Healthcare Delivery.

We report here on the process and findings of a research prioritisation exercise for universal health coverage (UHC) in South Africa, conducted during the course of 2019. As plans to roll out National Health Insurance (NHI) gather momentum and we transition into a pandemic recovery phase, we believe that it is now time to revisit these priorities, while recognising that experiences with the COVID-19 pandemic have revealed new system challenges and strengths and introduced new priorities. The UHC research priority-setting methodology followed a stepwise process of collation of evidence, expert brainstorming and the development of a survey completed by 68 members of the Public Health Association of South Africa. Themes related to leadership and governance were ranked most highly, and with other priorities generated, provide an initial road map of knowledge needs that could guide individual institutions and commissioning by funding bodies. We further reflect on the importance of researcher-decision-maker dialogue and strengthening the contribution of health policy and systems research to policy and practice, especially as new reforms are implemented.

Distant mood monitoring for depressive and bipolar disorders: a systematic review.

BACKGROUND: Broadening our knowledge of the longitudinal course of mood symptoms is cardinal to providing effective long-term treatments. Research indicates that patients with mental illness are willing to engage in the use of telemonitoring and mobile technology to assess and monitor their mood states. However, without the provision of distant support, adverse outcomes and events may be difficult to prevent and manage through self-monitoring. Understanding patient perspectives is important to achieving the best balance of self-monitoring, patient empowerment, and distant supporter involvement. METHODS: This systematic review synthesises quantitative and qualitative evidence of the effectiveness and feasibility of daily/weekly/monthly remote mood monitoring that includes distant support in participants with mood disorders. Inclusion criteria comprised mood monitoring of mood disorder patients as main intervention, study design, method of monitoring, and presence of psychotherapy and psychoeducation. Effectiveness was defined by the change in depression and/or mania scores. Feasibility was determined on participant feedback and completion/attrition rates. Studies were assessed for quality using the Mixed Methods Appraisal Tool version 2018. RESULTS: Nine studies of acceptable quality met the inclusion criteria. Distant mood monitoring was effective in improving depression scores but not mania scores. Feasibility, as measured through compliance and completion rates and participant feedback, varied. CONCLUSION: Distant mood monitoring with support may be a useful, acceptable, and feasible intervention for diverse groups of patients in terms of age and ethnicity. Further, it may be effective in improving symptoms of depression, increasing treatment adherence, and facilitating the prevention and management of adverse outcomes. As a task-shifting intervention, distant mood monitoring may help to alleviate the burden on mental health providers in developing countries.

Metabolic surgery in South Africa: an initial academic hospital experience.

BACKGROUND: In South Africa, 42.0% of adult females and 13.5% of adult males are classified as obese, the highest recorded numbers in Sub-Saharan Africa. Metabolic surgery has been proven to be a safe and effective treatment, yet due to demand on government resources has only been performed to a limited extent in public hospitals. The aim of this study was to describe the safety and efficacy of performing metabolic surgery at a single academic hospital in South Africa. METHOD: This was a single centre retrospective review of 57 metabolic surgery procedures performed from October 2011 to September 2017 at Tygerberg Hospital, Cape Town, South Africa. The primary outcome was safety including mortality and adverse events. Secondary outcomes included effect of surgery on weight and diabetes resolution. RESULTS: A total of 57 patients underwent laparoscopic metabolic surgery, of which 44 (83.0%) were female with a mean age (standard deviation) of 42.8 (8.0) years. Fifty-six patients (98%) underwent Roux-and-Y gastric bypass and one (2%) had a sleeve gastrectomy performed. There were no mortalities and overall morbidity was 14.0%, with 3 (5.3%) classified as major and 5 (8.8%) as minor. The follow-up rate at 1 year was 100%. Mean preoperative body mass index (BMI) was 58.8 kg/m2, and comorbidities included hypertension (59.6%), Type 2 Diabetes (42.1%), and dyslipidaemia (36.8%). There were no conversions to open surgery and at one year the mean (95% confidence interval) percentage excess body mass index loss was 50.4% (44.0-56.8%). CONCLUSION: Metabolic surgery can be performed safely in the public sector in South Africa, with short-term safety and efficacy outcomes comparable to international reports. Larger scale studies are needed to determine long-term outcomes and cost-effectiveness.

Neonatal, infant and child health in South Africa: Reflecting on the past towards a better future.

Although the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the 'Survive, thrive and transform' global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.

Total adventitial resection of the cardia: 'optimal local resection' for tumours of the oesophagogastric junction.

INTRODUCTION: Little is published about the local resection of oesophageal cancers. We adopted the principles of rectal cancer surgery, ie standard surgical dissection techniques as well as standard pathological processing and reporting, and assessed the feasibility of applying them to oesophagogastric junction (OGJ) cancer. METHODS: Over a two-year period consecutive patients with invasive cancers of the OGJ were studied. Following staging and neoadjuvant chemotherapy (NAC), a standard dissection defined as a total adventitial resection of the cardia (TARC) was performed. Standard histopathological processing involved external inking, photographing, transverse slicing and mounting of cut samples on megablocks. Hospital morbidity and mortality as well as survival at five years' follow-up were assessed. RESULTS: Forty consecutive patients had a TARC for OGJ carcinoma. Of these, 32 were offered NAC. Introducing TARC did not result in increased morbidity or mortality. Twenty-seven patients (68%) had an R0 resection that was directly related to the tumour stage and significantly related to a response to chemotherapy. Sixteen patients (42%) were alive five years after their TARC operation. CONCLUSIONS: Although the adventitia of the OGJ is not as well developed as that of the rectum, TARC can be performed safely as a standardised resection for OGJ cancers. Whereas the R0 rate for early stage tumours is very high, it remains disappointingly low for T3N1 tumours despite NAC. Improved long-term survival for these advanced tumours will only be achieved with better neoadjuvant and adjuvant therapies.

Surgical and endovascular management of penetrating innominate artery injuries.

OBJECTIVE: To review our management of penetrating innominate artery injuries by open and endovascular techniques. METHODS: Data regarding patient demography, clinical presentation, investigations, associated injuries, pathology, management, complications and mortality, were collected on patients treated at a single centre over 18 years. RESULTS: 39 innominate artery injuries were treated. There were 36 men and three women, with a mean age of 27 years (range 18-49). Thirty-eight injuries were due to stabwounds and one was the result of a gunshot wound. The most common clinical presentations were shock (47%) and haematoma(42%). Twenty-three patients had associated injuries. The most common pathology was false aneurysm in 21 patients followed by 13 actively bleeding injuries, 4 arteriovenous fistulas and 1 arterial occlusion. Thirty-four patients underwent surgical and five endovascular repair. Overall survival was 79%. The stroke rate for surviving patients was 6%. Patients treated with endovascular stenting had shorter hospital and intensive care unit stays than those treated with surgery. CONCLUSIONS: Innominate artery injuries have high rates of morbidity and mortality. A vascular surgical approach with pre-operative angiography, when possible and careful surgical planning by a dedicated team promotes better surgical results. Endovascular and hybrid procedures can become the method of choice when treating stable patients.

[Initiation of a cure for kwashiorkor patients using a whey milk product. A comparison with cows milk]. / Inisiasie van herstel by kwashiorkor-pasiënte d.m.v. 'n weimelkproduk. 'n Vergelyking met beesmelk.

Whey milk, a side-product of cheese production, is not utilized for human nutrition. Whey protein is of good nutritional quality with a high biological value, exceeding that of whole-milk protein. A whey milk product consisting of liquid whey milk 60%, whole cow's milk 40% and skimmed milk powder 0.5% was mixed, spray-dried and prepared in instant form. After reconstitution with water, it was compared with sterilized whole cow's milk for the initiation of cure in 30 acute kwashiorkor patients randomly allocated to the two feeds. The diets were given for 3 weeks. There were no statistically significant differences between the two diets with regard to weight gain or levels of serum albumin, globulin, calcium, phosphorus, alkaline phosphatase, sodium, potassium, chloride, bicarbonate, urea or haemoglobin. Judging from this limited investigation, whey milk deserves consideration for human utilization. Should economical production be possible, it could contribute towards preventing and treating protein energy malnutrition.