South African Medical Journal <p>The <em>South African Medical Journal</em> is published by the South African Medical Association, which represents most medical professionals in South Africa. </p><p>Other websites related to this journal: <a title="" href="" target="_blank"></a></p><p><span style="text-decoration: underline;">Back issues</span> of the journal from years 1886 - 2002 can be found on the journal's website under the 'Back Issues' link at the top of the home page.</p><p>The SAMJ 2010 impact factor is 1.676</p> Health and Medical Publishing Group en-US South African Medical Journal 2078-5135 <p>Copyright remains in the Author’s name. The work is licensed under a Creative Commons Attribution - Noncommercial Works License. Authors are required to complete and sign an Author Agreement form that outlines Author and Publisher rights and terms of publication. The Agreement form should be uploaded along with other submissions files and any submission will be considered incomplete without it <em>[forthcoming].</em></p><p>Material submitted for publication in the <em>SAMJ</em> is accepted provided it has not been published or submitted for publication elsewhere. Please inform the editorial team if the main findings of your paper have been presented at a conference and published in abstract form, to avoid copyright infringement. The <em>SAMJ</em> does not hold itself responsible for statements made by the authors.</p><p><strong>Previously published images</strong></p><p>If an image/figure has been previously published, permission to reproduce or alter it must be obtained by the authors from the original publisher and the figure legend must give full credit to the original source. This credit should be accompanied by a letter indicating that permission to reproduce the image has been granted to the author/s. This letter should be uploaded as a supplementary file during submission.</p><p> </p> Guest Editorial: Health and rehabilitation sciences in a clinical context No Abstract Ntobeko A.B. Ntusi Copyright (c) 2019-03-07 2019-03-07 109 3 139 141 Physiotherapy in rehabilitation and prohabilitation across the lifespan <p>There is considerable evidence to support the rise in non-communicable diseases (NCDs). Reduction of the NCD burden is of vital importance globally, including South Africa (SA). Recent evidence demonstrates that NCDs commence in early childhood and continue throughout the lifespan. Strengthening of interprofessional and multidisciplinary team efforts supports a decrease in the impact of NCDs on individuals, families and communities and enhances health-related quality of life to improve productivity of the SA economy. Mounting overweight/obesity rates and poor nutrition cause NCDs, which are preventable. It is important that healthcare practitioners identify causes of ill-health and promote health among patients, rather than await symptoms and then determine treatment. It is also critically important to inspire positive lifestyle changes in one’s patients.</p> N Naidoo R Barnes N Mlenzana K Mostert S.L. Amosun Copyright (c) 2019-03-07 2019-03-07 109 3 142 144 Prevention of treatment-induced ototoxicity: An update for clinicians <p>Ototoxicity is a common side-effect during treatment of a a number of life-threatening health conditions. Often, when treating such conditions, the focus tends to be on saving the patient’s life rather than preserving their hearing or vestibular function. However, advances in clinical management of these conditions, availability of less ototoxic alternative medicines and developments in interventions to prevent ototoxicity now give clinicians a better opportunity to save the patient’s life and preserve their hearing and vestibular function. Effective communication between audiologists, clinical pharmacists and physicians is critical in preventing drug-induced ototoxicity. Clinicians need to stay up to date regarding scientific and clinical developments related to the prevention of treatment-induced ototoxicity. This article reviews common ototoxic medicinal agents and strategies to prevent ototoxicity, and discusses recent developments towards preventing drug-induced ototoxicity.</p> L Ramma N Schellack B Heinze Copyright (c) 2019-03-07 2019-03-07 109 3 145 149 The apps are coming! But will they be legal in South Africa? <p>Technology is all around us. It helps us to be more productive every day. One of the main ways it does this is by automating processes that would otherwise have taken up our time. Doctors can leverage technology to help remove the burden of performing repetitive tasks, allowing them to focus on seeing patients. This article deals with ways in which technology could be used for certain tasks such as renewing prescriptions. Using technology in such a way would fall under the concept of telemedicine. Local guidelines are assessed to ascertain whether the use of apps by patients in South Africa for healthcare advice by doctors would be legal.</p> A Barit Copyright (c) 2019-03-07 2019-03-07 109 3 150 151 Alternating hemiplegia of childhood: First South African case report and verapamil as a possible treatment option <p>In this case report we describe a child with alternating hemiplegia of childhood, a rare neurodevelopmental disorder, and the effectiveness of an unconventional drug, verapamil, in treating this condition.</p> L.S. van Hillegondsberg I.A. Michaelis Copyright (c) 2019-03-07 2019-03-07 109 3 152 153 Perioperative comparison of the agreement between a portable fingertip pulse oximeter v. a conventional bedside pulse oximeter in adult patients (COMFORT trial) <p><strong>Background.</strong> Low-cost, portable fingertip pulse oximeters are widely available to health professionals and the public. They are often not tested to International Organization for Standardization standards, or only undergo accuracy studies in healthy volunteers under ideal laboratory conditions.</p><p><strong>Objectives.</strong> To pragmatically evaluate the agreement between one such device and a conventional bedside pulse oximeter in a clinical setting, in patients with varied comorbidities and skin pigmentations.</p><p><strong>Methods.</strong> A single-centre equipment comparison study was conducted. Simultaneous measurements were obtained in 220 patients with both a Contec CMS50D Fingertip Pulse Oximeter and a Nihon Kohden Life Scope MU-631 RK conventional bedside monitor. Peripheral oxygen saturations (SpO<sub>2</sub>) and pulse rates were documented, and patients’ skin tone was recorded using the Fitzpatrick scale. Data were assessed using a Bland-Altman analysis with bias, precision and limits of agreement (LOA) calculated with 95% confidence intervals (CIs). <em>A priori</em> acceptability for LOA was determined to be 3%, in keeping with international standards.</p><p><strong>Results.</strong> The mean difference (therefore bias) between the conventional and fingertip oximeters for all data was –0.55% (95% CI –0.73 - –0.36). Upper and lower limits of agreement were 2.16% (95% CI 1.84 - 2.47) and –3.25% (95% CI –3.56 - –2.94). Regression analysis demonstrated worsening agreement with decreasing SpO2. When samples were separated into ‘normal’ (SpO<sub>2</sub> ≥93%) and ‘hypoxaemic’ (SpO<sub>2</sub> &lt;93%) groups, the normal range displayed acceptable agreement between the two oximeters (bias –0.20% with LOA 2.20 - –2.27), while the hypoxaemic group fell outside the study’s <em>a priori</em> limits. Heart rate measurements had a mean difference of –0.43 bpm (LOA –5.61 - 4.76). The study was not powered to detect differences among the skin tones, but demonstrated no trend for this parameter to alter the SpO<sub>2</sub> measurements.</p><p><strong>Conclusions.</strong> During normoxia, portable fingertip pulse oximeters are reliable indicators of SpO<sub>2</sub> and pulse rates in patients with various comorbidities in a pragmatic clinical context. However, they display worsening agreement with conventional pulse oximeters during hypoxaemia. Skin tones do not appear to affect measurements adversely.</p> R.N. Smith R Hofmeyr Copyright (c) 2019-03-07 2019-03-07 109 3 154 158 Delay to diagnosis and breast cancer stage in an urban South African breast clinic <p><strong>Background.</strong> Breast cancer is the most common cancer in women in many low- and middle-income countries, and often presents at an advanced stage that affects prognosis irrespective of the care available. Although patient-related delay is commonly cited, the reasons for delay and the relationship of delay to stage are still poorly documented, especially in Africa.</p><p><strong>Objectives.</strong> To identify where patient-related socioeconomic delays occur and how these relate to stage at presentation.</p><p><strong>Methods.</strong> Consecutive women with a new breast cancer diagnosis were prospectively invited to complete a questionnaire on their socioeconomic characteristics and ability to access care. Clinical stage at presentation was documented.</p><p><strong>Results.</strong> Over 14 months, 252 women completed the questionnaire (response rate 71.6%). Their median age was 55 years (interquartile range 44 - 65), with 26.5% aged &lt;45 years. Stage at presentation was stage 1 in 15.5% of patients, stage 2 in 28.5% and stage 3 in 56.0%. Almost a third of the patients (30.4%) presented with a T4 tumour (6.1% inflammatory). Total delay in presenting to the breast clinic was significantly associated with locally advanced stage at presentation (<em>p</em>=0.021). Average delay differed between early stage (1.5 months) and locally advanced (2.5 months), and most delay occurred between acknowledging a breast symptom and seeking care. The least delay was between attending a health service and presenting at the open-access breast clinic, with 75.0% presenting within 1 month. Factors associated with delay were difficulties with transport, low level of education and fear of missing appointments due to work.</p><p><strong>Conclusions.</strong> Most women delayed in seeking breast care. Facilitating direct access to specialist breast clinics may reduce delays in presentation and improve time to diagnosis and care.</p> S Rayne K Schnippel D Kruger C-A. Benn C Firnhaber Copyright (c) 2019-03-07 2019-03-07 109 3 159 163 Evaluation of factors and patterns influencing the 30-day readmission rate at a tertiary-level hospital in a resourceconstrained setting in Cape Town, South Africa <p><strong>Background.</strong> Factors contributing to and causes of hospital readmissions have been investigated worldwide, but very few studies have been performed in South Africa (SA) and none in the Western Cape Province.</p><p><strong>Objectives.</strong> To investigate possible preventable and non-preventable factors contributing to readmissions to the Department of Internal Medicine at Tygerberg Hospital (TBH), Cape Town, within 30 days of hospital discharge. The researchers tested a risk-stratification tool (the LACE index) to evaluate the tool’s performance in the TBH system.</p><p><strong>Methods.</strong> A retrospective analysis was conducted of all 30-day readmissions (initial hospitalisation and rehospitalisation within 30 days) to the Department of Internal Medicine at TBH for the period 1 January 2014 - 31 March 2015. Potential risk factors leading to readmission were recorded.</p><p><strong>Results.</strong> A total of 11 826 admissions were recorded. Of these patients, 1 242 were readmitted within 30 days, representing a readmission rate of 10.5%. The majority of patients (66%) were readmitted within 14 days after discharge. The most important risk factor for readmission was the number of comorbidities, assessed using the Charlston score. The study also identified a large burden of potentially avoidable causes (35% of readmissions) due to system-related issues, premature discharge being the most common. Other reasons for 30-day readmission were nosocomial infection, adverse drug reactions, especially warfarin toxicity, inadequate discharge planning and physician error.</p><p><strong>Conclusions.</strong> Despite TBH being a low-resource, high-turnover system, the 30-day readmission rate was calculated at 10.5%. Global readmission rates vary from 10% to 25%, depending on the reference article/source used. We found that 35% of 30-day readmissions were potentially avoidable. Venous thromboembolism was a minor contributor to readmission but was associated with a very high mortality rate. A secondary outcome evaluated was the utility of the LACE and modified LACE (mLACE) index in the TBH environment. The risk tool performed well in the TBH population, and a high LACE and mLACE score correlated with an increased risk of 30-day readmission (<em>p</em>&lt;0.001).</p> R Dreyer A.J. Viljoen Copyright (c) 2019-03-07 2019-03-07 109 3 164 168 Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden <p><strong>Background.</strong> Many patients with previous pulmonary tuberculosis (PTB) continue to experience respiratory symptoms long after completion of tuberculosis (TB) therapy, often resulting in numerous hospital visits and admissions.</p><p><strong>Objectives.</strong> To describe the profile of patients with chronic lung disease (CLD) with or without a history of PTB, and their in-hospital outcomes.</p><p><strong>Methods.</strong> We conducted a retrospective review of patients with CLD admitted with respiratory symptoms to Dora Nginza Hospital, Port Elizabeth, South Africa, from 1 April 2016 to 31 October 2016. These patients were divided into two groups: CLD with a history of PTB (CLD-TB) and CLD without a history of PTB. Patients with current culture-positive TB were excluded. Baseline characteristics and clinical outcomes (duration of hospitalisation and in-hospital mortality) were compared between the two groups.</p><p><strong>Results.</strong> During the study period, a total of 4 884 patients were admitted and 242 patients received a diagnosis of CLD. In the CLD patient group, 173 had CLD-TB and 69 had no history of PTB. Patients with CLD-TB presented with respiratory symptoms a median of 41 months (interquartile range (IQR) 101) after completion of TB therapy. CLD-TB patients were predominantly male (59.5%), and compared with patients with no history of PTB were more likely to be HIV-positive (49.7% v. 8.7%; <em>p</em>=0.001) and had had more frequent hospital admissions before the current admission (median 2.0 (IQR 2.0) v. 0; <em>p</em>=0.001) and longer hospital stays (median 5 days (IQR 7) v. 2 (4); <em>p</em>=0.002). However, there was no statistically significant difference in in-hospital mortality between the two groups (17.3% v. 10.1%; <em>p</em>=0.165).</p><p><strong>Conclusions.</strong> In patients with CLD, a history of PTB is associated with numerous hospital admissions and longer hospital stays but not with increased in-hospital mortality. TB therefore continues to be a public health burden long after cure of active disease.</p> P Mkoko S Naidoo C Mbanga F Nomvete R Muloiwa S Dlamini Copyright (c) 2019-03-07 2019-03-07 109 3 169 173 How accurately do routinely reported HIV viral load suppression proportions reflect progress towards the 90-90-90 target in the population on antiretroviral treatment in Khayelitsha, South Africa? <p><strong>Background.</strong> The Joint United Nations Programme on HIV/AIDS (UNAIDS) third 90-90-90 target requires 90% of patients on antiretroviral treatment (ART) to be virally suppressed (&lt;1 000 copies/mL). In Khayelitsha, Cape Town, South Africa viral load (VL) suppression of &lt;400 copies/mL was reported as 89% in 2016, but only 56% of patients had a result recorded in routine data. We conceived a VL ‘cascade’ to represent the steps required for an expected VL to be reported as complete in routine data and thus contribute to reported VL suppression: among those for whom a VL is ‘expected’, a sample must be collected and tested (‘done’), a result must be ‘filed’ in the patient folder, ‘noted’ by a clinician and electronically ‘captured’. The low reported completion suggested gaps along the VL cascade and cast doubt on the validity of reported suppression.</p><p><strong>Objectives.</strong> To assess the validity of routinely reported VL suppression and identify barriers to VL completion.</p><p><strong>Methods.</strong> A retrospective cohort study between 1 July 2015 and 30 June 2016, which included all Khayelitsha patients receiving ART, with a routine VL expected, was conducted. We obtained data routinely captured on site and VL data from the laboratory system. A sample of 1 035 patient folders was reviewed. VL suppression was calculated using laboratory data, including all tests done, and compared with reported suppression based on on-site captured electronic data. Successful progression through each step on the VL cascade was estimated. We used logistic regression to identify factors associated with laboratory data and reported VL testing.</p><p><strong>Results.</strong> Of 22 991 patients for whom a routine VL test was due, 84% were done, 79% filed, 76% noted and 55% captured. Using all laboratory data, VL suppression was estimated as 82%, 87%, 89% and 91% at the 50, 200, 400 and 1 000 copies/mL thresholds, respectively, but reported suppression using captured results was 80%, 86%, 88% and 89% at those thresholds. Routine VL testing is more likely to be done in children &lt;15 years old (adjusted odds ratio (aOR) 1.89, 95% confidence interval (CI) 1.45 - 2.48) and pregnant women (aOR 1.90, 95% CI 1.28 - 2.81) than in men, adjusted for facility.</p><p><strong>Conclusions.</strong> Despite a low reported completion, VL testing completion was high. Reported suppression using captured data was similar to suppression calculated using all laboratory data, which provided an accurate measure of progress towards the 90-90-90 target. More work is needed to reach the 16% of patients missed by routine testing.</p> J Euvrard T Schulz K Hilderbrand M Bosland M Osler A Boulle M-A. Davies Copyright (c) 2019-03-07 2019-03-07 109 3 174 177 Venous thromboembolism risk and prophylaxis prescription in surgical patients at a tertiary hospital in Eastern Cape Province, South Africa <p><strong>Background.</strong> Venous thromboembolism (VTE) is a common complication during and after hospitalisation, and is regarded as the most common cause of preventable death in hospitalised patients worldwide. Despite its importance, there are few data on VTE risk and adherence to prophylaxis prescription guidelines in surgical patients from the South African (SA) public sector, especially from lowresource environments such as Eastern Cape Province.</p><p><strong>Objectives.</strong> To evaluate the risk and prescription of VTE prophylaxis to surgical patients at a tertiary government hospital in the Eastern Cape.</p><p><strong>Methods.</strong> A cross-sectional clinical audit of general surgical inpatients was performed on two dates during July and August 2017. Patients’ VTE risk was calculated by using the Caprini risk assessment model (RAM) and thromboprophylaxis prescription evaluated accordingly.</p><p><strong>Results.</strong> A total of 179 patients were included in the study, of whom 56% were male and 44% female. The average age was 45 (range 18 - 83) years. Of the total number of participants, 33% were elective cases and 67% were emergency admissions. With application of RAM, 77% of patients were at risk of VTE (Caprini score ≥2), with 81% of elective and 74% of emergency patients being at risk. The most prevalent risk factors for VTE were major surgery (34%), age 41 - 60 years (30%), age 61 - 74 years (20%) and sepsis during the previous month (27%). A contraindication to chemoprophylaxis was recorded in 30% of patients, with the most prevalent being renal dysfunction (40%), peptic ulcer disease (34%), active bleeding (17%), liver dysfunction (17%), coagulopathy (6%) and recent cerebral haemorrhage (6%). With regard to VTE risk profile and contraindications to chemoprophylaxis, the correct thromboprophylactic treatment was prescribed to 26% of at-risk patients, with 21% of elective and 27% of emergency admission patients receiving the correct therapy.</p><p><strong>Conclusions.</strong> Despite a high proportion of patients being at risk of VTE, the rate of adequate thromboprophylaxis prescription for surgical inpatients at Frere Hospital, East London, SA is very low. Increased availability of mechanical prophylaxis, as well as interventions to improve the rate of adequate prophylaxis prescription, needs to be evaluated for feasibility and effect in this hospital and other SA public hospitals.</p> W.D. Rocher T Page M Rocher D Nel Copyright (c) 2019-03-07 2019-03-07 109 3 178 181 Trauma electives in South Africa provide valuable training for international surgeons <p><strong>Background.</strong> Trauma electives in South Africa (SA) are common and many foreign-based surgeons have undertaken such electives over the past 3 decades. Despite this, little academic attention has been paid to these electives, which remain largely informal and unstructured. This project aims to redress this deficit.</p><p><strong>Objectives.</strong> To investigate and document the extent of trauma clinical electives and to assess their impact on the careers of foreign surgeons who have undertaken such electives.</p><p><strong>Methods.</strong> A mixed methods-style questionnaire was compiled, which sought to document the demographics of surgeons undertaking an SA trauma clinical elective, the trauma clinical experience they had prior to the elective, as well as the volume of experience they acquired during the elective.</p><p><strong>Results.</strong> Sixty questionnaires were sent out and 21 were completed. There were 16 male and 5 female respondents. Only 17 had undertaken a formal trauma rotation before their elective in SA. The mean number of major resuscitations managed prior to rotating through surgery departments in SA was 15, and the mean number managed during a 12-month rotation in SA was 204. It would take each respondent 14 years in their country of origin to acquire an equivalent level of exposure to major resuscitation. During the year before their elective, each surgeon had been exposed to a mean number of the following: 0.5 gunshot wounds (GSWs), 2 stab wounds (SWs), 0.1 blast injuries and 19 road traffic accidents (RTAs). The equivalent mean number for their year in SA was 106 GSWs, 153 SWs, 4 blast injuries and 123 RTAs. The time necessary to achieve a similar level of exposure to their SA experience if they had remained in their country of origin was 213 years for GSWs, 73 years for SWs, 41 years for blast injuries and 7 years for RTAs. Compared with their SA elective, it would take each respondent 3 years to insert as many central venous lines, 9 years to perform the same number of tube thoracostomies, 9 years to manage as many surgical airways, 18 years to explore as many SWs of the neck and 93 years to explore as many GSWs of the neck. Furthermore, it would take 33 years to see and perform as many laparotomies for SWs to the abdomen, 374 years to perform an equivalent number of GSWs to the abdomen and 34 years of experience to perform as many damage-control laparotomies in their countries of origin. In terms of vascular trauma, it would take 23 years to see as many vascular injuries secondary to SWs and 77 years to see an equivalent number of vascular injuries secondary to GSWs.</p><p><strong>Conclusions.</strong> A trauma clinical elective in SA provides an unparalleled exposure to almost all forms of trauma in conjunction with a welldeveloped academic support programme. Formalising these trauma electives might allow for the development of exchange programmes for SA trainees who wish to acquire international exposure to advanced general surgical training.</p> H Uchino V.Y. Kong F Plani W Bekker V Manchev J.L. Bruce G.L. Laing D.L. Clarke Copyright (c) 2019-03-07 2019-03-07 109 3 182 185 Assessment and management of venous thromboembolism risk during pregnancy and the puerperium (SAVE): The South African cohort <p><strong>Background.</strong> Venous thromboembolism (VTE) is associated with significant morbidity and mortality. Pregnancy and the puerperium are hypercoagulable states and increase the risk of VTE. There is a paucity of South African (SA) data related to use of thromboprophylaxis during pregnancy and the puerperium.</p><p><strong>Objectives.</strong> To evaluate local practice of VTE risk stratification among SA pregnant women and senior doctors’ attitudes to VTE prophylaxis.</p><p><strong>Methods.</strong> This was a cross-sectional descriptive study of conveniently sampled sites in the private and public health sectors. Patients with confirmed pregnancy and an underlying medical condition were enrolled after giving informed consent. Assessments were made based on the participating doctors’ questionnaires and case report forms. In essence, this was a local evaluation of a specific group of patients by a specific group of doctors.</p><p><strong>Results.</strong> Two hundred and twenty patients were enrolled at six sites. In the participating doctors’ opinion, 126/220 women assessed (57.2%) were at risk of VTE during pregnancy and the postpartum period (information was missing for 1 woman during the postpartum period). Of the women at risk of VTE, 23/126 (18.3%) were at high risk, 59/126 (46.8%) at moderate risk and 44/126 (34.9%) at low risk. Of the women identified as at risk of VTE, 104/127 (81.9%) received some form of VTE prophylaxis; 94/127 (74.0%) were at risk during pregnancy and 32/126 (25.4%) during the postpartum period. Of those who received pharmacological treatment, 15/15 received low-molecular-weight heparin during pregnancy and before delivery and 87/100 during the puerperium. Thirty-four patients received thromboprophylaxis for only 5 - 10 days after caesarean delivery, and 2 received mechanical thromboprophylaxis during pregnancy.</p><p><strong>Conclusions.</strong> Doctors participating in the study were generally aware of VTE risk during pregnancy and the puerperium. Pharmacological thromboprophylaxis was the most commonly used intervention to reduce VTE risk. Mechanical thromboprophylaxis was underutilised. Adherence to VTE guidelines, specifically in terms of duration of thromboprophylaxis and its utilisation during pregnancy, was suboptimal.</p> P Naidoo R Mothilal L.C. Snyman Copyright (c) 2019-03-07 2019-03-07 109 3 186 192 Erratum <p>In the article ‘Mental illness in the Western Cape Province, South Africa: A review of the burden of disease and healthcare interventions’ by Jacob and Coetzee, which appeared on pp. 176 - 180 of the March 2018 <em>SAMJ</em>, reference 2 has been changed to the following: Corrigall J, Ward C, Stinson K, <em>et al</em>. Decreasing the burden of mental illness: Final report 2007 (Volume 4 of 7). In: Myers JE, Naledi NT, eds. Western Cape Burden of Disease Reduction Project. University of Cape Town on behalf of the Provincial Department of Health, 2007. <a href=""></a> (accessed 5 February 2019). The online version of the article (<a href=""></a>) was corrected on 6 February 2019.</p> Claudia Naidu Copyright (c) 2019-03-07 2019-03-07 109 3 193 193 Erratum <p>In the article ‘Fulminant hepatitis B virus (HBV) infection in an infant following mother-to-child transmission of an e-minus HBV mutant: Time to relook at HBV prophylaxis in South African infants’, which appeared on pp. 389 - 392 of the May 2018 <em>SAMJ</em>, the first author’s name should have been B Ogunbosi and not O Babatunde. The online version of the article (<a href=""></a>) was corrected on 6 February 2019.</p> Claudia Naidu Copyright (c) 2019-03-07 2019-03-07 109 3 194 194