Malignant Extracranial Germ Cell Tumours: A First Report by the South African Children’s Cancer Study Group

OBJECTIVE To determine the overall survival (OS) and prognostic factors influencing outcomes in children and adolescents with malignant extracranial germ cell tumours (MEGCTs) in preparation for the development of a harmonised national treatment protocol. METHODS A retrospective folder review was undertaken at nine South African paediatric oncology units to document patient profiles, tumour and treatment-related data and outcomes. RESULTS Between 1 January 2000 and 31 December 2015, 218 patients were diagnosed with MEGCTs. Female sex (OR 2.26; p=0.037) and higher socio-economic status (SES) (HR 0.071; p=0.039) were associated with a significantly lower risk of death. Advanced clinical stage at diagnosis significantly affected 5-year OS: stage I -96%; stage II – 94.3%; stage III -75.5%; (p=0.017) and stage IV (60.1%; p<0.001). There was a significant association between earlier stage at presentation and higher SES (p=0.03). Patients with a serum AFP level of more than 33,000 ng/ml at diagnosis had significantly poorer outcomes (p=0.002). The use of chemotherapy significantly improved survival, irrespective of the regimen used (p33,000ng/ml were independently predictive of outcome. The relationship between SES and outcome is important as the implementation of a new national protocol aims to standardise care across the socio-economic divide.

Resource constrained innovation in a technology intensive sector: Frugal medical devices from manufacturing firms in South Africa

Most medical devices are designed by western firms from efficient innovation systems with a focus on their home markets. A disproportionately high percentage of imported medical devices in low resource settings become non-functional. Despite interest from global health and innovation studies, little is known about firms in emerging markets appreciative of challenges in their home environments. Using empirical evidence from innovative manufacturing firms in South Africa, this study investigates frugal orientation and mechanisms to innovate under resource constraints, in a technology intensive sector typically under the purview of western firms. Systematic analysis of six devices by adapting a global health lens reveals that while some innovations specifically address health challenges of low resource, others are more affordable technological innovations with universal relevance and some frugal elements. Resource constrained innovation strategies involved building advanced internal manufacturing capabilities to overcome institutional voids while forging multiple knowledge collaborations to complement inhouse capabilities. This drives frugality around design, engineering and manufacturing processes. Innovation delivery strategies are complementary to these processes. The evidence suggests fundamentally new products were designed in collaborative bottom up processes. The role of the state and global non-profits in harnessing frugal innovations for public health was found to be critical.

Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 – 2019

Background. A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality.

Objectives. To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS).

Methods. Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 – 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated.

Results. Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 – 49) years) than in the private sector (median (IQR) 54 (37 – 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector.

Conclusions. We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.

An analysis of paediatric snakebites in north-eastern South Africa

Background: Snakebites are an underappreciated health concern in middle- and lower-income countries. The lack of national data vastly impacts funding for this health crisis, as well as strategies for treatment and prevention. Children are particularly vulnerable to snakebite and data in this group is limited.
Methods: This study included paediatric patients, aged 13 years old or younger, admitted to Ngwelezana Tertiary Hospital, Department of Surgery with a snakebite or snakebite related complication, from 1 September 2008 to 31 December 2013. Data captured included demographics, time of presentation, syndromic symptoms, blood results and patient management.
Results: A total of 274 patients were included in this study. The median age at presentation was 8 years, with approximately 70% of the patients aged between 6 and 13 years, with a male predominance (56%). The median time of presentation after sustaining a snakebite was 7 hours (interquartile range 4–13 hours). The majority of patients (71%) presented with cytotoxic manifestations. A total of 53 patients received antivenom of whom 25% suffered adverse reactions. Fifty-six patients underwent one or more procedures on their affected limbs. Three patients required admission to the intensive care unit; all were part of the cytotoxic group and received antivenom. There were no recorded mortalities.
Conclusion: The majority of snakebites are cytotoxic in nature. One-fifth of the paediatric population require antivenom and one-fifth require a surgical procedure post envenomation. Adverse effects post antivenom use are common but manageable. Prevention programmes are needed to help reduce this burden of disease and a nationwide snakebite registry is long overdu

Myths and Misconceptions of Traumatic Brain Injuries Among High School Learners and University Students in South Africa

Traumatic Brain Injury (TBI) is a major cause of disability and death around the world with an annual worldwide prevalence rate ranging from 369 per 100 000 people (James et al., 2019). TBI is specifically more concerning in adolescents and young adults as rates of injuries acquired during this period are similar to adult rates, but with more far-reaching effects, especially in low and middle-income countries (Dewan et al., 2016). TBI has significant long-term effects (e.g., cognitive, behavioural, social) on adolescents and young adults, which are compounded in low and middle income countries (LMICs) like South Africa. However, myths and misconceptions regarding TBI and associated outcomes often cloud the understanding thereof and contribute to poor help-seeking behaviours post-TBI. Poor help-seeking behaviours post-TBI can impact TBI recovery and result in even worse impairments if appropriate help is not sought. This study aimed to describe and compare myths and misconceptions about head injuries or traumatic brain injuries (HI/TBI), including concussions, for high school learners (with/without HI/TBI) and university students (with/without HI/TBI). In terms of misconceptions, students (n=393) scored significantly higher on HI/TBI and concussion knowledge, compared to learners (n=80). Regression analyses showed that adolescence (learners) vs young adulthood (students) was a significant predictor of myths and misconceptions regarding TBI/HI; F (44, 369) = 3.32, p < .001; but not for concussion knowledge and attitudes; F (44, 369) = 1.10, p =.31 and F (44, 369) = .725, p =.904. Understanding what high school learners know and how this differs from university students' knowledge about TBI will help inform interventions tailored to adolescents and young adults – which is needed as they are a vulnerable population group.

Engaging surgeons among clinician-scientists

Since completion of the Human Genome Project at the turn of the century, there have been significant advances in genomic technologies together with genomics research. At the same time, the gap between biomedical discovery and clinical application has narrowed through translational medicine, so establishing the era of personalised medicine. In bridging these two disciplines, the clinician-scientist has become an integral part of modern practice. Surgeons and surgical diseases have been less represented than physicians and medical conditions among clinician-scientists and research. Here, we explore the possible reasons for this and propose strategies for moving forward. Discovery-driven personalised medicine is both the present and the future of clinical patient care worldwide, and South Africa is uniquely placed to build capacity for biomedical discovery in Africa. Diverse engagement across clinical disciplines, including surgery, is necessary in order to integrate modern medicine into a developing-world contextualised perspective.

Estimating the Specialist Surgical Workforce Density in South Africa

Background: South Africa is an upper middle-income country with inequitable access to healthcare. There is a maldistribution of doctors between the private and public sectors, the latter which serves 86% of the population but has less than half of the human resources.

Objective: The objective of this study was to estimate the specialist surgical workforce density in South Africa.

Methods: This was a retrospective record-based review of the specialist surgical workforce in South Africa as defined by registration with the Health Professionals Council of South Africa for three cadres: 1) surgeons, and 2) anaesthesiologists, and 3) obstetrician/gynaecologists (OBGYN).

Findings: The specialist surgical workforce in South Africa doubled from 2004 (N = 2956) to 2019 (N = 6144). As of December 2019, there were 3096 surgeons (50.4%), 1268 (20.6%) OBGYN, and 1780 (29.0%) anaesthesiologists. The specialist surgical workforce density in 2019 was 10.5 per 100,000 population which ranged from 1.8 in Limpopo and 22.8 per 100,000 in Western Cape province. The proportion of females and those classified other than white increased between 2004–2019.

Conclusion: South Africa falls short of the minimum specialist workforce density of 20 per 100,000 to provide adequate essential and emergency surgical care. In order to address the current and future burden of disease treatable by surgical care, South Africa needs a robust surgical healthcare system with adequate human resources, to translate healthcare services into improved health outcomes.

Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa

Background
Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients.

Methods
A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results
In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds.

Conclusions
Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.

Shock index as a prognosticator for emergent surgical intervention and mortality in trauma patients in Johannesburg: A retrospective cohort study

Introduction
Trauma is the leading cause of morbidity and mortality worldwide with exsanguination being the primary preventable cause through early surgical intervention. We assessed two popular trauma scoring systems, injury severity scores (ISS) and shock index (SI) to determine the optimal cut off values that may predict the need for emergent surgical intervention (ESI) and in-hospital mortality.

Methods
A retrospective analysis of patient records from a tertiary hospital’s trauma unit for the year 2019 was done. Descriptive statistics, univariate and multivariate logistic regression analyses were performed. Receiver operator characteristic (ROC) curve analysis was conducted and area under the curve (AUC) reported for predicting the need for ESI in all study participants, as well as in patients with penetrating injuries alone, based on continuous variables of ISS, SI or a combination of ISS and SI. The Youdin Index was applied to determine the optimal ISS and SI cut off values.

Results
A total of 1964 patients’ records were included, 89.0% were male and the median age (IQR) was 30 (26–37) years. Penetrating injuries accounted for 65.9% of all injuries. ISS and SI were higher in the ESI group with median (IQR) 11 (10–17) and 0.74 (0.60–0.95), respectively. The overall mortality rate was 4.5%. The optimal cut-off values for ESI and mortality by ISS (AUC) were 9 (0.74) and 12 (0.86) (p = 0.0001), with optimal values for SI (AUC) being 0.72 (0.60), and 0.91 (0.68) (p = 0.0001), respectively.

Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

Background
Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0–19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted.

Methods
We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library.

Results
We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health).

Conclusion
As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.