South African Medical Journal (SAMJ)
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Innovative interdisciplinary emergency neurology rotation: Building bridges for enhanced patient care
Get PDFThe South African guidelines on enuresis: 2024 update
Get PDFBackground. Enuresis, also referred to as nocturnal enuresis, is characterised by discrete episodes of urinary incontinence during sleep in children aged ≥5 years in the absence of congenital or acquired neurological disorders. This guideline is an update of the 2017 version.
Recommendations. The guideline provides recommendations and suggestions for various therapeutic options for enuresis available in South Africa (SA). These options include behavioural modification, urotherapy, pharmaceutical therapy, alarm therapy, alternative therapies, neuromodulation, psychological support and biofeedback. Additionally, it explores the role of a voiding diary, additional investigations and mobile phone applications (apps) in treating enuresis. The document also outlines standardised definitions for clarity.
Conclusion. This is an updated guideline endorsed by relevant key opinion leaders in SA, with additional input from international experts in the field
South African Rheumatism and Arthritis Association 2024 guidelines for the management of axial spondyloarthritis
Get PDFEarly diagnosis and prompt treatment initiation are essential in the management of axial spondyloarthritis (axSpA), also known as ankylosing spondylitis, remembering that underdiagnosis and overdiagnosis of axSpA are common. These South African guidelines offer screening tools and details of useful investigations, including imaging. Care of the axSpA patient requires a multidisciplinary holistic approach emphasising lifestyle interventions, particularly exercise, smoking cessation and psychosocial support. The ankylosing spondylitis disease activity score is recommended as a measure of disease activity, and a stepwise algorithm for therapy is provided. Screening for comorbidities and vaccination is advised
The burden and outcomes of firearm injuries at two district-level emergency centres in Cape Town, South Africa: A descriptive analysis
Get PDFBackground. In South Africa (SA), injuries are the second leading cause of years of healthy life lost, and interpersonal violence dominates the SA injury profile. Half of all injury-related deaths in SA are intentional, and firearms contribute to a quarter of these deaths. Injury surveillance systems are essential to develop, implement and monitor strategies that reduce preventable trauma.
Objectives. To describe the burden of patients with firearm injuries and their outcomes at district-level emergency centres in the Western Cape.
Methods. This study was a retrospective analysis of a prospectively collected database. All patients who presented to two district-level emergency centres with a firearm injury over a 12-month period (1 January 2019 - 31 December 2019) were eligible for inclusion.
Results. Firearm injuries represented 5.7% of the trauma burden at the two district emergency centres. Of the 776 patients with firearm injuries who were included, the median age was 27 years, and 91% were male. A total of 520 (67%) patients self-presented, and there were 18 (2.3%) deaths in the emergency centre and a further 23 (3%) as inpatients. Of the total where wound location was determined (n=595), 30.4% sustained more than one firearm injury, and 112 out of the 167 admitted to Mitchells Plain Hospital required at least one visit to theatre. This accounted for 413 theatre hours and 1 376 inpatient bed days at Mitchells Plain Hospital. A significant proportion of patients (n=219, 29%) were transferred from the emergency centres to a tertiary service for further care.
Conclusion. Firearm injuries represent a substantial proportion of the trauma burden at district emergency centres in the Western Cape Province. Managing patients with firearm injuries is resource intensive, as evident by their high acuity, the need for operative care, the long length of stay, the high burden on emergency medical services with interfacility transfers and the high demand for tertiary care. Data from this study aid our understanding of the prevalence and burden of firearm injuries at district level emergency centres, and multisectoral action, supported by evidence-based primary and secondary preventive strategies, is required to reduce the burden of firearm injuries, and mitigate their effects
Renal transplant recipient and deceased-donor risk profiles at Wits Donald Gordon Medical Centre, Johannesburg, South Africa: A 9-year review
Get PDFBackground. Renal transplantation is the gold-standard therapy for end-stage renal disease. Decision-making around the acceptance of deceased-donor organs is complex and time sensitive. Risk scoring systems for both donors and recipients attempt to simplify the allocation of renal grafts to the most appropriate recipient.
Objectives. To investigate the role of these transplant risk scores in the South African (SA) setting.
Methods. A total of 188 adult deceased-donor organ referrals over the 9-year period 1 January 2013 - 31 December 2021 were included. The Kidney Donor Risk Index (KDRI) and the UK KDRI were calculated for each donor. Recipients who were allocated these grafts were characterised, and the Hennepin Transplant Risk Score and the Kidney Transplant Morbidity Index (KTMI) were calculated.
Results. The median (interquartile range) KDRI was 1.2 (0.9 - 1.6), confirming that low- to average-risk donors were being utilised. Similarly, the median UK KDRI was 0.9 (0.8 - 1.2). Both these scores performed poorly in predicting graft and patient survival, with a C-statistic of 0.5. Renal recipient risk scores also demonstrated low- to average-risk patients being transplanted, with a median Hennepin score of 2 - 4 points and a KTMI of 2 points. These recipient scores predict increased recipient mortality at high scores, albeit with low sensitivity, and were not significantly associated with graft survival.
Conclusion. Deceased-donor and renal recipient risk scores commonly used internationally performed poorly in predicting graft survival in our cohort, and should be used with caution in the SA setting. A conservative approach to organ donor referral and utilisation as well as renal transplant recipient listing was noted
The state of paediatric deceased-organ donation at a South African tertiary public- sector hospital: A 14-year analysis
Get PDFBackground. Solid-organ transplantation (SOT) has been proven to be a highly effective and life-saving treatment modality for adults and children suffering from end-stage organ failure. However, high paediatric waiting-list mortality has been reported, and children may suffer irreversible physical and deleterious psychological effects if not transplanted timeously.
Objectives. To identify in-hospital barriers to organ donation and gain a better understanding of the paediatric donor landscape. Methods. A retrospective descriptive study of consecutive deceased-donor referrals at Red Cross War Memorial Children’s Hospital over a 14-year period, from 1 January 2007 to 31 December 2020.
Results. During the study period, 156 in-hospital deaths were recorded in the trauma unit and 1 425 in the paediatric intensive care unit. Ninety-three of the 1 581 patients (5.9%) were referred to the on-call transplant co-ordinator as potential organ donors, of whom 69% had been involved in a traumatic accident, including 52% in road traffic collisions. The mean age of the potential donors was 7 years with 60.2% being boys. On initial assessment, 67 of the 93 potential donors (72%) were assessed as eligible for donation of at least one solid organ. The transplant co-ordinator attempted to approach all families for consent; however, five families/next of kin could not be located despite multiple attempts. Among the remaining 62 eligible donors, 44 families/next-of-kin declined consent for solid-organ donation, resulting in a consent rate of 29% (n=18). Several families refused consent for religious reasons. One of the consented donors did not proceed to procurement as there were no suitable recipients. Seventeen donors proceeded to theatre, the intention being solid-organ procurement, but in 2 donors the organs were assessed as being unsuitable for transplant. From the remaining 15 donors, a total of 46 organs were procured and successfully transplanted: 14 livers, 30 kidneys and 2 hearts.
Conclusion. During the 14-year study period, only 15 deceased donors could be utilised for SOT, as a result of low in-hospital referral (5.9%) and consent rates (29%). The reasons for low referral and consent rates are complex and often multifactorial, which the current study was not designed to investigate in sufficient detail. Future studies should be designed to further interrogate our findings, while accommodating for nuances specific to the paediatric deceased-donor population and their families
Prevalence and predictors of severe Crohn’s disease at a tertiary hospital in South Africa
Get PDFBackground
Predicting severe Crohn\u27s disease (SCD) can assist in planning risk reduction therapy for SCD, thereby improving disease outcomes.
Objective
To determine the prevalence and predictors of SCD in a sample of South African patients.
Methods
This was a retrospective chart review of patients with Crohn\u27s disease (CD) attending the Gastroenterology Unit at a tertiary hospital in Durban, South Africa. Demographic and clinical variables at diagnosis of CD were collected and analysed for statistical association with development of SCD (defined as the presence of >/= 1 of the following over the course of CD: complex perianal disease, colonic resection >/= 2 small bowel resections, a single small bowel resection > 50cm, or construction of a definitive stoma). The prognostic utility of statistically significant variables was investigated by establishing their sensitivity, specificity, and predictive values for SCD.
Results
The study consisted of 93 patients. The rate of SCD was 64.5%, with 63.3 % of patients developing SCD within 1 year of CD diagnosis. Ileocolonic location (p = 0.046) and penetrating disease at initial diagnosis of CD (p = 0.021) were statistically associated with SCD. The sensitivity, specificity, positive predictive value, and negative predictive value of ileocolonic location for SCD was 72.7%, 47.4%, 66.7% and 54.6%. The sensitivity, specificity, positive predictive value, and negative predictive value of penetrating disease for SCD was 85.7%, 41.7%, 30.0% and 91.0%.
Conclusion
Most patients with CD developed SCD within 1 year of their CD diagnosis. CD with a penetrating phenotype at diagnosis is a good predictor for the devleopment of SCD and should be further investigated.
Resilience in the time of crisis: A review of the maternal, perinatal and reproductive health effects of COVID-19 in South Africa
Get PDFBackground. The COVID‐19 pandemic had a profound effect on the health sector globally and in South Africa (SA).
Objective. To review the effects of COVID‐19 on maternal, perinatal and reproductive health outcomes and service utilisation in SA.
Methods. Three routine national data collection systems were sourced: the District Health Information System, the Saving Mothers reports of the National Committee on Confidential Enquiry into Maternal Deaths and the Saving Babies reports from the National Perinatal Morbidity and Mortality Committee using data from the Perinatal Problem Identification Program.
Results. There were 35% and 8% increases in maternal and stillbirth mortality rates, respectively, in 2020 and 2021, which correlated with the COVID‐19 waves. However, in 2022, rates returned to pre‐COVID levels. Antenatal visits and facility births showed little change, but there was a shift to more rural provinces. The use of oral and injectable contraceptives and termination of pregnancy services decreased markedly in 2020 and 2021, with a sustained shift to long‐acting reversible contraceptives. The increase in maternal deaths was predominantly due to COVID‐19 respiratory complications, but also an increase in obstetric haemorrhage. Stillbirths increased significantly (10%) for birthweights between 2 000 g and 2 499 g, categorised mostly as unexplained stillbirths or preterm labour, but no increase in neonatal deaths was observed. Administrative avoidable factors increased by 24% in the 2020 ‐ 2022 triennium, but there was no increase in patient/community level or healthcare provider‐related avoidable factors during the pandemic years.
Conclusion. COVID‐19 caused a marked increase in maternal death and stillbirth rates in 2020 and 2021 due to both direct effects of the virus and indirect effects on functioning of the health system. The continued, although modified, health‐seeking behaviour of women and the rapid return to pre‐COVID‐19 mortality rates demonstrates enormous resilience in women and the health system
