Fairall L, Yende-Zuma N, Reddy T
… +10 more, Garrett N, Goga A, Bennet S, Folb N, Seocharan I, Mametja S, Semenya M, Simelane SRN, L-G, Gray GE
S Afr Med J
· 2025 Aug · PMID 41378633
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BACKGROUND: From March 2020 to June 2022, South Africa (SA) confronted successive waves of COVID-19, each linked to emerging SARS-CoV-2 variants. Vaccines played a critical role in preventing severe disease and death, bu...BACKGROUND: From March 2020 to June 2022, South Africa (SA) confronted successive waves of COVID-19, each linked to emerging SARS-CoV-2 variants. Vaccines played a critical role in preventing severe disease and death, but as new SARS-CoV-2 variants emerged, with increasing breakthrough infections, questions arose about the real-world effectiveness of first-generation vaccines containing the ancestral strain against evolving variants including Delta and Omicron BA.1 and BA.4/5 SARS-CoV-2. OBJECTIVES: To assess the real-world effectiveness of ancestral strain booster doses (either Ad26.COV2.S or BNT162b2) in preventing severe COVID-19 outcomes, including hospitalisation, admission to critical care and death, among essential workers in SA who received a primary dose of Ad26.COV2.S against emerging SARS-CoV-2 variants. METHODS: A retrospective cohort study was conducted using data from a large private health insurance scheme. Individuals who received a single dose of Ad26.COV2.S as their primary vaccination were included. Time-varying Cox regression models were used to assess the effectiveness of boosting with either Ad26.COV2.S or BNT162b2 v. not boosting against severe COVID-19 outcomes associated with emerging variants, adjusting for various demographic and clinical factors. RESULTS: By August 2021, a total of 407 961 individuals received a first dose of Ad26.COV2.S, of whom 350 688 were eligible for and 332 286 included in the vaccine effectiveness (VE) analysis. Of these, 206 359 (62%) received no further doses, while 113 957 (34%) received a second dose of Ad26.COV2.S and 11 970 (4%) received a second dose of BNT162b2 by August 2022. During the follow-up period (November 2021 - August 2022), 1 125 COVID-19-related hospital admissions, 198 admissions to critical care and 41 COVID-19-related deaths were recorded. Adjusted relative VE against severe outcomes was 34% (95% confidence interval (CI) 19 - 45) for hospital admission, 51% (95% CI 22 - 70) for critical care admission, and 89% (95% CI 13 - 98) for COVID-19- related death. CONCLUSION: While most participants remained unboosted, administration of either ancestral strain Ad26.COV2.S or BNT162b2 vaccination provided protection against severe COVID-19 outcomes among essential workers in SA during the dominance of the Omicron BA.1 and BA.4/5 variants, demonstrating cross-strain protection.
S Afr Med J
· 2025 Aug · PMID 41378632
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BACKGROUND: Screening and termination of pregnancy (TOP) for Down syndrome (DS) are both available in South Africa (SA), but DS is infrequently diagnosed prenatally in the public sector (7% in 2008), resulting in a high...BACKGROUND: Screening and termination of pregnancy (TOP) for Down syndrome (DS) are both available in South Africa (SA), but DS is infrequently diagnosed prenatally in the public sector (7% in 2008), resulting in a high live-birth prevalence (1.33 - 2.1 per 1 000). In the SA public sector, DS screening and confirmatory genetic testing are fully state subsidised for women of advanced maternal age (AMA) but, owing to the low positive predictive value of AMA-based screening, ultrasound-based screening is also offered. Given the limited resources and the steady increase in the number of pregnant women of AMA, the value of DS screening in altering pregnancy outcome needs to be critically assessed. OBJECTIVES: To determine the uptake of prenatal screening for DS, invasive testing and TOP in pregnant women of AMA, as well as factors influencing maternal decisions. METHODS: This retrospective cohort study, based on prospectively captured data, includes all women of AMA (>37 years at conception) seen at a regional fetal medicine unit in Cape Town offering fully state subsidised DS screening and testing for a geographically defined area, including mostly women of African or mixed ancestry. Screening was age- and ultrasound-based, and DS risks were calculated using published algorithms. Non-directive genetic counselling was provided to all women ≥40 years old (pre-screen if feasible), women with a relevant history, a fetal anomaly or DS risk higher than that of a woman aged 37 years. Participant characteristics, results, decisions and reasons to decline testing were recorded prospectively, and compared between women <40 completed years and ≥40 years old, and between women accepting or declining invasive testing or TOP. RESULTS: During the study period, 1 196 women of AMA were seen. Ninety-three received pre-screen counselling, and 44 of these declined DS screening (47.3% (95% confidence interval (CI) 36.9 - 57.9)). Uptake of invasive testing after screening was low (18.1% (CI 15.2 - 21.3)). Age category was not an independent confounder for this, but uptake was lower after previous miscarriage(s), higher after high-risk screening results and highest with a fetal anomaly. The most common reason for declining testing was opposition to TOP. The uptake of TOP for DS, when offered to those who were screened and had accepted invasive testing, was 65.8% (48.7 - 80.4). CONCLUSION: The uptake of screening and/or testing was low, and this reflected strong views on TOP for DS. As uptake of testing and/or TOP was higher with abnormal ultrasound findings, a prenatal screening programme addressing structural anomalies and aneuploidies simultaneously (i.e. ultrasound) is preferred over other DS screening tools that target DS specifically.
S Afr Med J
· 2025 Aug · PMID 41378631
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Prof. Jan Hendrik Louw (1915 - 1992) was a pioneering figure in paediatric and adult surgery in South Africa, and he left an indelible mark on teaching, training, research and academia. He excelled academically and gradu...Prof. Jan Hendrik Louw (1915 - 1992) was a pioneering figure in paediatric and adult surgery in South Africa, and he left an indelible mark on teaching, training, research and academia. He excelled academically and graduated from the University of Cape Town medical school with distinction in 1938. He was appointed to the Chair of Surgery at UCT and Groote Schuur Hospital in 1955, transforming the department into a centre of excellence in clinical practice, research and education. He was instrumental in developing paediatric surgery as a distinct specialty at the newly inaugurated Red Cross War Memorial Children's Hospital in 1956. Subsequent groundbreaking research with Christiaan Barnard investigating congenital intestinal atresia, which involved intrauterine fetal surgery in puppies, garnered international commendation. Known as a strict disciplinarian, his insistence on clinical excellence, rigorous academic standards and ethical responsibility became the hallmarks of surgical culture at UCT, Groote Schuur Hospital and beyond. His leadership in and contributions to medical politics were substantial, and his achievements and international reputation were affirmed by honorary fellowships from 11 international surgical colleges and the prestigious Denis Browne Gold Medal from the British Association of Paediatric Surgery. His seminal tome, In the Shadow of Table Mountain, documented from conception the history of the Medical School at UCT. His memory endures through the countless lives he touched, the surgeons he trained, and his contributions to global surgery. He retired in 1980, leaving a towering legacy in South African and international surgery.
S Afr Med J
· 2025 May · PMID 41378625
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BACKGROUND: Diarrhoeal disease is easily preventable and treatable. Despite proven interventions to prevent and treat the condition, it remains one of the leading causes of death in children under the age of 5 years. OBJ...BACKGROUND: Diarrhoeal disease is easily preventable and treatable. Despite proven interventions to prevent and treat the condition, it remains one of the leading causes of death in children under the age of 5 years. OBJECTIVES: To assess whether preventive measures of childhood diarrhoea were applied in infants admitted with acute diarrhoea, and to quantify morbidity and mortality in infancy due to acute diarrhoea. METHOD: This retrospective descriptive study was conducted at Pelonomi Tertiary Hospital in Bloemfontein, South Africa. Information on infants admitted with acute diarrhoeal disease was collected, namely their age in months, gender, length of stay, need for intensive care, the application of preventive measures of childhood diarrhoeal disease, such as breastfeeding, up-to-date immunisations, appropriate complementary feeds and their nutritional status. RESULTS: A total of 297 infants met the inclusion criteria over the 2-year period. The prevalence of acute diarrhoea was 24.8%. A total of 67% of the infants were not breastfeeding. Of the 67%, 52.2% had stopped breastfeeding before the age of 6 months, while 14.8 % were never breastfed. The average length of stay was 9.7 days. Severe malnutrition was noted in 29.3% of the infants. Of these, 8.42% had severe malnutrition with oedema, while 20.9% had severe malnutrition without oedema. Appropriate complementary feeds were provided to 79.5% of participants, and 61 (20.5%) were not provided with appropriate complementary feeds. Of these 61 infants, 48 were undernourished. Although most infants were discharged home, 4% (n=12) died. Five of the 12 infants (41.7%) who died did not receive the rotavirus vaccine. CONCLUSION: Acute diarrhoeal disease in infancy remains an important contributor to morbidity and mortality within this setting. This study suggests the implementation of preventive measures such as exclusive breastfeeding, appropriate complementary feeds, immunisations and early identification of undernourished infants to reduce infant mortality.
Gumede SS, Motala M, Yakobi A
… +2 more, Sibiya A, Bipath R
S Afr Med J
· 2025 May · PMID 41378624
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BACKGROUND: The global standard of care for advanced laryngeal squamous cell carcinoma (SCC) is total laryngectomy and neck dissection. While this approach aligns with international guidelines, there is no consensus on w...BACKGROUND: The global standard of care for advanced laryngeal squamous cell carcinoma (SCC) is total laryngectomy and neck dissection. While this approach aligns with international guidelines, there is no consensus on whether elective neck dissection (END) should be incorporated during primary surgery for clinically negative neck nodes (cN0) or as a therapeutic option after nodal relapse. It is therefore imperative to evaluate associated oncological outcomes and local contextual factors regarding END surgical approach in advanced laryngeal SCC. OBJECTIVE: To evaluate the lymph node outcomes and the rate of occult metastases (OM) of patients with advanced laryngeal cancer who underwent total laryngectomy with neck dissection. METHODS: A retrospective chart review was conducted at a South African hospital. Clinical records of 113 patients with stage III/IV laryngeal cancer who underwent total laryngectomy were retrieved from the hospital's health information system for analysis. Demographic data, postoperative care, and clinical and pathological reports were analysed. RESULTS: The patients were predominantly male (92.6%), of African origin (62%), with a mean age of 61.0 years and HIV seroposivity rate of 13.2%. Combined alcohol and tobacco use prevalence was 58.4%, while that of tobacco use alone was 31%. Overall histopathological tumour analyses showed that 74.3% had clear margins, 16.8% close margins and 8.0% positive margins. A total of 71.7% of the patients were initially classified as cN0, before histopathological results revealed 30.9% to have OM, with 3.75% having extranodal involvement. Substance use in the cN0 group with OM, regardless of HIV serostatus, was strongly associated with OM. CONCLUSION: This study supports the importance of END in advanced laryngeal SCC and cN0 patients, aligning with global OM rates. These findings provide critical insights into the local context, supporting the continuation of END as standard of care in our institution.
S Afr Med J
· 2025 May · PMID 41378623
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BACKGROUND: Early treatment with methotrexate (MTX) remains the mainstay of rheumatoid arthritis (RA) treatment. In patients with inadequate response to MTX, the European Alliance of Associations for Rheumatology (EULAR)...BACKGROUND: Early treatment with methotrexate (MTX) remains the mainstay of rheumatoid arthritis (RA) treatment. In patients with inadequate response to MTX, the European Alliance of Associations for Rheumatology (EULAR) recommends the addition of a biological disease-modifying antirheumatic drug (bDMARD) if poor prognostic factors are present. Despite patients in Africa frequently having poor prognostic factors, bDMARDs are often not available. Leflunomide (LEF) has been shown to be a potent DMARD, leading EULAR to question whether its efficacy is equivalent to MTX as a first-line agent. OBJECTIVE: To review LEF's use and safety profile in a low-resource setting, and its usefulness in patients with inadequate response to MTX. METHODS: A retrospective record review was done of all patients with RA who received LEF for at least 6 months between 2018 and 2020 at the Division of Rheumatology, Tygerberg Academic Hospital, Cape Town, South Africa. Patients in whom LEF was discontinued within the first 6 months were also included when assessing the discontinuation rate and side-effects. Demographic information, reasons for initiation, side-effects and treatment discontinuation were recorded. Efficacy data were recorded using the clinical disease activity index (CDAI) at 6-month intervals up to 24 months. RESULTS: A total of 210 patients who were on LEF were included. Most (n=177) patients were females from low-income backgrounds, with a mean age of 56.51 years and a mean (standard deviation) disease duration of 6.9 (1.0 - 13.8) years. Almost all patients (n=209; 99.52%) had poor prognostic factors, mainly high disease activity (mean CDAI 26.68) and previous exposure to ≥2 conventional synthetic DMARDs (csDMARDs). Most patients initiated LEF owing to loss of efficacy and poor response to triple therapy. After initiation of LEF, treatment targets were achieved by 98 (53%) patients, with 22 (11.9%) and 76 (41.1%) patients achieving clinical remission and low disease activity, respectively (p<0.001, confidence interval (CI) 9.90 -12.29). The mean CDAI decreased to 11.17 (p<0.001, CI 9.59 - 12.74). Most disease control was achieved within the first 6 - 12 months, and was sustained for 24 months. A total of 16 (7.62%) patients experienced side-effects, necessitating treatment discontinuation. Two pregnancies exposed to LEF in the first trimester resulted in healthy babies. CONCLUSION: LEF has been demonstrated to be an effective alternative csDMARD for patients with inadequate response to MTX-based therapies, reducing the mean CDAI from 26 to 11. It adds a viable alternative for RA patients with poor prognostic factors and lack of access to bDMARDs.
S Afr Med J
· 2025 May · PMID 41378622
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BACKGROUND: The remunerative work outside of the public service (RWOPS) policy enables public sector health professionals to engage in multiple job holding (MJH) in South Africa (SA) under specified conditions, but remai...BACKGROUND: The remunerative work outside of the public service (RWOPS) policy enables public sector health professionals to engage in multiple job holding (MJH) in South Africa (SA) under specified conditions, but remains controversial. Empirical evidence on health professionals' perspectives on the RWOPS policy stipulations is lacking. OBJECTIVE: To examine the perspectives of public sector medical doctors (MDs), professional nurses (PNs) and rehabilitation therapists (RTs) on the RWOPS policy. METHODS: In 2022, public sector MDs, PNs and RTs were surveyed in 14 Gauteng and 15 Mpumalanga province public sector hospitals. In addition to demographic and employment data, the self-administered questionnaire collected information on whether the health professionals had obtained permission for additional jobs, their opinions on RWOPS approval requirements and restrictions and the likelihood that they would leave the public sector if RWOPS was denied. Data analysis was performed using Stata 17. The factors influencing health professionals' perspectives on different aspects of the RWOPS policy were analysed using penalised logistic regression. RESULTS: A total of 1 397 health professionals completed the survey, for a response rate of 84.3%. Most MDs (61.1%) and RTs (60.5%) supported mandatory RWOPS approval, compared with 41.5% of PNs. Overall, 52.6% of MDs, PNs and RTs engaged in MJH also agreed with mandatory approval. Among those who engaged in MJH, the majority of MDs (84.7%) and RTs (87.4%) had RWOPS permission, compared with only 19.2% of PNs. MDs (odds ratio (OR) 9.9, p<0.001) and RTs (OR 30.9, p<0.001) were significantly more likely to obtain RWOPS approval than PNs. MDs (OR 2.2, p<0.001), RTs (OR 1.5, p=0.027), males (OR 1.4, p=0.039) and RWOPS participants (OR 2.8, p=0.030) were more likely to consider leaving if RWOPS was denied. CONCLUSION: Our findings highlight significant variation in obtaining MJH permission among health professionals. The diverse perspectives underscore the need for targeted communication and stakeholder engagement to clarify policy and improve compliance.
Gage C, Spies B, Crombie K
… +3 more, Slingsby T, Gwyther L, Stassen W
S Afr Med J
· 2025 May · PMID 41378621
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BACKGROUND: Approximately 56.8 million people worldwide require palliative care annually, while only 14% receive such care. Within low- to middle-income countries (LMICs), this imbalance is prominent, as these countries...BACKGROUND: Approximately 56.8 million people worldwide require palliative care annually, while only 14% receive such care. Within low- to middle-income countries (LMICs), this imbalance is prominent, as these countries contain up to 80% of patients requiring palliative care. To correct this imbalance, palliative care integration with other disciplines has been recommended. One developing area of integration in the South African (SA) LMIC context involves emergency medical services (EMS). OBJECTIVES: To describe the geographical and temporal distribution of the EMS and palliative situation intersection in Cape Town, SA. METHODS: A descriptive, retrospective patient record review was employed at two hospitals in Cape Town. Records of patients who received palliative care at hospitals after EMS transport between 1 January 2020 and 31 December 2020 were included. EMS intersection with palliative situations according to the time of day, working hours, day of the week and month of the year were subjected to χ2 testing for temporal analysis. Geospatial data were investigated using cluster and proximity analyses. RESULTS: Overall, 494 instances of EMS palliative situation transport were identified. Most occurred in peri-urban areas (78%, n=385), during the daytime (52%, n=257), out of office hours (53%, n=261) and on weekdays (76%, n=375). Statistically significant variation in distribution was found according to time of day (p<0.001), with 38% (n=188) of cases occurring between 13h00 and 19h00, and month of year (p<0.001), with 54% (n=267) occurring from June to October. Proximity analysis revealed a mean driving time of 6.69 minutes and distance of 3.65 km to palliative care facilities. CONCLUSION: EMS are frequently used for access to palliative care at any time of the day, week or year, particularly in peri-urban areas. EMS may further improve access through integration with palliative care. This efficient use of constrained resources should be pursued in SA, focusing on areas of increased demand.
S Afr Med J
· 2025 May · PMID 41378620
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BACKGROUND: Recommendations for preoperative investigations are available worldwide, and are advocated for in an attempt to reduce unnecessary testing, especially in healthy patients undergoing low-risk surgery. However,...BACKGROUND: Recommendations for preoperative investigations are available worldwide, and are advocated for in an attempt to reduce unnecessary testing, especially in healthy patients undergoing low-risk surgery. However, despite these guidelines, unnecessary preoperative testing still occurs. This is the first South African study comparing preoperative investigations ordered with the recommendations of both the National Institute for Health and Care Excellence (NICE) and local preoperative testing guidelines. OBJECTIVES: Primary objectives were to describe the preoperative investigations ordered in patients undergoing elective surgery, compare these with international and local guidelines, and assess the cost of overtesting. Secondary objectives were to assess the frequency of abnormal laboratory results in tests not indicated by the guidelines, as well as to assess patterns in overtesting. METHODS: This was a retrospective record review study of American Society of Anesthesiologists (ASA) 1 and 2 patients undergoing elective minor and intermediate surgical procedures in Tygerberg Hospital between November and December 2021. The preoperative investigations of 501 patients were studied, including laboratory tests (full blood count (FBC), urea, creatinine and electrolytes panel and international normalised ratio), point-of-care haemoglobin, chest radiographs (CXRs) and electrocardiograms. Tests were compared with guidelines, and the cost of any overtesting was calculated. Patterns in overtesting were evaluated. Data were sourced from electronic medical records. SPSS version 28 was used to analyse data. RESULTS: A total of 501 patients undergoing elective surgery were included. As many as 89% of the cohort had at least one unnecessary test done (95% confidence interval 85.9 - 91.6). Overall, FBCs and CXRs were the most overtested investigations, being done unnecessarily in one-third of patients. Redundant duplicate testing occurred 177 times. The projected potential cost savings on preoperative investigations if NICE guidelines were followed at Tygerberg Hospital are ZAR857 987 per annum, and ZAR696 515 per annum if the local guidelines are followed. Extra testing as per local guidelines compared with NICE guidelines was mostly unhelpful to reveal additional clinically relevant abnormalities. General surgery patients, patients aged >35 years, ASA 2 patients and females were subject to the highest levels of overtesting (p<0.001). CONCLUSION: Preoperative testing over and above testing recommended by both international and local guidelines is common, and represents an enormous area for potential cost savings in a resource-limited environment. Additional local studies are required to further expand on overtesting and the factors contributing to it.
S Afr Med J
· 2025 May · PMID 41378619
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Although sometimes innocuous, headaches in pregnancy may be associated with serious, even life-threatening conditions, with diagnosis delayed due to nonspecific findings associated with normal pregnancy. Meningiomas are...Although sometimes innocuous, headaches in pregnancy may be associated with serious, even life-threatening conditions, with diagnosis delayed due to nonspecific findings associated with normal pregnancy. Meningiomas are the most common primary tumours, have a strong female predisposition and are mostly benign. There is a paucity of information on the diagnosis and management of meningiomas during and after pregnancy. In this article, we describe two cases of meningioma with differing management, seen within a period of 6 months. In case one, iatrogenic preterm delivery of the baby at 33 weeks' gestation was executed to facilitate vision-saving neurosurgery. In our second case, delivery was at early term, with time allowed for postpartum re-evaluation before definitive neurosurgery.