Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420140007&lang=en vol. 104 num. 7 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>On mentorship</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Health systems science can learn from medicine's evidence revolution</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editor’s Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Mammography reporting at Tygerberg Hospital, Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Recommendations for the handling of fluorescent lamps in public schools in Johannesburg, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700005&lng=en&nrm=iso&tlng=en <![CDATA[<b>A rose by any other name is an Emergency Department</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700006&lng=en&nrm=iso&tlng=en <![CDATA[<b>Certificate of Need: legal nightmare in the making?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Exchange rate hurting chronic drug suppliers - but ARV pipeline safe, says government</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Women doctors have a rougher time - new association born</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Manilal Damodar Daya (1941 - 2013)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700010&lng=en&nrm=iso&tlng=en <![CDATA[<b>R B K (Ron) Tucker (1929 - 2014)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Can children aged 12 years or more refuse life-saving treatment without consent or assistance from anyone else?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700012&lng=en&nrm=iso&tlng=en The question of whether a child aged 12 years or more who is sufficiently mature and has the necessary mental capacity may refuse to consent to life-saving treatment without consent from a parent, guardian or caregiver or without the assistance of a parent or guardian is governed by the Constitution, the Children's Act, the National Health Act and the common law. The best interests of the child are paramount, and should the child unreasonably refuse to consent to life-saving treatment, the Minister of Social Development may give consent for such treatment in terms of the Children's Act. Otherwise, should a parent, guardian, caregiver or healthcare provider believe that such a refusal is not in the best interests of the child, he or she may approach the High Court for an order to provide such treatment. <![CDATA[<b>National expenditure on health research in South Africa: what is the benchmark?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700013&lng=en&nrm=iso&tlng=en The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors, was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure. <![CDATA[<b>The RWOPS debate - yes we can!</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700014&lng=en&nrm=iso&tlng=en Remunerated work outside of public service (RWOPS) has largely been seen in a negative light. This is partly a result of the Public Service Commission review undertaken in 2004, but attitudes are also shaped by unsubstantiated reports of abuse. There are, however, potential advantages for both patients and doctors if RWOPS is done without neglecting public sector service and academic commitments. We explore some of the issues around controlling RWOPS, and the experience with this in the Department of Surgery at the University of Cape Town, South Africa. <![CDATA[<b>A global call for action to combat antimicrobial resistance: Can we get it right this time?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700015&lng=en&nrm=iso&tlng=en Remunerated work outside of public service (RWOPS) has largely been seen in a negative light. This is partly a result of the Public Service Commission review undertaken in 2004, but attitudes are also shaped by unsubstantiated reports of abuse. There are, however, potential advantages for both patients and doctors if RWOPS is done without neglecting public sector service and academic commitments. We explore some of the issues around controlling RWOPS, and the experience with this in the Department of Surgery at the University of Cape Town, South Africa. <![CDATA[<b>Professional competence and professional misconduct in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700016&lng=en&nrm=iso&tlng=en Remunerated work outside of public service (RWOPS) has largely been seen in a negative light. This is partly a result of the Public Service Commission review undertaken in 2004, but attitudes are also shaped by unsubstantiated reports of abuse. There are, however, potential advantages for both patients and doctors if RWOPS is done without neglecting public sector service and academic commitments. We explore some of the issues around controlling RWOPS, and the experience with this in the Department of Surgery at the University of Cape Town, South Africa. <![CDATA[<b>Self-reported use of evidence-based medicine and smoking cessation 6 - 9 months after acute coronary syndrome: A single-centre perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700017&lng=en&nrm=iso&tlng=en BACKGROUND: Good evidence exists to support the use of secondary prevention medications (aspirin, statins, beta-blockers and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs)) and smoking cessation in patients after acute coronary syndromes (ACSs). Little is currently known about adherence to medication and smoking behaviour after discharge in South Africa. METHODS: We conducted a cross-sectional analysis of all patients with a diagnosis of ACS discharged from the Coronary Care Unit at Groote Schuur Hospital, Cape Town, between 15 November 2011 and 15 April 2012. Patients were telephoned 6 - 9 months after discharge and completed a standardised questionnaire detailing current medication use, reasons for non-adherence and smoking status. RESULTS: Prescribing of secondary prevention medications at discharge was high (aspirin 94.5%, statins 95.7%, beta-blockers 85.4%, ACEIs/ ARBs 85.9%), and 70.7% of patients were discharged on a combination of all four drugs. At 6 - 9-month follow-up, the proportion using these medications had dropped by 8.9% for aspirin, 10.1% for statins, 6.2% for beta-blockers and 17.9% for ACEIs/ARBs. Only 47.2% remained on all four drugs, a reduction of 23.5%. Of the 56.0% of patients who were smokers, 31.4% had stopped smoking. CONCLUSIONS: A significant decline in adherence to recommended therapy 6 - 9 months after discharge and a poor rate of smoking cessation suggest that efforts to educate patients about the importance of long-term adherence need to be improved. Furthermore, more effective interventions than in-hospital reminders about the hazards of smoking are needed to improve smoking cessation. <![CDATA[<b>Injury severity in relation to seatbelt use in Cape Town, South Africa: a pilot study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700018&lng=en&nrm=iso&tlng=en BACKGROUND: Injuries and deaths from road traffic collisions present an enormous challenge to the South African (SA) healthcare system. The use of restraining devices is an important preventive measure. OBJECTIVE: To determine the relationship between seatbelt use and injury severity in vehicle occupants involved in road traffic collisions in Cape Town, SA. METHODS: A prospective cohort design was used. Occupants of vehicles involved in road traffic collisions attended to by EMS METRO Rescue were included during the 3-month data collection period. Triage categories of prehospital patients were compared between restrained and unrestrained groups. Patients transferred to hospital were followed up and injury severity scores were calculated. Disposition from the emergency centre and follow-up after 1 week were also documented and compared. RESULTS: A total of 107 patients were included in the prehospital phase. The prevalence of seatbelt use was 25.2%. Unrestrained vehicle occupants were five times more likely to have a high triage score (odds ratio (OR) 5.4; 95% confidence interval (CI) 1.5 - 19.5). Fifty patients were transferred to study hospitals. Although seatbelt non-users were more likely to be admitted to hospital (p=0.002), they did not sustain more serious injuries (OR 0.44; 95% CI 0.02 - 8.8). CONCLUSION: The prevalence of seatbelt use in vehicle occupants involved in road traffic collisions was very low. The association between seatbelt non-use and injury severity calls for stricter enforcement of current seatbelt laws, together with the development and implementation of road safety interventions specifically focused on high-risk groups. <![CDATA[<b>Predicting outcome in severe traumatic brain injury using a simple prognostic model</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700019&lng=en&nrm=iso&tlng=en BACKGROUND: Several studies have made it possible to predict outcome in severe traumatic brain injury (TBI) making it beneficial as an aid for clinical decision-making in the emergency setting. However, reliable predictive models are lacking for resource-limited prehospital settings such as those in developing countries like South Africa. OBJECTIVE: To develop a simple predictive model for severe TBI using clinical variables in a South African prehospital setting. METHODS: All consecutive patients admitted at two level-one centres in Cape Town, South Africa, for severe TBI were included. A binary logistic regression model was used, which included three predictor variables: oxygen saturation (SpO2), Glasgow Coma Scale (GCS) and pupil reactivity. The Glasgow Outcome Scale was used to assess outcome on hospital discharge. RESULTS: A total of 74.4% of the outcomes were correctly predicted by the logistic regression model. The model demonstrated SpO2 (p=0.019), GCS (p=0.001) and pupil reactivity (p=0.002) as independently significant predictors of outcome in severe TBI. Odds ratios of a good outcome were 3.148 (SpO2 >90%), 5.108 (GCS 6 - 8) and 4.405 (pupils bilaterally reactive). CONCLUSION: This model is potentially useful for effective predictions of outcome in severe TBI. <![CDATA[<b>Assessing adherence to the 2010 antiretroviral guidelines in the antiretroviral roll-out clinic at 1 Military Hospital, South Africa: A retrospective, cross-sectional study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700020&lng=en&nrm=iso&tlng=en BACKGROUND: HIV research is a therapeutic area for which well-defined population-specific treatment and prophylaxis guidelines exist. However, there are limited objective, evidence-based data for assessing adherence to these guidelines. OBJECTIVE: To conduct a retrospective, cross-sectional study of adult HIV-infected patients receiving treatment at the antiretroviral (ARV) roll-out clinic of the Infectious Diseases Clinic Pharmacy at 1 Military Hospital (1MH) over a period of 3 years to assess clinicians' adherence to the 2010 ARV guidelines. METHODS: Pharmacy files from the pool of adult patients receiving treatment at the ARV roll-out clinic between 1 April 2009 and 31 March 2012 were selected. Variables used to establish adherence were assessed through evaluation of pharmacy scripts and laboratory tests. RESULTS: In accordance with the ARV guidelines, we found a switch in the first-line regimen from stavudine to tenofovir during the period following implementation. There was no difference in baseline blood tests conducted, suggesting that clinicians were recommending a standardised test panel. Notably, similar blood tests were routinely done during follow-up visits, despite no indication for doing so. While the number of blood tests was found to decrease over time, the type of blood tests requested for specific treatment regimens was not in accordance with the ARV guidelines. CONCLUSION: We used an evidence-based approach to critically assess variations from the delineated ARV guidelines. Adherence to clinical guidelines at 1MH, while demonstrating improvement in patient outcomes, highlighted the need for increased vigilance in monitoring failure of prescribers to comply with ARV guidelines. <![CDATA[<b>Childhood cancer survival rates in two South African units</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700021&lng=en&nrm=iso&tlng=en INTRODUCTION: Childhood cancer is relatively rare, but there is a very good chance of cure. While overall survival rates of >70% are reported from developed countries, survival is much less likely in developing countries and unknown in many countries in Africa. OBJECTIVE: To analyse survival rates of childhood cancers in two South African paediatric oncology units. METHODS: This retrospective review included all children (0 - 15 years) admitted with a malignancy at two paediatric oncology units (Universitas Hospital Academic Complex in Bloemfontein, Free State, and Tygerberg Hospital in Cape Town, Western Cape) between 1987 and 2011. The protocols used in the units were similar, and all the diagnoses were confirmed histologically. RESULTS: There were 3 241 children, 53.5% of whom were males. Median follow-up was 17 months. The most common cancers were leukaemia (25.0%), brain tumours (19.5%), lymphoma (13.0%) and nephroblastoma (10.0%). The prevalences of neuroblastoma and retinoblastoma were similar at 5.8% and 5.7%, respectively. Overall survival was calculated to be 52.1%. Lymphoma and nephroblastoma had the highest survival rates at 63.9% and 62.6%, respectively. Brain tumours had the lowest survival rate at 46.4%. A comparison between ethnic groups showed white children to have the highest survival rate (62.8%); the rate for children of mixed racial origin was 53.8% and that for black children 48.5%. CONCLUSIONS: Overall survival rates for children admitted to two paediatric cancer units in South Africa were lower than data published from developed countries, because many children presented with advanced disease. New strategies to improve cancer awareness are urgently required. <![CDATA[<b>Paediatric palliative medicine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700022&lng=en&nrm=iso&tlng=en INTRODUCTION: Childhood cancer is relatively rare, but there is a very good chance of cure. While overall survival rates of >70% are reported from developed countries, survival is much less likely in developing countries and unknown in many countries in Africa. OBJECTIVE: To analyse survival rates of childhood cancers in two South African paediatric oncology units. METHODS: This retrospective review included all children (0 - 15 years) admitted with a malignancy at two paediatric oncology units (Universitas Hospital Academic Complex in Bloemfontein, Free State, and Tygerberg Hospital in Cape Town, Western Cape) between 1987 and 2011. The protocols used in the units were similar, and all the diagnoses were confirmed histologically. RESULTS: There were 3 241 children, 53.5% of whom were males. Median follow-up was 17 months. The most common cancers were leukaemia (25.0%), brain tumours (19.5%), lymphoma (13.0%) and nephroblastoma (10.0%). The prevalences of neuroblastoma and retinoblastoma were similar at 5.8% and 5.7%, respectively. Overall survival was calculated to be 52.1%. Lymphoma and nephroblastoma had the highest survival rates at 63.9% and 62.6%, respectively. Brain tumours had the lowest survival rate at 46.4%. A comparison between ethnic groups showed white children to have the highest survival rate (62.8%); the rate for children of mixed racial origin was 53.8% and that for black children 48.5%. CONCLUSIONS: Overall survival rates for children admitted to two paediatric cancer units in South Africa were lower than data published from developed countries, because many children presented with advanced disease. New strategies to improve cancer awareness are urgently required. <![CDATA[<b>When is the right time? Complex issues around withdrawing life-sustaining treatment in children</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700023&lng=en&nrm=iso&tlng=en When should one withdraw treatment in children? The challenge is to recognise when a decision needs to be made. Parents may be in denial, and deciding which questions to ask may be difficult. Ethically, the guiding principle should be the child's best interests. May the parents or primary caregiver decide what the child's best interests are? Legislation in South Africa prevents a parent or caregiver from refusing treatment that medical professionals deem to be in the child's best interests. This article discusses the ethical and legal aspects around the decision to palliate in children. <![CDATA[<b>Talking to children: What to do and what not to do</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700024&lng=en&nrm=iso&tlng=en Talking to children can be very daunting. Talking to a sick child can be even more daunting. How can we ensure that our message comes across in a way that is suitable and will not cause more harm than good? <![CDATA[<b>Basic counselling skills</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700025&lng=en&nrm=iso&tlng=en George Bernard Shaw stated, 'The single biggest problem in communication is the illusion that it has taken place'. In the medical world, and especially one that involves children, this is unfortunately a reality. <![CDATA[<b>Managing pain in children at the end of life: What the GP should know</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700026&lng=en&nrm=iso&tlng=en Managing disease- and procedure-related pain in children is paramount. Chronically ill children, especially those requiring repeated procedures or admissions, may experience a significant burden of pain. If poorly managed, it has a negative impact on quality of life and parent-child relationships. According to the World Health Organization (WHO), the principles of palliative care are applicable to all children with chronic illnesses from the time of diagnosis. A key component of palliative care is good pain management. <![CDATA[<b>Physician self-care</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700027&lng=en&nrm=iso&tlng=en Many of us have worked in the interminable queues of outpatient departments. After a long day, we are greeted with the hopeful, tired faces of families with their ill loved ones. We are meant to be able to heal and cure. Yet, we often run out of options, treatments seem ineffective, and we have to hold the hands of those who are dying. Doctors have mostly been trained to cure. They make significant sacrifices in family life, sleep, personal time and hobbies to be able to pursue this ideal. Moving away from cure to compassionate care of dying patients, is a paradigm shift. This can be particularly difficult when caring for children with terminal illness. It is easier to accept death in the elderly as it is part of the natural order of life. Caring for dying children can, however, be draining on both staff and families. <![CDATA[<b>Abstracts</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000700028&lng=en&nrm=iso&tlng=en Many of us have worked in the interminable queues of outpatient departments. After a long day, we are greeted with the hopeful, tired faces of families with their ill loved ones. We are meant to be able to heal and cure. Yet, we often run out of options, treatments seem ineffective, and we have to hold the hands of those who are dying. Doctors have mostly been trained to cure. They make significant sacrifices in family life, sleep, personal time and hobbies to be able to pursue this ideal. Moving away from cure to compassionate care of dying patients, is a paradigm shift. This can be particularly difficult when caring for children with terminal illness. It is easier to accept death in the elderly as it is part of the natural order of life. Caring for dying children can, however, be draining on both staff and families.