South African Medical Journal (SAMJ)
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Overview: Second Comparative Risk Assessment for South Africa (SACRA2) highlights need for health promotion and strengthened surveillance
No full textBackground. South Africa (SA) faces multiple health challenges. Quantifying the contribution of modifiable risk factors can be used to identify and prioritise areas of concern for population health and opportunities for health promotion and disease prevention interventions.
Objective. To estimate the attributable burden of 18 modifiable risk factors for 2000, 2006 and 2012.
Methods. Comparative risk assessment (CRA), a standardised and systematic approach, was used to estimate the attributable burden of 18 risk factors. Risk exposure estimates were sourced from local data, and meta-regressions were used to model the parameters, depending on the availability of data. Risk-outcome pairs meeting the criteria for convincing or probable evidence were assessed using relative risks against a theoretical minimum risk exposure level to calculate either a potential impact fraction or population attributable fraction (PAF). Relative risks were sourced from the Global Burden of Disease, Injuries, and Risk Factors (GBD) study as well as published cohort and intervention studies. Attributable burden was calculated for each risk factor for 2000, 2006 and 2012 by applying the PAF to estimates of deaths and years of life lost from the Second South African National Burden of Disease Study (SANBD2). Uncertainty analyses were performed using Monte Carlo simulation, and age-standardised rates were calculated using the World Health Organization standard population.
Results. Unsafe sex was the leading risk factor across all years, accounting for one in four DALYs (26.6%) of the estimated 20.6 million DALYs in 2012. The top five leading risk factors for males and females remained the same between 2000 and 2012. For males, the leading risks were (in order of descending rank): unsafe sex; alcohol consumption; interpersonal violence; tobacco smoking; and high systolic blood pressure; while for females the leading risks were unsafe sex; interpersonal violence; high systolic blood pressure; high body mass index; and high fasting plasma glucose. Since 2000, the attributable age-standardised death rates decreased for most risk factors. The largest decrease was for household air pollution (–41.8%). However, there was a notable increase in the age-standardised death rate for high fasting plasma glucose (44.1%), followed by ambient air pollution (7%).
Conclusion. This study reflects the continued dominance of unsafe sex and interpersonal violence during the study period, as well as the combined effects of poverty and underdevelopment with the emergence of cardiometabolic-related risk factors and ambient air pollution as key modifiable risk factors in SA. Despite reductions in the attributable burden of many risk factors, the study reveals significant scope for health promotion and disease prevention initiatives and provides an important tool for policy makers to influence policy and programme interventions in the country
The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa
Get PDFBackground. Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce.
Objective. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases.
Methods. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated.
Results. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes.
Conclusion. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study
The characteristics and costs of severe theophylline toxicity in a tertiary critical care unit in Eastern Cape Province, South Africa
Get PDFBackground. Severe theophylline toxicity requiring haemodialysis accounts for approximately one-third of drug toxicity cases admitted to the Livingstone Tertiary Hospital (LTH) intensive care unit (ICU) in Gqeberha, South Africa, imposing a significant resource burden.
Objectives. To investigate the characteristics and burden of severe theophylline toxicity in an Eastern Cape Province tertiary hospital adult ICU.
Methods. A retrospective review of all severe theophylline toxicity admissions to the ICU from 1 January 2013 to 31 December 2018 was conducted. Demographic and clinical data were captured and analysed. The National Department of Health 2019 fees schedule was used to calculate costs based on duration of ICU stay and number of haemodialysis sessions received.
Results. Of the 57 patients included in the study, 84% were cases of deliberate self-harm. The majority were aged <40 years (77%) and female (79%). The mean (standard deviation (SD)) initial serum theophylline level was 612 (269) µmol/L. Complications included convulsions (n=12; 21%), arrhythmias (n=9; 16%), need for mechanical ventilation (n=7; 12%) and death (n=4; 7%). The main risk factors for these complications were age ≥30 years, an inappropriately normal or elevated initial serum potassium level, an elevated serum creatinine kinase level and an elevated initial serum theophylline level. Receiver operator characteristic curve analysis assessing the initial serum theophylline level as a discriminator for life-threatening complications produced an area under the curve of 0.71 for serum theophylline >400 µmol/L (sensitivity 88%, specificity 12%). All the 4 patients who died had an initial serum theophylline level >1 000 µmol/L. The mean (SD) cost per admission amounted to ZAR16 897 (10 718), with a mean of one 4-hour dialysis session per admission.
Conclusion. Severe theophylline toxicity, usually in the context of deliberate self-harm, is a preventable yet life-threatening toxicity encountered at LTH. Demographic risk factors include young females from certain areas in and around Gqeberha. Risk factors for complications include older age, paradoxically normal or elevated serum potassium levels, elevated serum creatinine kinase levels and an initial serum theophylline level >400 µmol/L. Patients with these clinical features should be closely monitored and treated timeously at an appropriate level of care. The need for ICU admission and dialysis, both limited resources, makes the treatment of severe theophylline toxicity costly. Further studies of the underlying psychosocial drivers, local prescribing practices and preventive interventions related to severe theophylline toxicity are required
Diabetes in the public healthcare sector of four South African provinces: A comparative analysis
Get PDFBackground. The growing burden of diabetes has long been under the radar in developing countries such as South Africa (SA). In recent years, there has been an unprecedented and exponential increase in recorded and undiagnosed diabetes mellitus (DM) cases. Unreliable data collection, overburdened health systems and poor infrastructure have all proved to be barriers to achieving optimum disease management. The District Health Information System (DHIS) serves as the data collection tool for the SA public healthcare sector. It is used in all nine SA provinces to gather data without individual patient identifiers. Objective. To analyse and compare the DM data collected by the DHIS in the Western Cape (WC), Eastern Cape (EC), KwaZulu-Natal (KZN) and Gauteng provinces of SA. Methods. An audit of diabetes-related data from the DHIS for 2016 was conducted. The data were then analysed using Excel. Time-series and cross-sectional analyses were made possible using pivot tables. Graphics were designed using Thinkcell software. Results. Of the four provinces surveyed, Gauteng recorded the highest incidence of DM, 67% higher than the reported global DM incidence estimate, while the WC had the lowest incidence. A similar pattern was also noted regarding the incidence of DM in people aged <18 years, with Gauteng having the highest and WC the lowest prevalence results. When comparing the number of DM-related consultations conducted in each province, the metropolitan districts were highlighted as hotspots of activity for DM care. This study found a moderate inversely proportional relationship between the incidence of DM in all provinces and education deprivation (p<0.05). Among the provinces that collected data on screening (excluding EC), KZN recorded the highest number of diabetic screenings. Conclusion. Metropolitan areas were highlighted as areas to be targeted, further reinforcing the current connection observed between urbanisation and DM in SA. The presence and recording of screening efforts is an excellent step in the right direction for the SA public healthcare sector and the DHIS. With improved interprovincial co-ordination regarding standardisation of the criteria and specifications of data collection fields, and enhanced training for data officers and primary collection agents, good quality and rich data is a very close possibility
Colonoscopy performed with selective use of sedation: A case report
Get PDFColonoscopy is the gold standard for diagnosis of colonic disease. We present a patient with chronic diarrhoea and a caecal tumour thatwas diagnosed with colonoscopy
Practising in a post-truth world: Pandemic ethics can inform patient autonomy and clinical communication
Get PDFThe COVID-19 pandemic posed an unprecedented challenge to modern bioethical frameworks in the clinical setting. Now, as the pandemic stabilises and we learn to ‘live with COVID’, the medical community has a duty to evaluate its response to the challenge, and reassess our ethical reasoning, considering how we practise in the future. This article considers a number of clinical and bioethical challenges encountered by the author team and colleagues during the most severe waves of the pandemic. We argue that the changed clinical context may require reframing our ethical thought in such a manner as to adequately accommodate all parties in the clinical interaction. We argue that clinicians have become relatively disempowered by the ‘infodemic’, and do not necessarily have adequate skills or training to assess the scientific literature being published at an unprecedented rate. Conversely, we acknowledge that patients and families are more empowered by the infodemic, and bring this empowerment to bear on the clinical consultation. Sometimes these interactions can be unpleasant and threatening, and involve inviting clinicians to practise against best evidence or even illegally. Generally, these requests are framed within ‘patient autonomy’ (which some patients or families perceive to be unlimited), and several factors may prevent clinicians from adequately navigating these requests. In this article, we conclude that embracing a framework of shared decision-making (SDM), which openly acknowledges clinical expertise and in which patient and family autonomy is carefully balanced against other bioethics principles, could serve us well going forward. One such principle is the recognition of clinician expertise as holding weight in the clinical encounter, when framed in terms of non-maleficence and beneficence. Such a framework incorporates much of our learning and experience from advising and treating patients during the pandemic