An evaluation of the Triage Early Warning Score in an urban accident and emergency department in KwaZulu-Natal

Objective: Triage is an essential first step in the efficient and effective running of any emergency department. A good triage tool saves lives and reduces mortality. The Triage Early Warning Score (TEWS) is a useful tool used to identify patients in emergency departments who are at risk of deterioration and who may require admission. As this triage tool has only been evaluated to a limited extent, this study assessed its effectiveness in identifying patients at risk of early deterioration to enable timely medical intervention.Design and setting: This was a retrospective study of medical records within the accident and emergency department of an urban public hospital.Outcome measures: The calculated TEWS was compared to one of four possible outcomes viz. discharge within 24 hours, admission to the ward, admission to the intensive care unit (ICU), or death in hospital. Pearsonfs chi-squared tests and cross-tabulation was used to determine the statistical significance of the association.Results: Of the 265 patient records analysed, 233 (87.9%) had a TEWS of < 7. Of patients with a TEWS of < 7, 53.7% were discharged, compared to 18.7% with a score . 7, who were discharged. The average score of the four patients who died was 9.5, and 8.2 for the three admitted to ICU. Higher TEWS were significantly associated with increased admission to hospital and in-hospital deaths (p-value 0.032).Conclusion: An effective triage scoring system ensures that those requiring emergency care are appropriately categorised. Prompt intervention will either reverse further physiological decline or facilitate timely referral to the appropriate service level, including ICU

An evaluation of insulin therapy initiation among patients with type 2 diabetes attending a public health facility in South Africa

Background: Clinically effective interventions that could reduce diabetic patients’ risk of long-term complications are needed to contain the rising cost of diabetes care associated with the increasing prevalence of this condition. Good glycaemic control needs to be rapidly attained and maintained by the appropriate initiation and adjustment of glucoselowering therapy. In patients with insulin-requiring type 2 diabetes who are not at goal glycaemia, this translates to the initiation and intensification of insulin therapy. The aim of this study was to evaluate the appropriateness of the initiation of insulin therapy in patients with poorly controlled insulin-requiring type 2 diabetes.Method: This descriptive retrospective study evaluated treatment regimens, dose adjustments and glycated haemoglobin A1c (HbA1c) measurements extracted from records of patients with type 2 diabetes suitable for inclusion. The observation period spanned the 24 months retrospective to study start. Data collected were transcribed into a spreadsheet suitable for statistical analysis.Results: Of the overall cohort of patients with insulin-requiring type 2 diabetes (n = 131), only 45.8% (n = 60) were commenced on insulin during the observation period, of whom 51.7% had subsequent adjustment of insulin dosage. Mean HbA1c at insulin initiation was 10.29% (± 2.42), and 10.63% (± 1.93) after adjustment of insulin dose (p-value > 0.05). Of those who remained on oral glucose-lowering therapy (n = 71), 57.7% had no change in medication dosage throughout the study period. Overall, 81.35% remained ≥ 1% above goal HbA1c by the end of the study period.Conclusion: This study found a discrepancy in the appropriate use and adjustment of insulin therapy according to metabolic status

The association between depression and adherence to antiretroviral therapy in HIV-positive patients, KwaZulu-Natal, South Africa

Background: Depressive disorders are associated with poorer health outcomes in people living with human immunodeficiency virus infection and acquired immunodeficiency syndrome (PLHIV) and have been shown to contribute to non-adherence to antiretroviral therapy (ART) in Western contexts. Limited data from developing countries are available. The aim of this study was to explore whether there was an association between depressive symptoms and adherence to ART among PLHIV in KwaZulu-Natal, South Africa.Method: A cross-sectional analytical study was undertaken in a population of HIV-positive patients accessing ART at a government funded, semi-urban clinic in the eThekwini Municipal District, KwaZulu-Natal, South Africa. The tools used to measure depressive symptoms and adherence were the Centre for Epidemiology Studies Depression Scale (CES-D)and clinic-based pill counts, respectively. Socio-demographic and clinical data were collected during interviews and from patient records.Results: Sixty-two per cent of the sample (n = 146) had higher-than-threshold levels on the depression scale, and 32% were less than 95% adherent to ART. High depression scores were associated with lower levels of education [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.0–4.1] and unemployment (OR 2.8; 95% CI, 1.3–6.0), while non-adherence was associated with unemployment (OR 2.4; 95% CI, 1.0–6.1) and mid-range CD4 counts (200–499 cells/ìl; OR 3.0; 95% CI,1.3–6.9). No significant association was found between depressive symptoms and non-adherence to ART (OR 0.5; 95% CI, 0.2–1.2; p-value, 0.125).Conclusion: The large percentage of participants who scored high on the CES-D suggests a high prevalence of major depression in the study population. No significant association was found between high depression scores and nonadherence to ART. Depressive symptoms were significantly linked to lower levels of education and unemployment, while non-adherence was associated with unemployment and mid-range CD4 counts (200–499 cells/ìl). The study had some limitations. Further studies are needed to determine the prevalence and causes of depression and its impact on PLHIV in this population and in the developing world

Sociodemographic and clinical profiles of suicidal patients requiring admission to hospitals south of Durban

Background: Suicidal behaviour has become a major public health concern worldwide. Non-fatal suicidal attempts outnumber fatal episodes by wide-ranging figures across, and within, many countries. Approximately 6 500 suicides and 130 000 suicide attempts occur annually in South Africa, with at least one suicide taking place every 40 seconds, compared to one suicide attempt every three seconds. It is more common for all forms of suicidal behaviour to occur in younger persons. This study aimed to analyse the characteristics of suicide attempters who were admitted to two community-based state hospitals in the south of Durban.Method: Adult patients presenting at two university-affiliated state  hospitals, following a suicide attempt during a two-year period, were invited to participate in the study. A World Health Organization standardised questionnaire was used to collect basic data relating to the suicide attempt. All participants provided informed consent. Data were analysed using SPSS® version 19.Results: The majority of the 688 participants were women who were young, single, unemployed, low-income earners, of Indian ethnicity, belonged to the Christian faith, and had a primary school education. Four hundred and thirty-eight participants (63.7%) suffered from varying levels of  depression. The majority of suicide attempts (97.2%) had taken placewithin the home environment of the attempters. Self-poisoning emerged as the dominant method that was used by 92.2% of all attempters.Conclusion: Disturbing levels of non-fatal suicidal behaviour were found in all the population groups. A number of modifiable factors were identified. These have implications for healthcare policy planners and prevention strategies

Adequacy of pain management in HIV-positive patients

Background: A growing body of literature supports the view that people infected with HIV suffer significant pain and that pain is not well recognised or managed by health care professionals. This study investigated the prevalence, severity, recognition and management of pain in adult patients with HIV infection in a South African hospital setting. Methods: The Brief Pain Inventory (BPI) (short form) questionnaire was administered to 100 consecutive, consenting HIVpositive patients admitted to an urban district-level hospital in KwaZulu-Natal. Convenience sampling was employed with participants recruited on consecutive days. Data sources comprised patient interviews and review of hospital records. A Pain Management Index derived from the BPI was calculated to establish the adequacy of pain management. Descriptive statistics were tabulated for the recognition of pain, pain severity and appropriateness of analgesia. Correlation analyses were used to assess the association between pain and daily life. Results: Ninety-one per cent of participants reported pain with 83% experiencing significant pain, in other words a “worst pain” rating of five or above on the BPI (short form) questionnaire. The correlation analysis between the severity of pain and its interference with daily life suggests that moderate and severe pain interferes with the patients’ daily functioning. Pain was documented on 71% of the patients’ medical charts that were reviewed; however, only 34% were considered to be adequately managed for their pain. Conclusion: Pain prevalence is high in the sample. While pain was recognised and noted in the majority of patients’ medical records, the management of pain was considered to be inadequate in a third of those experiencing pain.Keywords: HIV; pain; assessment; managemen

An evaluation of the medical internship programme at King Edward VIII hospital, South Africa in 2016

Background: In 2005, the Health Professions Council of South Africa  (HPCSA) extended the duration of the internship programme to ensure that all young medical graduates are adequately prepared to work at a district hospital during their year of community service. King Edward VIII hospital (KEH) is an HPCSA accredited training hospital, which has been training interns for many years. The aim of this study was to assess intern perceptions of their training at the hospital.Methods: This cross-sectional, descriptive study was conducted at KEH in November 2016. A questionnaire was used to collect data, which were analysed descriptively.Results: Only 53% of interns completed the questionnaire. Although  teaching and supervision were provided in all domains, perceptions of the quality ranged from excellent to poor. The majority of interns worked the 64–80 hours per month commuted overtime as required by the HPCSA. However, less than 10% expressed positive views regarding the condition of the facilities and infrastructure.Discussion and conclusions: The findings of this study were generally  positive with regard to teaching, supervision and hours worked, mostly in accordance with the requirements of the HPCSA. However, a response rate of 53% as well as the single location of the study may limit generalisability and a larger study involving interns across the country is recommended.Keywords hours worked, internship, South Africa, supervision, trainin

Will graduating medical students prefer to practise in rural communities?

Background: The shortage of doctors and their maldistribution between urban and rural areas contribute to inequitable health care delivery. Strategies are being sought by the government and universities to address these challenges. At the Nelson R Mandela School of Medicine of the University of KwaZulu-Natal the admissions policy ensures greater access to rural students and curricular interventions have been introduced to increase an awareness of the plight of vulnerable communities. This study attempted to ascertain the career intentions of final-year medical students and the influence of area of origin and gender on the location of their proposed future practice.Methods: The 2005 final-year cohort was surveyed by means of an anonymous questionnaire. Demographic information, area of origin and career intentions were canvassed. Students of rural origin were identified as those who matriculated from rural schools and lived more than 200 km from the nearest city. The data were analysed descriptively.Results: Female and rural students accounted for 63% and 11% of the sample respectively. Women were less likely than men to practise in rural areas. Thirty-five per cent indicated a preference for a public government service career as opposed to a private medical (26%) career. Slightly more than 13.7% (n = 26) of the cohort wished to pursue practice or  postgraduate careers overseas. Nearly 62% (n = 90) of the students in the current cohort received government subsidies for their studies.Conclusions: The increased intake of students from rural origin and curricular attempts to increase social awareness of vulnerable rural communities are inadequate to alter the perceptions of medical graduates towards rural practice. While government initiatives and medical schools are starting to work together to service rural communities, alternative strategies need to be explored to entice physicians to rural practice

Biofilter aquaponic system for nutrients removal from fresh market wastewater

Aquaponics is a significant wastewater treatment system which refers to the combination of conventional aquaculture (raising aquatic organism) with hydroponics (cultivating plants in water) in a symbiotic environment. This system has a high ability in removing nutrients compared to conventional methods because it is a natural and environmentally friendly system (aquaponics). The current chapter aimed to review the possible application of aquaponics system to treat fresh market wastewater with the intention to highlight the mechanism of phytoremediation occurs in aquaponic system. The literature revealed that aquaponic system was able to remove nutrients in terms of nitrogen and phosphorus

Contrasting Inflammatory Signatures in Peripheral Blood and Bronchoalveolar Cells Reveal Compartment-Specific Effects of HIV Infection

The mechanisms by which HIV increases susceptibility to tuberculosis and other respiratory infections are incompletely understood. We used transcriptomics of paired whole bronchoalveolar lavage cells (BLCs) and peripheral blood mononuclear cells to compare the effect of HIV at the lung mucosal surface and in peripheral blood. The majority of HIV-induced differentially expressed genes (DEGs) were specific to either the peripheral or lung mucosa compartments (1,307/1,404, 93%). Type I interferon signaling was the dominant signature of DEGs in HIV-positive blood but not in HIV-positive BLCs. DEGs in the HIV-positive BLCs were significantly enriched for infiltration with cytotoxic CD8+ T cells. Higher expression of type 1 interferon transcripts in peripheral CD8+ T cells and representative transcripts and proteins in BLCs-derived CD8+ T cells during HIV infection, including IFNG (IFN-gamma), GZMB (Granzyme B), and PDCD1 (PD-1), was confirmed by cell-subset specific transcriptional analysis and flow cytometry. Thus, we report that a whole transcriptomic approach revealed qualitatively distinct effects of HIV in blood and bronchoalveolar compartments. Further work exploring the impact of distinct type I interferon programs and functional features of CD8+ T cells infiltrating the lung mucosa during HIV infection may provide novel insights into HIV-induced susceptibility to respiratory pathogens

Adult mortality in sub‐Saharan Africa: Cross‐sectional study of causes of death in Zambia

Objective To describe the age‐sex pattern and socioeconomic differentials in causes of death among adults between the ages of 15 and 59 years in Zambia. Methods Using data from the 2010‐2012 Zambia sample vital registration with verbal autopsy survey, we calculated the percentage share of causes of death, the age‐sex cause‐specific death ratio, and cause‐eliminated life expectancy at age 15. Results HIV/AIDS was the leading cause of death across all socioeconomic subgroups contributing 40.7% of total deaths during the study period. This was followed by deaths due to injury and accidents (11.2%). Cause‐specific death ratios due to HIV/AIDS increased by age and peaked in the 35‐to‐39 age group, and were higher among females than males. The second leading cause of death was injuries and accidents for females and tuberculosis for males. The third leading cause of death was cardiovascular diseases for females and tuberculosis for males. Cause of death patterns varied notably by socioeconomic characteristics. Deaths attributable to non‐communicable diseases were more evident in adults aged 45 to 59 years. Eliminating HIV/AIDS in Zambia as a cause of death could raise life expectancy at age 15 by 5.77 years for males and by 6.40 years for females. Conclusion HIV/AIDS‐related health programmes and interventions should be further supported and strengthened, as they would significantly contribute to the reduction of adult mortality in Zambia