South African Medical Journal
The South African Medical Journal (SAMJ) is published under the auspices of the South African Medical Association, though it enjoys full editorial autonomy. The SAMJ :
- Provides a premier vehicle for the publication of medical research in South Africa and beyond;
- Provides high quality educational material for doctors;
- Informs the medical profession and the public on relevant health issues;
- Provides a forum for members of the profession to voice their opinions;
- Influences opinion and policy through the authority, relevance and quality of its contents;
- Is an important source for advertising and obtaining information about professional appointments.
This journal continues CME : Your SA Journal of CPD
|Publisher||Health and Medical Publishing Group (HMPG)|
|Coverage||Vol 93 Issue 1 2003 - current|
Background. Haemorrhagic shock is the leading cause of preventable early deaths from trauma. Acute coagulopathy on admission to a trauma unit is associated with worse outcomes. The relationship of haemorrhage to early mortality remains consistent regardless of mechanism of injury. Haemorrhage and haemorrhagic shock are increasingly amenable to interventions that result in reductions in morbidity and mortality.
Objectives. To assess the prevalence of coagulopathy in patients admitted to the level 1 trauma unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa, and correlate it with in-hospital mortality.
Methods. A retrospective analysis of the first 1 000 patients admitted to the trauma unit during the years 2007 - 2011 was performed. The admission international normalised ratios (INRs) were correlated with Injury Severity Scores (ISSs) and in-hospital mortality. A multivariable Poisson model with robust standard errors was used to assess the relationship between coagulopathy and mortality after adjustment for the confounding influence of age and gender. The data were analysed using the R statistics program.
Results. Of the 1 000 patients, 752 were male. There were 261 admissions directly from the scene and 739 inter-hospital transfers (nonscene). The mean INRs among survivors for all, scene and non-scene patients were 1.33, 1.30 and 1.34, respectively, and those among non-survivors 1.92, 2.01 and 1.88, respectively (p<0.001). The overall prevalence of coagulopathy was 48.7%, 46.9% in scene patients and 49.2% in non-scene patients. The mortality rate of scene patients with abnormal INR levels was 41.1% (adjusted relative risk (aRR) 3.59, 95% confidence interval (CI) 2.11 - 6.44; p<0.001) v. 25.1% for non-scene patients (aRR 1.67, 95% CI 1.15 - 2.05; p=0.004) (p=0.001).
Conclusions. There was a high prevalence of coagulopathy in our study. Raised admission INRs were associated with worse outcomes. There was a direct correlation between the INR and the ISS. INRs may offer predictive capabilities in resource-depleted environments where the ISS is not routinely calculated. Early recognition of acute coagulopathy may help reduce morbidity and mortality.
Background. Adeno-/tonsillectomy is a commonly performed procedure with internationally standardised and recognised indications. Despite this, there exists considerable international (190 - 850/100 000 people ≤19 years of age) and regional variation in rates. This cannot be accounted for by differences in clinical need or regional morbidity.
Objectives. To describe the adeno-/tonsillectomy rate in the South African (SA) private healthcare sector and regional variations thereof. To compare local rates with international rates and assess trends in adeno-/tonsillectomy practice.
Methods. Analysis of 2012 and 2013 adeno-/tonsillectomy data provided by the largest SA private healthcare funder, accounting for 30% of the medical scheme market. Rates are expressed per 100 000 people ≤19 years of age.
Results. The tonsillectomy rate in the SA private healthcare sector was 1 888/100 000 people ≤19 years of age in 2012. In 2013, the rate dropped significantly (p<0.001) to 1 755/100 000. This is more than double the highest national tonsillectomy rate reported in the literature. There was also considerable regional variation in this rate within SA.
Discussion. The SA tonsillectomy rate is very high when compared with international trends and varies regionally within the country. The literature does not support an increased burden of disease as the reason behind this. Rather, it is differences in training and clinical practice of clinicians, as well as social and family factors, that have been implicated.
Conclusion. The adeno-/tonsillectomy rate in the SA private healthcare sector is substantially higher than international norms. The reasons for this discrepancy require further consideration.
Background. Intimate partner violence (IPV) is actual or threatened physical, sexual, psychological, emotional or stalking abuse by an intimate partner. Despite the high prevalence of IPV in South Africa (SA), there is a paucity of data on university students training in fields where they are likely to have to manage the after-effects of such events in their personal capacity in the future.
Objectives. To ascertain the prevalence of IPV in an SA tertiary institution population with a diverse demographic profile.
Methods. Students from the faculty of health sciences and the faculty of humanities, social work department, completed an anonymous questionnaire. Students were made aware of psychological counselling available to them.
Results. Responses were obtained from 1 354 of 1 593 students (85.0%) (67.8% female, 45.9% black, 32.7% white, 16.6% Indian, 4.8% coloured). Of the respondents, 53.0% indicated that they were in a relationship. The prevalence of any type of IPV (sexual, physical or emotional abuse) among all respondents was 42.6%. Emotional abuse was reported by 54.9% of respondents, physical abuse by 20.0% and sexual abuse by 8.9%. Thirty-five females (6.5% of respondents who had suffered IPV) indicated that they had been emotionally, physically and sexually abused. Fourteen percent identified themselves as perpetrators of abuse, but only three perpetrators of sexual abuse reported having also been victims of sexual abuse. Most respondents (58.7%) knew where to get help.
Conclusion. The extent of IPV among the medical and social work students sampled was found to be unacceptably high, both as victims and as perpetrators. As a result of their exposure to IPV, these individuals may have difficulty in managing patients who have been subjected to abuse.
Background. Methamphetamine use among youth in the Western Cape Province of South Africa has increased at alarming rates over the past decade. Although current estimates of youth use exist, they range from 2% to 12%.
Objectives. To identify (i) the prevalence of methamphetamine use in Western Cape youth and (ii) the association between use and known risk factors for methamphetamine use.
Methods. Data were obtained from 10 000 Western Cape Province Grade 8 learners in 54 secondary schools (mean age 14.0 years). Prevalence was descriptively reported while risk factors for past-month use were modelled in a hierarchical logistic regression with demographic, socioeconomic status, substance use, sexual activity and relationship predictors.
Results. Approximately 5% (n=496) of learners had used methamphetamine within their lifetime. Of these users, 65% (n=322) had used in the past month or week. Compared to never users, past-month users were more likely to be male, less likely to have a present or partially present mother, less likely to live in an apartment/flat/brick house, more likely to have used alcohol and tobacco and more likely to report having a same-sex partner.
Conclusion. Results replicate previously known methamphetamine risk factors and highlight the need to address methamphetamine use in comprehensive prevention initiatives.
Background. Ongoing rationing of healthcare threatens services that are well established, and cripples others that desperately require investment. Burn, for one, remains a neglected epidemic in South Africa (SA), despite the magnitude of the problem.
Objective. To identify the prominent components contributing to the cost of hospital admission with paediatric burn injury. Determining the true costs of specialist services is important, so that resources can be allocated appropriately to achieve the greatest possible impact.
Methods. A retrospective study was undertaken over 1 year to determine patient demographics and injury details of 987 patients admitted with burn injuries to Red Cross War Memorial Children's Hospital, Cape Town, SA. The in-hospital financial records of 80 randomly selected patients were examined. This was followed by a prospective study to determine the financial implications of four cost drivers, i.e. bed cost per day, costs of medications received, costs of dressings for wound care, and costs of surgical intervention. A random selection of 37 dressing changes (in 31 paediatric patients) and 19 surgical interventions was observed, during which all costs were recorded.
Results. As expected, severe flame burns are responsible for more prolonged hospital stays and usually require surgical intervention. Scald burns comprise the greatest proportion of burn injuries, and therefore account for a considerable part of the hospital's expenditure towards burn care.
Conclusion. While community programmes aiming to prevent burn injuries are important, this study motivates for the implementation of accessible ambulatory services in low-income areas. This strategy would enable the burn unit to reduce its costs by limiting unnecessary admissions, and prioritising its resources for those with more severe burn injuries.
A review of the peri-operative management of paediatric burns : identifying adverse events : research
Background. Burn injuries are common in poverty-stricken countries. The majority of patients with large and complex burns are referred to burn centres. Of the children who qualify for admission, according to burn admission criteria, about half require some kind of surgical procedure to obtain skin cover. These range from massive full-thickness fire burns to skin grafts for small, residual unhealed wounds. Burn anaesthetic procedures are of the most difficult to perform and are known for high complication rates. Reasons include peri-operative sepsis, bleeding, issues around thermoregulation, the hypermetabolic state, nutritional and electrolyte issues, inhalation injuries and the amount of movement during procedures to wash patients, change drapes and access different anatomical sites. The appropriate execution of surgery is therefore of the utmost importance for both minor and major procedures.
Objective. To review the peri-operative management and standard of surgical care of burnt children.
Methods. This was a retrospective review and analysis of standard peri-operative care of burnt children at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. A total of 558 children were operated on and supervised by the first author. Factors that could adversely affect surgical and anaesthetic outcomes were identified.
Results. There were 257 males and 301 females in this study, with an average age of 50.1 months and average weight of 19.5 kg. The total body surface area involved was 1 - 80%, with an average of 23.5%. Inhalational injury was present in 11.3%, pneumonia in 13.1%, wound sepsis in 20.8%, and septicaemia in 9.7%, and organ dysfunction in more than one organ was seen in 6.1%. The average theatre temperature during surgery was 30.0°C. Core temperatures recorded at the start, halfway through and at completion of surgery were 36.9°C, 36.8°C and 36.5°C, respectively. The average preoperative and postoperative haemoglobin levels were 11.28 g/dL and 9.64 g/dL, respectively. Blood loss was reduced by the use of clysis from 1.5 mL/kg/% burn to 1.4 mL/kg/% burn. Adverse intraoperative events were seen in 7.6% of children.
Conclusion. Burn surgery is a high-risk procedure and comorbidities are common. Anaesthesia and surgery must be well planned and executed with special reference to temperature control, rapid blood loss, preceding respiratory illnesses and measures to reduce blood loss.