Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420140009&lang=en vol. 104 num. 9 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Reflections</b> <b>... they called it 'restructuring'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rationing healthcare in South Africa: Renal replacement therapy - a case in point</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Improved surgical output in district hospitals relies more on softer ingredients than on formal postgraduate training time</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Access to flucytosine for HIV-infected patients with cryptococcal meningitis - an urgent need</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900005&lng=en&nrm=iso&tlng=en <![CDATA[<b>Shielding blood donors from harm</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900006&lng=en&nrm=iso&tlng=en <![CDATA[<b>CoN - lifeline for patients, noose for healthcare providers?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Promote cheaper generic drugs to patients - and help contain medical inflation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Breaching the chasm between what's law and what's done</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Bernard Mandell</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900010&lng=en&nrm=iso&tlng=en <![CDATA[<b>Jean Mary Sharpe, 1929 - 2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Doctors Without Borders: Humanitarian quests, impossible dreams of Médecins Sans Frontières</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900012&lng=en&nrm=iso&tlng=en <![CDATA[<b>Simplifying trauma airway management in South African rural hospitals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900013&lng=en&nrm=iso&tlng=en South African emergency centres witness high levels of trauma. Successfully managing a compromised trauma airway requires considerable skill and expertise. In the rural healthcare setting, clinics and hospitals are often staffed by junior doctors without formal advanced airway training. Current airway management algorithms tend to ignore lack of resources and skill. We therefore propose a simplified guideline for the rural hospital practitioner. Our algorithm offers a step-by-step approach, with the aim of providing an easy sequence to follow that will ensure successful airway management and patient safety. The paucity of advanced airway equipment in most rural hospitals is taken into consideration. <![CDATA[<b>Should HIV be a notifiable disease?</b> <b>Old questions with some new arguments</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900014&lng=en&nrm=iso&tlng=en HIV notification enters national debate regularly, often introduced by politicians and supported by many individual healthcare workers. We argue that its proponents advance confused or poorly informed rationales for making HIV notifiable. We present reasons why making HIV notifiable would be inappropriate in South Africa, why the public health benefits of a notification programme are not even likely, and why there are risks of public health and human rights harms. <![CDATA[<b>Preventing hepatitis B and hepatocellular carcinoma in South Africa: The case for a birth-dose vaccine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900015&lng=en&nrm=iso&tlng=en Hepatitis B is a global public health issue, with some 2 billion people having current or past infection. In Africa, 65 million are chronically infected, an estimated 2.5 million of them in South Africa (SA). Hepatitis B and the associated complications of cirrhosis and hepatocellular carcinoma are entirely vaccine preventable. SA was one of the first ten countries in Africa to introduce universal hepatitis B vaccination in April 1995, but has no birth dose or catch-up programme. Although universal infant vaccination in SA has been successful in increasing population immunity to hepatitis B, improvements in terms of implementing protocols to screen all pregnant mothers for hepatitis B surface antigen (HBsAg) and ensuring full hepatitis B coverage, especially in rural areas, is required. The World Health Organization has recommended a birth dose of hepatitis B vaccine in addition to the existing hepatitis B vaccine schedule in order to further decrease the risk of perinatal transmission. We recommend that SA implement a birth-dose vaccine into the existing schedule to attenuate the risk of perinatal transmission, prevent breakthrough infections and decrease HBsAg carriage in babies born to HIV-positive mothers. <![CDATA[<b>The state of our prisons and what this reveals about our society</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900016&lng=en&nrm=iso&tlng=en Hepatitis B is a global public health issue, with some 2 billion people having current or past infection. In Africa, 65 million are chronically infected, an estimated 2.5 million of them in South Africa (SA). Hepatitis B and the associated complications of cirrhosis and hepatocellular carcinoma are entirely vaccine preventable. SA was one of the first ten countries in Africa to introduce universal hepatitis B vaccination in April 1995, but has no birth dose or catch-up programme. Although universal infant vaccination in SA has been successful in increasing population immunity to hepatitis B, improvements in terms of implementing protocols to screen all pregnant mothers for hepatitis B surface antigen (HBsAg) and ensuring full hepatitis B coverage, especially in rural areas, is required. The World Health Organization has recommended a birth dose of hepatitis B vaccine in addition to the existing hepatitis B vaccine schedule in order to further decrease the risk of perinatal transmission. We recommend that SA implement a birth-dose vaccine into the existing schedule to attenuate the risk of perinatal transmission, prevent breakthrough infections and decrease HBsAg carriage in babies born to HIV-positive mothers. <![CDATA[<b>Utilisation of prehospital intravenous access</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900017&lng=en&nrm=iso&tlng=en OBJECTIVE: To describe the use of intravenous (IV) therapy in the South African (SA) prehospital setting, and to determine the proportion of prehospital IV cannulations considered unnecessary when graded against the South African Triage Score (SATS) chart. METHODS: The study was conducted in the prehospital emergency medical care setting in the Western Cape Province, SA. Using a descriptive research design, we looked at the report forms of patients treated and transported by personnel currently employed in the public sector, serving the urban and rural areas stipulated by the municipal boundaries. All medical and trauma cases in which establishment of IV access was documented for the month of April 2013 were included. Interhospital transfers, unsuccessful attempts at IV access and intraosseous cannulation were excluded. RESULTS: When graded against the SATS, prophylactic IV access was not justified in 42.3% of the total number of cases (N=149) in which it was established, and therefore added no direct benefit to the continuum of patient care. It is worth noting that 18.8% (n=39) of the IV lines were utilised for fluid administration, as opposed to 9.2% (n=19) for the administration of IV medications. CONCLUSION: In view of the paucity of studies indicating a direct benefit of out-of-hospital IV intervention, the practice of precautionary, protocol-driven prophylactic establishment of IV access should be evaluated. Current data suggest that in the absence of scientific evidence, IV access should only be initiated when it will benefit the patient immediately, and precautionary IV access, especially in non-injured patients, should be re-evaluated. <![CDATA[<b>The pharmacoeconomics of routine postoperative troponin surveillance to prevent and treat myocardial infarction after non-cardiac surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900018&lng=en&nrm=iso&tlng=en BACKGROUND: A postoperative troponin leak that was previously considered clinically insignificant has been independently associated with 30-day mortality in unselected surgical patients <img border=0 width=32 height=32 src="../../../../../img/revistas/samj/v104n9/18s1.jpg">45 years of age following non-cardiac surgery. OBJECTIVES: To determine whether routine troponin surveillance following non-cardiac surgery and initiation of aspirin and statin therapy in troponin-positive patients is cost-effective. METHODS: Pharmacoeconomic analysis to determine the cost-effectiveness of routine postoperative surveillance for patients aged <img border=0 width=32 height=32 src="../../../../../img/revistas/samj/v104n9/18s2.jpg">45 years undergoing non-cardiac surgery. We compared the total expected cost of hospital care of patients who received routine troponin surveillance and subsequent introduction of statin and aspirin therapy for 30 days in troponin-positive patients with the cost of hospital care of patients who did not receive troponin surveillance. We estimated a 25% relative risk reduction following statin and aspirin therapy for postoperative vascular mortality and non-fatal myocardial infarction. RESULTS: Routine troponin surveillance with initiation of aspirin and statin therapy was cost-effective, with an incremental cost of -R16 724 per event avoided. CONCLUSION: Routine postoperative troponin surveillance in non-cardiac surgical patients <img border=0 width=32 height=32 src="../../../../../img/revistas/samj/v104n9/18s3.jpg">45 years of age requiring a postoperative night in hospital is potentially cost-effective. <![CDATA[<b>A survey on the treatment of atrial fibrillation in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900019&lng=en&nrm=iso&tlng=en BACKGROUND: The burden of cardiovascular disease is expected to escalate in developing countries. However, studies and guidelines concerning atrial fibrillation (AF) are restricted to the developed world. OBJECTIVES: To assess the treatment modalities of AF in South Africa. METHODS: A cross-sectional, observational, multicentre, national registry of the treatment of 302 patients with AF was conducted from February 2010 to March 2011. Specific drug use for rate or rhythm control, as well as drug use for stroke prevention, was surveyed. Events during the 12 months prior to the survey were also characterised, including non-drug treatments, resource utilisation and complications. RESULTS: The single most prevalent clinical characteristic was hypertension (65.9%). Rhythm control was being pursued in 109 patients (36.1%) with class Ic and class III antiarrhythmic agents, while rate control, mainly with beta-blockers, was pursued in the remainder of the patients. Concomitant use of other cardiovascular drugs was high, and 75.2% of patients were on warfarin for stroke prevention. There was a high burden of AF-related morbidity during the preceding year, with 32.5% reporting a history of heart failure, 8.3% a stroke and 5.3% a transient ischaemic attack. Therapeutic success, as defined by either the presence of sinus rhythm or rate-controlled AF, was achieved in 86.8% as judged clinically by the treating physician, but in only 70.2% according to the electrocardiogram criterion of heart rate 80 bpm. CONCLUSION: There were no striking differences from previously reported registries worldwide. The lack of application of strict rate control criteria is highlighted. <![CDATA[<b>Investigating hepatitis B immunity in patients presenting to a paediatric haematology and oncology unit in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900020&lng=en&nrm=iso&tlng=en BACKGROUND: Hepatitis B is an important public health concern in South Africa (SA). The hepatitis B virus (HBV) vaccine was introduced into the South African Expanded Programme on Immunisation (EPI-SA) in 1995. There is no 'catch-up' programme in place. The duration of protection after hepatitis B vaccination in the SA population is unknown. Waning of vaccine-induced immunity leaves people at risk of acquiring hepatitis B infection in settings where the prevalence of infection is high and horizontal transmission is likely. OBJECTIVE: To assess immunity to HBV in patients at presentation to a paediatric haematology and oncology unit. METHODS: An audit of hepatitis profiles was done of all new patients seen in the unit from January 2012 to December 2013. Patients were classified as immune (antibody levels to hepatitis B surface antigen (anti-HBs) <img border=0 width=32 height=32 src="../../../../../img/revistas/samj/v104n9/20s1.jpg">100 mIU/ml), low immune (anti-HBs 10 - 100 mIU/ml) and not immune (anti-HBs <img border=0 width=32 height=32 src="../../../../../img/revistas/samj/v104n9/20s2.jpg">10 mIU/ml). RESULTS: Of the 210 patients included (median age 6.5 years), 84 (40.0%) had no immunity to hepatitis B despite presumed vaccination as part of the EPI schedule. Six patients tested positive for hepatitis B core antibody (anti-HBc), consistent with previous infection. No patients had active hepatitis B infection (hepatitis B surface antigen-positive). Most human immunodeficiency virus (HIV)-infected patients were not immune to HBV (80.0%). CONCLUSION: A significant number of children in SA are not immune to hepatitis B despite vaccination being part of the EPI-SA. Combined passive-active immunisation should be considered for all oncology patients in settings where exposure to HBV is possible. Consideration should also be given to offering booster vaccination to the population as a whole. <![CDATA[<b>Rheumatic fever and rheumatic heart disease in Gauteng on the decline: Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900021&lng=en&nrm=iso&tlng=en BACKGROUND: The incidence of rheumatic fever (RF) and its complications has waned over the past three to four decades throughout the Western world, but RF remains a problem in developing countries and in the indigenous populations of some well-resourced countries. A marked decline in children presenting with acute rheumatic fever (ARF) and chronic rheumatic heart disease (RHD) has been observed over the past two decades at Chris Hani Baragwanath Academic Hospital (CHBAH) in southern Gauteng Province, South Africa, which mainly serves the periurban population of Soweto. OBJECTIVES: To analyse the observed decline in ARF and RHD, and consider the reasons for the decrease. METHODS: Review of children with ARF and RHD captured on a computerised database of all children seen in the Paediatric Cardiology Unit at CHBAH during 1993 - 2010. RESULTS: The records of 467 children with ARF and RHD were retrieved from the database. The majority provided addresses in Gauteng, Soweto and North West Province. The number of children documented to have ARF or RHD declined from 64 in 1993 to 3 in 2010. One-third of the patients underwent surgery, the majority mitral valve repair. Most of the patients requiring surgery had addresses in parts of Gauteng other than Soweto and other provinces, with relatively few originating from Soweto. CONCLUSION: The decline in the number of children with ARF and RHD presenting to CHBAH may be attributed to an improvement in socioeconomic conditions and better access to medical care for the referral population over the past two decades. <![CDATA[<b>Women's health and human rights</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900022&lng=en&nrm=iso&tlng=en BACKGROUND: The incidence of rheumatic fever (RF) and its complications has waned over the past three to four decades throughout the Western world, but RF remains a problem in developing countries and in the indigenous populations of some well-resourced countries. A marked decline in children presenting with acute rheumatic fever (ARF) and chronic rheumatic heart disease (RHD) has been observed over the past two decades at Chris Hani Baragwanath Academic Hospital (CHBAH) in southern Gauteng Province, South Africa, which mainly serves the periurban population of Soweto. OBJECTIVES: To analyse the observed decline in ARF and RHD, and consider the reasons for the decrease. METHODS: Review of children with ARF and RHD captured on a computerised database of all children seen in the Paediatric Cardiology Unit at CHBAH during 1993 - 2010. RESULTS: The records of 467 children with ARF and RHD were retrieved from the database. The majority provided addresses in Gauteng, Soweto and North West Province. The number of children documented to have ARF or RHD declined from 64 in 1993 to 3 in 2010. One-third of the patients underwent surgery, the majority mitral valve repair. Most of the patients requiring surgery had addresses in parts of Gauteng other than Soweto and other provinces, with relatively few originating from Soweto. CONCLUSION: The decline in the number of children with ARF and RHD presenting to CHBAH may be attributed to an improvement in socioeconomic conditions and better access to medical care for the referral population over the past two decades. <![CDATA[<b>Obstetric medicine: Interlinking obstetrics and internal medicine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900023&lng=en&nrm=iso&tlng=en Medical problems account for almost 50% of all maternal deaths in South Africa. The most recent report of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) (2008 - 2010) stated that 40.5% of deaths were due to non-pregnancy-related infections, which are mostly HIV-related, and 8.8% were due to medical or surgical disorders. Obstetric physicians have a specific role in managing pregnant and postpartum women with medical problems and, in partnership with obstetricians, can contribute to reducing maternal morbidity and mortality. There are physiological changes in almost all systems in pregnancy. For example, changes in the cardiovascular, respiratory and haematological systems are particularly important when assessing the cause and management of medical problems in pregnant women. Such problems may be unique to pregnancy, exacerbated by pregnancy, or unrelated to pregnancy. They may be present prior to pregnancy, or present for the first time in pregnancy. Some medical problems are worsened by pregnancy. Pregnant women may improve or remain stable, or their disease may predictably or unpredictably deteriorate. This article discusses the role of obstetric physicians in managing medical problems in pregnant women. A case is described of a pregnant woman with common medical problems, resulting in a serious complication when treatment is interrupted. <![CDATA[<b>Papshop: Not a 'melon'choly Pap smear workshop!</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900024&lng=en&nrm=iso&tlng=en As Head of Undergraduate Education in the Department of Obstetrics and Gynaecology at the University of Cape Town, South Africa, I have a particular interest in the competencies needed to perform primary care gynaecological procedures, one of which is the Pap smear. I was approached by a group of keen volunteer students to assist with Pap smear training to roll out a pilot screening programme at studentrun after-hours clinics in Cape Town and at volunteer rural health promotion clinics. This article describes a novel approach to teaching the Pap smear technique, using fruit and toilet rolls, which can easily be replicated in resource-constrained areas. Students branded the workshops as 'Papshops', and the name has stuck. Increasing numbers of students are now taught by peers already trained in prior Papshops, thereby expanding the teaching workforce. To date, during 2013 - 2014, Papshop students have performed almost 300 Pap smears for eligible women in under-resourced areas. <![CDATA[<b>Pregnancy and cardiac disease</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900025&lng=en&nrm=iso&tlng=en Medical disorders in pregnancy are one of the top five causes of maternal mortality in South Africa (SA), cardiac disease (CD) being the main contributor to this group. In developed countries, surgically corrected congenital heart disease (CHD) comprises the greater proportion of maternal deaths from CD. In SA and other developing countries, acquired heart disease such as rheumatic heart disease and cardiomyopathies are the major causes, although CHD remains significantly represented. Both congenital and acquired cardiac lesions may present for the first time during pregnancy. CD may also occur for the first time during or after pregnancy, e.g. peripartum cardiomyopathy. The risk to both the mother and the fetus increases exponentially with the complexity of the underlying disease. Generally, the ability to tolerate a pregnancy is related to: (i) the haemodynamic significance of any lesion; (ii) the functional class - New York Heart Association classes III and IV have poorer outcomes; (iii) the presence of cyanosis; and (iv) the presence of pulmonary hypertension. While the ideal time to assess these factors is before conception, women frequently present when already pregnant. This review discusses risk assessment and management of CD in pregnant women and the role of a combined cardiology and obstetric clinic. <![CDATA[<b>Pregnancy and the kidneys</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900026&lng=en&nrm=iso&tlng=en Renal disease in pregnancy may cause a feeling of trepidation, even in the most experienced physician. However, before disease can be established, it is important to understand the substantial physiological changes that may occur during a normal pregnancy. Renal disease may take several forms and pregnancy may be the first medical review for women with a previously undiagnosed renal problem. Patients may have pre-existing renal disease, e.g. diabetic nephropathy. Additionally, women with renal transplants and renal diseases, e.g. lupus nephritis, require immunosuppression. Hypertensive disorders of pregnancy, including pre-eclampsia, are the commonest medical complications in pregnancy, and remain the most prevailing direct cause of maternal mortality in South Africa (SA). Both pre-existing hypertension and renal disease increase the risk of pre-eclampsia, which predisposes to preterm delivery, and maternal morbidity and mortality. Pregnancy outcomes in renal disease are determined by baseline creatinine levels, hypertension and degree of proteinuria. The risk of progression of chronic kidney disease increases as renal function worsens. In SA, this is complicated by restricted access to dialysis in the state sector. To ensure the best outcome for mother and child, pre-pregnancy counselling and review of medication are essential. Renal patients and those with hypertension are at high risk of complications, and regular antenatal assessments by a multidisciplinary team are required to monitor blood pressure, proteinuria, diabetes control and fetal wellbeing. <![CDATA[<b>Rheumatic diseases and pregnancy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900027&lng=en&nrm=iso&tlng=en Rheumatic diseases predominantly affect young women of childbearing age; therefore pregnancy is a topic of major interest. Pregnancyinduced changes in immune function can have an effect on underlying disease activity. Systemic lupus erythematosus (SLE), the most common autoimmune disease affecting women during their reproductive years, has an increased incidence of disease flares during pregnancy. In rheumatoid arthritis, on the other hand, there is spontaneous improvement in disease symptoms. However, rheumatic diseases and their treatment can have a significant impact on pregnancy outcomes. Poor pregnancy outcomes are largely associated with high disease activity. Pregnant women with rheumatic diseases constitute a high-risk population, with potential adverse fetal and maternal outcomes. Treatment options can be limited in pregnant women owing to concerns about the adverse effects of commonly used medication on the fetus. The aim of this article is to discuss the optimal management of pregnant women with SLE and other rheumatic diseases, including antiphospholipid antibody syndrome, Sjögren's syndrome, systemic sclerosis, rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. The effects of pregnancy on underlying diseases and vice versa are discussed. <![CDATA[<b>Contraception: Everyone's responsibility</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000900028&lng=en&nrm=iso&tlng=en Contraception and fertility planning should form part of every consultation, as it is key to reducing maternal mortality and morbidity associated with unplanned pregnancy. It also prevents pregnancy in women who are medically unfit for pregnancy until their condition has been optimised. This is only the tip of the iceberg compared with the social and economic burden of unintended pregnancy. The South African (SA) National Department of Health has recognised the importance of contraception and fertility planning. A national policy and guideline have been formulated that promote this agenda. In the past, the commonest contraceptives used in SA were the combined oral contraceptive and the injectable contraceptive. Long-acting reversible contraceptives (LARCs) offer the most benefit, and have efficacy comparable to permanent contraception. Their failure rates are the same for typical and perfect use. In addition, continuation rates after one year of use remain high. The intrauterine contraceptive device, the levonorgestrel intrauterine system and the injectable progestogen contraceptives form part of this group of contraceptives. The most recently launched LARC is Implanon NXT. A comprehensive guideline to assess suitability of the various contraceptive methods in various medical conditions is the World Health Organization Medical Eligibility Criteria for contraceptive use. Counselling is key to choice and suitability of contraceptive methods. Compliance, in part, is dependent on adequate discussion of side-effects, availability and acceptance of the method.