SAMJ: South African Medical Journal

WSU Medical School - a study in innovation and resilience

Acute infective diarrhoea/gastroenteritis in infants

The fast neutron therapy programme for patients in South Africa should come to an end

Akhenaten, a unique pharaoh

Cataract surgery rates

Electrolyte supplementation drinking and renal failure

A dance of empowerment - lessons for the NHI?

Dismal use of legal safety net for mental health patients

A mental health review board in action

Recommendations pertaining to the use of viral vaccines: lnfluenza 2012

Embolic stroke from common carotid pseudo-aneurysm

Challenging beliefs: memoirs of a career

Lifeblood: how to change the world, one dead mosquito at a time

How times have changed - HIV and AIDS in South Africa in 2011

PHC re-engineering may relieve overburdened tertiary hospitals in South Africa

Under the National Health Insurance, a hospital is expected to provide service to patients based on its category. However, in reality the tertiary hospitals offer every level of care, resulting in poor quality of care and over-expenditure. The Polokwane/Mankweng Hospital Complex is a provincial tertiary hospital that delivers tertiary care as well as dealing with some secondary and primary care cases. This study evaluated the hospital casualty department in the Polokwane/Mankweng Hospital Complex. A sample of 250 patients’ records was selected by simple random sampling from a cohort of 14 113 patients who attended the Polokwane Hospital Casualty Department during the 1-year study period. Most patients were admitted in the casualty department as a result of injuries (25%). Only 20% (N=51) of the patients were referred from other health facilities. Half of the patients could have been managed at a regional or district hospital. The overall expenditure for the casualty unit during the 1-year study period was R10 321 401.42 and the combined unit cost was estimated at R731.34 per single emergency care patient excluding the capital costs. Referral systems must be strengthened to manage patients at regional and district level to reduce the burden on the Polokwane/ Mankweng Hospital Complex. It is hoped that the Primary Health Care (PHC) Re-engineering Policy will address this by strengthening the referral system in PHC facilities.

Progress of preventing mother-to-child transmission of HIV at primary healthcare facilities and district hospitals in three South African provinces

Improving national prevention of mother-to-child transmission (PMTCT) services in South Africa has been challenging. PMTCT outcomes were analysed at 58 primary- and secondary-level antenatal facilities across seven high HIV burden sub-districts in three provinces, over an 18-month period during which new South African PMTCT clinical guidelines were implemented and a nurse quality mentor programme was expanded. Early infant HIV DNA polymerase chain reaction test positivity reduced by 75.2% from 9.7% (95% confidence interval (CI) 8.1 - 11.5%) to 2.4% (95% CI 1.9 - 3.1%) (p<0.0005). HIV test positivity at 18 months of age decreased by 64.5% from 10.7% (95% CI 7.2 - 15.1%) to 3.8% (95% CI 2.4 - 5.6%) (p<0.0005). PMTCT outcomes have improved substantially at these facilities.

DVT prophylaxis in relation to patient risk profiling - the TUNE-IN study

BACKGROUND: Patients in acute hospital care show a high risk for venous thromboembolism (VTE); 52% of patients globally are at risk, with approximately only half receiving appropriate prophylaxis. OBJECTIVES: The TUNE-IN study's primary objective was to evaluate the use of VTE prophylaxis in the private sector in South Africa in hospitalised patients in relation to patient risk profile, via both a clinical assessment and utilising a modified risk assessment model (RAM). The secondary objective was to evaluate the relationship between prophylaxis and the level of mobility at discharge as well as on days 3, 7 and 14 post discharge. RESULTS: Of the 608 patients enrolled, 54.1% were evaluated to be at risk for VTE clinically whilst, with RAM assessment, 74.6% were assessed at risk. Adequate prophylaxis was given to only 70.9% of all patients. CONCLUSION: Data appear to correlate with global findings (ENDORSE study): more than 50% of hospitalised patients are at risk for VTE. Clinical risk assessment does not correlate with RAM utilisation, resulting in possible over-diagnosis of VTE risk in lowand moderate-risk patients, with the converse happening in highand highest-risk patients. Certain risk groups are easily defined for VTE risk (e.g. major orthopaedic surgery), but individual risk assessment is crucial as it often reveals underlying and overlooked risk factors, with BMI and age the most frequently overlooked risk factors.

Sudden and unexpected deaths in an adult population, Cape Town, South Africa, 2001-2005

BACKGROUND: According to the regulations of the National Health Act, all 'sudden and unexpected' deaths in South Africa should be referred to Forensic Pathology Services (FPS) for further investigation. OBJECTIVES: We aimed to determine the final outcomes of forensic postmortem examinations in 'sudden and unexpected' adult deaths referred to Tygerberg FPS between 2001 and 2005. METHODS: The study was a retrospective descriptive study. Demographic and autopsy data from adult cases of 'sudden and unexpected deaths' referred to Tygerberg FPS were collected and analysed. RESULTS: Some 816 adult cases of 'sudden' deaths were studied. The presumed manner of death was natural in 645 (79.0%) cases, unnatural in 99 (12.2%), and undetermined in 72 (8.8%). Diseases of the cardiovascular, respiratory and central nervous systems accounted for the majority of natural deaths. Infectious diseases accounted for most deaths in the youngest age group studied (18 - 29 years); however, ischaemic heart disease was the most prevalent cause of death in the total study population. CONCLUSIONS: This study highlighted the lack of useful preautopsy information and therefore the performance of 'unnecessary' medicolegal autopsies in a resource-limited country. Clinicians could ease the burden by giving useful information when referring cases to FPS. Feedback should be given to family members, especially where the cause of death may have an impact on surviving family members.

Persistent failure of the COIDA system to compensate occupational disease in South Africa

Cases of occupational disease, solvent encephalopathy and occupational asthma are used to exemplify failings of the workers' compensation system in South Africa, that include delays in processing claims, non-response to requests for information, and inadequate assessment of disability. These and other systemic deficiencies in administration of the Compensation for Occupational Injuries and Diseases Act of 1993 (COIDA) reduce access by workers with occupational disease to private medical care, and shift costs to workers and to public sector medical care. Another unintended effect is to promote under-reporting of occupational disease by employers and medical practitioners. Reforms have been tried or proposed over the years, including decentralisation of medical assessment to specialised units, which showed promise but were closed. Improved annual performance reporting by the Compensation Commissioner on the processing of occupational disease claims would promote greater public accountability. Given the perennial failings of the system, a debate on outsourcing or partial privatisation of COIDA's functions is due.

Nurse initiation and maintenance of patients on antiretroviral therapy: are nurses in primary care clinics initiating ART after attending NIMART training?

OBJECTIVES: To determine the percentage of nurses initiating new HIVpositive patients on therapy within 2 months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation. METHODS: A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1 736) of primary care nurses who had attended the NIMART course facilitated by the Foundation for Professional Development (FPD) between October 2010 and 31 March 2011 at primary care clinics in 7 provinces. Outcome measures were the number of nurses initiating ART within 2 months of attending the FPD-facilitated NIMART course. RESULTS: Of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. CONCLUSIONS: Despite numerous challenges, many primary care nurses working in the 7 provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positve patients on ART by 2012.

Text messages as a learning tool for midwives

The use of cell phone text messaging to improve access to continuing healthcare education in under-resourced settings is not well documented. We aimed to assess whether this method of education is acceptable to South African midwives in both the public and private sectors. Essential healthcare lessons from the Maternal Care book of the Perinatal Education Programme (PEP) were delivered via text message to more than 2 500 midwives each week for a period of 6 months. Each message concluded with a link to a website, where additional information about each lesson could be accessed. Results of a survey, conducted with 50 of the message recipients, demonstrated that the text messages were well received by the midwives; the information was widely shared with colleagues and was believed to improve learning and patient care. Lack of access to the Internet, or failure to utilise this facility to obtain additional information, indicated that limitations still exist in internet-based distance education, especially in the public sector. The use of text messaging promises to provide cost-effective learning opportunities, and improve a wide range of clinical services, such as the management of HIV-infected children and adults.

Comparative MIC evaluation of a generic ceftriaxone by broth microdilution on clinically relevant isolates from an academic hospital complex in South Africa

We evaluated the in vitro microbiological efficacy of a generic ceftriaxone product against several clinically significant organisms collected from sterile sites. The minimum inhibitory concentration (MIC) of each was determined simultaneously with the reference and the generic ceftriaxone product. Comparative analysis of MICs between the two products for each isolate was performed using both categorical (interpretive) agreement and essential (actual MIC value) agreement. A total of 260 isolates were tested. Overall, there was categorical agreement of 98.9% and essential agreement of 95.8%. The categorical agreement for all isolates (96.7 - 100%) accorded with international standards, as no very major errors were seen and the major error rate was less than 3%. Of the 90 isolates of E. coli (40), Klebsiella spp. (40) and Salmonella spp. (10), 87.6% had an MIC less than or equal to 0.12 mg/l. The generic ceftriaxone product showed equivalent efficacy by MIC determination to the reference formulation. Ceftriaxone remains a viable and useful antimicrobial agent against a variety of clinically relevant organisms in our setting.

Management guidelines for acute infective diarrhoea/gastroenteritis in infants

BACKGROUND: Acute onset vomiting and diarrhoea is one of the most common illnesses of infancy, and is second only to respiratory illnesses as a cause of childhood deaths worldwide. Existing guidelines for management of diarrhoea are often ignored in public and private practice, possibly because of a perception that the guidelines are too simple, or because of expectations of the need to give 'real' drug therapy to stop diarrhoea. OBJECTIVES: This guideline provides a problem-based approach to the basics of present-day management of acute gastroenteritis, and discusses the evidence for the recommendations. RECOMMENDATIONS: Each episode of diarrhoea must be seen as an opportunity for caregiver education in the prevention of the illness, in the 'what' and 'how' of oral rehydration and re-feeding, and in the recognition of when to seek help. The vast majority of patients recover rapidly, but serious complications do occur and must be recognised and managed correctly. VALIDATION: The guidelines are endorsed by the Paediatric Management Group (PMG) in South Africa. CONCLUSION: The aim of management is to help the child to maintain or regain hydration, and to recover from diarrhoea, with careful attention to adequate oral rehydration and judicious re-feeding.