Pandemics, professionalism and the duty of care: Concerns from the coalface

It is likely that the SARS-CoV-2 pandemic will affect a large part of the world's population and will last for several years. Many critical ethical issues have arisen in the healthcare context. While response from healthcare professionals to participating in the care of patients in the era of COVID-19 has generally been positive, there have also been disturbing experiences on the ground. The practice of medicine is a social contract with humanity. Challenges have arisen because the patient is both a victim and a vector of the coronavirus. All humans should have a natural instinct to care for those in need. Ethically and legally, healthcare professionals cannot be expected to assume a significant and unreasonable risk of harm. While fear is understandable, altruism and interest in serving the sick exemplify the value of solidarity. Social harms like stigmatisation and discrimination can occur. Concerns have been raised regarding protection of privacy and respect for rights of infected individuals. In the era of COVID-19, fear, misinformation and a detachment from one's calling put professionalism strongly to the test

A review of antenatal corticosteroid use in premature neonates in a middle-income country

Background. Antenatal corticosteroid (ANS) use in premature neonates has become a standard of practice. However, there is low ANS coverage in low- to middle-income countries (LMICs). Recent studies have questioned the efficacy of ANSs in such countries.Objective. To review the use of ANSs in preterm neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa.Methods. This was a retrospective observational study of all neonates with a birth weight of 500 - 1 800 g born at CMJAH between 1 January 2013 and 30 June 2016. Neonatal and maternal characteristics of neonates exposed to ANSs were compared with those of neonates who were not exposed.Results. The ANS coverage of the final sample was 930/2 109 (44.1%). The mean (standard deviation (SD)) birth weight was 1 292.4 (323.2) g and the mean gestational age 30.2 (2.9) weeks. Attending antenatal care and maternal hypertension were associated with increased use of ANSs, whereas vaginal delivery was associated with decreased use. In neonates weighing <1 500 g, the use of ANSs was associated with decreased mortality, decreased intraventricular haemorrhage and decreased patent ductus arteriosus. There was no association between ANSs and respiratory distress syndrome, necrotising enterocolitis, sepsis or need for respiratory support in all premature neonates, and no association with improved outcomes in those weighing ≥1 500 g.Conclusion. The benefits of ANSs in terms of neonatal morbidity in this study were not as marked as those published in high-income countries. A randomised controlled trial may be indicated in LMICs

An Evaluation of the Screening for Retinopathy of Prematurity in Very-Low-Birth-Weight Babies at a Tertiary Hospital in Johannesburg; South Africa

Background. Retinopathy of prematurity (ROP) is a leading cause of blindness for very-low-birth-weight (VLBW; 1 500 g) babies. ROP screening identifies babies that require treatment to prevent major visual impairment.Objectives. To evaluate the screening for ROP at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) by reviewing the number of babies screened according to the CMJAH guidelines; the grades of ROP found and the treatment modality received. Methods. This was a retrospective record review of VLBW babies born between 1 January 2013 and 31 December 2013 at CMJAH; whether inborn or transferred in. The babies were divided into two groups based on age at final outcome. Final outcome was defined as death; discharge or transfer out of the unit. The 'early' outcome group had their final outcome before day 28 of life. The 'late' outcome group had their final outcome at day 28 or more of life. The early outcome group qualified for outpatient ROP screening and the late outcome group qualified for inpatient ROP screening.Results. There were a total of 572 VLBW babies at CMJAH during this time period. The babies had a mean birth weight of 1 127 (standard deviation (SD) 244.75) g and gestational age of 29 (2.743) weeks. The mean duration of stay was 29 (21.66) days and there were 309 female babies. Of these 572 babies; 304 comprised the early outcome group and 268 comprised the late outcome group. In the early outcome group babies who were transferred out of the unit or died were excluded; therefore the remaining 147 babies discharged home qualified for outpatient ROP screening. Inpatient ROP screening was carried out in 36/147 (24.4%) of these babies (not in accordance with ROP screening guidelines). ROP was documented in 4/36 (11.1%). Outpatient ROP screening records were unavailable. Exclusions from the late outcome group included five babies. In the late outcome group 111/263 (42.2%) were screened for ROP. ROP was found in 17%. One baby required treatment with intravitreal antivascular endothelial growth factor (VEGF) and three babies required surgery. Conclusions. More than half of the babies in the late outcome group were not screened during their stay (57.8%). More than one-third of babies were discharged prior to reaching the current recommended age for screening. Efforts need to be intensified to identify and screen all eligible babies prior to discharge. Outpatient ROP screening is not well documented; therefore prevalence cannot be established

A Review of Chronic Lung Disease in Neonates at Charlotte Maxeke Johannesburg Academic Hospital from 1 January 2013 to 31 December 2014

Background. Chronic lung disease (CLD) remains a significant morbidity in preterm babies despite advances in neonatal care. The use of postnatal corticosteroids (PNCSs) to treat CLD remains controversial.Objectives. To describe the clinical characteristics of babies with CLD at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and to explore the use of PNCSs for the prevention and treatment of CLD.Methods. This was a 2-year retrospective review of neonates admitted to CMJAH. Neonates who were in hospital for =28 days were included. Comparisons were made between neonates with evolving CLD and those with no CLD.Results. A total of 485 neonates were analysed: 237 had evolving CLD and 245 did not have CLD. Overall incidence of evolving CLD was 5%. More neonates with CLD than those without CLD needed resuscitation at birth (48.5% v. 39.8%; p=0.02) and had low 5-minute Apgar scores (17.2% v. 10.6%; p=0.001). Neonates with CLD had increased prevalence of patent ductus arteriosus (30.4% v. 7.7%; p=0.001) and late-onset sepsis (56.5% v. 23.6%; p=0.001). The mortality rate was also higher in CLD babies (10.2 v. 2.4%; p=0.001). Necrotising enterocolitis (NEC) (29.2% v. 8%; p=0.005) and sepsis (83.3% v. 53.8%; p=0.008) were associated with increased mortality. The use of PNCSs was associated with less NEC (3.5% v. 17.2%; p=0.001) and improved survival (95.6% v. 81.7%; p=0.001).Conclusions. CLD remains a common morbidity in neonates despite advances in neonatal care. The use of PNCSs was shown to have short-term benefits. To get the most out of PNCS use for CLD; further studies need to be conducted to determine the safest type of steroid; safe doses and the duration of treatment

Birth Weight Recovery among very Low Birth Weight Infants Surviving to Discharge from Charlotte Maxeke Johannesburg Academic Hospital; Neonatal unit

Background. The recommended growth velocity (GV) of very low birth weight (VLBW) infants is 15 g/kg/day. Several factors have been associated with poor postnatal weight gain. Objective. To provide current information on the postnatal growth of VLBW infants at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH).Methods. This was a longitudinal study of VLBW infants surviving to discharge from CMJAH neonatal unit from August to October 2013.Results. Sixty-nine infants were included in the study. The mean GV was 13.2 g/kg/day; the median weight loss was 7.69 and the median time for regaining birth weight was 16 days. Fifty-one infants (73.9) regained their birth weight at or before 21 days. There was a decrease in mean z-scores for weight (ZSWs) from -0.32 (standard deviation 1.25) at birth to -1.94 (1.35) at discharge. A multiple linear regression showed a negative association between ZSW at discharge and number of days nil per os without parenteral nutrition (PN). Antenatal steroids were associated with poor GV. There were no factors associated with regaining birth weight after 21 days on multiple logistic regression.Conclusion. This study showed a GV in VLBW infants approaching recommended standards. Number of days without PN and use of antenatal steroids were associated with poor postnatal growth

Survival of Extremely Low-Birth-Weight Infants

Objectives. Survival of extremely low-birth-weight (ELBW) infants in a resource-limited public hospital setting is still low in South Africa. This study aimed to establish the determinants of survival in this weight category of neonates; who; owing to limited intensive care facilities; were not mechanically ventilated. Design. A retrospective study in which patient data were retrieved from the departmental computer database.Setting. The neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital; Johannesburg; South Africa. Subjects. Neonates admitted at birth between January 2006 and December 2010 with birth weights of =900 g. Outcome measures. Survival at discharge was the major outcome. Maternal variables were age; parity; gravidity; antenatal care; antenatal steroids; place and mode of delivery and HIV status. Neonatal variables were gestational age (GA); birth weight (BW); gender; place of birth; hypothermia; resuscitation at birth; sepsis; necrotising enterocolitis; intraventricular haemorrhage; jaundice; nasal continuous positive airway pressure (NCPAP) with or without surfactant; and Apgar scores. Results. A total of 382 neonates were included in the study. Overall survival was 26.5. The main causes of death; as per the Perinatal Problem Identification Programme (PPIP) classification; were extreme multi-organ immaturity and respiratory distress syndrome. The main determinants of survival were BW (odds ratio (OR) 0.994; 95 confidence interval (CI) 0.991 - 0.997) and GA (OR 0.827; 95 CI 0.743 - 0.919). Overall the rate of NCPAP use was 15.5; and NCPAP was not associated with improved survival. Conclusion. Survival of ELBW infants is low. BW and GA were the strongest predictors of survival. Effective steps are required to avoid extreme prematurity; encourage antenatal care; and provide antenatal steroids when preterm birth is anticipated