Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 106 num. 11 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>The doors of learning ...</b>]]> <![CDATA[<b>Preliminary results of allograft use from the South African skin bank</b>]]> <![CDATA[<b>We need more prospective studies for Kounis syndrome</b>]]> <![CDATA[<b>The dilemma of age estimation of children and juveniles in South Africa</b>]]> <![CDATA[<b>First report of <i>Wohlfahrtiimonas chitiniclastica </i>bacteraemia in South Africa</b>]]> <![CDATA[<b>Counting the public healthcare litigation bill</b>]]> <![CDATA[<b>New findings say 'never take a TB cure for granted'</b>]]> <![CDATA[<b>A fond and grateful farewell</b>]]> <![CDATA[<b>The epidemic of sexual violence in South Africa</b>]]> <![CDATA[<b>Understanding the intergenerational transmission of violence</b>]]> Intimate partner violence is a major public health and human rights issue in South Africa. This violence tends to run in families and generations, with little change over time and devastating consequences at individual, family and community levels. Understanding the mechanisms for intergenerational transmission of violence may offer important clues for prevention and intervention to halt this recurrence. Health professionals are well placed to identify patients at risk and intervene in families characterised by interpersonal violence. <![CDATA[<b>Current approaches to the management of adult survivors of sexual offences</b>]]> The adequate management of survivors of sexual offences is vital to ensure that both the healthcare and medicolegal needs of survivors are met. This article provides step-wise guidelines on current approaches to the management of adult survivors of sexual offences, which include the collection of evidence, medical management and treatment. <![CDATA[<b>Physical and sexual violence against children</b>]]> Violence against children represents a sobering reality for South African health professionals. Dealing with violence against children can easily take a heavy toll on health professionals' health, often resulting in compassion fatigue, or secondary traumatic stress, which is characterised by a blunted response to patients' suffering, in turn causing them secondary traumatisation. This article prepares health professionals in choosing the most appropriate and comfortable management for these unfortunate young victims of violence. <![CDATA[<b>Health system challenges: An obstacle to the success of isoniazid preventive therapy</b>]]> BACKGROUND. The researchers identified infection with HIV as the strongest risk factor in the reactivation of latent tuberculosis (TB) infection or progression to active disease. Isoniazid preventive therapy (IPT) is one of the interventions recommended by the World Health Organization and the South African (SA) National Department of Health to prevent progression to active TB disease in people living with HIV. Adherence to IPT is therefore the responsibility of healthcare clients and clinicians. OBJECTIVES. To describe the incidence of TB among clients who received IPT, rates of completing and not completing IPT among those who started it, and the reasons for non-completion. METHODS. A quantitative, non-experimental, descriptive retrospective cohort study was undertaken. The clinic records of 104 HIV-positive adults receiving care at a clinic in SA who started IPT between 1 July 2010 and 30 November 2011 were analysed. RESULTS. Sixty-six of 104 study respondents (63.5%) completed the IPT course. None of the respondents who completed IPT was diagnosed with TB, and 86.8% of the respondents who did not complete the programme did so because of the poor quality of healthcare they received, and not by their own choice. CONCLUSION. The study results strengthened the findings of similar local and international studies that IPT is advantageous in the prevention of TB. The finding that so many patients did not complete the programme as a result of drug dispensing or prescription problems is alarming, and revealed a major shortcoming in the healthcare system. <![CDATA[<b>Addressing tobacco smoking in South Africa: Insights from behavioural science</b>]]> Behavioural risk factors such as tobacco smoking contribute significantly to the global and local disease burden. This article surveys three behavioural science interventions that could reduce rates of tobacco smoking in South Africa. <![CDATA[<b>A report of three patients in whom the surgical closure of terminal branches of the external carotid arteries for treatment of migraine resulted in significantly reduced frequency of epileptic attacks</b>]]> Three patients under treatment for grand mal epilepsy, and who were also suffering from chronic migraine, underwent vascular surgery for their migraine. A serendipitous benefit from the successful vascular surgery for migraine was a significant reduction in the frequency of their grand mal seizures. <![CDATA[<b>Polyarteritis nodosa presenting as a bladder outlet obstruction</b>]]> Polyarteritis nodosa (PAN) of the urinary tract is rare. An unusual case of systemic PAN involving the bladder neck is described. A 27-year-old man, with known diastolic hypertension diagnosed 2 years earlier, was admitted with chronic urinary obstruction complicated by hydronephrosis. He had symptoms of myalgia and weight loss, was afebrile but had an elevated erythrocyte sedimentation rate and acute-on-chronic renal impairment. All virological and serological tests including hepatitis B and anti-neutrophil cytoplasmic antibody were negative. A computed tomography scan of the brain revealed small-vessel disease. A bladder neck mass was visualised on cystoscopy. Histological examination of this demonstrated a medium-sized necrotising vasculitis with small-vessel fibrinoid necrosis suggestive of PAN. At least six of the American College of Rheumatology criteria for PAN were met. The patient was treated with pulses of intravenous cyclophosphamide and oral corticosteroids with a good clinical response. <![CDATA[<b>Successful removal of a penile constriction wedding ring in a rural area</b>]]> BACKGROUND. Penile strangulation is a rarely described medical emergency. Removal of the strangulating object is challenging, with a lack of proper guidelines. OBJECTIVE. To describe the challenges faced during an attempt to urgently remove a metal object (wedding ring) constricting an erect penis. METHOD. We report a case of penile strangulation with a wedding ring in an adult man who presented at Van Velden Hospital casualty department, Limpopo, South Africa, and review the related literature. RESULT. The ring was successfully removed using an aspiration technique (via a pink needle). CONCLUSION. No proper guidelines exist for the treatment of this condition, so the 'best method' is the one with a successful outcome. <![CDATA[<b>Atypical chest pain: Needles in a haystack</b>]]> A 20-year-old man presented with a 6-month history of intermittent chest pain. Initial imaging demonstrated approximately 15 sewing needles lodged in his myocardium, predominantly in the left ventricle. The patient has been referred to cardiothoracic surgery for further management. His progress will be monitored closely. <![CDATA[<b>Is South Africa advancing towards National Health Insurance? The perspectives of general practitioners in one pilot site</b>]]> BACKGROUND. The launch of the National Health Insurance (NHI) White Paper in December 2015 heralded a new stage in South Africa's advancement towards universal health coverage. The 'contracting in' of private sector general practitioners (GPs), though only one component of the overall reformed system, is nevertheless crucial to address staff shortages and capacity, and also to realise the broader vision of a single unified, integrated system. OBJECTIVE. To report on the views and experiences of GP providers tasked with implementing the reforms at one pilot site, Tshwane District in Gauteng Province, providing an insight into the practical challenges the NHI scheme faces in implementation. METHODS. The study was qualitative in nature, using a combination of convenience and purposeful sampling to recruit participants. A thematic analysis of the data was conducted using Nvivo 10 software. RESULTS. The overall experiences of the GPs exposed a number of problems with the pilot. These included frustration with lack of appropriate infrastructure and equipment in NHI facilities, difficulties integrating into the facilities and lack of professional autonomy, as well as unhappiness with contracting arrangements. Despite strong support for the idea of NHI, there was general scepticism that private doctors would embrace the scheme on the scale required. CONCLUSION. The study suggests that the current pilots are still a long way from the vision of a single, integrated health system. While it may be argued that the pilots are not themselves the completed NHI, the findings suggest that it will take much longer to establish than the timeline envisaged by government. <![CDATA[<b>Medical waste disposal at a hospital in Mpumalanga Province, South Africa: Implications for training of healthcare professionals</b>]]> BACKGROUND. Healthcare professionals (HCPs) produce various types of waste in the course of rendering healthcare services. Each classification of waste must be disposed of according to the prescribed guidelines. Incorrect disposal of waste may pose a danger to employees, patients and the environment. HCPs must have adequate knowledge of the disposal of medical waste. OBJECTIVES. To determine the knowledge and practices of HCPs with regard to medical waste disposal at a hospital in Mpumalanga Province, South Africa. METHODS. A quantitative cross-sectional research approach was used. The study respondents included nurses, medical doctors, dental health staff and allied health staff. Data were collected through self-administered questionnaires and analysed using IBM SPSS version 22.0. RESULTS. A high proportion of HCPs did not have adequate knowledge regarding the disposal of medical waste, but nevertheless disposed of medical waste appropriately. While the knowledge and practices of HCPs with regard to medical waste disposal were not associated with age, gender or years of experience, there was an association between professional category and knowledge and practices. CONCLUSIONS. Disposal of medical waste is the responsibility of all HCPs. All categories of HCPs should receive regular training to improve their knowledge regarding disposal of medical waste and to minimise the risks associated with improper waste management. This will further increase compliance with the guidelines on disposal of medical waste. <![CDATA[<b>A cross-sectional study of peripartum blood transfusion in the Eastern Cape, South Africa</b>]]> BACKGROUND. Obstetric haemorrhage (OH) remains a major contributor to maternal morbidity and mortality. Blood transfusion is critical in OH management; yet, data on peripartum transfusion are lacking. A pilot study reported high rates of peripartum transfusion in a sample of South African (SA) hospitals, which was independently associated with HIV status. OBJECTIVES. To assess the incidence of peripartum transfusion in a sample of Eastern Cape, SA hospitals to evaluate generalisability of preceding study findings. METHODS. Hospital chart reviews were conducted of all deliveries at three large regional hospitals from February to June 2013. Additional clinical data were collected for patients who sustained OH and/or were transfused. RESULTS. A total of 7 234 women were enrolled in the study; 1 988 (27.5%) were HIV-positive. Of the 767 HIV-positive women with a CD4 count <350 cells/μL, 86.0% were on full antiretroviral therapy and 9.9% received drugs for prevention of mother-to-child transmission. The overall transfusion rate was 3.2%, with significant variability by hospital: Frere Hospital (1.5%), Dora Nginza Hospital (3.8%) and Cecilia Makiwane Hospital (4.6%). The number of red blood cell units per transfused patient and per delivery varied significantly by hospital. Bivariate analysis showed significant association between transfusion and HIV status. In a multivariate analysis, controlling for OH, age, mode of delivery, gestational age, parity and birthweight, this association (odds ratio 1.45; 95% confidence interval 0.78 - 2.71) was no longer significant. CONCLUSION. These findings confirm high rates of peripartum transfusion in SA. While this can be possibly ascribed to variability in practice and patient profile, variation in care and improvement in HIV treatment should be considered. <![CDATA[<b>Barriers to obstetric care among maternal near-misses</b>]]> BACKGROUND. There are several factors in the healthcare system that may influence a woman's ability to access appropriate obstetric care. OBJECTIVE. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. METHODS. This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The 'three-delays model' was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient. RESULTS. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses - obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions. CONCLUSIONS. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension. <![CDATA[<b>A review of the peri-operative management of paediatric burns: Identifying adverse events</b>]]> 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 17.6% 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. <![CDATA[<b>The hospital costs associated with acute paediatric burn injuries</b>]]> 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. <![CDATA[<b>The state of methamphetamine ('tik') use among youth in the Western Cape, South Africa</b>]]> 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. <![CDATA[<b>Intimate partner violence at a tertiary institution</b>]]> 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. <![CDATA[<b>Tonsillectomy rates in the South African private healthcare sector</b>]]> 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. <![CDATA[<b>Elevated international normalised ratios correlate with severity of injury and outcome</b>]]> 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 (non-scene). 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.