South African Medical Journal (SAMJ)
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Death trends for 2010 - 2022 for members of a large private medical scheme in South Africa
Get PDFBackground. In the absence of more recent national data on underlying causes of death in South Africa (SA), we examined mortality trends from 2010 to 2022 among members of a large private medical scheme. This analysis sheds light on the health profile of this specific demographic. Objective. To investigate trends in Discovery Health Medical Scheme (DHMS) members’ death rates and underlying cause of death patterns between 2010 and 2022.
Methods. All-cause deaths were compared across years accounting for demographic changes, by analysing age- and sex-standardised rates using 2019 age and sex population weightings. We used underlying cause-of-death data from death notifications.
Results. The 2019 age- and sex-standardised death rate was lower than the 2010 rate by 10%, with a steady decline experienced between 2010 and 2019. We have seen reduced age- and sex-standardised death rates from HIV/AIDS during this period, and despite the high prevalence, reduced age- and sex-standardised death rates from non-communicable diseases. Malignant neoplasms and cardiovascular disease have been and remained the two leading causes of death for Discovery Health Medical Scheme (DHMS) clients between 2012 and 2022. Age- and sex- standardised death rates, however, reached historic high levels during the first 2 years of the COVID-19 pandemic in SA. In 2020, overall age- and sex-standardised death rates for DHMS members increased to 542 deaths per 100 000 life years, which was higher than pre-pandemic levels. Age- and sex-standardised death rates went on to reach their highest level in the history of the scheme in 2021, at 767 deaths per 100 000 life years. Age- and sex-standardised death rates, however, had returned to near 2019 (pre-pandemic) levels by 2022, at 477 deaths per 100 000 life years. Males experienced a higher increase in age-standardised death rates during 2020 and remained at an increased risk of death in 2022 compared with pre-pandemic levels. When COVID-19 -related deaths are excluded, the age-standardised rates for both females and males in 2022 was lower than observed in the pre-pandemic years. While the low mortality experience could be related to competing causes and mortality displacement, further analysis over a longer period is needed to confirm this.
Conclusion. DHMS experienced the highest level of age- and sex-standardised death rates during 2020 and 2021, the initial 2 years of the COVID-19 pandemic. Most of this increase was explained by COVID-19 deaths
The association between serum fructosamine and random spot urine fructose levels with the severity of non-alcoholic fatty liver disease – an analytical cross-sectional study
Get PDFBackground. Non-alcoholic fatty liver disease (NAFLD) in South Africa and Africa at large is considered a hidden threat. Our local population is burdened with increased metabolic risk factors for NAFLD. Our setting requires a reasonable approach to screen for and aid the diagnosis of NAFLD.
Objectives. To investigate serum fructosamine and random spot urine fructose levels as biomarkers for the screening, diagnosis and monitoring of NAFLD. The primary objective of this study was to compare serum fructosamine and random spot urine fructose levels between groups with different levels of NAFLD severity as measured by ultrasound. A secondary objective was to determine the association, if any, between serum transaminases, the aspartate aminotransferase (AST) to platelet ratio index (APRI) score, serum fructosamine and urine fructose in different groups with steatosis.
Methods. Using a cross-sectional study design, 65 patients with three different levels of NAFLD, as detected by imaging, were enrolled. The primary exposures measured were serum fructosamine with random spot urine fructose, and secondary exposures were the serum transaminases (AST and alanine aminotransferase (ALT)) and the APRI score. Patients identified at the departments of gastroenterology, general internal medicine and diagnostic radiology were invited to participate.
Results. There were 38, 17 and 10 patients with mild, moderate and severe steatosis, respectively. There was no significant difference between the groups regarding serum fructosamine, measured as median (interquartile range): mild 257 (241 - 286) μmol/L, moderate 239 (230 - 280) μmol/L and severe 260 (221 - 341) μmol/L, p=0.5; or random spot urine fructose: mild 0.86 (0.51 - 1.30) mmol/L, moderate 0.84 (0.51 - 2.62) mmol/L and severe 0.71 (0.58 - 1.09) mmol/L, p = 0.8. ALT (U/L) differed between groups: mild 19 (12 - 27), moderate 27 (22 - 33), severe 27 (21 - 56), p=0.03, but not AST (U/L) (p=0.7) nor APRI (p=0.9). Urine fructose and ALT were correlated in the moderate to severe steatosis group (R=0.490, p<0.05), but not in the mild steatosis group. Serum fructosamine was associated with age in the mild steatosis group but not the moderate-severe steatosis group (R=0.42, p<0.01).
Conclusion. Serum fructosamine and random spot urine fructose did not vary with the severity of NAFLD, indicating that they would not be useful biomarkers in this condition.
An analysis of referral patterns of traumatic brain injury at Groote Schuur Hospital Trauma Centre
Get PDFBackground. Traumatic brain injury (TBI) can result in significant morbidity and mortality if not diagnosed in a timely manner. Brain computed tomography (CT) is the diagnostic gold standard but is of limited availability in most South African public hospitals, resulting in transfer of TBI patients to tertiary hospitals.
Objective. To describe the referral patterns and outcomes of patients with TBI referred to Groote Schuur Hospital Trauma Centre. Methods. This was a retrospective audit of all patients admitted to the Trauma Centre who had a brain CT scan for suspected TBI between 1 February 2022 and 31 March 2022. Demographic data (age, sex), mechanism of injury and Glasgow Coma Score were recorded. Referral pathways were determined, and final disposition of patients was recorded.
Results. A total of 522 patients had a brain CT for TBI. Of these, 314 (60.1%) were referred from other hospitals. CT scan was abnormal in 178 (34.1%) patients. Three hundred and two (58.6%) were discharged home within 24 hours. The mean time between referral and CT scan was 13 hours.
Conclusion. More than half of patients referred for a CT scan were discharged from the Trauma Centre within 24 hours of admission, which indicates additional costs and inefficiencies in the health system. These data are useful to guide resource planning and allocation for district hospitals, since less expensive point-of-care modalities now exist to diagnose TBI, and which are useful in indicating the prognosis of patients.
The utility of artificial intelligence in identifying radiological evidence of lung cancer and pulmonary tuberculosis in a high-burden tuberculosis setting
Get PDFBackground. Artificial intelligence (AI), using deep learning (DL) systems, can be utilised to detect radiological changes of various pulmonary diseases. Settings with a high burden of tuberculosis (TB) and people living with HIV can potentially benefit from the use of AI to augment resource-constrained healthcare systems.
Objective. To assess the utility of qXR software (AI) in detecting radiological changes compatible with lung cancer or pulmonary TB (PTB).
Methods. We performed an observational study in a tertiary institution that serves a population with a high burden of lung cancer and PTB. In total, 382 chest radiographs that had a confirmed diagnosis were assessed: 127 with lung cancer, 144 with PTB and 111 normal. These chest radiographs were de-identified and randomly uploaded by a blinded investigator into qXR software. The output was generated as probability scores from predefined threshold values.
Results. The overall sensitivity of the qXR in detecting lung cancer was 84% (95% confidence interval (CI) 80 - 87%), specificity 91% (95% CI 84 - 96%) and positive predictive value of 97% (95% CI 95 - 99%). For PTB, it had a sensitivity of 90% (95% CI 87 - 93%) and specificity of 79% (95% CI 73 - 84%) and negative predictive value of 85% (95% CI 79 - 91%).
Conclusion. The qXR software was sensitive and specific in categorising chest radiographs as consistent with lung cancer or TB, and can potentially aid in the earlier detection and management of these diseases
Rural-urban disparities and socioeconomic determinants of caesarean delivery rates in Zimbabwe: Evidence from the 2019 National Multiple Indicator Cluster Survey
Get PDFCaesarean sections (CSs) have increased globally, with concerns being raised involving overutilisation and inequalities in access. In Zimbabwe, where healthcare access varies greatly, we aimed to analyse factors associated with ever having a CS using the 2019 National Multiple Indicator Cluster Survey. The weighted national CS rate was 10.3%, and CS happened more commonly among women in urban than rural areas (15.7% v. 7.4%; odds ratio (OR) 2.34; (95% confidence interval (CI)) 1.71 - 3.20; p=0.001). Percentages of those having a CS significantly increased with education: overall χ2 for a trend of p=0.001 and wealth quintile, and overall χ2 for a trend of p=0.001. Women with insurance coverage were more likely to have had a CS than those without: 26.7% v. 8.7%; OR 3.82; 95% CI 2.51 - 5.83; p=0.001. The same was the case for women with access to the internet: 15.4% v. 7.0%, OR 2.42; 95%CI 1.71 - 3.41; p=0.001). These findings show an association that could indicate this being overutilised by insured women in urban settings, rather than being accessible based on clinical needs. Further research should explore reasons for these disparities and inform interventions to ensure equitable access to optimum childbirth in Zimbabwe
The management and clinical outcome of paracetamol poisoning in South African adults: A single-centre retrospective review
Get PDFBackground. Paracetamol is a commonly prescribed drug, and often implicated in pharmaceutical overdoses. Paracetamol-induced hepatotoxicity is a common cause of acute liver failure in many high-income countries, but little is known about the factors associated with severity of liver injury and poor clinical outcomes among those treated in sub-Saharan African settings.
Objective. To describe the characteristics of patients presenting with paracetamol poisoning, and to identify factors associated with severity of liver injury and poor outcomes in adults with biochemical evidence of paracetamol-induced liver damage treated at a South African (SA) tertiary hospital.
Methods. A retrospective medical record review was conducted of all adult patients (≥18 years old) admitted between August 2013 and August 2018 to a tertiary referral centre in Cape Town, SA, with paracetamol poisoning and biochemical evidence of liver impairment. Demographics, clinical and laboratory data were obtained. Management practices and clinical outcomes were assessed.
Results. The records of 91 patients were included in the analysis. The median (interquartile range (IQR)) age was 29 (23 - 39) years, and 63% were female. The majority of paracetamol poisonings followed an intentional overdose (91%). Acute single ingestions were the most common (81%) type of toxic ingestion, compared with staggered overdose and repeated supratherapeutic ingestion, and the median (IQR) number of tablets ingested was 22 (20 - 39). Two-thirds of patients developed mild liver injury and 12% developed acute kidney injury. The overall mortality rate was 12%. Mortality was lower in those who received intravenous N-acetylcysteine (NAC) before serum paracetamol concentrations were known compared with those who only received NAC after concentrations were known (8.8% v. 36%, p=0.03). A significant proportion of deaths occurred in those with accidental overdose compared with those with intentional overdosing (57% v. 7.2%; p=0.004). People living with HIV (p=0.04), a history of chronic alcoholism (p=0.04), chronic liver disease (p=0.01) and severity of acute kidney stage (p<0.001) were all associated with increased mortality.
Conclusion. A high case fatality rate was observed in the studied population. Early identification of at-risk individuals and prompt initiation of NAC can reduce poor outcomes. Larger multicentre studies are needed to identify independent predictors of paracetamol-induced hepatoxicity and mortality in Africa
The COVID-19 pandemic and blood utilisation in South Africa
Get PDFBackground. The COVID‐19 pandemic, first reported in December 2019, affected every sector of every country worldwide. Health services were the first to experience the direct impact. Blood services were advised to decrease blood utilisation in anticipation of reduced blood collections. The South African National Blood Services (SANBS) saw a substantial decline in blood demand following the institution of strict national lockdown measures, but the impact of the epidemic and various mitigation strategies remained unknown.
Objective. This retrospective study reviews red blood cell (RBC) utilisation during a 4‐year period from 2019 to 2022 in the South African (SA) population, stratified by public and private healthcare sectors.
Methods. To measure the impact of COVID‐19, blood utilisation pre COVID‐19 was compared with an acute COVID‐19 period and a post‐acute period. Each period covered 450 days. Blood utilisation was evaluated against the background of reported COVID‐19 cases and national lockdown regulations.
Results. With the onset of the COVID‐19 pandemic, overall RBC utilisation dropped by ~17%. The initial decline was more pronounced in the public sector. Overall, utilisation recovered to pre‐COVID‐19 levels in the post‐acute COVID‐19 period, but at different rates in the public and private sectors.
Conclusion. There was a significant change in RBC utilisation during the course of the COVID‐19 pandemic, much more pronounced in the public sector, which services 85% of the SA population. During the post‐acute COVID‐19 period, blood utilisation recovered, but at a much slower rate in the public sector. The COVID‐19 pandemic accentuated the differences in blood utilisation patterns between the public and private healthcare sectors in SA, and each sector’s resilience in adapting to the challenges of the epidemic
Sexual and reproductive health and rights, HIV and migration in southern Africa: A rapid review
Get PDFMigration, a prevalent global phenomenon, significantly impacts health, particularly in low- to middle-income countries. This article presents a rapid review aimed at mapping projects, lessons and policies concerning sexual and reproductive health (SRH), HIV and migration in southern Africa. Utilising a population-concept-context framework, the review focuses on understanding the scope, nature and extent of interventions, identifying lessons learnt, and assessing existing policies and strategies. A comprehensive search strategy and screening process resulted in 19 studies and reports for inclusion. The review highlighted diverse projects across southern Africa, addressing SRH and HIV among migrants, refugees and asylum seekers. Projects ranged from peer-education interventions to community-based referral systems, aiming to improve knowledge, access and outcomes related to SRH and HIV. The lessons learnt emphasised the importance of community involvement, healthcare worker (HCW) training and inclusive policies to address migrants’ diverse needs effectively. Additionally, projects facilitated cross-border collaborations and policy integration, enhancing access to SRH-HIV services and migrant health rights. Despite these efforts, challenges persist, including gender-based violence, financial barriers and xenophobic attitudes among HCWs. Limited access to comprehensive sexuality education and social protection for migrants underscores the need for further policy development and implementation. Nevertheless, existing policies, such as Botswana’s inclusive HIV treatment policy and South Africa’s National Strategic Plan for HIV, TB and STIs, demonstrate steps towards ensuring migrants’ rights to healthcare
