Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 107 num. 2 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Infectious diseases - the next big challenge</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Jeanne Marie Erica de Villiers (née Du Plessis)</b>]]> <![CDATA[<b>Anaemia (part 2)</b>]]> <![CDATA[<b>Anaemia: Approach to diagnosis (part 2)</b>]]> Anaemia is defined as a condition in which the number of red cells or their oxygen-carrying capacity is insufficient to meet physiological needs. It is the most common disorder globally and one of the conditions that general practitioners most frequently encounter. In the World Health Organization global database, anaemia is estimated to affect 1.6 billion people. Anaemia may result from (i) decreased bone marrow output; or (ii) peripheral loss, destruction or sequestration of red cells. As anaemia manifests in a whole range of conditions, it is important to embrace a structured diagnostic approach. The recommended approach incorporates clinical and pathophysiological considerations, red cell characteristics, and bone marrow activity. Causes of anaemia related to decreased bone marrow output have been discussed in the previous issue of SAMJ, in the first part of this two-part series. The focus of the current article is on peripheral causes of anaemia. <![CDATA[<b>The prevalence of skin scars in patients previously given intramuscular diclofenac injections attending the Pain Clinic at Universitas Academic Hospital, Bloemfontein, South Africa</b>]]> Intramuscular (IM) diclofenac rarely causes scarring (reported incidence <0.05%). Some patients attending the Pain Clinic at Universitas Academic Hospital, Bloemfontein, South Africa, presented with scars that had developed after IM diclofenac injections. We investigated the prevalence of scars in patients at the clinic and how the injections had been obtained. Patients attending the clinic over a period of 9 months who said they had received diclofenac (N=131) were included. Information was collected using a questionnaire and physical examination. Data obtained from 118 patients who were certain that they had received diclofenac were analysed. Ninety-three patients (78.8%) indicated they had not been warned about the possibility that a diclofenac injection could result in scarring. Scarring had occurred in 10 patients (8.5%). Two-thirds of the patients who had obtained diclofenac from a pharmacy had never had a prescription for it. Four patients had required medical treatment for an ulcer or abscess, of whom two had undergone surgery. The risk of skin lesions associated with IM diclofenac is higher than reported previously. Contrary to regulations, diclofenac injections were often dispensed to patients without a prescription. <![CDATA[<b>Exporting DNA - striking a balance between preventing exploitation and promoting innovation</b>]]> DNA contains the blueprint of life. Variations in the script determine the great diversity that characterises our planet. As the analysis of large datasets derived from DNA reveals the hidden secrets of normal and abnormal structure and function as well as our ancestry, the movement of DNA between research laboratories is becoming commonplace. DNA is a resource that can be used for the benefit or to the detriment of the individuals and communities from which it is derived. But can DNA be treated as a simple commodity? How do we deal with questions such as sovereignty, discrimination and commercialisation? What underlies the current trends in attempting to regulate the movement of DNA? And how can we achieve a balance between preventing exploitation and promoting innovation? This brief overview attempts to contextualise the current landscape in South Africa with regard to the DNA that is destined to leave our shores. <![CDATA[<b>Should doctors provide futile medical treatment if patients or their proxies are prepared to pay for it?</b>]]> Ethically and legally doctors are not obliged to provide futile treatment to patients, even if the patient or their proxies are prepared to pay for it. However, it may be justified where such treatment is harmless and has a placebo effect. In deciding about a request for futile treatment, doctors should be guided by the ethical principles of patient autonomy, beneficence, non-maleficence and justice. Guidelines are provided to assist doctors in making such decisions. Where futile treatment is withdrawn or refused, palliative care must always be offered. If it is decided to withdraw or refuse treatment, the patient or their proxy should be given the opportunity to contact another practitioner or institution that may be prepared to offer such treatment. <![CDATA[<b>Metabolic acidosis in a patient with metformin overdose</b>]]> We report a rare fatal case of acute metformin overdose in a 19-year-old woman. <![CDATA[<b>Intentional intravenous mercury injection</b>]]> Mercury toxicity is commonly associated with vapour inhalation or oral ingestion, for which there exist definite treatment options. Intravenous mercury injection is rarely seen, with few documented cases. Treatment strategies are not clearly defined for such cases, although a few options do show benefit. This case report describes a 29-year-old man suffering from bipolar disorder, who presented following self-inflicted intravenous injection of mercury. Clinical and radiographic features, possible adverse clinical sequelae in preexisting mental illness and further complications are discussed, as well as possible treatment strategies in light of relevant literature. <![CDATA[<b>Sustained reduction in antibiotic consumption in a South African public sector hospital: Four-year outcomes from the Groote Schuur Hospital antibiotic stewardship programme</b>]]> BACKGROUND. Overuse of antibiotics has driven global bacterial resistance to the extent that we have entered a post-antibiotic era, where infections that were once easily treatable are now becoming untreatable. Efforts to control consumption have focused on antibiotic stewardship programmes (ASPs), aimed at optimising use. OBJECTIVE. To report antibiotic consumption and cost over 4 years from a public hospital ASP in South Africa (SA). METHODS. A comprehensive ASP comprising online education, a dedicated antibiotic prescription chart and weekly dedicated ward rounds was introduced at Groote Schuur Hospital, Cape Town, in 2012. Electronic records were used to collect data on volume and cost of antibiotics and related laboratory tests, and to determine inpatient mortality and 30-day readmission rates. These data were compared with a control period before the intervention. RESULTS. Total antibiotic consumption fell from 1 046 defined daily doses/1 000 patient days in 2011 (control period) to 868 by 2013 and remained at similar levels for the next 2 years. This was driven by reductions in intravenous antibiotic use, particularly ceftriaxone. Inflation-adjusted cost savings on antibiotics were ZAR3.2 million over 4 years. Laboratory tests increased over the same period with a total increased cost of ZAR0.4 million. There was no significant change in mortality or 30-day readmission rates. CONCLUSIONS. The effects of a comprehensive ASP on medical inpatients at a public sector hospital in SA were durable over 4 years, leading to a reduction in total antibiotic consumption without adverse effect. When increased laboratory costs were offset there was a net cost saving of ZAR2.8 million. <![CDATA[<b>Antibiotic prescription patterns of South African general medical practitioners for treatment of acute bronchitis</b>]]> BACKGROUND. Antibiotic resistance is a significant public health problem. Prudent use of antibiotics is crucial in reducing this resistance. Acute bronchitis is a common reason for consultations with general medical practitioners, and antibiotics are often prescribed even though guidelines recommend not prescribing them for uncomplicated acute bronchitis. OBJECTIVE. To analyse the antibiotic prescription patterns of South African (SA) general medical practitioners in the treatment of acute bronchitis. METHODS. The 2013 claims for members of 11 health insurance schemes were analysed to assess antibiotic prescription patterns for patients diagnosed with acute bronchitis. The patterns were assessed by type of bronchitis, chronic health status of the patients, sex and age group. The types of antibiotic prescribed were also analysed. RESULTS. Of 166 821 events analysed, an antibiotic was prescribed in more than half (52.9%). There were significant differences by type of bronchitis and chronic health status. Patients with viral bronchitis were more likely to be prescribed an antibiotic than those with bacterial bronchitis (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.08 - 1.26). Patients with a chronic illness were less likely to be prescribed an antibiotic than those without (OR 0.58, 95% CI 0.57 - 0.60). More than 70% of the antibiotics prescribed were cephalosporins, penicillins and other beta-lactams. CONCLUSIONS. Prescription rates of antibiotics for acute bronchitis by SA general medical practitioners are high. There is an urgent need to follow the guidelines for antibiotic use for acute bronchitis to reduce the likelihood of increasing resistance to available antibiotics. <![CDATA[<b>Adenovirus-associated pneumonia in South African children: Presentation, clinical course and outcome</b>]]> BACKGROUND. Viruses have emerged as important aetiological agents of childhood pneumonia. OBJECTIVE. To investigate the clinical presentation, severity and outcome of adenovirus-associated pneumonia (AVP) in children. METHODS. A retrospective analysis of AVP cases over 12 months was performed, including demographic, clinical course and outcome (death, persistent lung disease (PLD)) data. RESULTS. Two hundred and six AVP cases (median age 12 months, interquartile range 6 - 24) were identified; 70 children (34.0%) were malnourished and 14 (6.8%) were HIV-infected. Twenty-nine children (14.1%) developed PLD, which was associated with hypoxia at presentation in 26 cases (89.7%; p=0.01) and necessitated admission to the intensive care unit (ICU) in 18 (62.1%; p<0.01); 18/206 children (8.7%) died. Admission to the ICU (odds ratio (OR) 8.3, 95% confidence interval (CI) 2.3 - 29.0) and a positive blood culture (OR 11.2, 95% CI 2.3 - 54.1) were independent risk factors for mortality. CONCLUSIONS. Adenovirus is a potential cause of pneumonia and PLD in young children in South Africa. ICU admission and a positive blood culture were associated with poor outcome. <![CDATA[<b>The influence of HIV infection on the age dependence of squamous cell carcinoma of the skin in South Africa</b>]]> BACKGROUND. Cancer incidence typically increases with age, but it is not known whether ethnic characteristics influence the age dependence of squamous cell carcinoma of the skin (SCC). OBJECTIVES. (i) To determine the age dependence of SCC in the black African, coloured and white population groups of South Africa (SA); and (ii) to show whether any differences in the rate of change of age dependence could be influenced by diversity in behaviour and lifestyle, especially with regard to the prevalence of HIV infection, rather than by a fundamental variation in cancer biology between the populations. METHODS. Linear regression analysis was applied to the logarithm of the age-specific incidence rates for SCC v. the logarithm of age between 35 and 74 years. The slopes of the regression (age exponent) were compared for each subset of gender, population group and year of diagnosis (between 2000 and 2010). RESULTS. The most notable feature was the low value of the age exponent in both male and female black African compared with the white and coloured populations. This finding could be explained in part by the difference in the prevalence of HIV infection in the black African population group compared with the white and coloured population groups. CONCLUSIONS. The prevalence of HIV infection in black Africans in SA tends to decrease the apparent age component in SCC compared with the white and coloured population groups. Other factors relating to lifestyle and behaviour that differ between the population groups are also likely to influence the age component in SCC. <![CDATA[<b>The spectrum of gastric cancer as seen in a large quaternary hospital in KwaZulu-Natal, South Africa</b>]]> BACKGROUND. Gastric cancer (GC) is the fifth most commonly diagnosed cancer in the world, with the third-highest associated mortality. It has a varying geographical, ethnic and socioeconomic distribution. OBJECTIVE. To assess the presentation and management of GC in the Durban metropolitan area, South Africa. METHODS. A retrospective review of 131 patients treated at the quaternary Inkosi Albert Luthuli Central Hospital in Durban from 2009 to 2014 was performed. RESULTS. The 131 patients were predominantly black African (n=59, 45.0%) and Indian (n=63, 48.1%). Gender was evenly distributed, with 72 males (55.0%) and 59 females (45.0%). The average age of the patients was 60 years (standard deviation 13.3). More than 70% were in advanced stages of cancer and were treated conservatively. There was no significant relationship between body mass index (BMI) and the position of the tumour (p=0.175). Creatinine and albumin levels differed significantly between the genders (p<0.001 and p=0.01, respectively). CONCLUSIONS. GC appears to have a disproportionately high prevalence among Indians in Durban, and the prevalence of GC appears to be slightly higher among males. Both these observations may simply reflect referral patterns and warrant further investigation. More than 70% of patients presented with advanced-stage disease, and anaemia was common. No relationship was found between BMI and the location of the tumour, although most of the cancers were in the body and distal part of the stomach. <![CDATA[<b>The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa</b>]]> BACKGROUND. Sepsis is a leading cause of morbidity and mortality worldwide, and the incidence appears to be increasing. In the resource-limited environment in low- and middle-income countries, the management of surgical sepsis (SS) continues to represent a significant portion of the workload for most general surgeons. OBJECTIVE. To describe the spectrum of SS seen at a busy emergency department, and categorise the outcomes. METHODS. The Pietermaritzburg Metropolitan Trauma Service (PMTS) and Pietermaritzburg Metropolitan Surgical Service (PMSS) in KwaZulu-Natal Province, South Africa (SA), maintain a prospective electronic registry. All patients with features of sepsis among emergency general surgical patients >15 years of age admitted to the PMSS over the period January 2012 - January 2015 were identified. From this cohort, all patients with sepsis that required surgical source control or who had a documented surgical source of sepsis (i.e. had SS) were selected for analysis. RESULTS. Of a total of 6 020 adult surgical patients on the database, a cohort of 1 240 acute surgical patients with features of sepsis were identified, and 675 with SS were then analysed further. Of the 675 patients, 49.2% were male, and the mean age was 46 years (standard deviation (SD) 19); 47.0% presented to the PMSS directly from within the metropolitan area, while the remaining 53.0% were referred from hospitals outside the area. Physiological parameters (mean values) on presentation were as follows: systolic blood pressure 123 mmHg (standard deviation (SD) 23), respiratory rate 22 breaths/min (SD 5.2), heart rate 107 bpm (SD 19), temperature 37°C (SD 2) and white cell count 20 χ 10(9)/L (SD 8). Of the patients, 21.6% were known to be HIV-positive, 13.5% (91/675) were negative and 64.9% were of unknown status; 57.6% had intra-abdominal sepsis, 26.1% diabetes-related limb sepsis and the remaining 16.3% soft-tissue infections; 17.5% required intensive care unit admission, with a mean length of stay of 4 days (SD 4), and 30.7% developed complications. In this last group (n=207), a total of 313 morbidities were identified. The overall mortality rate was 12.7% (86/675). The mortality rate for intra-abdominal sepsis was 13.1%, for diabetic foot sepsis 14.2% and for necrotising fasciitis 27.3%. CONCLUSIONS. The spectrum of SS in SA is different to that seen in the developed world. Intra-abdominal sepsis is the most common SS and is overwhelmingly caused by acute appendicitis. Diabetic foot infection is a major cause of SS, reflecting the increasing burden of non-communicable chronic diseases in SA. <![CDATA[<b>An investigation of diverticular disease among black patients undergoing colonoscopy at Dr George Mukhari Academic Hospital, Pretoria, South Africa</b>]]> BACKGROUND. Diverticular disease was previously thought to be non-existent in the black African population. Studies over the past four decades, however, have shown a steady increase in the prevalence of the disease. OBJECTIVE. To report on the profile and current prevalence of diverticular disease in the black South African (SA) population at Dr George Mukhari Academic Hospital, Pretoria, SA. METHODS. A retrospective descriptive study was performed in black SA patients who were diagnosed with diverticular disease by colonoscopy between 1 January and 31 December 2015. RESULTS. Of 348 patients who had undergone colonoscopies and who were eligible for inclusion in this study, 47 were diagnosed with diverticular disease - a prevalence of 13.50% (95% confidence interval 10.30 - 17.50). The greatest number of patients diagnosed were in their 7th and 8th decades, with an age range of 46 - 86 (mean 67) years. There was a female predominance of 57.45%. Lower gastrointestinal bleeding was the most common (65.96%) indication for colonoscopy. The left colon was most commonly involved (72.34%), followed by the right colon (55.31%). A substantial number of patients had pancolonic involvement (27.65%). CONCLUSION. This retrospective study suggests that there has been a considerable increase in the prevalence of diverticular disease among black South Africans, possibly owing to changes in dietary habits and socioeconomic status. <![CDATA[<b>Calcific uraemic arteriolopathy (calciphylaxis) in patients on renal replacement therapy</b>]]> BACKGROUND. Calcific uraemic arteriolopathy (calciphylaxis) is an unusual and potentially fatal condition characterised by small-vessel calcification and ischaemic skin necrosis. It mainly affects patients with end-stage renal disease (ESRD) on haemodialysis, but may rarely occur in the absence of ESRD in conditions such as primary hyperparathyroidism, malignancy, alcoholic liver disease and connective tissue disease. METHODS. We reviewed the records of all patients diagnosed with calciphylaxis while on renal replacement therapy at Tygerberg Hospital, Cape Town, South Africa, between 1990 and 2014, to describe its presentation, course and final outcome. RESULTS. Nineteen patients developed calciphylaxis over this period. Their median age was 34 years and 13 (68.4%) were female. Fifteen (78.9%) had received a kidney transplant. All patients had painful skin lesions that rapidly progressed to infarction. Small-vessel calcification was seen on skin biopsy in 13 patients. Twelve patients had hyperparathyroidism. Several of the transplanted patients had been treated for graft rejection in the year preceding the diagnosis. Treatment consisted of good wound care and efforts to normalise serum calcium and phosphate levels. Five patients received an urgent parathyroidectomy. The outcome was fatal in 17 patients, with sepsis being the main cause of death. CONCLUSIONS. In our patients, calciphylaxis carried a worse prognosis than previously reported internationally. It should always be considered in the differential diagnosis of painful skin lesions in the dialysis or transplant patient. <![CDATA[<b>Analysis of mutations causing familial hypercholesterolaemia in black South African patients of different ancestry</b>]]> BACKGROUND. Familial hypercholesterolaemia (FH) is usually caused by mutations in three genes (LDLR, APOB and PCSK9). OBJECTIVE. To identify the spectrum of FH-causing mutations in black South African (SA) patients. METHODS. DNA samples of 16 unrelated South African FH patients with elevated low-density lipoprotein cholesterol levels, tendon xanthomas and corneal arcus (3 clinically homozygous FH and 13 heterozygous FH) of ethnic African origin were screened for mutations in the LDLR (coding region, promoter and intron/exon boundaries), APOB (part of exon 26) and PCSK9 genes (exon 7), using high-resolution melting. RESULTS. Eight LDLR mutations were identified, for an overall detection rate of 8/19 predicted FH-causing alleles (42.1%). The previously reported six base pair deletion p.(D47_G48del) was found in two patients, and two novel variants (c.1187-25T>C and c.1664T>G p.(L555R)) were found, both predicted to be pathogenic using in silico web-based predictive algorithms. No pathogenic variants in APOB or PCSK9 were found. CONCLUSIONS. These findings contribute to the knowledge of allelic heterogeneity in the spectrum of FH-causing mutations in black SA patients, signifying their ancestral diversity. The relatively low overall detection rate may reflect locus heterogeneity of the FH phenotype in black SA FH patients. <![CDATA[<b>Burden, genotype and phenotype profiles of adult patients with sickle cell disease in Cape Town, South Africa</b>]]> BACKGROUND. An exponential increase in the number of sickle cell disease (SCD) patients in paediatric services in Cape Town, South Africa, has been reported. The trend in adult/adolescent services has not been investigated. OBJECTIVES. To evaluate epidemiological trends of SCD and the profile of patients affected by SCD attending the Haematology Clinic at Groote Schuur Hospital (GSH), Cape Town. METHODS. (i) A retrospective review of the number of SCD patients over the past 20 years; (ii) a cross-sectional analysis of clinical and haematological characteristics of SCD patients; and (iii) molecular analysis of the haemoglobin S mutation, the haplotype in the β-globin-like genes cluster, the 3.7 kb α-thalassaemia gene deletion and 19 selected single-nucleotide polymorphisms (SNPs) associated with fetal haemoglobin (HbF) levels. RESULTS. From 1995 to 2016, 81 adolescent/adult patients with SCD were registered, mostly originating from other African countries (n=61, 75.3%). There was an increase of over 200% in new cases (n=47) during the last quarter of the two decades investigated. Data from 34 of 58 regular attendees (58.6%) were analysed. The mean age of the patients was 26.1 years (standard deviation (SD) 9.8), and 70.6% were male. With the exception of four patients with sickle/p-thalassaemia, all the patients had SCD (haemoglobin SS). The co-inheritance of a single 3.7 kb α-globin deletion was found in 42.3% of cases (n=11). The Bantu haplotype was the most observed (65.4% of chromosomes). Most HbF-promoting SNPs were not associated with variable levels of haematological indices. CONCLUSIONS. There is an increasing burden of adult SCD patients at GSH. National health and academic institutions need to adapt policies and healthcare professional training accordingly. <![CDATA[<b>Is it possible to differentiate tuberculous and cryptococcal meningitis in HIV-infected patients using only clinical and basic cerebrospinal fluid characteristics?</b>]]> BACKGROUND. Tuberculous and cryptococcal meningitis (TBM and CM) are the most common causes of opportunistic meningitis in HIV-infected patients from resource-limited settings, and the differential diagnosis is challenging. OBJECTIVE. To compare clinical and basic cerebrospinal fluid (CSF) characteristics between TBM and CM in HIV-infected patients. METHODS. A retrospective analysis was conducted of clinical, radiological and laboratory records of 108 and 98 HIV-infected patients with culture-proven diagnosis of TBM and CM, respectively. The patients were admitted at a tertiary centre in São Paulo, Brazil. A logistic regression model was used to distinguish TBM from CM and derive a diagnostic index based on the adjusted odds ratio (OR) to differentiate these two diseases. RESULTS. In multivariate analysis, TBM was independently associated with: CSF with neutrophil predominance (odds ratio (OR) 35.81, 95% confidence interval (CI) 3.80 - 341.30, p=0.002), CSF pleocytosis (OR 9.43, 95% CI 1.30 - 68.70, p=0.027), CSF protein &gt;1.0 g/L (OR 5.13, 95% CI 1.38 - 19.04, p=0.032) and Glasgow Coma Scale <15 (OR 3.10, 95% CI 1.03 - 9.34, p=0.044). Nausea and vomiting (OR 0.27, 95% CI 0.08 - 0.90, p=0.033) were associated with CM. Algorithm-related area under the receiver operating characteristics curve was 0.815 (95% CI 0.758 - 0.873, p<0.0001), but an accurate cut-off was not derived. CONCLUSION. Although some clinical and basic CSF characteristics appear useful in the differential diagnosis of TBM and CM in HIV-infected patients, an accurate algorithm was not identified. Optimised access to rapid, sensitive and specific laboratory tests is essential. <![CDATA[<b>Readiness to adopt a performance measurement system for substance abuse treatment: Findings from the Service Quality Measures initiative</b>]]> BACKGROUND. A performance measurement system - the Service Quality Measures (SQM) initiative - has been developed to monitor the quality of South Africa (SA)'s substance abuse treatment services. Identifying factors associated with readiness to adopt this system may inform strategies to facilitate its robust implementation. OBJECTIVE. To examine factors associated with readiness to adopt a performance measurement system among SA substance abuse treatment providers. METHODS. We surveyed 81 treatment providers from 13 treatment sites in the Western Cape, SA. The survey examined awareness, resources, organisational climate, leadership support and readiness to adopt the SQM system. Regression analysis was used to identify factors associated with readiness to adopt this system. RESULTS. Readiness to adopt the SQM initiative was high (M=5.64, standard deviation 1.63). In bivariate analyses, caseload size (F=3.73 (degrees of freedom (df)=3.70), p=0.015), awareness (r=0.78, p<0.0001), leadership support (r=0.70, p<0.0001), resources (r=0.65, p<0.0001), openness to change (r=0.372, p=0.001), and external pressure to change were associated with readiness to adopt the SQM. In multivariate analyses, only awareness of the SQM initiative (B=0.34, standard error (SE) 0.08, t=4.4, p<0.0001) and leadership support (B=0.45, SE 0.11, t=4.0, p<0.0001) were significantly associated with readiness to adopt this system. CONCLUSION. While treatment providers report high levels of readiness to adopt the SQM system, findings show that the likelihood of adoption can be further increased through improved provider awareness and enhanced leadership support for this health innovation.