South African Medical Journal (SAMJ)
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Wound documentation by doctors in academic emergency departments, Gauteng Province, South Africa
Get PDFBackground. Medical doctors manage trauma cases daily, most needing medicolegal documentation. Wound documentation is a vital skill required by doctors.
Objectives. To describe and compare the knowledge and practices of documentation of clinical findings on the J88 form, looking at the accuracy of wound features and wound size estimation, focusing on participant gender, medical level of experience and type of injury simulated.
Methods. This was a multi-centre, prospective, observational, cross-sectional study of three academic emergency departments in the University of the Witwatersrand academic circuit using questionnaires, moulage and wound characteristic rubrics.
Results. Eighty-three doctors participated in the study. This was equally spread between sexes. According to wound rubrics, participants scored an average of 48% for accuracy of J88 form completion. The most precise wound description was abrasion (62.5%). The least precise wound description was stab wound (33.3%). Most participants (63.8%) noted on the questionnaire that they always indicate bruises; however, 25.3% missed the simulated bruise. The most frequently documented wound features were location and size estimation (98.8%). The least documented wound feature was the age and mechanism of the injury (<6%). Large wounds (>5 cm length) were underestimated (p<0.001), with accurate size estimations of smaller wounds (<5 cm). Perceptions of undergraduate training in wound documentation were evenly divided between acceptable and poor, while postgraduate training was generally regarded as poor.
Conclusion. This study found that wound documentation among emergency department doctors was poor, with participants scoring an average of 48% across the marking rubric. More training at both undergraduate and postgraduate levels is recommended
Identification and management of iron deficiency anaemia in hospitalised children in Durban, South Africa
Get PDFBackground. Despite iron deficiency anaemia (IDA) being a global challenge, guidelines on identifying and managing children in infection- burdened areas are unclear. Little is known about the investigation and treatment of IDA for hospitalised children in HIV-endemic areas.
Objectives. To determine the prevalence of anaemia in hospitalised children and to describe the factors that impact the identification and management of IDA in an urban area of South Africa (SA).
Methods. A cross-sectional study was conducted at a referral hospital in Durban, SA, from 1 January 2019 to 31 December 2019. A chart review was performed for the clinical and laboratory data of 1 138 hospitalised children between 1 and 5 years old who had full blood count results. Standard statistical analyses were performed, including comparative analyses between those with and without anaemia.
Results. There was a 24% prevalence rate of anaemia (46.2% of whom were moderate-severe). There was a greater prevalence for anaemia in malnourished children (p<0.0001) and those HIV exposed (p<0.0001). Despite 65.9% of anaemic children having microcytic hypochromic anaemia, iron studies were only performed in 12/273 (4.4%), and stool samples were tested in 16/273 (5.9%). The majority (260/273, 95.2%) of all anaemic children had a Mentzer index >13, suggesting a high prevalence of IDA. Only 10/273 (3.7%) were provided with iron. Children with microcytic hypochromic anaemia were no different in clinical presentation or outcome to other anaemic children. High numbers (55.1%) were on antibiotics, and this high infection burden may have affected the identification and management of IDA.
Conclusion. Malnourished and HIV-exposed children have a higher prevalence of anaemia. Despite this, <10% of children had basic investigations to identify IDA. This study highlights the urgent need to implement guidelines in identifying IDA and providing iron replacement in hospitalised children in areas with high infection burdens, including SA.
HIV index testing implementation at public health clinics in South Africa
Get PDFBackground. Most ongoing HIV infection is caused by individuals with undiagnosed or untreated HIV. HIV index testing services (ITS), also known as risk network recruitment, have been recommended by international and national programmes to increase diagnosis of untreated people living with HIV (PLHIV) to link them to HIV treatment services. The scale of routine implementation of ITS is unclear.
Objectives. To describe clinic-level adoption and implementation of ITS in South Africa (SA).
Methods. We used random sampling to select participating healthcare facilities from all nine SA provinces. A survey link was sent to a facility manager via email or WhatsApp. Summary statistics were used to describe the findings.
Results. From August 2022 to March 2024, we sent a survey link to 350 systematically sampled clinics; 305 (87.1%) completed the survey. Of those clinics, 260 (85.2%) reported some form of ITS implementation. More than half (n=166, 63.8%) reported using client (passive) referral. Available intimate partner violence (IPV) mitigation services provided counselling by lay HIV testing counsellors for most (n=215, 82.7%) facilities; 120 (46.1%) also had an on-site social worker to assist with IPV mitigation, and 12 (4.1%) had no IPV service available. Approximately half of the clinics offering ITS depended on a supporting non-governmental organisation to provide this service.
Conclusion. ITS was reported to be provided by most public clinics in SA. However, the majority provided passive ITS, depending on the index client to refer their contacts to a local clinic for HIV testing. This approach had little evidence of effectiveness
Access to oncology care in western KwaZulu-Natal Province before, during and after the COVID-19 pandemic
Get PDFBackground. Timely access to oncological care is essential. International experience suggests that the COVID-19 pandemic negatively impacted this. Knowledge of the experience in South Africa is limited.
Objective. To assess the effect of COVID-19-associated lockdowns on access to cancer care for public sector patients in western KwaZulu- Natal Province (KZN).
Methods. A retrospective chart review was conducted in the Oncology Department of Grey’s Hospital (GHOD), a tertiary hospital in KZN, to determine times between onset of symptoms, diagnosis, first consultation at GHOD and treatment. Patient demographics were included. Patients were stratified by both date of first GHOD appointment and of biopsy with respect to the various lockdown stages.
Results. A total of 360 patient files over four time periods (pre COVID-19, hard and soft lockdown and post-COVID-19) were reviewed. When stratified by first GHOD appointment, only waiting time from GHOD review to treatment decreased, with all other waiting times remaining stable. The average number of new patients seen per day decreased during soft lockdown, with the proportion of patients referred from primary care facilities most affected.
Conclusion. Despite the challenges of a global pandemic, access to GHOD care was not compromised in terms of patient waiting times. The absolute number of patients seen decreased, however, particularly those referred from primary care facilities. This study reviewed the entire COVID-19 period and shows that the impact of COVID-19 on patients who accessed care was not necessarily negative. The need for research regarding diagnosis and referral at primary and secondary care levels during the pandemic is highlighted
Penicillin remains an effective agent against Group A Streptococcus in low- and middle-income countries: A systematic review and meta-analysis of antibiotic resistance and associated genes
Get PDFBackground. Driven by the extensive use of antibiotics, antibiotic resistance has become an issue globally, in both hospital and community settings. Limited access to laboratory diagnostic testing often results in undetected resistance, which may only be detected once empiric treatment fails. There have been numerous reports on the increase of antibiotic resistance in group A Streptococcus (Strep A), particularly macrolide resistance.
Objectives. To document the prevalence of antibiotic resistance in Strep A in low- and middle-income countries (LMICs) to the most widely used antibiotics. Where possible, resistance data were correlated with emm typing data.
Methods. We employed an extensive search strategy to identify studies in LMICs reporting on Strep A susceptibility to commonly prescribed antibiotics. Inclusion criteria required that isolates underwent emm typing. Two reviewers independently extracted data and assessed quality; statistical analyses, including meta-analysis using Stata software, evaluated the association between AMR and emm subtypes, and heterogeneity was assessed with Cochrane’s Q and I2 statistics.
Results. Fifty studies met the eligibility criteria and were included in this review. A range of phenotypic resistance testing methods was employed across the studies, the most common being disc diffusion. Three studies exclusively used molecular testing. For the Strep A antimicrobial resistance (AMR) quantitative synthesis, 23 commonly used antibiotics were included in the meta-analysis. Increased resistance was observed among the macrolides (erythromycin, clindamycin, azithromycin), clarithromycin and tetracycline. Differences were observed in resistance patterns across emm types, with emm1, emm12 and emm60 showing higher resistance rates to tetracycline and erythromycin. The ermB (57.60%) and tetM (52.18%) genes were the most prevalent AMR genes among the studies. No resistance to penicillin, amoxicillin/clavulanic acid, cefotaxime, cefuroxime, linezolid, ofloxacin or teicoplanin was reported.
Conclusion. This review comprehensively characterises the latest evidence on the prevalence of antibiotic resistance in Strep A in LMICs. Strep A in LMICs continues to be highly susceptible to antibiotics in vitro, primarily to penicillins. Strep A macrolide resistance patterns in LMICs are similar to those observed in high-income countries. The findings of this review may serve to inform effective treatment decisions and public health interventions
Re: Monitoring District Health System performance in South Africa: A proposed dashboard based on key pragmatic indicators
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