South African Medical Journal - October 2022 Vol 112 No 10

Introduction

A descriptive study of the spectrum of dermatological surgery services provided by the University of KwaZulu-Natal department of dermatology at Inkosi Albert Luthuli Central Hospital

Dermatological surgery is the practice of dermatology specialising in surgical procedures and minimally invasive treatments. Globally,  outpatient  dermatological surgery has been shown to be cost-effective, safe, efficacious and convenient for patients.  There is a paucity of data describing  dermatological surgery in South Africa  (SA).  A retrospective chart review of patients attending the Inkosi Albert Luthuli Central Hospital (IALCH) dermatological surgery clinic in Durban, KwaZulu-Natal (KZN), was conducted over 15 months (1 January 2019 - 31 March 2020). It coincided with the conclusion of the Global Health Dermatologic Surgery training programme, an international collaboration providing dermatological training to the University of KZN Department of Dermatology. The aim of the study was to describe the spectrum of surgical indications for dermatological surgery.

The South African Health Reforms 2015 - 2020: The Road Ahead

The South African Health Reforms 2015 - 2020, which follows a similar review of the previous 5 years, is a wide-ranging and valuable review of the South African (SA) health sector over the most recent quinquennial.  While the review understandably focuses to a large extent on the SA public health sector, the current and possible future role of the private sector is discussed in some of the chapters. Much has been written about the health system in SA before and since the democratic transition in 1994, and this publication both references many of these publications and attempts to place them in context over the review period.

Dolutegravir as first-line antiretroviral therapy in South Africa: Beware the one-size-fits-all approach

In July 2019, the World Health Organization (WHO) recommended the use of the integrase inhibitor dolutegravir (DTG) as the preferred first-line  and  second-line  treatment for HIV for all populations,  including pregnant women and those of childbearing potential.  Since  then, many low- and  middle-income  countries  (LMICs)  have  updated  their guidelines and transitioned to DTG-based  HIV  treatment regimens  from the efavirenz  (EFV)-based  initial  first-line antiretroviral therapy (ART). South Africa (SA) updated its national HIV guideline in 2020 to include DTG as the preferred drug for patients newly initiating ART, those experiencing side-effects on EFV and those who prefer to use DTG. It is anticipated that a new drug in the ART arsenal will offer benefits such as lower cost, reduced pill burden, suppressed viral load, fewer side-effects, and a higher genetic barrier to resistance.  While DTG does offer many of these benefits as a first-line option, there are a few considerations when initiating a patient on a DTG-based regimen.

Fetal intervention (EXIT procedure) for a rare fetal abnormality in a public sector hospital in South Africa – exploring what is possible

Congenital high airway obstruction syndrome (CHAOS) is a rare condition, the incidence of which is unclear, where there is complete or near-complete obstruction of the upper airway. It can be diagnosed antenatally by the characteristic ultrasonographic findings of enlarged echogenic lungs, eversion of the diaphragm and dilatation of the bronchial tree distal to the obstruction.  The sequelae of the condition are fetal cardiac failure with hydrops and, without fetal or intrapartum intervention, is usually fatal after birth

Evaluating the neutrophil-to-lymphocyte ratio as an indicator for early referral of patients with COVID-19 pneumonia to a high-care facility

The ongoing COVID 19 pandemic has placed significant strain on the South African (SA) public healthcare sector, emphasising pre existing weaknesses in the system.  One such challenge brought to light at Universitas Academic Hospital, Bloemfontein, during the pandemic was the difficulty surrounding interhospital patient transfers in Free State Province.  With our facility being one of the main high care treatment centres in the province, we received referrals from hospitals up to 300 km from Bloemfontein. In addition to large travelling distances, the poor road conditions, scarcity of ambulances, and increased overall pressure on the emergency medical services caused by the pandemic further hampered efficient transfer of patients.

Autologous whole blood clot and negative-pressure wound therapy in South Africa: A comparison of the cost and social considerations

Hard-to-heal wounds refer to all chronic or non-healing wounds that have not healed by at least 40 - 50% after 4 weeks of standard care treatment.  Hard-to-heal wounds may progress slowly, or healing may be interrupted or delayed, due to several intrinsic and extrinsic factors.  These factors include high levels of proteases, prolonged inflammation, reduced growth factors, recurrent infections, the inability of epidermal or dermal cells to respond to reparative stimuli, and formation of  drug-resistant biofilms.  Hard-to-heal wounds benefit from alternative therapies and interventions managed by a wound care specialist in an interprofessional team.

Training, guideline access and knowledge of antiretroviral interactions: Is the South African private sector being left behind?

With an estimated 8.2 million people living with HIV in South Africa (SA) in 2021, and an estimated adult (15 - 49 years old) population prevalence of 19.5%, SA has the largest antiretroviral therapy (ART) programme in the world.  In terms of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets, 92% of South Africans knew their status, 72% were on ART and 66% were virally suppressed in 2020.

Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres

In response to increases in antibiotic  consumption  and to the rising prevalence of multidrug and extensive drug resistance among common  bacterial  infections  in  South  Africa (SA), a One Health-based national strategic framework for antimicrobial resistance, an implementation plan and a mechanism for the governance of antimicrobial stewardship (AMS) at national, provincial, district and hospital levels was developed by the National Department of Health.  While the importance of improving outpatient antibiotic use is acknowledged, no comprehensive recommendations to curb the use in the primary healthcare setting have been made, owing to the lack of sufficient data to guide such efforts.  A targeted application of AMS principles to the ambulatory setting has the potential to affect the most common indications for systemic antibiotic use, in that the majority (80%) of antibiotic use occurs in primary care, with acute respiratory-tract infections being the most common indication.

Leveraging routine data in impact evaluation: Understanding data systems in primary healthcare prior to a matched cluster-randomised evaluation of adherence guidelines in South Africa

For treatment of chronic diseases, including antiretroviral therapy (ART) for HIV/AIDS, to be effective, patients must initiate treatment as early as allowed under prevailing guidelines, remain in care for long periods of time, consistently achieve high levels of adherence to their treatment regimen and, as a result, exhibit stable monitoring test results and/or treatment completion.   In the case of HIV/AIDS, treatment is lifelong and requires consistent, nearly complete adherence to sustain an undetectable viral load. Numerous studies and reviews have indicated that suboptimal retention in care and adherence to ART in South Africa (SA) poses a serious threat to the long-term success of the national HIV response.  In order to improve patient care and reduce disengagement from care, there is a push for research studies to produce results quickly and affordably.

Heterologous vaccination of BNT162b2 in Ad26. COV2.S-vaccinated healthcare workers elicits long-term humoral immune response

On 31 December 2019, the World Health Organization (WHO) China country office was informed of an outbreak of pneumonia with unknown  aetiology in a cluster of patients linked to a seafood market in Wuhan City, Hubei Province.   The causative agent, isolated by Chinese authorities on 7 January 2020, was identified as a new type of the coronavirus (nCoV) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing the clinical syndrome coronavirus disease 2019 (COVID-19).  As of 4 May 2022, SARS-CoV-2 had infected >512 million individuals and caused >6.24 million deaths worldwide, according to the WHO Health Emergency Dashboard.