SAMJ: South African Medical Journal

The blame game

**Manuscripts not suitable for general readership of the South African Medical Journal with the reply from the editor**

Latest results show urgent need to address child restraint use

This Is How It Is: True Stories from South Africa

Success brings new challenges in circumcision campaign

Evolving concepts of stroke and stroke management in South Africa: Quo vadis?

Medical management of acute ischaemic stroke

This article provides a practical overview of current medical treatments for acute ischaemic stroke, particularly for those in a busy family or general practice. Stroke is defined as an acute neurological deficit lasting >24 hours and caused by cerebrovascular disease. It may be ischaemic, caused by vessel stenosis or occlusion, or haemorrhagic, caused by rupture of vessels, resulting in intraparenchymal and/or subarachnoid haemorrhage. Transient ischaemic attack is defined as a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction, replacing the old time-based definition. The goals of management of patients with an acute stroke are as follows: make an accurate assessment and diagnosis, limit the extent of the brain injury, avoid and treat stroke-related complications, evaluate the underlying aetiology that is closely linked to the prognosis for recurrent stroke, institute appropriate secondary prevention and facilitate post-stroke recovery.

Mechanical thrombectomy for acute ischaemic stroke

Rapid, safe and effective arterial recanalisation to restore blood flow and improve functional outcome is the primary goal of hyperacute management of acute ischaemic stroke. This is possible either through thrombolysis or direct mechanical removal of clot from the blocked artery. Current evidence from randomised controlled trials shows that, for correctly selected patients, functional independence can be achieved in 32 - 71% of those who undergo clot removal. It is estimated that 10 - 15% of all ischaemic stroke patients have large-vessel occlusion and qualify for mechanical thrombectomy. It is important to have systems in place to identify and treat these patients.

Post-stroke rehabilitation

This article offers insight into post-stroke rehabilitation. Stroke is a major public health issue with high mortality and morbidity rates, both nationally and internationally. Recent medical advances resulted in improvements in mortality rates, but the disabling long-term effects of stroke are still prevalent. Post-stroke rehabilitation improves patient outcomes by decreasing the chance of developing secondary complications and maximising the patient's independence despite their impairments. Post-stroke rehabilitation is delivered by an interdisciplinary team experienced in the rehabilitation process. There are specific focus areas during this process, which ensure a holistic approach. Early discharge planning is essential and can help to ease the transition from inpatient rehabilitation to a patient's home environment. Stroke recovery is heterogeneous and multilayered; therefore, it is difficult to accurately predict post-stroke outcomes, but the importance of early interventions and ongoing outpatient rehabilitation is stressed.

Reimagining liver transplantation in South Africa: A model for justice, equity and capacity building - the Wits Donald Gordon Medical Centre experience

The challenge of providing effective and integrated liver transplant services across South Africa's two socioeconomically disparate healthcare sectors has been faced by Wits Donald Gordon Medical Centre (WDGMC) since 2004. WDGMC is a private academic hospital in Johannesburg and serves to supplement the specialist and subspecialist medical training provided by the University of the Witwatersrand. Over the past 14 years, our liver transplant programme has evolved from a sometimes fractured service into the largest-volume liver centre in sub-Saharan Africa. The growth of our programme has been the result of a number of innovative strategies tailored to the unique nature of transplant service provision. These include an employment model for doctors, a robust training and research programme, and a collaboration with the Gauteng Department of Health (GDoH) that allows us to provide liver transplantation to state sector patients and promotes equality. We have also encountered numerous challenges, and these continue, especially in our endeavour to make access to liver transplantation equitable but also an economically viable option for our hospital. In this article, we detail the liver transplant model at WDGMC, fully outlining the successes, challenges and innovations that have arisen through considering the provision of transplant services from a different perspective. We focus particularly on the collaboration with the GDoH, which is unique and may serve as a valuable source of information for others wishing to establish similar partnerships, especially as National Health Insurance comes into effect.

**Life-threatening hyperkalaemia due to trimethoprim in a patient treated for Pneumocystis jirovecii pneumonia**

Hyperkalaemia is a potentially life-threatening condition frequently encountered in hospitalised patients. Among the many causes of hyperkalaemia, drugs have often been implicated. In the South African context, with the high burden of HIV, there is an increased incidence of opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP), and consequently many patients receive high doses of trimethoprim-sulfamethoxazole. A lesser-known side-effect of the trimethoprim component of this combination antibiotic is hyperkalaemia. We report a case in which life-threatening hyperkalaemia developed after institution of high-dose co-trimoxazole for PJP.

Atypical presentation of Crimean-Congo haemorrhagic fever: Lessons learned

An atypical case of Crimean-Congo haemorrhagic fever is presented. The diagnosis of the case in the presence of several comorbidities was complicated and illustrates the importance of maintaining a high index of suspicion for viral haemorrhagic fever in cases presenting with multisystem disease and an epidemiological history that could present opportunities for exposure to a haemorrhagic fever virus.

Midwife-led obstetric units working 'CLEVER': Improving perinatal outcome indicators in a South African health district

BACKGROUND: South Africa did not meet its Millennium Development Goals with regard to the reduction in maternal and under-5 mortality. Furthermore, many birthing women do not receive intrapartum care with empathy and endure disrespectful and abusive care.OBJECTIVES: To implement a multicomponent, context-specific intervention package to change the complex interplay between preventable maternal and perinatal mortality and morbidity and poor clinical governance and supervision in midwife-led labour units.METHODS: A mixed-methods intervention study was conducted in Tshwane District, South Africa, in 10 midwife-led obstetric units (MOUs), from which a purposive sample consisting of five units was selected for the intervention. The intervention took place in three phases: (i) baseline measurement; (ii) implementation of the so-called 'CLEVER' intervention package in the five intervention units, based on the results of the first phase; and (iii) a review of health systems improvements and perinatal outcomes. The intervention had three pillars: (i) feedback of the baseline measurement to the intervention units to raise awareness and solicit participation; (ii) health systems strengthening; and (iii) intensive weekly engagement for 3 months, with further monthly support afterwards. Observation of barriers during baseline activities contributed to the health systems strengthening and improvement strategies during implementation.RESULTS: Perinatal outcome indicators for the year before the intervention were compared with data for the year in which the intervention took place and the year after the intervention. Significant declines were observed in in-facility fresh stillbirths, meconium aspiration and birth asphyxia in the intervention MOUs from 2015 to 2017. The control group showed some decline during the period owing to support from district clinical specialist team members.CONCLUSIONS: CLEVER as a context-specific, multicomponent, clinically focused intervention package may have contributed to improved perinatal morbidity and mortality rates in MOUs.

The association between preterm labour, perinatal mortality and infant death (during the first year) in Bishop Lavis, Cape Town, South Africa

BACKGROUND: We present further analyses from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigatedOBJECTIVES: To describe pregnancy and neonatal outcome in a large prospective study where information on the outcome of pregnancy was known in >98.3% of participants and ultrasound was used to determine gestational age (GA).METHODS: As part of the Safe Passage Study of the PASS Network in Cape Town, South Africa, the outcomes of 6 866 singleton pregnancies were prospectively followed from recruitment in early pregnancy until the infant was 12 months old to assess pregnancy outcome. Fetal growth was assessed by z-scores of the birth weight, and GA at birth was derived from early ultrasound assessments. The effects of fetal growth restriction and preterm delivery on pregnancy outcome were determined.RESULTS: There were 66 miscarriages, 107 stillbirths at >22 weeks' gestation, 66 stillbirths at >28 weeks' gestation, 29 and 18 neonatal deaths at >22 and >28 weeks' gestation, respectively, and 54 post-neonatal deaths (28 days - 12 months). The miscarriage rate was 9.6/1 000 and the infant mortality rate 12.4/1 000. Of the births, 13.8% were preterm. For deliveries at >22 and >28 weeks, the stillbirth rates were 15.7 and 9.8/1 000 deliveries, respectively. For deliveries at >22 and >28 weeks, the neonatal death rates were 4.3 and 2.7/1 000 live births, respectively. For these pregnancies the perinatal mortality rates were 20.0/1 000 (>22 weeks) and 12.5/1 000 (>28 weeks), respectively. Only 15.9% of stillbirths occurred during labour (in 15.9% of cases it was uncertain whether death had occurred during labour). In the majority of cases (68.2%) fetal death occurred before labour, and 82.2% of stillbirths and 62.1% of neonatal deaths occurred in deliveries before 37 weeks. Including the miscarriages, stillbirths and infant deaths, there were 256 pregnancy losses; 77.3% were associated with deliveries before 37 weeks. Only 1.8% of all the women were HIV-positive, whereas the HIV-positive rate was 3.7% among those who had stillbirths. Birth weight was below the 10th centile in 25.6% of neonatal and post-neonatal deaths compared with 17.7% of survivors.CONCLUSIONS: Preterm birth and fetal growth restriction play significant roles in fetal, neonatal and infant losses

Factors related to hospital readmissions in people with spinal cord injury in South Africa

BACKGROUND: People with spinal cord injury (PWSCI) face various challenges after being discharged from rehabilitation that can result in readmission to hospital. Little is known about readmission of PWSCI in South Africa (SA). Readmission is costly, interrupts community involvement and negatively affects quality of lifeOBJECTIVES: To investigate readmission rates within 5 years of rehabilitation, causes of readmission and factors related to readmission in PWSCI in Pretoria, SAMETHODS: We quantitatively analysed retrospective data gathered from files of patients admitted to a private rehabilitation facility in Pretoria between January 2008 and December 2012. Data were analysed using Stata 13 statistical software. Descriptive statistics were initially presented. Univariate logistic regression was used to identify individual factors that had significant association with the outcome measure (readmission). Thereafter, multivariate logistic regression was used to identify risk factors for readmission. The level of statistical significance was set at p<0.5RESULTS: Data from 543 patient files were analysed. In total, 100 patients (18%) were readmitted between January 2008 and December 2012. Twenty-eight of the 100 readmitted patients had a subsequent second readmission, 10 patients had a third readmission, and 2 patients were readmitted for a fourth time. The most common reason for readmission was secondary health conditions (SHCs) (80%), followed by further rehabilitation, including gait rehabilitation (12%). Eight patients (8%) had undocumented reasons for readmission. The common SHCs in the first readmission were pressure ulcers (39%), followed by urinary tract infections (12%), deteriorating neurological status (6%) and constipation (3%). Patients with paraplegia had 2.3 times greater odds of readmission compared with tetraplegics (p=0.000, 95% CI 1.47 -3.55). Those in the category T1 - T6 level of injury had 2.6 times greater odds of readmission (p=0.04, 95% CI 1.04 - 6.71, while those with incomplete spinal cord injury had 2.5 times greater odds (p=0.001, 95% CI 1.44 - 4.46CONCLUSIONS: Factors related to patient injury profile such as type, completeness and level of injury were associated with a significant risk of readmission. SHCs were the main cause of readmission, and there is a need for effective programmes for their prevention

Validation and effect on diabetes control of glycated haemoglobin (HbA1c) point-of-care testing

BACKGROUND: Optimal control of diabetes mellitus (DM) remains daunting globally. Point-of-care testing (POCT) for glycated haemoglobin (HbAlc) enables the clinician to make immediate management decisions and thereby improve DM control and complications. Better control is increasingly being striven for in developing countries where availability of POCT devices is limitedMETHODS: Every alternate patient who visited the diabetes clinic at Edendale Hospital, Durban, South Africa, between 1 June 2017 and 31 August 2017 was invited to participate in the study. These patients made up the POCT group, with the remainder making up the control laboratory group. The POCT group had Quo-Test HbAlc POCT done at the clinic visit and their treatment was adjusted based on the HbAlc reading, while the control group received standard treatment. The two groups of patients were reviewed at 3 months to identify differences in diabetes control between themRESULTS: Data from 266 patients were analysed (135 in the POCT group v. 131 in the control group). There was no significant difference between the price of the POCT and laboratory HbAlc tests (p=0.823). The POCT and laboratory HbAlc values showed good correlation at baseline (r=0.995; p<0.001). The two groups of patients were evenly matched in respect of most demographic and clinical variables. Patients in the POCT group showed a significant improvement in mean (standard deviation) glycaemic control between baseline and 3 months (9.61 (2.46) v. 8.98 (2.15); p<0.043). No improvement was noted in the control group (9.58 (2.49) v. 9.43 (2.15);p=0.823CONCLUSIONS: The Quo-Test HbAlc POCT had good correlation with standard laboratory methods in respect of both glycaemic control and price. Patients who had POCT at baseline showed a significant improvement in glycaemic control at 3 months. HbAlc POCT in the setting of a multifaceted approach to diabetes care has been shown to have definite benefits

Mortality among older patients admitted to the medical wards of Groote Schuur Hospital, Cape Town, South Africa, 2010 - 2013

BACKGROUND: Geriatric medicine is an evolving specialty in Africa, and little is known about mortality among older patients admitted to medical wardsOBJECTIVES: To determine mortality rates and associated factors among older medical inpatientsMETHODS: Electronic data on patients aged >60 years admitted to the medical wards of Groote Schuur Hospital, Cape Town, South Africa, between January 2010 and December 2013 were analysed. Data extracted included sex, age, causes of death, and length of stay from date of admission to discharge or death. Results of laboratory tests carried out during the admission were also obtainedRESULTS: In all, 11 254 older patients were admitted (mean (standard deviation) age 70.7 (7.9) years). There were 1 701 deaths (15.1%). The unadjusted mortality rate was 29.6 deaths per 1 000 patient-days (PD). The majority (87.5%) were admitted as emergency cases. Mortality in the first 24 hours was 32.4 deaths per 1 000 PD. There was a significant increase in mortality with increasing age (p<0.001). Stroke was the commonest cause of mortality (14.5%). The predictors of mortality were short length of stay on admission (odds ratio (OR) 1.047, 95% confidence interval (CI) 1.033 - 1.061), high white blood cell count (OR 1.064, 95% CI 1.054 - 1.074), low platelet count (OR 0.999, 95% CI 0.996 - 1.000), low haemoglobin (OR 0.940, 95% CI 0.917 - 0.964) and high blood urea (OR 1.042, 95% CI 1.033 - 1.051CONCLUSIONS: Mortality among older medical inpatients was high. Modifiable predictors of mortality, especially related to laboratory derangements, should be identified and addressed promptly

Four-year review of admissions to a South African regional hospital general surgery department

BACKGROUND: There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) contextOBJECTIVES: To retrospectively review data from an electronic discharge summary database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admittedMETHODS: All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems - Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysisRESULTS: Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 - 43.8) and a mean length of stay of 4.9 days (95% CI 4.7 - 5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 yearsCONCLUSIONS: A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information

A retrospective review on benzodiazepine use: A case study from a chronic dispensary unit

BACKGROUND: Benzodiazepines (BZDs) are highly effective hypnotic and anxiolytic agents and among the most frequently used drugs in the world, but there are significant disadvantages associated with their use. Identifying possible irrational BZD prescribing is important to ensure safe and effective use of these agents. No studies have been conducted in other African countries, and this is the only study in the Western Cape (WC) Province of South Africa (SA), highlighting the paucity of local researchOBJECTIVES: To identify the most commonly prescribed BZDs at a chronic dispensary unit (CDU) in the WC and describe the indications, co-prescribing patterns and patient factors in different areas of the WCMETHODS: A retrospective, quantitative study was carried out using prescription data from a CDU in the Western Cape Department of Health, SA. Data for January 2017 were analysed. Associations between BZD therapeutic indications and co-prescribing patterns were assessed, together with demographic data. Data were coded and descriptive and inferential analysis was done using Stata version 14RESULTS: A total of 1 396 prescriptions met the inclusion criteria and were analysed. Overall, clonazepam was the most frequently prescribed BZD (n=691 prescriptions, 49.5%), followed by diazepam (n=298, 21.4%), lorazepam (n=222, 15.9%) and oxazepam (n=185, 13.3%). The most common therapeutic indication for BZDs was epilepsy (n=294, 21.1%), followed by depression (n=166, 11.9%) and depression with concomitant anxiety (n=79, 5.7%). The most common concomitant drug class associated with BZD use was antiepileptics (n=1 581), followed by other BZDs (n=706) and analgesics and antipyretics (n=665). Female patients were more likely than males to be prescribed BZDs (p<0.001), and the mean (standard deviation) age of BZD users was 51.3 (19.5) yearsCONCLUSIONS: BZDs were most commonly prescribed to female patients and middle-aged adults. Clonazepam was the most frequently prescribed BZD, indicating a preference for long-acting BZDs. Epilepsy was the most common therapeutic indication and antiepileptics were the most common concomitant drug class prescribed, implying that BZDs have a primary role in the management of epileptic conditions in the public healthcare sector. Future studies should include the private sector, as regulations in the public sector greatly influence the patterns of BZD use