South African Medical Journal (SAMJ)
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The development of a nurse-led preoperative anaesthesia screening tool by Delphi consensus
Get PDFBackground. Low- and middle-income countries have a critical shortage of specialist anaesthetists. Most patients arriving for surgery are of low perioperative risk. Without immediate access to preoperative specialist care, an appropriate interim strategy may be to ensure that only high-risk patients are seen preoperatively by a specialist. Matching human resources to the burden of disease with a nurse-administered pre-operative screening tool to identify high-risk patients who might benefit from specialist review prior to the day of surgery may be an effective strategy.
Objective. To develop a nurse-administered preoperative anaesthesia screening tool to identify patients who would most likely benefit from a specialist review before the day of surgery, and those patients who could safely be seen by the anaesthetist on the day of surgery. This would ensure adequate time for optimisation of high-risk patients preoperatively and limit avoidable day-of-surgery cancellations.
Methods. A systematic review was conducted to identify preoperative screening questions for use in a three-round Delphi consensus process. A panel of 16 experienced full-time clinical anaesthetists representing all university-affiliated anaesthesia departments in South Africa participated to define a nurses’ screening tool for preoperative assessment.
Results. Ninety-eight studies were identified, which generated 79 questions. An additional 14 items identified by the facilitators were added to create a list of 93 questions for the first round. The final screening tool consisted of 81 questions, of which 37 were deemed critical to identify patients who should be seen by a specialist prior to the day of surgery.
Conclusion. A structured nurse-administered preoperative screening tool is proposed to identify high-risk patients who are likely to benefit from a timely preoperative specialist anaesthetist review to avoid cancellation on the day of surgery
Assessing awareness and treatment knowledge of preventable blindness in rural and urban South African communities
Get PDFBackground. Preventable blindness is a global public health problem. In South Africa (SA) the prevalence of blindness is increasing, with a higher proportion of cataracts than the global norm, and a large rural population with limited access to specialised eye-care services.
Objective. To determine the level of knowledge regarding preventable blindness and treatment options within a rural and urban population. Setting. Rural and urban areas in the Eastern Cape, SA.
Methods. A descriptive cross-sectional study was conducted among 309 participants. Questionnaires were administered by fieldworkers at the different sites. Proportions were calculated and χ2 tests done to determine whether there was any significant relationship between the categorical variables. Data analysis was done using Stata version 15.
Results. Participants were almost equally distributed among the urban (49.2%) and rural areas (50.8%). Both groups had a similar composition of males and females. Most participants had completed high school. The results showed a statistically significant difference between the urban and rural participants’ knowledge about the causes of blindness: refractive error χ 2 (1, N=30) = 8.20, p<0.05, and cataract χ2 (1, N=28) = 8.64, p<0.05. The top two differences in the views between urban and rural participants regarding symptoms associated with eye problems (p<0.05) were: ‘people who need spectacles have double vision’, χ2 (1, N=122) = 28.19; and ‘people who need spectacles squint their eyes’, χ2 (1, N=124) = 17.37. The majority of urban participants reported opting to go to a private optometrist for eye health services, while the majority of rural participants would go to a pharmacy. Both groups were aware of the role of ageing in blindness.
Conclusion. Urban participants in this study appeared to be more knowledgeable than rural participants about the causes and symptoms of blindness and its treatment options. These findings should provide some value to those who provide primary healthcare services in rural areas as there is a clear opportunity for patient education and health promotion regarding the causes and symptoms of these common preventable causes of blindness. Addressing this knowledge gap regarding the causes and symptoms of blindness and the treatment options is a critical first step for awareness programmes in rural areas. Without this, there will be little demand for any treatment or service. Future studies are needed to understand which health promotion interventions are effective in preventable blindness in rural populations
Clinical course, management and outcomes of COVID-19 in HIV-infected renal transplant recipients: A case series
Get PDFBackground. HIV‐infected kidney transplant recipients with COVID‐19 are at increased risk of acute illness and death owing to their underlying comorbidities and chronic immunosuppression.
Objectives. To describe the incidence, clinical presentation and course of COVID‐19, vaccination status, and SARS‐CoV‐2 antibody positivity rate among HIV‐infected‐to‐HIV‐infected kidney transplant recipients in South Africa (SA).
Methods. This retrospective study reports on rates of SARS‐CoV‐2 infection, COVID‐19 and mortality among SA HIV‐infected kidney transplant recipients who received organs from HIV‐infected donors (HIV positive to HIV positive), before and after vaccination. Patient demographics, clinical presentation, course, management and disease outcomes were analysed. Antibody serology tests were performed between May and September 2022.
Results. Among 39 HIV‐positive‐to‐HIV‐positive transplant recipients, 11 cases of COVID‐19 were diagnosed from March 2020 to September 2022. Six patients (55%) required hospitalisation, of whom 3 were admitted to a high‐care unit or intensive care unit. Two patients required mechanical ventilation, and 2 received acute dialysis. One patient was declined access to intensive care. Four patients (10%) died of COVID‐19 pneumonia. All the COVID‐19‐positive patients had at least one comorbidity. Vaccination data were available for 24 patients, of whom 5 had refused SARS‐CoV‐2 vaccination. SARS‐CoV‐2 antibody data were available for 20 patients; 4 vaccinated patients had a negative nucleocapsid protein antibody test and a positive spike protein antibody test, suggesting vaccination‐acquired immunity. The remaining 16 patients demonstrated immunity that was probably due to COVID infection, and of these, 14 were also vaccinated. Of the 11 COVID‐19 cases, only 1 was observed after vaccination.
Conclusion. In our case series, ~10% of the HIV‐positive‐to‐HIV‐positive transplant recipients died of COVID‐19 pneumonia. This mortality rate appears higher than figures reported in other transplant cohorts. However, it is likely that the actual number of cases of SARS‐CoV‐2 infection was much higher, as the study only included polymerase chain reaction‐confirmed cases. It remains unclear whether HIV infection, transplant or the combination of the two drives poorer outcomes, and larger studies adjusting for important demographic and biological factors may isolate these effects
Lower respiratory tract infection admissions and deaths among children under 5 years in public sector facilities in the Western Cape Province, South Africa, before and during the COVID-19 pandemic (2019 - 2021)
Get PDFBackground. The COVID‐19 pandemic resulted in the implementation of strict public health and social measures (PHSMs) (including mobility restrictions, social distancing, mask‐wearing and hand hygiene), limitations on non‐essential healthcare services, and public fear of COVID‐19 infection, all of which potentially affected transmission and healthcare use for other diseases such as lower respiratory tract infections (LRTIs).
Objective. To determine changes in LRTI hospital admissions and in‐facility mortality in children aged <5 years in the Western Cape Province during the pandemic.
Methods. We conducted a retrospective analysis of LRTI admissions and in‐facility deaths from January 2019 to November 2021. We estimated changes in rates and trends of LRTI admissions during the pandemic compared with pre‐pandemic period using interrupted time series analysis, adjusting for key characteristics.
Results. There were 36 277 children admitted for LRTIs during the study period, of whom 58% were male and 51% were aged 28 days ‐ 1 year. COVID‐19 restrictions were associated with a 13% step reduction in LRTI admissions compared with the pre‐COVID‐19 period (incidence rate ratio (IRR) 0.87, 95% confidence interval (CI)) 0.80 ‐ 0.94). The average LRTI admission trend increased on average by 2% per month during the pandemic (IRR 1.02, 95% CI 1.02 ‐ 1.04).
Conclusions. The COVID‐19 surges and their associated measures were linked to declining LRTI admissions and in‐facility deaths, likely driven by a combination of reduced infectious disease transmission and reduced use of healthcare services, with effects diminishing over time. These findings may inform future pandemic response policies
The association between tobacco and alcohol use and health outcomes in individuals living with diabetes and prediabetes in South Africa: A cross-sectional study
Get PDFBackground. Smoking and alcohol misuse are lifestyle factors that can be controlled and have significant health effects. Both these factors increase the risk of developing conditions such as diabetes mellitus because they affect glucose metabolism and can interfere with blood glucose control in individuals with diabetes. Research on tobacco and alcohol use and specific health outcomes among adults with prediabetes or type 2 diabetes mellitus (T2DM) could provide valuable information leading to more efficient treatment and management of this disease.
Objectives. To assess the association between tobacco and alcohol use and specific health outcomes among South African adults with prediabetes or T2DM.
Methods. Data from the 2016 South African Demographic and Health Survey were analysed using Stata v17. Participants were classified into prediabetes or T2DM groups, based on a glycated haemoglobin cut-off of 5.7% or self-report of a previous diagnosis of T2DM. Exposures of interest were self-reported current tobacco smoking and problem/risky alcohol use. The associations between these exposures and health outcomes in the different groups were assessed using multivariable logistic regression analysis. We adjusted for specific confounders in the regression models.
Results. Of a total of 6 108 participants (mean (standard deviation) age 41 (19) years), 72.2% (n=4 409) had prediabetes and 27.8% (n=1 699) T2DM; 17.7% (n=1 084) were current smokers and 9.3% (n=565) reported problem/risky alcohol use. Current smoking was significantly associated with 40% increased odds of shortness of breath (adjusted odds ratio (aOR) 1.40; 95% confidence interval (CI) 1.1 - 1.7; p<0.001) and 67% increased odds of chronic obstructive pulmonary disease (COPD)/asthma (aOR 1.67; 95% CI 1.2 - 2.2; p<0.001). Problem/risky alcohol use was significantly associated with 40% increased odds of COPD/asthma (aOR 1.40; 95% CI 1.1 - 1.7; p=0.001) and 92% increased odds of having cancer (aOR 1.92; 95% CI 1.5 - 2.5; p<0.001).
Conclusion. There is a need for targeted smoking cessation programmes and alcohol misuse counselling among individuals living with diabetes and prediabetes
Vaccines in the fight against antimicrobial resistance – perspectives from South Africa
Get PDFAntimicrobial resistance (AMR), in which microbes adapt to and resist current therapies, is a well-recognised global problem that threatens to reverse gains made by modern medicine in the last decades. AMR is a complex issue; however, at its core, it is driven by the overuse and inappropriate use of antimicrobials. Socioeconomic factors have been identified as significant contributors to the emergence and exacerbation of AMR, especially in populations facing inadequate access to healthcare, poor sanitation services and high morbidity and mortality rates. Weak healthcare systems and water, sanitation and hygiene have been highlighted as fundamental risk factors for AMR emergence and transmission. Behavioural factors, such as purchasing antibiotics without a prescription from a registered healthcare professional, not completing the prescribed course or overly prolonged courses of antibiotics, using antibiotics to treat viral infections, lack of access to quality antibiotics, and the proliferation of substandard or falsified (SF) drugs, have also been identified as significant contributors to AMR. Low- and middle-income countries have a higher incidence of antibiotics being dispensed without a prescription than higher-income countries
Liver cystic echinococcosis: A retrospective study on the demographics and clinical profile of patients managed at a single tertiary institution in central Eastern Cape Province, South Africa
Get PDFBackground. Cystic echinococcosis (CE) is a zoonotic disease with an Africa-wide prevalence of 1.7%. CE is caused by the tapeworm Echinococcus granulosus sensu lato, with the liver being the most commonly affected organ. In South Africa (SA), there is a paucity of data on liver CE demographics and management.
Objectives. To describe the demographics and clinical profile of patients with liver CE in a single tertiary hospital in Eastern Cape Province, SA.
Methods. A 4-year (2019 - 2022) retrospective clinical record review study was conducted on patients presenting with liver CE to the Department of Surgery at Frere Hospital. The demographics, clinical characteristics and management of patients with liver CE are reported.
Results. A total of 56 patients diagnosed with and managed for liver CE were included in the study. The mean age of the patients was 37.5 years. Abdominal pain (n=39; 69.6%) was the most common presenting symptom, and a palpable abdominal mass (n=36; 64.3%) was the predominant presenting sign. Most patients had disease confined to the liver (n=35; 62.5%). The right lobe of the liver was most commonly affected (n=38; 67.9%), and most patients had a single liver cyst on imaging (n=32; 57.1%). The majority of the patients (n=36; 64.3%) were managed with surgical partial cystectomy, with a perioperative bile leak being the most common complication.
Conclusion. In our setting, liver CE contributes to a significant local burden of the disease. The disease often has a nonspecific clinical presentation, necessitating imaging for the diagnosis. We observed good short-term outcomes in patients managed with combined partial cystectomy and medical therapy, although there is a risk of perioperative bile leak