Mapimhidze D, Bailly J, Brown K
… +2 more, Bailey J, Verburgh E
S Afr Med J
· 2025 Feb · PMID 41378589
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BACKGROUND: Primary immune thrombocytopenia (ITP) is an acquired autoimmune disease characterised by an isolated thrombocytopenia of <100 × 109/L in the absence of identifiable secondary causes. Treatment is indicated wh...BACKGROUND: Primary immune thrombocytopenia (ITP) is an acquired autoimmune disease characterised by an isolated thrombocytopenia of <100 × 109/L in the absence of identifiable secondary causes. Treatment is indicated when the platelet count is <20 - 30 × 109/L, but may be commenced at higher platelet counts when the risk of bleeding is high. Corticosteroids are the backbone of initial treatment of ITP. There is a paucity of data in South Africa (SA) on the outcomes of newly diagnosed ITP patients treated with corticosteroids. OBJECTIVES: To describe the response, remission and clinical outcomes of newly diagnosed primary ITP patients on first-line corticosteroids. METHODS: This was a retrospective cohort study of 68 patients with a new diagnosis of ITP, seen at the Clinical Haematology Unit at Groote Schuur Hospital, Cape Town, SA, over a 5-year period (2016 - 2020). Demographic and clinical data were obtained from paper and electronic record systems. All participants with secondary causes were excluded. The initial platelet responses to corticosteroids and the final outcomes at last follow-up were determined. Initial platelet responses were classified into no response (NR), partial response (PR) and complete response (CR) in accordance with consensus definitions. Remission was defined as maintenance of a CR after being off corticosteroids for ≤6 months. Categorical variables were described by frequencies and percentages, while numerical variables were described by medians and interquartile ranges (IQRs) as data were non-parametric. RESULTS: The majority of patients were female (88.2%) and the median (IQR) age at diagnosis was 36 (23.0 - 55.5) years. The female to male ratio was 7.5:1. Most (92.4%) patients responded to corticosteroids, with 74.2% achieving a CR and 18.2% achieving a PR. Only five patients failed to respond (7.6%). The median (IQR) time to achieve CR was 15 (8 - 25) days, and the median (IQR) time to achieve PR was 10.5 (8 - 22) days. Half of the patients went into remission. Following remission, two patients (6.1%) subsequently relapsed at day 344 and day 777, respectively. Hypertension and/or diabetes mellitus were newly diagnosed in 10.6% of patients. CONCLUSION: Corticosteroids are effective first-line therapy for ITP, but are not remission-inducing in all patients. For those patients progressing to chronic ITP, there is a need to investigate cost-effective treatment. Some patients are at high risk of developing new hypertension and diabetes mellitus on corticosteroids, and should be monitored.
S Afr Med J
· 2025 Feb · PMID 41378588
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BACKGROUND: Tuberculosis (TB) is a major contributor to mortality among patients affected by HIV. TB diagnosis can be challenging, especially in those who are severely ill and unable to produce sputum. Urine lipoarabinom...BACKGROUND: Tuberculosis (TB) is a major contributor to mortality among patients affected by HIV. TB diagnosis can be challenging, especially in those who are severely ill and unable to produce sputum. Urine lipoarabinomannan (LAM) is a rapid point-of-care diagnostic tool that is used on urine. The dilemma arises if a urine LAM test yields a negative result when the clinical presentation is strongly suggestive of TB. OBJECTIVE: To investigate how a urine LAM test result changes the physician's decision to start TB treatment in people living with HIV in Kalafong Provincial Tertiary Hospital (KPTH). METHOD: A cross-sectional study was done at KPTH in the internal medicine wards, family medicine and HIV outpatient departments. Patients who were HIV positive with a strong TB diagnosis suspicion, had a CD4 count <200 cells/mm3, were aged >13 years and had a urine LAM done to investigate TB were included. Outcomes investigated were: presenting symptoms, clinical signs, radiological and haematological investigations, including CD4 count and HIV viral load, urine LAM results and whether TB treatment was initiated or not. At KPTH, a register of all patients who have been given a urine LAM test is held at the TB notification centre, which was where the information regarding urine LAM results was retrieved from, as well as whether treatment was initiated or not. The patients' clinical hospital records and National Health Laboratory Service lab results were retrieved for necessary information. RESULTS: There were 430 patient records and urine LAM results retrieved: 307 (71.4%) had negative results and 123 (28.6%) had positive results. Of the 307 (71.4%) with a negative result, 120 (39.1%) were initiated on treatment, and only 3 of those who had positive results (1.6%) did not receive treatment. The urine LAM test results appeared to influence clinicians' decisions to treat when the result was positive. If the urine LAM was negative, clinicians still initiated treatment based on adequate clinical suspicion and other investigations. There was significant incongruency between patients with a negative urine LAM test who received TB treatment (p<0.001). CONCLUSION: The use of the urine LAM did not change the physician's decision to start TB treatment where the was a high suspicion of TB based on clinical presentation and other investigations. Physicians depended more on their clinical intuition where the urine LAM was negative.
S Afr Med J
· 2025 Feb · PMID 41378587
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BACKGROUND: Anaesthetic drug wastage negatively impacts the already constrained economy in developing countries such as South Africa (SA). However, safe anaesthetic drug administration during both elective and emergency...BACKGROUND: Anaesthetic drug wastage negatively impacts the already constrained economy in developing countries such as South Africa (SA). However, safe anaesthetic drug administration during both elective and emergency surgeries can be achieved without increasing wastage or costs. Drugs frequently wasted include those required in emergencies. Cost-reduction strategies, particularly in drug wastage, represent a potential area for short-term savings in hospital drug budgets. Increasing clinician awareness of drug wastage can help modify practices, leading to reduced waste while maintaining high-quality patient care. OBJECTIVE: To evaluate wastage of commonly administered anaesthetic drugs, and to evaluate preventable and routine drug wastage and its cost. METHODS: A prospective observational study was conducted in the operating theatre of Chris Hani Baragwanath Academic Hospital, a tertiary hospital in SA. Prospective data were collected for all patients who presented for elective and emergency surgical procedures at this institution over a 2-week period. Drug preparation and administration were determined by the treating anaesthesiologist. The amount of remaining drug in syringes and opened ampoules was considered as wasted. Routine drug wastage was defined as the remaining drug after the required dose was administered, while preventable drug wastage referred to drugs drawn but not administered to the patient. RESULTS: Data were collected from 373 participants, of whom 58% were undergoing elective surgery. The average drug wastage was 29.7%, comprising 21.3% routine wastage and 8.4% preventable wastage, with an effect size of 0.47 (p<0.001). Propofol accounted for the highest frequency of routine drug wastage, while preventable wastage was predominantly attributed to adrenaline, atropine and suxamethonium (emergency pharmacological agents). The average cost of routine wastage was ZAR3.85, significantly higher than the ZAR1.32 for preventable drug wastage (p<0.001). Multivariate regression analysis revealed a significant association between paediatric surgical cases and increased anaesthetic drug wastage (p=0.004). CONCLUSION: The cost and wastage of anaesthetic drugs pose significant challenges in healthcare institutions, particularly in developing countries with limited resources. Implementing cost-effective strategies, such as using smaller ampoules and prefilled syringes, has been demonstrated to reduce drug wastage without compromising patient care.
Naidoo KL, Munian L, Neethling B
… +1 more, Rapiti N
S Afr Med J
· 2025 Feb · PMID 41378586
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BACKGROUND: Despite iron deficiency anaemia (IDA) being a global challenge, guidelines on identifying and managing children in infection- burdened areas are unclear. Little is known about the investigation and treatment...BACKGROUND: Despite iron deficiency anaemia (IDA) being a global challenge, guidelines on identifying and managing children in infection- burdened areas are unclear. Little is known about the investigation and treatment of IDA for hospitalised children in HIV-endemic areas. OBJECTIVES: To determine the prevalence of anaemia in hospitalised children and to describe the factors that impact the identification and management of IDA in an urban area of South Africa (SA). METHODS: A cross-sectional study was conducted at a referral hospital in Durban, SA, from 1 January 2019 to 31 December 2019. A chart review was performed for the clinical and laboratory data of 1 138 hospitalised children between 1 and 5 years old who had full blood count results. Standard statistical analyses were performed, including comparative analyses between those with and without anaemia. RESULTS: There was a 24% prevalence rate of anaemia (46.2% of whom were moderate-severe). There was a greater prevalence for anaemia in malnourished children (p<0.0001) and those HIV exposed (p<0.0001). Despite 65.9% of anaemic children having microcytic hypochromic anaemia, iron studies were only performed in 12/273 (4.4%), and stool samples were tested in 16/273 (5.9%). The majority (260/273, 95.2%) of all anaemic children had a Mentzer index >13, suggesting a high prevalence of IDA. Only 10/273 (3.7%) were provided with iron. Children with microcytic hypochromic anaemia were no different in clinical presentation or outcome to other anaemic children. High numbers (55.1%) were on antibiotics, and this high infection burden may have affected the identification and management of IDA. CONCLUSION: Malnourished and HIV-exposed children have a higher prevalence of anaemia. Despite this, <10% of children had basic investigations to identify IDA. This study highlights the urgent need to implement guidelines in identifying IDA and providing iron replacement in hospitalised children in areas with high infection burdens, including SA.
S Afr Med J
· 2025 Feb · PMID 41378585
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The legalisation of private cannabis use in South Africa presents significant challenges for occupational health, especially in safety- sensitive environments. This article analyses the medical, legal and ethical issues...The legalisation of private cannabis use in South Africa presents significant challenges for occupational health, especially in safety- sensitive environments. This article analyses the medical, legal and ethical issues surrounding workplace cannabis use, focusing on the pharmacodynamics and pharmacokinetics of delta-9-tetrahydrocannabinol (THC), the primary psychoactive compound. The recent legal precedent that critiques the effectiveness of zero-tolerance policies is reviewed, and the establishment of per se THC thresholds that are medically and legally sound is proposed. The study advocates for a tailored approach to risk categorisation and testing protocols in workplaces, aiming to support occupational health professionals in developing policies that are effective, ethical and compliant with legal standards.
S Afr Med J
· 2025 Feb · PMID 41378584
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BACKGROUND: An implementation framework for community-oriented primary care (COPC) was developed in the Cape Metro, Western Cape Province, South Africa. In 2018, four learning sites were identified to experiment with the...BACKGROUND: An implementation framework for community-oriented primary care (COPC) was developed in the Cape Metro, Western Cape Province, South Africa. In 2018, four learning sites were identified to experiment with the framework. A study was undertaken to explore the implementation of this framework. OBJECTIVES: To explore the process and progress of implementation, as well as the perceptions of the barriers and enablers of implementation. METHODS: A programmatic process evaluation with a descriptive exploratory qualitative study design was used. A logic model was developed, and defined inputs, outputs and the sources of evidence for the implementation process. RESULTS: The understanding of COPC and its underlying philosophy contrasted with the traditional model of care, and the paradigm shift was challenging. Strong leadership was identified as a facilitator for change. Community and stakeholder engagement were the most challenging issues. COPC requires a wide range of skills and expertise supported by appropriate training and clear role definition. The use of electronic devices in the community was both an advantage and a barrier. CONCLUSION: Implementation of COPC needs to be understood as a reform of the model of care, and not as an additional project or service. The findings can guide policy, further scale-up and implementation of COPC.
Van As AB, Sidler D, Allema JH
… +16 more, Leva E, Marincowitz GJO, Tonkin S, Rose PC, Govender S, London L, De Agustin JC, Schimanek C, De Bruin G, Khamag O, Peck C, Almaliki CS, Hamunyela KS, Arnold M, Jaffer MN, Heyns Buckley K
S Afr Med J
· 2025 Feb · PMID 41378581
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Conco DN, Levin J, Komane B
… +4 more, Blanchard K, Bessenaar T, Nkosi NG, Fonn S
S Afr Med J
· 2025 Feb · PMID 41378579
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BACKGROUND: The occurrence of abortion-related morbidity indicates limited access to safe abortion. Globally, unsafe abortions remain a persistent, yet preventable, cause of maternal mortality. South Africa (SA) is inter...BACKGROUND: The occurrence of abortion-related morbidity indicates limited access to safe abortion. Globally, unsafe abortions remain a persistent, yet preventable, cause of maternal mortality. South Africa (SA) is internationally recognised for its progressive reproductive rights framework, supported by its Constitution and laws. However, evidence suggests that women encounter barriers to accessing safe abortions, including stigma, resistance from healthcare providers, a shortage of trained professionals and a lack of awareness of their rights. We hypothesised that, 20 years after the promulgation of the Choice on Termination of Pregnancy Act, the incidence of incomplete abortion (ICA) and the prevalence of abortion-related morbidity would change, influenced by access to safe abortion and the introduction of medication abortion. We wanted to compare our data with 2000 and 1994 survey results to assess change. OBJECTIVES: To estimate the incidence of incomplete abortion and describe the prevalence of abortion-related morbidity in SA public hospitals in 2018. METHODS: This was a cross-sectional, retrospective study. We selected a stratified random sample of public hospitals. We extracted data from medical records of women who presented with ICA during a predetermined 21-day period in 2018. Data were captured directly into a REDCap database. To estimate the national incidence of ICA, we used population estimates for 2018, comprising 17 199 227 women aged 12 - 49 years, and 1 200 436 live births. The prevalence of ICA morbidity is reported. We compared the rates in this study with those reported from similar studies in 2000 and 1994. RESULTS: We found 913 medical records of women presenting with ICA in the 56 public hospitals. ICA incidence was 367 (274 - 459) per 100 000 women aged 12 - 49 years. The average age of the women was 27 years, and the majority had a previous pregnancy before the ICA. A large proportion (73.9%) of women were in the first trimester. There was no sign of infection in 92.5% of records, no organ failure in 99.1% of records and there were no deaths. There was no change in the ICA incidence when compared with the 1994 and 2000 results. Women's mean age and having a previous pregnancy were similar in the three studies (1994, 2000 and 2018). The proportion of women presenting in the first trimester increased over time: 60.5% in 1994, 67.1% in 2000 and 73.9% in 2018. There has been a decline in the prevalence of abortion-related morbidity, demonstrated by lower levels of severity, no signs of infections and no organ failure. CONCLUSION: ICA incidence has not changed, but related morbidity is declining. Various factors could explain our findings, but the lack of change in ICA incidence indicates that access to formal abortion care has not improved over the past 20 years.
Nietz S, Cubasch H, Buccimazza I
… +6 more, Čačala S, Phakathi B, Joffe M, Chen WCC, Norris S, Ruff P
S Afr Med J
· 2025 Feb · PMID 41378578
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BACKGROUND: Monitoring quality indicators to improve breast cancer care is well established in high-income countries. This is the first evaluation of diagnostic and surgical quality indicators for initial benchmarking of...BACKGROUND: Monitoring quality indicators to improve breast cancer care is well established in high-income countries. This is the first evaluation of diagnostic and surgical quality indicators for initial benchmarking of breast cancer care in South Africa (SA). OBJECTIVE: To measure the adherence rates to quality indicators among women with breast cancer in SA. METHODS: Ten quality indicators were evaluated for 3 545 breast cancer patients across four SA surgical breast units using a shared electronic patient record system. Data quality and adherence rates with differences between units were determined. The effect of HIV status on adherence was assessed by multivariate Poisson regression analyses. RESULTS: Our electronic patient record reliably measured most quality indicators. Rates of positive margins (5.7%), overall axillary surgery (95.8%) and appropriate treatment sequencing in locally advanced breast cancer patients (98.4%) consistently reached minimum international standards. Rates of multidisciplinary team discussion (72.2%), radiotherapy (66.7%) and sentinel node biopsy (39.6%) showed wide cross-site variance. Histopathology reporting (62.0%), breast-conserving surgery (19.4%) and number of nodes excised with axillary dissection (47.3%) and sentinel node biopsy (82.7%) were consistently below minimum standards. Unit volumes were achieved consistently in Gauteng Province, but only for some years in KwaZulu-Natal Province; surgeon volumes were achieved across all units. HIV status did not affect adherence levels. Most quality indicators were well measurable, but data quality on reoperations and surgeon volumes was poor. CONCLUSION: We evaluated local quality indicators for an initial benchmark, and the most emergent gaps in care are the receipt of radiotherapy and underutilisation of sentinel node biopsy.
S Afr Med J
· 2025 Feb · PMID 41378577
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BACKGROUND: Infective endocarditis (IE) poses significant diagnostic and therapeutic challenges, especially in cases of blood culture-negative infective endocarditis (BCNIE). Among patients undergoing surgery for IE, val...BACKGROUND: Infective endocarditis (IE) poses significant diagnostic and therapeutic challenges, especially in cases of blood culture-negative infective endocarditis (BCNIE). Among patients undergoing surgery for IE, valve tissue may be evaluated for additional microbiological information by performing a broad-range 16S rDNA polymerase chain reaction (PCR) test, tissue culture and tissue histopathology. In patients with BCNIE, these diagnostic tests may identify the causative agents, guide further clinical management and improve local IE-related epidemiological data. The clinical utility of additional analysis of explanted tissue in a local South African (SA) setting has yet to be described. OBJECTIVES: To assess the clinical utility of performing PCR, culture and histopathology on the tissue of surgically explanted valves in BCNIE patients in an SA public sector hospital. We assess their diagnostic yield and treatment impact in a cohort of BCNIE patients treated with empirical antibiotic regimens. METHODS: We analysed data from the Groote Schuur Hospital (GSH) Infective Endocarditis Registry, a prospective observational study of adult patients with infective endocarditis. Participants for this analysis were selected based on clinical and pathological criteria for IE and negative blood cultures. All participants were treated between January 2017 and March 2021. RESULTS: During the study period, we identified 165 IE cases, 57 (34.5%) of which were blood-culture negative. BCNIE patients had a mean (standard deviation) age of 40.2 (13.4) years, and 41 (71.9%) were male. Twenty-seven of the 57 BCNIE patients underwent cardiac surgery and had tissue analysis performed. Tissue PCR identified an aetiological agent in 17/27 (63%) cases, with Bartonella spp. (12/27, 44%) being the most common organism. Tissue culture was positive in 3/27 (11%) cases, but the organisms identified were thought to reflect sample contamination. Tissue histopathology was performed in 22/27 (81.5%) cases and provided macroscopic confirmation of IE, but did not identify any specific organisms in any of the specimens. Only a small subset of the overall BCNIE cohort (11/57 (19.3%)) had serum serology for Bartonella spp. and Coxiella spp. performed, and 5/11 (45.5%) were positive for Bartonella spp. There was a 100% concordance rate between positive serum serology and tissue PCR. Tissue PCR impacted the antimicrobial regimen in 20/27 (74%) cases. Tissue culture and tissue histopathology did not influence antibiotic regimens in any patients. CONCLUSION: In this single-centre study, perioperative serum serological testing was underutilised in BCNIE. Tissue PCR was valuable in determining the aetiology of BCNIE, and influenced management. Tissue culture and histopathology had a poor yield and added little value in identifying the microbiological cause of BCNIE. Finally, the most common BCNIE causative organism identified by additional non-culture testing in our setting is Bartonella spp.
S Afr Med J
· 2025 Feb · PMID 41378576
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BACKGROUND: South Africa (SA), like the rest of the global village, is faced with the need to address health worker shortages, improve the performance of health workers and ensure an equitable distribution of health work...BACKGROUND: South Africa (SA), like the rest of the global village, is faced with the need to address health worker shortages, improve the performance of health workers and ensure an equitable distribution of health workers in all settings. This requires leadership, governance and stewardship acumen to put in place policies, practices and resources that are essential to recruit and retain human resources for health. OBJECTIVE: To determine whether SA possesses a strong and competent policy and strategic framework that would guide the development of a sufficient, fairly distributed and well-performing health workforce. METHODS: A cross-sectional descriptive quantitative study was undertaken using pretested anonymous questionnaires to solicit responses about the ability, strategies and policies needed to address health workforce challenges. The study was undertaken in SA with decision- makers and/or those who contribute to health sector reforms in SA in the realisation of the National Health Insurance (NHI). They were individuals and stakeholders who interact with and/or are in the employment of statutory health councils, regulatory bodies, medical aid administrators, medical schemes, voluntary bodies/organisations and healthcare workers who are registered with the SA Pharmacy Council, Health Professions Council of SA and SA Nursing Council. RESULTS: The findings indicate that the current policies and frameworks to address health worker shortage, their performance improvement and the rural-urban disparities in the distribution of health workers are not sufficient to address the current challenges. The study found that specific efforts to address policy shortcomings need to be embarked upon. CONCLUSION: The current policies and strategies are not sufficient to address health workforce challenges to improve performance, maintain appropriate skills, improve working conditions and ensure an equitable distribution of health workers to address the healthcare needs of SA. Commitment to the NHI should be matched with the capacity to deliver health services, which is highly dependent on the availability of a qualified and motivated workforce. The capacity to deliver services aligned to the objectives of the NHI will require that policy-makers consider interventions aimed at addressing challenges related to recruitment and limitation of career opportunities. Performance and productivity challenges may best be addressed by meaningful engagements and collaboration with the private for-profit, voluntary and independent sectors.
S Afr Med J
· 2025 Feb · PMID 41378575
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Advanced cell-based and gene therapy products emerged during the 1990s as new health product categories for treating and curing previously untreatable or incurable conditions. These products are complex, diverse and ther...Advanced cell-based and gene therapy products emerged during the 1990s as new health product categories for treating and curing previously untreatable or incurable conditions. These products are complex, diverse and therapeutically specific, requiring specialised regulatory frameworks. During the last three decades, several jurisdictions have constructed specific regulatory frameworks to ensure these products' safety, clinical efficacy and quality. As these are new and disruptive products, these frameworks are continuously evolving. However, South Africa (SA)'s regulatory frameworks for medicines, human biological materials and genetically modified organisms have not kept pace with scientific and technological developments, leaving regulatory gaps. We briefly describe these novel products and their regulatory frameworks, and propose a way forward in SA.