South African Medical Journal - July 2023 Vol 113 No 7

Introduction

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: Special patient groups and surgical aspects

Snakebite is not only confined to the adult population, but children and even pregnant women are at risk, although the latter are uncommonly bitten. Venom ophthalmopathy is painful, and found after venom ‘spitting’ by the spitting cobra groups. Cytotoxic bites may lead to extensive swelling or areas of tissue necrosis, and as such, the emergency unit may refer the patient to a surgeon for assessment. This article addresses these patient groups and the current best practice of eye care, wound care and surgical management. It also provides a useful set of clinical records to use during the management of snakebite presentations approved by the South African Snakebite Symposium (SASS), held in Nelspruit on 29 and 30 July 2022.

Namibian spitting cobra, Naja nigricincta nigricincta (zebra snake): Oral flora and antibiotic sensitivity, a cross-sectional study

African spitting cobras, such as Naja nigricollis, Naja mossambica and Naja nigricincta nigricincta, most often bite at night while the victims are asleep. Spitting cobra bites frequently result in local necrosis and secondary infection, often culminating in disfigurement, loss of function and amputation. Small children and babies are often bitten. Children are particularly vulnerable to snake envenomation, and suffer a high morbidity and mortality from these severely cytotoxic bites. Naja nigricincta nigricincta (Western barred spitting cobra/zebra snake) (Fig.  1) is endemic to central and northern Namibia and southern Angola, and accounts for most of the venomous bites encountered in these areas of Namibia. This cytotoxic venom typically results in a severe dermonecrosis. This resembles a type of venom-induced necrotising fasciitis, with fast-spreading necrosis in the fascial planes between skin and deeperlying muscles.

Cerebral palsy and its medicolegal implications in lowresource settings – the need to establish causality and revise criteria to implicate intrapartum hypoxia: A narrative review

Worldwide in the past half century, one medical malpractice claim, i.e.  birth-related cerebral palsy (CP), has had a major impact on obstetric care, resulting in defensive practices to prevent litigation. CP litigation has arguably the highest quantum claims, resulting in skyrocketing insurance premiums for obstetricians, therefore placing service delivery under serious threat. This phenomenon is not restricted to high-income settings. The impact is enormous in South Africa (SA), for example, where the public health service contingent liabilities for alleged CP-related medical negligence amounted to USD314 million in the years 2018 - 2019. Litigants implicate an adverse event at birth in causation of CP, with the suggestion that the outcome could have been prevented by better intrapartum care.

The accuracy of the Thompson score in predicting early outcome in neonates with hypoxic ischaemic encephalopathy treated with therapeutic cooling in a tertiary hospital.

Hypoxic ischaemic encephalopathy (HIE) is still a major contributor to neonatal mortality and morbidity in developing countries. It contributes significantly to the death of children under 5 years of age. It is the second highest cause of neonatal mortality after prematurity, contributing to 23% of neonatal deaths worldwide and 8% of mortality in children under 5 years of age. An incidence of 6 per 1 000 live births in developed countries and 132 per 1 000 live births in developing countries has been reported. A South African (SA) study found an incidence of 8.7 to 15.2 per 1 000 live births at Chris Hani Baragwanath Academic Hospital (CHBAH). A presumptive diagnosis of HIE is often made when an infant has an Apgar score of ≤5 at 5 and 10 minutes, requires continuous ventilatory support for >10 minutes, has a base deficit of ≥12 on a blood gas done within an hour of birth and has clinical signs of encephalopathy. Multiple factors have been shown to increase the risk of developing HIE. Maternal factors include antepartum haemorrhage, hypertension and cardiac diseases. Other factors include abruptio placentae, uterine rupture, amniotic fluid embolisation, cord prolapse and prolonged labour. Affected infants present with an abnormal state of consciousness that may include hyperalertness, irritability, lethargy or coma. Associated respiratory compromise, cardiac compromise, feeding difficulties and seizures may also be noted. Clinical tools such as Sarnat and Sarnat staging and Apgar scores are used in the immediate assessment of the neonatal depression and staging of the encephalopathy. The Thompson score (TS) is another tool based originally on Sarnat and Sarnat staging, but in a simplified format (Table 1). The purpose of the TS was to predict neurodevelopmental outcome at 1  year of age in neonates suspected to have suffered an intrapartum hypoxic ischaemic insult. This score was established before the era of therapeutic hypothermia (TH).

Evaluation of the national clinical sentinel surveillance system for sexually transmitted infections in South Africa: Analysis of provincial and district-level data

Sexually transmitted infections (STIs) remain a significant global health challenge owing to the impact on population health outcomes, healthcare resource challenges and socioeconomic burden. In 2017, World Health Organization estimates of syphilis, gonorrhoea and chlamydia infections in South Africa (SA) suggested >4 million cases in women and 6 -10 million cases in men aged 15 - 49 years. Prevalence estimates of 6.6% and 3.4% for gonorrhoea and 14.7% and 6.0% for chlamydia in women and men, respectively, are among the highest globally. In addition to acute illness, which is often easily treatable, undiagnosed, untreated or suboptimally treated STIs and repeated infections may increase the risk of severe sequelae, vertical transmission and HIV acquisition or transmission. STI surveillance and control interventions are, therefore, increasingly recognised as a public health priority.

Profile of human papillomavirus genotypes in breast and oesophageal cancer patients in Pretoria, South Africa

According to the World Health Organization, global estimates of the burden of cancer reached 18.1 million new cases and 9.1 million deaths in 2018. A meta analysis of the global burden of disease for the period 1990 - 2017 indicated that the burden of cancer quantified as disability-adjusted life-years had risen from sixth place in 1990 to second in 2017.

Private healthcare sector spine surgery: Patient and surgeon profiles from a large open medical scheme in South Africa

Spinal pathology may have significant implications for functional ability, work productivity and quality of life, highlighting the need for effective treatment. While many spinal disorders improve with conservative management, spinal surgery may provide an equivalent or superior outcome in some cases. Relatively few studies have investigated the overall profile of spine surgery in a particular context, with the existing literature focused largely on specific spinal pathologies or procedures. However, it is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context, access to healthcare and the relative burden of trauma and infection. In developed countries with good access to healthcare and long life expectancy, the majority of spine surgery would be expected to involve treatment of degenerative pathologies among older adults. Conversely, in developing countries with limited healthcare resources and a lower socioeconomic context, a significant proportion of spine surgeries may involve preventable pathologies, such as trauma and infection, among relatively younger patients.