Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 107 num. 12 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>The world's first human-to-human heart transplant at Groote Schuur Hospital: 50 years later</b>]]> <![CDATA[<b>Members Of Heart Transplant Team, Groote Schuur Hospital 3 December 1967</b>]]> <![CDATA[<b>Cardiac Transplantation The Anaesthetist's View: A Case Report</b>]]> <![CDATA[<b>The Operation: A Human Cardiac Transplant: An Interim Report of a Successful Operation Performed at Groote Schuur Hospital, Cape Town</b>]]> <![CDATA[<b>Thank you from HMPG and the editors</b>]]> <![CDATA[<b>Acute high-altitude illness</b>]]> <![CDATA[<b>Development of the MB ChB curriculum map at the University of KwaZulu-Natal, South Africa</b>]]> <![CDATA[<b>Human dignity and the future of the voluntary active euthanasia debate in South Africa</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Joseph (Ozzie) Ozinsky</b>]]> <![CDATA[<b>Cecil Moss</b>]]> <![CDATA[<b>Donald (Don) Leonard Fisher-Jeffes</b>]]> <![CDATA[<b>Lamivudine monotherapy in children and adolescents: The devil is in the detail</b>]]> Although expanded access to antiretroviral therapy (ART), and starting lifelong ART as soon as possible after diagnosis of HIV, have dramatically improved survival and reduced morbidity in HIV-infected children and adolescents, ~20% of children will develop virological failure (VF). Children and adolescents may be at higher risk of VF and drug resistance for a number of reasons, including prevention of mother-to-child exposure, reliance on a caregiver to administer ART, poor palatability of paediatric drugs, tuberculosis/HIV co-treatment in protease inhibitor (PI) (mainly lopinavir/ritonavir)-based regimens, and adolescence being associated with poor adherence. In children with VF, if adherence issues are addressed and re-suppression is not achieved, a switch to second- or third-line drugs may be indicated, which is the gold standard in management. However, in the face of ongoing adherence challenges, with potential accumulation of resistance mutations, limited treatment options due to extensive resistance and limited approved paediatric formulations, other strategies have been used. These include continuing a failing PI regimen, switching to a holding regimen (one or more nucleoside reverse transcriptase inhibitors) or discontinuing ART. Lamivudine monotherapy is a common choice when holding regimens are used, on the premise that the lamivudine-associated M184V resistance mutation reduces viral replication and may maintain clinical and immunological stability compared with discontinuing treatment altogether. However, this strategy is generally associated with immunological, and in some cases clinical, decline after starting lamivudine monotherapy. We discuss the pros and cons of using this therapy in children. We also propose guidance for using lamivudine monotherapy, suggesting clinical and immunological criteria for its use. Close monitoring and adherence support are required with this approach. Given many new emerging ART drugs and strategies, lamivudine monotherapy should be administered temporarily, while efforts to improve adherence are implemented. It should not be considered a default option in children with VF. <![CDATA[<b>Prevalence and predictors of late presentation for HIV care in South Africa</b>]]> BACKGROUND. Many people living with HIV in South Africa (SA) are not aware of their seropositive status and are diagnosed late during the course of HIV infection. These individuals do not obtain the full benefit from available HIV care and treatment services. OBJECTIVES. To describe the prevalence of late presentation for HIV care among newly diagnosed HIV-positive individuals and evaluate sociodemographic variables associated with late presentation for HIV care in three high-burden districts of SA. METHODS. We used data abstracted from records of 8 138 newly diagnosed HIV-positive individuals in 35 clinics between 1 June 2014 and 31 March 2015 to determine the prevalence of late presentation among newly diagnosed HIV-positive individuals in selected high-prevalence health districts. Individuals were categorised as 'moderately late', 'very late' or 'extremely late' presenters based on specified criteria. Descriptive analysis was performed to measure the prevalence of late presentation, and multivariate regression analysis was conducted to identify variables independently associated with extremely late presentation. RESULTS. Overall, 79% of the newly diagnosed cases presented for HIV care late in the course of HIV infection (CD4+ count <500 cells/ µL and/or AIDS-defining illness in World Health Organization (WHO) stage III/IV), 19% presented moderately late (CD4+ count 351 -500 cells/iL and WHO clinical stage I or II), 27% presented very late (CD4+ count 201 - 350 cells/^L or WHO clinical stage III), and 33% presented extremely late (CD4+ count <200 cells/µL and/or WHO clinical stage IV) for HIV care. Multivariate regression analysis indicated that males, non-pregnant women, individuals aged &gt;30 years, and those accessing care in facilities located in townships and inner cities were more likely to present late for HIV care. CONCLUSIONS. The majority of newly diagnosed HIV-positive individuals in the three high-burden districts (Gert Sibande, uThukela and City of Johannesburg) presented for HIV care late in the course of HIV infection. Interventions that encourage early presentation for HIV care should be prioritised in SA and should target males, non-pregnant women, individuals aged &gt;30 years and those accessing care in facilities located in inner cities and urban townships. <![CDATA[<b>Application opportunities of geographic information systems analysis to support achievement of the UNAIDS 90-90-90 targets in South Africa</b>]]> In an effort to achieve control of the HIV epidemic, 90-90-90 targets have been proposed whereby 90% of the HIV-infected population should know their status, 90% of those diagnosed should be receiving antiretroviral therapy, and 90% of those on treatment should be virologically suppressed. In this article we present approaches for using relatively simple geographic information systems (GIS) analyses of routinely available data to support HIV programme management towards achieving the 90-90-90 targets, with a focus on South Africa (SA) and other high-prevalence settings in low- and middle-income countries. We present programme-level GIS applications to map aggregated health data and individual-level applications to track distinct patients. We illustrate these applications using data from City of Johannesburg Region D, demonstrating that GIS has great potential to guide HIV programme operations and assist in achieving the 90-90-90 targets in SA. <![CDATA[<b>Disclosing details about the medical treatment of a deceased public figure in a book: Who should have consented to the disclosures in <i>Mandela's Last Days?</i></b>]]> A recently published book by the head of Nelson Mandela's medical team made personal disclosures about his treatment of the late president in his final years up until his death. The author claimed that he had written the book at the request of family members. This was contested by some family members and the executors of Mandela's estate, and the book was subsequently withdrawn by the publishers. The Mandela book case raises ethical and legal questions about who should consent to publication of medical information about public figures after their death. The ethical rules of conduct of the Health Professions Council of South Africa (HPCSA) state that confidential information about a deceased person should only be divulged 'with the written consent of his or her next of kin or the executor of his or her estate'. 'Next of kin' is not defined, however, and problems arise when family members and the executors are divided about giving such written consent. It is recommended that in such cases the specific order of priority for consent by relatives in the National Health Act be followed. However, conduct that is unethical under the rules of the HPCSA may not necessarily be actionable under the law. For instance, the law does not protect the confidentiality of deceased persons, and generally when people die their constitutional and common-law personality rights -including their right to privacy and confidentiality - die with them. This means that the next of kin or executors of the estates of deceased persons may not bring actions for damages on behalf of such persons for breaches of confidentiality arising after their deaths. The next of kin may, however, sue in their personal capacity if they can show that the disclosures were an unlawful invasion of their own privacy. Conversely, if the privacy of interests of the next of kin are not harmed where there has been publication without their consent, they will not be able to sue for damages. <![CDATA[<b>Berg adder <i>(Bitis atropos): </i>An unusual case of acute poisoning</b>]]> A 5-year-old boy presented to hospital with mild local cytotoxic and severe neurotoxic symptoms. The neurotoxic symptoms included ptosis, fixed dilated pupils and flaccid paralysis with respiratory failure. Mild hyponatraemia was also a clinical feature. After various unsuccessful treatment options were followed, the Tygerberg Poison Information Centre was contacted and a diagnosis of berg adder bite was made. Berg adder bites are uncommon and therefore not usually considered in the differential diagnosis of a patient presenting with an unexplained clinical picture. A timeous poison information helpline consultation is recommended in this situation. <![CDATA[<b>Impact of Xpert MTB/RIF rollout on management of tuberculosis in a South African community</b>]]> BACKGROUND. The Xpert MTB/RIF test shortens the time to microbiological confirmation of pulmonary tuberculosis (TB) under research conditions. OBJECTIVE. To evaluate the field impact of Xpert MTB/RIF rollout on TB diagnostic yield and time to treatment in a South African (SA) community. METHODS. We compared TB investigation outcomes for 6-month calendar periods before and after Xpert MTB/RIF rollout in a semi-rural area of SA. The proportion of adult patients who tested positive by sputum smear microscopy, liquid culture or Xpert MTB/RIF and the proportion of positive sputum smear, liquid culture or Xpert MTB/RIF tests were compared. Secondary outcomes included time to laboratory diagnosis and treatment initiation. Data were collected from the National Health Laboratory Service database and from the Western Cape Provincial Department of Health TB register. RESULTS. Regional rollout of Xpert MTB/RIF testing occurred in 2013. Of the 15 629 patients investigated in the post-rollout period, 7.9% tested positive on GeneXpert, compared with 6.4% of the 10 741 investigated in the pre-rollout period who tested positive by sputum smear microscopy (p<0.001). Median laboratory processing time was <1 day for Xpert MTB/RIF (interquartile range (IQR) 0 - 1) compared with 1 day (IQR 0 - 16) for sputum smear microscopy (p=0.001). The median time to TB treatment initiation was 4 days (IQR 2 - 8) after rollout compared with 5 days (IQR 2 - 14) before (p=0.001). CONCLUSIONS. Patients investigated for suspected pulmonary TB were more likely to be diagnosed after rollout of Xpert MTB/RIF testing, although the benefit to diagnostic yield was modest, and Xpert MTB/RIF testing was associated with a marginal improvement in time to treatment initiation. <![CDATA[<b>Defining the need for surgical intervention following a snakebite still relies heavily on clinical assessment: The experience in Pietermaritzburg, South Africa</b>]]> BACKGROUND. This audit of snakebites was undertaken to document our experience with snakebite in the western part of KwaZulu-Natal (KZN) Province, South Africa (SA). OBJECTIVE. To document our experience with snakebite in the western part of KZN, and to interrogate the data on patients who required some form of surgical intervention. METHODS. A retrospective study was undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, SA. The Hybrid Electronic Medical Registry was reviewed for the 5-year period January 2012 - December 2016. All patients admitted to the service for management of snakebite were included. RESULTS. The offending snake is rarely identified, and the syndromic approach is now the mainstay of management. Most envenomations seen during the study period were cytotoxic, presenting with painful progressive swelling (PPS). We did not see any purely neurotoxic or haemotoxic envenomations. Antivenom is required for a subset of patients. The indications are essentially PPS that increases by >15 cm over an hour, PPS up to the elbow or knee after 4 hours, PPS of the whole limb after 8 hours, threatened airway, shortness of breath, associated clotting abnormalities and compartment syndrome. If no symptoms have manifested within 1 hour of a snakebite, clinically significant envenomation is unlikely to have occurred. Antivenom is associated with a high rate of anaphylaxis and should only be administered when absolutely indicated, preferably in a high-care setting under continuous monitoring. The need for surgery is less well defined. Urgent surgery is indicated for compartment syndrome of the limb, which is a potentially life- and limb-threatening condition. Its diagnosis is usually made clinically, but this is difficult in snakebites. Morbidity and cost increase dramatically once fasciotomy is required, as evidenced by much longer hospital stay. There is frequently a degree of cross-over between cytotoxicity and haemotoxicity in envenomations that require fasciotomy, which means that fasciotomy may result in catastrophic bleeding and should be preceded by the administration of antivenom, especially in patients with a low platelet count or a high international normalised ratio. Physiological and biochemical markers are unhelpful in assessing the need for fasciotomy. Objective methods include measurement of compartment pressures and ultrasound. CONCLUSION. The syndromic management of snakebite is effective and safe. There is a high incidence of anaphylactic reactions to antivenom, and its administration must be closely supervised. In our area we overwhelmingly see cytotoxic snakebites with PPS. Surgery is often needed, and we need to refine our algorithms in terms of deciding on surgery. <![CDATA[<b>A comparison of private and public sector intensive care unit infrastructure in South Africa</b>]]> BACKGROUND. Intensive care units (ICUs) are designed to care for patients who are often at increased risk of acquiring healthcare-associated infections. The structure of ICUs should be optimally designed to facilitate the care of these critically ill patients, and minimise their risk of infection. National regulations (R158) were developed to govern the building and registration of private hospitals, and until recently equivalent regulations were not available for public hospitals. OBJECTIVE. To assess and compare the compliance of ICUs in the private and public sectors with the R158 regulations. METHODS. A cross-sectional study design was used to assess the infrastructure of 25 private sector and 6 public sector ICUs in eThekwini Health District, KwaZulu-Natal Province, South Africa. We used the R158 checklist, which was developed by the KwaZulu-Natal Department of Health Private Licensing Unit and Infection Prevention and Control Unit. The aspects covered in the R158 checklist were categorised into the design, general safety and patient services of the ICUs. RESULTS. Most of the ICUs in both sectors met the general safety requirements. There were varying levels of compliance with the design criteria. Only 7 (28.0%) and 1 (16.7%) of the private and public ICUs, respectively, had sufficient space around the beds. Twenty-two private ICUs (88.0%) and 4 public ICUs (66.7%) had isolation rooms, but only some of these isolation rooms (15 private and 2 public) had appropriate mechanical ventilation. None of the ICUs had clinical hand-wash basins in the nurse stations and dirty utility rooms. The majority of the ICUs had the required number of oxygen and electric outlets at the bedside. None of the public ICUs met the light intensity requirement over the bed area. CONCLUSIONS. Adequate spacing in ICUs is an issue in many cases. Interventions need to be put in place to ensure that ICUs meet the relevant design standards. There is an urgent need to revise the R158 regulations to reflect current best practices, particularly with regard to infection control. The same standards should be applied to ICUs in the private and public health sectors to maintain quality of care to patients. <![CDATA[<b>Mortality trends in the City of Cape Town between 2001 and 2013: Reducing inequities in health</b>]]> BACKGROUND. The City of Cape Town (CoCT), South Africa, has collected cause-of-death data from death certificates for many years to monitor population health. In 2000, the CoCT and collaborators set up a local mortality surveillance system to provide timeous mortality data at subdistrict level. Initial analyses revealed large disparities in health across subdistricts and directed the implementation of public health interventions aimed at reducing these disparatities. OBJECTIVES. To describe the changes in mortality between 2001 and 2013 in health subdistricts in the CoCT. METHODS. Pooled mortality data for the periods 2001 - 2004 and 2010 - 2013, from a local mortality surveillance system in the CoCT, were analysed by age, gender, cause of death and health subdistrict. Age-specific mortality rates for each period were calculated and age-standardised using the world standard population, and then compared across subdistricts. RESULTS. All-cause mortality in the CoCT declined by 8% from 938 to 863 per 100 000 between 2001 - 2004 and 2010 - 2013. Mortality in males declined more than in females owing to a large reduction in male injury mortality, particularly firearm-related homicide. HIV/ AIDS and tuberculosis (TB) mortality dropped by ~10% in both males and females, but there was a marked shift to older ages. Mortality in children aged <5 years dropped markedly, mostly owing to reductions in HIV/AIDS and TB mortality. Health inequities between subdistricts were reduced, with the highest-burden subdistricts achieving the largest reductions in mortality. CONCLUSIONS. Local mortality surveillance provides important data for planning, implementing and evaluating targeted health interventions at small-area level. Trends in mortality over the past decade indicate some gains in health and equity, but highlight the need for multisectoral interventions to focus on HIV and TB and homicide and the emerging epidemic of non-communicable diseases. <![CDATA[<b>Geographical maldistribution of surgical resources in South Africa: A review of the number of hospitals, hospital beds and surgical beds</b>]]> BACKGROUND. The global burden of surgical disease has been studied to a limited extent. Despite the proven benefits of surgery, surgical services remain poorly resourced. Contributing to this global crisis is the critical lack of data regarding available resources. OBJECTIVE. To analyse the distribution of some resources necessary for the provision of surgical care. The distribution and number of surgical resources (number of surgical beds) relative to the general resources (number of hospitals and total number of beds) in South Africa were analysed. METHODS. All hospitals in the country, including those in the public and private sectors, were contacted, and the total number of hospitals, the level of care (district v. regional v. tertiary), the total number of hospital beds, and the number of surgical beds were determined. The data were analysed according to the provincial distribution and the public v. private sector distribution relative to the size of the population. RESULTS. A total of 544 hospitals were included in the study - 327 in the public sector and 217 in the private sector. The public sector hospitals included 257 district-, 49 regional- and 21 tertiary-level hospitals. Nationally, there were 1 hospital, 187 hospital beds and 42 surgical beds per 100 000 population. Gauteng Province (GP), the Eastern Cape, KwaZulu-Natal (KZN) and the Western Cape had the most hospitals and GP had the largest number of private hospitals. GP and KZN had the largest total number of beds (n=29 181 and n=22 889, respectively) and number of surgical beds (n=7 289 and n=4 651, respectively). GP had the largest number of private surgical beds (n=4 837). There was a marked variation in the number of hospitals, total number of beds, and number of surgical beds among provinces. CONCLUSION. This study provided an estimation of the number of hospitals, total number of beds, and number of surgical beds, and showed a marked variation among provinces and between the public and private sectors. <![CDATA[<b>Acne in South African black adults: A retrospective study in the private sector</b>]]> BACKGROUND. Acne vulgaris is the most common skin disorder affecting teenagers and young adults, and is becoming increasingly common in middle-aged women. It affects all skin types and ethnic groups, but dark-skinned individuals are burdened by post-inflammatory hyperpigmentation (PIH) as a sequela. PIH causes distress in acne patients even after the inflammatory lesions have resolved. OBJECTIVE. To describe the characteristics of acne in black South African adults in the private health sector in Durban, KwaZulu-Natal Province. METHODS. A retrospective study of records of patients attending two large private dermatology clinics in central Durban, mainly catering for black patients, was performed. Data were collected for the period January - December 2014. Records with acne as a diagnosis were retrieved and analysed with regard to age, demographics, type and severity of acne, therapy, HIV status and outcomes. RESULTS. Of a total of ~3 000 charts available for the 12-month period, 242 had acne as a diagnosis and were retrieved and analysed. Of these patients, 204 (84.3%) were female and the remainder were male. The mean age was 28.5 years (under-18s were excluded from the study). Inflammatory acne was the most frequently encountered form (58.6%). Fifteen patients (6.2%) were on topical treatment only, and 226 (93.4%) were on topical plus systemic treatment. PIH was the most common sequela (81.0% of patients). CONCLUSIONS. The majority of the patients were young females with inflammatory acne, and PIH was the most common sequela. Early and vigorous treatment of acne may minimise its complications, including those seen mainly in black patients. <![CDATA[<b>Multimorbidity in a large district hospital: A descriptive cross-sectional study</b>]]> BACKGROUND. There is substantial research documenting the burden of disease globally and in the South African (SA) primary care context. Few studies address the disease profile and its implications in the SA hospital setting. OBJECTIVES. To describe the disease profile in the internal medicine department of a large district hospital, using variables related to comorbidity and patient length of stay. The study included specific exploration into the HIV/tuberculosis (TB) syndemic, the acuity of HIV disease, and lifestyle risk factors. METHODS. The sample population consisted of all consecutive admissions to the internal medicine department of a large district hospital in the Cape metropole during May 2015. A retrospective folder review and subsequent data analysis were completed. RESULTS. Hypertension, HIV, type 2 diabetes mellitus, TB and cardiac failure were the five most prevalent diseases. Extensive multimorbidity was observed, with 86.0% of patients suffering from two or more diseases concurrently. The average number of comorbidities per patient was 3.4, although no clear relationship between the number of comorbidities and length of stay was found. Of the various diseases, only TB and HIV were associated with above-average length of stay, particularly among co-infected patients and those who had defaulted from or never received antiretroviral (ARV) treatment. Compared with patients currently receiving ARVs, much higher proportions of patients who had defaulted from or never received ARV treatment had CD4+ counts <200 cells/µL. Of the lifestyle risk factors investigated, a history of excessive alcohol use and/or drug use was associated with an increased length of stay. Most patients were discharged home, with 15.7% being referred to other institutions. CONCLUSIONS. Chronic conditions, particularly HIV, TB and non-communicable diseases, represented much of the disease profile in the internal medicine department. Of the comorbidities investigated, the greatest contributor to length of stay was HIV/TB co-infection. Factors such as HIV, TB and substance use that increase length of stay cannot be impacted upon by the district hospital staff in isolation. To improve the health of communities, we require partnerships between doctors, community health providers and patients with their families. Multimorbidity was widespread, suggesting the need to include an understanding of multimorbidity, including the patient perspective, in medical education and health system reform. <![CDATA[<b>Hepatitis C: A South African literature review and results from a burden of disease study among a cohort of drug-using men who have sex with men in Cape Town, South Africa</b>]]> BACKGROUND. Hepatitis C virus (HCV) is a chronic infection of increasing importance, especially among people living with HIV/AIDS. Co-infection with HIV can accelerate progression of HCV liver disease to cirrhosis and end-stage liver failure and elevate the risk of hepatocellular carcinoma. Globally, men who have sex with men (MSM) and people who inject drugs are at increased risk of HCV infection compared with the general population. Few studies on HCV in these key populations have been done in South Africa (SA). OBJECTIVE. To describe the disease burden of HCV in drug-using MSM who attend harm-reduction services at the Anova Health Institute's Health4Men clinic in Cape Town, SA. METHODS. In 2012 - 2014, attendees of an MSM-focused harm-reduction programme were invited to participate in our study. After informed consent, participants completed a brief demographic questionnaire and underwent phlebotomy for anti-HCV antibody, hepatitis B virus (HBV) surface antigen and surface antibody testing. Participants received counselling and education with regard to their results. HIV status was extracted from the case notes of participants who had previously been tested at the study site. Data were analysed using standard statistical techniques. RESULTS. Forty-one MSM were enrolled - 11 (27.0%) tested anti-HCV antibody-positive, indicating prior exposure to HCV or chronic infection; 10/11 (91.0%) were positive for HBV surface antibodies, suggesting previous HBV exposure or vaccination; and 1 (2.0%) screened positive for HBV. Of the HCV-seropositive individuals, HIV status was known in 8/11; 3/8 (37.5%) were HIV-positive. CONCLUSION. We demonstrated a high burden of HCV exposure or infection among a small urban cohort of MSM who inject drugs. We recommend active screening of MSM (especially those who report drug use) for HCV, and the development of referral networks for access to treatment. <![CDATA[<b>Auditing stillbirths at Lower Umfolozi War Memorial Regional Hospital: A 12-month review</b>]]> BACKGROUND. Although the total number of stillbirths worldwide was estimated at 2.6 million in 2009, there is currently a dearth of literature on stillbirths in developing countries and rural settings, where the majority of such births occur. The 'Hands Up' Mortality and Morbidity Extraction Tool (HUMMET), developed at Lower Umfolozi War Memorial Regional Hospital (LUWMRH) in 2010, outlines a systematic approach to summarising individual cases of adverse perinatal outcomes. OBJECTIVES. To depict the HUMMET form by describing the detailed demographic and obstetric profile of patients who delivered a stillborn infant at LUWMRH, as well as risk factors associated with these stillbirths between 1 April 2014 and 31 March 2015. The findings add to a global initiative advanced by the Lancet series on stillbirths, aimed at raising awareness of stillbirth statistics in low- and middle-income countries. METHODS. A total of 310 detailed stillbirth case summaries of 305 patients were collected during the study period, representing 90% of the total number of stillborn infants delivered at LUWMRH. A retrospective audit of the HUMMET forms was conducted and the cases were further summarised in a Microsoft Excel spreadsheet that allowed for a univariate analysis of the variables. RESULTS. The stillbirth rate at LUWMRH is much higher than that at other regional hospitals owing to the number of at-risk referrals and emergency cases from surrounding clinics and district hospitals. Referrals were from local clinics (49%) and district hospitals (45%), 35% of stillbirths were due to abruptio placentae and a large proportion were associated with gestational hypertension, pre-eclampsia and/or eclampsia. Avoidable factors were predominantly a late patient response to reduced fetal movements and delays in transfer to hospital. Twenty percent of stillbirths were associated with inappropriate monitoring or management of the obstetric condition at the district hospital. CONCLUSION. The HUMMET form provides a systematic approach to analysing cases of perinatal morbidity and mortality in line with the requirements of the Perinatal Problem Identification Programme database, but provides more details on the circumstances and contributing factors. A repeat audit is recommended to determine whether interventions have been effective. <![CDATA[<b>Obstetric spinal hypotension: Preoperative risk factors and the development of a preliminary risk score - the PRAM score</b>]]> BACKGROUND. Obstetric spinal hypotension is a common and important problem during caesarean delivery. Identifying patients at risk for hypotension may guide clinical decision-making and allow timeous referral. OBJECTIVE. Using preoperative risk factors, to develop a simple scoring system to predict systolic hypotension. METHODS. This prospective, single-centre, observational study of patients undergoing elective or urgent caesarean delivery assessed body mass index, baseline heart rate, baseline mean arterial pressure (MAP), maternal age, urgency of surgery (elective v. non-elective) and preoperative haemoglobin concentration as predictors of spinal hypotension (systolic blood pressure <90 mmHg). We used empirical cut-point estimations in a logistic regression model to develop a scoring system for prediction of hypotension. RESULTS. From 504 eligible patients, preoperative heart rate (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.00 - 1.03; p=0.012), preoperative MAP (OR 0.97, 95% CI 0.95 - 0.98; p<0.001) and maternal age (OR 1.05, 95% CI 1.02 - 1.08; p=0.002) were found to be predictors of hypotension. We derived a preliminary scoring system (pulse rate &gt;90 bpm, age &gt;25 years, MAP <90 mmHg - the PRAM score) for the prediction of systolic hypotension following obstetric spinal anaesthesia. Patients with three factors had a 53% chance of developing hypotension, compared with the overall incidence of 30%. The PRAM score showed good discrimination, with a c-statistic of 0.626 (95% CI 0.576 - 0.676) and good calibration. CONCLUSIONS. Preoperative heart rate, preoperative MAP and maternal age were predictive of hypotension in elective and emergency caesarean delivery. The PRAM score shows promise as a simple, practical means to identify these patients preoperatively, but requires prospective validation. <![CDATA[<b>Gendered risk factors associated with self-harm mortality among youth in South Africa, 2006 - 2014</b>]]> BACKGROUND. Despite efforts to reduce self-harm mortality, death rates remain high, with almost 12% of all youth deaths in South Africa (SA) attributed to this cause. There are gendered differences in causes of death among youth, but little is known about the sex-specific risk factors. OBJECTIVE. To identify the levels and sex-specific determinants of self-harm mortality among youth in SA. METHODS. This was a cross-sectional study of SA death notification forms from 2006 to 2014. Descriptive and analytical statistical techniques were used, including cause-specific mortality rates, proportional mortality ratios and logistic regression models. RESULTS. A total of 1 122 youth (15 - 24 years of age) deaths due to self-harm causes were reported over the study period, during which rates of self-harm mortality increased. More deaths of males (n=818) than females (n=304) were reported. Almost 60% of deaths (p<0.05) were of 20 - 24-year-olds, and 46.4% (p<0.05) of those who died had a secondary education. Almost 10% of females (p<0.05) were pregnant at the time of death. Hanging was the most common type of self-harm mortality among males (79.2%) and females (49.3%). While 11.0% (n=90) of self-harm deaths of males were due to poisoning, more females used this method (39.8%, n=121). The probability of self-harm mortality for males increased according to certain provinces of residence. For females the odds were higher for those who were pregnant (odds ratio (OR) 1.3; p<0.05) and non-South African (OR 1.7; p<0.05) and had secondary education (OR 1.4; p<0.05). CONCLUSIONS. The study showed gender differentials in the determinants of self-harm mortality among youth in SA. For this reason, uniform approaches to awareness campaigns need to be altered to address the specific needs of youth. While males have higher rates than females, the prevalence of self-harm mortality in pregnant females is of concern and needs to be addressed specifically, as it relates not only to suicidal ideation and behaviour but also to youth sexual and reproductive health programmes in the country.