Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 107 num. 1 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Climate change - no denial</b>]]> <![CDATA[<b>A novel blood test for tuberculosis prevention and treatment</b>]]> <![CDATA[<b>Transoral robotic surgery (TORS) in South Africa (1) </b>]]> <![CDATA[<b>Transoral robotic surgery (TORS) in South Africa (2)</b>]]> <![CDATA[<b>Cost considerations in determining the affordability of adjuvant trastuzumab in breast cancer (1)</b>]]> <![CDATA[<b>Cost considerations in determining the affordability of adjuvant trastuzumab in breast cancer (2)</b>]]> <![CDATA[<b>Yes, we can eradicate tuberculosis in South Africa</b>]]> <![CDATA[<b>From an exasperated pathologist</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b> Steve Lawn (13 March 1966 - 23 September 2016)</b>]]> <![CDATA[<b>Pieter Stephanus Bothma (29 August 1957 - 21 July 2016)</b>]]> <![CDATA[<b>Theo Berkowitz (3 February 1929 - 3 July 2016)</b>]]> <![CDATA[<b>Missed opportunities for circumcising boys</b>]]> <![CDATA[<b>South Africa's salt reduction strategy: Are we on track, and what lies ahead?</b>]]> <![CDATA[<b>Anaemia (part 1)</b>]]> <![CDATA[<b>Anaemia: Approach to diagnosis</b>]]> Anaemia is defined as a condition in which the number of red cells or their oxygen-carrying capacity is insufficient to meet physiological needs. It is the most common disorder globally and one of the conditions that general practitioners most frequently encounter. In the World Health Organization global database, anaemia is estimated to affect 1.6 billion people. As anaemia manifests in a wide range of conditions, it is important to embrace a structured diagnostic approach. The recommended approach set out in this article incorporates clinical and pathophysiological considerations, red cell characteristics, and bone marrow activity. In this issue of CME, the first of two parts on anaemia, the causes of anaemia related specifically to decreased red cell production are discussed. <![CDATA[<b>Cutting the cost of South African antiretroviral therapy using newer, safer drugs</b>]]> Antiretrovirals are a significant cost driver for HIV programmes. Current first-line regimens have performed well in real-life programmes, but have a low barrier to virological resistance and still carry toxicity that limits adherence. New drug developments may mean that we have access to safer, more robust and cheaper regimens, but only if the appropriate clinical trials are conducted. We briefly discuss these trials, and demonstrate the large cost savings to the South African HIV programme if these are successful. <![CDATA[<b>Outbreak of carbapenem-resistant <i>Providencia rettgeri</i> in a tertiary hospital</b>]]> The emergence of resistance to multiple antimicrobial agents in pathogenic bacteria is a significant public health threat, as there are limited effective antimicrobial agents for infections caused by multidrug-resistant (MDR) bacteria. Several MDR bacteria are now frequently detected. Carbapenem resistance in Enterobacteriaceae is often plasmid mediated, necessitating stringent infection control practices. We describe an outbreak of carbapenem-resistant Providencia rettgeri involving 4 patients admitted to intensive care and high-care units at a tertiary hospital. Clinical and demographic characteristics of 4 patients with carbapenem-resistant P. rettgeri were documented. All P. rettgeri isolated in these cases had a carbapenem-resistant antibiogram, with resistance to imipenem, ertapenem and meropenem. These cases could be epidemiologically linked. A multiprong approach, simultaneously targeting antibiotic stewardship, universal precautions and appropriate transmission-based precaution practices, is integral to prevention and control of nosocomial infections. <![CDATA[<b>Tackling the climate targets set by the Paris Agreement (COP 21): Green leadership empowers public hospitals to overcome obstacles and challenges in a resource-constrained environment</b>]]> The healthcare sector itself contributes to climate change, the creation of hazardous waste, use of toxic metals such as mercury, and water and air pollution. To mitigate the effect of healthcare provision on the deteriorating environment and avoid creating further challenges for already burdened health systems, Global Green Hospitals was formed as a global network. Groote Schuur Hospital (GSH), as the leading academic hospital in Africa, joined the network in 2014. Since then, several projects have been initiated to reduce the amount of general waste, energy consumption and food waste, and create an environmentally friendlier and more sustainable hospital in a resource-constrained public healthcare setting. We outline the various efforts made to reduce the carbon footprint of GSH and reduce waste and hazardous substances such as mercury and polystyrene, and elaborate how obstacles and resistance to change were overcome. The hospital was able to halve the amount of coal and water used, increase recycling by 50% over 6 months, replace polystyrene cups and packaging with Forest Stewardship Council recyclable paper-based products, reduce the effect of food wastage by making use of local farmers, and implement measures to reduce the amount of expired pharmaceutical drugs. To improve commitment from all involved roleplayers, political leadership, supportive government policies and financial funding is mandatory, or public hospitals will be unable to tackle the exponentially increasing costs related to climate change and its effects on healthcare. <![CDATA[<b>The National Health Insurance, the decentralised clinical training platform, and specialist outreach</b>]]> According to the Constitution of South Africa (SA), citizens living in remote areas are entitled to the same level of healthcare as those with access to tertiary hospitals. Specialist outreach has been shown to achieve this. When SA's National Health Services Commission convened (1942 - 1944), Gluckman summarised: 'Where the need is greatest the supply of hospitals is least.' Primary healthcare (PHC) characterised the Kark's Pholela Health Centre and was highly regarded. Although PHC underpins National Health Insurance (NHI) planning, both preventive and curative healthcare are needed. The KwaZulu-Natal (KZN) provincial Department of Health and the University of KZN College of Health Sciences' 5-year plan for a decentralised clinical teaching platform (DCTP) is ambitious, requiring optimum co-operation between health department and university. Reservations can be addressed through sustained specialist outreach. Above all, the patient must be the chief beneficiary. The NHI and DCTP overlap with specialist outreach, but cannot do without it. <![CDATA[<b>The intraocular CD4/CD8 ratio in a black South African patient with Beh├žet's disease uveitis</b>]]> A 33-year-old black South African male patient was referred to our uveitis service with a 5-year history of panuveitis refractory to treatment. He had an associated history of recurrent mouth and genital ulcers, predating the uveitis history by about 2 years. The measurement of his intraocular CD4/CD8 ratio helped make a diagnosis of Behcet's disease uveitis. <![CDATA[<b>Pulmonary nocardiosis caused by <i>Nocardia otitidiscaviarum</i> in an adult asthmatic female patient: The presence of acid-fast branching filaments is always significant</b>]]> We report a case of pulmonary nocardiosis in a 41-year-old asthma patient. Chest radiographs showed bilateral air space and consolidations. Acid-fast branching filaments were demonstrated in sputum, and the grown organism was identified phenotypically and confirmed using 16S rDNA sequencing (accession no. KX500116). The patient received a combination of medical treatments, but developed complications, which were managed over the next 3 months, after which she was discharged. Pulmonary nocardiosis should be considered in patients undergoing steroid therapy or when a chronic infection does not respond to first-line treatment. <![CDATA[<b>Classifying snakebite in South Africa: Validating a scoring system</b>]]> OBJECTIVE. To develop and validate a scoring system for managing snakebites in South Africa (SA). METHODS. We studied all snakebite admissions to a regional hospital in KwaZulu-Natal, SA. The primary outcome was an active treatment intervention (ATI) defined as antivenom treatment or any surgical procedure. The development cohort consisted of 879 patients with snakebite who presented to the Ngwelezane Hospital Emergency Department from December 2008 to December 2013. Factors predictive of ATI and the optimal cut-off score for predicting an ATI were identified. These factors were then used to develop a standard scoring system. The score was then tested prospectively for accuracy in a new validation cohort consisting of 100 patients admitted for snakebite to our unit from 1 December 2014 to 31 March 2015. Accuracy of the score was determined. RESULTS. Of 879 snakebite admissions, 146 in the development cohort and 40 of 100 in the development validation cohort reached the primary endpoint of an ATI. Six risk predictors for ATI were identified from the development cohort: age <14 years (odds ratio (OR) 2.13), delay to admission &gt;7 hours (OR 4.63), white cell count &gt;10 x 10(9)/L (OR 3.15), platelets <92 x 10(9)/L (OR 2.35), haemoglobin <7.1 g/dL (OR 5.68), international normalised ratio &gt;1.2 (OR 2.25). Each risk predictor was assigned a score of 1;receiver operating characteristic curve analysis returned a value of &gt;4 out of 6 as the optimal cut-off for prediction of an ATI (area under the curve 0.804; 95% confidence interval 0.758 - 0.84). Testing of the score on the validation cohort produced a specificity of 96.6% and a sensitivity of 22.5%. The positive predictive value and negative predictive value were 81.8% and 65.2%, respectively. CONCLUSION. Our results show that the identified score is a useful adjunct to clinical assessment in managing snakebite. Its value is greatest when used in those patients who fall in the mild to moderate clinical category. Until our severity score has been validated (or modified) for use across SA, we propose to name it the Zululand Severity Score; a true SA Severity Score may follow. <![CDATA[<b>Immunisation coverage in the rural Eastern Cape </b><b>一</b><b> are we getting the basics of primary care right? Results from a longitudinal prospective cohort study</b>]]> BACKGROUND. Immunisations are one of the most cost-effective public health interventions available and South Africa (SA) has implemented a comprehensive immunisation schedule. However, there is disagreement about the level of immunisation coverage in the country and few studies document the immunisation coverage in rural areas. OBJECTIVE. To examine the successful and timely delivery of immunisations to children during the first 2 years of life in a deeply rural part of the Eastern Cape Province ot SA. METHODS. From January to April 2013, a cohort of sequential births (N=470) in the area surrounding Zithulele Hospital in the OR Tambo District of the Eastern Cape was recruited and followed up at home at 3, 6, 9,12 and 24 months post birth, up to May 2015. Immunisation coverage was determined using Road-to-Health cards. RESULTS. The percentages of children with all immunisations up to date at the time of interview were: 48.6% at 3 months, 73.3% at 6 months, 83.9% at 9 months, 73.3% at 12 months and 73.2% at 24 months. Incomplete immunisations were attributed to stock-outs (56%), lack of awareness of the immunisation schedule or of missed immunisations by the mother (16%) and lack of clinic attendance by the mother (19%). Of the mothers who had visited the clinic for baby immunisations, 49.8% had to make multiple visits because of stock-outs. Measles coverage (of at least one dose) was 85.2% at 1 year and 96.3% by 2 years, but 20.6% of babies had not received a second measles dose (due at 18 months) by 2 years. Immunisations were often given late, particularly the 14-week immunisations. CONCLUSIONS. Immunisation rates in the rural Eastern Cape are well below government targets and indicate inadequate provision of basic primary care. Stock-outs of basic childhood immunisations are common and are, according to mothers, the main reason for their childrens immunisations not being up to date. There is still much work to be done to ensure that the basics of disease prevention are being delivered at rural clinics in the Eastern Cape, despite attempts to re-engineer primary healthcare in SA. <![CDATA[<b>Surveillance of healthcare-associated infection in hospitalised South African children: Which method performs best?</b>]]> BACKGROUND. In 2012, the South African (SA) National Department of Health mandated surveillance of healthcare-associated infection (HAI), but made no recommendations of appropriate surveillance methods. METHODS. Prospective clinical HAI surveillance (the reference method) was conducted at Tygerberg Childrens Hospital, Cape Town, from 1 May to 31 October 2015. Performance of three surveillance methods (point prevalence surveys (PPSs), laboratory surveillance and tracking of antimicrobial prescriptions) was compared with the reference method using surveillance evaluation guidelines. Factors associated with failure to detect HAI were identified by logistic regression analysis. RESULTS. The reference method detected 417 HAIs among 1 347 paediatric hospitalisations (HAI incidence of 31/1000 patient days; 95% confidence interval (CI) 28.2 - 34.2). Surveillance methods had variable sensitivity (S) and positive predictive value (PPV): PPS S = 24.9% (95% CI 21-29.3), PPV = 100%; laboratory surveillance S = 48.4% (95% CI 43.7 - 53.2), PPV = 55.2% (95% CI 50.1-60.2); and antimicrobial prescriptions S = 66.4% (95% CI 61.8 - 70.8%), PPV = 88.5% (95% CI 84.5 - 91.6). Combined laboratory-antimicrobial surveillance achieved superior HAI detection (S = 84.7% (95% CI 80.9 - 87.8%), PPV = 97% (95% CI 94.6 - 98.4%)). Factors associated with failure to detect HAI included patient transfer (odds ratio (OR) 2.0), single HAI event (OR 2.8), age category 1 - 5 years (OR 2.1) and hospitalisation in a general ward (OR 2.3). CONCLUSIONS. Repeated PPSs, laboratory surveillance and/or antimicrobial prescription tracking are feasible HAI surveillance methods for low-resource settings. Combined laboratory-antimicrobial surveillance achieved the best sensitivity and PPV. SA paediatric healthcare facilities should individualise HAI surveillance, selecting a method suited to available resources and practice context. <![CDATA[<b>Retinopathy of prematurity in a cohort of neonates at Groote Schuur Hospital, Cape Town, South Africa</b>]]> BACKGROUND. Severe retinopathy of prematurity (ROP) can cause blindness. Before 2016, resource limitations precluded routine screening for ROP at Groote Schuur Hospital (GSH), Cape Town, South Africa. Previous pilot studies at GSH found no patients with ROP requiring treatment; however, improved preterm infant survival may affect the prevalence. OBJECTIVES. To determine the prevalence and severity of ROP, describe potential risk factors, and assess the feasibility of ROP screening. Methods. Infants with a birth weight (BW) of <1 251 g or a gestational age (GA) of <31 weeks were screened from November 2012 to May 2013. RESULTS. Three hundred and thirteen ROP examinations were performed in 135 of 191 eligible infants. The mean GA and BW were 30.1 weeks (standard deviation (SD) 1.9) and 1 056 g (SD 172), respectively. ROP was diagnosed in 40 infants (29.6%); 8 (5.9%) had severe ROP and 2 (1.5%) received laser treatment. Infants with ROP had a lower mean GA (29.2 weeks (SD 1.6) v. 30.5 weeks (SD 1.9)) (p<0.002) and a lower mean BW (988 g (SD 181) v.1 085 g (SD 160)) (p=0.001) than those without ROP. Infants weighing <1 000 g had a 2.5 times higher risk than those with a BW of &gt;1 000 g of having ROP (95% confidence interval 1.05 - 5.90; p=0.03). Blood transfusions (p<0.002) and late-onset sepsis (p=0.024) were strongly associated with ROP. Screening was completed in 91.1% (123/135) of the infants. CONCLUSIONS. The prevalence and severity of ROP have increased at GSH. The strong association between ROP, BW and GA suggests that infants with lower BWs and GAs should be prioritised for screening in our resource-limited setting. <![CDATA[<b>Characteristics and outcome of long-stay patients in a paediatric intensive care unit in Cape Town, South Africa</b>]]> BACKGROUND. Paediatric intensive care is a costly, specialised and limited resource in low- and middle-income countries. The implications of extended paediatric intensive care unit (PICU) stay in South Africa (SA) are not known. OBJECTIVES. To describe the characteristics, outcomes and resource consumption of long-stay patients (LSPs) and to identify predictive factors for long PICU stay. METHODS. A retrospective review of routinely collected data on all children admitted to an SA PICU over one calendar year. Long PICU stay was defined statistically as &gt;19 days. Long- and short-stay patient (SSP) groups were compared, and variables significantly associated with long stay on univariate analysis were entered into a stepwise multiple regression model. RESULTS. Over the study period,1126 children (median age 8 months, 60.9% male) were admitted to the PICU, occupying 5 936 bed-days; 54 LSPs (4.8%) utilised 1 807 (30.4%) bed-days. Mortality and the standardised mortality ratio (actual/mean predicted mortality) in LSPs and SSPs were 29.6% v.12% (p = 0.002) and 2.4 v. 0.7 (p=0.002), respectively. Median duration of stay for LSPs and SSPs was 29.5 days and 2 days, respectively (p<0.0001). LSPs were younger than SSPs (median 4 months (interquartile range 2 - 17) v. 9 months (2 - 34); p=0.03), and fewer were male (48% v. 61.6%, p=0.049). On multivariate analysis, only female gender was independently associated with long PICU stay. Conclusions. LSPs represent a small proportion of PICU admissions, yet have a higher mortality rate than SSPs and consume disproportionate PICU resources. No predictive model could be established for early recognition of potential LSPs to plan PICU bed allocation effectively. <![CDATA[<b>Supernumerary registrar experience at the University of Cape Town, South Africa</b>]]> BACKGROUND. Despite supernumerary registrars (SNRs) being hosted in South African (SA) training programmes, there are no reports of their experience. OBJECTIVES. To evaluate the experience of SNRs at the University of Cape Town, SA, and the experience of SNRs from the perspective of SA registrars (SARs). METHODS. SNRs and SARs completed an online survey in 2012. RESULTS. Seventy-three registrars responded; 42 were SARs and 31 were SNRs. Of the SNRs 47.8% were self-funded, 17.4% were funded through private organisations, and 34.8% were funded by governments. Average annual income was ZAR102 349 (range ZAR680 -460 000). Funding was considered insufficient by 61.0%. Eighty-seven percent intended to return to their home countries. Personal sacrifices were deemed worthwhile from academic (81.8%) and social (54.5%) perspectives, but not financially (33.3%). Only a small majority were satisfied with the orientation provided and with assimilation into their departments. Almost half experienced challenges relating to cultural and social integration. Almost all SARs supported having SNRs. SNRs reported xenophobia from patients (23.8%) and colleagues (47.8%), and felt disadvantaged in terms of learning opportunities, academic support and on-call allocations. CONCLUSIONS. SNRs are fee-paying students and should enjoy academic and teaching support equal to that received by SARs. Both the university and the teaching hospitals must take steps to improve the integration of SNRs and ensure that they receive equal access to academic support and clinical teaching, and also need to take an interest in their financial wellbeing. Of particular concern are perceptions of xenophobia from SA medical colleagues. <![CDATA[<b>A novel FKRP-related muscular dystrophy founder mutation in South African Afrikaner patients with a phenotype suggestive of a dystrophinopathy</b>]]> BACKGROUND. Fukutin-related protein (FKRP) muscular dystrophy is an autosomal recessive disorder caused by mutations in the FKRP gene. The condition is often misdiagnosed as a dystrophinopathy. A previously unreported mutation, c.1100T>C in exon 4 of FKRP, had been identified in homozygous form in two white South African (SA) Afrikaner patients clinically diagnosed with a dystrophinopathy. Objectives. To investigate whether the c.1100T>C mutation and the common European FKRP mutation c.826C>A are present in other patients of Afrikaner origin with suspected dystrophinopathy, and whether a founder haplotype exists. METHODS. The c.1100T>C mutation was initially tested for using an amplification refractory mutation system technique in 45 white SA Afrikaner patients who had tested negative using multiplex ligation probe amplification screening for exonic deletions/duplications in the dystrophin gene. Sequencing analysis was used to confirm the c.1100T>C mutation and screen for the c.826C>A mutation. Two cohorts (each numbering 100) of Afrikaans and other white controls were screened for the c.1100T>C and c.826C>A mutations, respectively. RESULTS. Of the 45 patients, 8 patients (17.8%) were homozygous for c.1100T>C, 2 (4.4%) were compound heterozygotes for c.1100T>C and c.826C>A, and 1(2.2%) was heterozygous for c.1100T>C with a second unidentified mutation. The c.1100T>C mutation was found in 1/100 controls, but no heterozygotes for the c.826C>A mutation were identified. Linked marker analysis for c.1100T>C showed a common haplotype, suggesting a probable founder mutation in the SA Afrikaner population. CONCLUSION. FKRP mutations may be relatively common in Afrikaners, and screening should be considered in patients who have a suggestive phenotype and test negative for a dystrophinopathy. This test will be useful for offering diagnostic, carrier and prenatal testing for affected individuals and their families. As FKRP muscular dystrophy is autosomal recessive in inheritance, the implications of a positive diagnosis in a family differ significantly from those of an X-linked dystrophinopathy. <![CDATA[<b>Primary cutaneous malignancies in the Northern Cape Province of South Africa: A retrospective histopathological review</b>]]> BACKGROUND. Excessive sun exposure and a high prevalence of HIV increase skin cancer risk in South Africa (SA). OBJECTIVE. To describe the nature and extent of skin cancers presenting in the public and private health sectors of the Northern Cape Province of SA. METHODS. A retrospective analysis of histologically confirmed new primary cutaneous malignancies from 1 January 2008 to 31 December 2012 was conducted using public and private health sector databases. Types, quantity and distribution of common invasive malignancies by population group, age, gender, anatomical site and health sector were explored. One-year cumulative incidence was calculated and logistic regression models were used to analyse incidence and melanoma thickness trends. RESULTS. A total of 4 270 biopsies (13 cutaneous malignancies) were identified. The commonest was squamous cell carcinoma (SCC), followed by basal cell carcinoma, Kaposi's sarcoma (KS), cutaneous malignant melanoma (CMM) and basosquamous carcinoma, in descending order. The odds of a white male developing SCC increased by 8% each year (odds ratio (OR) 1.08, 95% confidence interval (CI) 1.01-1.15; p=0.022), while the odds of a black male developing SCC and KS decreased by 9% (OR 0.91,95% CI 0.84 - 0.99; p=0.033) and 18% (OR 0.82, 95% CI 0.70 - 0.97; p=0.022), respectively, each year. SCC and CMM were diagnosed at more advanced stages in the public than in the private healthcare sector. CMM is being detected earlier, as indicated by low-stage depth increasing by 72% annually (OR 1.72, 95% CI 1.04 - 3.01; p=0.042). CONCLUSIONS. Results suggest that reported skin cancer patterns are changing. There is a need for further research and equitable appropriation of financial resources and effort towards developing primary skin cancer prevention initiatives in SA.