Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 108 num. 6 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>'If exercise was a pill'</b>]]> <![CDATA[<b>Under-5 mortality and the contribution of congenital disorders in South Africa</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Lionel Palmer Miles</b>]]> <![CDATA[<b>Decentralised clinical training of health professionals will expand the training platform and enhance the competencies of graduates</b>]]> <![CDATA[<b>How climate change can fuel listeriosis outbreaks in South Africa</b>]]> <![CDATA[<b>Anaesthesia in South Africa</b>]]> <![CDATA[<b>Anaesthesia for paediatric patients: Minimising the risk</b>]]> Advances in paediatric anaesthesia include the availability of dedicated facilities with appropriate equipment, monitoring and specialised personnel trained in paediatric anaesthesia and resuscitation. These developments have contributed to the reduction in perioperative risk for paediatric patients. However, access to all the resources available in dedicated paediatric facilities is limited in resource-constrained settings. The objective of this review is to provide guidance with regard to the selection of suitable facilities for perioperative care, risk stratification and patient selection, safe selection of medication and standardisation of its use, and implementation of specific anaesthetic techniques that can minimise risk in the paediatric surgical population. <![CDATA[<b>Managing spinal hypotension during caesarean section: An update</b>]]> Hypotension is common after spinal local anaesthesia for caesarean section. However, the substandard treatment of spinal hypotension and associated complications are responsible for up to two-thirds of deaths that occur in South Africa (SA) for caesarean section under spinal anaesthesia. In some cases, spinal hypotension may be predicted by simple parameters such as age &gt;25 years, preoperative heart rate &gt;90 bpm and preoperative mean arterial pressure <90 mmHg. Heart rate variability and point-of-care echocardiography also predict hypotension with greater accuracy, but are limited by equipment and training issues. Spinal anaesthesia is absolutely contraindicated if the parturient is hypovolaemic. Left lateral tilt is still advised, despite the absence of strong supporting evidence. The dose of spinal bupivacaine should not be reduced in obese patients. Crystalloid co-loading is an adequate fluid strategy in most cases, but is of limited efficacy in the prevention of hypotension. It is imperative that immediately after the patient is placed supine, close attention is paid to communication with her, heart rate changes and pulse volume. Early intervention with phenylephrine is the first-line approach for hypotension if heart rate is preserved under spinal anaesthesia. Phenylephrine infusions (25 - 50 μg/min) are easy to administer, maintain baseline maternal haemodynamics and are applicable to the SA context. The vigilant use of phenylephrine boluses (50 - 100 μg), targeting maternal heart rate as a surrogate for cardiac output, is also effective. Noradrenaline has been used successfully to prevent spinal hypotension, but evidence does not yet suggest practice change. Local and international guidelines have recently been published. <![CDATA[<b>Myocardial injury after non-cardiac surgery: Time to shed the ignorance</b>]]> Perioperative cardiovascular complications are common and place a significant burden on public healthcare systems. A large proportion of such complications are due to a new clinical entity, i.e. myocardial injury after non-cardiac surgery (MINS). It is important to understand MINS, its prognosis and management in the perioperative period. A literature review of MINS was done. MINS is defined as an elevated postoperative cardiac troponin level that was considered as resulting from myocardial ischaemia without evidence of a non-ischaemic cause for the troponin elevation. The perioperative milieu (surgical stress response, sympathetic activation, hypercoagulability, hypotension, bleeding, anaemia and pain) contributes to the pathophysiology of a relative myocardial hypoperfusion and ischaemia, which differentiates MINS from myocardial infarction in non-surgical patients. Globally, >7% of adults >45 years of age suffer MINS, with South African (SA) studies confirming similar event rates. More than 80% of MINS patients are asymptomatic for myocardial ischaemia, and therefore would not fulfil the universal definition of myocardial infarction, despite having a similar prognosis to those with the latter condition. Accurate diagnosis of MINS therefore relies on routine daily postoperative cardiac troponin surveillance for 48 - 72 hours postoperatively in patients with a >5% risk of major perioperative cardiovascular complications. This approach is cost-effective in SA. One in 10 patients with MINS dies within 30 days of surgery, and 1 in 5 develops major cardiovascular complications. Short- and long-term mortality could be improved by simple treatment strategies, including cardiovascular therapy intensification, and by ensuring aspirin use and statin therapy. All recommendations promote the involvement of a multidisciplinary team. MINS is a common, serious perioperative cardiovascular complication with public healthcare implications that has been underappreciated in SA. A multidisciplinary approach with simple treatment strategies should be adopted. <![CDATA[<b>Prolonged paralysis in a child with organophosphate pesticide poisoning</b>]]> A 17-month-old boy presented to a local community health centre in Cape Town, South Africa, with severe organophosphate pesticide poisoning (OPP), necessitating the use of intravenous atropine to control cholinergic symptoms, as well as emergency intubation for ongoing respiratory distress. He required prolonged ventilatory support in the intensive care unit at his referral hospital and had subsequent delayed neurological recovery, spending 8 days in hospital.We present this case to emphasise the importance of adequate atropinisation in the management of severe OPP and to highlight the dangers of inappropriate use of suxamethonium for intubation in patients with OPP. <![CDATA[<b>Posthumous conception: Recent legal developments in South Africa</b>]]> Posthumous conception - when a deceased person's gametes are used for procreative purposes - made its debut in South African (SA) courts in NC v Aevitas Fertility Clinic. A widow was granted the right to use her deceased husband's sperm for procreation. Against the background of legislative ambiguity, this case creates legal certainty that posthumous conception is legally permissible in SA - at least where deceased persons provided written consent that their gametes can be used by their surviving spouses or life partners after their death, and where there is no controversy about such consent. <![CDATA[<b><i>Staphylococcus aureus </i>and <i>Escherichia coli </i>levels on the hands of theatre staff in three hospitals in Johannesburg, South Africa, before and after handwashing</b>]]> BACKGROUND. Hand hygiene is a fundamental component of infection control. Hand contamination with Staphylococcus aureus and Escherichia coli may contribute to infections. OBJECTIVES. To assess the effectiveness of different handwashing methods in reducing the levels of bacterial flora, especially S. aureus and E. coli, on the hands of theatre staff. METHODS. A cross-sectional study was conducted among 70 staff in surgical theatres of three randomly chosen hospitals in Johannesburg, South Africa. Samples were taken before and after handwashing using the modified glove juice method and the fingernail press technique. Standard microbiological techniques were used to identify bacteria. Descriptive statistics and non-parametric analysis were used to compare the differences between hospitals and to determine the effects of handwashing on microbial flora and skin irritation. RESULTS. S. aureus organisms were isolated in the prewash samples of 29 (41%) and in the postwash samples of 20 (29%) workers. Of the 29 with positive prewash cultures, 19 (65.5%) showed decreased postwash counts, while 10 (34.5%) showed no change or increased counts. Four workers with a negative prewash count had a positive postwash count. No statistical differences were found between postwash counts categorised by the type of cleansing formula used and the washing technique. E. coli organisms were identified in the prewash count of the fingertip press of one worker. CONCLUSIONS. Almost half of the theatre staff carried S. aureus isolates on their hands prior to handwashing and approximately one-third after handwashing. Closer monitoring of handwashing techniques should be introduced. <![CDATA[<b>Economic evaluation of safety-engineered devices and training in reducing needlestick injuries among healthcare workers in South Africa</b>]]> BACKGROUND. Healthcare workers (HCWs) are at increased risk of contracting various communicable diseases. Needlestick injuries (NSIs) are a common mechanism of exposure. Training in basic universal precautions and utilisation of safety-engineered devices (SEDs) are interventions known to reduce the risk of NSI. OBJECTIVES. To assess the cost-utility of SEDs v. a training programme in universal precautions (TP) v. a combination strategy to reduce NSIs among South African HCWs. METHODS. A Markov model comparing SEDs v. a TP v. a combination strategy against current practice was developed. A hypothetical cohort of HCWs working in the SA public sector was followed from a payer's perspective for a period of 45 years, and discounted costs and benefits were assessed. Data were obtained from the National Department of Health, suppliers and published literature. One-way and probabilistic sensitivity analysis was conducted. RESULTS. Over the study time horizon, our model estimated that 2 209, 3 314 and 4 349 needlestick injuries per 1 000 HCWs could be prevented if a TP, SEDs or a combination strategy, respectively, was adopted compared with current practice. All three candidate interventions were cost-effective at a willingness to pay (WTP) of one times the gross domestic product per capita (USD6 483.90/quality-adjusted life-year (QUALY) gained). SEDs as a stand-alone intervention was dominated by a combination strategy. Compared with current practice, the incremental cost-effectiveness of training was USD32.90/QALY v. USD432.32/QALY for SEDs and USD377.08/QALY for a combination strategy. Results were sensitive to the effectiveness of the interventions. Probabilistic sensitivity analysis showed that at a WTP of USD6 483.90/QALY gained, a combination strategy would be cost-effective 95.4% of the time. CONCLUSIONS. A combination strategy in which both SEDs and a TP are adopted is preferred. <![CDATA[<b>Medical students' perspectives on euthanasia and physician-assisted suicide and their views on legalising these practices in South Africa</b>]]> BACKGROUND. Euthanasia/physician-assisted suicide have been a controversial and sometimes taboo topic for a long time, not only in South Africa (SA) but also internationally. A recent (SA) judicial case has seen the topic debated again. Consensus on accepting or abolishing these practices in SA has yet to be reached. All relevant role players need to be adequately engaged before policy can be informed. OBJECTIVES. To determine the views of future doctors (medical students) regarding euthanasia and physician-assisted suicide (PAS) and to ascertain their stance on its legalisation in South Africa (SA). METHODS. A paper-based, semi-quantitative descriptive study design consisting of 16 questions, using convenience sampling of third- to fifth-year medical students at Stellenbosch University, was used. RESULTS. The overall response rate was 69.3% (N=277). In total, 52.7% of participants (n=146) felt that the practices of euthanasia/PAS should be legalised in SA. Responses varied depending on patient morbidities. If a patient had terminal disease with intractable suffering, 41.9% of participants would terminate the patient's life upon request. A further 36.1% of participants stated that they would have no part in ending a patient's life, while 35.0% said that they would be comfortable with providing the patient with the correct means to end their life (PAS). The majority (80.1%) of participants indicated that they would prefer a dedicated ethics committee to decide who receives euthanasia/PAS. Many factors influenced participants' responses, but differences in opinion between and within the various religious groups were particularly evident in the responses received. CONCLUSIONS. More than half the respondents in this study were open to legalising euthanasia/PAS, substantially more than in previous studies. However, only 41.9% of respondents would consider actually performing euthanasia/PAS, for certain patients. Views of other healthcare workers as well as the public are required before policy can be informed. <![CDATA[<b>Poor anticoagulation control in patients taking warfarin at a tertiary and district-level prothrombin clinic in Cape Town, South Africa</b>]]> BACKGROUND. Warfarin is the most commonly used anticoagulant for both primary and secondary prevention of thromboembolism. For anticoagulation efficacy, the international normalised ratio (INR) needs to be within the therapeutic range for at least 65% of time on warfarin. OBJECTIVES. To describe INR control in patients on long-term warfarin and identified predictors of good INR control at two dedicated warfarin follow-up clinics in Cape Town, South Africa (SA). METHODS. We reviewed clinical records of patients in care at the INR clinics at Mitchell's Plain Community Health Centre and Groote Schuur Hospital. We included patients who had been on warfarin therapy for at least 27 months and excluded patients with <6 months of INR monitoring data or a &gt;70-day gap between INR tests in the calculation period, and if &gt;25% of follow-up time was at an alternative site. The time in therapeutic range (TTR) over 180 days using the Rosendaal method was calculated, and we categorised INR control as good if the TTR was &gt;65%. We constructed a multivariate logistic regression model to identify associations with good INR control. RESULTS. We included 363 patients, with a median age of 55 years (interquartile range (IQR) 44 - 64), of whom 65.6% were women. The most common indications for warfarin were valvular heart disease (45.7%) and atrial fibrillation (25.1%). The mean TTR was 47%, with only 91/363 patients having good INR control. In a multivariate model adjusted for age, sex, clinic and target INR, patients aged &gt;55 years were more likely to have good INR control than younger patients (adjusted odds ratio 1.69, 95% confidence interval 1.03 - 2.79). Poorly controlled patients had more frequent INR monitoring than those with good INR control, with a median of 8 INRs (IQR 6 - 10) v. 6 INRs (IQR 5 - 8) in the 180-day period (p<0.0001). CONCLUSIONS. Only 25.1% of patients in our study achieved good INR control, despite regular INR monitoring. There is an urgent need to improve anticoagulation control of patients receiving warfarin in SA. Validated dosing algorithms are required, and access to lower warfarin dosage formulations may optimise individual dose titration. Advocacy for these formulations is advised. <![CDATA[<b>Phenotypic and genotypic correlation of carbapenememase-producing Enterobacteriaceae and problems experienced in routine screening</b>]]> BACKGROUND. The emergence and transmission of carbapenem-resistant Enterobacteriaceae (CRE) is a concern in both the clinical and public health arenas. Reliable and accurate detection of these organisms is required for patient management and infection prevention and control purposes. In the routine laboratory, phenotypic methods are utilised for identification of CRE. OBJECTIVES. To investigate the phenotypic profiles of suspected carbapenemase-producing Enterobacteriaceae (CPE) isolates generated by the automated MicroScan Walkaway system making use of the Clinical and Laboratory Standards Institute (CLSI) guidelines, and correlate these with carbapenemase production by molecular methods. METHODS. Antimicrobial susceptibility testing was performed using the MicroScan Walkaway system, and the presence of six carbapenemase genes (blaNDM, blaVIM, blaIMP, blaOXA-48 and variants, blaGES and blaKPC) was screened for using a multiplex real-time polymerase chain reaction. RESULTS. A total of 2 678 isolates were evaluated. Klebsiella pneumoniae accounted for 62.9% of the isolates (n=1 685), followed by Enterobacter cloacae (n=361, 13.5%). Carbapenemases accounted for 75.2% of isolates; blaOXA-48 and its variants predominated (n=978, 36.5%), followed by blaNDM (n=904, 33.8%), blaVIM (n=108, 4.0%), blaIMP (n=35, 1.3%), blaGES (n=24, 0.9%) and blaKPC (n=18, 0.7 %). CONCLUSIONS. A considerable number of isolates expressing a carbapenemase or carbapenemases (the majority of which were blaOXA-48producing) were susceptible to third-and fourth-generation cephalosporins and carbapenems, demonstrating that confirmed carbapenemase-producing isolates are not presenting as possible carriers of carbapenemases using routine diagnostic methods. Similar results were obtained when CLSI and European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints were applied and are suitable for the purpose of patient management. However, since genotyping assays are costly, it is suggested that routine laboratories first perform comprehensive phenotypic screening for CPE. <![CDATA[<b>Is adrenal suppression in asthmatic children reversible? A case series</b>]]> BACKGROUND. Six hypocortisolaemic asthmatic children on steroids given at physiological doses were identified during a previous study. OBJECTIVES. To establish whether hypothalamic-pituitary-adrenal axis suppression (HPAS) could be reversed in hypocortisolaemic asthmatic children treated with steroids without sacrificing asthma control. METHODS. In this case series, treatment of six hypocortisolaemic patients was modified by introducing steroid-sparing asthma medications. Serum cortisol and repeat overnight metyrapone tests (ONMTPTs) were done until HPAS was reversed in all patients. A retrospective folder review was performed and the following data were extracted: body mass index standard deviation score (BMI SDS), adherence, daily steroid type and dose, treatment modification, serum cortisol, final ONMTPT result and time taken to achieve normalisation. RESULTS. The median serum cortisol level recovered to 311 nmol/L after 0.9 years (median). The ONMTPT normalised within 3.3 years (median). Steroid load decreased from 9.2 to 5.0 hydrocortisone equivalent mg/m²/d (medians), while asthma score improved from 1.42 to 0.85 (medians). Poor adherence was noted in two children before and four after treatment modification. BMI SDS decreased from -0.08 to -0.16 (medians). CONCLUSIONS. Hypocortisolaemia and HPAS could be reversed in asthmatic children treated with physiological doses of steroids by reducing steroid load by 40% and supplementing therapy with steroid-sparing medication. Poor adherence may have either contributed to or retarded HPA recovery. Simultaneously, asthma control improved. Confirmation by a prospective study would be ideal, but may not be feasible. <![CDATA[<b>Outcomes of outpatient ureteral stenting without fluoroscopy at Groote Schuur Hospital, Cape Town, South Africa</b>]]> BACKGROUND. Ureteral stenting is generally a theatre-based procedure that requires a multidisciplinary team and on-table imaging. Limited hospital bed numbers and theatre time in our centre in Cape Town, South Africa, have led us to explore an alternative approach. OBJECTIVES. To see whether outpatient insertion of ureteric stents under local anaesthesia without fluoroscopy was a possible and acceptable alternative to theatre-based ureteral stenting. METHODS. Ureteral stenting (double-J stents and ureteric catheters) was performed with flexible cystoscopy under local anaesthesia and chemoprophylaxis, but without fluoroscopic guidance, in an outpatient setting. Every patient had an abdominal radiograph and an ultrasound scan of the kidney after the procedure to confirm stent position. RESULTS. Three hundred and sixteen procedures (276 double-J stents and 40 ureteric catheters) were performed in 161 men and 155 women. The overall success rate for the procedures was 85.4%, independent of gender (p=0.87), age (p=0.13), type of device inserted (p=0.81) or unilateral/bilateral nature of the procedure (p=1.0). Procedures with a successful outcome were performed in a significantly (p<0.0001) shorter median time (10 minutes (interquartile range (IQR) 5 - 15)) than failed procedures (20 minutes (IQR 10 - 30)). Patients with a pain score of &gt;5 experienced a significantly (p=0.02) greater proportion of failure (27.3%) than patients with a pain score of <5 (12.5%). Difficulties were encountered in 23.7% of procedures, with a significantly higher proportion being registered in failed interventions compared with successful ones (82.6% v. 13.7%; p<0.0001). CONCLUSIONS. The procedure was easily mastered and technically simple, and represents savings in cost, time and human resources in our setting. <![CDATA[<b>Predictors of unplanned pregnancies among female students at South African Technical and Vocational Education and Training colleges: Findings from the 2014 Higher Education and Training HIV and AIDS survey</b>]]> BACKGROUND. Unplanned pregnancies among college/tertiary female students pose a serious public health concern in South Africa (SA) and are associated with adverse health and social outcomes that impact negatively on educational progress and future career prospects. OBJECTIVES. To examine the potential predictors of unplanned pregnancy among female students at Technical and Vocational Education and Training (TVET) colleges in SA. METHODS. This analysis used data drawn from the 2014 Higher Education and Training HIV and AIDS survey, which was a nationally representative survey of TVET college students in SA. Associations between unplanned pregnancy and the explanatory variables were assessed using bivariate analysis. Multivariate logistic regression analysis was used to identify the effect of several independent predictors of unplanned pregnancy. RESULTS. Of 1 002 female students who responded to the question on unplanned pregnancy, 74.6% reported having had an unplanned pregnancy. Predictors significantly associated with a reduced likelihood of unplanned pregnancy among female TVET students included living with a husband (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.13 - 0.62; p=0.002), having two (OR 0.45, 95% CI 0.23 - 0.88; p=0.003) or three (OR 0.07, 95% CI 0.01 - 0.39; p=0.003) previous pregnancies, and not having had an abortion (OR 0.16, 95% CI 0.04 - 0.62; p=0.008). CONCLUSIONS. The high level of unplanned pregnancies is indicative of the state of women's reproductive health services at SA TVET colleges. The findings suggest that certain groups of female students are at increased risk of unplanned pregnancy and would benefit from targeted family planning interventions tailored to their needs. <![CDATA[<b>High risk of suicide among high-school learners in uMgungundlovu District, KwaZulu-Natal Province, South Africa</b>]]> BACKGROUND. Worldwide, suicide affects the most vulnerable populations, including adolescents and young adults. It is estimated that suicide will contribute more than 2% to the global burden of disease by 2020. Information about the prevalence of suicidal behaviour and the sociodemographic characteristics and risk factors associated with suicide in the South African (SA) rural context is important for local and national policy and contributes to global understanding of the phenomenon. OBJECTIVE. To investigate key demographic factors and behaviours associated with planning and attempting suicide among high-school learners. METHODS. In a cross-sectional study, we used stratified random sampling to select 16 schools in uMgungundlovu District, KwaZulu-Natal Province, SA. All grade 10 learners (N=1 759) at these schools completed a self-administered questionnaire (Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System). Data analysis was carried out with Stata 13 statistical software using generalised estimating equations. RESULTS. In total, 222 learners (12.6% of the 1 759) had made plans to attempt suicide during the previous 12 months, 261 (14.8%) had actually attempted suicide, and 218 attempts had resulted in the learner being treated by a doctor or nurse (12.4%). The risk of planning suicide increased with age. For male learners, being threatened with a weapon on school property (adjusted odds ratio (AOR) 3.7, 95% confidence interval (CI) 1.9 - 7.1; p<0.01) or bullied through Facebook or WhatsApp (AOR 3.1, 95% CI 1.5 - 7.1; p<0.01) significantly increased the likelihood of making a suicide attempt that resulted in treatment by a doctor or nurse. For female learners, engaging in risk behaviours increased this likelihood, risk factors including being physically hurt by someone they were dating (1 - 3 times AOR 3.3, 95% CI 1.9 - 5.7; p<0.01, ≥4 times AOR 10.0, 95% CI 2.5 - 40.2 (p<0.01) and number of drinks consumed in the past month (AOR 2.0, 95% CI 1.4 - 3.0; p<0.01). CONCLUSIONS. The prevalence of suicide attempts among these SA learners was high and was influenced by multiple factors. Routine surveillance systems are urgently required to develop context-based interventions for male and female learners at uMgungundlovu District rural high schools.