Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 109 num. 11 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Vaping – not the smoke-ending panacea</b>]]> <![CDATA[<b>Why we need to evaluate the quality of tuberculosis care in South Africa's private health sector</b>]]> <![CDATA[<b>Reflections on undergraduate teaching</b>]]> <![CDATA[<b>Extended-spectrum beta-lactamase-producing <i>Klebsiella pneumoniae </i>isolated from an abattoir worker in Cameroon</b>]]> <![CDATA[<b>Virchow's triad revisited</b>]]> <![CDATA[<b>Venous thromboembolism in pregnancy</b>]]> Pregnancy-related venous thromboembolic events are important preventable causes of morbidity and mortality in South Africa. All pregnant patients should be evaluated for thrombotic risk at different stages of their pregnancy and appropriate preventive steps taken. Maternal and fetal wellbeing must be kept in mind, as well as physiological changes leading to altered drug pharmacokinetics. Managing the patient with thrombotic risk in pregnancy, diagnosing venous thromboembolism (VTE) during pregnancy and treatment of venous thromboembolic events should be managed by a team. Excellent recent reviews on this subject are available, including risk factor stratification in anticoagulant therapy; managing the patient at time of labour; diagnosing VTE; and managing neuraxial anaesthesia in the pregnant patient on anticoagulant therapy. <![CDATA[<b>When to transfuse: Red blood cell and platelet transfusion thresholds in clinical practice</b>]]> Blood component transfusion is a frequently prescribed intervention in healthcare that depends on the availability of a limited and expensive resource. The transfusion of blood products may be life-saving, but it is not without risk. Society guidelines and clinical trials guide transfusion decisions regarding transfusion thresholds, as well as the appropriateness of prophylactic v. therapeutic transfusion strategies. This review provides a practical and evidence-informed approach to the transfusion of red blood cells and platelets in commonly encountered clinical settings. <![CDATA[<b>Changing priorities in maternal and perinatal health in Gert Sibande District, South Africa</b>]]> Gert Sibande District is a predominantly rural district in Mpumalanga Province, South Africa (SA), with a population of just over 1.1 million. It has a high prevalence of HIV infection and pregnancy-related hypertensive disease. In 2010 the district was one of the worst-performing health districts in SA, with a maternal mortality ratio of 328.0 per 100 000 births. Various programmes were introduced between 2010 and 2017 to address major causes of maternal and perinatal morbidity and mortality in the district. The focus has been on HIV-related morbidity, the direct obstetric causes of maternal and perinatal morbidity and mortality, and health systems strengthening. During the period 2010 - 2017, there was a steady decline in institutional maternal mortality with a drop of 71% in maternal deaths over a period of 6 years, from 328.0 per 100 000 births to 95.0. However, the ratio levelled off in 2016 and 2017, mainly as a result of a changing disease profile. The stillbirth rate showed a decline of 24.4% over a period of 8 years. With perseverance, rapid response and evidence-based strategies it was possible to more than halve the institutional maternal mortality ratio within 6 years. However, with the changing disease profile, conditions such as hypertensive disease in pregnancy should be prioritised and new strategies developed to further reduce maternal and perinatal mortality and morbidity. <![CDATA[<b>Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error</b>]]> The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention. <![CDATA[<b>Sending patients electronic reminders on the need for urgent treatment to prevent life-threatening illnesses: Some lessons to be learned and a cautionary reminder</b>]]> A patient's widow recently successfully sued a doctor who had not followed up on unanswered SMS (text) messages sent to her husband warning him that he needed urgent treatment for a life-threatening form of malaria. The messages had gone to her late husband's previous cellphone number and were never received by him. The doctor raised several false defences and attempted to defend himself without being represented by a lawyer. This article highlights a number of important lessons about the dangers of relying exclusively on electronic messaging, raising spurious defences, and resorting to self-representation in serious malpractice cases. It also makes some suggestions on what should be done to avoid such dangers. <![CDATA[<b>Pit latrines: A potential risk factor for latrodectism in rural South Africa?</b>]]> Latrodectus spp. spider bites usually occur away from domestic sites, in the open fields or bushes. We report 3 cases of latrodectism that were identified to be associated with bites by these spiders in a rural domestic setting, specifically while the victim was using a pit latrine. <![CDATA[<b>One-stop haematuria clinic: First experience in South Africa</b>]]> BACKGROUND. Haematuria is the most common symptom of urological cancers, specifically bladder cancer, and timely diagnosis can prevent disease from progressing to a more advanced or incurable stage. One-stop haematuria clinics (OSHCs) have become commonplace in urological services in developed countries during the past three decades.OBJECTIVES. To assess the efficacy of this specialised clinic, aimed at providing an investigative service for patients with haematuria, in decreasing morbidity and mortality by earlier diagnosis of urological malignancy. We also report on the outcomes of this study.METHODS. A total of 275 patients who attended the weekly OSHC at Groote Schuur Hospital, Cape Town, South Africa (SA), between January 2012 and October 2015 were retrospectively included in the study (out of 477 folders reviewed). Only patients with visible haematuria (275/477) were included, and characteristics such as gender, age, self-identified ethnicity, and outcomes following OSHC attendance (diagnoses and stage/grade/type of cancers) were recorded.RESULTS. While the majority of cases were classified as indeterminate following investigation, one-fifth (55/275) of the patients were diagnosed with urological neoplasms, mainly bladder cancer (87.2%, n=48). The 50 - 69-year age group was the most common window for diagnosis of a neoplasm. Forty-six patients (46/55) with urothelial cancers were diagnosed at a relatively early stage and were therefore offered curative management; 5 patients presented with late-stage disease and risked poor outcomes after management. The remaining 4 identified cases were adenocarcinomas and squamous cell carcinomas. Most patients presented with high-grade cancers (43.2%). A small subset of patients were diagnosed with renal cell carcinoma (11.6%) and upper-tract transitional cell carcinoma (1.6%).CONCLUSIONS. This audit revealed that an OSHC can streamline diagnosis of urological malignancies in the SA setting, and highlights the fact that the patients most at risk for developing malignant conditions were the ones frequently diagnosed at a later stage and hence potentially facing a poorer prognosis. These findings support the setting up of such clinics in other SA hospitals to improve ease of early access to the urological service. <![CDATA[<b>Closed traction reduction of cervical spine facet dislocations: Compelled bylaw</b>]]> BACKGROUND. Following a 2015 ruling, the South African (SA) Constitutional Court obligates closed reduction of cervical facet dislocations sustained through low-energy injury mechanisms, within 4 hours of injury. Closed traction reduction of cervical facet dislocations requires specific equipment and expertise, which have limited availability in SA.OBJECTIVES. To review the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in a tertiary-level orthopaedic department and training facility, and to consider the feasibility of such a reduction within 4 hours after injury.METHODS. The clinical records and imaging screens of patients presenting with cervical facet dislocations to an academic training hospital between November 2008 and March 2016 were retrospectively reviewed, with specific attention to demographic information, mechanism of injury, time delays from injury to treatment and factors resulting in delay, as well as the success rate in closed cervical reduction.RESULTS. Ninety-one patients with cervical dislocation presented during the study period, of whom 69 were included for further review. The mean age at presentation was 37.6 (range 18 - 65) years. Successful reduction was achieved in 71% (n=49) of cases, with a median delay time from injury to reduction of 26 (interquartile range (IQR) 19.50 - 31.75) hours. Only 1 patient of 69 patients received successful reduction within 6 hours after injury. Neurological improvement was noticed in 5 of 53 patients with neurological deficit - after successful reduction. Two patients improved with two American Spinal Injury Association (ASIA) grades (from A to C), and 2 improved with one ASIA grade (from A to Β and D to E).CONCLUSIONS. Successful reduction of a cervical facet dislocation within 4 hours presents a challenge to healthcare infrastructure globally. The relative scarcity of this type of injury (91 cases during 8 years in a tertiary referral hospital) prevents district-level clinicians from readily acquiring a level of experience to confidently perform closed reduction of these injuries, unless very specific training and support are provided towards this end. <![CDATA[<b>Orthopaedic referrals using a smartphone app: Uptake, response times and outcome</b>]]> BACKGROUND. It is well established that South Africa (SA) suffers an immense burden of violence and injuries. The responsibility of providing care for these injuries falls mainly on public health services, resulting in overloading of the health system. Prior to a recent intervention, the large burden had been exacerbated by limitations in the traditional referral system that highlighted the need for a better referral system. Vula's smartphone app was introduced at Tygerberg Hospital in August 2016. This study evaluated the uptake, response times and outcomes using this app.OBJECTIVES. The main objectives of the study were to describe: (i) the number of referrals; (ii) referral response times; (Hi) referring facilities; and (iv) referral outcomes. Secondary objectives were to: (i) evaluate whether the referral outcome pathway was appropriate; and (ii) assess professional conduct and evidence of upskilling.METHODS. This retrospective, descriptive study investigated Vula app referrals to the Division of Orthopaedic Surgery at Tygerberg Hospital between 1 August 2016 and 31 March 2017. Vula was advertised to key facilities in the hospital's referral network. All referrals to the division during the study period were systematically included in the analysis of operational outcomes, although some were excluded from the subsequent referral outcome analysis. Operational outcomes included the number of referrals, referring facilities and referral response times. Referral outcome analysis included the clinical diagnosis, referral pathway, whether the referral was used for upskilling and whether it was conducted in a professional manner.RESULTS. A total of 2 275 referrals from 39 different facilities were received during the study period from 238 individual users; 50% of referrals received a response within 11 minutes, while a small percentage received no response. Clinical and demographic characteristics of 1 985 patients included in the referral outcome analysis indicated that the majority of trauma and emergency referrals involved males, with closed fractures being the most frequent clinical presentation. Although the most common referral outcome was immediate transfer, one-third of the patients were treated at the referring hospital with advice only.CONCLUSIONS. The large volume of orthopaedic referrals received through the Vula app suggests that Vula represents a successful alternative to traditional referral methods. Referrals managed by advice only could suggest that Vula facilitates some relief for the overburdened trauma services. Future research could further explore Vula's role in strengthening the public health system, including interventions for high-volume referral areas and upskilling of referring health workers. <![CDATA[<b>The impact of international benchmarking on the price of immunosuppressive medicines for transplant recipients in South Africa</b>]]> BACKGROUND. External reference pricing (ERP) is an internationally applied pricing policy to regulate the price of medicines. In 2005, the South African (SA) Minister of Health published a Government Gazette of regulations relating to a transparent pricing system for medicines and scheduled substances, stating that the Minister must publish a methodology for conforming to international benchmarks. In May 2014, the most recent proposed benchmark methodology was published, detailing that international benchmarking of medicines (IBM) requires that the lowest price in a selected basket of countries (Australia, Canada, New Zealand, Spain and SA) be used as the ultimate price for the purposes of benchmarking of originator products.OBJECTIVES. To provide a broad observational basis for the use of IBM and the proposed countries as a pricing tool; the feasibility of using BRICS countries (Brazil, Russia, India, China and SA) as comparator countries; and a small sample comparison of local state tender pricing in relation to the IBM proposed basket of comparator country pricing. Immunosuppressant medicines for organ transplant patients were used for this comparison, as they are relatively expensive and there is reluctance to implement pricing and reimbursement policy options to contain their costs.METHODS. Ex-manufacturer medicine pricing information for 2016, 2017 and 2018 was sourced for immunosuppressive medicines for SA (public and private sectors), Australia, New Zealand, Canada, Spain, Brazil and Russia. Unit prices were compared for products with the same international non-proprietary name (INN), strength, formulation and manufacturer. In most cases the products were matched on product name, bearing translation nuances in mind.RESULTS. Across all 3 years, in the majority of products, ERP using the proposed basket of comparator countries Australia, New Zealand, Canada and Spain lowered the local private sector ex-manufacturer price of medicine. Similarly, for the majority of products comparing local pricing with that of available BRICS country pricing data, the comparison lowered the price. For 92% of products where a comparison could be made, the SA state tender price was the lowest available price.CONCLUSIONS. Conducting an ERP analysis consumes time and resources. However, it may prove to reduce a current or proposed medicine price and may be considered as one of a range of medicine pricing policies employed by a country. It should not be used in isolation from other medicine pricing and reimbursement policies. <![CDATA[<b>Elevated unidentified antibodies in sickle cell anaemia patients receiving blood transfusions in Cape Town, South Africa</b>]]> BACKGROUND. Sickle cell disease (SCD) is an inherited haemoglobinopathy in which homozygous individuals suffer from numerous complications including vaso-occlusion, infection and haemolytic anaemia. Patients therefore often require blood transfusions, which may lead to elevated levels of allogeneic antibodies. In South Africa (SA), the number of patients with SCD has risen significantly owing to migration and changing demographics, leading to an increased need for blood products.OBJECTIVES. Against the above background, to determine the incidence of alloimmunisation and the presence of clinically significant antibodies in SCD patients requiring transfusions in Cape Town, SA.METHODS. Information on SCD patients receiving blood products between 2010 and 2012, including demographics, number of units transfused and the presence and type of alloantibodies, was collected. The results were compared with those for non-SCD controls who had received a similar number of transfusions.RESULTS. Of 182 patients analysed, 91 had SCD. Twenty-two percent of the SCD patients and 13.2% of the controls had become alloimmunised (p=0.12), while the proportions of those receiving transfusions and acquiring clinically significant antibodies were similar between the two groups (p=0.17 and p=0.19, respectively). However, the total number and amount of unidentified antibodies were significantly increased in patients with SCD (p=0.02 and p<0.001, respectively).CONCLUSIONS. This study concluded that patients with SCD develop increased numbers of unidentified antibodies, which may be important in the selection of suitable donors. <![CDATA[<b>Intron 22 inversion real-time polymerase chain reaction detection in haemophilia A families from central South Africa</b>]]> BACKGROUND. Intron 22 inversion (inv22) may account for 45% of all cases of severe haemophilia A. Haemophilia A is underdiagnosed in South Africa (SA), and owing to limited resources the genotypes of most haemophilia A patients are unknown.OBJECTIVES. To screen the haemophilia A population in central SA for inv22 using two novel detection methods.METHODS. We recruited 62 participants from 27 families affected by haemophilia A in Free State and Northern Cape provinces. We screened for inv22 with our previously reported conventional polymerase chain reaction (PCR) method, as well as with a newly developed real-time PCR method. Sanger sequencing was performed to confirm the PCR results.RESULTS. With the real-time PCR method, 10 of the severe haemophilia A patients and 3 carriers tested inv22-positive. The conventional PCR method and real-time PCR results were comparable in all but one case, where the discrepancy was attributed to sample-specific degradation. Inv22 was found in 29.4% of the severe haemophilia A population and 22.2% of the potential carriers. The inv22 status of most SA haemophilia A patients is currently unknown. The 29.4% of haemophilia A patients who were positive for inv22 was lower than the expected 45%, which could indicate a more prominent mutation than inv22 in the SA population.CONCLUSIONS. The above finding needs to be confirmed by performing comprehensive factor VIII gene (F8) genotyping on the remainder of the haemophilia A patients in SA. The study contributes to genetic research in haemophilia A and lays a foundation for future research in haemophilia A genetics in SA. <![CDATA[<b>The utility of hyperlactataemia in the definition of septic shock: Evaluating the Sepsis-3 definitions in a sub-Saharan African intensive care unit</b>]]> BACKGROUND. Sepsis-3 definitions were published in 2016 and included hyperlactataemia (serum lactate &gt;2.0 mmol/L) as a mandatory component of the new definition of septic shock. These data were collected mainly from high-income countries and lack adequate validation in scenarios outside these countries.OBJECTIVES. To evaluate admission serum lactate as a predictor of intensive care unit (ICU) mortality in patients with infection and hypotension requiring inotropic support.METHODS. This was a retrospective observational study of 170 patients with infection and hypotension requiring inotropic support admitted to the ICU at King Edward VIII Hospital in Durban, South Africa. Admission serum lactate was evaluated as a predictor of ICU mortality in this cohort.RESULTS. The study population had a median age of only 42 years. The ICU mortality rate for the cohort was 49.4%. Most patients were surgical (71.8%), with the most common source of sepsis being abdominal (55.9%). The ICU mortality rate was 40.9% in patients with a lactate level <2.0 mmol/L and 52.4% in those with a level &gt;2.0 mmol/L; this did not reach statistical significance. The optimal cut-off was 4.5 mmol/L, at which there was a clear, statistically significant difference in mortality between patients without (39.3%) and with hyperlactataemia (59.3%) (p=0.009).CONCLUSIONS. Hyperlactataemia was associated with increased mortality. However, a lactate level &gt;2.0 mmol/l, as proposed in Sepsis-3, did not reach statistical significance, and a higher cut-off of &gt;4.5 mmol/L was more appropriate. <![CDATA[<b>The estimated burden of fungal disease in South Africa</b>]]> BACKGROUND. With a population of 56.5 million, over 7 million persons living with HIV, one of the world's highest rates of tuberculosis (TB) and a large proportion of the population living in poverty, South Africa (SA)'s fungal disease burden is probably substantial and broad in scope.OBJECTIVES. To estimate the burden of fungal disease in SA.METHODS. Using total and at-risk populations and national, regional and occasionally global data, we estimated the incidence and prevalence of the majority of fungal diseases in SA.RESULTS. Estimates for the annual incidence of HIV-related life-threatening fungal disease include cryptococcal meningitis (8 357 cases), Pneumocystis pneumonia (4 452 cases) and endemic mycoses (emergomycosis, histoplasmosis and blastomycosis, with 100, 60 and 10 cases per year, respectively). We estimate 3 885 cases of invasive aspergillosis annually. The annual burden of candidaemia and Candida peritonitis is estimated at 5 421 and 1 901 cases, respectively. The epidemic of pulmonary TB has probably driven up the prevalence of chronic pulmonary aspergillosis to 99 351 (175.8/100 000), perhaps the highest in the world. Fungal asthma probably affects >100 000 adults. Mucosal candidiasis is common, with an annual prevalence estimated at 828 666 and 135 289 oral and oesophageal cases, respectively, complicating HIV infection alone (estimates in other conditions not made), and over a million women are estimated to be affected by recurrent vulvovaginal candidiasis each year. Tinea capitis in children is common and conservatively estimated at >1 000 000 cases. The inoculation mycoses sporotrichosis, chromoblastomycosis and eumycetoma occur occasionally (with 40, 40 and 10 cases estimated, respectively). Overall, we estimate that over 3.2 million South Africans are afflicted by a fungal disease each year (7.1% of the population).CONCLUSIONS. Significant numbers of South Africans are estimated to be affected each year by fungal infections, driven primarily by the syndemics of HIV, TB and poverty. These estimates emphasise the need for better epidemiological data, and for improving the diagnosis and management of these diseases.