South African Medical Journal (SAMJ)
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Strengthening primary care mental health services – lessons from the South African HIV programme
Get PDFThe changing landscape of antimicrobial resistance and use in South Africa: The need for access to new antibiotics: A position paper
Get PDFAntibiotic resistance is a global threat, with a disproportionate burden of mortality in low- and middle-income countries. It is increasing in both the public and private healthcare sectors within South Africa, especially in Gram-negative organisms, and is associated with increased use of World Health Organization watch and reserve antibiotics. There is a need for improved access to new antibiotics to treat infections caused by drug-resistant organisms in order to limit side-effects and improve patient outcomes of currently available antibiotics. We propose the responsible introduction of these new antibiotics with both administrative and clinical oversight in order to preserve the longevity of these precious antibiotics
Analysis of emergency centre recidivism for interpersonal violence in a district-level hospital in Cape Town, South Africa
Get PDFBackground. Interpersonal violence is a major cause of morbidity and mortality in low- and upper-middle-income countries. It is postulated that a significant portion of these patients have repeated presentations to an already overburdened healthcare system. Data describing the burden of interpersonal violence recidivism are poor.
Objective. To determine and describe the burden of emergency centre recidivism for interpersonal violent injury presenting to Khayelitsha Hospital, Cape Town, over a 2-year period.
Methods. An analysis of a prospectively collected observational database combined with a retrospective chart review was conducted of all trauma patients who presented to Khayelitsha Hospital from 1 October 2020 to 30 September 2022. All patients (aged ≥14 years) with ≥2 presentations for interpersonal violence-related injuries were included. Cases were limited to the inclusion of mechanisms of injury attributable to stab wounds, blunt assault, firearm injury and gender-based violence. Recidivist cases were identified by repeat hospital number on the electronic hospital patient system. Repeat cases were manually reviewed for inclusion. Summary statistics are used to describe all variables.
Results. In total, 10 218 interpersonal violence presentations were identified over the study period, and 1 125 (11.0%) were attributed to recidivists (522 patients). The mean (standard deviation) age was 30 (7.7) years, and most were male (n=463, 88.7%). Stab wounds (n=583, 51.8%) and blunt assault injuries (n=456, 40.5%) were the main mechanisms of injury. Repeat presentation occurred within a median of 198 (25th - 75th percentile, 81.5 - 373.9) days. A total of 337 (64.6%) patients presented with higher acuity at one of their subsequent visits.
Conclusion. Recidivist presentations represent a significant proportion of interpersonally violently injured patients, and are likely to be under-documented. Recidivism poses a measurable burden, and further research is needed to facilitate the identification of at-risk individuals, and specific secondary prevention strategies should be developed to prevent or reduce escalating patterns of injury associated with interpersonal violence
Guidance for the gastrointestinal evaluation and management of iron deficiency in Sub-Saharan Africa
Get PDFBackground. Over 30% of the world’s population is anaemic, with a significant proportion of these being iron deficient. As iron deficiency (ID) anaemia in men and post-menopausal women is mostly caused by gastrointestinal blood loss or malabsorption, the initial evaluation of a patient with ID anaemia involves referral to a gastroenterologist. The current drive towards patient blood management in sub-Saharan Africa (SSA)prescribes that we regulate not only the use of blood transfusion but also the management of patients in whom the cause of iron loss or inadequate iron absorption is sought. Recommendations have been developed to: (i) aid clinicians in the evaluation of suspected gastrointestinal iron loss and iron malabsorption, and often a combination of these; (ii) improve clinical outcomes for patients with gastrointestinal causes of ID; (iii) provide current, evidence-based, context-specific recommendations for use in the management of ID; and (iv) conserve resources by ensuring rational utilisation of blood and blood products.
Method. Development of the guidance document was facilitated by the Gastroenterology Foundation of Sub-Saharan Africa and the South African Gastroenterology Society. The consensus recommendations are based on a rigorous process involving 21 experts in gastroenterology and haematology in SSA. Following discussion of the scope and purpose of the guidance document among the experts, an initial review of the literature and existing guidelines was undertaken. Thereafter, draft recommendation statements were produced to fulfil the outlined purpose of the guidance document. These were reviewed in a round-table discussion and were subjected to two rounds of anonymised consensus voting by the full committee in an electronic Delphi exercise during 2022 using the online platform, Research Electronic Data Capture. Recommendations were modified by considering feedback from the previous round, and those reaching a consensus of over 80% were incorporated into the final document. Finally, 44 statements in the document were read and approved by all members of the working group.
Conclusion. The recommendations incorporate six areas, namely: general recommendations and practice, Helicobacter pylori, coeliac disease, suspected small bowel bleeding, inflammatory bowel disease, and preoperative care. Implementation of the recommendations is aimed at various levels from individual practitioners to healthcare institutions, departments and regional, district, provincial and national platforms. It is intended that the recommendations spur the development of centre-specific guidelines and that they are integrated with the relevant patient blood management protocols. Integration of the recommendations is intended to promote optimal evaluation and management of patients with ID, regardless of the presence of anaemia
The paediatric liver transplant experience in Johannesburg, South Africa: A broad overview and update
Get PDFBackground:
The Wits Transplant Unit performed its first paediatric liver transplant in 2005. Initial experiences from the unit were published in 2012 and 2014. Since then, significant progress has been made in capacity-building the unit, improving outcomes and enhancing service delivery. This paper presents a broad overview and update of the unit’s 17-year experience.
Methods:
We conducted a retrospective review of all paediatric liver transplants performed in Johannesburg from 1 January 2005 to 31 December 2021 with a minimum one-year follow-up. Data were accessed from the Wits Donald Gordon Medical Centre Paediatric Liver Transplant Research Database (University of the Witwatersrand Human Research Ethics approval: M190749). The following data were collected: donor and recipient sociodemographic and clinical characteristics, details of transplant procedures, donor grafts and recipient outcomes (post-operative complications, graft and recipient survival).
Results:
A total of 270 transplants were performed during the review period. Two thirds of recipients (n=180, 67%) were younger than 5 years at time of transplant and half (n=135, 50%) received a living donor graft. The most common indication for liver transplant was biliary atresia, followed by acute liver failure. Unadjusted recipient survival was 80% (95% CI: 75-85%) at one year, and 68% (95% CI: 59-75%) at five years. Waiting list mortality decreased from 27.3% in 2017 to 5.9% in 2021. One hundred and fifty-four (57.0%) recipients experienced at least one type of intervention requiring surgical complication - the most common being biliary in nature (n = 91; 33.7%).
Conclusion:
Over last seventeen years, a sustainable paediatric liver transplantation service has been established in Johannesburg. Living donor, split and ABO incompatible liver transplants have been incorporated in response to the severe organ shortage in South Africa. However, our outcomes can be improved. Additionally, a national transplant initiative to coordinate timeous referrals and expand access to liver transplantation for children with severe acute and chronic liver failure is advised
Primary and tertiary management of ocular surface lesions in HIV-infected patients in Ehlanzeni, Mpumalanga Province
Get PDFBackground. In sub-Saharan Africa, ocular surface squamous neoplasia (OSSN) is the most common ocular surface tumour and is strongly associated with HIV infection. This range of ocular malignancies can be managed early to prevent large tumours requiring invasive treatment, facial disfigurement and mortality. Primary healthcare workers (HCWs) play a critical role in the early identification of the lesion. In addition, the ocular lesion can also be the presenting sign of HIV infection in individuals who have not yet been diagnosed. The aim of the present study was to assess the management of suspicious conjunctival growths in HIV-infected patients in primary health facilities and a specialist eye clinic in South Africa.
Objectives. To assess the knowledge, attitude and current practice of HCWs working in HIV clinics regarding ocular surface lesions and to evaluate the management of patients with ocular surface lesions at a tertiary hospital.
Methods. A cross-sectional study design was used (November 2020 - May 2021), for which 149 HCWs were invited to assessments about their knowledge, attitudes and practices regarding ocular surface lesions. In addition, files of patients with ocular surface lesions who presented between January 2018 and August 2020 to the eye clinic were reviewed using a data extraction sheet.
Results. One hundred-and-three HCWs agreed to participate in the survey (response rate 69.1%). Of these participants, 84.5% were experienced professional nurses (6 - 15 years of work experience) but had minimal experience with detection and management of eye complaints and lesions. Twenty-seven (26.2%) of the participants recognised some ocular surface lesions and 86 (83.5%) reported that they would refer patients with suspicious lesions. Sixty-two files were reviewed and 51 (82.2%) of the patients had an HIV-positive diagnosis. Fifty percent had carcinoma-in situ and squamous cell carcinoma of the conjunctiva. Thirty-one (50%) of the patients were lost to follow-up.
Conclusion. OSSN is an important manifestation of HIV infection. It would be beneficial for patients to receive a basic ocular examination as part of the baseline clinical evaluation; this may contribute to early referral to an eye care facility. The health system would benefit from establishing an eye health support system with the nearby health facilities, thereby educating primary HCWs about the association between HIV and OSSN
Kidney transplant utilising donors after circulatory death: The first report from the African continent
Get PDFBackground. At Groote Schuur Hospital in Cape Town, South Africa, the number of deceased organ donors has declined over the past 2 decades, necessitating a more liberal approach to donor selection. In 2007, measures to expand the deceased kidney donor pool were implemented, including an HIV positive-to-positive transplant programme and the utilisation of extended-criteria donors as well as donors after circulatory death (DCDs).
Objectives. To report on our institutional experience with DCD kidney transplants and to encourage this approach among other African centres to improve access to transplantation.Methods. An observational cohort study of consecutive DCD kidney transplants at Groote Schuur Hospital over a 17-year period was performed. Primary endpoints were 1-, 2- and 5-year graft and patient survival. Secondary endpoints included the incidence of delayed graft function (DGF), 30-day morbidity, length of stay, and donor and recipient clinical characteristics.
Results. Fifteen DCD procurements were performed, with no kidneys discarded. Thirty kidney transplants were performed, with a median (interquartile range) cold ischaemic time of 11.5 (8 - 14) hours. The incidence of DGF was 60.0%, and 30-day morbidity (other than DGF) was 20.0%. Graft survival at 1, 2 and 5 years was 100%, 96.0% and 73.7%, respectively. Patient survival at 1, 2 and 5 years was 93.3%, 93.3% and 88.4%, respectively.
Conclusion. Long-term graft and patient survival was comparable with the international literature. DCD may present a unique opportunity to expand deceased donation throughout Africa, particularly in areas affected by a lack of brain death legislation and religious or cultural objections to donation after brain death
Will South Africa meet the Sustainable Development Goals target for maternal mortality by 2030?
Get PDFIn September 2015, South Africa (SA) and 192 countries adopted Agenda 2030, which included the Sustainable Development Goals. With a mere 6 years to go before 2030, it is useful to understand what progress SA is making towards their attainment. In this short report, we assess progress towards meeting the maternal mortality target, globally and in SA. The maternal mortality ratio that countries are expected to reach is no more than 70 deaths per 100 000 live births. A range of sources is used to show progress, with an emphasis on the reports of the National Committee on Confidential Enquiries into Maternal deaths, which reports on the number of maternal deaths in health facilities, together with reasons for these deaths and recommendations to reduce preventable mortality
Prevalence, associated factors, management and outcomes of hypokalaemia in hospitalised patients at a South African tertiary centre
Get PDFBackground. Hypokalaemia is a common electrolyte disorder encountered in hospitalised patients and is associated with significant morbidity and mortality. There is a lack of data regarding its prevalence, associated factors, management and outcomes among hospitalised patients in South Africa (SA).
Objectives. To evaluate the prevalence, associated factors, management and risk factors for all-cause mortality in hospitalised adult patients with hypokalaemia at a tertiary centre in SA.
Methods. We conducted a retrospective cohort study of all adult patients admitted with, or who developed, hypokalaemia during hospitalisation in 2019. Hypokalaemia was defined as a serum potassium concentration (K+) <3.5 mmol/L. Based on a sample size calculation, a computer-generated random sample of 245 patients was used.
Results. The period prevalence of hypokalaemia was 6.8% (3 539/52 243). The median (interquartile range) age was 46 (33 - 63) years, and 60% were female. Patients who died had a lower K+ during hospitalisation (3.0 mmol/L v. 3.2 mmol/L, p<0.01). Half of the patients had hypokalaemia on admission. The most common causes were gastrointestinal (37%) and renal (36%) losses. More than half (56.7%) of the patients received no potassium replacement, and of those discharged, only 37.5% were normokalaemic. In-hospital mortality was 16.7%. Only blood pH was associated with in-hospital death (adjusted odds ratio 0.01, 95% confidence interval 0.00 - 0.92, p=0.046). On survival analysis, there was no difference regarding in-hospital death by K+ category (log rank p=0.786).
Conclusion. Although the prevalence of hypokalaemia among adult patients who were hospitalised was found to be low, their in-hospital mortality rate was high. Moreover, the investigations and management of hypokalaemia were frequently found to be inadequate. Therefore, it is imperative for healthcare providers in the hospital setting to enhance their knowledge and management of hypokalaemia. The findings of this study have implications for developing evidence-based guidelines for managing hypokalaemia in SA