South African Medical Journal

Ismail Ahmed Motala (1937 - 2022)

A I Motala — 2024-01-30

No abstract.

A diagnostic dilemma for a common but not-so-typical street pesticide

F Uys — 2024-01-30

The illegal practice of combining organophosphates (OPs) with other compounds such as carbamates and pyrethroids, creating ‘street pesticides’, is common in South Africa. These agents contain mostly unknown quantities of unregulated toxins and contribute to atypical and unpredictable clinical presentations following human ingestion. We present such a case in a patient with intentional rodenticide ingestion. The initial presentation in the emergency department was a classic cholinergic toxidrome, and clinical resolution was achieved after provision of atropine. This was followed 12 hours later by an acute decompensation resulting from an apparent sympathetically driven episode of autonomic instability and acute pulmonary oedema requiring immediate respiratory and haemodynamic support. In our discussion, we explore this secondary decompensation and suggest various pathophysiological explanations for this atypical clinical course following what had appeared to be OP poisoning. The patient was discharged home after a total of 6 days in hospital.

Loadshedding and healthcare: Salt in the wound?

Thandeka Dakalo Malange — 2024-01-30

No abstract.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

C Day — 2024-01-30

Background. Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect, increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% of self-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.
Objectives. To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.
Methods. Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district and tertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conducted to identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic at Groote Schuur Hospital.
Results. A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA, with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48) of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48) of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling at the allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.
Conclusion. Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk for type 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Risk stratification of hospital admissions for COVID-19 pneumonia by chest radiographic scoring in a Johannesburg tertiary hospital

H C Labuschagne — 2024-01-30

Background. Chest radiographic scoring systems for COVID-19 pneumonia have been developed. However, little is published on the utility of 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 with clinical parameters, disease course and clinical outcomes. To assess inter-rater reliability and developing predictive models of the clinical outcome using the Brixia score and clinical parameters.
Methods. Retrospective investigation was conducted of adult participants with established COVID-19 pneumonia admitted at a tertiary institution from 1 May to 30 June 2020. Two radiologists, blinded to clinical data, assigned Brixia scores. Brixia scores were compared with clinical parameters, length of stay and clinical outcomes (discharge/death). Inter-rater agreement was determined. Multivariable logistic regression 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% confidence interval (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 intensive care 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 median age 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 model combining Brixia score, age, male gender and obesity (sensitivity 84%; specificity 63%) as well as a model with Brixia score and C-reactive protein (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 SA risk stratification models incorporating comorbidities and a serological marker. When used in conjunction with age, male gender, obesity and CRP, the Brixia scoring system is a promising and reliable risk stratification tool. This may help inform the clinical decision pathway in resource-limited settings like ours during future waves of COVID-19.

Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi

T Ruderman — 2024-01-30

Background. Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependent diabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report of implementation of SMBG in a rural, low-income country setting.
Objectives. To evaluate adherence and change in clinical outcomes with SMBG implementation at two rural hospitals in Neno, Malawi.
Methods. Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participants monitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluate glucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked and documented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a 6-month period.
Results. Participants brought their glucometers and logbooks to the clinic 95 - 100% of the time. Adherence with measuring glucose values and recording them in logbooks eight times a week was high (mean (standard deviation) 69.4% (15.7) and 69.0% (16.6), respectively). Mean HbA1c decreased from 9.0% (75 mmol/mol) at enrolment to 7.8% (62 mmol/mol) at 6 months (mean difference 1.2% (95% confidence interval (CI) 0.6 - 2.0; p=0.0005). The difference was greater for type 1 diabetes (1.6%; 95% CI 0.6 - 2.7; p=0.0031) than for type 2 diabetes (0.9%; 95% CI 0.1 - 1.9; p=0.0630). There was no documented increase in hypoglycaemic events, and no hospitalisations or deaths occurred.
Conclusion. SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improved HbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research on long-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

Factors associated with partner notification intentions among symptomatic sexually transmitted infection service attendees in South Africa

B Da Costa Dias — 2024-01-30

Background. In South Africa (SA), a client-initiated partner notification (PN) approach is implemented for the management of sexual
partners of patients presenting with sexually transmitted infections (STIs) or STI syndromes.
Objectives. To explore the demographic, sexual behavioural and clinical characteristics associated with PN intentions among symptomatic STI service attendees at sentinel primary healthcare facilities in three SA provinces.
Methods. We analysed cross-sectional data obtained from 1 293 adults enrolled into STI aetiological surveillance during 2019 - 2020 in Gauteng, KwaZulu-Natal and Western Cape provinces. Self-reported sexual practices, PN intentions and clinical data were collected using nurse-administrated questionnaires. We assessed gender-stratified factors associated with the index case’s willingness to notify their sexual partners of their STI syndrome diagnosis. Univariable and multivariable Poisson regression models with robust error variance were used to determine factors associated with gender-stratified PN intentions.
Results. The enrolled participants comprised 887 male (68.6%) and 406 female (31.4%) STI clients. Self-reported PN intentions were higher among women than men (83.5% v. 64.4%; p<0.001). Multivariable analyses revealed that casual sex partnerships during the preceding 3-month period and enrolment at the KwaZulu-Natal site were independent barriers to PN intent among male participants. For females, enrolment at the Gauteng site was independently associated with lower PN intentions, while presenting with genital ulcer syndrome was a motivator towards PN intent. The primary reasons cited for non-disclosure across both genders were casual sexual encounters, followed by geographically distant partnerships and fear of disclosure.
Conclusion. We show that demographic and behavioural characteristics, as well as relationship dynamics, may influence the PN intentions of STI service attendees in SA. Alternative PN strategies should be considered, based on the reported barriers, to increase overall STI notification, strengthen partner management and ultimately reduce STI incidence.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation

M M Sunnyraj — 2024-01-30

Background. Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of ‘PD first’ programmes.
Objectives. To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg.
Methods. After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher’s exact test were used to compare continuous and categorical variables where appropriate.
Results. Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range.
Conclusion. PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

What are health policy and systems research priorities for universal health coverage in South Africa?

H Schneider — 2024-01-30

We report here on the process and findings of a research prioritisation exercise for universal health coverage (UHC) in South Africa, conducted during the course of 2019. As plans to roll out National Health Insurance (NHI) gather momentum and we transition into a pandemic recovery phase, we believe that it is now time to revisit these priorities, while recognising that experiences with the COVID‑19 pandemic have revealed new system challenges and strengths and introduced new priorities. The UHC research priority-setting methodology followed a stepwise process of collation of evidence, expert brainstorming and the development of a survey completed by 68 members of the Public Health Association of South Africa. Themes related to leadership and governance were ranked most highly, and with other priorities generated, provide an initial road map of knowledge needs that could guide individual institutions and commissioning by funding bodies. We further reflect on the importance of researcher-decision-maker dialogue and strengthening the contribution of health policy and systems research to policy and practice, especially as new reforms are implemented.

Transcatheter vascular plugs for the treatment of massive haemoptysis from Rasmussen aneurysms

J A Shaw — 2024-01-30

Rasmussen aneurysms are abnormalities of the pulmonary arterial system caused by tuberculosis (TB). They are associated with a high mortality rate when they cause life-threatening haemoptysis. High TB-prevalence regions have a large burden of TB-related haemoptysis but often limited resources. This series of 25 patients who presented with life-threatening haemoptysis from current and/or previous TB were found to have abnormal pulmonary arteries on computed tomography pulmonary angiogram (CTPA), which were judged to be likely contributors to their bleeding, either in isolation or with concomitant abnormal bronchial or systemic vasculature. These patients underwent transcatheter placement of Amplatzer vascular plugs in the feeder pulmonary artery. Bronchial and systemic lesions were addressed separately as needed. Immediate technical success was achieved in all patients, but four of them experienced intraoperative haemoptysis related to dislodgement of the occluding platelet plug by the high-pressure automatic injector and wire. At 48 hours after the procedure, 18 (72%) remained haemoptysis-free. Six of these experienced recurrence within 1 year of their procedure. Pulmonary artery placement of an Amplatzer vascular plug is a feasible option for treating bleeding Zasmussen aneurysms, but should be part of a combined approach to addressing suspected culprit vascular lesions in all intrathoracic vascular systems.