Showing papers in "South African Medical Journal in 2015"
TL;DR: If the authors' overuse and misuse of antibiotics is not halted now, about 10 million people will die annually from drug-resistant bacterial infections within 35 years, and the world’s economy will lose more than 7% of its gross domestic product by 2050.
Abstract: If our overuse and misuse of antibiotics is not halted now, about 10 million people will die annually from drug-resistant bacterial infections within 35 years. The hammer blow will fall hardest on Africa and Asia, accounting for 4.1 and 4.7 million deaths, respec tively, and the world’s economy will lose more than 7% of its gross domestic product (USD210 trillion) by 2050. These numbers should make people sit up, listen and change behaviour.
547 citations
TL;DR: This is an area of concern, and a concentrated effort should be done to make CS in SA safer, by a cross-cutting analysis of the 2011-2013 national data.
Abstract: Background. In the latest (2011 - 2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10 000 CSs performed. Objective. To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011 - 2013 national data. Methods. Data from the 2011 - 2013 triennial review were entered into an Excel database and analysed on a national and provincial basis. Results. There were 1 243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism. Conclusion. This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are made to this effect.
131 citations
TL;DR: While considerable gains have been made in reducing tobacco use over the past 20 years, tobacco use and its determinants need to be monitored to ensure that tobacco control strategies remain effective.
Abstract: Background . Data on tobacco use have informed the effectiveness of South Africa (SA)’s tobacco control strategies over the past 20 years. Objective . To estimate the prevalence of tobacco use in the adult SA population according to certain demographic variables, and identify the factors influencing cessation attempts among current smokers. Methods . A multistage disproportionate nationally representative stratified cluster sample of households was selected for the South African National Health and Nutrition Examination Survey, conducted in 2012. A sample of 10 000 households from 500 census enumerator areas was visited. A detailed questionnaire was administered to all consenting adults in each consenting household. Results. Of adult South Africans, 17.6% (95% confidence interval (CI) 6.3 - 18.9) currently smoke tobacco. Males (29.2%) had a prevalence four times that for females (7.3%) (odds ratio 5.20, 95% CI 4.39 - 6.16; p <0.001). The provinces with the highest current tobacco smoking prevalence were the Western Cape (32.9%), Northern Cape (31.2%) and Free State (27.4%). Among current tobacco smokers, 29.3% had been advised to quit smoking by a healthcare provider during the preceding year, 81.4% had noticed health warnings on tobacco packages, and 49.9% reported that the warning labels had led them to consider quitting. Conclusion . A large proportion of adult South Africans continue to use tobacco. While considerable gains have been made in reducing tobacco use over the past 20 years, tobacco use and its determinants need to be monitored to ensure that tobacco control strategies remain effective.
105 citations
TL;DR: Evidence is offered relating to articles published in this issue, namely ‘Improving access to antiretrovirals in rural South Africa – a call to action’, and the editorial by Yach and Alexander, ‘Turbo-charging tobacco control in South Africa’.
Abstract: 'Cochrane Corner’ in the August SAMJ offers evidence relating to articles published in this issue, namely ‘Improving access to antiretrovirals in rural South Africa – a call to action’, ‘Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa’ and ‘Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey’, and the editorial by Yach and Alexander, ‘Turbo-charging tobacco control in South Africa’.
90 citations
TL;DR: The identified time periods and age groups need to be targeted for interventions to delay sexual debut and prevent sexual coercion among young people.
Abstract: Background. Early sexual debut, voluntary or coerced, increases risks to sexual and reproductive health. Sexual coercion is increasingly receiving attention as an important public health issue owing to its association with adverse health and social outcomes. Objective. To describe voluntary and coerced experience at sexual debut. Methods. A longitudinal perspective among 2 216 adolescents (1 149 females, 1 067 males) in a birth cohort study in South Africa, analysing data collected on six occasions between 11 and 18 years. Results. The median age of sexual debut was 16 years for females and 15 for males. Reported coerced sexual debut included children <11 years of age. Males reported earlier sexual debut, with both voluntary and coerced sexual experience, than females ( p <0.0001). Sexual coercion at early sexual debut among both male and female adolescents occurred mostly through sexual intercourse with older adolescents and partners of the same age. Conclusion. The identified time periods and age groups need to be targeted for interventions to delay sexual debut and prevent sexual coercion among young people. More research is needed to understand underlying predisposing risk factors for sexual coercion at sexual debut, both early and not early.
72 citations
TL;DR: About half of the patients with NCDs had comorbidity, and multimorbidality was common in patients with COPD and osteoarthritis, however, levels of multimOrbidity were substantially lower than reported in higher-income countries.
Abstract: Background. Multimorbidity in non-communicable diseases (NCDs) is a complex global healthcare challenge that is becoming increasingly prevalent. In Africa, comorbidity of communicable diseases and NCDs is also increasing. Objectives. To evaluate the extent of multimorbidity among patients with NCDs in South African (SA) primary healthcare (PHC). Methods. A dataset obtained from a previous morbidity survey of SA ambulatory PHC was analysed. Data on conditions considered active and ongoing at consultations by PHC providers were obtained. Results. Altogether 18 856 consultations were included in the dataset and generated 31 451 reasons for encounter and 24 561 diagnoses. Hypertension was the commonest NCD diagnosis encountered (13.1%), followed by type 2 diabetes (3.9%), osteoarthritis (2.2%), asthma (2.0%), epilepsy (1.9%) and chronic obstructive pulmonary disease (COPD) (0.6%). The majority of patients (66.9%) consulted a nurse and 33.1% a doctor. Overall 48.4% of patients had comorbidity and 14.4% multimorbidity. Multimorbidity (two or more conditions) was present in 36.4% of patients with COPD, 23.7% with osteoarthritis, 16.3% with diabetes, 15.3% with asthma, 12.0% with hypertension and 6.7% with epilepsy. Only 1.1% also had HIV, 1.0% TB, 0.4% depression and 0.04% anxiety disorders. Conclusion. About half of the patients with NCDs had comorbidity, and multimorbidity was common in patients with COPD and osteoarthritis. However, levels of multimorbidity were substantially lower than reported in higher-income countries. Future clinical guidelines, training of PHC nurses and involvement of doctors in the continuum of care should address the complexity of patients with NCDs and multimorbidity.
60 citations
TL;DR: A multidisciplinary team at Tygerberg Hospital has performed the first-ever successful penile transplant, giving hope to victims of botched ritual circumcisions and penile cancer and even men with severe erectile dysfunction.
Abstract: A multidisciplinary team at Tygerberg Hospital has performed the first-ever successful penile transplant, giving hope to victims of botched ritual circumcisions and penile cancer and even men with severe erectile dysfunction.
59 citations
TL;DR: Most patients in SA's public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions, however, the most common comorbidity, HIV infection, was not associated with in-hospital mortality.
Abstract: Background . Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: ( i ) poverty-related diseases; ( ii ) non-communicable diseases; ( iii ) HIV and related diseases; and ( iv ) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country. Objectives . To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA. Methods . A 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient noncardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA. Results . The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 - 3.7). The rate of postoperative admission to critical care units was 255/3 927 (6.5%; 95% CI 5.7 - 7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2 120/3 915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 - 55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 - 51.4). Conclusions . Most patients in SA’s public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions. Non-communicable diseases have a larger proportional contribution to mortality than infections and injuries. However, the most common comorbidity, HIV infection, was not associated with in-hospital mortality. The study was registered on ClinicalTrials.gov (NCT02141867).
59 citations
TL;DR: Considerable multimorbidity and unmet treatment needs exist among patients with NCDs attending public sector PHC clinics in SA, and improved strategies are required for diagnosing and managing N CDs in this sector.
Abstract: Background. South Africa (SA) is facing a heavy burden of non-communicable diseases (NCDs). Few studies address multimorbidity, control and treatment of NCDs in patients attending primary healthcare (PHC) clinics. Objectives. To describe multimorbidity, related risk factors, disease severity and treatment status of patients with four important NCDs attending public sector PHC clinics in two districts in SA. Methods. A cross-sectional sample of patients completed baseline data collection for a randomised controlled trial of a health systems intervention. The study population comprised adults attending PHC clinics in the Eden and Overberg districts of the Western Cape in 2011. Four subgroups of patients were identified: hypertension, diabetes, chronic respiratory disease and depression. A total of 4 393 participants enrolled from 38 clinics completed a baseline structured questionnaire and had measurements taken. Prescription data were recorded. Results. Of participants with hypertension, diabetes, respiratory disease and depression, 80%, 92%, 88% and 80%, respectively, had at least one of the other three conditions. There were low levels of control and treatment: 59% of participants with hypertension had a blood pressure ≥140/90 mmHg, the mean haemoglobin A1c (HbA1c) value in participants with diabetes was 9%, 12% of participants in the depression group were prescribed an antidepressant at a therapeutic dose, and 48% of respiratory participants were prescribed a b2-agonist and 34% an inhaled corticosteroid. Conclusion. Considerable multimorbidity and unmet treatment needs exist among patients with NCDs attending public sector PHC clinics. Improved strategies are required for diagnosing and managing NCDs in this sector.
56 citations
TL;DR: The potential of mobile health to improve the health system is described, which includes engaging with users and providers of health services, providing accessible health information, and capturing feedback on the quality of care.
Abstract: This editorial describes the potential of mobile health (mHealth) to improve the health system. MomConnect was the first, HIV treatment guidelines the second, and B-Wise the third of a series of South African National Department of Health initiatives that use mobile technology. These uses include engaging with users and providers of health services, providing accessible health information, and capturing feedback on the quality of care.
50 citations
TL;DR: A unique UFSP2 mutation is reported that segregates with the BHD phenotype and is reported to be implicating the ubiquitin-fold modifier 1 cascade in this form of severe hip osteoarthropathy.
Abstract: Background. Beukes hip dysplasia (BHD) is an autosomal dominant disorder of variable penetrance that was originally identified in a large South African family of European origin. BHD is characterised by bilateral dysmorphism of the proximal femur, which results in severe degenerative osteoarthropathy. Previous studies mapped the disorder to a 3.34 Mb region on chromosome 4q35. Objective. To fine-map the BHD locus and identify the disease-causing mutation by direct sequencing. Results. The linked BHD allele was refined to 1.33 Mb, reducing the number of candidate genes from 25 to 16. Analysis of protein coding and invariant splice-site sequences in three distantly related individuals identified a single-candidate disease-causing variant c.868T>C within exon 8 of the ubiquitin-fold modifier 1 (Ufm1)-specific peptidase 2 gene, UFSP2. The presence of this unique mutation was confirmed in all 17 affected members of the BHD family who were genotyped. The mutation segregated with the BHD phenotype in the extended family with a two-point (single marker) LOD score of 10.4 (θ = 0.0 and 80% penetrance). The mutation predicts the substitution of a highly conserved amino acid, p.Tyr290His, in the encoded protein. In vitro functional assays performed using purified recombinant wild-type and mutant UFSP2 protein demonstrated that the BHD mutation abolishes UFSP2-mediated C-terminal cleavage of its substrate, Ufm1. Conclusion. We report a unique UFSP2 mutation that segregates with the BHD phenotype. The predicted amino acid substitution inactivates UFSP2 proteolytic function, thus implicating the ubiquitin-fold modifier 1 cascade in this form of severe hip osteoarthropathy. The facile polymerase chain reaction-based assay we describe could be used to confirm the diagnosis of BHD, or for presymptomatic testing of members of the extended BHD family.
TL;DR: Particular factors relating to health workers’ professional and personal contexts contribute to the problem and need to be addressed if it is to be solved.
Abstract: Abuse of mothers in maternity settings is widespread globally. In South Africa, this human rights violation has been documented by many sources. Particular factors relating to health workers’ professional and personal contexts contribute to the problem and need to be addressed if it is to be solved. Several local and international initiatives are discussed as possible solutions.
TL;DR: While private healthcare reporting decreased by 28% from 2005 to 2007, this represented a minimal impact on overall cancer reporting (net decrease of <4%).
Abstract: Background. The National Cancer Registry (NCR) was established as a pathology-based cancer reporting system. From 2005 to 2007, private health laboratories withheld cancer reports owing to concerns regarding voluntary sharing of patient data. Objectives. To estimate the impact of under-reported cancer data from private health laboratories. Methods. A linear regression analysis was conducted to project expected cancer cases for 2005 - 2007. Differences between actual and projected figures were calculated to estimate percentage under-reporting. Results. The projected NCR case total varied from 53 407 (3.8% net increase from actual cases reported) in 2005 to 54 823 (3.7% net increase) in 2007. The projected number of reported cases from private laboratories in 2005 was 26 359 (19.7% net increase from actual cases reported), 27 012 (18.8% net increase) in 2006 and 27 666 (28.4% net increase) in 2007. Conclusion. While private healthcare reporting decreased by 28% from 2005 to 2007, this represented a minimal impact on overall cancer reporting (net decrease of <4%).
TL;DR: The pathophysiology, aetiology, clinical presentation and management of dyspnoea are reviewed, which include a spectrum of disorders, from benign to serious and life-threatening entities.
Abstract: Dyspnoea, also known as shortness of breath or breathlessness, is a subjective awareness of the sensation of uncomfortable breathing. It may be of physiological, pathological or social origin. The pathophysiology of dyspnoea is complex, and involves the activation of several pathways that lead to increased work of breathing, stimulation of the receptors of the upper or lower airway, lung parenchyma, or chest wall, and excessive stimulation of the respiratory centre by central and peripheral chemoreceptors. Activation of these pathways is relayed to the central nervous system via respiratory muscle and vagal afferents, which are consequently interpreted by the individual in the context of the affective state, attention, and prior experience, resulting in the awareness of breathing. The clinical evaluation and approach to the management of dyspnoea are directed by the clinical presentation and underlying cause. The causes of dyspnoea are manifold, and include a spectrum of disorders, from benign to serious and life-threatening entities. The pathophysiology, aetiology, clinical presentation and management of dyspnoea are reviewed.
TL;DR: The first report from the South African Children's Tumour Registry (SACTR), which covers the whole of South Africa, provides minimal estimates of cancer incidence and discusses the challenges of cancer surveillance and control in a child population in a middle-income country.
Abstract: Background. Childhood cancer is an emerging problem in Africa. Its extent is hazy because data are scarce, but it should be addressed. This is the first report from the South African Children’s Tumour Registry (SACTR), which covers the whole of South Africa (SA). It provides minimal estimates of cancer incidence and discusses the challenges of cancer surveillance and control in a child population in a middle-income country. Only about 2% of the African population is covered by cancer registries producing comparable incidence data. Objective. To present and interpret incidence patterns and trends of childhood cancer over a 21-year period. The results should raise awareness of the problem of childhood cancer in an African population and provide sensible data for taking this problem in hand. Methods. All eligible and validated cancer cases registered in the SACTR over the period 1987 - 2007 and classified according to the International Classification of Childhood Cancer were included. Population data were retrieved from official sources and estimated for the population subcategories. Incidence rates were standardised to the world standard and time trends were evaluated using joinpoint models, adjusting for sex and age. Results. Based on the 11 699 cases, the overall age-standardised average annual incidence rate was 45 per million. Threefold differences in the overall incidence rates were observed between the ethnic groups, ranging from 116 for whites to 37 for black Africans, and they differed by diagnostic group. Differences between the nine provinces of SA relate to the ethnic composition and prevailing socioeconomic status. The overall incidence rate declined by 1.2% per year for the whole country ( p <0.01). However, the decline was mainly observed during the first few years of the study period, after which rates stabilised or increased. Conclusions. Diagnosis and notification of childhood cancer should improve. The differences in incidence between ethnic groups suggest the priorities for cancer control.
TL;DR: An overview of the selection procedures used by all eight medical schools in SA, and the student demographics (race and gender) at these medical schools, is provided to determine to what extent collective practices are achieving the goals of student diversity and inclusivity.
Abstract: Background. Selection of medical students at South African (SA) medical schools must promote equitable and fair access to students from all population groups, while ensuring optimal student throughput and success, and training future healthcare practitioners who will fulfil the needs of the local society. In keeping with international practices, a variety of academic and non-academic measures are used to select applicants for medical training programmes in SA medical schools. Objectives. To provide an overview of the selection procedures used by all eight medical schools in SA, and the student demographics (race and gender) at these medical schools, and to determine to what extent collective practices are achieving the goals of student diversity and inclusivity. Methods. A retrospective, quantitative, descriptive study design was used. All eight medical schools in SA provided information regarding selection criteria, selection procedures, and student demographics (race and gender). Descriptive analysis of data was done by calculating frequencies and percentages of the variables measured. Results. Medical schools in SA make use of academic and non-academic criteria in their selection processes. The latter include indices of socioeconomic disadvantage. Most undergraduate medical students in SA are black (38.7%), followed by white (33.0%), coloured (13.4%) and Indian/Asian (13.6%). The majority of students are female (62.2%). The number of black students is still proportionately lower than in the general population, while other groups are overrepresented. Conclusion. Selection policies for undergraduate medical programmes aimed at redress should be continued and further refined, along with the provision of support to ensure student success.
TL;DR: Positive family communication, cohesion and support predictive of a secure parent-adolescent attachment relationship reduced the risk of a depressive symptom outcome and secure adolescents were able to regulate their emotions, buffering against the development of depressive symptoms.
Abstract: Background. Adolescence represents a challenging transitional period where changes in biological, emotional, cognitive and social domains can increase the risk of developing internalised problems including subthreshold depression. Adolescent-parent attachment style, perceived support and family functioning may increase risk for depressive symptoms or may reduce such risk. Adolescent-parent attachment, adolescent-perceived support from parents and family functioning were examined as correlates of depressive symptom presentation within this age group. Methods. Participants included a maternal parent and an adolescent (65.5% female) from each family. Adolescents were in Grade 7 ( n =175) or Grade 10 ( n =31). Data were collected through home interviews. The Self-Report of Family Inventory (SFI), Experiences of Close Relationships Scale (ECR), Network of Relationships Inventory (NRI), Children’s Depression Inventory (CDI) and Child Behavior Checklist (CBCL) were used to assess depression, parental support and attachment. Results. Two models were examined: one with adolescent report of depressive symptoms as the outcome and a second with parent report of adolescent internalising symptoms as the outcome. The model predicting adolescent-reported depressive symptoms was significant with older age, higher levels of avoidant attachment, and higher levels of youth-reported dysfunctional family interaction associated with more depressive symptomatology. In the model predicting parent report of adolescent internalising symptoms only higher levels of dysfunctional family interaction, as reported by the parent, were associated with higher levels of internalising symptoms. Conclusion. Positive family communication, cohesion and support predictive of a secure parent-adolescent attachment relationship reduced the risk of a depressive symptom outcome. Secure adolescents were able to regulate their emotions, knowing that they could seek out secure base attachment relations within their family and from friends during times of stress, buffering against the development of depressive symptoms.
TL;DR: Methamphetamines use is associated with severe hypertension, mesangiocapillary glomerulonephritis and CKD, and the chronic effects of abuse on the kidneys and blood pressure have not been documented.
Abstract: Background: Methamphetamine abuse has risen dramatically in South Africa. The chronic effects of abuse on the kidneys and blood pressure have not been documented. This study reviewed patients referred for evaluation of kidney disease and/or hypertension, who had been abusing methamphetamines. Methods: The records of patients referred to the renal unit between 2005 and 2013 who had been using methamphetamines were retrospectively reviewed. Patient demographics, biophysical parameters, blood pressure, renal function, renal ultrasound and biopsy findings, complications of chronic kidney disease and comorbidities were recorded. Results: Forty-seven patients were included in the study. Their mean age was 29 years. Hypertension was present in 42 (89.4%) of patients, with malignant hypertension in 21 (44.7%). Forty-five (95.7%) had chronic kidney disease (CKD), and 26 (55.3%) had end-stage renal disease. Renal biopsies were performed in 24 patients. Twelve (50.0%) of the biopsies showed hypertensive changes and 14 (58.3%) mesangiocapillary glomerulonephritis type 1, with deposition of IgM and C3 complement. Conclusion: Methamphetamine use is associated with severe hypertension, mesangiocapillary glomerulonephritis and CKD.
TL;DR: This is the first documented laboratory-confirmed outbreak of OXA-181-producing K. pneumoniae in SA, and highlights the importance of enforcing strict adherence to infection control procedures and the need for ongoing surveillance of antibiotic-resistant pathogens in local hospitals.
Abstract: Background. Klebsiella pneumoniae is an opportunistic pathogen often associated with nosocomial infections. A suspected outbreak of K. pneumoniae isolates, exhibiting reduced susceptibility to carbapenem antibiotics, was detected during the month of May 2012 among patients admitted to a haematology unit of a tertiary academic hospital in Cape Town, South Africa (SA). Objectives. An investigation was done to determine possible epidemiological links between the case patients and to describe the mechanisms of carbapenem resistance of these bacterial isolates. Methods. Relevant demographic, clinical and laboratory information was extracted from hospital records and an observational review of infection prevention and control practices in the affected unit was performed. Antimicrobial susceptibility testing including phenotypic testing and genotypic detection of the most commonly described carbapenemase genes was done. The phylogenetic relationship of all isolates containing the bla OXA-181 carbapenemase gene was determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing. Results. Polymerase chain reaction analysis identified a total of seven bla OXA-181 -positive, carbapenem-resistant K. pneumoniae isolates obtained from seven patients, all from a single unit. These isolates were indistinguishable using PFGE analysis and belonged to sequence type ST-14. No other carbapenemase enzymes were detected. Conclusion. This is the first documented laboratory-confirmed outbreak of OXA-181-producing K. pneumoniae in SA, and highlights the importance of enforcing strict adherence to infection control procedures and the need for ongoing surveillance of antibiotic-resistant pathogens in local hospitals.
TL;DR: Only once prevalence data and an assessment of care needs are available will it be possible to propose improving health services for the growing aged population, especially those with dementia in poorer rural communities.
Abstract: Dementia is one of the biggest challenges to society today, with an increasing prevalence as the global population ages. The 2013 worldwide estimate was 44 million persons with dementia, with predictions that about 70% of new cases will occur in low- and middle-income countries (LMICs). With negligible published prevalence data for South Africa, little is known about the impact of dementia, especially in poorer communities. Successful community dementia prevalence screening has been conducted in ten LMICs worldwide, using a one-step diagnostic procedure developed in the UK by the 10/66 group. The prevalence of dementia needs to be established locally across various communities. Awareness, education, training and skilled resources for diagnosis and care are minimal. Only once prevalence data and an assessment of care needs are available will it be possible to propose improving health services for the growing aged population, especially those with dementia in poorer rural communities.
TL;DR: The prevalence of anaemia among antenatal attendees in a regional hospital in Durban, SA was 42.7%, significantly higher in HIV-positive compared with HIV-negative pregnant women and in the majority the anaemia was mild and normocytic and normochromic.
Abstract: Background. Anaemia is a major global health problem affecting an estimated 42% of pregnant women worldwide. There is a paucity of South African (SA) data on anaemia in pregnancy, despite the fact that parasitic infections are endemic and the nutritional status of sections of the population is poor. Objective. To determine the prevalence of anaemia among antenatal attendees in a regional hospital in Durban, SA. Methods. This was a cross-sectional prospective study in a regional health facility in an urban setting serving a population of low socioeconomic status. Venous blood samples to perform a full blood count were obtained from antenatal attendees at their first clinic visit. Results. Two thousand pregnant women were studied; the mean (standard deviation) age and gestational age at booking was 27.6 (7.6) years and 21.7 (7.1) weeks, respectively. Eight hundred and fifty-four (42.7%) were anaemic (haemoglobin (Hb) levels <11 g/dL). The majority (81.4%) were mildly anaemic. There were five (0.6%) cases of severe anaemia (Hb <7 g/dL). The prevalence of anaemia was significantly higher in HIV-positive compared with HIV-negative pregnant women (71.3% v. 28.7%; p<0.0001). The common morphology was normochromic normocytic (n=588, 68.9%). Conclusion. The prevalence of anaemia was 42.7%. In the majority (81.4%) the anaemia was mild and normocytic and normochromic (68.9%). Anaemia is a common problem among antenatal attendees in an SA urban population.
TL;DR: This review addresses both the epidemiology of HF in SSA and principles of management that focus specifically on symptom relief, prevention of hospitalisation and improving survival in this population.
Abstract: Despite medical advances, heart failure (HF) remains a global health problem and sub-Saharan Africa (SSA) is no exception, with decompensated HF being the most common primary diagnosis for patients admitted to hospital with heart disease. In SSA the in-hospital mortality rate of decompensated HF is up to 8.3%. HF is a clinical syndrome that is caused by a diverse group of aetiologies, each requiring unique management strategies, highlighting the need for diagnostic certainty and a broad understanding of the complex pathophysiology of this condition. While there are a number of advanced medical, device and surgical interventions being tailored for HF internationally, the fundamental basic principles of HF management, such as patient education, effective management of congestion and initiation of disease-modifying medical therapies, remain a challenge on our continent. This review addresses both the epidemiology of HF in SSA and principles of management that focus specifically on symptom relief, prevention of hospitalisation and improving survival in this population.
TL;DR: Despite significant daily sunlight availability in Africa and the Middle East, persons living in these regions are frequently vitamin D insufficient or deficient as discussed by the authors, which may lead to hypovitaminosis D.
Abstract: Exposure to sunlight, specifically ultraviolet B (UVB), is essential for cutaneous vitamin D synthesis. Despite significant daily sunlight availability in Africa and the Middle East, persons living in these regions are frequently vitamin D insufficient or deficient. Vitamin D insufficiency (25-hydroxyvitamin D (25(OH)D) between 15 and 20 ng/mL (37.5-50 nmol/L)) has been described in various population groups, ranging from 5% to 80%. Risk factors include traditional dress and avoidance of sunlight exposure, and multiple dietary factors as a result of specific cultural beliefs. Vitamin D resistance due to calcium deficiency mechanisms has been described in similar population groups, which may lead to hypovitaminosis D. Should the new diseases related to hypovitaminosis D prove to be truly associated, Africa and the Middle East will become an epicentre for many of these conditions. Urgent attention will need to be paid to cultural dress and dietary behaviours if hypovitaminosis D is to be taken seriously. Should such factors not be correctable, new strategies for supplementation or food fortification will have to be devised.
TL;DR: The ability of the CHCs and district hospitals to perform the signal functions (lifesaving services) of basic and comprehensive emergency obstetric care was poor in many of the districts studied, implying that safe maternity care was not consistently available at many facilities conducting births.
Abstract: Aim. To assess the functionality of healthcare facilities with respect to providing the signal functions of basic and comprehensive emergency obstetric care in 12 districts. Setting. Twelve districts were selected from the 52 districts in South Africa, based on the number of maternal deaths, the institutional maternal mortality ratio and the stillbirth rate for the district. Methods. All community health centres (CHCs) and district, regional and tertiary hospitals were visited and detailed information was obtained on the ability of the facility to perform the basic (BEmONC) and comprehensive (CEmONC) emergency obstetric and neonatal care signal functions. Results. Fifty-three CHCs, 63 district hospitals (DHs), 13 regional hospitals and 4 tertiary hospitals were assessed. None of the CHCs could perform all seven BEmONC signal functions; the majority could not give parenteral antibiotics (68%), perform manual removal of the placenta (58%), do an assisted delivery (98%) or perform manual vacuum aspiration of the uterus in a woman with an uncomplicated incomplete miscarriage (96%). Seventeen per cent of CHCs could not bag-and-mask ventilate a neonate. Less than half (48%) of the DHs could perform all nine CEmONC signal functions (81% could perform eight of the nine functions), 24% could not perform caesarean sections, and 30% could not perform assisted deliveries. Conclusions. The ability of the CHCs and district hospitals to perform the signal functions (lifesaving services) of basic and comprehensive emergency obstetric care was poor in many of the districts studied. This implies that safe maternity care was not consistently available at many facilities conducting births.
TL;DR: The current research and existing responses to migration and health in southern Africa are outlined, including public health researchers and health workers.
Abstract: The impact of global increases in human mobility on health systems is a little understood but highly political issue in recipient countries. South Africa (SA) is the greatest recipient of migrants from the Southern African Development Community. There is a policy of free primary health care for all in SA – as outlined in the Constitution and the National Health Act – but its interpretation is less inclusive within implementation guidelines and practice. As a result, non-nationals face access challenges, and public health responses have engaged with migration to a limited extent. Migration provides opportunities for health and economic benefits, and has the potential to positively and negatively affect health systems. To maximise positive impact and mitigate against potential negative consequences requires attention and engagement of policy-makers from health and other sectors, including public health researchers and health workers. We outline our current research and existing responses to migration and health in southern Africa.
TL;DR: A brief review of how poverty and income levels are defined is offered to provide insight into the shortcomings of such definitions and into what ‘eradicating poverty in all its forms’ would mean if considered within more realistic boundaries.
Abstract: It is clear that the World Bank definition of poverty is outdated and requires revision. A brief review of how poverty and income levels are defined is offered to provide insight into the shortcomings of such definitions and into what ‘eradicating poverty in all its forms’ would mean if considered within more realistic boundaries.
TL;DR: The ASCI Unit at GSH is established to be one of the key role players in acute SCI management in SA and data capturing and analysis of SCIs should be encouraged to guide management and prevention strategies, and to optimise outcomes.
Abstract: Background. Spinal cord injury (SCI) is devastating to both patient and society, with acute management and ongoing care being extremely expensive. Few epidemiological data are available on SCIs in South Africa (SA). Objectives. To identify the epidemiological profile of SCI patients at Groote Schuur Hospital (GSH), Cape Town, SA, and identify seasonal trends and peak periods. As the majority of the injuries are preventable, these data are important to develop prevention strategies. Methods. A retrospective review of prospectively collected data was conducted on all patients admitted to the Acute Spinal Cord Injury (ASCI) Unit at GSH from 1 April 2003 to 31 March 2014. All cases registered on a prospectively maintained database were included in the study. Results. The total number of patients admitted to the ASCI Unit was 2 042, with an average of 185 admissions per year. The male/female ratio was 5.25:1. The 21 - 30-year-old age category was the largest, comprising 33.5% of the patients. The most prevalent cause of injury was motor vehicle accidents (44.6%), followed by violence-related injuries (27.2%). Thirty-two point two per cent of patients needed ventilatory support, and 91.5% of mechanically ventilated patients were successfully weaned. December was the busiest month in the unit. In patients in whom neurological deficit was incomplete, the average motor function improvement was 16.0%. Conclusions. Data capturing and analysis of SCIs should be encouraged in SA to guide management and prevention strategies, and to optimise outcomes. This study establishes the ASCI Unit at GSH to be one of the key role players in acute SCI management in SA.
TL;DR: Severe acute malnutrition remains a problem in public health, especially in developing countries, and adhering to programmatic approaches for diagnosis and management ensures lower mortality rates and better outcomes.
Abstract: Malnutrition remains a global health concern and contributes significantly to childhood mortality. Nearly half of all deaths in children <5 years of age are attributed to undernutrition, especially in developing countries. It is important to differentiate between acute and chronic malnutrition, as the management and mortality for these two conditions differ. Management should follow integrative management protocols to ensure that mortality and morbidity are minimised. General principles for inpatient management of acute malnutrition can be divided into two phases, i.e. the initial stabilisation phase (usually in the first week) for acute complications, and the much longer rehabilitation phase. The initial phase lasts approximately 1 week and involves intensive monitoring and treatment. Severe acute malnutrition remains a problem in public health, especially in developing countries. Adhering to programmatic approaches for diagnosis and management ensures lower mortality rates and better outcomes.
TL;DR: There is a wide clinical spectrum of renal disease in the course of HIV infection, including acute kidney injury, electrolyte and acid-basedisturbances, HIV-associated glomerular disease, acute-on-chronic renal disease and side-effects related to the treatment of HIV.
Abstract: In hypertensive patients without chronic kidney disease (CKD) the goal is to keep blood pressure (BP) at ≤140/90 mmHg. When CKD is present, especially where there is proteinuria of ≥0.5 g/day, the goal is a BP of ≤130/80 mmHg. Lifestyle measures are mandatory, especially limitation of salt intake, ingestion of adequate quantities of potassium, and weight control. Patients with stages 4 - 5 CKD must be carefully monitored for hyperkalaemia and deteriorating kidney function if angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are used, especially in patients >60 years of age with diabetes or atherosclerosis. BP should be regularly monitored and, where possible, home BP-measuring devices are recommended for optimal control. Guidelines on the use of antidiabetic agents in CKD are presented, with the warning that metformin is contraindicated in patients with stages 4 - 5 CKD. There is a wide clinical spectrum of renal disease in the course of HIV infection, including acute kidney injury, electrolyte and acid-base disturbances, HIV-associated glomerular disease, acute-on-chronic renal disease and side-effects related to the treatment of HIV.
Journal Article•
TL;DR: Urgent attention will need to be paid to cultural dress and dietary behaviours if hypovitaminosis D is to be taken seriously, and new strategies for supplementation or food fortification will have to be devised.
Abstract: Exposure to sunlight, specifically ultraviolet B (UVB), is essential for cutaneous vitamin D synthesis. Despite significant daily sunlight availability in Africa and the Middle East, persons living in these regions are frequently vitamin D insufficient or deficient. Vitamin D insufficiency (25-hydroxyvitamin D (25(OH)D) between 15 and 20 ng/mL (37.5 - 50 nmol/L)) has been described in various population groups, ranging from 5% to 80%. Risk factors include traditional dress and avoidance of sunlight exposure, and multiple dietary factors as a result of specific cultural beliefs. Vitamin D resistance due to calcium deficiency mechanisms has been described in similar population groups, which may lead to hypovitaminosis D. Should the new diseases related to hypovitaminosis D prove to be truly associated, Africa and the Middle East will become an epicentre for many of these conditions. Urgent attention will need to be paid to cultural dress and dietary behaviours if hypovitaminosis D is to be taken seriously. Should such factors not be correctable, new strategies for supplementation or food fortification will have to be devised.