Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 106 num. 10 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Passing the baton to pharmacists and nurses: New models of antibiotic stewardship for South Africa?</b>]]> <![CDATA[<b>The future cost of cancer in South Africa: An interdisciplinary cost management strategy</b>]]> <![CDATA[<b>Cancer research in South African academic and research institutions</b>]]> <![CDATA[<b>South Africa's adoption of the World Health Organization's 'test and treat' guidelines: Are we too ambitious?</b>]]> <![CDATA[<b>Biomedical research and capacity building: Bilateral collaboration between research institutes in South Africa and Cameroon</b>]]> <![CDATA[<b>Alpha-thalassaemia trait as a cause of unexplained microcytosis in a South African population</b>]]> <![CDATA[<b>Private practice-driven research</b>]]> <![CDATA[<b>Election politics ride roughshod over clinicians, patients</b>]]> <![CDATA[<b>Living their passion for upliftment - RuDASA award winners</b>]]> <![CDATA[<b>An uphill battle - getting rehab into mainstream rural medicine</b>]]> <![CDATA[<b>How can we manage intimate partner violence better?</b>]]> <![CDATA[<b>Intimate partner violence is everyone's problem, but how should we approach it in a clinical setting?</b>]]> Intimate partner violence (IPV) is a silent public health epidemic in South Africa (SA). Interpersonal violence in SA is the second highest burden of disease after HIV/AIDS, and for women 62% of the former is ascribed to IPV. SA, therefore, has the highest reported intimate femicide rate in the world. IPV has far-reaching consequences, stretching across generations. The cost to the economy and burden on health services are considerable. IPV presents in many ways, cutting across all medical disciplines. Therefore, all medical professionals should be conversant with this issue. This article provides essential, practical steps required for identifying and managing IPV, applicable to any setting. These steps are summarised as six Rs: Realise that abuse is happening (be aware of cues); Recognise and acknowledge the patient's concerns; Relevant clinical assessment; Risk assessment; cRisis plan; and Refer as needed for medical, social, psychological and/or legal assistance. <![CDATA[<b>Intimate partner violence: A helpful guide to legal and psychosocial support services</b>]]> Violence against women is a significant problem that profoundly affects the physical and mental wellbeing of those affected. While medicolegal interventions in South Africa have been firmly established to respond to sexual offences, no formal protocols on intimate partner violence interventions at primary healthcare level are in place yet. In support of recent policy recommendations for the development of a combined health and social sector system response to intimate partner violence, this article provides health professionals with insight into domestic violence and current legal and psychosocial support services. It focuses on how to support and advise abused women about practicalities of obtaining protection orders and accessing shelter services. <![CDATA[<b>Mental health, intimate partner violence and HIV</b>]]> Intimate partner violence (IPV) and HIV are intersecting epidemics in South Africa (SA). Despite recognition that IPV and HIV are bidirec-tionally linked, less attention has been given to mental health - a key health condition that is at the nexus of both violence and HIV/AIDS. While SA healthcare professionals have made great strides in treating HIV, the corresponding conditions of IPV and mental health receive far less clinical care. Treating mental health has the potential to positively effect HIV care and treatment, but is also a powerful gateway to enhanced comprehensive health in patients. Improving skills in managing the mental health of patients will lead to better health for them and quality of life for affected families. It can also assist health systems to deal more effectively with complex cases that so rarely achieve positive health outcomes. <![CDATA[<b><i>'Esprit de corps': </i>Towards collaborative integration of pharmacists and nurses into antimicrobial stewardship programmes in South Africa</b>]]> With the global threat of antimicrobial resistance now more emergent than ever, there should be wider collaboration between members of the multidisciplinary healthcare team. This article proposes possible ways of engagement between the pharmacist, nurse and doctor. The pharmacist and nurse are placed in an ideal position through united efforts (camaraderie) to redirect healthcare towards improved patient outcomes while also reducing antimicrobial resistance. <![CDATA[<b>Molecular detection of carbapenemase-producing genes in referral Enterobacteriaceae in South Africa: A short report</b>]]> Molecular confirmation of carbapenemase-producing Enterobacteriaceae (CPE) was introduced in South Africa (SA) at the end of 2011. We report on the detection of these resistance genes based on referral isolates. Enterobacteriaceae with non-susceptibility to any of the carbapenems according to defined criteria for antimicrobial susceptibility testing results were sent to a reference laboratory. A proportion of isolates had limited demographic, epidemiological and clinical data available. Organism identification was reconfirmed using reference laboratory methods, and the presence of carbapenemases was confirmed with a real-time polymerase chain reaction. We analysed 1 503 significant isolates received for confirmation from the National Health Laboratory Service and some private laboratories during 2012 - 2015 and confirmed one or more carbapenemase-producing genes in 68% of isolates, the most common organism being Klebsiella pneumoniae (60%). The most common carbapenemase genes were blaNDM, followed by blaOXA-48 and its variants. BlaOXA-48 and its variants demonstrated non-susceptibility to ertapenem in 89% of the isolates when analysed by the phenotypic method, and to ceftazidime in 34%. Overall, the detection rate for carbapenemases in K. pneumoniae blood isolates in the public sector was 1.9% during the 4-year period. This report indicates the presence of CPE in SA, and it is important for all healthcare workers to be aware of this major public health threat so that infection prevention and control measures can be implemented to prevent the spread of CPE in healthcare facilities. <![CDATA[<b>Button batteries in the oesophagus: A surgical emergency</b>]]> We describe two cases of missed battery ingestion that led to extensive morbidity, requiring surgical management that would not have been necessary had the batteries been removed timeously. <![CDATA[<b>Cost considerations in determining the affordability of adjuvant trastuzumab in breast cancer</b>]]> The drug eost of adjuvant trastuzumab to benefit one patient with localised human epidermal growth factor receptor 2 (HER2)-positive breast cancer depends on the baseline survival rate (BLSR) of the prognostic group of the patient. This varies from ZAR13 752 900 (BLSR 90%) to ZAR4 006 100 (BLSR 60%). All treated patients are exposed to potential toxicity. The value and affordability of treatments need to be considered, as there are finite resources available in our healthcare system. All patients must have access to cost-effective treatments. However, patient selection for expensive treatments is important, as expenditure on patients where the gains are relatively small will result in resources not being available for other patients. The state, healthcare institutions and the pharmaceutical industry need to work together to optimise the benefits of treatment to patients. <![CDATA[<b>Sudden and unexpected childhood deaths investigated at the Pretoria Medico-Legal Laboratory, South Africa, 2007 - 2011</b>]]> BACKGROUND. Sudden and unexpected death is well known to occur in infants, and although sudden deaths are less frequent after the first birthday, they still account for a significant proportion of childhood deaths. In 2009, 1.9% of the total deaths in the USA were childhood deaths. In South Africa (SA) this proportion was much higher at 11.85%. According to the law, sudden and unexpected deaths are generally investigated as unnatural deaths. Establishing an exact underlying anatomical cause of death will depend on available resources and can be difficult in a substantial proportion of cases. METHODS. A retrospective descriptive case audit was conducted at the Pretoria Medico-Legal Laboratory (PMLL), SA, from 1 January 2007 through to 31 December 2011. All children aged 1 - 18 years who died suddenly and unexpectedly were included. RESULTS. Ninety-eight cases were identified, which constituted nearly 1% of total admissions to the PMLL. The majority of the deaths were of children aged 1 - 5 years, and the male/female ratio was 1.04:1. In the largest proportion of cases (n=28, 28.6%), the medicolegal investigation, including autopsy and ancillary investigations, did not establish an underlying anatomical cause of death. In the cases where a cause of death was established, pneumonia was the most common diagnosis (n=22, 22.4%). CONCLUSIONS. The fact that the cause of the largest proportion of deaths could not be ascertained emphasises the need for consideration of additional investigative techniques, such as molecular/genetic screening, which have provided an underlying cause of death in a significant number of cases in other countries. There is a lack of published research on the causes and incidence of sudden unexpected deaths in children in SA, and further research in this area is needed. <![CDATA[<b>HIV/AIDS-associated Kaposi's sarcoma of the gastrointestinal tract: A pictorial spectrum</b>]]> We briefly report two cases of HIV/AIDS-associated Kaposi's sarcoma affecting the gastrointestinal tract. Both patients were seen at Edenvale General Hospital, Johannesburg, South Africa. <![CDATA[<b>Diagnostic challenges with acellular bacterial meningitis</b>]]> An immunocompetent adult presenting with acellular pneumococcal meningitis is a rare occurrence and may pose a diagnostic challenge. <![CDATA[<b>Angio-oedema associated with colistin</b>]]> A 50-year-old woman known to have type 1 diabetes mellitus presented with a rare case of angio-oedema associated with colistin use. The angio-oedema was temporally associated with the use and discontinuation of colistin with the reasonable exclusion of important differential diagnoses. Pseudoallergy may be a probable underlying mechanism. However, we cannot exclude the possibility of hereditary angio-oedema type 2 or 3, or that her concomitant medications (particularly enalapril) and her renal impairment contributed to the risk and severity of her angio-oedema. <![CDATA[<b>South African congenital disorders data, 2006 - 2014</b>]]> BACKGROUND. The National Department of Health in South Africa (SA) routinely collects congenital disorder (CD) data for its national CD surveillance system. The current system has been implemented since 2006, but no reports on the data collected, methodology, achievements or challenges have been published to date. OBJECTIVES. To ascertain the effectiveness of the current national CD surveillance system and its implementation. METHOD. A descriptive, retrospective study using an audit of the current database was undertaken to evaluate the number of notifications received, types of CDs reported and the quality of reporting across SA for data received from 2006 to 2014. RESULTS. A total of 14 571 notifications were received, including 13 252 CDs and 1 319 zero notifications, across all nine provinces. Commonly reported CDs included Down syndrome, cleft lip and palate, talipes equinovarus, neural tube defects and albinism. CONCLUSIONS. The major challenges identified included erratic compliance by health facilities and a lack of healthcare providers trained in human genetics related to CDs. This has led to misdiagnosed and undiagnosed CDs, collectively resulting in under-reporting of cases by > 98% during the review period. Owing to limited human and financial resources, it is recommended that the surveillance system be modified into an electronic format. This should be piloted alongside relevant training in specific sentinel sites, to improve data coverage and quality for further evaluation. <![CDATA[<b>Risk of cardiovascular disease among teachers in Cape Town: Findings of the South African PaCT pilot study</b>]]> BACKGROUND. The accelerating epidemic of cardiovascular disease (CVD) and other non-communicable diseases (NCDs) highlights the need to establish long-term cohort studies in Africa. OBJECTIVE. The Partnership for Cohort Research and Training (PaCT) seeks to study NCDs in South Africa (SA), Uganda, Tanzania and Nigeria on a long-term basis. Pilot studies at each site have tested feasibility. The SA site additionally studied the prevalence of CVD risk factors and categorised participants' 10-year predicted risk of a cardiovascular event. METHODS. We enrolled teachers from 111 public schools in the Metro South Education District in Cape Town, SA, between January 2011 and May 2012. Participants completed a self-administered questionnaire and biological measurements, and chose post or email for 6-month follow-up. RESULTS. The participation of schools was permitted by 53.2% of principals, and 489 of 1 779 teachers agreed to participate. Of teachers willing to participate in the follow-up, 52% were retained, three-quarters by post and a quarter by email. Their mean age was 46.3 years and 70.3% were female. The prevalence of CVD risk factors was high and featured hypertension (48.5%), hypercholesterolaemia (20.5%), smoking (18.0%), diabetes (10.1%) and chronic kidney disease (10.4%), while 84.7% were overweight or obese. Of the participants, 18.7% were at high risk of a heart attack or stroke within 10 years. CONCLUSION. Establishing a cohort study among teachers has challenges but also opportunities for addressing CVD, which will soon impose a substantial burden on Cape Town's education system. <![CDATA[<b>Outcomes of treatment of drug-susceptible tuberculosis at public sector primary healthcare clinics in Johannesburg, South Africa: A retrospective cohort study</b>]]> BACKGROUND. Despite the large number of tuberculosis (TB) patients treated in South Africa (SA), there are few descriptions in the published literature of drug-susceptible TB patient characteristics, mode of diagnosis or treatment outcomes in routine public sector treatment programmes. OBJECTIVE. To enhance the evidence base for public sector TB treatment service delivery, we reported the characteristics of and outcomes for a retrospective cohort of adult TB patients at public sector clinics in the Johannesburg Metropolitan Municipality (JHB), SA. METHODS. We collected medical record data for a retrospective cohort of adult (>18 years) TB patients registered between 1 April 2011 and 31 March 2012 at three public sector clinics in JHB. Data were abstracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. We report patient characteristics, mode of diagnosis, mode of treatment supervision, treatment characteristics, HIV status and treatment outcomes for this cohort. RESULTS. A total of 544 patients were enrolled in the cohort. Most (86%) were new TB cases, 81% had pulmonary TB, 58% were smear-positive at treatment initiation and 71% were HIV co-infected. Among 495 patients with treatment outcomes reported, 80% (n=394) had successful outComes, 11% (n=55) were lost to follow-up, 8% (n=40) died and 1% (n=6) failed treatment. CONCLUSIONS. Primary healthcare clinics in JHB are achieving relatively high rates of success in treating drug-susceptible TB. Missing laboratory results were common, including follow-up smears, cultures and drug susceptibility tests, making it difficult to assess adherence to guidelines and leaving scope for substantial improvements in record-keeping at the clinics involved. <![CDATA[<b>Inappropriate medicine prescribing in older South Africans: A cross-sectional analysis of medicine claims data</b>]]> BACKGROUND. Prescribing for older patients is a well-recognised problem, and inappropriate items are prescribed frequently. Several tools and criteria are available to promote rational prescribing in older patients. OBJECTIVE. To determine the prevalence of potentially inappropriate prescriptions (PIPs) in older South African patients. METHODS. A retrospective drug utilisation review was conducted using medicine claims data over a 1-year period. Patients aged &gt;65 years with at least one paid claim for any medicine item during this period were included. The prevalence of PIPs was identified by applying the 2012-Beers criteria list. RESULTS. A total of 103 420 patients, mean age 74.0 years (standard deviation 6.7), 57.1% female, were included in the analysis. The number of PIPs identified was 562 852 in 71 206 patients (68.9%). The most common medicines inappropriately prescribed were oestrogen (oral and patch formulations only) (12.4%), meloxicam (7.3%), amitriptyline and combinations thereof (6.5%), diclofenac (6.4%), ibuprofen (6.1%), alprazolam (5.3%), meprobamate and combinations thereof (5.0%), sliding-scale insulin (3.3%), amiodarone (3.1%) and doxazosin (2.6%). Medicines were inappropriately prescribed to women statistically significantly more often than to men (1.9:1; p<0.001), although this difference was not of practical significance (Cramer's V=0.06). CONCLUSIONS. Medicine use in older patients must be appropriate and evaluated regularly. According to explicit criteria, PIPs were found to be common in older patients registered on the database. Monitoring of PIPs may increase the quality of prescribing, but explicit criteria cannot substitute for clinical judgement based on the individual patient. <![CDATA[<b>Correlation between rivaroxaban (Xarelto) plasma activity, patient clinical variables and outcomes in a South African centre</b>]]> BACKGROUND. Low-molecular-weight heparin and vitamin K antagonists such as warfarin are the gold standard for prohylaxis and treatment of venous thromboembolic disease (VTED). Direct oral anticoagulants (DOACs) result in predictable anticoagulation with significantly reduced inter- and intra-patient variability. DOAC absorption is rapid, with a short half-life and relatively few drug interactions. DOACs are effective and safe at fixed doses without activity monitoring. However, specific situations may require assessment of accurate drug activity. Rivaroxaban, a DOAC targeting activated coagulation factor X (FXa), is registered for the prevention and treatment of VTED in South Africa. OBJECTIVES. To establish a prophylactic rivaroxaban activity level range and determine any associations with clinical complications, viz. haemorrhage and/or thrombosis. METHODS. Samples from 115 orthopaedic patients were tested 3 hours after a prophylactic oral dose of 10 mg rivaroxaban with STAGO rivaroxaban anti-FXa reagent on an automated coagulation analyser. Patient demographics and clinical outcomes were documented. RESULTS. The mean rivaroxaban anti-FXa level was 105.7 ng/mL. Two patients developed adverse events on therapy. One patient had minor bleeding (menorrhagia) (drug activity level 288.7 ng/mL) and another a deep-vein thrombosis (drug activity level 34.7 ng/mL). Statistical analysis demonstrated an association between drug activity and advancing age (p=0.008), most apparent among those aged >65 years. CONCLUSIONS. Measuring rivaroxaban activity levels may reduce uncertainty if treatment failure and complications occur. Patients aged >65 years should be closely monitored. A local expected rivaroxaban activity level for patients on rivaroxaban prophylaxis has been established. <![CDATA[<b>Comparison of the prevalence and characteristics of inpatient adverse events using medical records review and incident reporting</b>]]> BACKGROUND. Information on adverse events (AEs) in hospitalised patients in developing countries is scanty. OBJECTIVE. To compare the magnitude and characteristics of inpatient AEs in a tertiary, not-for-profit healthcare facility in Kenya, using medical records review and incident reporting. METHODS. Estimation of prevalence was done using incidents reported in 2010 from a random sample of medical records for hospital admissions. Nurse reviewers used 18 screening criteria, followed by physician reviewers to confirm occurrence. An AE was defined as an unexpected clinical event (UE) associated with death, disability or prolonged hospitalisation not explained by the disease condition. The kappa statistic was used to estimate inter-rater agreement, and analysis was done using logistic regression. RESULTS. The study identified 53 UEs from 2 000 randomly selected medical records and 33 reported UEs from 23 026 admissions in the index year. The prevalences of AEs from medical records review and incident reports were 1.4% (95% confidence interval (CI) 0.9 - 2.0) and 0.03% (95% CI 0.012 - 0.063), respectively. Compared with incident reporting, review of medical records identified more disability (13.2% v. 0%; p=0.03) and prolonged hospital stays (43.4% v. 18.2%; p=0.02). CONCLUSIONS. Review of medical records is preferable to incident reporting in determining the prevalence of AEs in health facilities with limited inpatient quality improvement experience. Further research is needed to determine whether staff education and a positive culture change through promotion of non-punitive UE reporting or a combination of approaches would improve the comprehensiveness of AE reporting. <![CDATA[<b>Injury Severity Score coding: Data analyst v. emerging m-health technology</b>]]> BACKGROUND. The cost of Abbreviated Injury Scale (AIS) coding has limited its utility in areas of the world with the highest incidence of trauma. We hypothesised that emerging mobile health (m-health) technology could offer a cost-effective alternative to the current gold-standard AIS mechanism in a high-volume trauma centre in South Africa. METHODS. A prospectively collected sample of consecutive patients admitted following a traumatic injury that required an operation during a 1-month period was selected for the study. AISs and Injury Severity Scores (ISSs) were generated by clinician-entered data using an m-health application (ISS eTHR) as well as by a team of AIS coders at Vancouver General Hospital, Canada (ISS VGH). Rater agreements for ISSs were analysed using Bland-Altman plots with 95% limits of agreement (LoA) and kappa statistics of the ISSs grouped into ordinal categories. Reliability was analysed using a two-way mixed-model intraclass correlation coefficient (ICC). Calibration and discrimination of univariate logistic regression models built to predict in-hospital complications using ISSs coded by the two methods were also compared. RESULTS. Fifty-seven patients were managed operatively during the study period. The mean age of the cohort was 27.2 years (range 14 - 62), and 96.3% were male. The mechanism of injury was penetrating in 93.4% of cases, of which 52.8% were gunshot injuries. The LoA fell within -8.6 - 9.4. The mean ISS difference was 0.4 (95% CI -0.8 - 1.6). The kappa statistic was 0.53. The ICC of the individual ISS was 0.88 (95% CI 0.81 - 0.93) and the categorical ISS was 0.81 (95% CI 0.68 - 0.87). Model performance to predict in-hospital complications using either the ISS eTHR or the ISS VGH was equivalent. CONCLUSIONS. ISSs calculated by the eTHR and gold-standard coding were comparable. Emerging m-health technology provides a cost-effective alternative for injury severity scoring. <![CDATA[<b>Pertussis in children in Bloemfontein, South Africa: A 7-year retrospective review</b>]]> BACKGROUND. Pertussis vaccination in the 1950s was associated with a decrease in the incidence of pertussis. A resurgence of pertussis has been documented, mainly in well-resourced countries since the 1990s. The burden of pertussis has not been well described in South Africa (SA). Epidemiological data are important for rational implementation of vaccination strategies. OBJECTIVE. To describe the morbidity and mortality of children with pertussis admitted to public sector hospitals in Bloemfontein, SA. METHODS. A retrospective descriptive hospital-based study of children diagnosed with pertussis by polymerase chain reaction testing from April 2008 to March 2015. RESULTS. One hundred and eighty-three laboratory results confirmed pertussis; 105/183 children (57.4%) were <18 weeks old. Clinical data, available for 154/183 cases (84.2%), showed that 141/154 children (91.6%) were admitted to hospital, of whom one-third required intensive care. Hospital admission was associated with young age (p<0.001). The median hospital stay was 9.0 days (interquartile range 6 - 14.5), and hospital stay was longer for children aged <18 weeks than for those aged &gt;18 weeks (p=0.006; 95% confidence interval 1 - 5 days). Of the 154 children, 139 (90.3%) had a cough, which lasted < 7 days in 110/137 cases (80.3%). The total white cell count was &gt;20.0 χ 10(9)/L in 58/144 cases (40.3%). Eight children (5.2%) died. CONCLUSIONS. This case series highlights the importance of pertussis as a problem in children. Most children had a history of cough lasting < 7 days. Young infants were most severely affected, requiring prolonged hospital stay, often with admission to a paediatric intensive care unit. <![CDATA[<b>The value and role of non-invasive prenatal testing in a select South African population</b>]]> BACKGROUND. Concerns have been raised about the injudicious use of non-invasive prenatal testing (NIPT) using cell-free DNA (cfDNA), which often leads to inaccuracies in interpretation of the role and value of cfDNA in prenatal screening. OBJECTIVE. To determine the value and role of NIPT in a select South African (SA) population. METHODS. A retrospective review of patients who elected to have NIPT between 1 October 2013 and 30 June 2015 at the Morningside Mediclinic Maternal and Fetal Medicine Centre in Johannesburg, SA. Patients had NIPT after either combined first-trimester screening (CFTS) or a second-trimester ultrasound scan. Data were collected on details of the first- and/or second-trimester screening, results of the NIPT, invasive tests done, decisions made in the event of abnormal results, and pregnancy outcomes. RESULTS. Overall, 3 473 first- and second-trimester fetal assessments were done at the centre during the study period, and 2.3% of patients (n=82) elected to have NIPT. The majority of these individuals elected to have NIPT on the basis of positive findings on CFTS, or markers of aneuploidy detected on a second-trimester ultrasound scan. Of the tests done, 97.6% produced results. Of those with no results, one did not meet quality metrics and the other had a low fetal fraction of cfDNA. There were two abnormal NIPT results, one indicating a high risk of trisomy 13 and the other a triploidy. Patients who screened negative elected not to have an invasive test. CONCLUSION. The value of NIPT in this study was that it made it possible to avoid a number of invasive tests. NIPT had a role in contingency screening. <![CDATA[<b>Fatalities involving illicit drug use in Pretoria, South Africa, for the period 2003 - 2012</b>]]> BACKGROUND. Globally, illicit drugs are responsible for many fatalities annually, yet accurate data on the nature and extent of these deaths in South Africa (SA) are lacking. OBJECTIVES. To investigate the presence and profile of illicit drugs detected in deceased persons who were subjected to medicolegal autopsies and upon whom analyses were carried out in search of illicit drugs in their body fluids at the Pretoria Medico-Legal Laboratory (PMLL), SA, over a 10-year period. METHODS. A retrospective descriptive case audit was conducted for the period 2003 - 2012. RESULTS. Screening for illicit drugs was requested in 385 out of 22 566 medicolegal autopsies. Results were available for only 281 of these cases, with 154 cases showing the presence of one or more illicit drugs. The demographic profile of positive cases indicated the majority to be male (90.3%) and white (85.1%). Decedents who tested positive for illicit drugs were predominantly aged between 20 and 30 years (51.9%). The most frequently detected drug was heroin, the presence of which was confirmed in 35.2% of cases, followed by cocaine in 19.9%. Alcohol in combination with an illicit drug or drugs was detected in 56 cases (36.4%). CONCLUSIONS. Results from this study indicate that illicit drugs were implicated in a considerable number of fatalities in Pretoria. However, it is believed that the figures are a gross under-representation of the actual number of drug users who died during this period. It is therefore recommended that further research be conducted and that drug screening be requested routinely when unnatural deaths are investigated at medicolegal mortuaries, not only to ensure the administration of justice but also to obtain more accurate data for purposes of public health programmes and improve insight into the burden of illicit drug use in SA.