South African Medical Journal - Volume 106, Issue 5, 2016
Volumes & issues
Volume 106, Issue 5, 2016
Medicine and the law - HIV testing of children is not simple for health providers and researchers : legal and policy frameworks guidance in South Africa : in practiceSource: South African Medical Journal 106, pp 451 –453 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10484More Less
Antiretroviral treatment coverage for children and adolescents is significantly lower than that for adults. A first step in improving this situation is ensuring increased access to HIV counselling and testing services. Current legal and policy frameworks outline four norms that should inform HIV testing of children in South Africa: limiting HIV testing to defined circumstances, and ensuring that consent is obtained, counselling is provided and confidentiality is maintained. Implementing these norms is not simple, and we discuss the challenges and opportunities they present for children, their families, health providers and researchers working in this area. Better alignment between evolving public health approaches and the HIV counselling and testing legal/policy frameworks (and the internal coherence of domestic frameworks) would better serve children, their parents and those who work with them.
Source: South African Medical Journal 106, pp 454 –455 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10355More Less
Five recent trials have shown that mechanical removal of clot from cerebral arteries after a stroke can achieve a functional independent outcome in up to 60% of patients. This was an absolute benefit of between 13.5% and 31% for patients who had clot removal initiated within 6 hours of symptoms over those who had best medical treatment. Coupled with this, there is a strong drive to develop stroke units internationally and in South Africa. As a starting point, more primary stroke care centres that can administer intravenous thrombolysis are needed. Comprehensive stroke centres that can offer mechanical thrombectomy are available, but more will be required as referral of patients increases. Collaboration of all role-players will ensure that we can deliver training and care at the best level for stroke patients.
Healthcare delivery - introducing a multifaceted approach to the management of diabetes mellitus in resource-limited settings : in practiceSource: South African Medical Journal 106, pp 456 –458 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10409More Less
Globally diabetes mellitus (DM) and its complications are placing an enormous burden on individual patients and countries alike. South Africa is a developing country already under enormous pressure from communicable diseases such as HIV and tuberculosis. Added to this is DM, which serves to fuel the interactions between communicable and non-communicable diseases. Data from KwaZulu-Natal Province (KZN) have demonstrated that the majority of patients with DM in the public healthcare sector are diagnosed and started on treatment at their local resource-limited healthcare clinics. This article describes introduction of a multifaceted approach to the management of DM in a resource-limited clinic at Edendale Hospital, Pietermaritzburg, KZN. Strategies like this may help provide a blueprint for other resource-limited healthcare facilities in developing countries.
Case report - Haemotoxic snakebite in rural KwaZulu-Natal, South Africa : a case presenting with haematemesis : in practiceAuthor M. WagenerSource: South African Medical Journal 106, pp 459 –460 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9124More Less
A 36-year-old man who had been bitten on the left index finger by a snake identified as a boomslang (Dispholidus typus) presented with haematemesis and hypovolaemic shock. Coagulopathy was presumed, and the platelet count was 2 x 109L. Findings on upper endoscopy included oesophageal petechial haemorrhages, severe haemorrhagic gastritis and an antral ulcer. The patient was successfully managed using freeze-dried plasma, packed red blood cells, isotonic crystalloids and polyvalent antivenom.
Case report - on your toes : detecting mediastinal air on the chest radiograph in ecstasy abusers : in practiceSource: South African Medical Journal 106, pp 461 –462 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9867More Less
Abnormal mediastinal air may be caused by inhalational illicit drug use subsequent to barotrauma resulting from coughing after deep inhalation and breath holding. It may also arise from oesophageal rupture due to retching after ingestion of the illicit drug. The history can alert the practitioner to this cause of chest pain. As chest radiographs are widely accessible and mediastinal air is easily recognisable, the chest radiograph should be included and carefully scrutinised in the diagnostic workup of chest pain in the recreational drug abuser. It is prudent to exclude oesophageal rupture, particularly in the setting of retching, before deciding on conservative and expectant management.
Case report - sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) and cirrhosis of the liver : a case report and literature review : in practiceSource: South African Medical Journal 106, pp 463 –464 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9614More Less
Patients with cirrhosis of the liver usually present with a small, shrunken liver and a large spleen. The presence of an unusually huge liver should prompt the treating doctor to look for another cause, as this may be treatable and improve the patient's outcome. In South Africa tuberculosis and lymphoma in the presence of HIV infection should be excluded. Sinus histiocytosis with massive lymphadenopathy and cirrhosis is a rare combination and has not been reported before in the literature. This case is intended to make clinicians aware of this rare combination of diseases.
Care report - Syphilitic lymphadenitis clinically and histologically mimicking lymphogranuloma venereum : in practiceSource: South African Medical Journal 106, pp 465 –467 (2016) http://dx.doi.org/:10.7196/SAMJ.2016v106i5.8723More Less
An inguinal lymph node was discovered incidentally during surgery for a suspected strangulated inguinal hernia. The patient had recently been treated for candidal balanoposthitis and was known to have a paraphimosis. A new foreskin ulcer was discovered when he was admitted for the hernia surgery. The lymph node histology showed stellate abscesses suggestive of lymphogranuloma venereum (LGV). Chlamydial serologic tests were negative. As the histological appearance and clinical details provided were thought to suggest LGV, tissue was also sent for a real-time quadriplex polymerase chain reaction assay. This was used to screen for Chlamydia trachomatis in conjunction with other genital ulcer-related pathogens. The assay was negative for C. trachomatis, but positive for Treponema pallidum. Further histochemical staining of the histological specimen confirmed the presence of spirochaetes.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10662More Less
The vast majority of paediatric burns occur in developing countries, and many of these injuries are entirely preventable. In general, four paediatric injury patterns have been identified in toddlers and infants, who are at a significantly increased risk of burn injuries. Children < 2 years of age are often innocent bystanders, but as they grow older physical mobility, social independence and gender-specific high-risk activities come into play.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10348More Less
Source: South African Medical Journal 106, pp 470 –471 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9062More Less
Bartonella spp. was first described as a possible cause of culture-negative endocarditis in 1993, and has since emerged as a significant cause of this condition worldwide. We describe a complicated case of culture-negative endocarditis in an immune-competent male patient, which was confirmed on resected heart valves to have been caused by Bartonella quintana by broad-range 16S ribosomal RNA polymerase chain reaction. The objective of this report is to highlight the clinical, diagnostic and therapeutic challenges of Bartonella endocarditis.
Source: South African Medical Journal 106, pp 472 –476 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10821More Less
Maternal deaths associated with caesarean deliveries (CDs) have been increasing in South Africa over the past decade. The objective of this report is to bring national attention to this increasing epidemic of maternal deaths due to bleeding associated with CD in the majority of provinces of the country. Individual chart reviews of women who died from bleeding at or after CD show that 71% had avoidable factors. Among the steps we can take are to improve surgical skills and experience, especially in rural hospitals; to improve clinical observations in the immediate postoperative period and in the postnatal wards; and to ensure that appropriate oxytocic agents are given to prevent postpartum haemorrhage. CEOs and medical managers of health facilities, district clinical specialists, heads of obstetrics and gynaecology, and midwifery training institutions must show leadership and accountability in providing an appropriate environment to ensure that women who require CD receive the procedure for the correct indications and in a safe manner to minimise risks.
Source: South African Medical Journal 106, pp 477 –484 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10674More Less
Objectives. National trends in age-standardised death rates (ASDRs) for non-communicable diseases (NCDs) in South Africa (SA) were identified between 1997 and 2010.
Methods. As part of the second National Burden of Disease Study, vital registration data were used after validity checks, proportional redistribution of missing age, sex and population group, demographic adjustments for registration incompleteness, and identification of misclassified AIDS deaths. Garbage codes were redistributed proportionally to specified codes by age, sex and population group. ASDRs were calculated using mid-year population estimates and the World Health Organization world standard.
Results. Of 594 071 deaths in 2010, 38.9% were due to NCDs (42.6% females). ASDRs were 287/100 000 for cardiovascular diseases (CVDs), 114/100 000 for cancers (malignant neoplasms), 58/100 000 for chronic respiratory conditions and 52/100 000 for diabetes mellitus. An overall annual decrease of 0.4% was observed resulting from declines in stroke, ischaemic heart disease, oesophageal and lung cancer, asthma and chronic respiratory disease, while increases were observed for diabetes mellitus, renal disease, endocrine and nutritional disorders, and breast and prostate cancers. Stroke was the leading NCD cause of death, accounting for 17.5% of total NCD deaths. Compared with those for whites, NCD mortality rates for other population groups were higher at 1.3 for black Africans, 1.4 for Indians and 1.4 for coloureds, but varied by condition.
Conclusions. NCDs contribute to premature mortality in SA, threatening socioeconomic development. While NCD mortality rates have decreased slightly, it is necessary to strengthen prevention and healthcare provision and monitor emerging trends in cause-specific mortality to inform these strategies if the target of 2% annual decline is to be achieved.
Source: South African Medical Journal 106, pp 485 –488 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10269More Less
Background. Perioperative research is currently unco-ordinated in South Africa (SA), with no clear research agenda.
Objective. To determine the top ten national research priorities for perioperative research in SA.
Methods. A Delphi technique was used to establish consensus on the top ten research priorities.
Results. The top ten research priorities were as follows: (i) establishment of a national database of (a) critical care outcomes, and (b) critical care resources; (ii) a randomised controlled trial of preoperative B-type natriuretic peptide-guided medical therapy to decrease major adverse cardiac events following non-cardiac surgery; (iii) a national prospective observational study of the outcomes associated with paediatric surgical cases; (iv) a national observational study of maternal and fetal outcomes following operative delivery in SA; (v) a steppedwedge trial of an enhanced recovery after surgery programme for (a) surgery, (b) obstetrics, (c) emergency surgery, and (d) trauma surgery; (vi) a stepped-wedge trial of a surgical safety checklist on patient outcomes in SA; (vii) a prospective observational study of perioperativeoutcomes after surgery in district general hospitals in SA; (viii) short-course interventions to improve anaesthetic skills in rural doctors; (ix) studies of the efficacy of simulation training to improve (a) patient outcomes, (b) team dynamics, and (c) leadership; and (x) development and validation of a risk stratification tool for SA surgery based on the South African Surgical Outcomes Study (SASOS) data.
Conclusions. These research priorities provide the structure for an intermediate-term research agenda.
Active surveillance of hospital-acquired infections in South Africa : implementation, impact and challenges : researchAuthor W. LowmanSource: South African Medical Journal 106, pp 489 –493 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10783More Less
Background. Hospital-acquired infections (HAIs) are a significant although unquantified burden in South Africa. Lack of adequate surveillance compounds this problem.
Objective. To report on the establishment and outcomes of a unit-specific surveillance system for hospital-acquired infections, based on international standards, in a private academic hospital.
Methods. Active unit-specific surveillance of device-associated infections (DAIs) was introduced over a 2-year period. The surveillance system was based on the US National Healthcare Safety Network (NHSN) utilising standardised definitions. Analysis of DAI rates and device utilisation was done according to Centers for Disease Control and Prevention methods. Comparative analysis using study-derived annualised data and existing NHSN data was done.
Results. Surveillance results of DAI rates showed significant reductions in intensive care unit-related ventilator-associated pneumonia(42%) and central line-associated bloodstream infections (100%) over a 3-year period. Substantial variations in DAI rates and utilisation ratios between wards highlight the importance of unit-specific surveillance.
Conclusions. Active surveillance requires a significant investment in resources and is a sustained operational challenge, although equally significant benefits are derived from a better understanding of HAIs with more targeted interventions and efficient use of resources. A robust surveillance system is an essential component of any healthcare infection prevention and control programme and is a prerequisite to contextualising the HAI burden of hospitals.
Source: South African Medical Journal 106, pp 494 –496 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i4.9949More Less
Background. Nosocomial infections represent one of the challenging problems of modern medicine. Healthcare providers play an important role in the transmission of these infections on their hands, clothing and equipment. Modern security systems require personnel to wear clearly displayed identity (ID) tags, and to have an easily accessible access disc. These access and ID tags are often worn around the neck on a lanyard, and could possibly harbour bacteria and be a vector for cross-infection.
Method. Saline-moistened swabs of the front and back of ID tags of 50 healthcare workers were taken for bacterial culture. Swabs were inoculated onto standard microbiological media. Potential pathogens were subjected to sensitivity testing while organisms resembling normal skin commensals were reported as such.
Results. Twenty-eight of the 50 (56%) ID swabs cultured exhibited no bacterial growth. Eighteen (36%) swabs grew primarily skin flora. Neutrophils were observed under microscopy on two (4%) swabs. Seven (14%) swabs grew potentially pathogenic bacteria. Doctors were found to have almost three times the risk of carrying pathogenic bacteria on their ID tags compared with nurses. Recent patient contact also showed a higher incidence of colonisation. There were no statistically significant differences between variables such as ward or area of work, nature of patient contact, time since qualification, level of qualification or length of employment at Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
Conclusions. Prevention of hospital-acquired infections is important in any setting. The ID tag has been identified as a possible source of infection spread in this and previous studies. The ID tag has to date been neglected as a potential source of pathogen spread, and efforts to make staff aware of this potential danger should be considered in every institution.
The costs of delivering human papillomavirus vaccination to Grade 4 learners in KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 106, pp 497 –501 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9988More Less
Background. The national human papillomavirus (HPV) vaccination roll-out in South Africa provides two doses of Cervarix to all female Grade 4 learners in state schools. This study estimated the costs of vaccinating all learners in KwaZulu-Natal Province (females or males and females) using either the two- or three-dose strategies for both the bivalent and quadrivalent vaccines.
Objective. To determine costs of the HPV vaccination programme in KwaZulu-Natal.
Methods. Costs were determined adapting World Health Organization vaccination costing guidelines.
Results. The 2014 current cost of delivering three doses of Gardasil was ZAR510 per learner. The projected cost of delivering Cervarix to female learners at two or three doses over the period 2014 - 2018, adjusted for inflation, was ZAR172 717 342 and ZAR250 048 426, respectively. Similarly, the cost for Gardasil at these doses was ZAR197 482 200 and ZAR287 194 361, respectively. For male and female learners the cost for Cervarix over this period at two or three doses was ZAR337 101 132 and ZAR540 150 713, respectively. Similarly, the cost for Gardasil at these doses was ZAR426 597 971 and ZAR620 392 784, respectively. Accounting for population variation for females over 5 years, the cost of two doses of Cervarix ranged from ZAR168 888 677 to ZAR 176 545 977 at the lower and upper 95% confidence intervals (CIs), respectively. For three doses the cost ranged from ZAR244 505 544 to ZAR255 591 263 at the lower and upper 95% CIs, respectively. Similarly, the cost for two doses of Gardasil ranged from ZAR193 104 566 to ZAR201 859 798. For three doses the cost ranged from ZAR280 828 057 to ZAR293 560 614.
Conclusion. This study gives decision makers a basis for structured planning and cost apportionment to ensure effective roll-out of the HPV vaccination programme.
Intimate partner violence in early adolescence : the role of gender, socioeconomic factors and the school : researchSource: South African Medical Journal 106, pp 502 –509 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9770More Less
Background. Intimate partner violence (IPV) among adolescents is common worldwide, but our understanding of perpetration, gender differences and the role of social-ecological factors remains limited.
Objectives. To explore the prevalence of physical and sexual IPV perpetration and victimisation by gender, and associated risk and protective factors.
Methods. Young adolescents (N=2 839) from 41 randomly selected public high schools in the Western Cape region of South Africa (SA), participating in the PREPARE study, completed a self-administered questionnaire.
Results. The participants' mean age was 13.65 years (standard deviation 1.01), with 19.1% (541/2 839) reporting being victims/survivors of IPV and 13.0% (370/2 839) reporting perpetrating IPV. Girls were less likely to report being a victim/survivor of physical IPV (odds ratio (OR) 0.72; 95% confidence interval (CI) 0.57 - 0.92) and less likely to be a perpetrator of sexual IPV than boys (OR 0.33; 95% CI 0.21 - 0.52). Factors associated with perpetration of physical and sexual IPV were similar and included being a victim/survivor (physical IPV: OR 12.42; 95% CI 8.89 - 17.36, sexual IPV: OR 20.76; 95% CI 11.67 - 36.93), being older (physical IPV: OR 1.26; 95% CI 1.08 - 1.47, sexual IPV: OR 1.36; 95% CI 1.14 - 1.62 ), having lower scores on school connectedness (physical IPV: OR 0.59; 95% CI 0.46 - 0.75, sexual IPV: OR 0.56; 95% CI 0.42 - 0.76) and scoring lower on feelings of school safety (physical IPV: OR 0.66; 95% CI 0.57 - 0.77, sexual IPV: OR 0.50; 95% CI0.40 - 0.62).
Conclusions. Physical and sexual IPV was commonly reported among young adolescents in SA. Further qualitative exploration of the role of reciprocal violence by gender is needed, and the role of 'school climate'-related factors should be taken into account when developing preventive interventions.
Source: South African Medical Journal 106, pp 510 –513 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.10251More Less
Background. Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is, however, potentially preventable.
Objective. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication.
Method. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May 2013 to February 2014.
Results. Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (p< 0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring, transfer by an intern as opposed to other medical/ paramedical staff, and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02).
Conclusion. Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring.
An analysis of inter-healthcare facility transfer of neonates within the eThekwini Health District of KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 106, pp 514 –518 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i5.8554More Less
Objectives. To investigate delays in the transfer of neonates between healthcare facilities and to detect any adverse events encountered during neonatal transfer.
Methods. A prospective study was conducted from December 2011 to January 2012. A quantitative, non-experimental design was used to undertake a descriptive analysis of 120 inter-healthcare facility transfers of neonates within the eThekwini Health District (Durban) of KwaZulu-Natal Province, South Africa. Data collection was via questionnaire. Data collection was restricted to the Emergency Medical Services (EMSs) of eThekwini Health District, which is the local public ambulance provider.
Results. All transfers were undertaken by road ambulances: 83 (62.2%) by frontline ambulances; 35 (29.2%) by the obstetric unit; and 2 (1.7%) by the planned patient transport vehicles. Twenty-nine (24.2%) transfers involved critically ill neonates. The mean (standard deviation (SD)) time to complete an inter-healthcare facility transfer was 3 h 49 min (1 h 57 min) (range 0 h 55 min - 10 h 34 min). Problems with transfer equipment were common due to poor resource allocation, malfunctioning equipment, inappropriate equipment for the type of transfer and dirty or unsterile equipment. The study identified 10 (8.3%) physiologically related adverse events, which included 1 (0.8%) death plus a further 18 (15.0%) equipment-related adverse events.
Conclusions. EMS is involved in transporting a significant number of intensive care and non-intensive care neonates between healthcare facilities. This study has identified numerous factors affecting the efficiency of inter-facility transfer of neonates and highlights a number of areas requiring improvement.
Source: South African Medical Journal 106, pp 519 –523 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i5.9952More Less
Background. Investigators and sponsors of clinical trials have an ethical obligation to disseminate clinical trial results, whether positive or negative, in a timely manner.
Objectives. To determine the publication rate and average time to reporting for clinical trials carried out in South Africa (SA) and to explore factors indicating whether a study is published or not.
Methods. A registry-based quantitative retrospective analysis of 79 SA clinical trials for new medicines registered between January 2008 and December 2010 was performed. The relevant trial identification number in the register was used to track all peer-reviewed publications subsequent to registration. Tracking of clinical trials was done through a systematic literature search of the electronic journal databases of the South African Medical Journal (SAMJ), the Cochrane Library, Public Library of Science Medical Journal (PLoS Medicine) and BioMed Central, all of which are indexed on MEDLINE via PubMed. In addition, a manual search of the Open Access Journal of Clinical Trials databases and reference lists on articles related to the trial medicine was performed.
Results. Of the 79 clinical trials surveyed, 72 were concluded by December 2014. Only 35 (48.6%) of them had the results published in a peer-reviewed journal, the current benchmark for dissemination of trial results. The majority (82.9%) of those published had a positive outcome. Of the 35 trials that were published, 77.1% were published within 2 years. The average time from completion to initial reporting was 22 months. Fewer than half (40.5%) of the clinical trials surveyed were placebo controlled.
Conclusion. The absence of complete outcomes data from SA clinical trials warrants utmost attention. The study puts forward a case to the regulatory body and research ethics committees to compel all data from clinical trials to be made accessible to clinicians and the public in general by being published in an easily accessible form and in a timely manner.