South African Medical Journal - Volume 105, Issue 10, 2015
Volumes & issues
Volume 105, Issue 10, 2015
Source: South African Medical Journal 105 (2015)More Less
Source: South African Medical Journal 105, pp 799 –801 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8758More Less
Take a tidal wave of patients, a trickle of specialists and a small shoal of medical students eager to palpate, probe and prick (at the very least), and mix them together in the public sector sea for several consecutive years. No CPD points for guessing the range of adverse events that can follow, and inevitably will.
Source: South African Medical Journal 105, pp 801 –802 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8760More Less
The 'sacred' value of autonomy in euthanasia and assisted suicide is not absolute, because people change their minds - while passing enabling laws 'holds grave consequences' for both individuals and society. This was the view of Dr Tom Angier of the University of Cape Town (UCT)'s Department of Philosophy, who contended that the 'sacred trilogy' of values,compassion, dignity and autonomy in the euthanasia debate would be undermined by a euthanasia-practising regime.
Source: South African Medical Journal 105, pp 802 –804 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8603More Less
A cool-as-a-cucumber Carltonville mine engineer walked out of hospital 19 days after being impaled from groin to upper back by a 2-metre, 2 cm-thick industrial crowbar, his survival and recovery due to his presence of mind, and world-class trauma surgery. The crowbar pierced three of his body cavities - his pelvis, abdomen and chest - missing his heart by 5 cm and destroying a kidney.
Author E.L. SubramoneySource: South African Medical Journal 105, pp 805 –807 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7802More Less
Non-typhoidal salmonellae are important pathogens causing bacteraemia, especially in immuno compromised patients, but there are limited data explicitly describing the clinical characteristics and outcome in these individuals. Recurrent invasive salmonellosis has been recognised as an AIDS-defining condition in HIV-positive patients since the 1980s. Salmonella meningitis is an infrequent complication of Salmonella sepsis, accounting for 0.8 - 6% of all cases of bacterial meningitis, and is associated with a high mortality rate.
Source: South African Medical Journal 105, pp 808 –809 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8208More Less
Approximately 5% of the ~3 million asthmatics in South Africa have severe asthma that is associated with substantial morbidity, cost, absenteeism, preventable mortality, and the requirement for costly chronic medication that may be associated with significant adverse events. There is an unmet need for alternative safer and more effective interventions for severe asthma. A recently introduced option, bronchial thermoplasty (BT), imparts radio frequency-generated heat energy to the airways to cause regression of airway smooth muscle. The effectiveness of this technique has been confirmed in randomised control trials and is now endorsed by several international guidelines, including the Global Initiative for Asthma (GINA) guideline, the British Asthma Guideline, and the UK National Institute of Clinical Excellence (NICE) guideline. We recommend BT as a potential therapeutic intervention for severe uncontrolled asthma, provided that it is performed by an experienced pulmonologist at an accredited centre and done within the broader context of appropriate management of the disease by doctors experienced in treating difficult-to-control asthma.
Recommendations for the use of endoscopic lung volume reduction in South Africa : role in the treatment of emphysema : forumSource: South African Medical Journal 105, pp 810 –815 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8147More Less
Emphysema is a very common cause of morbidity and mortality in South Africa (SA). Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) is increasingly being used internationally for the treatment of advanced emphysema in a subset of patients with advanced disease, aiming to obtain the same functional advantages as surgical lung volume reduction while reducing risks and costs. In addition to endobronchial valves, ELVR using endobronchial coils is now available in SA. The high cost of these interventions underscores the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The Assembly on Interventional Pulmonology of the South African Thoracic Society appointed a committee comprising both local and international experts to extensively review all relevant evidence and provide advice on the use of ELVR in SA based on published evidence, expert opinion and local access to the various devices.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.9980More Less
Geography in the South African (SA) context is as singular a driver of health-seeking behaviour as the burden of disease. This is the dilemma facing the rural patient presented with the 'choice' of health facilities where access could mean long transit times, or as is often the case, an expensive commute.
Source: South African Medical Journal 105, pp 817 –822 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8102More Less
Background. The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has not translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinical impact, limiting generalisability to resource-constrained settings.
Objectives. To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa.
Methods. A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a 5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation with the referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as well as usefulness without a change in management.
Results. The results show that 83.8% of the patients' management was impacted on by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment after myocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor's diagnosis, yet were still associated with a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients to determine referral to a tertiary facility.
Conclusion. ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. This should alert policy makers against restriction of access to ECHO and promote training of personnel in its use.
The wrong and wounding road : paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period : researchSource: South African Medical Journal 105, pp 823 –826 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8090More Less
Background. Injury in childhood is a major cause of potentially preventable morbidity and mortality. In order to implement effective preventive strategies, epidemiological data on mechanisms of injury and outcome are essential.
Objectives. To assess the causation, severity of injury, morbidity and mortality of paediatric trauma admitted to a level 1 trauma intensive care unit (TICU).
Methods. Children were defined as being < 16 years of age. The study covered the 5-year period January 2008 - December 2012. Eligible patients were identified from a prospective database maintained in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, Durban,South Africa. Data extracted were referral source, mechanism of injury, age and gender distribution, injury severity score (ISS), anatomical distribution of injury and mortality.
Results. A total of 181 patients admitted during the study period accounted for 15.9% of all admissions. There were 84 females (46.4%) and 97 males (53.6%), with a median age of 7 years (interquartile range (IQR) 4 - 10). Sources of admission were directly from the scene in 38 cases (21.0%), from a primary healthcare facility in 47 (26.0%), from a regional hospital in 56 (31.0%) and from a tertiary facility in 40 (22.0%). Mortality rates according to location of transfer were regional hospital 8 deaths (30.8%), tertiary facility 7 (26.9%), primary health clinic 7 (26.9%), and from the scene 4 (15.4%). Mechanisms of injury were pedestrian-motor vehicle collision (PMVC) in 105 cases(58.0%), motor vehicle passenger in 38 (21.0%), non-vehicular blunt trauma in 18 (10.0%), gunshot wounds (GSWs) in 12 (6.6%), stab wounds in 6 (3.3%), bull goring in 1 (0.5%) and bicycle accident 1 (0.5%). The median ISS for all admissions was 25 (IQR 16 - 38). ISSs were >25 in 98 patients (54.1%), 16 - 25 in 51 (28.2%), 9 - 15 in 9 (4.9%) and < 9 in 13 (7.2%); 61.9% of patients had head injuries, 48.1% injuries to the extremities, 41.4% abdominal trauma, 40.3% thoracic trauma, 20.4% external soft-tissue trauma, 9.9% cervical injury and 9.4% facial trauma. There were 26 deaths (14.4%), of which PMVCs accounted for 16 (61.5%), motor vehicle passengers for 7 (26.9%), blunt trauma for 2 (7.7%) and GSWs for 1 (3.8%). The majority of deaths (92%) were of patients with an ISS >25. Of the 26 patients who died, 88.4% had a head injury, 46.2% an extremity injury, 38.5% an external injury, 34.6% abdominal or chest injuries, 19.2% neck injury and 11.5% facial injury.
Conclusions. Motor vehicle-related injuries, especially PMVCs, dominate severe paediatric trauma and there is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality.
Interpersonal violence as a major contributor towards the skewed burden of trauma in KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 105, pp 827 –830 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8380More Less
Background. Trauma is one of the foremost causes of death worldwide, but there is a paucity of data on demographics and injury patterns in developing countries.
Objectives. To quantify and describe the major trauma burden at a regional hospital in KwaZulu-Natal (KZN), South Africa (SA), over a 5-year period.
Methods. Ngwelezane Hospital is a large regional hospital in northern KZN. A database is maintained of all major trauma patients admitted to the Emergency Department (ED) resuscitation unit. Statistical analysis was performed to quantify the burden of trauma and analyze trends in these data.
Results. Over a 5-year period, 3 735 major trauma patients were admitted to the ED resuscitation unit. Analysis showed a male predominance, with a mean patient age of 28.6 years. An average of 62 patients per month were admitted, the rate peaking over the holiday seasons. Trauma secondary to interpersonal violence (IPV) predominated. A disproportionately high level of pedestrian-motor vehicle collisions (PMVCs) in relation to total road traffic collisions was noted. Blunt force trauma secondary to motor vehicle collisions was the leading cause of death, while blunt force trauma secondary to PMVCs carried the highest mortality rate.
Conclusion. This study highlights the high incidences of both IPV and PMVCs typical of trauma in an SA setting. The demographics and injury patterns noted may be used to drive public health interventions to address this burden of trauma.
Source: South African Medical Journal 105, pp 831 –834 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7766More Less
Background. Major incidents put pressure on any health system. There are currently no studies describing the epidemiology of major incidents in South Africa (SA). The lack of data makes planning for major incidents and exercising of major incident plans difficult.
Objective. To describe the epidemiology of major incidents in the Western Cape Province, SA.
Methods. A retrospective analysis of the Western Cape Major Incident database was conducted for the period 1 December 2008 - 30 June2014. Variables collected related to patient demographics and incident details. Summary statistics were used to describe all variables.
Results. Seven hundred and seventy-seven major incidents were reviewed (median n=11 per month). Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district had the highest incidence (11.97/10 000 population). Transport-related incidents occurred most frequently (94.0%, n=730). Minibus taxis were involved in 312 major incidents (40.2%). There was no significant difference between times of day when incidents occurred. A total of 8 732 patients were injured (median n=8 per incident); ten incidents involved 50 or more victims. Most patients were adults (80.0%, n=6 986) and male (51.0%, n=4 455). Of 8 440 patients, 630 (7.5%) were severely injured. More than half of the patients sustained minor injuries (54.6%, n=4 605).
Conclusion. Major incidents occurred more often than would have been expected compared with other countries, with road traffic crashes the biggest contributor. A national database will provide a better perspective of the burden of major incidents.
Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury (GSH ASCI) Unit, Cape Town, South Africa, over the past 11 years : researchSource: South African Medical Journal 105, pp 835 –839 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8072More Less
Background. Spinal cord injury (SCI) is devastating to both patient and society, with acute management and ongoing care being extremely expensive. Few epidemiological data are available on SCIs in South Africa (SA).
Objectives. To identify the epidemiological profile of SCI patients at Groote Schuur Hospital (GSH), Cape Town, SA, and identify seasonal trends and peak periods. As the majority of the injuries are preventable, these data are important to develop prevention strategies.
Methods. A retrospective review of prospectively collected data was conducted on all patients admitted to the Acute Spinal Cord Injury (ASCI) Unit at GSH from 1 April 2003 to 31 March 2014. All cases registered on a prospectively maintained database were included in the study.
Results. The total number of patients admitted to the ASCI Unit was 2 042, with an average of 185 admissions per year. The male/female ratio was 5.25:1. The 21 - 30-year-old age category was the largest, comprising 33.5% of the patients. The most prevalent cause of injury was motor vehicle accidents (44.6%), followed by violence-related injuries (27.2%). Thirty-two point two percent of patients needed ventilatory support, and 91.5% of mechanically ventilated patients were successfully weaned. December was the busiest month in the unit. In patients in whom neurological deficit was incomplete, the average motor function improvement was 16.0%.
Conclusions. Data capturing and analysis of SCIs should be encouraged in SA to guide management and prevention strategies, and to optimise outcomes. This study establishes the ASCI Unit at GSH to be one of the key role players in acute SCI management in SA.
Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa : more ambulances won't help : researchSource: South African Medical Journal 105, pp 840 –844 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8087More Less
Background. Response time is viewed as a key performance indicator in most emergency medical services (EMS) systems.
Objective. To determine the effect of increased emergency vehicle numbers on response time performance for priority 1 incidents in an urban EMS system in Cape Town, South Africa, using discrete-event computer simulation.
Method. A simulation model was created, based on input data from part of the EMS operations. Two different versions of the model were used, one with primary response vehicles and ambulances and one with only ambulances. In both cases the models were run in seven different scenarios. The first scenario used the actual number of emergency vehicles in the real system, and in each subsequent scenario vehicle numbers were increased by adding the baseline number to the cumulative total.
Results. The model using only ambulances had shorter response times and a greater number of responses meeting national response time targets than models using primary response vehicles and ambulances. In both cases an improvement in response times and the number of responses meeting national response time targets was observed with the first incremental addition of vehicles. After this the improvements rapidly diminished and eventually became negligible with each successive increase in vehicle numbers. The national response time target for urban areas was never met, even with a seven-fold increase in vehicle numbers.
Conclusion. The addition of emergency vehicles to an urban EMS system improves response times in priority 1 incidents, but alone is not capable of the magnitude of response time improvement needed to meet the national response time targets.
The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 105, pp 844 –847 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8273More Less
Introduction. Emergency medical services (EMS) are sometimes required to respond to cases that are later found not to be emergencies, resulting in high levels of inappropriate responses. This study evaluated the extent to which this occurs.
Methods. All cases dispatched over 72 hours by the eThekwini EMS in Durban, South Africa, were prospectively enrolled in a quantitative descriptive study. Vehicle control forms containing dispatch data were matched and compared with patient report forms containing epidemiological and clinical data to describe the nature and extent of inappropriate responses based on patient need. Data were subjected to simple descriptive analysis, correlations and Ï?2 testing.
Results. A total of 1 385 cases met the study inclusion criteria. Marked variations existed between dispatch and on-scene priority settings, most notably in the highest priority 'red-code' category, which constituted >56% of cases dispatched yet accounted for < 2% at the scene (p< 0.001). Conversely, >80% of 'red-code' dispatches required a lower priority response. When comparing resource allocation according to patient interventional needs, >58% of cases required either no intervention or transport only and almost 36% required basic life support intervention only (p< 0.001). Moreover, < 12% of advanced life support dispatches were for patients found to be 'red code' at the scene.
Conclusion. There is a significant mismatch between the dispatch of EMS resources and actual patient need in the eThekwini district, with significantly high levels of inappropriate emergency responses.
A 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town, South Africa : researchSource: South African Medical Journal 105, pp 848 –852 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8274More Less
Background. An increase in autopsied community assault (CA) fatalities was observed at the Tygerberg Forensic Pathology Services (FPS), Cape Town, South Africa (SA). There is a paucity of information on the incidence and prevalence of these cases in SA.
Objectives. To determine the patterns and trends of injuries sustained in so-called CA fatalities.
Methods. A retrospective and descriptive study was conducted. Fatal CA cases admitted to the Tygerberg FPS over the 10-year period 1 January 2003 - 31 December 2012 were reviewed. Data were collected from autopsy/postmortem reports, contemporaneous notes, attached hospital records, the South African Police Services (SAPS) 180 form (completed by the SAPS representative) and other FPS documentation.
Results. A total of 424 cases of fatal CA were seen during the study period, with an annual increase between 2003 and 2007 and a second peak in 2012. The cause of death in most cases was multiple injuries (42.0%), with blunt-force trauma being the basis of most injuries sustained. The area with the greatest burden of injury was the township of Mfuleni (73 CA deaths per 100 000 population). There was a predominance of males, with only one female fatality recorded.
Conclusion. Adequate policing in prevalent areas is essential to address unnecessary loss of life and the burden imposed by these cases on the criminal justice system and healthcare services.
Source: South African Medical Journal 105, pp 853 –857 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8187More Less
Background. In 2011, the Department of Health of the Western Cape Province, South Africa, requested a review of current burn services in the province, with a view to formulating a more efficient and cost-effective service. This article considers the findings of the review and presents strategies to improve delivery of appropriate burn care at primary and secondary levels.
Methods. Surveys were conducted at eight rural and urban hospitals, two outreach workshops on burn care, four regional hospitals and at least 60 clinics in Cape Town and in the Western Cape as far as Ladismith. A survey on community management of paediatric burns wasalso included in the study.
Results. The incidence of burns was highest in the winter months, more than half of those affected were children, and the majority of burns were scalds from hot liquids. Most burn injuries managed at primary level were minor, with 75% of patients treated by nurse practitioners and discharged. The four regional secondary hospitals managed the majority of moderate to severe burns. There is room for improvement in terms of treatment facilities and consumables at all levels, regional hospitals being particularly restricted in terms of outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a burns unit when indicated.
Conclusion. The community management of paediatric burns was satisfactory, although considerable delays in transfer and insufficient pain control hampered appropriate care. A great need for ongoing education at all levels was identified. Ten strategies are presented that could, if implemented, lead to tangible improvements in the management of burn patients at primary and secondary levels in the Western Cape.
Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective : researchSource: South African Medical Journal 105, pp 858 –861 (2015) http://dx.doi.org/http://dx.doi.org/:10.7196/SAMJnew.8329More Less
Background. Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience.
Patients and methods. All patients who had SEMS placement for oesophageal cancer at Grey's Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007 - 2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications.
Results. A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age >70 years n=95 patients, tumour >8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture(n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality.
Conclusion. The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance.