SAMJ: South African Medical Journal

Obituary - Prof. Herman van Coeverden de Groot (1932 - 2022)

Obituary - Peter Ian Folb (1938 - 2022)

Erratum

Melanoma crude incidence rates among white South Africans climbing as in other countries: An urgent call for targeted skin cancer prevention and awareness campaigns

The firearm pandemic: Time to act and flatten the curve

Autoimmune encephalitis

Autoimmune encephalitis: Epidemiology, pathophysiology and clinical spectrum (part 1)

Since the identification of anti-N-methyl-D-aspartate (NMDA) receptor antibodies about 15 years ago, many patients with rapidly progressing psychiatric symptoms, abnormal movements, seizures or unexplained coma have been diagnosed with autoimmune encephalitis (AE). The symptom onset is often unspecific, and might mimic psychiatric disease, but the later course is frequently characterised by severe disease, often requiring intensive care. Clinical and immunological criteria are helpful in identifying the patients, but no biomarkers exist to guide the clinician in therapy or predict outcome. While persons of all ages can be affected by AE, some types of AE affect more children and young adults and are more prevalent in women. This review focuses on encephalitides associated with neuronal cell-surface or synaptic antibodies, which can result in characteristic syndromes, and are often recognisable on clinical grounds. AE subtypes associated with antibodies against extracellular epitopes can occur with or without tumours. Because the antibodies bind and alter the function of the antigen, the effects are often reversible if immunotherapy is initiated, and the prognosis is favourable in most instances. The first part of this series introduces the topic, provides an overview of currently known neuronal surface antibodies and how they present, describes the most common subtype anti-NMDA receptor encephalitis, and discusses the difficulties in recognising patients with underlying AE among patients with new-onset psychiatric disorders.

Should a provincial MEC responsible for health, registered with the Health Professions Council of South Africa, who publicly humiliates a vulnerable undocumented foreigner who has received urgent medical attention for childbirth at an understaffed government hospital, be disciplined for unprofessional conduct?

The Limpopo MEC for Health, during a hospital visit, was recently shown in a video to have humiliated a vulnerable undocumented Zimbabwean woman patient, resulting in the hospital workers present laughing at the unfortunate patient. The patient had arrived at a hospital in the province that was short-staffed and under-resourced because of failings on the part of the Department of Health. She wished to give birth to her child in a safe environment, because the shortage of proper facilities in Zimbabwe posed a threat to her and her unborn child. The conduct of the MEC is measured against the patient's rights under the Constitution of South Africa and the National Health Act 61 of 2003, and her conduct is discussed in the light of the Health Professions Act 56 of 1974 and the Ethical Rules of Conduct of the Health Professions Council of South Africa (HPCSA). The conclusion reached is that the MEC had breached the Constitution, the National Health Act, the Health Professions Act and the Ethical Rules of Conduct of the HPCSA, and should be disciplined by the HPCSA, as required by the Health Professions Act.

Impact of interventions for tuberculosis prevention and care in South Africa - a systematic review of mathematical modelling studies

BACKGROUND: Substantial additional efforts are needed to prevent, find and successfully treat tuberculosis (TB) in South Africa (SA). In the past decade, an increasing body of mathematical modelling research has investigated the population-level impact of TB prevention and care interventions. To date, this evidence has not been assessed in the SA context OBJECTIVE: To systematically review mathematical modelling studies that estimated the impact of interventions towards the World Health Organization's End TB Strategy targets for TB incidence, TB deaths and catastrophic costs due to TB in SA METHODS: We searched the PubMed, Web of Science and Scopus databases for studies that used transmission-dynamic models of TB in SA and reported on at least one of the End TB Strategy targets at population level. We described study populations, type of interventions and their target groups, and estimates of impact and other key findings. For studies of country-level interventions, we estimated average annual percentage declines (AAPDs) in TB incidence and mortality attributable to the intervention RESULTS: We identified 29 studies that met our inclusion criteria, of which 7 modelled TB preventive interventions (vaccination, antiretroviral treatment (ART) for HIV, TB preventive treatment (TPT)), 12 considered interventions along the care cascade for TB (screening/case finding, reducing initial loss to follow-up, diagnostic and treatment interventions), and 10 modelled combinations of preventive and care-cascade interventions. Only one study focused on reducing catastrophic costs due to TB. The highest impact of a single intervention was estimated in studies of TB vaccination, TPT among people living with HIV, and scale-up of ART. For preventive interventions, AAPDs for TB incidence varied between 0.06% and 7.07%, and for care-cascade interventions between 0.05% and 3.27% CONCLUSION: We describe a body of mathematical modelling research with a focus on TB prevention and care in SA. We found higher estimates of impact reported in studies of preventive interventions, highlighting the need to invest in TB prevention in SA. However, study heterogeneity and inconsistent baseline scenarios limit the ability to compare impact estimates between studies. Combinations, rather than single interventions, are likely needed to reach the End TB Strategy targets in SA

Acute kidney injury after major non-cardiac surgery: Incidence and risk factors

BACKGROUND: Acute kidney injury (AKI) is a major post-surgical complication that contributes to morbidity and mortality. AKI is well documented after cardiac surgery. However, less is known regarding the incidence and risk factors following major non-cardiac surgery. Globally the incidence of AKI post major surgery has been evaluated; however, there are no data available for South Africa (SA OBJECTIVES: To ascertain the incidence of AKI after major non-cardiac surgery at a tertiary academic SA hospital. Secondary outcomes were to identify perioperative risk factors that are associated with an elevated risk to develop AKI in the postoperative period METHODS: The study was conducted at Tygerberg Hospital, a single tertiary centre in Cape Town, SA. Perioperative records of adults who underwent major non-cardiac surgery were retrospectively collected. Variables pertaining to potential risk factors for AKI were captured, and serum creatinine levels were recorded up to 7 days postoperatively and compared with baseline measurements to determine whether AKI had developed. Descriptive statistics along with logistic regression analysis were used to interpret results RESULTS: The overall incidence of AKI was 11.2% (95% confidence interval (CI) 9.8 - 12.6). Based on surgical discipline, trauma surgery (19%), followed by abdominal (18.5%) and vascular surgery (17%) had the highest incidence. Independent AKI risk factors were identified after multivariate analysis. These were: chronic obstructive pulmonary disease (odds ratio (OR) 2.19; 95% CI 1.09 - 4.37; p=0.005), trauma surgery (OR 3.00; 95% CI 1.59 - 5.64; p=0.001), abdominal surgery (OR 2.14; 95% CI 1.33 - 3.45; p=0.002), vascular surgery (OR 2.42; 95% CI 1.31 - 4.45; p=0.004), urology procedures (OR 2.45; 95% CI 1.31 - 4.45; p=0.005), red blood cell transfusion (OR 1.81; 95% CI 1.21 - 2.70; p=0.004), emergency surgery (OR 1.74; 95% CI 1.15 - 2.65; p=0.009) and inotrope use (OR 2.77; 95% CI 1.80 - 4.26;p<0.001 CONCLUSION: The results of our study are in keeping with international literature regarding the incidence of AKI after major non-cardiac surgery. The risk factor profile, however, is in several regards different from what has been found elsewhere

SARS-CoV-2 mutations on diagnostic gene targets in the second wave in Zimbabwe: A retrospective genomic analysis

BACKGROUND: SARS-CoV-2 continues to be a major issue in resource-limited settings, particularly owing to the limited supply of vaccines caused by inequitable distribution OBJECTIVE: To monitor diagnostic gene targets to identify potential test failures caused by mutations, which is important for public health METHODS: Here we analysed the genome sequence of SARS-CoV-2 from the second wave in Zimbabwe. A total of 377 samples were sequenced at Quadram Institute Bioscience. After quality control, 192 sequences passed and were analysed RESULTS: The Beta variant was dominant during this period, contributing 77.6% (149) of the genomes sequenced and having a total of 2994 mutations in diagnostic polymerase chain reaction target genes. Many single nucleotide polymorphism mutations resulted in amino acid substitution that had the potential to impact viral fitness by increasing the rate of transmission or evading the immune response to previous infection or vaccination CONCLUSION: There were nine lineages circulating in Zimbabwe during the second wave. The B.1.351 was dominant, accounting for >75%. There were over 3 000 mutations on the diagnostic genes and lineage B.1.351, contributing almost two-thirds of the mutations. The S-gene had the most mutations and the E-gene was the least mutated

Clinical impact of plasma concentrations of first-line antituberculosis drugs

BACKGROUND: The clinical significance of low antituberculosis (anti-TB) drug concentrations has not been fully elucidated OBJECTIVES: To investigate the clinical consequences of first-line drug concentrations in adult patients with drug-susceptible pulmonary TB in South Africa (SA METHOD: We conducted a pharmacokinetic study nested within the control arm of the Improving Treatment Success (IMPRESS) trial (NCT 02114684) in Durban, SA. During the first 2 months of treatment, participants received weight-based dosing of first-line anti-TB drugs (rifampicin, isoniazid, pyrazinamide and ethambutol), and had plasma drug concentrations measured at 2 and 6 hours after drug administration during the 8th week of treatment. Intermediate (8 weeks), end-of-treatment (6 months) and follow-up TB outcomes were assessed using World Health Organization criteria RESULTS: We measured plasma drug concentrations on available samples in 43 participants. Peak drug concentrations were below the therapeutic range in 39/43 (90.7%) for rifampicin, 32/43 (74.4%) for isoniazid, 27/42 (64.3%) for pyrazinamide and 5/41 (12.2%) for ethambutol. At the end of the intensive phase of treatment (week 8), 20.9% (n=9/43) of participants remained culture positive. We did not find a relationship between the concentrations of first-line drugs and treatment outcomes at week 8. All participants were cured at the end of treatment, and there were no relapses during the 12-month follow-up period CONCLUSION: Treatment outcomes were favourable despite low drug concentrations as defined by current reference thresholds