South African Medical Journal (SAMJ)
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Time to thrombolysis and factors contributing to delays in patients presenting with ST-elevation myocardial infarction at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
Get PDFBackground. Acute coronary syndrome is a public health burden both worldwide and in South Africa (SA). Guidelines recommend thrombolysis within 1 hour of symptom onset and 30 minutes of hospital arrival for patients with ST-elevation myocardial infarction (STEMI) in order to prevent morbidity and mortality. There is a paucity of data pertaining to the time between onset of chest pain and thrombolysis in STEMI patients in SA.
Objectives. To elucidate the time to thrombolytic therapy, establish the reasons for treatment delays, and calculate the loss of benefit of thrombolysis associated with delays in treatment of patients presenting with STEMI at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, SA.
Method. A prospective observational study of 100 consecutive patients with STEMI was conducted at CHBAH (2021 - 2022).
Results. The mean (standard deviation) age was 55.6 (11.6) years, with a male predominance (78%). Thrombolytic therapy was administered to 51 patients, with a median (interquartile range (IQR)) time to thrombolysis of 360 (258 - 768) minutes; 10 of the patients who received a thrombolytic (19.6%) did so within 30 minutes of arrival at the hospital. The median (IQR) time from symptom onset to calling for help was 60 (30 - 240) minutes, the median time from arrival of help to hospital arrival was 114 (48 - 468) minutes, and the median in-hospital delay to thrombolysis after arrival was 105 (45 - 240) minutes. Numerous reasons that led to delay in treatment were identified, but the most frequent was prehospital delays related to patient factors. Late presentation resulted in 26/49 patients (53.1%) not receiving thrombolytic therapy. Five patients died and 43 suffered from heart failure. Thirty per 1 000 participants could have been saved had they received thrombolytic therapy within 1 hour from the onset of chest pain.
Conclusion. Prehospital and hospital-related factors played a significant role in delays to thrombolysis that led to increased morbidity and mortality of patients with STEMI
Risk stratification of hospital admissions for COVID-19 pneumonia by chest radiographic scoring in a Johannesburg tertiary hospital
Get PDFBackground. Chest radiographic scoring systems for COVID-19 pneumonia have been developed. However, little is published on the utilityof these scoring systems in low- and middle-income countries.Objectives. To perform risk stratification of COVID-19 pneumonia in Johannesburg, South Africa (SA), by comparing the Brixia score withclinical parameters, disease course and clinical outcomes. To assess inter-rater reliability and developing predictive models of the clinicaloutcome using the Brixia score and clinical parameters.Methods. Retrospective investigation was conducted of adult participants with established COVID-19 pneumonia admitted at a tertiaryinstitution from 1 May to 30 June 2020. Two radiologists, blinded to clinical data, assigned Brixia scores. Brixia scores were compared withclinical parameters, length of stay and clinical outcomes (discharge/death). Inter-rater agreement was determined. Multivariable logisticregression extracted variables predictive of in-hospital demise.Results. The cohort consisted of 263 patients, 51% male, with a median age of 47 years (interquartile range (IQR) = 20; 95% confidenceinterval (CI) 46.5 - 49.9). Hypertension (38.4%), diabetes (25.1%), obesity (19.4%) and HIV (15.6%) were the most common comorbidities.The median length of stay for 258 patients was 7.5 days (IQR = 7; 95% CI 8.2 - 9.7) and 6.5 days (IQR = 8; 95% CI 6.5 - 12.5) for intensivecare unit stay. Fifty (19%) patients died, with a median age of 55 years (IQR = 23; 95% CI 50.5 - 58.7) compared with survivors, of medianage 46 years (IQR = 20; 95% CI 45 - 48.6) (p=0.01). The presence of one or more comorbidities resulted in a higher death rate (23% v. 9.2%;p=0.01) than without comorbidities. The median Brixia score for the deceased was higher (14.5) than for the discharged patients (9.0)(p<0.001). Inter-rater agreement for Brixia scores was good (intraclass correlation coefficient 0.77; 95% CI 0.6 - 0.85; p<0.001). A modelcombining Brixia score, age, male gender and obesity (sensitivity 84%; specificity 63%) as well as a model with Brixia score and C-reactiveprotein (CRP) count (sensitivity 81%; specificity 63%) conferred the highest risk for in-hospital mortality.Conclusion. We have demonstrated the utility of the Brixia scoring system in a middle-income country setting and developed the first SArisk stratification models incorporating comorbidities and a serological marker. When used in conjunction with age, male gender, obesityand CRP, the Brixia scoring system is a promising and reliable risk stratification tool. This may help inform the clinical decision pathway inresource-limited settings like ours during future waves of COVID-19
Medicine and the Law: Failure to obtain informed consent – is it a criminal offence?
Get PDFThere is a plethora of literature that suggests that a failure by a medical practitioner to obtain informed consent from a patient amounts to assault. Assault is a loaded concept in South African (SA) law, and has applicability to both criminal and civil law. When one thinks of the term ‘assault’, it is normally associated with a criminal activity. It is well documented that a civil case can be levelled against a medical practitioner who fails to obtain informed consent from a patient. However, the criminal law aspect has not been explored in the same level of detail. This article aims to delve deeper into this aspect by outlining the requirements for assault as defined by the SA common law, and to evaluate whether a criminal offence has actually been committed by a medical practitioner in the event that proper informed consent was not obtained
SARS-CoV-2 mutations on diagnostic gene targets in the second wave in Zimbabwe: A retrospective genomic analysis
Get PDFBackground. SARS-CoV-2 continues to be a major issue in resource-limited settings, particularly owing to the limited supply of vaccinescaused by inequitable distribution.Objective. To monitor diagnostic gene targets to identify potential test failures caused by mutations, which is important for public health.Methods. Here we analysed the genome sequence of SARS-CoV-2 from the second wave in Zimbabwe. A total of 377 samples weresequenced at Quadram Institute Bioscience. After quality control, 192 sequences passed and were analysed.Results. The Beta variant was dominant during this period, contributing 77.6% (149) of the genomes sequenced and having a total of 2994mutations in diagnostic polymerase chain reaction target genes. Many single nucleotide polymorphism mutations resulted in amino acidsubstitution that had the potential to impact viral fitness by increasing the rate of transmission or evading the immune response to previousinfection or vaccination.Conclusion. There were nine lineages circulating in Zimbabwe during the second wave. The B.1.351 was dominant, accounting for >75%.There were over 3 000 mutations on the diagnostic genes and lineage B.1.351, contributing almost two-thirds of the mutations. The S-genehad the most mutations and the E-gene was the least mutated
Prevention of vertical transmission of HIV in Khayelitsha, South Africa: A contemporary review of services after 20 years
Get PDFBackground. The first vertical transmission of HIV prevention (VTP) programme in South Africa was launched in 1999 in Khayelitsha, Western Cape Province (WC). Since then, VTP guidelines have expanded in complexity and scope.Objectives. To describe contemporary VTP uptake in Khayelitsha and quantify vertical transmission (VT) risk factors based on linked routine electronic health data.
Methods. In the WC, all patients at public health facilities have a unique identifier allowing linkage across electronic health platforms through a health information exchange hosted within the WC Department of Health. We conducted a cohort analysis of mother-infant pairs where the mother was living with HIV and attended any obstetric care in Khayelitsha in 2017. Descriptive statistics assessed VTP coverage along the care cascade, including maternal viral load (VL) testing and early infant diagnosis (EID). Logistic regression analysis quantified a priori-defined risk factors associated with VT.
Results. Antenatal HIV prevalence in the cohort was 31.3%, and VT was 1.8% by 12 months. Of women living with HIV, 88.3% knew of their positive status at the first antenatal visit and 77.9% were already receiving antiretroviral therapy (ART). Most women diagnosed prior to delivery (94.5%) were initiated on ART; 85.0% received an antenatal VL test, of whom 88.0% were virologically suppressed. Women who were not virally suppressed had a five-fold (adjusted odds ratio (aOR) 5.3; 95% confidence interval (CI) 2.5 - 12.3) increased VT risk compared with those who were suppressed. Women who attended no antenatal care were at higher risk of VT (aOR 1.6; 95% CI 0.7 - 3.6) than those who did attend. EID coverage was suboptimal: a birth HIV polymerase chain reaction (PCR) test was available for 79.2% of infants, and a low proportion with a negative birth test had a repeat test around 10 weeks (57.9%). Data linkage identified an additional 15 infants living with HIV who were not detected by HIV-PCR testing alone.
Conclusion. Although most women presented to care already knowing their HIV status, ART initiation was suboptimal prior to the first antenatal visit but improved over the course of pregnancy. The VT rate based on laboratory HIV-PCR testing alone underestimated HIV transmission: linked data from multiple sources suggested higher VT than programme-reported rates based on HIV-PCR testing alone
Trisomy 21 screening with αlpha software and the Fetal Medicine Foundation algorithm
Get PDFBackground. Screening for trisomy 21 provides pregnant women with accurate risk information. Different algorithms are used to screen for trisomy 21 in South Africa (SA). The Fetal Medicine Foundation (FMF) provides software to screen for trisomy 21 in the first trimester by ultrasound or a combination of ultrasound and biochemistry (combined screening), and requires regular and stringent quality control. With αlpha software, first trimester combined screening and screening with biochemistry alone in the first or second trimester are possible. The αlpha screening requires quality control of biochemical tests, but not of ultrasound measurements. Ideally, a screening test should have a high detection and a low screen positive rate. Despite the availability of these screening programmes, only a minority of infants with trisomy 21 are detected prenatally, raising questions about the effectiveness of screening.
Objectives. To determine the screen positive and detection rates of prenatal screening for trisomy 21 in the SA private healthcare system. Methods. Data from the three largest laboratories collected between 2010 and 2015 were linked with genetic tests to assess screen positive and detection rates. Biochemical screening alone with αlpha software (first or second trimester) and combined screening using either FMF or αlpha software were compared.
Results. One-third of an estimated 675 000 pregnancies in private practice in the 6-year study period underwent screening. There were 687 cases of trisomy 21 in 225 021 pregnancies, with only 239 (35%) diagnosed prenatally. The screen positive rates were 11.8% for first trimester biochemistry, 7.6% for second trimester biochemistry, 7.3% for first trimester FMF software ultrasound alone, 3.7% for combined first trimester screening with FMF software, and 3.5% for combined first trimester screening with αlpha software. The detection rates for a 5% false positive rate were 63% for first trimester biochemistry, 69% for second trimester biochemistry, 95% for combined first trimester screening with FMF software and 80% for combined first trimester screening with αlpha software. Detection and confirmation rates were highest with FMF software.
Conclusion. Screening with FMF software has a similar screen positive rate and better detection rate than screening with αlpha software. The low prenatal detection rate of trisomy 21 is mainly due to a low prevalence of screening. More research is needed in the SA setting to explore why screening and confirmatory testing after high-risk results are not performed in many pregnancies
Introductory Editorial: Snakebite CME Series
Get PDFThis is the introduction article and editorial that will address the latest approaches to safe management of snakebite in South Africa and shares the evidence and expert consensus from the recent South African Snakebite Symposium (SASS) meeting held in July 2022
Outcomes of burns patients in a developing country: A single centre’s experience
Get PDFBackground. Pelonomi Tertiary Hospital is the only hospital in the Free State Province with a burns unit. We do not have official data to assess our performance in the management of burns.
Objective. To determine the Lethal Area 50 (LA50) index for the Pelonomi Tertiary Hospital’s burns unit. Furthermore, to determine the morbidity that affects burns patients at the institution, and the factors associated with outcomes.
Methods. We used Redcap to capture demographic and clinical data of burn patients admitted to our institution between January 2014 and December 2018. Logistic regression was used to determine significant predictors of the outcomes. The LA50 was calculated by performing a probit regression of survival by total body surface area (TBSA). We used SAS 9.4 statistics software package.Results. Our study had a male preponderance, with 59.7% (601) male, 39.9% (401) female and 0.4% (4) missing sex. We had a mean age of 19.4 years, of which 53.38% (n=537) were paediatric patients and 46.32% (n=469) adults. The mean length of hospital stay was 16.88 days. Our LA50 was 37%, and the overall mortality was 14.63%, with a mean age of 33.96, a mean TBSA of 43.3% and a mean revised Baux score of 80.55 for the mortality group. The paediatric group had a 5.03% (n=27) mortality rate, with 88.88% of these being children under 5 years with an LA50 of 45%, and the adult group had a 25.56% (n=120) mortality rate with an LA50 of 34%. Factors associated with mortality were age (p<0.0001), TBSA (p<0.0001), female sex (p=0.4126), full-thickness burns (p=0.7160) and burns to the head (p=0.9038). The leading cause of injury was hot water (46.5% of patients), followed by fire at 38.6%. HIV was the leading comorbidity, affecting 6.9% (n=67) of patients, followed by hypertension at 4.67% (n=47), and 2.58% (n=26) of patients had epilepsy. The leading complication was sepsis, affecting 14.67% (n=144) of patients. The average waiting time between admission and skin graft was 25.29 days, and for debridement was 3.57 days.
Conclusion. The epidemiology of burn patients and working conditions at Pelonomi Tertiary Hospital are similar to other burn units in the country; however, our mortality rate is higher than at most centres. The LA50 is low, but in keeping with the rest of Africa, and our predictors of mortality are in keeping with those found in other studies in other parts of the world