Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420150005&lang=en vol. 105 num. 5 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The World Health Organization Global Action Plan for antimicrobial resistance</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500002&lng=en&nrm=iso&tlng=en <![CDATA[<b>VIM-2 carbapenemase-producing <i>Pseudomonas aeruginosa </i>in a patient from Port Elizabeth, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Paediatric chemoprophylaxis for child contacts of patients with drug-resistant tuberculosis: Are current guidelines effective in preventing disease?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Tracking antenatal HIV prevalence in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500005&lng=en&nrm=iso&tlng=en <![CDATA[<b>Outcomes in treatment with darunavir/ritonavir in ART-experienced paediatric patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500006&lng=en&nrm=iso&tlng=en <![CDATA[<b>Better menstrual management options for adolescents needed in South Africa: What about the Menstrual Cup?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Masterly inactivity: A forgotten precept</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Lifesaving water quality solution 'ignored'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Little-used medical technology could help thousands see, hear and feel better</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500010&lng=en&nrm=iso&tlng=en <![CDATA[<b>SAMA pitches in to help victims of adverse medical events</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Tygerberg Hospital keeps more hearts beating with pioneering service</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500012&lng=en&nrm=iso&tlng=en <![CDATA[<b>Government inability to harness high-tech radiology blurs NHI vision</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500013&lng=en&nrm=iso&tlng=en <![CDATA[<b>Philippe Emile Agnes Schuermans (1943 - 2014)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500014&lng=en&nrm=iso&tlng=en <![CDATA[<b>The simple bread tag - a menace to society?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500015&lng=en&nrm=iso&tlng=en Foreign bodies (FBs) are potentially life-threatening when inhaled by a child, depending on where they lodge. Symptoms can range from acute upper airway obstruction to mild, vague respiratory complaints. Between 80% and 90% of inhaled FBs occlude the bronchi, while the larynx is a less common site. The commonest inhaled paediatric FBs are organic, e.g. seeds or nuts. Plastic FBs are less common and more difficult to diagnose. They are generally radiolucent on lateral neck radiographs and are often clear and thin. We report three cases of an unusual plastic laryngeal FB, the bread tag. Plastic bread tags were first reported in the medical literature as an ingested gastrointestinal FB in 1975. Since then, over 20 cases of gastrointestinal complications have been described. We report what is to our knowledge the first paediatric case of an inhaled bread tag, and also the first case series, briefly discuss the symptoms and options for removal of laryngeal FBs, and highlight the dangers of the apparently harmless bread tag. Images of the bread tags in situ and after their removal are included. <![CDATA[<b>Updated recommendations for the management of upper respiratory tract infections in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500016&lng=en&nrm=iso&tlng=en BACKGROUND: Inappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), most of which are viral, significantly adds to the burden of antibiotic resistance. Since the introduction of pneumococcal conjugate vaccines in South Africa in 2009, the relative frequency of the major bacterial pathogens causing acute otitis media (AOM) and acute bacterial rhinosinusitis (ABRS) has changed RECOMMENDATIONS: Since URTIs are mostly viral in aetiology and bacterial AOM and ABRS frequently resolve spontaneously, these recommendations include diagnostic criteria to assist in separating viral from bacterial causes and hence select those patients who do not require antibiotics. Penicillin remains the drug of choice for tonsillopharyngitis and amoxicillin the drug of choice for both AOM and ABRS. A dose of 90 mg/kg/d is recommended for children, which should be effective for pneumococci with high-level penicillin resistance and will also cover most infections with Haemophilus influenzae. Amoxicillin-clavulanate (in high-dose amoxicillin formulations available for both children and adults) should be considered the initial treatment of choice in patients with recent antibiotic therapy with amoxicillin (previous 30 days) and with resistant H. influenzae infections pending the results of studies of local epidemiology (β-lactamase production >15%). The macrolide/azalide class of antibiotics is not recommended routinely for URTIs and is reserved for β-lactam-allergic patients CONCLUSION: These recommendations should facilitate rational antibiotic prescribing for URTIs as a component of antibiotic stewardship. They will require updating when new information becomes available, particularly from randomised controlled trials and surveillance studies of local aetiology and antibiotic susceptibility patterns <![CDATA[<b>Description of an internal medicine outreach consultant appointment in western KwaZulu-Natal, South Africa, 2007 to mid-2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500017&lng=en&nrm=iso&tlng=en This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented 'multifaceted' as opposed to 'simple' outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. <![CDATA[<b>Antibiotic administration in the critically ill - in need of intensive care!</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500018&lng=en&nrm=iso&tlng=en This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented 'multifaceted' as opposed to 'simple' outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. <![CDATA[<b>Key to antimicrobial stewardship success: Surveillance by diagnostic microbiology laboratories</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500019&lng=en&nrm=iso&tlng=en This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented 'multifaceted' as opposed to 'simple' outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. <![CDATA[<b>Rheumatic fever and rheumatic heart disease in Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500020&lng=en&nrm=iso&tlng=en This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented 'multifaceted' as opposed to 'simple' outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. <![CDATA[<b>Community- versus healthcare-acquired bloodstream infections at Groote Schuur Hospital, Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500021&lng=en&nrm=iso&tlng=en BACKGROUND: Bloodstream infections (BSIs) cause considerable morbidity and mortality. The epidemiology of bacterial infections differs in community and hospital settings. Regular surveillance and reporting of pathogens and antimicrobial susceptibility can assist in appropriate management of BSIs OBJECTIVES: To describe the distribution of organisms and of antibiotic susceptibility among isolates from blood cultures at a tertiary academic hospital during a 1-year period, stratifying by place of infection acquisition METHODS: This was a retrospective descriptive study of bloodstream isolates from cultures from adults (&gt;13 years of age) routinely submitted between 1 October 2011 and 30 September 2012 to the clinical laboratory at Groote Schuur Hospital, Cape Town, South Africa. Community-acquired infections were compared with healthcare-acquired infections, defined as infections developing at least 48 hours after admission or within 3 months of admission to a healthcare facility. Frequencies and proportions of infecting organisms are presented, along with susceptibility results for selected pathogens. The hospital-acquired isolates were stratified by ward (emergency, general medical or general surgical ward or intensive care unit (ICU)) to determine organism frequency and susceptibility patterns by hospital ward RESULTS: Among adults, 740 non-duplicate pathogens were isolated from BSIs. Nearly three-quarters of infections were healthcare acquired. Enterobacteriaceae and non-fermentative Gram-negative bacilli were predominant among healthcare-acquired pathogens (39.2% and 28.5%, respectively), while Enterobacteriaceae and Gram-positive organisms were the most common among community-acquired pathogens (39.2% and 54.3%, respectively). The majority of community-acquired Enterobacteriaceae were highly susceptible to antibiotics (gentamicin 95.6%, ceftriaxone 96.1% and ciprofloxacin 92.2%), whereas 64.6% of healthcare-associated isolates were susceptible to gentamicin, 58.5% to ceftriaxone and 70% to ciprofloxacin. All community-acquired Staphylococcus aureus isolates v. 52.4% of healthcare-acquired isolates were susceptible to cloxacillin. The susceptibility of healthcare-acquired Pseudomonas aeruginosa and Acinetobacter baumanii complex isolates was <80% to all antibiotics with the exception of colistin. Klebsiella spp., S. aureus and Escherichia coli were the commonest causes of healthcare-acquired infections in all areas outside of the ICUs, whereas Acinetobacter was common in the ICUs and rare in all other areas CONCLUSION: The distinction between community- and healthcare-acquired infections is critical in antibiotic selection because narrow-spectrum agents can be utilised for community-acquired infections. The considerable antibiotic resistance of healthcare-acquired pathogens highlights the importance of infection prevention and control. This type of surveillance could be incorporated into routine laboratory practice <![CDATA[<b>A prospective observational study of bacteraemia in adults admitted to an urban Mozambican hospital</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500022&lng=en&nrm=iso&tlng=en BACKGROUND: Bacteraemia is a common cause of fever among patients presenting to hospitals in sub-Saharan Africa. The worldwide rise of antibiotic resistance makes empirical therapy increasingly difficult, especially in resource-limited settings OBJECTIVES: To describe the incidence of bacteraemia in febrile adults presenting to Maputo Central Hospital (MCH), an urban referral hospital in the capital of Mozambique, and characterise the causative organisms and antibiotic susceptibilities. We aimed to describe the antibiotic prescribing habits of local doctors, to identify areas for quality improvement METHODS: Inclusion criteria were: (i) &gt;18 years of age; (ii) axillary temperature &gt;38°C or <35°C; (iii) admission to MCH medical wards in the past 24 hours; and (iv) no receipt of antibiotics as an inpatient. Blood cultures were drawn from enrolled patients and incubated using the BacT/Alert automated system (bioMérieux, France). Antibiotic susceptibilities were tested using the Kirby-Bauer disc diffusion method RESULTS: Of the 841 patients enrolled, 63 (7.5%) had a bloodstream infection. The most common isolates were Staphylococcus aureus, Escherichia coli, and non-typhoidal Salmonella. Antibiotic resistance was common, with 20/59 (33.9%) of all bacterial isolates showing resistance to ceftriaxone, the broadest-spectrum antibiotic commonly available at MCH. Receipt of insufficiently broad empirical antibiotics was associated with poor in-hospital outcomes (odds ratio 8.05; 95% confidence interval 1.62 - 39.91; p=0.04 CONCLUSION: This study highlights several opportunities for quality improvement, including educating doctors to have a higher index of suspicion for bacteraemia, improving local antibiotic guidelines, improving communication between laboratory and doctors, and increasing the supply of some key antibiotics <![CDATA[<b>Kaposi's sarcoma, a South African perspective: Demographic and pathological features</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500023&lng=en&nrm=iso&tlng=en BACKGROUND: The incidence of Kaposi's sarcoma (KS) has increased dramatically since the onset of the AIDS epidemic. Of the estimated 66 200 cases of KS worldwide, 58 800 are considered to have occurred in sub-Saharan Africa OBJECTIVES: To describe the epidemiology and pathological characteristics of KS at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa METHODS: A retrospective cross-sectional study design was used. Nine hundred and thirty-eight histopathology reports of KS diagnosed in 901 patients at CHBAH between 2005 and 2009 were reviewed. Age, gender, topographic site, CD4 count, HIV status, KS histological stage, findings of human herpesvirus 8 latency-associated nuclear antigen 1 immunohistochemistry and concomitant pathological findings were recorded RESULTS: The male/female ratio was 1.2:1, the mean age 37 years and the median CD4 count 128 cells/μL. Lower limb skin biopsies accounted for 49.6% of cases. Paediatric, visceral and endemic KS accounted for only limited proportions (1.4%, 1.4% and 1.3% of biopsies, respectively). There were concomitant pathological findings in 4.6% of biopsy specimens, infections and inflammatory dermatoses being the most frequent CONCLUSION: The findings of this study highlight the need for allocation of diagnostic and treatment resources for KS. Documentation of the various demographic aspects of KS will prove to be of historical, clinical and histopathological interest as the long-term outcomes of antiretroviral therapy begin to emerge <![CDATA[<b>Ocular surface squamous neoplasia among HIV-infected patients in Botswana</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500024&lng=en&nrm=iso&tlng=en BACKGROUND: Ocular surface squamous neoplasia (OSSN) is a group of ocular tumours that has been rising in incidence among HIV-infected individuals in sub-Saharan Africa. Surgical excision is the mainstay of treatment for OSSN in this region METHODS: This retrospective cohort study examined the clinical characteristics and treatment modalities used for 468 patients with OSSN from a large tertiary referral center in Gaborone, Botswana, over a 10-year period from 1998 to 2008 RESULTS: The estimated annual incidence of OSSN in Botswana reached a peak of 7.0 cases per 100 000 persons per year in 2004. The mean age of the patients in the study was 38 years (interquartile range 30 - 44), and 53.9% were women. Of the patients, 48.5% were known to be HIV-infected, 1.5% were HIV-uninfected, and 50.0% had unknown HIV status. Among HIV-infected patients with CD4 counts, the median CD4 count was 192 cells/μL. As initial OSSN treatment, 20.7% of patients received simple surgical excision, 70.9% received surgical excision with adjunctive beta radiation, 0.9% received evisceration, 1.3% received enucleation, and 6.2% underwent surgical removal of unknown type. The overall rate of known recurrence was 7.1%; however, among those with at least 6 months of follow-up, the recurrence rate was 24.2%. Rates of known recurrence after simple surgical excision and surgical excision with adjunctive beta-radiation were 10.3% and 5.4%, respectively CONCLUSION: This study confirms the high incidence of OSSN among young individuals in Botswana. Further investigation is warranted to determine the most effective treatment modalities to prevent recurrence of OSSN among patients in sub-Saharan Africa <![CDATA[<b>Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500025&lng=en&nrm=iso&tlng=en BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented OBJECTIVES: To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care METHODS: A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled RESULTS: Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly CONCLUSION: ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery <![CDATA[<b>Validation of a severity-of-illness score in patients with tuberculosis requiring intensive care unit admission</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500026&lng=en&nrm=iso&tlng=en BACKGROUND: There is a paucity of data on the determinants of mortality due to tuberculosis (TB) in the intensive care unit (ICU OBJECTIVE: To develop a simple severity-of-illness score for use in patients with TB admitted to an ICU METHODS: A scoring system was generated by retrospectively identifying the four most significant and clinically unrelated predictors of mortality from an existing prospectively collected dataset (January 2012 - May 2013), and combining these with known predictors of poor outcome RESULTS: Of 83 patients admitted with TB, 38 (45.8%) died in the ICU. The four parameters identified from the retrospective analysis were: (i) HIV co-infection with a CD4 cell count <200/μL; (ii) a raised creatinine level: (iii) a chest radiograph showing diffuse parenchymal infiltrates/miliary pattern; and (iv) absence of TB treatment on admission. These were combined with septic shock and a low arterial partial pressure of oxygen/fractional inspired oxygen (P:F) ratio to generate a six-point severity-of-illness score (one point for each parameter). The scores for survivors were significantly lower than those for non-survivors (mean (standard deviation) 2.27 (1.47) v. 3.58 (1.08); p<0.01). A score of &gt;2 was associated with significantly higher mortality than a score of <2 (7.1% v. 46.4%; odds ratio (OR) 15.03; 95% confidence interval (CI) 1.86 - 121.32; p<0.01), whereas a score of &gt;3 was associated with a significantly higher mortality than a score of <3 (64.6% v. 20.0%; OR 7.29; 95% CI 2.64 - 20.18; p<0.01 CONCLUSION: The proposed scoring system identified patients at increased risk of dying from TB in the ICU. Further prospective studies are indicated to validate its use <![CDATA[<b>Outcomes of TB/HIV co-infected patients presenting with antituberculosis drug-induced liver injury</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500027&lng=en&nrm=iso&tlng=en BACKGROUND: South Africa has a significant burden of tuberculosis (TB). Anti-TB drug-induced liver injury (TB DILI) is one of the most serious adverse events that can arise from TB treatment (TBT). There are limited data on TB DILI among HIV-infected patients and those on antiretroviral therapy (ART OBJECTIVE: To describe characteristics of HIV-infected patients presenting with TB DILI and the proportion reintroduced on standard or modified TBT after DILI METHODS: This was a retrospective study of TB/HIV co-infected patients with DILI between 1 July 2009 and 30 September 2012. The primary focus of interest was HIV-infected patients with TB DILI on ART (ART/TB DILI) v. not on ART (TB DILI RESULTS: A total of 94 patients were included, 41 with TB DILI and 53 with ART/TB DILI. Compared with patients with TB DILI, patients with ART/TB DILI were more likely to present with symptomatic DILI (71.2% v. 51.2%; p=0.03) and had a lower median alanine aminotransferase level at diagnosis (89 IU/L v. 118 IU/L; p=0.008), a lower rate of ALT decline (-23 IU/L v. -76 IU/L; p=0.047) and longer duration of TBT at DILI diagnosis (53 days v. 11 days; p<0.001). In 71.8% of patients, standard TBT was reintroduced. More patients with ART/TB DILI than TB DILI required modified TBT (37.2% v.17.1%; p=0.05; crude odds ratio 2.17; 95% confidence interval 0.95 - 4.96). The rate of death/loss to follow-up was higher in the ART/TB DILI group (18.9% v. 14.5% CONCLUSION: A significant number of TB/HIV co-infected patients were not able to tolerate standard TBT. Furthermore, ART appears to complicate TBT, with relatively fewer patients reintroduced on standard TBT <![CDATA[<b>The poor children of the poor: Coping with diabetes control in a resource-poor setting</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500028&lng=en&nrm=iso&tlng=en BACKGROUND: Coping with diabetes control is difficult for newly diagnosed and experienced patients alike. Children with diabetes face severe challenges, as they may not yet have attained the necessary cognitive, fine motor or psychosocial skills required for performance of the tasks required from the diabetic patient. Most therefore require some adult assistance OBJECTIVES: To establish whether paediatric diabetic patients are adequately supported by their families in terms of giving insulin injections and doing home blood glucose monitoring (HBGM), and whether insulin and the necessary equipment are appropriately stored in their homes METHODS: Patients attending a paediatric diabetes clinic were interviewed. The data collected included demographic variables, type of insulin, measurement of insulin doses, administration of insulin, and blood glucose monitoring tests RESULTS: Twenty-five subjects were interviewed: 18 measured the insulin themselves, five mothers and one aunt did so, and in one case the mother and patient did so together. The four children aged <10 years had their insulin measured by their mothers, but one had to administer the injection himself. Eight of the nine children aged 11 - 15 years measured and administered the insulin themselves; in four cases the doses were checked by an adult. The mothers of four children did the fingerpricks, and eight children were helped with measuring the results. Only two children aged 11 - 15 years had their doses checked by an adult CONCLUSION: Adult assistance with regard to both insulin injections and HBGM is rarely forthcoming. The children seem not to be sufficiently supported by their families <![CDATA[<b>The success of various management techniques used in South African children with type 1 diabetes mellitus</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500029&lng=en&nrm=iso&tlng=en BACKGROUND: Despite the availability of international guidelines for the treatment of type 1 diabetes mellitus (T1DM) in children, important aspects of treatment are not accessible to all young patients in South Africa (SA OBJECTIVE: To investigate factors in diabetes management strategies that are associated with poor glycaemic control and decreased quality of life (QoL) in SA children with T1DM METHODS: Eighty children (mean (standard deviation) age 12.9 (2.7) years) with T1DM were asked to answer standardised questionnaires on demographics, management techniques used and perceptions of diabetes. The height and weight of each child was recorded and glycosylated haemoglobin (HbA1c) measured. Informed consent and assent for each participant was obtained before enrolment RESULTS: A total of 51.4% of the participants had poor metabolic control, with an HbA1c level &gt;10.0% (86 mmol/mol). Factors in clinical practice found to have a significant association with decreased HbA1c and/or QoL were healthcare system (p<0.001), insulin administration (p=0.001), correction dose (p=0.002), carbohydrate counting (p<0.001) and number of severe hyperglycaemic events (p=0.048). Regular exercise did not show any association with HbA1c classification or QoL. Children from single-parent households were prone to unsuccessful diabetes management regardless of treatment techniques used (p=0.002 CONCLUSIONS: The use of premixed insulin without access to rapid-acting insulin, absence of correction doses for hyperglycaemia and lack of carbohydrate counting showed significant association with poor diabetes management. Some recommendations regarding the adoption of more effective diabetes management strategies in the public healthcare system are suggested <![CDATA[<b>Self-monitoring of blood glucose measurements and glycaemic control in a managed care paediatric type 1 diabetes practice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500030&lng=en&nrm=iso&tlng=en BACKGROUND: Intensive diabetes management requires intensive insulin treatment and self-monitoring of blood glucose (SMBG) measurements to obtain immediate information on the status of the blood glucose level and to obtain data for pattern analysis on which meal planning, insulin and lifestyle adjustments can be made. The value and optimal frequency of SMBGs are often questioned OBJECTIVES: To document the relationship between SMBG frequency and glycaemic control in a managed care paediatric type 1 diabetes practice METHODS: A retrospective analysis was performed on 141 managed care paediatric and adolescent patients over a 1-year period from 1 February 2010 to 30 January 2011. The patients were stratified according to their insulin regimen. The frequency of SMBG was analysed and glycaemic control measured by glycated haemoglobin (HbA1c RESULTS: A highly significant decrease (p<0.0001) in HbA1c was found when moving from two injections per day to three- and five-injection regimens. The average HbA1c and its variability reduced as the diabetes regimen became more intensive. A highly significant decrease (p<0.001) in HbA1c levels was detected as the frequency of SMBG increased, with an average decrease of 0.19% in HbA1c per unit increase in the number of SMBG measurements performed per day. The modal frequency of five SMBG measurements per day was required to achieve the American Diabetes Association and International Society for Pediatric and Adolescent Diabetes guideline recommended target HbA1c of <7.5% for a paediatric population CONCLUSION: A beneficial relationship exists between frequency of SMBG and lower HbA1c in paediatric patients with type 1 diabetes <![CDATA[<b>Role of splenectomy for immune thrombocytopenic purpura (ITP) in the era of new second-line therapies and in the setting of a high prevalence of HIV-associated ITP</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500031&lng=en&nrm=iso&tlng=en BACKGROUND: New agents are being used as second-line treatment for immune thrombocytopenia (ITP) and have brought into question the relevance of splenectomy for steroid-resistant ITP METHODS: We retrospectively analysed 73 patients who underwent splenectomy for ITP at our institution over an 11-year period. The median follow-up period was 25 months; patients with follow-up of <1 month were excluded. The outcomes of splenectomy were compared in HIV-positive v. HIV-negative patients RESULTS: The rate of complete response was 83%, and response was sustained for at least 1 year or until latest follow-up in 80% of patients. Twelve patients were HIV-positive. Splenectomy was laparoscopic in 43 patients (62%) with an overall 16% complication rate. The 90-day mortality rate was 1.38%. There was no statistically significant difference in response or complication rate in the HIV-positive patients. There was a statistically significant (p=0.017) poorer response to splenectomy in the patients with steroid-resistant ITP CONCLUSION: Splenectomy is effective and safe irrespective of HIV status and remains an appropriate second-line treatment for ITP. Further research is needed to corroborate our finding of lower response in patients who are steroid-resistant, as this might be a subgroup of patients who may benefit from thrombopoietin agonists as second-line therapy <![CDATA[<b>Practical solutions to the antibiotic resistance crisis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500032&lng=en&nrm=iso&tlng=en BACKGROUND: New agents are being used as second-line treatment for immune thrombocytopenia (ITP) and have brought into question the relevance of splenectomy for steroid-resistant ITP METHODS: We retrospectively analysed 73 patients who underwent splenectomy for ITP at our institution over an 11-year period. The median follow-up period was 25 months; patients with follow-up of <1 month were excluded. The outcomes of splenectomy were compared in HIV-positive v. HIV-negative patients RESULTS: The rate of complete response was 83%, and response was sustained for at least 1 year or until latest follow-up in 80% of patients. Twelve patients were HIV-positive. Splenectomy was laparoscopic in 43 patients (62%) with an overall 16% complication rate. The 90-day mortality rate was 1.38%. There was no statistically significant difference in response or complication rate in the HIV-positive patients. There was a statistically significant (p=0.017) poorer response to splenectomy in the patients with steroid-resistant ITP CONCLUSION: Splenectomy is effective and safe irrespective of HIV status and remains an appropriate second-line treatment for ITP. Further research is needed to corroborate our finding of lower response in patients who are steroid-resistant, as this might be a subgroup of patients who may benefit from thrombopoietin agonists as second-line therapy <![CDATA[<b>Role of antibiotic stewardship in extending the age of modern medicine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500033&lng=en&nrm=iso&tlng=en Antibiotic resistance is threatening modern medicine. Overuse and misuse of antibiotics is driving resistance to such an extent that we have entered the post-antibiotic era, where some multidrug- and pandrug-resistant bacterial infections are no longer treatable. If the situation is not reversed, 10 million people will die annually of drug-resistant infections by 2050. More than just a question of mortality, such infections are causing the closure of wards, cancellation of operations, and interference with other common medical procedures that rely on antibiotics for their success. The response to this crisis requires co-ordinated international action with increased surveillance of bacterial resistance, infection prevention, and antibiotic stewardship, i.e. access to affordable, quality-assured antibiotics prescribed appropriately. This review describes antibiotic stewardship at the individual patient and programmatic level, which must be adopted by every prescriber if we are to preserve modern medicine for future generations. <![CDATA[<b>Diagnosis of bacterial infection</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500034&lng=en&nrm=iso&tlng=en Accurate diagnosis of bacterial infection is crucial to avoid unnecessary antibiotic use and to focus appropriate therapy. Bacterial infection is the combination of the presence of bacteria and inflammation or systemic dysfunction; therefore, more than one diagnostic modality is usually required for confirmation. History and examination to determine if a patient fits a clinical case definition is sometimes adequate to confirm or exclude a diagnosis. The second stage is bedside tests - some are used widely, such as urine dipstick tests, but others, such as skin scrapings of petechial rashes, are underutilised. The third stage is laboratory tests - indirect non-culture-based tests, including C-reactive protein and procalcitonin tests, when negative, can be used to prevent the unnecessary use of antibiotics. Direct non-culture-based tests detect antigens or specific antibodies, e.g. group A streptococcal antigen testing can be employed to reduce antibiotic use. Culture-based tests are often considered the reference standard in modern microbiology. Because of slow turnaround times, these tests are frequently used to focus or stop antibiotic therapy after empiric initiation. Nucleic acid amplification tests raise the possibility of detecting organisms with high sensitivity, specificity and reduced turnaround time, and novel diagnostic modalities relying on nanotechnology and mass spectrometry may dramatically alter the practice of microbiology in future. <![CDATA[<b>Optimising the administration of antibiotics in critically ill patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500035&lng=en&nrm=iso&tlng=en Optimal outcome and a reduction in the potential for resistance require that appropriate pharmacokinetic (PK) targets are achieved. Consequently, we need to target drug concentrations that are significantly higher than those conventionally presumed to be adequate. Drug exposure varies according to the molecular weight, degree of ionisation, protein binding and lipid solubility of each agent. In critically ill patients, hypoalbuminaemia increases the free fraction of hydrophilic drugs, which in turn increases the volume of distribution and clearance (CL), both of which result in reduced drug levels. Similarly, augmented renal clearance (ARC), defined as a creatinine clearance (CLcr) of >130 mL/min/1.73 m², which occurs frequently in critically ill patients, particularly younger patients with normal or near-normal creatinine levels, may also significantly reduce drug exposure. Studies have demonstrated a greater mortality and lower cure with ARC, particularly with the additive effects of obesity, hypoalbuminaemia and increasing resistance, if conventional dosages are used. These concepts apply to antibiotics targeting Gram-negative and -positive organisms. Knowledge of PK and the resistance profiles of organisms in each environment is necessary to prescribe appropriately. This article discusses these issues and the doses that should be used. <![CDATA[<b>Twitter: A tool to improve healthcare professionals' awareness of antimicrobial resistance and antimicrobial stewardship</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500036&lng=en&nrm=iso&tlng=en The World Health Organization urges international collaboration for the containment of antimicrobial resistance (AMR) or 'superbugs'. If left unchecked, AMR could result in 4.1 million deaths in Africa by 2050. Furthermore, without effective antibiotics, surgical procedures would become much riskier and in many cases impossible. Antimicrobial stewardship requires a multidisciplinary approach; however, many programmes still struggle to achieve the 'reach' required to educate and engage all healthcare providers (HCPs). Twitter use among South Africans has grown by 129% in 12 months, from 2.4 million to 5.5 million. HCPs can use Twitter to network and connect with worldwide experts, obtain real-time news from medical conferences, participate in live Twitter chats conducted by experts or medical organisations, or participate in international journal clubs. Used responsibly and professionally, Twitter can spread the call to action and connect frontline healthcare professionals to help win the battle against AMR. <![CDATA[<b>Use of vaccines as a key antimicrobial stewardship strategy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500037&lng=en&nrm=iso&tlng=en Vaccination may prevent bacterial infections and decrease the potential for transmission. Some effective vaccines may reduce bacterial colonisation and exposure to antimicrobials by minimising the spread of resistant strains; in this regard, a substantial indirect immunity has been demonstrated that protects unvaccinated members of society. One of the best documented examples of the crucial role of vaccination has been an adjunct to an antimicrobial stewardship programme. Pneumococcal conjugate vaccines (PCVs), for example, target the most virulent pneumococcal serotypes, which are linked to invasive disease and associated with antibiotic resistance. In this regard, recent local data highlight the remarkable impact of the sequential introduction of 7- and 13-valent PCV (PCV7/PCV13) on the incidence of penicillin-, ceftriaxone- and multidrug-resistant pneumococcal infections in South Africa in only 4 years. Equally impressive have been vaccines directed towards viruses such as influenza, which also have direct and indirect effects on antibiotic consumption. <![CDATA[<b>Role of infection control in combating antibiotic resistance</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500038&lng=en&nrm=iso&tlng=en Infection control has been identified as one of the key interventions in controlling the threat of antibiotic resistance. Reducing the transmission of multidrug-resistant organisms (MDROs) reduces the need for broad-spectrum antibiotics in particular, while interventions that decrease the risk of infection have an impact on the use of any antibiotic. Hand hygiene remains the cornerstone of decreasing the transmission of MDROs. Alcohol-based hand rubs are a cheap, effective and convenient means of performing hand hygiene. Patients colonised or infected with MDROs should be placed on contact precautions, although implementation remains challenging in resource-limited environments. Screening for certain MDROs may play a role in curbing transmission of these organisms. If implemented, screening must be part of a comprehensive infection control strategy. In resource-limited settings, the costs and potential benefits of screening programmes need to be carefully weighed up. Care bundles have been shown to reduce the incidence of common healthcare-associated infections, including catheter-associated urinary tract infection, ventilator-associated pneumonia, central line-associated bloodstream infection and surgical site infection. These bundles are relatively inexpensive, and can play an important role in reducing antibiotic use and improving clinical outcomes. <![CDATA[<b>A lady with a broken heart: Apical ballooning syndrome</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000500039&lng=en&nrm=iso&tlng=en Infection control has been identified as one of the key interventions in controlling the threat of antibiotic resistance. Reducing the transmission of multidrug-resistant organisms (MDROs) reduces the need for broad-spectrum antibiotics in particular, while interventions that decrease the risk of infection have an impact on the use of any antibiotic. Hand hygiene remains the cornerstone of decreasing the transmission of MDROs. Alcohol-based hand rubs are a cheap, effective and convenient means of performing hand hygiene. Patients colonised or infected with MDROs should be placed on contact precautions, although implementation remains challenging in resource-limited environments. Screening for certain MDROs may play a role in curbing transmission of these organisms. If implemented, screening must be part of a comprehensive infection control strategy. In resource-limited settings, the costs and potential benefits of screening programmes need to be carefully weighed up. Care bundles have been shown to reduce the incidence of common healthcare-associated infections, including catheter-associated urinary tract infection, ventilator-associated pneumonia, central line-associated bloodstream infection and surgical site infection. These bundles are relatively inexpensive, and can play an important role in reducing antibiotic use and improving clinical outcomes.