Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420140005&lang=en vol. 104 num. 5 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Pink ribbons for breast cancer awareness - a perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Well-trained generalists can help improve surgical capacity at district hospitals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rapid, minimally invasive adult voluntary male circumcision with the Unicirc, a novel disposable device</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500004&lng=en&nrm=iso&tlng=en <![CDATA[<b>'It would have been better if I had HIV instead of diabetes'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500005&lng=en&nrm=iso&tlng=en <![CDATA[<b>Call for closure of Folateng private wards in public hospitals in southern Gauteng</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500006&lng=en&nrm=iso&tlng=en <![CDATA[<b>Parents' perceptions of HIV counselling and testing in schools: Study methodology deeply flawed</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500007&lng=en&nrm=iso&tlng=en <![CDATA[<b>A new horizon for the medical device sector in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Lowering private investor risk to build a healthier country</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Population-based health funding under attack</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500010&lng=en&nrm=iso&tlng=en <![CDATA[<b>Dirk Johannes Jacobus van Velden (1932 - 2013)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Breast care: A health professional's guide to diagnosis and management of common breast conditions</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500012&lng=en&nrm=iso&tlng=en <![CDATA[<b>Health and fracking: Should the medical profession be concerned?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500013&lng=en&nrm=iso&tlng=en The use of natural gas that is obtained from high-volume hydraulic fracturing (fracking) may reduce carbon emissions relative to the use of coal and have substantial economic benefits for South Africa. However, concerns have been raised regarding the health and environmental impacts. The drilling and fracking processes use hundreds of chemicals as well as silica sand. Additional elements are either released from or formed in the shale during drilling. These substances can enter the environment in various ways: through failures in the well casing; via alternative underground pathways; as wastewater, spills and leaks on the wellpad; through transportation accidents; and as air pollution. Although many of these chemicals and elements have known adverse health effects, there is little evidence available on the health impacts of fracking. These health concerns have not yet been fully addressed in policy making, and the authors recommend that the voice of health professionals should be part of the public debate on fracking and that a full health impact assessment be required before companies are given the go-ahead to drill. <![CDATA[<b>Odyssean malaria outbreaks in Gauteng Province, South Africa, 2007 - 2013</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500014&lng=en&nrm=iso&tlng=en BACKGROUND: Odyssean malaria refers to malaria transmitted by translocated mosquitoes and is a diagnosis of exclusion, as the probability of finding the responsible vector is miniscule. We believe that road traffic from endemic areas in and around South Africa is the source of most of the infected mosquitoes. Because of the unexpected nature of the disease, diagnosis is often delayed and severe and complicated malaria is common. OBJECTIVES: To describe outbreaks of odyssean malaria during the period 2007 through 2013 in Gauteng Province, South Africa, and to educate healthcare workers about this form of malaria. METHODS: Site visits, environmental hygiene inspections, patient interviews, and entomological investigations for adult mosquitoes and larvae in potential breeding sites were done in each identified outbreak. RESULTS: Over the period, 14 laboratory-proven and 7 probable cases of odyssean malaria were investigated. There were 2 deaths (9.5% case fatality rate, approximately 10 times higher than the national fatality rate for malaria). We describe two recent clusters of cases in detail, and emphasise the importance of clinician awareness of this rare but frequently severe form of malaria. CONCLUSION: Odyssean malaria cases are inevitable in South Africa, given the volume of road, rail and air traffic from malaria risk areas into Gauteng and other non-endemic provinces. It is likely that many cases are missed, owing to the rare and sporadic nature of the condition. Malaria should always be kept in mind as a cause of unexplained fever and thrombocytopenia, even in the absence of a travel history. <![CDATA[<b>Tuberculosis preventive therapy: An underutilised strategy to reduce individual risk of TB and contribute to TB control</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500015&lng=en&nrm=iso&tlng=en Tuberculosis (TB) remains a global health problem, and South Africa (SA) has one of the world's worst TB epidemics. The World Health Organization (WHO) estimated in 1999 that one-third of the world's population was latently infected with TB. In SA up to 88% of HIV-uninfected young adults (31 - 35 years) are latently infected with TB. In the most recent meta-analysis, 6 - 12 months of isoniazid preventive therapy (IPT) was associated with a lower incidence of active TB than placebo (relative risk (RR) 0.68; 95% confidence interval (CI) 0.54 -0.85), with the greatest benefit among individuals with a positive tuberculin skin test (TST) (RR 0.38; 95% CI 0.25 - 0.57). A clinical trial of IPT given with antiretroviral therapy (ART) for 12 months reduced TB incidence by 37% compared with ART alone (hazard ratio (HR) 0.63; 95% CI 0.41 - 0.94). The effect of IPT is limited in high-burden countries. IPT for 36 months v. 6 months reduced TB incidence among HIV-positive, TST-positive participants by 74% (HR 0.26; 95% CI 0.09 - 0.80). A study of more than 24 000 goldminers confirmed that IPT is safe, with only 0.5% experiencing adverse events. A meta-analysis of studies of IPT since 1951 did not show an increased risk of developing resistance. Alternative TB preventive therapy regimens, including high-dose isoniazid and rifapentine given weekly for 3 months, have been shown to have similar efficacy to IPT. Mathematical modelling suggests that scaling up continuous IPT targeted to HIV-positive persons, when used in combination with other treatment and prevention strategies, may substantially improve TB control. <![CDATA[<b>Diagnosis and treatment of imported and odyssean malaria</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500016&lng=en&nrm=iso&tlng=en Tuberculosis (TB) remains a global health problem, and South Africa (SA) has one of the world's worst TB epidemics. The World Health Organization (WHO) estimated in 1999 that one-third of the world's population was latently infected with TB. In SA up to 88% of HIV-uninfected young adults (31 - 35 years) are latently infected with TB. In the most recent meta-analysis, 6 - 12 months of isoniazid preventive therapy (IPT) was associated with a lower incidence of active TB than placebo (relative risk (RR) 0.68; 95% confidence interval (CI) 0.54 -0.85), with the greatest benefit among individuals with a positive tuberculin skin test (TST) (RR 0.38; 95% CI 0.25 - 0.57). A clinical trial of IPT given with antiretroviral therapy (ART) for 12 months reduced TB incidence by 37% compared with ART alone (hazard ratio (HR) 0.63; 95% CI 0.41 - 0.94). The effect of IPT is limited in high-burden countries. IPT for 36 months v. 6 months reduced TB incidence among HIV-positive, TST-positive participants by 74% (HR 0.26; 95% CI 0.09 - 0.80). A study of more than 24 000 goldminers confirmed that IPT is safe, with only 0.5% experiencing adverse events. A meta-analysis of studies of IPT since 1951 did not show an increased risk of developing resistance. Alternative TB preventive therapy regimens, including high-dose isoniazid and rifapentine given weekly for 3 months, have been shown to have similar efficacy to IPT. Mathematical modelling suggests that scaling up continuous IPT targeted to HIV-positive persons, when used in combination with other treatment and prevention strategies, may substantially improve TB control. <![CDATA[<b>AGREE to disagree: Critical appraisal and the publication of practice guidelines</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500017&lng=en&nrm=iso&tlng=en Tuberculosis (TB) remains a global health problem, and South Africa (SA) has one of the world's worst TB epidemics. The World Health Organization (WHO) estimated in 1999 that one-third of the world's population was latently infected with TB. In SA up to 88% of HIV-uninfected young adults (31 - 35 years) are latently infected with TB. In the most recent meta-analysis, 6 - 12 months of isoniazid preventive therapy (IPT) was associated with a lower incidence of active TB than placebo (relative risk (RR) 0.68; 95% confidence interval (CI) 0.54 -0.85), with the greatest benefit among individuals with a positive tuberculin skin test (TST) (RR 0.38; 95% CI 0.25 - 0.57). A clinical trial of IPT given with antiretroviral therapy (ART) for 12 months reduced TB incidence by 37% compared with ART alone (hazard ratio (HR) 0.63; 95% CI 0.41 - 0.94). The effect of IPT is limited in high-burden countries. IPT for 36 months v. 6 months reduced TB incidence among HIV-positive, TST-positive participants by 74% (HR 0.26; 95% CI 0.09 - 0.80). A study of more than 24 000 goldminers confirmed that IPT is safe, with only 0.5% experiencing adverse events. A meta-analysis of studies of IPT since 1951 did not show an increased risk of developing resistance. Alternative TB preventive therapy regimens, including high-dose isoniazid and rifapentine given weekly for 3 months, have been shown to have similar efficacy to IPT. Mathematical modelling suggests that scaling up continuous IPT targeted to HIV-positive persons, when used in combination with other treatment and prevention strategies, may substantially improve TB control. <![CDATA[<b>The burden of imported malaria in Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500018&lng=en&nrm=iso&tlng=en BACKGROUND: The Western Cape Province of South Africa (SA) is not malaria endemic; however, a considerable number of patients present with malaria to our healthcare services. OBJECTIVES: To establish the frequency of patients presenting with malaria at Groote Schuur Hospital (GSH), Cape Town, SA, and to describe their demographics, clinical outcomes and laboratory findings. METHODS: An observational, retrospective, descriptive study was conducted, which included all patients presenting with smear-positive malaria to GSH over a 4-year period between 1 April 2008 and 31 March 2012. RESULTS: During the study period, 134 malaria patients presented to GSH for management; 85% (n=114) were male, median age was 27 years. Of the total smear-positive tests, 96% (n=128) were Plasmodium falciparum, 3% (n=4) P. ovale, and in 1% (n=2) the species was not identified. The number of malaria patients increased markedly, from 6 cases in 2008 to 50 cases in 2012. Of the patients, 48.3% (n=57) were from Somalia, 8.5% (n=10) from SA and 29% (n=30) from other African countries. One SA patient acquired transfusion-transmitted malaria from a pooled platelet product, and the other SA patients had travelled to malaria-endemic areas. The remaining cases were from countries outside of Africa, including 13% (n=15) from Bangladesh. Almost two-thirds (62%; n=72) were admitted to hospital with a median length of stay of 3 days (range 1 - 32). Clinical outcomes were good with only one death and the remaining patients being discharged. CONCLUSION: Imported malaria is imposing a significant burden on health resources. The costs of medical care for the emergency treatment of foreign nationals needs to be recognised, and adequately budgeted for. Only a small area within South Africa (SA) is malaria endemic and this is in the north-eastern part of KwaZulu-Natal, and in Mpumalanga and Limpopo provinces.[1] All cases of malaria in other areas of SA are imported, either from malaria-endemic parts of SA or from further afield. A large number of migrants travel to SA for economic, political and social reasons. According to the United Nations Refugee Agency, SA was the leading worldwide destination country of new asylum seekers between 2006 and 2011. Between 2008 and 2012, the SA Department of Home Affairs registered 778 600 new asylum applications, with Zimbabweans accounting for more than half of these.[2] However, as only a proportion of migrants to SA are registered as asylum seekers, the true number of migrants is unknown. Many foreign migrants come from malaria-endemic areas and present to SA healthcare services after arrival. Groote Schuur Hospital (GSH) in Cape Town is a tertiary hospital serving the Western Cape Province, with 975 beds and a busy medical casualty department that handles ~40 000 patients/year. The aim of this study was to establish the number of malaria patients presenting to GSH over the 4-year period between 1 April 2008 and 31 March 2012, and to describe their demographics, clinical outcomes and laboratory findings. <![CDATA[<b>Perceptions of mental illness among Muslim general practitioners in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500019&lng=en&nrm=iso&tlng=en BACKGROUND: Mental health literacy on the part of medical practitioners is an important component of mental healthcare. General practitioners (GPs) are typically the first doctors consulted by a person who is ill. Exploration of their perceptions regarding mental illness, aetiological issues and treatment is important. OBJECTIVE: To investigate perceptions of mental illness in a sample of 10 South African Muslim GPs (five male, five female) in the Lenasia area (Johannesburg, South Africa). METHODS: Using a qualitative approach, semi-structured interviews were conducted with each GP. The questionnaire encompassed 37 questions relating to the context in which the GPs practised, perceptions of mental illness, understanding of religion and culture, and treatment of mental illness (including aspects of spiritual illness). Thematic content analysis was used to analyse the data. RESULTS: Six dominant themes were identified, namely GPs' understanding of mental illness and its causation; stigma, secrecy and somatisation; the beneficial effects of religion in mental illnesses; perceptions of spiritual illnesses; collaboration with traditional healers; and collaboration with psychiatrists and psychologists. CONCLUSION: Greater awareness regarding the stigmatisation of mental illness is needed. Furthermore, it is important that healthcare professionals have an understanding of religious and cultural taxonomies of illness and the use of traditional healing as a mode of treatment. Participants identified a need for increased collaboration between healthcare professionals, including traditional healers. Local and international research consistently emphasises the importance of mental health literacy on the part of healthcare professionals and community members. Mental health literacy extends beyond the biopsychosocial sphere and calls for a greater awareness of religious and cultural values that can influence healthcare professionals and their patients. General practitioners (GPs) are often the first point of entry when people seek medical treatment, and their perceptions of mental illness, aetiological issues and treatment are important. An examination of current research in the South African (SA) context indicates that research has focused on the prevalence of mental illness generally and across different groups.[1] It has also focused on assessing the role of traditional healers and traditional healing in relation to more conventional care.[2] Issues of mental health literacy[3] and explanatory models of mental illness[4] have been addressed. This research has mainly been quantitative. Qualitative studies have examined perceptions of mental illness in samples of traditional healers, volunteer counsellors, community members, psychologists and psychiatrists, but not among GPs.[5,6] The GP, often the family physician and the community doctor, is typically the first professional from whom a person who is ill seeks treatment and healthcare advice. According to Ng,[7] culture can often influence mental illness in terms of perception, conception, experience of symptoms, classification, treatment, recognition, labelling and the course of mental illness. This is particularly the case in the SA context, where supernatural, religious, magical and moralistic approaches to mental illness exist.[5-7] Spiritual punishment or sorcery is often identified as a cause of illness.[5,7] It is therefore essential that GPs' perceptions of mental illness be explored, as they deal with patients from various cultures and religions and are well positioned to inform research on mental illness in SA. <![CDATA[<b>Evaluation of the visual prostate symptom score in a male population with great language diversity and limited education: A study from Namibia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500020&lng=en&nrm=iso&tlng=en BACKGROUND: A visual prostate symptom score (VPSS) using pictograms was developed to assess the force of the urinary stream, urinary frequency, nocturia and quality of life (QoL). OBJECTIVE: To compare the VPSS with the international prostate symptom score (IPSS) and maximum (Qmax) and average (Qave) urinary flow rates in men from diverse language groups with limited schooling. METHODS: Men with lower urinary tract symptoms admitted to the urology ward at Windhoek Central Hospital, Namibia, were evaluated. Patients who were unable to complete the questionnaires alone were assisted by a doctor or nurse. Local ethics committee approval was obtained. Statistical analysis was performed using Student's t-test and Spearman's rank correlation test. RESULTS: One hundred men (mean age 56.3 years, range 20.1 - 95.4) were evaluated over a period of one year. All the men understood one or more of 15 languages, and 30 were illiterate; 32 had <5 years of schooling, 34 had 5 - 9 years and 34 had &gt;9 years. The VPSS took significantly less time to complete than the IPSS. There were statistically significant correlations between the total VPSS and IPSS scores, between the four VPSS questions and the corresponding IPSS questions, and between Qmax and Qave and the VPSS total and VPSS questions on the force of the urinary stream and QoL. CONCLUSION: The VPSS pictograms depicting the force of the urinary stream and QoL correlated significantly with Qmax and Qave, indicating that they can be used as single-item questions to rapidly assess bladder outflow obstruction in men with limited education. <![CDATA[<b>Prevalence of oral and oropharyngeal human papillomavirus in a sample of South African men: A pilot study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500021&lng=en&nrm=iso&tlng=en BACKGROUND: Human papillomavirus (HPV) infection is well known to be associated with head and neck cancers (HNCs). HPV-associated HNCs are related to sexual behaviour, particularly the lifetime number of oral sex partners, but the epidemiology of oral and oropharyngeal HPV in South African men has not yet been studied. OBJECTIVES: To determine the oral and oropharyngeal HPV strain prevalence and associated factors in a selected male population in Pretoria, South Africa (SA). METHODS: Male factory workers were recruited. Oral rinse and gargle samples were tested for 37 HPV types using the Linear Array HPV Genotyping Test (Roche Molecular Systems). A questionnaire was used to obtain information regarding age, medical conditions, substance and alcohol use and sexual behaviour. HIV testing was optional. RESULTS: The HPV prevalence was 5.6% among men (N=125) aged 17 - 64 years. High-risk HPV (hrHPV) types 16 and 68 were found in two men. Oral sex seemed to be an uncommon practice in the majority of respondents, but the two respondents with hrHPV did practise oral sex. There was a statistically significant association between HPV infection and an increased number of sexual partners (p=0.027), but not between HPV and substance use, HIV status or clinical mucosal pathology. CONCLUSION: The prevalence of oral and oropharyngeal HPV was lower than reported in other countries. An association between oral HPV and having multiple sexual partners was found. A larger nationwide study would give a more representative view of the burden of oral and oropharyngeal HPV infection in SA. <![CDATA[<b>Evaluation of adherence to national treatment guidelines among tuberculosis patients in three provinces of South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500022&lng=en&nrm=iso&tlng=en BACKGROUND: Standardised tuberculosis (TB) treatment through directly observed therapy (DOT) is available in South Africa, but the level of adherence to standardised TB treatment and its impact on treatment outcomes is unknown. OBJECTIVES: To describe adherence to standardised TB treatment and provision of DOT, and analyse its impact on treatment outcome. METHODS: We utilised data collected for an evaluation of the South African national TB surveillance system. A treatment regimen was considered appropriate if based on national treatment guidelines. Multivariate log-binomial regression was used to evaluate the association between treatment regimens, including DOT provision, and treatment outcome. RESULTS: Of 1 339 TB cases in the parent evaluation, 598 (44.7%) were excluded from analysis owing to missing outcome or treatment information. The majority (697, 94.1%) of the remaining 741 patients received an appropriate TB regimen. Almost all patients (717, 96.8%) received DOT, 443 (59.8%) throughout the treatment course and 274 (37.0%) during the intensive (256, 34.6%) or continuation (18, 2.4%) phase. Independent predictors of poor outcome were partial DOT (adjusted risk ratio (aRR) 3.1, 95% confidence interval (CI) 2.2 - 4.3) and previous treatment default (aRR 2.3, 95% CI 1.1 - 4.8). CONCLUSION: Patients who received incomplete DOT or had a history of defaulting from TB treatment had an increased risk of poor outcomes. <![CDATA[<b>Human resource management practices in a medical complex in the Eastern Cape, South Africa: Assessing their impact on the retention of doctors</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500023&lng=en&nrm=iso&tlng=en BACKGROUND: Human resource management (HRM) practices have the potential to influence retention of doctors in the public health sector. OBJECTIVE: To explore the key human resource (HR) practices affecting doctors in a medical complex in the Eastern Cape, South Africa. METHODS: We used an open-ended questionnaire to gather data from 75 doctors in this setting. RESULTS: The most important HR practices were paying salaries on time and accurately, the management of documentation, communication, HR staff showing that they respected and valued the doctors, and reimbursement for conferences and special leave requests. All these practices were judged to be poorly administered. Essential HR characteristics were ranked in the following order: task competence of HR staff, accountability, general HR efficiency, occupation-specific dispensation adjustments and performance management and development system efficiency, and availability of HR staff. All these characteristics were judged to be poor. CONCLUSION: HRM practices in this Eastern Cape medical complex were inadequate and a source of frustration. This lack of efficiency could lead to further problems with regard to retaining doctors in public sector service. <![CDATA[<b>Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500024&lng=en&nrm=iso&tlng=en BACKGROUND: Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low- and middle-income countries this strategy is underused, under-resourced and poorly researched. OBJECTIVE: To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan. METHODS: Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. RESULTS: Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 - 0.85). The intrarater agreement was also high with 87% exact agreement (95% CI 67 - 100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of over-triage did not exceed the acceptable threshold of 30 - 50%. Under-triage was acceptable for all except emergency cases (66%). CONCLUSION: ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed. <![CDATA[<b>Breast cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500025&lng=en&nrm=iso&tlng=en BACKGROUND: Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low- and middle-income countries this strategy is underused, under-resourced and poorly researched. OBJECTIVE: To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan. METHODS: Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. RESULTS: Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 - 0.85). The intrarater agreement was also high with 87% exact agreement (95% CI 67 - 100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of over-triage did not exceed the acceptable threshold of 30 - 50%. Under-triage was acceptable for all except emergency cases (66%). CONCLUSION: ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed. <![CDATA[<b>The challenges of managing breast cancer in the developing world - a perspective from sub-Saharan Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500026&lng=en&nrm=iso&tlng=en Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model. <![CDATA[<b>Down-staging of breast cancer in the pre-screening era: Experiences from Chris Hani Baragwanath Academic Hospital, Soweto, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500027&lng=en&nrm=iso&tlng=en We aimed to investigate the stage of breast cancer at first diagnosis and assess possible determinants of late-stage presentation. A consecutive series of women with newly diagnosed breast cancer at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, South Africa were analysed. We retrospectively reviewed electronic patient records. Data were extracted for: (i) stage and year at diagnosis; (ii) travel distance (estimated straight-line distance from GPS-coded residential address to CHBAH); (iii) receptor subtypes; and (iv) age of patient. Generalised linear models were applied to estimate risk ratios for late- v. early-stage disease. Of the patients (N=1 071) studied, the mean age was 55 years and 90% were black Africans. Patients who lived &gt;20 km from the hospital (n=347; 61.8%) presented with late-stage disease (stage 3/4) compared with 50.2% who lived <20 km from the hospital (n=724; p=0.02). The majority of patients (74%) &gt;70 years of age who lived &gt;20 km away presented with advanced breast cancer. However, in younger patients, age showed no clear association with stage at presentation. Travel distance was an important predictor of later-stage disease at diagnosis, which was more noticeable in elderly patients. Patients with more aggressive triple-negative and HER2+ tumours presented with later-stage disease. <![CDATA[<b>Side-effects of systemic therapy for the management of breast cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500028&lng=en&nrm=iso&tlng=en Systemic treatment for breast cancer is given as neoadjuvent therapy to reduce tumour bulk before surgery, and as adjuvant therapy after surgery to control micrometastatic disease, reduce tumour bulk and improve quality of life in metastatic disease. Systemic therapy is divided into endocrine therapy, chemotherapy and biological response modifier therapy. All therapies will cause a higher rate of anxiety and depression, and loss of libido, which for many is a major problem. In pre-menopausal patients fertility issues should be discussed as the agents used can cause a decrease in or, in some cases, loss of fertility. <![CDATA[<b>The management of breast cancer-related lymphoedema</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500029&lng=en&nrm=iso&tlng=en Lymphoedema is a chronic debilitating condition characterised by an accumulation of protein-rich fluid in interstitial spaces due to insufficient functioning of the lymphatic system. The condition may be referred to as primary (congenital malformation) or secondary (damage to the lymphatic system) lymphoedema. Lymphoedema is currently incurable, but can be alleviated with appropriate treatment. However, if ignored, it can progress and become difficult to manage. <![CDATA[<b>Stigma, survivorship and solutions: Addressing the challenges of living with breast cancer in low-resource areas</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500030&lng=en&nrm=iso&tlng=en Breast cancer in developing nations is characterised by late diagnosis. The causes are multifactorial and many are addressed in other articles in this edition of CME. Breast cancer is also seen in younger women. The late-presentation trend is slowly changing in some areas, and an increasing number of women are presenting with early disease. These patients, if managed appropriately, have a more favourable prognosis. As a result, developing nations must now begin to consider the concerns of breast cancer survivorship. In developed countries, there are a number of organisations that support breast cancer survivors. In this article, we highlight some of the psychosocial aspects of living with breast cancer in low-resource areas. <![CDATA[<b>An approach to the management of locally advanced breast cancer: Part 1</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500031&lng=en&nrm=iso&tlng=en Locally advanced breast cancer (LABC) comprises a heterogeneous group of diseases. It incorporates a subset of stage IIB (T3N0) disease, stage III disease and inflammatory breast cancer. In the developed world, 7% of breast cancer patients have stage III disease at diagnosis. In developing countries, LABC constitutes about 30 - 60% of all cases, most probably attributable to a lack of education and poor socioeconomic status. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, USA demonstrates a median survival of 4.9 years, while the 5-year relative survival rate for this group of women is 55% with multimodality treatment, excluding biologics. <![CDATA[<b>An approach to the management of locally advanced breast cancer: Part 2</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500032&lng=en&nrm=iso&tlng=en Caring for a patient with locally advanced breast cancer requires a multidisciplinary approach, whether cure or palliation. Patient expectations need to be discussed, while alternative and holistic approaches help to reinforce the patient's belief that their decision regarding care is correct. It is important to recognise that a patient's decision to choose 'no treatment' should be treated with respect. Psychological support and care are vital, requiring a non-judgemental relationship built on trust. <![CDATA[<b>ABC - Advocates for Breast Cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000500033&lng=en&nrm=iso&tlng=en Breast and cervical cancer are leading causes of cancer-related mortality in South African women. Early detection of breast cancer is imperative to improve survival rates. However, public awareness is lacking and healthcare facilities for the diagnosis and treatment of the disease, particularly in the public sector, are inadequate. A cancer alliance, Advocates for Breast Cancer (ABC), was formed in 2014 to campaign for a national breast healthcare policy for South Africa to prioritise the management of this disease.