Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 108 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Alcohol harms - the next challenge</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Johan Benjamin Janeke</b>]]> <![CDATA[<b>Christopher John Bretherton Hundleby</b>]]> <![CDATA[<b>Bleeding disorders (part 1)</b>]]> <![CDATA[<b>Inherited bleeding disorders</b>]]> Abnormal bleeding is a common clinical presentation in general practice, and a rational approach to this problem is therefore required. Investigation of a suspected bleeding disorder necessitates a comprehensive history, thorough physical examination and systematic laboratory work-up. Inherited bleeding disorders (IBDs) typically manifest in childhood, but may present later in life after a haemostatic challenge (such as trauma, surgery, tooth extraction). This two-part CME series is intended to provide insight to the medical practitioner on the clinical spectrum, diagnosis and management of bleeding disorders. Bleeding due to inherited disorders is the subject of discussion in part 1 (current issue), and in part 2 (forthcoming issue) the focus is on bleeding from acquired causes. Patients diagnosed with an IBD should ideally be referred to a dedicated tertiary healthcare facility, e.g. haemophilia centre, for management and follow-up. <![CDATA[<b>Nutritional supplements for people being treated for active tuberculosis: A technical summary</b>]]> Tuberculosis and nutrition are intrinsically linked in a complex relationship. Altered metabolism and loss of appetite associated with tuberculosis may result in undernutrition, which in turn may worsen the disease or delay recovery. We highlight an updated Cochrane review assessing the effects of oral nutritional supplements in people with active tuberculosis who are receiving antituberculosis drug therapy. The review authors conducted a comprehensive search (February 2016) for all randomised controlled trials comparing any oral nutritional supplement, given for at least 4 weeks, with no nutritional intervention, placebo or dietary advice only in people receiving antituberculosis treatment. Of the 35 trials (N=8 283 participants) included, seven assessed the provision of free food or high-energy supplements, six assessed multi-micronutrient supplementation, and 21 assessed single- or dual-micronutrient supplementation. There is currently insufficient evidence to indicate whether routinely providing free food or high-energy supplements improves antituberculosis treatment outcomes (i.e. reduced death and increased cure rates at 6 and 12 months), but it probably improves weight gain in some settings. Plasma levels of zinc, vitamin D, vitamin E and selenium probably improve with supplementation, but currently no reliable evidence demonstrates that routine supplementation with multi-, single or dual micronutrients above the recommended daily intake has clinical benefits (i.e. reduced death, increased cure rate at 6 and 12 months, improved nutritional status) in patients receiving antituberculosis treatment. In South Africa, most provinces implement a supplementation protocol based on nutritional assessment and classification of individuals rather than on disease diagnosis or treatment status. <![CDATA[<b>'Covering doctors' standing in for unavailable colleagues: What is the legal position?</b>]]> Covering doctors are those who stand in for colleagues when the latter are unable to deal with their patients. Covering doctors who begin to issue telephonic instructions to nurses or other healthcare practitioners regarding the treatment of the patients they are covering are in the same position as any other doctors treating patients. They cannot argue that the patients they are covering only become their patients once an emergency or crisis occurs or when they see the patients for the first time, and that prior to that their function is merely to monitor the patient's progress. They also cannot rely on telephone instructions for long periods of time when the patient's health may be in danger, without seeing the patient. However, if covering doctors are found to be negligent they can still escape liability if the plaintiff cannot prove a causal link between their negligence and the harm that resulted 'beyond a reasonable doubt'. <![CDATA[<b>A cool ECG</b>]]> The electrocardiographic changes of hypothermia are discussed in this case of a man who was brought to an emergency centre with altered mental status. The main ECG signs are a shivering artefact baseline, J waves, and PR-, QRS- and QT-interval prolongation. <![CDATA[<b>South African clinical practice guidelines: A landscape analysis</b>]]> BACKGROUND: South Africa (SA) is in the process of implementing National Health Insurance (NHI), which will require co-ordination of health provision across sectors and levels of care. Clinical practice guidelines (CPGs) are tools for standardising and implementing care, and are intended to influence clinical decision-making with consequences for patient outcomes, health system costs and resource use. Under NHI, CPGs will be used to guide the provision of healthcare for South Africans. It is therefore important to explore the current landscape of CPG developers and development. OBJECTIVE: To identify and describe all CPGs available in the public domain produced by SA developers for the SA context. METHODS: We conducted a cross-sectional evaluation using a two-part search process: an iterative, electronic search of grey literature and relevant websites (161 websites searched), and a systematic search for peer-reviewed literature (PubMed) after publication year 2000. CPGs were identified, and data were extracted and categorised by two independent reviewers. Any discrepancies were referred to a third reviewer. Data extracted included a description of the developer, condition, and reporting of items associated with CPG quality. RESULTS: A search conducted in May 2017 identified 285 CPGs published after January 2000. Of those, 171 had been developed in the past 5 years. Developers included the national and provincial departments of health (DoH), professional societies and associations, ad hoc collaborations of clinicians, and the Council for Medical Schemes. Topics varied by developer; DoH CPGs focused on high-burden conditions (HIV/AIDS, tuberculosis and malaria), and other developers focused on non-communicable diseases. A conflict of interest statement was included in 23% of CPGs developed by societies or clinicians, compared with 4% of DoH CPGs. CONCLUSION: Accessing CPGs was challenging and required extensive searching. SA has many contributors to CPG development from the public and private sectors and across disciplines, but there is no formal co-ordination or prioritisation of topics for CPG development. Different versions of the CPGs were identified and key quality items were poorly reported, potentially affecting the usability and credibility of those available. There was substantial variation in CPG comprehensiveness and methodological approach. Establishing a national CPG co-ordinating unit responsible for developing standards for CPG development along with clinical quality standards, and supporting high-quality CPG development, is one essential step for moving forward with NHI. <![CDATA[<b>Opportunities to optimise Colistin stewardship in hospitalised patients in South Africa: Results of a multisite utilisation audit</b>]]> BACKGROUND: Colistin is an old antibiotic that has been reintroduced as salvage therapy in hospitalised patients because it is frequently the only agent active against Gram-negative bacteria. Various guidelines for colistin administration have led to confusion in establishing the appropriate dose, which has potential for adverse consequences including treatment failure or toxicity. The emergence and spread of colistin resistance has been documented in South Africa (SA), but no local information exists on how and why colistin is used in hospitals, and similarly, compliance with current dosing guidelines is unknown. OBJECTIVES: To evaluate the current utilisation of colistin in SA hospitals, in order to identify stewardship opportunities that could enhance the appropriate use of this antibiotic. METHODS: Electronic patient records of adult patients on intravenous (IV) colistin therapy for >72 hours in four private hospitals were retrospectively audited over a 10-month period (1 September 2015 - 30 June 2016). The following data were recorded: patient demographics, culture and susceptibility profiles, diagnosis, and indication for use. Compliance with six colistin process measures was audited: obtaining a culture prior to initiation, administration of a loading dose, administration of the correct loading dose, adjustments to maintenance dose according to renal function, whether colistin was administered in combination with another antibiotic, and whether de-escalation following culture and sensitivity results occurred. Outcome measures included effects on renal function, overall hospital mortality, intensive care unit length of stay (LoS), and hospital LoS. RESULTS: Records of 199 patients on IV colistin were reviewed. There was 99.0% compliance with obtaining a culture prior to antibiotic therapy, 93.5% compliance with prescription of a loading dose, and 98.5% compliance regarding prescription of colistin in combination with another agent. However, overall composite compliance with the six colistin stewardship process measures was 82.0%. Non-compliance related to inappropriate loading and maintenance doses, lack of adjustment according to renal function and lack of de-escalation following culture sensitivity was evident. Significantly shorter durations of treatment were noted in patients who received higher loading doses (p=0.040) and in those who received maintenance doses of 4.5 MU twice daily v. 3 MU three times daily (p=0.0027). In addition, compared with patients who survived, more patients who died received the 3 MU three times daily maintenance dose (p=0.0037; phi coefficient 0.26). CONCLUSIONS: The study identified multiple stewardship opportunities to optimise colistin therapy in hospitalised patients. Urgent implementation of a stewardship bundle to improve colistin utilisation is warranted. <![CDATA[<b>Self-reported alcohol use and binge drinking in South Africa: Evidence from the National Income Dynamics Study, 2014 - 2015</b>]]> BACKGROUND: Although the South African (SA) government has implemented alcohol control measures, alcohol consumption remains high. OBJECTIVES: To quantify the prevalence of self-reported current drinking and binge drinking in SA, and to determine important covariates. METHODS: We used the 2014 - 2015 National Income Dynamics Study, a nationally representative dataset of just over 20 000 individuals aged >15 years. Multiple regression logit analyses were performed separately by gender for self-reported current drinkers (any amount), self-reported bingers as a proportion of drinkers, and self-reported bingers as a proportion of the total population. An individual was defined as a binge drinker if he/she reported consumption of >5 standard drinks on an average drinking day. RESULTS: Current alcohol use (any amount) in 2014 - 2015 was reported by 33.1% of the population (47.7% males, 20.2% females). Of drinkers, 43.0% reported binge drinking (48.2% males, 32.4% females). The prevalence of self-reported binge drinking as a percentage of the total population was 14.1% (22.8% males, 6.4% females). Although black African males and females were less likely than white males and females to report drinking any amount, they were more likely to report binge drinking. Coloured (mixed race) females were more likely than black African females to report drinking any amount. Males and females who professed a religious affiliation were less likely than those who did not to report drinking any alcohol. The prevalence of self-reported binge drinking was highest among males and females aged 25 - 34 years. Smoking cigarettes substantially increased the likelihood of drinking any amount and of binge drinking for both genders. CONCLUSION: In SA, one in three individuals reported drinking alcohol, while one in seven reported binge drinking on an average day on which alcohol was consumed. Strong, evidence-based policies are needed to reduce the detrimental effects of alcohol use. <![CDATA[<b>Prevalence of tobacco use in selected Johannesburg suburbs</b>]]> BACKGROUND: Tobacco smoking is estimated to kill more than 44 000 South Africans every year. Studies have shown that since the introduction of tobacco control measures, national smoking prevalence has declined in South Africa (SA). OBJECTIVE: To determine the prevalence of tobacco smoking over a 7-year period in five impoverished neighbourhoods in Johannesburg, SA. METHODS: Data were collected through the annual administration of a prestructured questionnaire to one adult respondent in preselected dwellings from 2006 to 2012. Information was collected on socioeconomic status, smoking practices and health status. RESULTS: Over the 7-year period of the analysis, smoking levels remained unchanged. The proportion of households with one or more smokers varied significantly across the five study neighbourhoods. Approximately 20% of households in Hillbrow and as many as 77% in Riverlea had a member who smoked. CONCLUSIONS: Despite a national downward trend in smoking levels, tobacco use remains high and persistent in certain vulnerable communities, requiring scaled-up action to reduce the risk of a range of tobacco-related diseases. <![CDATA[<b>Predictors of treatment success in smoking cessation with varenicline combined with nicotine replacement therapy v. varenicline alone</b>]]> BACKGROUND: Identification of the predictors of treatment success in smoking cessation may help healthcare workers to improve the effectiveness of attempts at quitting. OBJECTIVE: To identify the predictors of success in a randomised controlled trial comparing varenicline alone or in combination with nicotine replacement therapy (NRT). METHODS: A post-hoc analysis of the data of 435 subjects who participated in a 24-week, multicentre trial in South Africa was performed. Logistic regression was used to analyse the effect of age, sex, age at smoking initiation, daily cigarette consumption, nicotine dependence, and reinforcement assessment on abstinence rates at 12 and 24 weeks. Point prevalence and continuous abstinence rates were self-reported and confirmed biochemically with exhaled carbon monoxide readings. RESULTS: The significant predictors of continuous abstinence at 12 and 24 weeks on multivariate analysis were lower daily cigarette consumption (odds ratio (OR) 1.86, 95% confidence interval (CI) 1.21 - 2.87, p=0.005 and OR 1.83, 95% CI 1.12 - 2.98, p=0.02, respectively) and older age (OR 1.52, 95% CI 1.00 - 2.31, p=0.049 and OR 1.79, 95% CI 1.13 - 2.84, p=0.01, respectively). There was no difference in the predictors of success in the univariate analysis, except that older age predicted point prevalence abstinence at 12 weeks (OR 1.47, 95% CI 1.00 - 2.15, p=0.049). The findings were inconclusive for an association between abstinence and lower nicotine dependence, older age at smoking initiation and positive reinforcement. CONCLUSION: Older age and lower daily cigarette consumption are associated with a higher likelihood of abstinence in patients using varenicline, regardless of the addition of NRT. <![CDATA[<b>Good correlation between the Afinion AS100 analyser and the ABX Pentra 400 analyser for the measurement of glycosylated haemoglobin and lipid levels in older adults in Durban, South Africa</b>]]> BACKGROUND: The Afinion AS100 analyser is a small bench-top, multi-assay, point-of-care (POC) analyser that is able to measure glycated haemoglobin (HbA1c) and lipid levels. OBJECTIVE: To assess performance of the Afinion analyser compared with a reference laboratory test for the measurement of HbA1c and lipid levels. METHOD: The study involved men and women enrolled in a cross-sectional study, Sexual health, HIV infection and comorbidity with non-communicable diseases among Older Persons (SHIOP), which was conducted from February to May 2016. Whole blood was drawn aseptically by a trained study nurse into a serum separator gel tube and an ethylenediaminetetra-acetic acid (EDTA) tube. The EDTA whole blood was used to measure HbA1c levels, and serum to measure total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride levels. Lin's correlation coefficient was used to assess the agreement between the Afinion and ABX Pentra 400 analysers for each marker. RESULTS: A total of 435 older individuals were included in the study. The proportion of HbAlc results that were correctly classified by the Afinion analyser was 92.2%. Bland-Altman analysis and linear regression analysis showed a very good agreement (correlation concordance 0.89) between the two analysers for the measurement of HbAlc. The two-way scatter plot for TC showed a substantial correlation (0.80). However, a total of 69 cholesterol results that were within the normal range on the Pentra were misclassified as abnormal on the Afinion. The readings obtained for HDL-C levels with the Afinion were shown to be slightly overestimated when compared with the Pentra. However, correlation for HDL-C on the two analysers was 0.93, indicating an almost perfect agreement. Seventy-four LDL-C results were erroneously classified as abnormal on the Afinion but were within the normal range on the Pentra, resulting in a substantial correlation of 0.75. An excellent agreement was observed between triglyceride measurements (0.99). CONCLUSION: This study supports the use of the Afinion AS100 analyser in POC testing for the measurement of HbAlc, triglycerides and HDL-C in a South African setting. <![CDATA[<b>Anaemia, renal dysfunction and in-hospital outcomes in patients with heart failure in Botswana</b>]]> BACKGROUND: Anaemia and renal dysfunction are associated with an increased morbidity and mortality in heart failure (HF) patients. OBJECTIVE: To estimate the frequency and impact of anaemia and renal dysfunction on in-hospital outcomes in patients with HF. METHODS: A total of 193 consecutive patients with HF admitted to Princess Marina Hospital, Gaborone, Botswana, from February 2014 to February 2015, were studied. Anaemia was defined as haemoglobin <13 g/dL for men and <12 g/dL for women. Renal dysfunction was defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², calculated by the simplified Modification of Diet in Renal Disease formula. The in-hospital outcomes included length of hospital stay and mortality. RESULTS: The mean (standard deviation (SD)) age was 54.2 (17.1) years and 53.9% of the patients were men. The overall median eGFR was 75.9 mL/min/1.73 m² and renal dysfunction was detected in 60 (31.1%) patients. Renal dysfunction was associated with hypertension (p=0.01), diabetes mellitus (p=0.01) and a lower haemoglobin level (p=0.008). The mean (SD) haemoglobin was 12.0 (3.0) g/dL and 54.9% of the patients were anaemic. Microcytic, normocytic and macrocytic anaemia were found in 32.1%, 57.5% and 10.4% of patients, respectively. The mean (SD) haemoglobin level for males was significantly higher than for females (12.4 (3.3) g/dL v. 11.5 (2.5) g/dL; p=0.038). Anaemia was more common in patients with diabetes (p=0.028) and in those with increased left ventricular ejection fraction (p=0.005). Neither renal dysfunction nor anaemia was significantly associated with the length of hospital stay or in-hospital mortality. CONCLUSION: Anaemia and renal dysfunction are prevalent in HF patients, but neither was an independent predictor of length of stay or in-hospital mortality in this population. These findings indicate that HF data in developed countries may not apply to countries in sub-Saharan Africa, and call for more studies to be done in this region. <![CDATA[<b>Keeping our heads above water: A systematic review of fatal drowning in South Africa</b>]]> BACKGROUND: Drowning is defined as the process of experiencing respiratory impairment from submersion/immersion in liquid, and can have one of three outcomes - no morbidity, morbidity or mortality. The World Health Organization African region accounts for approximately 20% of global drowning, with a drowning mortality rate of 13.1 per 100 000 population. The strategic implementation of intervention programmes driven by evidence-based decisions is of prime importance in resource-limited settings such as South Africa (SA). OBJECTIVE: To review the available epidemiological data on fatal drowning in SA in order to identify gaps in the current knowledge base and priority intervention areas. METHODS: A systematic review of published literature was conducted to review the available epidemiological data describing fatal drowning in SA. In addition, an internet search for grey literature, including technical reports, describing SA fatal drowning epidemiology was conducted. RESULTS: A total of 13 published research articles and 27 reports obtained through a grey literature search met the inclusion and exclusion criteria. These 40 articles and reports covered data collection periods between 1995 and 2016, and were largely focused on urban settings. The fatal drowning burden in SA is stable at approximately 3.0 per 100 000 population, but is increasing as a proportion of all non-natural deaths. Drowning mortality rates are high in children aged <15 years, particularly in those aged <5. CONCLUSIONS: This review suggests that SA drowning prevention initiatives are currently confined to the early stages of an effective injury prevention strategy. The distribution of mortality across age groups and drowning location differs substantially between urban centres and provinces. There is therefore a need for detailed drowning surveillance to monitor national trends and identify risk factors in all SA communities.