Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 109 num. 7 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Violence in hot weather: Will climate change exacerbate rates of violence in South Africa?</b>]]> <![CDATA[<b>The elephant in the room - part two</b>]]> <![CDATA[<b>Healthy Hearts: A student-led heart-health initiative</b>]]> <![CDATA[<b>Therapeutic use exemptions - serving athlete patients</b>]]> <![CDATA[<b>The National Asthma Education Programme and asthma in Africa</b>]]> <![CDATA[<b>Does South Africa need a diabetes-in-pregnancy study group?</b>]]> <![CDATA[<b>Screening and diagnosis of gestational diabetes mellitus in South Africa: What we know so far</b>]]> The early detection and management of gestational diabetes mellitus (GDM) present an ideal opportunity to decrease perinatal complications and adverse long-term health outcomes in mothers and their offspring. This review describes the major GDM screening and diagnostic strategies used worldwide, including novel screening and diagnostic methods that are being explored. It highlights the varied screening and diagnostic strategies currently employed in South Africa (SA). The lack of uniform GDM diagnostic criteria and variation in clinical practice hamper early detection and management of GDM, which negatively affects maternal and child health. We recommend that an SA diabetes-in-pregnancy study group, comprising interested obstetricians, physicians, endocrinologists, public health specialists, dieticians and scientists, be established to make evidence-based recommendations on affordable, accessible and applicable GDM screening and diagnostic and management strategies. <![CDATA[<b>Prevalence of and risk factors for gestational diabetes mellitus in South Africa</b>]]> Gestational diabetes mellitus (GDM) is associated with adverse maternal, fetal and perinatal complications. Without appropriate glucose management, women with GDM and their offspring have an increased risk of developing type 2 diabetes and other metabolic conditions later in life, thereby adding to the growing burden of non-communicable diseases (NCDs). This review provides an update of GDM in South Africa (SA), showing that its prevalence is increasing, and highlights treatment and management strategies currently employed. Although the increase in GDM prevalence may partly be due to less stringent diagnostic criteria, the role of the increasing obesogenic environment in SA is an additional factor. Future research should focus on reducing the rising obesity epidemic and in so doing aim to prevent the development of GDM in SA. Such initiatives will have a positive impact on decreasing maternal and child morbidity and mortality and the future burden of NCDs. <![CDATA[<b>Safeguarding the future of genomic research in South Africa: Broad consent and the Protection of Personal Information Act No. 4 of 2013</b>]]> Genomic research has been identified in South Africa (SA) as important in developing a strong bio-economy that has the potential to improve human health, drive job creation and offer potential solutions to the disease burden harboured by low- and middle-income countries. Central to the success of genomic research is the wide sharing of biological samples and data, but the true value of data can only be unlocked if there are laws and policies in place that foster the legal and ethical sharing of genomic data. The introduction and entry into force of SA's Protection of Personal Information Act (POPIA) No. 4 of 2013 is to be welcomed, but the wording of POPIA as it pertains to consent for the processing of personal information for research purposes has sparked a debate about the legal status of broad consent. We argue that a purposive interpretation of the legislation would permit broad consent for the processing of personal information for research. Although there are ongoing debates surrounding the ethical use of broad consent in Africa, the objective of this article is not to engage with the ethics of broad consent itself, but rather to focus on the legal status of broad consent for genomic data sharing under POPIA. <![CDATA[<b>Patient blood management: A solution for South Africa</b>]]> For more than 70 years the default therapy for anaemia and blood loss was mostly transfusion. Accumulating evidence demonstrates a significant dose-dependent relationship between transfusion and adverse outcomes. This and other transfusion-related challenges led the way to a new paradigm. Patient blood management (PBM) is the application of evidence-based practices to optimise patient outcomes by managing and preserving the patient's own blood. 'Real-world' studies have shown that PBM improves patient outcomes and saves money. The prevalence of anaemia in adult South Africans is 31% in females and 17% in males. Improving the management of anaemia will firstly improve public health, secondly relieve the pressure on the blood supply, and thirdly improve the productivity of the nation's workforce. While high-income countries are increasingly implementing PBM, many middle- and low-income countries are still trying to upscale their transfusion services. The implementation of PBM will improve South Africa's health status while saving costs. <![CDATA[<b>Recurrent idiopathic spontaneous coronary artery dissection</b>]]> Spontaneous coronary artery dissection (SCAD) is a relatively rare cause of acute coronary syndrome and sudden cardiac death, which frequently affect young women in the absence of established cardiovascular risk factors. Advancements in cardiovascular imaging account for the increasing recognition of this diagnosis and associated diagnoses, although classic diagnostic modalities such as electrocardiography remain of paramount importance. We present a young woman with recurrent SCAD and briefly discuss her management and its outcome. <![CDATA[<b>Child mortality trends and causes of death in South Africa, 1997 - 2012, and the importance of a national burden of disease study</b>]]> BACKGROUND: The Rapid Mortality Surveillance System has reported reductions in child mortality rates in recent years in South Africa (SA). In this article, we present information about levels of mortality and causes of death from the second SA National Burden of Disease Study (SA NBD) to inform the response required to reduce child mortality furtherOBJECTIVES: To estimate trends in and causes of childhood mortality at national and provincial levels for the period 1997 - 2012, to highlight the importance of the SA NBDMETHODS: Numbers of registered child deaths were adjusted for under-reporting. Adjustments were made for the misclassification of AIDS deaths and the proportion of ill-defined natural causes. Non-natural causes were estimated using results from the National Injury Mortality Surveillance System for 2000 and the National Injury Mortality Survey for 2009. Six neonatal conditions and 11 other causes were consolidated from the SA NBD and the Child Health Epidemiological Reference Group lists of causes of death for the analysis. The NBD cause-fractions were compared with those from Statistics South Africa, the United Nations Children's Fund (UNICEF) and the Institute for Health Metrics and Evaluation (IHMERESULTS: Under-5 mortality per 1 000 live births increased from 65 in 1997 to 79 in 2004 as a result of HIV/AIDS, before dropping to 40 by 2012. The neonatal mortality rate declined from 1997 to 2001, followed by small variations. The death rate from diarrhoeal diseases began to decrease in 2008 and the death rate from pneumonia from 2010. By 2012, neonatal deaths accounted for 27% of child deaths, with conditions associated with prematurity, birth asphyxia and severe infections being the main contributors. In 1997, KwaZulu-Natal, Free State, Mpumalanga and Eastern Cape provinces had the highest under-5 mortality, close to 80 per 1 000 live births. Mortality rates in North West were in the mid-range and then increased, placing this province in the highest group in the later years. The Western Cape had the lowest mortality rate, declining throughout the period apart from a slight increase in the early 2000sCONCLUSIONS: The SA NBD identified the causes driving the trends, making it clear that prevention of mother-to-child transmission of HIV, the Expanded Programme on Immunisation and programmes aimed at preventing neonatal deaths need to be equitably implemented throughout the country to address persistent provincial inequalities in child deaths. The rapid reduction of childhood mortality since 2005 suggests that the 2030 Sustainable Development Goal target of 25 per 1 000 for under-5 mortality is achievable for SA. Comparison with alternative estimates highlights the need for cause-of-death data from civil registration to be adjusted using a burden-of-disease approach <![CDATA[<b>Patterns of renal disease: A 30-year renal biopsy study at Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa</b>]]> BACKGROUND: Data on renal pathology from sub-Saharan Africa are limitedOBJECTIVES: To report on biopsy-confirmed renal pathology over 30 years in Soweto, South Africa (SAMETHODS: Retrospective analysis was conducted of 1 848 adult native renal biopsies performed at Chris Hani Baragwanath Academic Hospital between 1 January 1982 and 31 December 2011RESULTS: There was an even gender distribution, and 96.4% of patients were of black ethnicity. The mean (standard deviation) age of patients was 33.5 (12.6) years. The main clinical indications for renal biopsy were nephrotic syndrome (47.7%), acute kidney injury (19.8%) and asymptomatic urine abnormalities (8.1%). Secondary glomerular diseases (SGNs) (49.3%) occurred more frequently than primary glomerular diseases (PGNs) (39.7%). SGNs increased during the study period, while PGNs decreased (p<0.001). The most frequent PGNs were focal segmental glomerulosclerosis (FSGS) (29.6%), membranous glomerulonephritis (25.7%) and membranoproliferative glomerulonephritis (18.1%). Lupus nephritis (LN) (31.0%) was the most frequent SGN, followed by HIV-associated nephropathy (HIVAN) (13.3%) and malignant hypertension (12.5%). HIV-positive biopsies constituted 19.7% of all biopsies, and the proportion increased over time. In HIV-positive patients, the most common diagnoses were HIVAN (32.7%), HIV immune complex disease (11.8%) and FSGS (11.3%CONCLUSIONS: This study contributes to our knowledge of renal pathology in SA and shows some data that differ from studies in other regions. The increase in SGNs probably reflects the influence of HIV and LN in the study population <![CDATA[<b>#FeesMustFall2016: Perceived and measured effect on clinical medical students</b>]]> BACKGROUND: Medical students are under immense academic stress. Campus unrest can contribute to stress and influence academic performance, social behaviour, emotional stability and financial expensesOBJECTIVES: To investigate the effects of #FeesMustFall2016 (#FMF2016) on the 2016 3rd-year (semester 6) clinical medical students at the University of the Free State (UFS), Bloemfontein, South AfricaMETHODS: In phase 1 of the project, anonymous questionnaires were completed by the clinical students who experienced physical test disruption during #FMF2016. Opinions regarding academic performance, financial expenses, behaviour changes and stress levels were gathered. The students also completed a formal post-traumatic stress screening assessment. In phase 2 of the project, the academic performance of these students was compared with that of students not affected by #FMF2016RESULTS: Of the target population of 138 students, 87.0% completed the questionnaires. Three-quarters of the respondents reported a negative effect on academic performance, and most did not believe that the delivering of lectures on Blackboard was a good way of training. Alcohol consumption increased in 31.9% of the students. Criteria for post-traumatic stress disorder (PTSD) were met in 12.7% of students. Compared with previous and later cohorts of students there were no clear differences regarding marks, but there was a tendency towards poorer performance and more failures the next yearCONCLUSIONS: Semester 6 medical students at UFS reported that the #FMF2016 protests had a negative effect on academic, social, financial and stress aspects. PTSD was present in 12.7% of students compared with 7.8% in similar populations <![CDATA[<b>Agreeing on the minimum: An 11-year review of Prescribed Minimum Benefits appeals</b>]]> BACKGROUND: Prescribed Minimum Benefits (PMBs) in South Africa (SA) are a set of minimum health services that all members of medical aid schemes have access to regardless of their benefit options or depleted funds. Medical aid schemes are liable to pay for these services. However, ~40% of all complaints received by the Council for Medical Schemes (CMS) are in relation to PMBs. Individuals/stakeholders who are unsatisfied with judgments on their complaints are allowed to appealOBJECTIVES: To determine and describe the pattern of PMB appeals from 1 January 2006 to 31 December 2016METHODS: This was a descriptive cross-sectional study that utilised the CMS Judgments on Appeals database. Data for PMBs, levels of appeal, judgments, appellants, respondents and medical scheme types were extracted. The CMS's lists of chronic conditions, PMBs and registered schemes were used to confirm PMBs and to categorise schemes as either open (i.e. to all South Africans) or restricted (i.e. only open to members of specific organisations). Data were extracted and frequencies were calculated using Stata software, version 14RESULTS: All eligible appeal reports (N=340) were retrieved and 123 PMB appeals were included in the study (36.2%). The median number of PMB appeals per year was 11 (interquartile range 9 - 27). Open schemes accounted for 82.1% of all the PMB appeals. Half of the total appeals (50.4%, 62/123) were by medical aid schemes appealing their liability to pay for PMBs, and of these 69.4% (43/62) were found in favour of members. The remaining half (49.6%, 61/123) were appeals by members appealing that schemes were liable to pay, and of these 80.3% (49/61) were found in favour of the medical aid schemes. Treatment options that were scheme exclusions constituted 34.4% (21/61) of reasons why schemes were found not liable to pay. Various types of cancers and emergency conditions constituted one-quarter of all PMB appealsCONCLUSIONS: While the pattern is unclear and the extent of the problem is masked, this study shows that a quarter of the conflict resulting in PMB appeals was due to various types of cancers and emergency conditions. Medical schemes should revise their guidelines, policies and criteria for payment of these two services and improve their communication with healthcare providers and members <![CDATA[<b>Increase in blood pressure over a 7-year period in a mixed-ancestry South African population</b>]]> BACKGROUND: An increase in the prevalence of high blood pressure (BP) has been reported globally and in the South African (SA) populationOBJECTIVES: To investigate temporal changes in absolute BP levels and hypertension prevalence in the mixed-ancestry South AfricansMETHODS: Participants were from two independent cross-sectional surveys conducted during 2008/09 (N=928) and 2014/16 (N=1 969) in Bellville South, Cape Town, SA. Participants' eligibility was based on several criteria, including age >20 years and neither bedridden nor pregnant. Data were obtained by administered questionnaires, clinical measurements (BP and anthropometry) and biochemical assessments (oral glucose tolerance tests and cotinine levels). Known hypertension was based on a self-reported history of doctor-diagnosed hypertension and ongoing treatment. Comparison across years was based on the crude prevalence of hypertension as well as direct age-standardised prevalence, based on the SA 2011 mixed-ancestry population distribution, in 10-year age incrementsRESULTS: In all, 708 participants (76.3%) in 2008/09 and 1 488 (75.6%) in 2014/16 were female. Between 2008/09 and 2014/16, mean systolic BP increased from 124 to 136 mmHg (absolute mean difference 15 mmHg) and mean diastolic BP from 75 to 85 mmHg (absolute mean difference 9 mmHg) in the overall sample. The prevalence of screen-detected hypertension increased from 11.6% to 24.8%, with a similar increase in males and females, while the prevalence of known cases remained stable. These changes remained significant after adjustment for age and genderCONCLUSIONS: A rightward shift in absolute BP translated into a significant increase in the prevalence of hypertension over time in this population. The predominant increases in screen-detected hypertension suggest that the deteriorating profile was not matched by efforts to detect and manage individuals with higher-than-optimal BP levels <![CDATA[<b>Characterisation of protease resistance mutations in a South African paediatric cohort with virological failure, 2011 - 2017</b>]]> BACKGROUND: Advances in HIV management have improved treatment outcomes in the HIV-infected population. However, these advances have not been without multifaceted challenges. In sub-Saharan Africa, their impact is reflected in the increased emergence of HIV drug resistance mutations. With the rise in exposure of children to protease inhibitors (PIs), the possibility of increasing PI resistance remains a concernOBJECTIVES: To describe a group of antiretroviral-experienced children with PI drug resistance mutations after failure on first- or second-line regimens in a public sector setting in South AfricaMETHODS: This was a retrospective cohort study of 22 children perinatally infected with HIV who had HIV genotyping conducted between January 2011 and December 2017RESULTS: Of the 236 children who had HIV genotyping conducted, 22 (9.3%) had evidence of HIV PI resistance mutations. Twenty-one of the 22 children (95.5%) had major mutations in the protease region of the HIV genome. Of these children, 66.7% (14/21) had loss of response to both boosted lopinavir and atazanavir, with boosted darunavir remaining susceptible in only 12 (57.1%). The most frequent major PI mutations were V82A (76.2%), M46I/M46L (76.2%), I54V (62.0%) and L76V(33.3%CONCLUSIONS: We observed a high rate of PI resistance mutations, with a resulting loss of PIs that could be used in construction of third-line regimens. To build on improvements from the introduction of antiretroviral therapy, increased efforts are needed by both health professionals and caregivers to improve adherence measures in children perinatally infected with HIV <![CDATA[<b>Workmen's compensation for occupational hand injuries</b>]]> BACKGROUND: The Compensation for Occupational Injuries and Diseases Act No. 130 of 1993, as amended in 1997 (COIDA), provides payment to healthcare providers for treatment of occupational injuries in South Africa (SA). Patients and employers are often unaware of procedures for claiming, and patients then carry the burden of costs themselves. Additionally, under-billing results in a loss of income for treating hospitals. Hand injuries are common occupational injuries and form the focus of this studyOBJECTIVES: To investigate whether occupational hand injuries treated at the Martin Singer Hand Unit at Groote Schuur Hospital, Cape Town, were accurately captured and allocated correct professional fee coding and billing. Accurate capturing and billing would allow for access to the Compensation Fund and allocation of finances to improve service delivery, as well as avoid unnecessary costs to otherwise uninsured patientsMETHODS: All new hand injuries presenting to the hand unit at the hospital in August 2017 were sampled in a retrospective folder review. Injuries on duty (IODs) were identified and analysed further. Coding and billing were compared with independent private quotesRESULTS: Sixty new hand injuries presented during the month. Fifteen were IODs, but only 6 were recognised by administration. The other 9 were billed at minimum income rates and 5 of these patients also had operations, which were not billed for. A total of ZAR88 871.99 was under-billed in terms of professional fees only. The 9 incorrectly classified patients had to bear costs themselves at a median of ZAR130.00 eachCONCLUSIONS: There were large discrepancies in billing for occupational hand injuries. This resulted in costs to the patients and loss of income for the facility. Access to the Compensation Fund is vital in financing resources in the overburdened public sector. Suggestions for improvement include accessing COIDA funds in order to improve administration at the unit, so improving identification, coding and billing of occupational hand injuries <![CDATA[<b>INTERGROWTH-21st v. local South African growth standards (Theron-Thompson) for identification of small-for-gestational-age fetuses in stillbirths: A closer look at variation across pregnancy</b>]]> BACKGROUND: Global growth standards for fetuses were recently developed (INTERGROWTH-21st). It has been advocated that professional bodies should adopt these global standardsOBJECTIVES: To compare the ability of INTERGROWTH-21st with local standards (Theron-Thompson) to identify small-for-gestational-age (SGA) fetuses in stillbirths in the South African (SA) settingMETHODS: Stillbirths across SA were investigated (&gt;500 g, 28 - 40 weeks) between October 2013 and December 2016 (N=14 776). The study applied the INTERGROWTH-21st standards to classify stillbirths as <10th centile (SGA) compared with Theron-Thompson growth charts, across pregnancy overall and at specific gestational agesRESULTS: The prevalence of SGA was estimated at 32.2% and 31.1% by INTERGROWTH-21st and Theron-Thompson, respectively. INTERGROWTH-21st captured 13.8% more stillbirths as SGA in the earlier gestations (28 - 30 weeks, p<0.001), but 4.0% (n=315) fewer between 33 and 38 weeks (p<0.001). Observed agreement and the Kappa coefficient were lower at earlier gestations and at 34 - 36 weeksCONCLUSIONS: Our findings demonstrated differences in the proportion of stillbirths considered SGA at each gestational age between the INTERGROWTH-21st and the local SA standard, which have not been considered previously by other studies <![CDATA[<b>Maternal alcohol use and children's emotional and cognitive outcomes in rural South Africa</b>]]> BACKGROUND: Alcohol use in South Africa (SA) is increasing. The World Health Organization (WHO) states that SA is the third-largest drinking population in Africa, with the highest rate of fetal alcohol syndrome in the world. Internationally, parental drinking during childhood is a risk factor for poor child mental health, behavioural problems and weaker educational outcomes in middle childhood. However, parental alcohol use in Africa is under-researched, and much of the literature on maternal alcohol consumption is restricted to clinical and pregnancy samplesOBJECTIVES: To investigate alcohol use and hazardous drinking (HD) among mothers/primary caregivers of children aged 7 - 11 years in a rural SA cohort. We explored risk factors for drinking and the association between HD and child behaviour/cognitionMETHODS: The primary outcome measure was the WHO Alcohol Use Disorder Identification Test (AUDIT) using the standardised cut-off for HD (>8). Secondary measures were the Patient Health Questionnaire Depression Scale (PHQ-9), Patient Health Questionnaire General Anxiety Disorder Scale (GAD-7), Parenting Stress Index, short form (PSI-36), Child Behaviour Checklist (CBCL, parent reported), Kaufman Developmental Assessment Battery (KABC-II) for child cognition, and Neuropsychological Assessment Battery, 2nd edition, subtests (NEPSY-II) for executive function. We compared characteristics of those drinking/not drinking, using χ² tests, and modelled outcomes on parenting stress, cognitive outcomes and CBCL scores for children using logistic regression analysis. We grouped mothers/ caregivers engaged in HD to examine its effect on parent/child outcomes using t-tests to test for significant differencesRESULTS: Of 1 505 women (1 266 mothers and 239 caregivers) with 1 536 children, 12% reported consuming alcohol and 3% reported HD. Higher maternal/caregiver age (31 - 40 years, adjusted odds ratio (aOR) 0.57 (95% confidence interval (CI) 0.4 - 0.9); >41 years, aOR 0.30 (95% CI 0.2 - 0.5)), education (matriculation, aOR 0.49 (95% CI 0.3 - 0.9); post matriculation, aOR 0.30 (95% CI 0.1 - 0.6)), and a stable relationship with the father (aOR 0.6 (95% CI 0.4 - 1.0)) were associated with no alcohol use. Food insecurity increased the odds of alcohol use (aOR 1.52 (95% CI 1.1 - 2.1)), while parental mental health (parenting stress, anxiety) and child mental health problems were associated with approximately double the odds of consuming alcohol in univariate analysis. Children of HD mothers/caregivers had higher mean scores for psychological problems (CBCL total score: no HD (mean 45.0) v. HD (mean 48.9); p=0.029) and lower cognitive scores (KABC Learning Scale: no HD (mean 14.3) v. HD (mean 12.8); p=0.017CONCLUSIONS: While HD rates were low, maternal/caregiver alcohol use negatively impacted on parenting and children's behavioural/ cognitive outcomes. International evidence suggests that integrated approaches engaging parents and families may be more effective for parent-child outcomes than individual psychiatric or medical care for the parent on their own <![CDATA[<b>Frailty in perioperative patients in three South African academic hospitals</b>]]> BACKGROUND: Frailty is a state characterised by diminished physiological reserve that leaves an individual vulnerable to external stressors and delays recovery. Frailty assessments are proving to be more valuable in predicting poor perioperative outcomes than other well-known perioperative risk assessment tools. Very few studies using validated frailty assessment tools have been done to assess the prevalence of frailty in South Africa (SA), and none have assessed the intraoperative implications of frailty in a surgical population.OBJECTIVES: To determine the demographics and frailty levels of patients presenting for surgery at three academic hospitals in Johannesburg, compare intraoperative complications between the frail and non-frail patients, and compare the association between frailty scores and American Society of Anesthesiologists Physical Status (ASA-PS) scores.METHODS: We prospectively enrolled 299 patients aged 18 - 90 years undergoing various types of elective surgery between mid-November 2016 and mid-March 2017 in three SA academic hospitals. Frailty was assessed using the nine-point Clinical Frailty Scale (CFS) and defined as a score of >5. The CFS and demographic and clinical data were documented by the anaesthetists assigned to the respective elective lists. The primary outcome measure was intraoperative complications (hypotension, desaturation, and need for vasopressors and blood transfusion). We also compared associations between the patients' comorbidities and frailty and those between the CFS and ASA-PS scores.RESULTS: Of a total of 299 patients included in the study (mean age (standard deviation) 50.6 (15.8) years), 156 (52%) were women and 67 (22%) were classified as frail. Compared with patients who were not classified as frail, the frail group had significantly higher incidences of hypotension (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.083 - 3.259; p=0.02) and desaturation (OR 3.79, 95% CI 1.367 - 10.54; p=0.01), and were more likely to need vasopressors (OR 2.81, 95% CI 1.607 - 4.912; p=0.00) and blood transfusion (OR 3.26, 95% CI 1.138 -9.368; p=0.02). On multivariable logistic regression analysis, adjusting for factors related to frailty such as age, gender and comorbidities, desaturation was significantly associated with frailty (adjusted OR (aOR) 4.21, 95% CI 1.31 - 13.53; p=0.01), and the frail were more likely to require blood transfusion (aOR 5.36, 95% CI 1.50 - 19.16; p=0.01) and were older and had more comorbidities. Higher ASA-PS scores were also strongly associated with frailty.CONCLUSIONS: The prevalence of frailty was high among surgical patients. Consistent with other studies, frailty was associated with older age and multiple comorbidities. The association between frailty and intraoperative complications found in this study may indicate and help inform areas of further research.