Biomedical subjects
S R Benatar
Publications and source records attributed to S R Benatar.
Transition towards a new South Africa.
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Dying and 'euthanasia'.
Medical progress, secularisation of life, growing acceptance of individual human rights (including the right to refuse medical treatment) and of shared decision-making in medicine have focused public attention on the ways in which life may, and perhaps even ought to, be allowed to end in our complex modern era. Intense and thoughtful bio-ethical debate over many years has 'unpacked' the many different understandings and interpretations of the word euthanasia. The consequent conceptual clarification together with recognition and acknowledgement of psychological implications has facilitated a growing rational consensus on openly accepting the withholding and withdrawing of treatment (under defined conditions) within the realm of sound medical practice. This is clearly distinct from assisted suicide and active euthanasia which are generally considered unacceptable perversions of medical practice. Given the ability to sustain life for prolonged periods, often in a permanent state of unconsciousness, the unrealistic expectations of some medical personnel and the lay public, the severe constraints on health care facilities in South Africa and the totally inadequate allocation of resources for highly effective medical treatments, it is appropriate to re-open public debate on the limits of 'striving officiously to keep alive' and on the distinction between 'allowing to die' and 'killing'. Concern that 'rational' arguments reflect moral decay rather than moral progress keeps the debate open and focuses attention on some 'slippery slope' consequences.
Levels of care needed by medical inpatients in a teaching hospital.
Medical inpatients in a teaching hospital ward were studied daily for 2 weeks. The registrar responsible for each patient decided each day what level of care would be most appropriate, and what elements of care were needed for the patient on that day. From their documented assessments on 308 of 458 recorded days registrars considered that 54.5% of patient-days (168 of 308 days) could appropriately have been spent at a lower of level of care than the academic hospital, had such beds been available. The assessments of the registrars in the study ward were similar to assessments of all medical registrars in all other general medical wards in the hospital. Professional staff in the study ward recorded task duration each time any work was done for a patient. Nurses spent 23.9% more time per patient on those whom registrars thought could be treated at lower levels. Doctors spent 15.0% more time per patient on those whose presence in the hospital registrars considered appropriate. Health care could be provided more economically if more lower-level facilities were available. This could perhaps also be achieved with reorganisation of care within a teaching hospital but steps would have to be taken to ensure maintenance of continuity of care and staff-patient relationships.
South African health care in change.
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Medicine and health care in South Africa--five years later.
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Academic boycott--political strategy or moral imperative? Selective support as a justifiable alternative.
Academic boycott has been justified as an appropriate political strategy in the struggle against the oppression of apartheid. Moral outrage against racist policies has led to the claim that academic boycott is a morally imperative component of a broader sanctions policy. This claim has neither been substantiated by a reasoned ethical argument nor weighted against an ethically justifiable approach that is consistent with universal humanitarian aspirations and which allows rejection of apartheid to be coupled to constructive endeavours.
The South African Medical and Dental Council--some proposals for change.
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Universal access to health care--gathering momentum.
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Confidentiality in medicine.
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Academic freedom in South Africa.
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A unitary health service for South Africa.
Medicine throughout the world is facing many critical challenges. In South Africa these are exacerbated by the effects apartheid has had on the structure, funding, distribution and delivery of health care. The demographic, economic, political, ethical and management problems facing our health services and the arguments in favour of privatisation are briefly reviewed. The case against privatisation of health care is buttressed by moral, economic and sociological justification for developing a unitary national health service/insurance system. In a rapidly changing South Africa medical care could become the leading edge of an enlightened social policy, which may facilitate peaceful progress towards a better future for all in our country and sub-continent.
The pattern of care in the medical wards of a teaching hospital.
The Appropriateness Evaluation Protocol was applied in the internal medicine unit of a major South African teaching hospital to determine the proportion of patient days justifying hospital care. A high proportion of total inpatient days was found to be justified (71%); this was similar to hospitals in the USA and better than a comparable hospital in the UK. Only a small proportion of the non-justified days (3%) was explained by the demographic and hospital variables examined. Inappropriate days occurred nearer the end of a stay, and were disproportionate in patients not from the city in which the hospital was situated. Cerebrovascular accidents accounted for close to 10% of total inpatient days. A significant proportion of patient days (23%) did not include a documented doctor contact. Nursing observations were applied routinely, with little association with other indicators of the severity of the patient's condition. This study method is simple, reliable, reproducible and informative. It should be used more widely as a means of launching discussion and evaluation of hospital activity, both in the public and the private sectors.
Ventilatory responses to carbon dioxide in four ethnic groups in Cape Town.
Ventilatory responses to carbon dioxide (Sco2) were measured in 80 healthy adult subjects from four ethnic groups living in Cape Town. The mean Sco2 was 1.77 +/- 0.14 l/min/mmHg in whites, 1.13 +/- 0.09 l/min/mmHg in mixed race people, 0.99 +/- 0.11 l/min/mmHg in Indians and 0.87 +/- 0.10 l/min/mmHg in blacks. The difference between whites and the other three ethnic groups was highly significant (P less than 0.0001), whereas the differences between blacks, mixed race subjects and Indians were not. However, correction of Sco2 for differences in lung size, i.e. Sco2/vital capacity, eliminated the differences between whites and the other groups.
Dissatisfaction of registrars in training at the University of Cape Town Teaching Hospitals.
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Miliary tuberculosis: rapid diagnosis, hematologic abnormalities, and outcome in 109 treated adults.
PURPOSE: The purpose of this study was to determine the clinical and laboratory characteristics, diagnostic methods, and prognostic variables in adults treated for miliary tuberculosis in the rifampicin era. PATIENTS AND METHODS: Computerized records of our community-based university teaching hospital over a 10-year period (1978 to 1987) were analyzed. A total of 109 patients were identified, including 12 who did not have miliary nodules on the chest radiograph (all of whom were shown to have hematogenous dissemination). Predisposing conditions were present in 46 patients. RESULTS: Clinical features were similar to those of previously reported series. Hematologic abnormalities were common: leukopenia (less than 4 x 10(9)/L) was present in 16 of 107 patients (15%), thrombocytopenia (less than 150 x 10(9)/L) in 24 of 104 (23%), and lymphopenia (less than 1.5 x 10(9)/L) in 82 of 94 (87%). Pancytopenia was found in six patients, three of whom recovered. Disseminated intravascular coagulation occurred in four patients, all of whom died. Adenosine deaminase levels were elevated in only seven of 11 serosal exudates and in seven of 12 samples of abnormal cerebrospinal fluid. Fiberoptic bronchoscopy was diagnostic in 44 of 51 patients (86%), bone marrow examination in 19 of 22 (86%), and liver biopsy in all 10 patients. Twenty-six patients (24%) died of miliary tuberculosis a median of 6 days after starting treatment. Survivors were followed up for a median of 51 weeks. Stepwise logistic regression identified aged (greater than 60 years), lymphopenia, thrombocytopenia, hypoalbuminemia, elevated transaminase levels, and treatment delay as independent predictors of mortality. CONCLUSIONS: Miliary tuberculosis commonly causes hematologic derangements, some of which are helpful prognostically. Fiberoptic bronchoscopy compares favorably to liver and bone marrow biopsy in sputum smear-negative cases. Mortality remains high and treatment should be begun as soon as the diagnosis is suspected.
Experience with fibreoptic bronchoscopy in the diagnosis of pulmonary shadows in renal transplant recipients over a 12-year period.
Despite improvements in immunosuppressive therapy, pulmonary infections remain an important cause of morbidity and mortality in renal transplant recipients. Over a 12-year period (1 January 1977 to 31 December 1988) we prospectively assessed the value of fibreoptic bronchoscopy in diagnosing radiographic pulmonary shadows in this group of patients. Forty-eight bronchoscopies were performed on 46 patients. A definitive diagnosis was established in 28/48 (58%) procedures (and was partially definitive for one of two organisms ultimately identified in another). The procedure failed in 19/48 (40%), although in 15 of these, the radiographic shadows resolved on antibiotics (9) or spontaneously (3) or autopsy revealed acute pneumonia (3). In four instances a specific diagnosis was made by alternative means. Clinically useful information which led to changes in management was obtained in 17/48 (35%) procedures and bronchoscopy was thought to have favourably influenced survival in 16/48 (33%). Fibreoptic bronchoscopy is in our experience a safe (only one pneumothorax and no significant haemorrhage) and useful technique in evaluating pulmonary shadows in renal transplant recipients.
Primary pulmonary hypertension and thromboembolic pulmonary hypertension--similarities and differences.
In a retrospective study of 36 patients with primary pulmonary hypertension (PPH) and 16 patients with chronic large vessel thromboembolic pulmonary hypertension (TPH) the diagnostic value of clinical features, chest radiographs, electrocardiographs, radionuclide lung scanning and cardiac catheterization was assessed. PPH patients were younger, had higher prevalence of Raynaud's phenomenon, right axis deviation, right ventricular hypertrophy on electrocardiograph and higher pulmonary artery pressures than TPH patients, but these features were not diagnostic. Although pulmonary angiography is considered by some to be necessary in distinguishing these two conditions, radionuclide lung scanning proved a safe and effective noninvasive method for this purpose.