Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 103 num. 9 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Ensuring equitable access to high quality care</b>: <b>The task of uplifting trauma care in rural and district hospitals</b>]]> <![CDATA[<b>Trauma</b>: <b>South Africa's other epidemic</b>]]> <![CDATA[<b>Starch safety in resuscitation</b>]]> <![CDATA[<b>Poisoning and pesticides</b>]]> <![CDATA[<b>Prediction equations for spirometry in South Africa</b>]]> <![CDATA[<b>Temperature regulation in emergency, surgical and critical care</b>]]> <![CDATA[<b>HIV-prevention studies</b>: <b>Educate smarter, boost women's earning power</b>]]> <![CDATA[<b>Drug stock-outs</b>: <b>Inept supply-chain management and corruption</b>]]> <![CDATA[<b>Doctor shortages</b>: <b>Unpacking the 'Cuban solution'</b>]]> <![CDATA[<b>An inside view</b>: <b>A Cuban trainee's journey</b>]]> <![CDATA[<b>Harold Victor Forbes Jordaan</b>]]> <![CDATA[<b>The dilemma of treating major burns in South Africa</b>]]> The major challenge facing South African burn surgeons is the current and future management of major burns. Survival is greatly dependent on adequate therapeutic measures. Various therapeutic measures can be instituted to overcome the shortage of donor skin, as we describe. Each of these methods has its specific role in the management of major burns. The use of very expensive and highly specialised techniques for individual patients cannot be justified when more accessible and cost-effective methods are available. To serve the greater population of burn victims, every effort should be made to use these available methods rather than channelling scarce financial resources into procedures that have a very limited role in South Africa. <![CDATA[<b>External patient temperature control in emergency centres, trauma centres, intensive care units and operating theatres</b>: <b>A multi-society literature review</b>]]> Here we review the available literature supporting the routine and timely use of external patient warming devices of all possible types during emergency department and peri-operative situations, including the role of best ambient temperature, and provides a best-practice statement on the need for such devices. It aims to present a guideline document endorsed by the major South African professional societies in the field of emergency and peri-operative care. <![CDATA[<b>'We don't see that in South Africa'</b>]]> Here we review the available literature supporting the routine and timely use of external patient warming devices of all possible types during emergency department and peri-operative situations, including the role of best ambient temperature, and provides a best-practice statement on the need for such devices. It aims to present a guideline document endorsed by the major South African professional societies in the field of emergency and peri-operative care. <![CDATA[<b>Traumatic brain injury</b>: <b>The South African landscape</b>]]> Here we review the available literature supporting the routine and timely use of external patient warming devices of all possible types during emergency department and peri-operative situations, including the role of best ambient temperature, and provides a best-practice statement on the need for such devices. It aims to present a guideline document endorsed by the major South African professional societies in the field of emergency and peri-operative care. <![CDATA[<b>The promotion of road safety by healthcare professionals in South Africa</b>]]> Here we review the available literature supporting the routine and timely use of external patient warming devices of all possible types during emergency department and peri-operative situations, including the role of best ambient temperature, and provides a best-practice statement on the need for such devices. It aims to present a guideline document endorsed by the major South African professional societies in the field of emergency and peri-operative care. <![CDATA[<b>Demographic profile of severe traumatic brain injury admissions to Red Cross War Memorial Children's Hospital, 2006 - 2011</b>]]> BACKGROUND: Paediatric traumatic brain injury (PTBI) is a major public health problem. However, recent epidemiological data for PTBI in South Africa (SA) are lacking. OBJECTIVES: To establish a demographic profile of severe PTBI admissions to the Red Cross War Memorial Children's Hospital (RCWMCH) over a 5-year period, by investigating trends in annual admissions, age, sex, language, time and day of injury, and aetiology. METHODS: This retrospective, descriptive, quantitative study included children admitted to the RCWMCH with severe traumatic brain injury (TBI) between June 2006 and April 2011, who required intracranial monitoring. We used the Division of Paediatric Neurosurgery's TBI database to identify cases for inclusion in the study and to gather demographic and injury information. RESULTS: Descriptive statistics suggested that: (i) the number of annual admissions did not vary substantially across the study period; (ii) the peak admission age was 6 years; (iii) more boys than girls were admitted; (iv) the major mechanism of injury was pedestrian road traffic accidents; and (v) most injuries occurred on weekends. These results are discussed against the backdrop of international research on PTBI and reflect the extent to which epidemiological findings on TBI in high-income countries compare with those from low- and middle-income countries such as SA. CONCLUSION: The identification of aetiological factors and the description of demographic profiles of children sustaining TBI constitutes a basis for preventative policy administration and intervention strategies in SA. <![CDATA[<b>The effect of traffic calming on pedestrian injuries and motor vehicle collisions in two areas of the eThekwini Municipality</b>: <b>A before-and-after study</b>]]> BACKGROUND: Motor vehicle collisions and pedestrian injuries in areas where schools are located are public health problems in Durban. OBJECTIVE: To evaluate the effect of traffic calming humps on the number and severity of incidences of collisions and injuries in the Chatsworth and KwaMashu residential areas of the eThekwini Municipality. METHODS: The evaluation used an observational interrupted time-series study design, with data obtained from the eThekwini Traffic Authority for roads constituting the routes to 34 schools for 2 years prior to and following the implementation of road humps (excluding the intervening year of implementation). A non-probability convenience sample of 19 schools with 39 roads in Chatsworth and 15 schools with 24 roads in KwaMashu was selected. RESULTS: The traffic calming humps improved safety in both areas with respect to the severity of collisions. Serious pedestrian-vehicle collisions (PVCs) dropped by 23% and 22%, while fatal collisions decreased by 68% and 50% in Chatsworth and KwaMashu, respectively. The median annual PVC rate/km of road/year decreased from 1.41 to 0.96 (p=0.007) and from 2.35 to 1.40 (p<0.001) in Chatsworth and KwaMashu, respectively. There was a 1.6% reduction in the median number of fatal or serious PVCs after implementation in Chatsworth (p=0.03) while in KwaMashu, although the number of collisions decreased, the median number increased by 9% (p=0.07). CONCLUSIONS: Traffic calming has been shown to be effective in reducing the number of PVCs but needs to be supported by additional measures to further improve the safety of pedestrians. <![CDATA[<b>Laboratory tests for malaria</b>: <b>A diagnostic conundrum?</b>]]> OBJECTIVES: To detect malarial parasites using the peripheral blood smear (PBS) and to compare the PBS with the immunochromatographic antigen test (i.e. OptiMAL and polymerase chain reaction (PCR)). METHODS: Six ml of blood was collected from each of 170 patients clinically suspected of having malaria. These samples were used to perform PBS examination, the OptiMAL test and PCR by standard protocol. RESULTS: PBS examination found malarial parasites in 86 (50.6%) samples. In comparison, 71 (41.8%) samples were positive by OptiMAL test whereas PCR could detect malarial parasites in only 44 (25.9%) samples. All 84 (49.4%) samples which were negative by PBS were negative by both OptiMAL and PCR. The sensitivity and specificity were respectively 85.54% and 100% for OptiMAL and 51.12% and 100% for PCR. CONCLUSION: Depending on the tests' operational feasibility, and the availability of adequate trained personnel, equipment and laboratory management systems, and considering its sensitivity and cost-effectiveness, peripheral blood smear remains the test of choice for malaria, especially in endemic areas. <![CDATA[<b>Patterns of seatbelt use in different socioeconomic communities in the Cape Town Metropole, South Africa</b>]]> BACKGROUND: Road traffic injuries are a leading cause of death and may be related to social inequality. OBJECTIVE: To establish whether patterns of seatbelt use vary between different socioeconomic communities in the Cape Town Metropole, South Africa. METHODS: Vehicles and their occupants at 7 high-volume crossings (3 in high-income areas) were placed under surveillance for 2 hours each during November 2010. All occupants were eligible for inclusion except occupants of non-motorised vehicles, two-wheel motorised vehicles, buses, taxis, heavy goods vehicles and emergency vehicles. Child seatbelt use was recorded only for children who appeared older than 3 years. RESULTS: A total of 4 651 vehicles with 6 848 occupants were surveyed. Rates of seatbelt use were 45.1% (n=3 090) for all occupants, 54.0% (n=2 513) for drivers, 33.1% (n=521) for front-seat passengers (adults 33.2%, n=452; children 32.7%, n=69) and 9.0% (n=56) for rear-seat passengers (adults 4.0%, n=13; children 14.4%, n=43). Occupants from high-income areas were more likely to wear seatbelts (odds ratio (OR) 4.35; 95% confidence interval (CI) 3.89 - 4.88). Use of child restraints was poor overall (22.3%, n=114), but also varied according to income areas (high income 40.9%, n=99; low income 0.03%, n=6; OR 26.77; 95% CI 11.44 - 62.63). DISCUSSION: The impact of road traffic injuries is significant, but can be decreased by using appropriate restraining devices. Seatbelt use in South Africa, although compulsory, is neither strictly adhered to nor enforced. Their use is proportionally lower in lower-income areas. Specific interventions are required to target these communities directly. <![CDATA[<b>Paramedic rapid sequence induction (RSI) in a South African emergency medical service: A retrospective observational study</b>]]> BACKGROUND: Early access to critical care interventions may improve outcomes for severely ill and injured patients. South Africa (SA) faces the unique challenges of prolonged pre-hospital times and limited access to physicians. In 2008, the Health Professions Council of SA introduced paramedic rapid sequence induction (RSI), the gold standard critical care intervention for emergency airway management; however, the risk to benefit ratio in this context is unclear. OBJECTIVE: We conducted a pilot study to identify if paramedic RSI in the SA pre-hospital care setting is effective and safe. METHODS: We undertook a retrospective observational study of paramedic RSI performed by an emergency medical service, between 12 December 2009 and 12 December 2011. RESULTS: Eighty-six RSIs were performed during the study period. No failed intubations were reported. Heart rate was significantly reduced from a median baseline value of 112 to 90 bpm, and oxygen saturations improved from 92% to 99% at handover following RSI. Nineteen patients (22%), however, had an adverse event (AE). Female patients (odds ratio (OR) 18.3; 95% confidence interval (CI) 3.46 - 99.38; p=0.001) and patients subsequently transported by helicopter (OR 7.24; 95% CI 1.44 - 36.32; p=0.016) remained independently associated with AEs after adjusting for confounders. CONCLUSIONS: RSI performed by specially trained paramedics is effective in terms of self-reported success. However, the 1 in 5 AE rate highlights safety concerns. The importance of a robust clinical governance programme to identify problems, refine practice and improve the quality of care is underscored. <![CDATA[<b>Accuracy of after-hour 'red dot' trauma radiograph triage by radiographers in a South African regional hospital</b>]]> BACKGROUND: The global demand for diagnostic imaging exceeds the supply of radiologists and is of particular significance in poorly resourced healthcare environments where many radiographs are unreported. Delayed or absent reporting may negatively impact patient management. In well-resourced countries there is recognition that extending the role of radiographers to radiological reporting tasks helps meet service demands. AIM: To determine the accuracy of acute fracture detection by South African radiographers working in an after-hour setting. METHOD: We performed a retrospective study of radiographers at a Western Cape Regional Hospital over 2 months in 2011. The sensitivity and specificity of radiographers' fracture detection were compared with that of a consultant radiologist. Differences were evaluated using the McNemar chi-squared test, with p<0.05 regarded as significant. RESULTS: A total of 369 radiographs were analysed. The overall accuracy of reporting by radiographers was 93.7%, with 74.4% sensitivity for fracture detection. Experienced radiographers performed better than inexperienced radiographers; adult fractures were more consistently identified than paediatric fractures, and appendicular fractures were better visualised than axial fractures. In all instances there was a significant difference between fracture detection by radiographers and the radiologist. Experienced radiographers evaluating appendicular fractures in adults achieved the highest sensitivity (89.9%), which was not significantly different from that of a consultant radiologist (p=0.88). CONCLUSION: The performance of experienced radiographers in our study is comparable with that of experienced radiographers internationally, who have no specific training in trauma radiograph reporting. However, additional training is required if role extension is to be considered. <![CDATA[<b>Endotracheal tube cuff pressures - the worrying reality: A comparative audit of intra-operative versus emergency intubations</b>]]> OBJECTIVES: The primary aim was to assess the need for objective cuff pressure monitoring in the theatre complex and trauma centre at Groote Schuur Hospital, Cape Town, South Africa. Secondary aims were to determine whether the tube size, tube make or place of intubation affected cuff pressure. METHOD: Endotracheal tube cuff pressures of 91 patients in the trauma centre and 100 patients in the theatre complex were randomly measured using a Mallinckrodt cuff pressure gauge. The measurements were recorded on a standardised data sheet and transferred to an electronic database for analysis. RESULTS: There was a significant difference between cuff pressures in the trauma centre and those in the theatre complex (p<0.001), the means being 55 cmH2O and 25 cmH2O, respectively. The site of intubation had a significant (p=0.001) effect on cuff pressures, with mean pressures as follows: on scene - 71 cmH2O; referral hospital - 57 cmH2O; and Groote Schuur trauma centre - 42 cmH2O. Only 30% of cuff pressures measured in the trauma centre were below 30 cmH2O, and, alarmingly, 17% were between 91 and 120 cmH2O. In the theatre complex, 77% of cuff pressures were in the acceptable range. Digital balloon palpation corresponded poorly (correlation coefficient 0.47) with measured cuff pressure, and statistical analysis showed that it tended to underestimate the pressure at higher cuff pressures. CONCLUSION: The risk of a high cuff pressure is roughly two- to threefold higher in emergency patients than in theatre patients. These unacceptably high cuff pressures are especially concerning in view of the fact that many trauma patients are hypotensive and therefore more susceptible to mucosal ischaemia. <![CDATA[<b>Outcomes following prehospital airway management in severe traumatic brain injury</b>]]> BACKGOUND: Prevention of hypoxia and thus secondary brain injury in traumatic brain injury (TBI) is critical. However there is controversy regarding the role of endotracheal intubation in the prehospital management of TBI. OBJECTIVE: To describe the outcome of TBI with various airway management methods employed in the prehospital setting in the Cape Town Metropole. METHODS: The study was a cohort descriptive observational analysis of 124 consecutively injured adult patients who were admitted for severe TBI (Glasgow Coma Score <8) to Groote Schuur and Tygerberg hospitals between 1 January 2009 and 31 August 2011. Patients were categorised by their method of airway management: rapid sequence intubation (RSI), sedation-assisted intubation, failed intubation, basic airway management, and intubated without drugs. Good outcomes were defined by a Glasgow Outcome Score of 4 - 5. RESULTS: There was a statistically significant association between airway management and outcome (p=0.013). Patients who underwent basic airway management had a higher proportion of a good outcome (72.9%) than patients who were intubated in the prehospital setting. A good outcome was observed with 61.8% and 38.4% of patients who experienced sedation-assisted intubation and RSI, respectively. Patients intubated without drugs had the poorest outcome (88%), followed by rapid sequence intubation (61.5%) and by the sedation assisted group (38.2%). CONCLUSION: Prehospital intubation did not demonstrate improved outcomes over basic airway management in patients with severe TBI. A large prospective, randomised trial is warranted to yield some insight into how these airway interventions influence outcome in severe TBI. <![CDATA[<b>The Kimberley Hospital Rule (KHR) for urgent computed tomography of the brain in a resource-limited environment</b>]]> BACKGROUND: The indications for urgent computed tomography of the brain (CTB) in the acute setting are controversial. While guidelines have been proposed for CTB in well-resourced countries, these are not always appropriate for resource-limited environments. Furthermore, no unifying guideline exists for trauma-related and non-trauma-related acute intracranial pathology. Adoption by resource-limited countries of more conservative scanning protocols, with outcomes comparable to well-resourced countries, would have significant benefit. A multidisciplinary team from Kimberley Hospital in the Northern Cape Province of South Africa adopted the principles defined in the National Institute for Health and Care Excellence (NICE) guideline for the early management of head injury and drafted the Kimberley Hospital Rule (KHR), a proposed unifying guideline for the imaging of acute intracranial pathology in a resource-limited environment. OBJECTIVE: To evaluate the sensitivity and specificity of the KHR. METHODS: A prospective cohort study was conducted in the Northern Cape Province between 1 May 2010 and 30 April 2011. All patients older than 16 years presenting to emergency departments with acute intracranial symptoms were triaged according to the KHR into three groups, as follows: group 1 - immediate scan (within 1 hour); group 2 - urgent scan (within 8 hours); and group 3 - no scan required. Patients in groups 1 and 2 were studied. The primary outcome was CTB findings of clinically significant intracranial pathology requiring acute change in management. RESULTS: Seven hundred and three patients were included. The KHR achieved 90.3% sensitivity and 45.5% specificity, while reducing the number of immediate CTBs by 36.0%. CONCLUSION: The KHR is an accurate, unifying clinical guideline that appears to optimise the utilisation of CTB in a resource-limited environment. <![CDATA[<b>Haemodialysis for post-traumatic acute renal failure - factors predicting outcome</b>]]> BACKGROUND: Post-traumatic acute renal failure requiring renal replacement therapy in an intensive care unit (ICU) is associated with high mortality. OBJECTIVE: To assess indicators of improved survival. METHODS: This was a retrospective cohort study of 64 consecutive trauma patients (penetrating and blunt trauma and burns) who underwent haemodialysis (HD) over a period of 5 years. Information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily ICU records were collected. The majority of the patients were dialysed with continuous venovenous haemofiltration in the early years of the study and later with sustained low-efficiency dialysis. RESULTS: Of the 64 patients 47 died, giving an overall mortality rate of 73%. Mortality was highest in the burns patients (84%). Survival in all patients, irrespective of injury, was unrelated to the Revised Trauma Score, Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score or Trauma Injury Severity Score. The duration of HD did not differ significantly between the three trauma groups, and age was not a significant predictor of survival. Patients who were polyuric at the time of the initiation of HD had a lower mortality rate than those who were oliguric, anuric or normouric, although this did not reach statistical significance (p=0.09). CONCLUSIONS: Acute renal failure in trauma patients is associated with a low survival rate. Controversial conclusions have been presented in the literature. In this study, none of the parameters previously reported to affect survival proved to be valid, although the number of patients was comparable with those in other studies. Since understanding of the predictors and course of renal failure in trauma patients is still at an early stage, there is a need for multicentre prospective studies. <![CDATA[<b>Human fascioliasis in South Africa</b>]]> Human fascioliasis has the widest latitudinal, longitudinal and altitudinal distribution of any vector-borne disease, yet only 3 cases have been reported from South Africa, the last in 1964. We report 2 cases from the same geographic area associated with local consumption of watercress, suggesting an endemic focus. <![CDATA[<b>Heart Failure Society of South Africa (HeFSSA) perspective on the European Society of Cardiology (ESC) 2012 chronic heart failure guideline</b>]]> DISCLAIMER: This guideline does not override the health professional's responsibility to make appropriate decisions according to the circumstances of the patient. It is also the health professional's responsibility to verify the locally approved indications for the drugs and devices mentioned in this guideline. BACKGROUND: The South African Heart Association (SA Heart) is an affiliate of the European Society of Cardiology (ESC). SA Heart endorses ESC treatment guidelines with modification to suit local circumstances. The Heart Failure Society of South Africa (HeFSSA) is a special interest group of SA Heart. This guideline has been compiled on behalf of the HeFSSA and is based on the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. The focus is on heart failure with reduced ejection fraction (HF-REF) (i.e. ejection fraction <50%). We have recommended interventions in symptomatic patients with HF-REF in general to clarify the 'grey area' between the ESC guidelines definition of REF (<50%) and the predefined ejection fraction used in randomised heart failure trials (<35%). OBJECTIVE: To highlight new changes in the diagnosis and treatment of chronic heart failure with particular emphasis on areas that are relevant to SA. CONCLUSIONS: Randomised clinical trials are a crucial, but not the only, guide in treating HF-REF patients. There always remain questions that are unanswered and groups of patients not studied, so prudent clinical decisions are required. <![CDATA[<b>Guideline for the diagnosis and management of multiple sclerosis</b>: <b>A Southern African perspective</b>]]> Before making a diagnosis of multiple sclerosis (MS), it is imperative that alternative diagnoses are considered and excluded. This is particularly important in South Africa, which is a moderate prevalence MS area, has a high burden of neurological infections and where the majority of the people are black - an ethnic group that has a very low frequency of MS. Before applying diagnostic criteria, there should be no better explanation for the patient's presentation. This guideline, written on behalf of the Multiple Sclerosis Society of South Africa, aims to assist in the diagnosis and treatment of MS in Southern Africa. <![CDATA[<b>Guideline for the diagnosis and management of multiple sclerosis in children</b>]]> Paediatric multiple sclerosis (MS) represents a particular MS subgroup with unique diagnostic challenges. Due to the narrow window of environmental exposures and clinical disease expression, children with MS may represent an important study population for gaining a better understanding of the pathogenesis of the disease. The International Paediatric MS Study Group (IPMSSG) was formulated to clarify the diagnostic and therapeutic dilemmas in this population. This guideline was adapted from the International Paediatric Multiple Sclerosis Study Group guideline and endorsed by PANDA, South Africa.