90.8% of deaths occurred in children aged ≤5 years. Of children admitted with an inhalational injury, 89.5% died. No child with a burn injury >60% of total body surface area (TBSA) survived.
Conclusions. Our overall mortality rate was 7.9%, and the rate declined significantly over the 3-year study period from 11.7% to 5.1%. Age ≤5 years, the presence of inhalational injury, burn injury >30% of TBSA and admission to the PBICU were significant risk factors for mortality.
Validating homicide rates in the Western Cape Province, South Africa : findings from the 2009 Injury Mortality Survey : researchSource: South African Medical Journal 106, pp 193 –195 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10211More Less
Background. The Western Cape Province had the highest homicide rates in South Africa during the early 2000s. South African Police Service (SAPS) data suggested a significant decline in homicide rates in the Western Cape since 2007. It ranked second highest to the Eastern Cape Province until 2013 and ranked highest again at 52.1/100 000 in 2015. A recent national injury mortality survey offers an alternative data source to assess whether the decline in homicide rates in the Western Cape was real.
Methods. A retrospective record review of autopsies was conducted from 45 state mortuaries in eight provinces for 2009. In addition, mortality data for the Western Cape were sourced from the Provincial Injury Mortality Surveillance System. Age-standardised mortality rates and crude homicide rates per 100 000 population were calculated to compare with the SAPS crude rates.
Results. Our study found that the Western Cape had a provincial age-standardised homicide rate of 40.1/100 000 in 2009 and ranked fourth highest among the nine provinces. The crude homicide rate of 43/100 000 for the Western Cape was similar to the SAPS provincial homicide rate of 42.4/100 000. The Northern Cape Province was the only notable exception to our provincial homicide rate ranking comparison with the SAPS for 2009.
Conclusions. The Western Cape is fortunate to have alternative data sources to monitor trends in homicides over time. The latest release of the 2014/2015 SAPS crime statistics should be assessed in a similar manner, with a more recent data source, to validate accuracy of the provincial rates on a regular basis.
Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients : researchSource: South African Medical Journal 106, pp 196 –200 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9870More Less
Background. Ventilator-associated pneumonia (VAP) has recently been classified as possible or probable. Although direct attributable mortality has been difficult to prove, delay in instituting appropriate therapy has been reported to increase morbidity and mortality. Recent literature suggests that in possible VAP, instituting directed therapy while awaiting microbiological culture does not prejudice outcome compared with best-guess empirical therapy.
Objectives. To ascertain outcomes of directed v. empirical therapy in possible and probable VAP, respectively.
Methods. Endotracheal aspirates were obtained from patients with suspected VAP. Those considered to have possible VAP were given directed therapy following culture results, whereas patients with more convincing evidence of VAP were classed as having probable VAP and commenced on empirical antimicrobials based on microbiological surveillance.
Results. Pneumonia was suspected in 106 (36.8%) of 288 patients admitted during January - December 2014. Of these, 13 did not fulfil the criteria for VAP. Of the remaining 93 (32.2%), 31 (33.3%) were considered to have probable and 62 (66.7%) possible VAP. The former were commenced on empirical antimicrobials, with 28 (90.3%) receiving appropriate therapy. Of those with possible VAP, 34 (54.8%) were given directed therapy and in 28 (45.2%) no antimicrobials were prescribed. Of the latter, 24 recovered without antimicrobials and 4 died, 3 from severe traumatic brain injury and 1 due to overwhelming intra-abdominal sepsis. No death was directly attributable to failure to treat VAP. No significant difference in mortality was found between the 34 patients with possible VAP who were commenced on directed therapy and the 31 with probable VAP who were commenced on empirical antimicrobials (p=0.75).
Conclusions. Delaying antimicrobial therapy for VAP where clinical doubt exists does not adversely affect outcome. Furthermore, this policy limits the use of antimicrobials in patients with possible VAP following improvement in their clinical condition despite no therapy.
An analysis of patients transported by a private helicopter emergency medical service in South Africa : researchSource: South African Medical Journal 106, pp 201 –205 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9919More Less
Background. A helicopter emergency medical service (HEMS) is a specialist flying emergency service where on-board medical personnel have both the knowledge and equipment to perform complicated medical procedures. The paucity of literature describing the types of patients flown by HEMS in South Africa (SA) and their clinical outcome poses a challenge for current aeromedical services, as there is no baseline information on which to base flight criteria, staffing and policy documents. This has the potential to hamper the advancement of HEMS in SA.
Objectives. To undertake a descriptive analysis of patients flown by the Netcare 911 HEMS over a 12-month period in Gauteng and KwaZulu-Natal (KZN) provinces, SA, and to assess patient outcomes. The clinical demographics of patients transported by the HEMS were analysed, time frames from dispatch of the helicopter to delivery of the patient to the receiving hospital determined, and patient outcomes at 24 hours and 72 hours analysed.
Methods. The study utilised a retrospective quantitative, descriptive design to analyse patients transported by a private HEMS in SA. All complete records of patients transported by the Netcare 911 HEMS between 1 January and 31 December 2011 were included.
Results. The final study population comprised 537 cases, as 10 cases had to be excluded owing to incomplete documentation. Of the 537 cases, 82 (15.3%) were managed by the KZN HEMS and 455 (84.7%) by the Gauteng HEMS. Adult males were the patients most commonly flown in both Gauteng and KZN (350/455 patients (76.9%) in Gauteng and 48/82 (58.5%) in KZN were males, and 364/455 patients (80.0%) in Gauteng and 73/82 (89.0%) in KZN were adults). Motor vehicle collisions were the most common incidents necessitating transport by HEMS in both operations (n=193, 35.9%). At the 24-hour follow-up, 339 patients (63.1%) were alive and stable, and at the 72-hour followup, 404 (75.3%) were alive and stable.
Conclusions. The study findings provided valuable information that may have an impact on the current staffing and authorisation criteria of SA HEMS operations.
Source: South African Medical Journal 106, pp 206 –209 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10106More Less
Background. Animal bites are a major cause of preventable traumatic injuries.
Objectives. To provide more epidemiological information on animal bites, and assist in increasing awareness of the problem.
Methods. A retrospective chart review was performed including children aged >13 years presenting with bite injuries (excluding dog and human bites) to the trauma unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, over a 25-year period.
Results. Two hundred and thirteen children were eligible to be entered into the study. The median age was 2.9 years (range 1.2 - 6.5), with boys slightly predominating (54.9%). Most (74.6%) of the bite injuries were inflicted by mammals, the majority (64.8) of mammalian bites being rat bites. The proportions of boys and girls in the age group 0 - 4 years bitten by rats significantly differed from the proportions in the age group >4 years (p=0.039). In the age group 0 - 4 years more girls suffered rat bites, while more boys were bitten in the age group >4 years. Of 91 rat bites, 81 (89.0%) occurred inside the house. The hands (43.9%) and the head/face/neck region (39.0%) were most affected. The underdeveloped suburbs of Philippi, Gugulethu and Khayelitsha in Cape Town represented a disproportionate number (41.6%) of rat bites.
Conclusions. There is a relationship between poverty, unemployment, poor housing, informal settlements and rodent infestation. These high-risk populations need to be the target for government rat eradication programmes.
Author H.M. SebitloaneSource: South African Medical Journal 106, pp 210 –213 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9903More Less
Background. Thrombocytopenia (TCP) complicates 5 - 8% of pregnancies. Most cases of TCP are gestational, and the condition is usually mild and occurs in the latter part of pregnancy. Apart from pregnancy-associated medical complications such as pre-eclampsia, HIV infection is a recognised cause of TCP, and a relatively high prevalence of TCP during pregnancy would be expected in a setting with a high antenatal seroprevalence of HIV.
Methods. This was a sub-analysis of the data from a prospective trial in which the incidence of postpartum sepsis in HIV-infected women was compared with that in HIV-uninfected women. Women who were considered at low risk and eligible for vaginal delivery were recruited at 36 weeks' gestation, and followed up for 6 weeks after delivery. Full blood counts and CD4 counts of HIV-infected women were obtained at baseline and repeated 6 weeks after delivery.
Results. The prevalence of TCP was 5.3% during pregnancy and 1.2% 6 weeks after delivery. The prevalence was similar among HIV-infected (6.0%) and HIV-uninfected women (4.7%) (p=0.292). Among the HIV-infected women, who were not receiving antiretroviral therapy (mean CD4 cell count of 453 cells/µL), there was no significant association between immunosuppression and the severity of TCP.
Conclusions. Most of the TCP seen during pregnancy is of the gestational variety, and in this study HIV infection did not increase its prevalence or its severity.
Which test is best for diagnosing peanut allergy in South African children with atopic dermatitis? : researchSource: South African Medical Journal 106, pp 214 –220 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10125More Less
Background. Diagnosing peanut allergy based on sensitisation alone leads to an unacceptable rate of overdiagnosis.
Objective. To define parameters that may help differentiate peanut allergy from asymptomatic sensitisation in a cohort of South African (SA) children with atopic dermatitis (AD). It is the first study in SA to utilise oral food challenge tests and analyse peanut component patterns.
Methods. This was a prospective, observational study at a paediatric university hospital in Cape Town, SA. Children with AD, aged 6 months - 10 years, were recruited randomly. They were assessed for sensitisation and allergy to peanut by questionnaire, skin-prick tests (SPTs), immuno solid-phase allergen chip (ISAC) tests, ImmunoCAP component tests to Ara h 1, 2, 3, 8 and 9, and incremental food challenges.
Results. One hundred participants (59 Xhosa (black Africans) and 41 of mixed race, median age 42 months) were enrolled. Overall, 44% of patients were peanut sensitised and 25% had a true peanut allergy. SPTs and ImmunoCAP Ara h 2 produced the highest areas under the receiver operating characteristic curve for predicting peanut allergy in peanut-sensitised patients. The ISAC test was less sensitive, more specific and produced significantly lower median values than ImmunoCAP tests. Ara h 2 was the most useful component in differentiating allergy from tolerance in both ethnic groups, being positive in 92% of allergic and 40% of sensitised but tolerant children (p< 0.001). There was little additional contribution from Ara h 1 and 3. Ara h 8 and 9 were associated with tolerance. Commonly used 95% positive predictive values (PPVs) for SPTs, peanut-specific IgE and Ara h 2 levels fared suboptimally in our population. Maximum PPVs for this study population were found at SPT 11 mm, peanut IgE 15 kU/L and ImmunoCAP Ara h 2 of 8 kU/L, but these adjusted levels still had suboptimal PPVs in Xhosa subjects. Severe peanut allergy was associated with increased median peanut IgE and Ara h 2.
Conclusions. The component Ara h 2 was useful for differentiating allergy from tolerance in both ethnic groups in this SA cohort. Ninety-five percent PPVs for peanut allergy tests may need to be revised, especially in Xhosa patients. An SPT result ≥11 mm as well as Ara h 2 ≥8 kU/L had the best predictive value for peanut allergy.