South African Medical Journal - Volume 106, Issue 7, 2016
Volumes & issues
Volume 106, Issue 7, 2016
Public health officials and MECs should be held liable for harm caused to patients through incompetence, indifference, maladministration or negligence regarding the availability of hospital equipment : in practice - medicine and the lawAuthor D.J. McQuoid-MasonSource: South African Medical Journal 106, pp 681 –683 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10722More Less
There have been several reports of state hospitals not having functional equipment such as radiological equipment. Where these are due to incompetence, indifference, maladministration or negligence by the public officials concerned, they may be held personally liable for the resulting harm to patients. However, the courts have often observed that where the State has been sued vicariously for the wrongs of public officials, it has not obtained reimbursement from the offending official. It has therefore been suggested that irresponsible public servants should be sued in their personal capacity (in addition to the State), to prevent taxpayers always having to pay for their misdeeds. If an individual public official cannot afford to pay all the damages awarded, the injured party can recover the balance from the State by citing it as a vicarious joint wrongdoer.
Surrogate motherhood in illness that does not cause infertility : in practice - medicine and the lawAuthor D.W. JordaanSource: South African Medical Journal 106, pp 684 –685 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10668More Less
The threshold requirement for surrogate motherhood requires that a commissioning parent or parents are permanently unable to give birth to a child. The question has arisen of a commissioning mother who suffers from a permanent illness that does not cause infertility but that renders pregnancy a significant health risk to her and/or to her prospective child in utero. The threshold requirement inability to give birth to a child should not be interpreted narrowly as referring only to a commissioning parent's inherent inability to give birth to a child, but should be interpreted broadly as referring only to a commissioning parent's effective inability to give birth to a child - allowing consideration of the medical sequelae of pregnancy for the commissioning mother and her prospective child. A broad interpretation of the threshold requirement is compatible with legislative intent, case law and our constitutional commitment to human rights.
Burkitt's lymphoma patients in Northwest Cameroon have a lower incidence of sickle cell trait (Hb AS) than healthy controls : in practice - case reportSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10693More Less
Contradictory findings have been reported from Africa with regard to the risk of developing Burkitt's lymphoma (BL) in sickle cell trait (AS) carriers. Haemoglobin electrophoresis was performed in 78 BL patients in the Northwest region of Cameroon, and in 78 nearest-neighbour controls of the same age, sex and tribe from the same village. AS was confirmed in 4 of 78 (5.13%) BL patients and in 11 of 78 (14.10%) controls (χ2, p=0.052; Fisher's exact, one-tailed, p=0.050). Sickle cell trait carriers had a marginal statistically reduced risk of developing BL.
Resolution of a periodontoid rheumatoid pannus mass in an elderly patient treated with a rigid cervical collar : a case report and literature review : in practice - case reportSource: South African Medical Journal 106, pp 687 –688 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.9861More Less
In patients with C2 rheumatoid pannus with spinal cord compression the treatment of choice is extensive surgery either through a transoral resection of the dens axis or a dorsal stabilisation, or both. We present a case of an 11-mm rheumatoid pannus with significant compression of the spinal cord, which failed surgical treatment with respect to dorsal stabilisation. Therefore, rigid cervical collar for 8 weeks followed by soft collar for another 4 weeks was chosen as a treatment option. During the follow-up period of 1 year, the pannus reduced significantly and the spinal cord decompressed. In cases where surgery is not an option or is technically very demanding, the alternative of cervical collar immobilisation is a satisfying option.
A case of refractory thrombotic thrombocytopenic purpura treated with plasmapheresis and rituximab : in practice - case reportSource: South African Medical Journal 106, pp 689 –691 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.9856More Less
Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder with no prevalence or incidence studies in sub-Saharan Africa. Acquired TTP has several causes, all of which lead to decreased activity of von Willebrand factor cleaving protease (ADAMTS13) due to autoantibodies that are directed towards ADAMTS13. We report a case of a 46-year-old man who presented with most of the classic clinical manifestations of TTP.
Schwannoma extending from the umbilical region to the mid-thigh, compressing the major vessels of the right leg : a case report and review of the literature : in practice - case reportSource: South African Medical Journal 106, pp 692 –694 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10252More Less
Schwannomas are benign, usually encapsulated, nerve sheath tumours derived from Schwann cells. They commonly arise from the cranial nerves as acoustic schwannomas and are extremely rare in the pelvis and retroperitoneal area (<0.5% of reported cases) unless they are combined with Von Recklinghausen disease (type 1 neurofibromatosis). We report the case of a 23-year-old woman with a mass extending from the umbilical region in the abdomen to the upper two-thirds of the thigh. As this tumour is so rare, and in order to ensure optimal treatment and survival for our patient, a computed tomography-guided biopsy was performed before en bloc tumour excision. Because of the possibility of malignancy, complete excision of the mass was performed, with pelvic blunt dissection. Histological examination showed a benign neoplasm, originating from the cells of peripheral nerve sheaths; the diagnosis was a schwannoma. Abdominal schwannomas are rare neoplasms that can be misdiagnosed. Laparoscopy is a safe and efficient option for approaching benign pelvic tumours and may offer the advantage of better visualisation of structures owing to the magnification in laparoscopic view, especially in narrow anatomical spaces. However, in our case laparoscopy was not considered owing to the size and anatomical location of the tumour.
Analysis of 5 years of morbidity and mortality conferences in a metropolitan South African trauma service : researchSource: South African Medical Journal 106, pp 695 –698 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10549More Less
Background. Since 2008 the Pietermaritzburg Metropolitan Trauma Service (PMTS) has run a structured, self-reporting, metropolitan morbidity and mortality conference (MMC). In 2012 a hybrid electronic medical registry (HEMR) was introduced to capture routine data and to generate reports on morbidity and mortality. This paper reviews our experience in setting up a metropolitan MMC and compares the quality of the reported morbidity data from the pre- and post-HEMR era.
Methods. We compared data from the MMC before and after the introduction of the HEMR to audit the impact of these meetings on the reporting and analysis of surgical morbidity and mortality in our service.
Results. During the 4-year period from 2008 to 2011, a total of 208 MMCs were held. A total of 10 682 patients were admitted by the PMTS during that period, of whom 87% were males, and the mean age was 26 years. Penetrating trauma accounted for 40.9% (4 344/10 628) of the total workload. A total of 432 (4.1%) morbidities were identified. Of these, 36.6% (158) were related to human error, 32% (138/432) were related to surgical pathologies and the remaining 31.9% (136/432) were related to systemic diseases. There was an exponential increase in the reporting of morbidity each year. The total in-hospital mortality was 3% (358/10 682). Following the introduction of the HEMR, from 2012 to 2014, 6 217 patients were admitted. A total of 1 314 (21.1%) adverse events and 315 (5.1%) deaths were recorded by the HEMR. The adverse events were divided into 875 'pathology-related' morbidities and 439 'error-related' morbidities.
Conclusions. The development of the MMC led to increased reporting of morbidity and mortality. The introduction of the HEMR resulted in a dramatic improvement in the capturing of morbidity and mortality data, suggesting that a paper-based self-reporting system tends to underestimate morbidity. Over one-third of all morbidities were related to human error. Common morbidities have been identified.
Source: South African Medical Journal 106, pp 699 –703 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10429More Less
Background. Despite ranking third as a cause of hospital-acquired acute kidney injury (AKI), iatrogenic contrast-induced nephropathy (CIN) impacts significantly on morbidity and mortality and is associated with high hospital costs. In sub-Saharan Africa, the rates and risk factors for CIN and patient outcomes remain unexplored.
Methods. We conducted a prospective observational study at the Charlotte Maxeke Johannesburg Academic Hospital, South Africa, from 1 July 2014 to 30 July 2015. Hospitalised patients undergoing computed tomography scan contrast media administration and angiography were consecutively recruited to the study and followed up for development of AKI. CIN was defined as an increase in serum creatinine >25% or an absolute increase of >44 μmol/L from baseline at 48 - 72 hours post exposure to contrast media. Outcome variables were the occurrence of CIN, length of hospitalisation and in-hospital mortality.
Results. We recruited 371 hospitalised patients with a mean (standard deviation) age of 49.3 (15.9). The rates of CIN, assessed using an absolute or relative increase in serum creatinine from baseline, were 4.6% and 16.4%, respectively. Anaemia was an independent predictor for the development of CIN (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.01 - 2.87; p=0.04). The median serum albumin was 34 g/L (interquartile range (IQR) 29 - 39.5) and 38 g/L (IQR 31 - 42) in the CIN and control groups, respectively (p=0.01), and showed a significant trend for CIN development (RR 1.68, 95% CI 0.96 - 2.92; p=0.06). Mortality was significantly increased in the CIN group (22.4% v. 6.8%; p<0.001), and CIN together with anaemia increased mortality twofold (RR 2.39, 95% CI 1.20 - 4.75; p=0.01) and threefold (RR 3.32, 95% CI 1.48 - 7.43; p=0.003), respectively.
Conclusions. CIN has a relatively high incidence in sub-Saharan Africa and predicts poorer clinical outcomes. The presence of CIN and anaemia positively predicted mortality. Caution should be exercised in patients with hypoalbuminaemia and anaemia undergoing contrast media administration.
Glomerular disease and acute kidney injury in Sudan : demographics, histological diagnosis and outcome : researchSource: South African Medical Journal 106, pp 704 –708 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i4.10392More Less
Background. Acute kidney injury (AKI) is a relatively common clinical condition, associated with high rates of mortality. Although there is extensive literature on the nature and consequence of AKI in the developed world, much less is known in the developing world and more specifically in sub-Saharan Africa (SSA).
Objectives. To describe the demographics, histological diagnosis and clinical course of patients presenting with AKI to a single centre in Sudan.
Methods. Retrospective data were collected on 100 consecutive patients with AKI and an active urinary sediment, who underwent diagnostic native percutaneous renal biopsy.
Results. The mean (standard deviation) age of those biopsied was 33.6 (14.1) years of age, with a preponderance (58%) of females. The most common clinical indications for biopsy were AKI associated with haematuria and proteinuria (72%), AKI and proteinuria (22.5%) or AKI and haematuria (5%). The frequencies of the most common primary glomerulonephritides (GN) were focal segmental GN (15%) and mesangiocapillary GN (8%). Lupus nephritis was the most frequent secondary GN associated with AKI (31%) and the most common overall histological diagnosis. Peak creatinine, but not oliguria, at presentation predicted likelihood of remaining dialysis-dependent. Age at presentation but not baseline renal function by estimated glomerular filtration rate (eGFR), was associated with the likelihood of having residual chronic kidney disease following an episode of AKI.
Conclusions. The data suggested differences in the pattern of intrinsic renal/glomerular disease leading to AKI to those published and mainly derived from the developed world and patients in SSA.
Major decline in malaria morbidity and mortality in the Union of Comoros between 2010 and 2014 : the effect of a combination of prevention and control measures : researchSource: South African Medical Journal 106, pp 709 –714 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10902More Less
Background. Malaria remains a public health challenge in sub-Saharan Africa. In response to this, many countries are working towards achieving the World Health Assembly and Roll Back Malaria Partnership target of a 75% decline in malaria incidence.
Objective. To assess trends in malaria morbidity and mortality in the three islands of the Comoros Archipelago from 2010 to 2014.
Methods. This was a retrospective study in which all confirmed malaria cases and deaths recorded between 2010 and 2014 were accessed from the national malaria control database. Trends and comparisons in malaria incidence and case fatality rates for all age groups, including under-5 children and pregnant women, were analysed using Microsoft Excel and SPSS version 16.
Results. A substantial decline in malaria incidence was observed for each island between 2010 and 2014; from 75.98 cases per 1 000 population in 2010 to 0.14 in 2014 in Moheli, 60.60 to 0.02 in Anjouan and 235.36 to 5.47 in Grand Comoro. Additionally, a general reduction in malaria case fatalities was observed. In Moheli, there were no case fatalities between 2010 and 2014, while there was a decline in the case fatality rate in Anjouan (from 1.20 fatalities per 1 000 cases to 0) and Grand Comoros (0.51 to 0). There were also significant differences (p<0.05) in malaria incidence and case fatalities between the three islands. A similar trend was observed for pregnant women and under-5 children.
Conclusion. Our study indicates a significant decline in malaria morbidity and mortality in the islands of Moheli, Anjouan and Grand Comoro from 2010 to 2014. This considerable reduction is attributed to a combination of malaria prevention and control interventions implemented during the study period.
Source: South African Medical Journal 106, pp 715 –720 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10651More Less
Background. The World Health Organization, African Region, set the goal of achieving measles elimination by 2020. Namibia was one of seven African countries to implement an accelerated measles control strategy beginning in 1996. Following implementation of this strategy, measles incidence decreased; however, between 2009 and 2011 a major outbreak occurred in Namibia.
Methods. Measles vaccination coverage data were analysed and a descriptive epidemiological analysis of the measles outbreak was conducted using measles case-based surveillance and laboratory data.
Results. During 1989 - 2008, MCV1 (the first routine dose of measles vaccine) coverage increased from 56% to 73% and five supplementary immunisation activities were implemented. During the outbreak (August 2009 - February 2011), 4 605 suspected measles cases were reported; of these, 3 256 were confirmed by laboratory testing or epidemiological linkage. Opuwo, a largely rural district in north-western Namibia with nomadic populations, had the highest confirmed measles incidence (16 427 cases per million). Infants aged ≤11 months had the highest cumulative age-specific incidence (9 252 cases per million) and comprised 22% of all confirmed cases; however, cases occurred across a wide age range, including adults aged ≥30 years. Among confirmed cases, 85% were unvaccinated or had unknown vaccination history. The predominantly detected measles virus genotype was B3, circulating in concurrent outbreaks in southern Africa, and B2, previously detected in Angola.
Conclusion. A large-scale measles outbreak with sustained transmission over 18 months occurred in Namibia, probably caused by importation. The wide age distribution of cases indicated measles-susceptible individuals accumulated over several decades prior to the start of the outbreak.
How long are elderly patients followed up with mammography after the diagnosis of breast cancer? A single-centre experience in a developing country : researchSource: South African Medical Journal 106, pp 721 –723 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10405More Less
Background. The effect of breast cancer on elderly South African (SA) patients is not well characterised. The lack of data with regard to disease burden, post-treatment surveillance and breast cancer relapse poses a challenge to providing optimum follow-up care to this group of patients.
Objectives. To assess the effect of breast cancer and adherence to post-treatment surveillance programmes among the local elderly population attending the breast oncology clinics at Addington and Inkosi Albert Luthuli Central hospitals in Durban, KwaZulu-Natal, SA.
Methods. A retrospective review was undertaken of all patients aged ≥65 years diagnosed with breast cancer during 2007. Hospital records were reviewed for a period of 5 years to ascertain the stage of the disease, treatment received, adherence to post-treatment surveillance mammograms, incidence of new mammographic findings and recurrence, site of recurrence, mode of detection of recurrence, disease-free survival, and overall survival rates at 5 years.
Results. In our study, the incidence of breast cancer in the elderly population was 26.7%. A significant percentage of patients (56.3%) were diagnosed at an advanced stage of disease. Of the 46.9% who had received surveillance mammography, only 6.3% received their post-treatment surveillance mammograms on time, in accordance with international recommendations. New mammographic findings were detected in 26.7% of patients during the 5-year follow-up. During the follow-up period, 15.6% of the total number of study patients presented with disease recurrence. Eighty percent of cases of recurrence were detected clinically. The overall survival at 5 years was 65.6%.
Conclusion. Our study highlights the significant number of elderly patients with advanced disease at diagnosis, poor compliance with internationally recommended annual post-treatment surveillance mammograms, and the relatively low overall 5-year survival rate compared with that of international studies.
High prevalence of primary dyslipidaemia in black South African patients at a tertiary hospital in northern Gauteng, South Africa : researchSource: South African Medical Journal 106, pp 724 –729 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10337More Less
Background. The prevalence of cardiovascular disease is projected to be 38.7% for the USA in 2020, including coronary heart disease at 8.6% and stroke at 3.6%. In South Africa (SA), premature deaths due to heart and blood vessel diseases in people of working age (35 - 64 years) have been predicted to increase by 41% between 2007 and 2030, with enormous negative economic impact. Atherosclerosis underlies much of the pathogenesis, which involves risk factors including dyslipidaemia. Secondary dyslipidaemia associated with diabetes mellitus, hypothyroidism, chronic renal disease, cholestasis, nephrotic syndrome, alcohol excess, drugs such as thiazide diuretics and antiretroviral agents may respond to treatment of underlying causes, but residual dyslipidaemia may in such cases be due to primary disorders of metabolism. Primary dyslipidaemias are uncommon and to a large extent underdiagnosed, especially in the black population of SA, reflecting a lack of clinical and laboratory awareness or expertise. Specific diagnoses enable effective intervention in the patients as well as the families.
Objective. To assess the burden and prevalence of dyslipidaemia in the SA black population at Dr George Mukhari Hospital in the north region of Gauteng.
Method. A retrospective data analysis of 12-month lipid profiles comprising triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol and directly measured low-density lipoprotein (LDL) cholesterol (LDLC).
Results. There were 24 656 requests for 6 348 patients. The lipid cut-off levels were somewhat arbitrary but were based on the commonly used decision-making levels in the treatment guidelines. Severe hypercholesterolaemia (>7 mmol/L) was seen in 299 (4.7%) patients and extreme hypercholesterolaemia (>12 mmol/L) was seen in 30 (0.5%) patients. LDLC (>5 mmol/L) occurred in 80 (1.3%) patients and >10 mmol/L in 19 (0.3%) patients. A predominant triglyceride problem was seen in 578 (9.1%) patients with TG (>2 mmol/L) and TC (<5 mmol/L), whereas moderate hypertriglyceridaemia (>5 mmol/L) was present in 113 (1.8%) patients, and more severe hypertriglyceridaemia (>10 mmol/L) in 10 (0.2%). TC (>5 mmol/L) with LDL (>3 mmol/L) but TG in the normal range was seen in 369 (5.8%) patients, indicating a cholesterol-predominant problem. In contrast, LDLC (>3 mmol/L) and TG (>1.7 mmol/L) was seen in 249 (3.87%) representing mixed hyperlipidaemia. Paediatric patients with severe dyslipidaemia mostly suffered from nephrotic syndrome.
Conclusion. A significant burden and a high prevalence of dyslipidaemias were present in adults in whom a monogenic disorder should be considered. The extent and severity of dyslipidaemia justify a special clinic and laboratory to ensure accurate diagnosis with effective intervention for patients and their families.
Academic staff recruitment and retention challenges at the University of Botswana medical school : researchSource: South African Medical Journal 106, pp 730 –734 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.10482More Less
Background. Sub-Saharan Africa has a greater share of the global burden of disease, poverty, and inadequate human resources for health compared with other regions of the world. Botswana, like other regional countries, is failing to successfully recruit and retain academics at its medical school.
Objectives. To document the medical school's staff recruitment and retention trends and challenges, and to propose possible solutions.
Methods. This was a descriptive research study involving review and analysis of the University of Botswana medical school's staff number targets, actual numbers on post, and other relevant publicly available university documents. The numbers and country of origin of staff recruited from 2008 to 2013 were recorded. Net staff gain or loss per year was then calculated. Student numbers were analysed and related to staff availability. As there was a multilevel change in university management in 2011, the periods and events before and after April 2011 were analysed. Publicly available University of Botswana documents about the university's organisational structure, policies, and processes were reviewed.
Results. Over a 5-year period, the school recruited 74 academics worldwide; 30 of them left the school. Retention was a greater challenge than recruitment. The school had difficulty recruiting locals and senior academics, regardless of specialty. It appears that staff loss occurred regardless of country of origin.
Conclusion. The authors suggest that multilevel change in management was one of the most likely contributors to the school's recruitment and retention challenges. The University of Botswana must comprehensively address these.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.11156More Less
Chronic diseases in the Western world : Increasing incidence or increasing overdiagnosis? SAMJ 106 (5), p. 422 : erratumSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i7.11158More Less