South African Medical Journal (SAMJ)
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Prevalence and correlates of 30-day suicidal ideation and intent: Results of the South African National Student Mental Health Survey
Get PDFBackground. Although suicide prevention is recognised as a priority among university students in South Africa (SA), it is unclear whatproportion of students require urgent indicated interventions and what the characteristics are of these students.Objective. To assess the prevalence and sociodemographic correlates of 30-day suicidal ideation, frequency of ideation and self-reported intention to act on ideation in the next year among a national sample of SA university students.Methods. Self-report cross-sectional data were collected online from students (N=28 268) at 17 universities across SA as part of the national student mental health survey. Students reported suicidal ideation in the past 30 days, frequency of ideation and intention to act on ideation in the next year. Data were weighted within institutions by gender and population group, and across the four main types of universities (historically white, historically disadvantaged, technical and distance learning) to correct for response rate discrepancies. Prevalence was estimated with these weighted in the total sample and across types of universities. Poisson regression with robust error variances was used to investigate associations of sociodemographic characteristics with ideation and intention to act on suicidal ideation. Results are reported as relative risks (RRs) with design-based 95% confidence intervals (CIs).Results. Thirty-day prevalence of suicidal ideation was 24.4% (standard error (SE) 0.3), with 2.1% (SE 0.1) and 4.1% (SE 0.1), respectively,reporting suicidal ideation all/almost all the time, or most of the time. A total of 1.5% (SE 0.1) of respondents reported being very likely to act on their suicidal ideation, while 3.9% (SE 0.2) were somewhat likely, 8.7% (SE 0.2) were not very likely and 85.8 (SE 0.5) either reported no suicidal ideation or that they were not at all likely to act on this ideation. Risk of suicidal ideation with high intent in the total sample was elevated among females (RR 1.9, 95% CI 1.3 - 2.7) and gender non-conforming students (RR 4.3, 95% CI 1.4 - 13.0) relative to males, black African students compared with white students (RR 3.6, 95% CI 1.9 - 7.1), students whose parents did not progress to secondary school compared with students whose parents had a university education (RR 1.6, 95% CI 1.0 - 2.5) and sexual minority students compared with heterosexual students (RR 1.9, 95% CI 1.3 - 2.6). Among students with 30-day ideation (controlling for frequency of ideation), only two of these predictors of high intent remained significant: identifying as black African (RR 2.7, 95% CI 1.4 - 5.1), and having parents with less than secondary education (RR 1.5, 95% CI 1.0 - 2.1).Conclusion. Scalable suicide prevention interventions are needed to reach the large number of SA students who report suicidal ideation with intent
Prevalence and outcome of acute kidney injury in burn victims at a tertiary centre in Cape Town, South Africa
Get PDFBackground. Burn victims commonly experience acute kidney injury (AKI), which can lead to significant morbidity and mortality. Objective. To investigate the prevalence of AKI in burn patients, the causes of AKI and the rate of in-hospital mortality.
Methods. A retrospective cohort study was conducted on patients admitted to the Tygerberg Hospital Burn Unit between 1 April 2018, and 31 March 2019. The study included all burn patients >18 years old, except for those with end-stage kidney disease or cold burn wounds, skin donors or readmissions. AKI was defined using the Kidney Disease Improving Global Outcomes criteria, and multivariable logistic regression was used to identify predictors of AKI and death, along with Kaplan-Meier survival analysis.
Results. The prevalence of AKI was 27% (58/215). The most common causes of burns were open fires (37%) and shack fires (17%). Patients with AKI had higher scores on the abbreviated burn severity index (ABSI) (7 v. 5, p<0.01), required more mechanical ventilation (69% v. 33%, p<0.01) and experienced more sepsis (35% v. 12%, p<0.01). Predictors of AKI included ABSI score (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.21 - 1.80, p<0.01), mechanical ventilation (aOR 7.75, 95% CI 1.23 - 48.65, p=0.03) and high admission lactate (aOR 1.57, 95% CI 1.04 - 2.39, p=0.03). Mortality was higher in patients with AKI (34% v. 6%, p<0.01). ABSI score (aOR 2.16, 95% CI 1.56 - 2.99, p<0.01) and vasopressor use (aOR 7.71, 95% CI 2.15 - 27.60, p<0.01) were identified as predictors of death. The survival analysis revealed that AKI was associated with higher mortality (log rank, p<0.01).
Conclusion. The study highlights the high prevalence of AKI among burn victims requiring tertiary care and its association with high mortality rates. Improving living conditions in informal settlements could help prevent burns and their complications
‘Listen to my heart’: Qualitative researchers and people living with rheumatic heart disease collaborate to direct future RHD research
Get PDFBackground. Rheumatic heart disease (RHD) is a preventable chronic cardiac condition that causes over 350 000 deaths annually, largely in low and middle-income countries, as a direct result of structural inequalities and inadequate access to comprehensive healthcare. People living with and affected by this disease are a key stakeholder group and need to be directing research priorities.
Objective. To improve care and provide direction for future research, a group of qualitative researchers and pe living with RHD from six countries convened in Cape Town in 2016.
Methods. People with RHD shared their lived experiences while RHD researchers, clinicians and advocates presented a spectrum of qualitative research methods to explore these experiences. The Continuum of Care© (CoC, developed by the Medtronic Foundation) was used as a framework to guide participant discussions. Thematic summaries of the discussions were undertaken in an iterative process throughout the workshop.
Results. Three themes emerged in the summaries: there is no ‘typical’ patient journey; a biomedical focus on RHD does not reflect people’s lived experiences; and a diversity of research methods is required to investigate experiences of people living with RHD.Practice implications. Qualitative research methods are invaluable for allowing patient ‘voices’ to be heard. To this end, qualitative approaches should be incorporated in all RHD research to ensure maximum benefit for patients.
Conclusion. Greater understanding of the patient journey was gained for strengthening and expanding the global RHD research agenda. Future research should reflect on and incorporate the realities of patients’ lived experiences, and these experiences should be integrated into healthcare models for chronic conditions
The impact of HIV co-infection on presentation and outcome in adults with tuberculous pericarditis: Findings from the IMPI trial
Get PDFBackground. Little is known about the impact of HIV infection on clinical presentation, complications, and morbid pericarditis-relatedoutcomes of tuberculous pericarditis and its predictors.Objective. To assess the impact of HIV infection on presentation and outcomes in the multicountry Investigation of the Management of Pericarditis (IMPI) randomised controlled trial of immunotherapy in tuberculous pericarditis conducted in sub-Saharan Africa.Methods. We compared clinical features and outcomes of 1 370 adult patients treated for tuberculous pericarditis (939 and 431 HIVinfected and uninfected, respectively) enrolled in the IMPI trial. Cox proportional hazards models were used to determine independent predictors of outcomes of HIV-associated tuberculous pericarditis.Results. At presentation, HIV-infected (v. uninfected) patients were younger (median age 34.0 years v. 47.7 years), had lower body mass (mean weight 56 kg v. 60 kg), higher prevalence of tachycardia (58.5% v. 51.9%), hypotension (9.4% v. 3.9%), anaemia (65.9% v. 26.8%), and radiographic pulmonary infiltrates compatible with tuberculosis (35.4% v. 27.4%), but had lower rates of peripheral oedema (37.1% v. 48.3%). HIV-infected (v. uninfected) patients were less likely to develop constrictive pericarditis (4.1% v. 10.0% at 1 year, p<0.0001 (hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.27 - 0.63, p<0.0001)). However, there was no difference in case fatality rate at 1 year (14.9% v. 12.2%, respectively, p=0.09; (HR 1.20, 95%CI 0.90 - 1.59, p=0.22)). Among HIV-infected patients, heart failure New York Heart Association (NYHA) class III - IV, low body mass, hypotension, and peripheral oedema were independently associated with death.Conclusion. HIV infection alters the cardiovascular presentation and reduces the incidence of constrictive pericarditis, but does notincrease case fatality. Mortality in HIV-infected patients is independently predicted by markers of pericardial and tuberculosis diseaseseverity
The use of emergency medical services for palliative situations in Western Cape Province, South Africa: A retrospective, descriptive analysis of patient records
Get PDFBackground. An estimated 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. To correct this imbalance, integration between palliative services and other disciplines has been recommended. While improved palliative care integration is a priority in the South African (SA) LMIC context, emergency medical services (EMS) and palliative care remain non-integrated. This has resulted in poor palliative situation management by EMS and a lack of research concerning their intersection.
Objective. To examine EMS use for palliative situations in the Western Cape (WC) Province of SA by describing frequency of intersection, patient characteristics and outcomes.Methods. An observational, descriptive, retrospective patient record review was employed at two hospitals with palliative care services in the WC. All patient records of those who arrived at the hospitals between 1 January 2020 and 31 December 2020 via EMS conveyance leading to palliative care provision were included in the study.
Results. In total, 1 207 unique patients received palliative care services at both hospitals during the study period. Of these, 395 (33%) made use of EMS for hospital conveyance on 494 occasions. The median (range) patient age was 60 (20 - 93) years, and most transports involved male patients (54%, n=265). Family members were the primary caregivers in most instances (89%, n=440), dyspnoea was the chief complaint (36%, n=178) and cancer was the most frequent diagnosis (32%, n=159). The median length of hospital stay was 6 days, with most patients discharged home (60%, n=295).
Conclusion. EMS in SA frequently encounter palliative situations for symptoms that may be managed within their scope of practice. Consequently, it appears that EMS have an important role to fulfil in the care of patients with palliative needs. Integrating EMS and palliative care may result in improved palliative care provision and, therefore, EMS and palliative care integration would be beneficial in SA
Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa
Get PDFPostpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service
Commentary on the published position statement regarding the pathogenesis of fetal basal ganglia- thalamic hypoxic-ischaemic injury
Get PDFSurgical training and capacity development in the South African internship programme
Get PDFMedical practitioners in South Africa manage a quadruple burden of disease. Junior doctors, who contribute significantly to the health workforce, must complete 2 years of internship training and 1 year of community service work in state health facilities after graduation to register as an independent medical practitioner. The aim of this article is to give a critical appraisal of the current national internship programme and why it was implemented, and outline suggestions for future changes. There is a compelling need to train competent, confident doctors while ensuring that the requirements and demands of our health system remain a central concern