Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420120010&lang=pt vol. 102 num. 10 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The self-destructing private sector is no less a blot on our health system than the crumbling public health system</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Getting back to where it all started -the patient</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>SAMJ gets new Editor-in-Chief</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Some South African universities provide good specialist otorhinolaryngology training</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Thieves of the state - a response</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Intimate partner violence</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Private healthcare 'lost line in the sand' - Zokufa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000007&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Most SA sunblock products 'can't take the heat, tests show</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000008&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>ANC 'lost the plot' on healthcare policy - union leader</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000009&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Mandatory cover? 'Yes, but not now' - Zokufa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000010&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>OBITUARIES</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000011&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Plague, Pox and Pandemics</b>: <b>a Jacana Pocket History of Epidemics in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000012&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Poor maternal outcomes</b>: <b>a factor of poor professional systems design</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000013&lng=pt&nrm=iso&tlng=pt South Africa is struggling to improve maternal and perinatal outcomes, resulting in failure to achieve the Millennium Goal for maternal health. Staff attitudes and skills have been identified as a factor affecting deaths and adverse outcomes in mothers. Huge training efforts are required from health departments to ensure that staff have the required skills to provide the services. The integrated approach to training of nurse professionals, which includes midwifery as a part of undergraduate training, has a devastating effect on the quality of midwifery. Training of midwifery is unfocused and forced upon those who have no interest in improving maternal outcomes. Maternal care is provided in professional silos by professionals who are not equipped with appropriate skills. Unless this systems design error is corrected, and a single-output training model introduced to professionals providing maternal care, we are unlikely to see a a major change in our maternal outcomes. New models based on inter-professional training and task sharing need to be developed for the country, including redefining of professional accountability for maternal care. <![CDATA[<b>Addressing poor maternal and perinatal outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000014&lng=pt&nrm=iso&tlng=pt South Africa is struggling to improve maternal and perinatal outcomes, resulting in failure to achieve the Millennium Goal for maternal health. Staff attitudes and skills have been identified as a factor affecting deaths and adverse outcomes in mothers. Huge training efforts are required from health departments to ensure that staff have the required skills to provide the services. The integrated approach to training of nurse professionals, which includes midwifery as a part of undergraduate training, has a devastating effect on the quality of midwifery. Training of midwifery is unfocused and forced upon those who have no interest in improving maternal outcomes. Maternal care is provided in professional silos by professionals who are not equipped with appropriate skills. Unless this systems design error is corrected, and a single-output training model introduced to professionals providing maternal care, we are unlikely to see a a major change in our maternal outcomes. New models based on inter-professional training and task sharing need to be developed for the country, including redefining of professional accountability for maternal care. <![CDATA[<b>Unforeseen ethical/legal complications with screening tests in the capitation model of medical aid schemes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000015&lng=pt&nrm=iso&tlng=pt In the South African health care system patients/consumers are divided into those who can afford private care and those who rely on state medical assistance. The system is under pressure to fund delivery of medical care to its beneficiaries. We consider the effects of different funding models on medicolegal liability of health professionals serving the private sector. Medical reasons should determine the service rendered. However, financial implications of services rendered and defensive practice of medicine also contribute to treatment received by a patient and its remuneration. Practitioners who commit to delivering a predetermined set of services within a particular time for a predetermined 'lump sum' are only paid for the service specifically requested. Should disease be found other than those contracted for, we argue that inaction with regard to that disease would be deemed to be negligent or unethical according to legal and ethical considerations. <![CDATA[<b>Blood-brain barrier integrity in a zolpidem-responder patient</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000016&lng=pt&nrm=iso&tlng=pt A 27-year-old neurologically disabled but fully conscious male zolpidem-responder patient was investigated for blood-brain barrier (BBB) dysfunction 5 years after a traumatic brain injury. A baseline single-photon emission computed tomography (SPECT) technetium-99m-labelled hexamethylpropylene amine oxime (99mTcHMPAO) brain scan was performed and the patient was administered 10 mg zolpidem daily. The patient was rescanned 2 weeks later when 99mTcHMPAO was injected 1 hour after zolpidem application. SPECT technetium-99m-labelled diethylene-triamine-pentacetic acid (99mTcDTPA) BBB scans were also performed before and after zolpidem treatment. There was decreased uptake of 99mTcHMPAO in the left frontoparietal brain region, left temporal region and left thalamus on baseline scanning; this improved within 1 hour after Zolpidem treatment at the follow-up scan. The 99mTcDTPA scan remained within normal limits before and after Zolpidem treatment. The patient's neurological disabilities, especially coordination, speech and gait, improved markedly. The Barthel index remained normal, but the Tinetti falls efficacy scale improved from 21/100 to 15/100. The results implied that the underlying cause for the patient's long-term neurological disability and brain suppression was not due to a long-term dysfunctional BBB. <![CDATA[<b>Sexuality, disability and human rights</b>: <b>Strengthening healthcare for disabled people</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000017&lng=pt&nrm=iso&tlng=pt A 27-year-old neurologically disabled but fully conscious male zolpidem-responder patient was investigated for blood-brain barrier (BBB) dysfunction 5 years after a traumatic brain injury. A baseline single-photon emission computed tomography (SPECT) technetium-99m-labelled hexamethylpropylene amine oxime (99mTcHMPAO) brain scan was performed and the patient was administered 10 mg zolpidem daily. The patient was rescanned 2 weeks later when 99mTcHMPAO was injected 1 hour after zolpidem application. SPECT technetium-99m-labelled diethylene-triamine-pentacetic acid (99mTcDTPA) BBB scans were also performed before and after zolpidem treatment. There was decreased uptake of 99mTcHMPAO in the left frontoparietal brain region, left temporal region and left thalamus on baseline scanning; this improved within 1 hour after Zolpidem treatment at the follow-up scan. The 99mTcDTPA scan remained within normal limits before and after Zolpidem treatment. The patient's neurological disabilities, especially coordination, speech and gait, improved markedly. The Barthel index remained normal, but the Tinetti falls efficacy scale improved from 21/100 to 15/100. The results implied that the underlying cause for the patient's long-term neurological disability and brain suppression was not due to a long-term dysfunctional BBB. <![CDATA[<b>Introducing a national health insurance system in South Africa</b>: <b>a general practitioner's bottom-up approach to costing</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000018&lng=pt&nrm=iso&tlng=pt BACKGROUND: The introduction of national health insurance (NHI) is an important debate in South Africa, with affordability and institutional capacity being the key issues. NHI costing has been dominated by estimates of exorbitant cost. However, capitation is not only a different payment system but also a different service delivery model, and as a result there are opportunities for risk management and efficiencies. OBJECTIVE: This study explores how private general practitioners (GPs) may choose to embrace these service delivery concepts and deal with the cost implications to meet NHI requirements. METHODS: Data were collected from 598 solo private GPs through a self-administered online questionnaire survey across South Africa. RESULTS: In spite of poor engagement with the public sector, and some challenges in costing and organisation, GPs appear to have an affordable and pro-active response to NHI capitation costing and fee setting. On average, they would accept a minimum global fee of R4.03 million to look after a population of 10 000 people for personal healthcare services. CONCLUSION: At a total cost to the country of R16.9 billion, government could affordably use GPs to develop the primary healthcare part of NHI to cover the entire South African uninsured population. It is anticipated that a similar approach would be successful in other developing countries. <![CDATA[<b>Challenges with using estimates when calculating ART need among adults in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000019&lng=pt&nrm=iso&tlng=pt BACKGROUND: The Foundation for Professional Development (FPD) collects information annually on HIV/AIDS service provision and estimates service needs in the City of Tshwane MetropolitanMunicipality (CTMM). METHODS: Antiretroviral therapy (ART) data from the Department of Health and Statistics South Africa (SSA) mid-year population estimates were used to approximate the ART need among adults in the CTMM. RESULTS: According to SSA data, ART need decreased dramatically from 2010 to 2011 and was lower than the number of adults receiving ART. Although the noted difference was probably due to changes in the calculations by SSA, no detailed or confirmed explanation could be offered. CONCLUSIONS: We provide a constructive contribution to the discussion regarding the use of model-derived estimates of ART need. <![CDATA[<b>Reasons why patients with primary health care problems access a secondary hospital emergency centre</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000020&lng=pt&nrm=iso&tlng=pt BACKGROUND: Many patients present to an emergency centre (EC) with problems that could be managed at primary healthcare (PHC) level. This has been noted at George Provincial Hospital in the Western Cape province of South Africa. AIM: In order to improve service delivery, we aimed to determine the patient-specific reasons for accessing the hospital EC with PHC problems. METHODS: A descriptive study using a validated questionnaire to determine reasons for accessing the EC was conducted among 277 patients who were triaged as green (routine care), using the South African Triage Score. The duration of the complaint, referral source and appropriateness of referral were recorded. RESULTS: Of the cases 88.2% were self-referred and 30.2% had complaints persisting for more than a month. Only 4.7% of self-referred green cases were appropriate for the EC. The three most common reasons for attending the EC were that the clinic medicine was not helping (27.5%), a perception that the treatment at the hospital is superior (23.7%), and that there was no PHC service after-hours (22%). CONCLUSIONS: Increased acceptability of the PHC services is needed. The current triage system must be adapted to allow channelling of PHC patients to the appropriate level of care. Strict referral guidelines are needed. <![CDATA[<b>Tuberculosis in an inflammatory bowel disease cohort from South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000021&lng=pt&nrm=iso&tlng=pt BACKGROUND: Potent immunosuppressive therapy is standard treatment for inflammatory bowel disease (IBD) but carries a risk of reactivating latent tuberculosis (TB). No data exist on the burden of TB in South African patients with IBD. OBJECTIVE: To evaluate the burden of TB in IBD patients attending a large tertiary IBD clinic. METHODS: Data pertaining to patients attending the Groote Schuur Hospital IBD clinic were retrospectively analysed. Data were extracted from an existing IBD database, patient notes, the National Health Laboratory Services database and chest X-ray analysis. RESULTS: Of 614 patients, 72 (11.7%) were diagnosed with TB; 40 (55.6%) developed TB prior to the diagnosis of IBD. On regression analysis, coloured IBD patients were at increased risk for TB development (p=0.004, odds ratio (OR) 3.57, 95% confidence interval (CI) 1.49 - 8.56), as were patients with extensive Crohn's disease (CD) compared with those with less extensive disease (p=0.001, OR 2.84, 95% CI 1.27 - 6.33). No other risk factors, including the use of immunosuppressive agents, were identified for the development of TB. CONCLUSIONS: Of over 600 patients, 12% had TB either before or after IBD diagnosis. The high rate of previous TB and positive association with ethnicity probably reflect the high burden of TB in a socio-economically disadvantaged community. We recommend that IBD patients should be screened actively and monitored for TB when immunosuppressive medications are used. <![CDATA[<b>Implementation of Xpert MTB/RIF for routine point-of-care diagnosis of tuberculosis at the primary care level</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000022&lng=pt&nrm=iso&tlng=pt Xpert MTB/RIF (Xpert) offers rapid detection of Mycobacterium tuberculosis and rifampicin resistance. However, little is known about routine point-of-care (POC) use in high TB/HIV burden settings. We describe our experiences of launching Xpert as the POC, initial diagnostic for all TB suspects at a primary healthcare clinic in Johannesburg, South Africa. Noted important benefits of POC Xpert were fewer clinic visits, rapid detection of TB and rifampicin resistance, real-time assessment of accompanying household members of new TB cases, and increased staff motivation for TB screening. While Xpert results are available within 2 hours, actual turnaround time was longer for most patients because of sample preparation time and clinic congestion. Consequently, a GX4 instrument did not result in a 16-test capacity during an 8-hour working day, and some patients did not receive same-day results. Loss to follow-up was an unforeseen challenge, overcome by clinic flow changes, marking of clinic files, documenting patients' physical description and locating patients in the clinic by cell phone. Staff with high school education successfully performed the assay after minimal training. Human resource requirements were considerable, with a minimum of 2 staff needed to supervise sputum collection, process sputum, perform assays, and document results for an average of 15 TB suspects daily. POC placement of the instrument transferred logistical responsibilities to the clinic, including quality assurance, maintenance, stock control and cartridge disposal. POC use of Xpert is feasible at the primary healthcare level but must be accompanied by financial, operational and logistical support <![CDATA[<b>Determinants of mortality in Nigerian children with severe anaemia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012001000023&lng=pt&nrm=iso&tlng=pt BACKGROUND: Severe anaemia (haemoglobin concentration <50 g/l) is a major cause of paediatric hospital admissions and deaths in the tropics. OBJECTIVES: To examine the pattern and predictors of mortality among severely anaemic children. METHODS: A prospective cross-sectional study was conducted among children with severe anaemia at the Children's Emergency Room of the University Teaching Hospital, Ado-Ekiti, Nigeria. Sociodemographic characteristics, clinical features, laboratory findings and co-morbidities of the survivors and those who died were compared by logistic regression analysis. RESULTS: Of the 1 735 children admitted, 311 (17.9%) had severe anaemia, with a case-fatality rate of 9.3%. The presence of respiratory distress (95% confidence interval (CI) 2.1 - 3.6, p=0.031); acidosis (95% CI 1.8 - 2.7, p=0.010); coma (95% CI 0.1 - 0.3, p=0.001); hypotension (95% CI 2.0 - 4.2, p=0.020); and bacteraemia (95% CI 3.1 - 3.9; p=0.008) were the significant independent predictors of death with regression analysis. CONCLUSION: Early recognition with prompt and appropriate anticipatory intervention is essential to reduce mortality from severe anaemia.