South African Medical Journal (SAMJ)
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Profile of deliberate self-poisoning admissions in KwaZulu-Natal Province, South Africa (2018 - 2023) and the impact of COVID-19
No full textBackground. Deliberate self-poisoning (DSP) is a common method of attempted suicide globally, particularly among young adults and women. In South Africa (SA), DSP is the second most frequent method of attempted suicide, after hanging. The COVID-19 pandemic raised concerns about potential increases in suicidal behaviour, but data on its impact on DSP in resource-constrained settings are limited.
Objective. To describe the profile of DSP admissions at a large tertiary hospital in KwaZulu-Natal (KZN) Province, SA, over 2018 - 2023, and to assess whether the COVID-19 pandemic influenced the frequency or outcomes of these cases.
Methods. I conducted a retrospective review of all DSP admissions from 2018 to 2023 at a large tertiary hospital in KZN, SA. All patients aged ≥13 years who intentionally ingested a toxic substance (overdose or poison) were included. Demographic information, substances ingested and clinical outcomes (intensive care unit (ICU) admission, acute medical complications, in-hospital mortality) were recorded. Descriptive statistics were used to characterise the patient cohort, and multivariate logistic regression was used to identify independent predictors of acute medical complications, including an assessment of the COVID-19 pandemic period as a potential risk factor.
Results. A total of 716 DSP cases were analysed over the study period, with a median age of 26 years and a female predominance (64.7%). Medication overdose was the principal mechanism (81%), and the most frequently involved substances were paracetamol (17.6%) and antiretroviral (ARV) medications (16.8%). Acute clinical outcomes were generally favourable: 3.4% of patients required ICU admission, 1.3% developed serious medical complications and the in-hospital mortality rate was 0.7%. A history of psychiatric illness was a strong independent predictor of acute medical complications (odds ratio 9.4, p=0.007). The annual volume of DSP cases showed no significant difference across the pre-pandemic (2018 - 2019), pandemic (2020 - 2021) and post-pandemic (2022 - 2023) periods (p=0.18).
Conclusion. DSP in this setting predominantly affects young adults, especially females, and often involves overdose of readily accessible medications (notably paracetamol and ARV drugs). While acute outcomes were largely favourable, with low rates of severe complications and death, the high involvement of common pharmaceuticals underscores the need for preventive strategies to reduce DSP incidents. Notably, no surge in DSP cases was observed during the COVID-19 pandemic, suggesting that the pandemic’s impact on suicidal behaviour is context-specific.
Case fatality in severe acute malnutrition: Determinants and modifiable factors in hospitalised children in Vhembe district, South Africa
No full textBackground. In 2019, one-quarter of child deaths in South African (SA) hospitals were attributed to severe acute malnutrition (SAM).
Objectives. To identify demographic, clinical, case management and health system factors contributing to mortality in children aged <5 years with SAM admitted to three hospitals in Vhembe district, Limpopo, SA.
Methods. A retrospective record review was conducted for children aged 6 - 59 months admitted with SAM over a 30-month period. Bivariable and multivariable regression analyses were used to determine mortality factors.
Results. A total of 245 children with SAM were identified, with a median (interquartile range) age of 14 (10 - 18) months. The overall SAM case-fatality rate was 26.9% (66/245), significantly higher than routine data estimates. Key clinical factors associated with mortality included diarrhoea at presentation (odds ratio (OR) 3.34, 95% confidence interval (CI) 1.38 - 8.10), anaemia (OR 3.30, 95% CI 1.28 - 8.50), raised C-reactive protein (OR 9.29, 95% CI 2.81 - 30.76) and hyponatraemia (OR 6.64, 95% CI 2.70 - 16.31). Additional contributors included late presentation, self-referral, limited triage, poor recognition and management of comorbidities and inadequate compliance with SAM guidelines. HIV status and shock were not significant determinants of mortality.
Conclusion. SAM mortality was alarmingly high, particularly in the context of a high middle-income country setting with established treatment protocols. The striking discrepancy between the observed case fatality rate and routine district health information system data highlights the need for review of data quality and reporting systems. Targeted interventions addressing both clinical risk factors and systemic gaps are essential to reduce mortality and improve outcomes for children with SAM
Aneuploidy screening in women of advanced age in the public healthcare setting of a low- to middle- income country – an observational cohort study
Get PDFBackground. Screening and termination of pregnancy (TOP) for Down syndrome (DS) are both available in South Africa (SA), but DS is infrequently diagnosed prenatally in the public sector (7% in 2008), resulting in a high live-birth prevalence (1.33 - 2.1 per 1 000). In the SA public sector, DS screening and confirmatory genetic testing are fully state subsidised for women of advanced maternal age (AMA) but, owing to the low positive predictive value of AMA-based screening, ultrasound-based screening is also offered. Given the limited resources and the steady increase in the number of pregnant women of AMA, the value of DS screening in altering pregnancy outcome needs to be critically assessed.
Objectives. To determine the uptake of prenatal screening for DS, invasive testing and TOP in pregnant women of AMA, as well as factors influencing maternal decisions.
Methods. This retrospective cohort study, based on prospectively captured data, includes all women of AMA (>37 years at conception) seen at a regional fetal medicine unit in Cape Town offering fully state subsidised DS screening and testing for a geographically defined area, including mostly women of African or mixed ancestry. Screening was age- and ultrasound-based, and DS risks were calculated using published algorithms. Non-directive genetic counselling was provided to all women ≥40 years old (pre-screen if feasible), women with a relevant history, a fetal anomaly or DS risk higher than that of a woman aged 37 years. Participant characteristics, results, decisions and reasons to decline testing were recorded prospectively, and compared between women <40 completed years and ≥40 years old, and between women accepting or declining invasive testing or TOP.
Results. During the study period, 1 196 women of AMA were seen. Ninety-three received pre-screen counselling, and 44 of these declined DS screening (47.3% (95% confidence interval (CI) 36.9 - 57.9)). Uptake of invasive testing after screening was low (18.1% (CI 15.2 - 21.3)). Age category was not an independent confounder for this, but uptake was lower after previous miscarriage(s), higher after high-risk screening results and highest with a fetal anomaly. The most common reason for declining testing was opposition to TOP. The uptake of TOP for DS, when offered to those who were screened and had accepted invasive testing, was 65.8% (48.7 - 80.4).
Conclusion. The uptake of screening and/or testing was low, and this reflected strong views on TOP for DS. As uptake of testing and/or TOP was higher with abnormal ultrasound findings, a prenatal screening programme addressing structural anomalies and aneuploidies simultaneously (i.e. ultrasound) is preferred over other DS screening tools that target DS specifically
Nocardia species epidemiology and susceptibility profiles from 2019 to 2022 in South Africa
Get PDFBackground. Nocardia species cause infections in humans, from localised to disseminated disease. They constitute a public health threat owing to the lack of sufficient information about them. In South Africa (SA), the last publication on this organism was in 2010. Predominant species types and antibiotic susceptibilities may have changed over this period.
Objective. To address the knowledge gap surrounding Nocardia species and their antibiotic susceptibilities in SA.
Methods. This was a retrospective and cross-sectional study. Data were collected from the Central Data Warehouse (CDW) of the National Health Laboratory Service (NHLS) on suspected Nocardia species from 1 January 2019 to 31 December 2022. Organism speciation was performed using 16S rRNA sequencing and antibiotic susceptibility testing (AST) by the broth microdilution (BMD) method. Data analysis included patient age, sample types from which the organism was cultured, distribution in the various SA provinces, species types and species AST profiles, including a record of trimethoprim-sulfamethoxazole (TMP/SMX) non-susceptibility.
Results. One hundred and sixty-five positive culture results were analysed. The majority of positive cultures (28%, n=46) were from the 30 - 39-year age group. The organism was predominantly cultured from pus samples (31%, n=51). The top two provinces from which the largest numbers of isolates were submitted were Gauteng (69%, n=114) and Western Cape (18%, n=30) provinces. Two percent (n=4) of isolates were not sequenced, and 18% (n=30) of isolates lacked AST results. Twenty-nine percent (n=47) of the Nocardia species that were sequenced could not be speciated using 16S rRNA sequencing. The top two species country-wide were N. abscessus complex (25%, n=42) and N. cyriacigeorgica (18%, n=29). Approximately 90% (n=121) of all isolates tested were TMP/SMX susceptible.
Conclusion. The predominant isolation of Nocardia species from pus samples suggests that the majority were deep-seated infections. The most common Nocardia species types and the AST profiles have changed over time. The study highlights the need for alternative methods for the speciation of this organism
Leflunomide as an alternative csDMARD for rheumatoid arthritis in a resource-constrained setting: A real-life experience
Get PDFBackground. Early treatment with methotrexate (MTX) remains the mainstay of rheumatoid arthritis (RA) treatment. In patients with inadequate response to MTX, the European Alliance of Associations for Rheumatology (EULAR) recommends the addition of a biological disease-modifying antirheumatic drug (bDMARD) if poor prognostic factors are present. Despite patients in Africa frequently having poor prognostic factors, bDMARDs are often not available. Leflunomide (LEF) has been shown to be a potent DMARD, leading EULAR to question whether its efficacy is equivalent to MTX as a first-line agent.
Objective. To review LEF’s use and safety profile in a low-resource setting, and its usefulness in patients with inadequate response to MTX.
Methods. A retrospective record review was done of all patients with RA who received LEF for at least 6 months between 2018 and 2020 at the Division of Rheumatology, Tygerberg Academic Hospital, Cape Town, South Africa. Patients in whom LEF was discontinued within the first 6 months were also included when assessing the discontinuation rate and side-effects. Demographic information, reasons for initiation, side-effects and treatment discontinuation were recorded. Efficacy data were recorded using the clinical disease activity index (CDAI) at 6-month intervals up to 24 months.
Results. A total of 210 patients who were on LEF were included. Most (n=177) patients were females from low-income backgrounds, with a mean age of 56.51 years and a mean (standard deviation) disease duration of 6.9 (1.0 - 13.8) years. Almost all patients (n=209; 99.52%) had poor prognostic factors, mainly high disease activity (mean CDAI 26.68) and previous exposure to ≥2 conventional synthetic DMARDs (csDMARDs). Most patients initiated LEF owing to loss of efficacy and poor response to triple therapy. After initiation of LEF, treatment targets were achieved by 98 (53%) patients, with 22 (11.9%) and 76 (41.1%) patients achieving clinical remission and low disease activity, respectively (p<0.001, confidence interval (CI) 9.90 -12.29). The mean CDAI decreased to 11.17 (p<0.001, CI 9.59 - 12.74). Most disease control was achieved within the first 6 - 12 months, and was sustained for 24 months. A total of 16 (7.62%) patients experienced side-effects, necessitating treatment discontinuation. Two pregnancies exposed to LEF in the first trimester resulted in healthy babies.
Conclusion. LEF has been demonstrated to be an effective alternative csDMARD for patients with inadequate response to MTX-based therapies, reducing the mean CDAI from 26 to 11. It adds a viable alternative for RA patients with poor prognostic factors and lack of access to bDMARDs