Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 107 num. 5 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Undergraduate antibiotic stewardship training: Are we leaving our future prescribers 'flapping in the wind'?</b>]]> <![CDATA[<b>A randomised controlled trial comparing laparoscopy with laparotomy in the management of women with ruptured ectopic pregnancy</b>]]> <![CDATA[<b>Naude <i>et al. </i>avoid answering the essential question: Mistake or mischief?</b>]]> <![CDATA[<b>A skin test for latent tuberculosis</b>]]> <![CDATA[<b><i>Serratia marcescens </i>infection or hypoxic-ischaemic encephalopathy in neonates: Is magnetic resonance imaging a problem-solving tool?</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Meeting the complex needs of individuals with rare genetic disorders in South Africa - lessons from tuberous sclerosis complex</b>]]> <![CDATA[<b>Diagnosis, monitoring and treatment of tuberous sclerosis complex: A South African consensus response to international guidelines</b>]]> Tuberous sclerosis complex (TSC) is a genetic disorder with multi-system manifestations and a high burden of disease. In 2013, an international panel of TSC experts revised the guidelines for the diagnosis, surveillance and treatment of the disorder. In South Africa (SA), a local multidisciplinary group of healthcare professionals and TSC researchers reviewed the international guidelines to generate an SA consensus clinical update on the identification, diagnosis, treatment and lifelong monitoring of individuals who live with TSC. We strongly endorse dissemination and use of the international guidelines for the assessment, monitoring and treatment of TSC. In addition, we strongly support access to genetic testing and to mTOR (mammalian target of rapamycin) inhibitors to treat subependymal giant cell astrocytomas not amenable to surgery and renal angiomyolipomas larger than 3 cm, and as adjunctive treatment for refractory focal seizures. We await with interest results from mTOR inhibitor trials of skin and TSC-associated neuropsychiatric disorders (TAND). With regard to training, we recommend the inclusion of TSC in undergraduate and postgraduate medical and health sciences curricula, and the promotion of other continuing professional development events to raise awareness about TSC. We also support the development of a TSC user/carer/parent organisation to provide an informal support network for families across SA. We acknowledge that some progress has been made in recent years in SA, but much remains to be done. We hope that this SA consensus clinical update based on the international guidelines will make a positive contribution to increase knowledge and improve clinical care for all patients who live with TSC in SA, and their families. <![CDATA[<b>Health research and safeguards: The South African journey</b>]]> Health research, as a social good, needs to be conducted in the interests of the common good. Because of the unfortunate exploitation of research participants globally, safeguards for protections are necessary. Most international codes and guidelines originated as responses to the abuse and mistreatment of research subjects. By the 1890s, antivivisectionists were already calling for laws to protect children, as a result of the increasing numbers of institutionalised children being subjected to vaccine experiments in Europe and the USA. Just after the turn of the century, the first attempt to test a polio vaccine was thwarted after the American Public Health Association condemned the programme. In South Africa, medical scientists were busy with discoveries and innovations as far back as the 1800s. In December 1967, the historic first human heart transplant was undertaken in Cape Town. Although it is unclear how much research preceded this procedure, there is no doubt that the operation was done in a research setting, and it had a far-reaching impact. <![CDATA[<b>Assisted suicide and assisted voluntary euthanasia: Stransham-Ford High Court case overruled by the Appeal Court - but the door is left open</b>]]> Whether persons wishing to have doctor-assisted suicide or voluntary active euthanasia may make a court application based on their rights in the Constitution has not been answered by the Appeal Court. Therefore, if Parliament does not intervene beforehand, such applications can be made - provided the applicants have legal standing, full arguments are presented regarding local and foreign law, and the application evidence is comprehensive and accurate. The Appeal Court indicated that the question should be answered by Parliament because 'issues engaging profound moral questions beyond the remit of judges to determine, should be decided by the representatives of the people of the country as a whole'. However, the Government has not implemented any recommendations on doctor-assisted suicide and voluntary active euthanasia made by the South African Law Commission 20 years ago. The courts may still develop the law on doctor-assisted death, which may take into account developments in medical practice. Furthermore, 'the possibility of a special defence for medical practitioners or carers would arise and have to be explored'. <![CDATA[<b>Human dignity and the future of the voluntary active euthanasia debate in South Africa</b>]]> The issue of voluntary active euthanasia was thrust into the public policy arena by the Stransham-Ford lawsuit. The High Court legalised voluntary active euthanasia - however, ostensibly only in the specific case of Mr Stransham-Ford. The Supreme Court of Appeal overturned the High Court judgment on technical grounds, not on the merits. This means that in future the courts can be approached again to consider the legalisation of voluntary active euthanasia. As such, Stransham-Ford presents a learning opportunity for both sides of the legalisation divide. In particular, conceptual errors pertaining to human dignity were made in Stransham-Ford, and can be avoided in future. In this article, I identify these errors and propose the following three corrective principles to inform future debate on the subject: (i) human dignity is violable; (ii) human suffering violates human dignity; and (iii) the 'natural' causes of suffering due to terminal illness do not exclude the application of human dignity. <![CDATA[<b>Ethical and legal perspectives on use of social media by health professionals in South Africa</b>]]> Use of social media has increased exponentially throughout the world. Social media provides a platform for building social and professional relationships that can be used by all, including healthcare professionals. Alongside the benefits of creating networks and spreading information wider and faster than is possible with traditional communication channels, however, it presents ethical and legal challenges. For health professionals, it poses a threat to confidentiality and privacy owed to patients, colleagues and employers. It is vital for health professionals to acknowledge that the same ethical and legal standards apply both online and offline, and that they are accountable to professional bodies and the law for their online activities. This article seeks to explore the ethical and legal pitfalls facing health professionals using social media platforms. Importantly, it seeks to create awareness about the cyberpsychology phenomenon called the 'online disinhibition effect', responsible for lowering restraint during online activities. <![CDATA[<b>Biobanks in South Africa: A global perspective on privacy and confidentiality</b>]]> The Universal Declaration of Bioethics and Human Rights (UDBHR) of the United Nations Educational, Scientific and Cultural Organization (UNESCO) was adopted unanimously in 2005 by the world community as a universal guideline, according to which members of the global community were accountable to each other. Research results from UNESCO show that the UDBHR has had little or no impact in South Africa (SA). The primary objective of this article is to promote awareness of the UDBHR in SA and Africa by focusing on Article 9 of the Declaration, which accepts the right to privacy and confidentiality. For this objective to be relevant in the SA context, depends on whether the guidelines of the National Department of Health's Ethics in Health Research: Principles, Processes and Structures of 2015 acknowledge biobanks of the universally accepted ethical guidelines on privacy and confidentiality of autonomous persons and whether these guidelines are broadly in accordance with global bioethical guidelines. <![CDATA[<b>Legal liability for failure to prevent pregnancy (wrongful pregnancy)</b>]]> Can the conception of a child ever constitute damage recoverable in law? This article considers the liability of healthcare practitioners for failing to prevent a pregnancy. Developments leading to the recognition of wrongful pregnancy as a cause of (legal) action in South Africa (SA), are briefly outlined. The salient points of the relevant judgments by SA courts are set out to expose the rationale underlying the judgments and to highlight that recognition of liability for wrongful pregnancy resulted from an application of fair and equitable principles of general application. Conduct that could expose practitioners to liability is identified from reported cases and inferred from general principles laid down in case law. <![CDATA[<b>Paraquat poisoning: Acute lung injury - a missed diagnosis</b>]]> Paraquat is a herbicide of great toxicological importance because it is associated with high mortality rates, mainly due to respiratory failure. We report the case of a 28-year-old man admitted to the casualty department at Ngwelezana Hospital, Empangeni, KwaZulu-Natal, South Africa, with a history of vomiting and abdominal pain after ingestion of ~100 mL of an unknown substance, later identified as paraquat, together with an unknown amount of alcohol, in a suicide attempt. He developed respiratory distress associated with lung parenchymal infiltrates that required ventilatory support and later a spontaneous pneumothorax, and died in the intensive care unit. We discuss the importance of a high index of suspicion of paraquat poisoning in rural areas, where paraquat is readily available as a herbicide on farms, in patients with a similar presentation. We further stress the importance of identifying the classic radiological progression after paraquat poisoning, to help avoid a delay in diagnosis if the culprit substance is not known (as happened in our case). Lastly, we look at the importance of avoiding oxygen supplementation, and early administration of immunosuppressive therapy, to improve outcome. <![CDATA[<b>A rare case of massive hepatosplenomegaly due to acute lymphoblastic leukaemia in pregnancy</b>]]> Acute lymphoblastic leukaemia (ALL) is rarely seen in pregnancy. Massive hepatosplenomegaly as a presentation of ALL has not been described previously in any patient population. A 30-year-old pregnant woman presented at 16 weeks' gestation with epistaxis, jaundice, diffuse abdominal pain and distension, massive hepatosplenomegaly and peripheral oedema. On the basis of blood tests, bone marrow biopsy and imaging, a diagnosis of ALL complicated by massive hepatosplenomegaly with splenic infarctions was made. The patient was referred to oncology for appropriate chemotherapy. <![CDATA[<b>South African medical students' perceptions and knowledge about antibiotic resistance and appropriate prescribing: Are we providing adequate training to future prescribers?</b>]]> BACKGROUND. Education of medical students has been identified by the World Health Organization as an important aspect of antibiotic resistance (ABR) containment. Surveys from high-income countries consistently reveal that medical students recognise the importance of antibiotic prescribing knowledge, but feel inadequately prepared and require more education on how to make antibiotic choices. The attitudes and knowledge of South African (SA) medical students regarding ABR and antibiotic prescribing have never been evaluated. OBJECTIVE. To evaluate SA medical students' perceptions, attitudes and knowledge about antibiotic use and resistance, and the perceived quality of education relating to antibiotics and infection. METHODS. This was a cross-sectional survey of final-year students at three medical schools, using a 26-item self-administered questionnaire. The questionnaires recorded basic demographic information, perceptions about antibiotic use and ABR, sources, quality, and usefulness of current education about antibiotic use, and questions to evaluate knowledge. Hard-copy surveys were administered during whole-class lectures. RESULTS. A total of 289 of 567 (51%) students completed the survey. Ninety-two percent agreed that antibiotics are overused and 87% agreed that resistance is a significant problem in SA - higher proportions than those who thought that antibiotic overuse (63%) and resistance (61%) are problems in the hospitals where they had worked (p<0.001). Most reported that they would appreciate more education on appropriate use of antibiotics (95%). Only 33% felt confident to prescribe antibiotics, with similar proportions across institutions. Overall, prescribing confidence was associated with the use of antibiotic prescribing guidelines (p=0.003), familiarity with antibiotic stewardship (p=0.012), and more frequent contact with infectious diseases specialists (p<0.001). There was an overall mean correct score of 50% on the knowledge questionnaire, with significant differences between institutions. Students who used antibiotic prescribing guidelines and found their education more useful scored higher on knowledge questionnaires. CONCLUSION. There are low levels of confidence with regard to antibiotic prescribing among final-year medical students in SA, and most students would like more education in this area. Perceptions that ABR is less of a problem in their local setting may contribute to inappropriate prescribing behaviours. Differences exist between medical schools in knowledge about antibiotic use, with suboptimal scores across institutions. The introduction and use of antibiotic prescribing guidelines and greater contact with specialists in antibiotic prescribing may improve prescribing behaviours. <![CDATA[<b>Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study</b>]]> BACKGROUND. Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. OBJECTIVE. To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA). METHODS. The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, observational cohort study of all patients &gt;16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. RESULTS. Of the 3 927 SASOS patients, 255 (6.5%) were admitted to critical care units; of these admissions, 144 (56.5%) were planned, and 111 (43.5%) unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001). Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001). CONCLUSION. The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate 'high care-dependency units' for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on (NCT02141867). <![CDATA[<b>Factors associated with contracting malaria in Ward 29 of Shamva District, Zimbabwe, 2014</b>]]> BACKGROUND. Malaria cases at Wadzanayi Clinic in Shamva District, Zimbabwe, increased drastically, surpassing the epidemic threshold, in week four of December 2013. This rise was sustained, which necessitated an investigation of the outbreak. OBJECTIVES. To identify risk factors and system weaknesses to improve epidemic preparedness and response. METHODS. An unmatched 1:1 case-control study was conducted in Ward 29 of Shamva District in Zimbabwe. Epidemic preparedness and response were assessed using the Zimbabwean epidemic preparedness and response guidelines. RESULTS. The sociodemographic characteristics of all participants were similar, except for gender. The risk factors for contracting malaria were performing early morning chores (odds ratio (OR) 2.75; 95% confidence interval (CI) 1.20 - 6.32), having a body of water near the home (OR 3.41; 95% CI 1.62 - 7.20) and having long grass near the home (OR 2.61; 95% CI 1.10 - 6.37). Protective factors were staying indoors at night (OR 0.13; 95% CI 0.06 - 0.28) and staying in a sprayed home (OR 0.36; 95% CI 0.21 - 0.92). All cases were diagnosed with a malaria rapid diagnostic test. All complicated cases were treated with quinine. Four out of 58 uncomplicated cases were treated with quinine. The rest were treated with co-artemether. There was no documentation of the outbreak response by the district health executive. Respraying (indoor residual spraying) was carried out, with a coverage of 78% of rooms sprayed. One nurse out of seven at Wadzanayi Clinic was trained in integrated disease surveillance and response, and malaria case management. District malaria thresholds were outdated. Malaria commodities such as drugs and sprays did not have reorder limits. CONCLUSION. This study re-emphasises the importance of environmental- and personal-level factors as determinants of malaria. Poor outbreak preparedness and response may have propagated the malaria outbreak in this setting. Health education and the use of mosquito repellants should be emphasised. Larvicide may reduce the malaria burden. Epidemic preparedness and response need to be strengthened. Outbreak investigation remains important. This study emphasises the need for malaria interventions to be tailored to locally prevailing determinants to avert outbreaks. <![CDATA[<b>Predicting postoperative haemoglobin changes after burn surgery</b>]]> BACKGROUND. Burn surgery is associated with significant blood loss and fluid shifts that cause rapid haemoglobin (Hb) changes during and after surgery. Understanding the relationship between intraoperative and postoperative (day 1) Hb changes may assist in avoiding postoperative anaemia and unnecessary peri-operative blood transfusion. OBJECTIVE. To describe the Hb changes into the first day after burn surgery and to identify factors predictive of Hb changes that would guide blood transfusion decisions. METHODS. This was a single-institution, retrospective cohort study that included 158 patients who had undergone burn surgery. Hb was measured at the start and end of surgery, and on the first day (16 - 32 hours) after surgery, and the results were analysed. Peri-operative factors (Hb at the end of surgery, total body surface area operated on (TBSA-op), fluid administration and intraoperative blood administration) were evaluated to determine their association with Hb changes on the first day after surgery. RESULTS. The mean (standard deviation) preoperative Hb was 10.6 (2.29) g/dL, the mean postoperative Hb was 9.4 (2.01) g/dL, and the mean Hb on the first day after surgery was 9.2 (2.19) g/dL. Median total burn surface area was 7% (interquartile range 9%, min. 1%, max. 45%), with a mean body surface area operated on (debridement area plus donor area) of 9.7%. Of the 158 patients, 26 (16%) had an Hb <7 g/dL (transfusion trigger) on the first day after surgery. For patients with a high (&gt; 9 g/dL), intermediate (&gt; 7 - <9 g/dL), or low (<7 g/dL) Hb measurement at the end of burn surgery, those with an Hb below the transfusion trigger on the first day after burn surgery were 0%, 27%, and 75%, respectively. End-of-surgery Hb and TBSA-op strongly predicted the first day Hb level. In the intermediate group, 55% of patients with a TBSA-op &gt;11% had an Hb below the transfusion trigger on the first day after surgery. CONCLUSION. Hb at the end of burn surgery was the best predictor of Hb on the first day after surgery. Patients with an Hb <7 g/dL remained as such on the first postoperative day. Half of the patients with an end-of-surgery Hb &gt; 7 - <9 g/dL and who had &gt;11% TBSA-op had an Hb <7 g/dL on the first postoperative day. <![CDATA[<b>Influence of HIV and other risk factors on tuberculosis</b>]]> BACKGROUND. Tuberculosis (TB) notification in South Africa has increased six-fold over the past two decades, mainly because of the HIV epidemic. OBJECTIVES. To describe the sociodemographic and outcome characteristics of TB patients, and to identify risk factors associated with TB treatment outcomes stratified by HIV status. METHODS. A cross-sectional study was used to analyse data from the Cape Town Metro East geographical service area (GSA) electronic TB register (ETR.Net), including adult patients aged >15 years who initiated TB treatment between 1 July 2011 and 30 June 2012. RESULTS. TB case notification in the GSA was 922 per 100 000 population. Of the 12 672 TB patients registered, 50.5% were co-infected with HIV. The death rate in co-infected patients was 5.4% v. 2.8% in HIV-negative patients, the rate of treatment success 66.6% v. 73.5%, and the rate of unfavourable treatment outcome 28.1% v. 23.7%. The Khayelitsha subdistrict had the highest proportion of TB burden (37.0%) and co-infection (47.6%). Fourteen percent of patients had extrapulmonary TB, 65.9% of whom were co-infected with HIV. In the multivariate analysis, HIV infection (relative risk (RR) 1.2), retreatment (RR 1.4) and sputum smear microscopy not done (RR 1.4) were significantly associated with unfavourable treatment outcome. The Eastern (RR 0.9) and Northern (RR 0.7) subdistricts were less likely to have unfavourable outcomes compared with Khayelitsha. In the stratified analysis, retreatment and smear not done were significant risk factors for an unfavourable treatment outcome in both co-infected and HIV-negative patients. CONCLUSIONS. The burdens of both TB and co-infection were high in this community, although HIV prevalence varied. Mortality was higher and treatment completion lower in co-infected patients than in those who were HIV-negative. Co-infection, previous TB treatment and smear not done were significant risk factors for an unfavourable outcome in all patients. <![CDATA[<b>Bacteria isolated from the airways of paediatric patients with bronchiectasis according to HIV status</b>]]> BACKGROUND. Knowledge of which bacteria are found in the airways of paediatric patients with bronchiectasis unrelated to cystic fibrosis (CF) is important in defining empirical antibiotic guidelines for the treatment of acute infective exacerbations. OBJECTIVE. To describe the bacteria isolated from the airways of children with non-CF bronchiectasis according to their HIV status. METHODS. Records of children with non-CF bronchiectasis who attended the paediatric pulmonology clinic at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from April 2011 to March 2013, or were admitted to the hospital during that period, were reviewed. Data collected included patient demographics, HIV status, and characteristics of the airway samples and types of bacteria isolated. RESULTS. There were 66 patients with non-CF bronchiectasis over the 2-year study period. The median age was 9.1 years (interquartile range 7.2 - 12.1). The majority of patients (78.8%) were HIV-infected. A total of 134 samples was collected (median 1.5 per patient, range 1 - 7), of which 81.3% were expectorated or induced sputum samples. Most bacteria were Gram negatives (72.1%). Haemophilus influenzae was the most common bacterium identified (36.0%), followed by Streptococcus pneumoniae (12.6%), Moraxella catarrhalis (11.1%) and Staphylococcus aureus (10.6%). There were no differences between HIV-infected and uninfected patients in prevalence or type of pathogens isolated. CONCLUSION. Bacterial isolates from the airways of children with non-CF bronchiectasis were similar to those in other paediatric populations and were not affected by HIV status. <![CDATA[<b>Obstructive pulmonary disease in patients with previous tuberculosis: Pathophysiology of a community-based cohort</b>]]> BACKGROUND. An association between chronic airflow limitation (CAL) and a history of pulmonary tuberculosis (PTB) has been confirmee in epidemiological studies, but the mechanisms responsible for this association are unclear. It is debated whether CAL in this context should be viewed as chronic obstructive pulmonary disease (COPD) or a separate phenotype. OBJECTIVE. To compare lung physiology and high-resolution computed tomography (HRCT) findings in subjects with CAL and evidence oi previous (healed) PTB with those in subjects with smoking-related COPD without evidence of previous PTB. METHODS. Subjects with CAL identified during a Burden of Obstructive Lung Disease (BOLD) study performed in South Africa were studied Investigations included questionnaires, lung physiology (spirometry, body plethysmography and diffusing capacity) and quantitative HRCT scans to assess bronchial anatomy and the presence of emphysema (<-950 HU), gas trapping (<-860 HU) and fibrosis (&gt;-200 HU). Finding; in subjects with a past history and/or HRCT evidence of PTB were compared with those in subjects without these features. RESULTS. One hundred and seven of 196 eligible subjects (54.6%) were enrolled, 104 performed physiology tests and 94 had an HRCT scan. Based on history and HRCT findings, subjects were categorised as no previous PTB (NPTB, n=31), probable previous PTB (n=33) or definite previous PTB (DPTB, n=39). Subjects with DPTB had a lower diffusing capacity (Δ=-17.7%; p=0.001) and inspiratory capacity (Δ=-21.5%; p=0.001) than NPTB subjects, and higher gas-trapping and fibrosis but not emphysema scores (Δ=+6.2% (p=0.021), +0.36% (p=0.017) and +3.5% (p=0.098), respectively). CONCLUSIONS. The mechanisms of CAL associated with previous PTB appear to differ from those in the more common smoking-related COPD and warrant further study. <![CDATA[<b>Validating the utilisation of venous bicarbonate as a predictor of acute kidney injury in crush syndrome from sjambok injuries</b>]]> BACKGROUND. Crush injury secondary to sjambok beatings is a well-described phenomenon in southern Africa. Owing to a number of factors, it can result in acute kidney injury (AKI). In 1992, Muckart et al. described a risk stratification system using venous bicarbonate (VB) that can be used in the management of these patients. OBJECTIVE. To validate this score in the modern era of AKI risk stratification. METHODS. A retrospective study was performed on a local trauma database from June 2010 to December 2012. All patients with crush injury from sjambok/blunt instrument beatings were included in the analysis. VB was compared with the Kidney Disease Improving Global Outcomes scoring system for AKI. Serum base excess (BE) and creatine kinase were also examined as biomarkers. The endpoints were the need for renal replacement therapy (RRT) and mortality. RESULTS. Three hundred and ten patients were included. The overall mortality rate was 1.9%, 14.8% of patients had AKI, and 3.9% required RRT. Both VB and BE performed well in RRT prediction, with areas under the receiver operating characteristic curve of 0.847 (95% confidence interval (CI) 0.756 - 0.938; p<0.001) and 0.871 (95% CI 0.795 - 0.947; p<0.001), respectively. The sensitivity and specificity of BE were 83.3% and 80.2% at an optimal cut-point of -7.25 mmol/L, while those of VB were 83.3% and 79.5% at an optimal cut-point of 18.85 mmol/L. VB was significantly different across the AKI risk groups (p<0.001), in keeping with the original Muckart risk stratification system. CONCLUSION. The risk stratification score using VB is valid and should continue to be used as a tool in the management of patients with sjambok injuries. BE performs well in predicting the need for RRT, with a value of <-7.25 mmol/L indicating severe injury. <![CDATA[<b>Codeine misuse and dependence in South Africa: Perspectives of addiction treatment providers</b>]]> BACKGROUND. General practitioners are referring patients with codeine-related problems to specialist treatment facilities, but little is known about the addiction treatment providers, the kinds of treatment they provide, and whether training or other interventions are needed to strengthen this sector. OBJECTIVES. To investigate the perspectives of addiction treatment providers regarding treatment for codeine misuse or dependence. METHOD. Twenty addiction treatment providers linked to the South African Community Epidemiology Network on Drug Use and the South African Addiction Medicine Society were contacted telephonically and asked 20 questions. RESULTS. While many participants had received training in pharmacological management of individuals with opioid dependence, only two had received specific training on codeine management. Between half and two-thirds of the treatment settings they worked in provided detoxification, pharmacotherapy, psychosocial treatment and aftercare. Very few treatment settings offered long-term treatment for codeine misuse and dependence. Participants indicated that over half of their codeine patients entered treatment for intentional misuse for intoxication, and dependence resulting from excessive or long-term use. The main barriers to patients entering treatment were seen as denial of having a problem, not being ready for change, mental health problems, stigma, and affordability of treatment. Participants identified a need for further training in how to manage withdrawal and detoxification, treatment modalities including motivational interviewing, and relapse prevention. CONCLUSIONS. Gaps in training among treatment providers need to centre on how to manage withdrawal from codeine use and detoxification, motivational interviewing and relapse prevention. Interventions are needed to address barriers to entering treatment, including user denial. <![CDATA[<b>Osteogenesis imperfecta type 3 in South Africa: Causative mutations in <i>FKBP10</i></b>]]> BACKGROUND. A relatively high frequency of autosomal recessively inherited osteogenesis imperfecta (OI) type 3 (OI-3) is present in the indigenous black southern African population. Affected persons may be severely handicapped as a result of frequent fractures, progressive deformity of the tubular bones and spinal malalignment. OBJECTIVE. To delineate the molecular basis for the condition. METHODS. Molecular investigations were performed on 91 affected persons from seven diverse ethnolinguistic groups in this population. RESULTS. Following polymerase chain reaction amplification and direct cycle sequencing, FKBP10 mutations were identified in 45.1% (41/91) OI-3-affected persons. The homozygous FKBP10 c.831dupC frameshift mutation was confirmed in 35 affected individuals in the study cohort. Haplotype analysis suggests that this mutation is identical among these OI-3-affected persons by descent, thereby confirming that they had a common ancestor. Compound heterozygosity of this founder mutation was observed, in combination with three different deleterious FKBP10 mutations, in six additional persons in the cohort. Four of these individuals had the c.831delC mutation. CONCLUSION. The burden of the disorder, both in frequency and severity, warrants the establishment of a dedicated service for molecular diagnostic confirmation and genetic management of persons and families with OI in southern Africa.