Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420150002&lang=pt vol. 105 num. 2 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>On getting published in the SAMJ</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Helpful hints for writing SI units</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Implications of Cochrane Review on restricting or banning alcohol advertising in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Full circle</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>HMPG secures top-drawer CEO</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Hands-on student training in private hospitals has arrived</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200007&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Honing healthcare leaders' competence and attitudes equals facility-level delivery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200008&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Mannie Stein, 1920 - 2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200009&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Dance with Suitcase: A Memoir resting on Movement</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200010&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Digitalis reappraised: Still here today, but gone tomorrow?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200011&lng=pt&nrm=iso&tlng=pt Digoxin is one of the oldest of drugs acting on the heart and still one of the most frequently used. While in atrial fibrillation digoxin continues to have a valid role in the control of ventricular rate when added to beta-blockers and calcium antagonists, digoxin for heart failure is no longer a supportable option in view of the negative recent meta-analysis. <![CDATA[<b>Recommendations pertaining to the use of influenza vaccines and influenza antiviral drugs: influenza 2015</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200012&lng=pt&nrm=iso&tlng=pt Digoxin is one of the oldest of drugs acting on the heart and still one of the most frequently used. While in atrial fibrillation digoxin continues to have a valid role in the control of ventricular rate when added to beta-blockers and calcium antagonists, digoxin for heart failure is no longer a supportable option in view of the negative recent meta-analysis. <![CDATA[<b>Trauma quality improvement: The Pietermaritzburg Metropolitan Trauma Service experience with the development of a comprehensive structure to facilitate quality improvement in rural trauma and acute care in KwaZulu-Natal, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200013&lng=pt&nrm=iso&tlng=pt Improving the delivery of efficient and effective surgical care in rural South Africa is a mammoth task bedevilled by conflict between the stakeholders, who include rural doctors, surgeons, ancillary staff, researchers, educators and administrators. Management training is not part of most medical school curricula, yet as they progress in their careers, many clinicians are required to manage a healthcare system and find the shift from caring for individual patients to managing a complex system difficult. Conflict arises when management-type interventions are imposed in a top-down manner on surgical staff suspicious of an unfamiliar field of study. Another area of conflict concerns the place of surgical research. Researchers are often accused of not being sufficiently focused on or concerned about the tasks of service delivery. This article provides an overview of management theory and describes a comprehensive management structure that integrates a model for healthcare systems with a strategic planning process, strategic planning tools and appropriate quality metrics, and shows how the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, South Africa, successfully used this structure to facilitate and contextualise a diverse number of quality improvement programmes and research initiatives in the realm of rural acute surgery and trauma. We have found this structure to be useful, and hope that it may be applied to other acute healthcare systems. <![CDATA[<b>Must doctors disclose their fees before treatment?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200014&lng=pt&nrm=iso&tlng=pt The bioethical principles of patient autonomy, beneficence, non-maleficence and justice or fairness require doctors to disclose their fees before treating patients. The provisions regarding disclosures about fees in the Health Professions Act and National Health Act are in conflict. Those in the National Health Act are likely to be applied by the courts to impose a legal duty on healthcare practitioners to disclose their fees before treating patients. This is because the National Health Act is consistent with the access to healthcare provision in the Constitution, as the nature of the access is often determined by the patient's ability to afford the treatment. Given the unequal bargaining power between doctors and patients, very few patients may ask doctors what their fees are before being treated. It is feasible for doctors to provide such information, or an estimate, and ethically and legally they have a duty to do so. <![CDATA[<b>Evidence insufficient to confirm the value of population screening for diabetes and hypertension in low- and middle-income settings</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200015&lng=pt&nrm=iso&tlng=pt To assess the evidence from systematic reviews on the effect on morbidity and mortality of blanket screening for hypertension or diabetes mellitus compared with targeted, opportunistic or no screening, we searched for relevant systematic reviews and conducted duplicate study selection, data extraction and quality appraisal. Results were summarised narratively. We included two completed reviews of moderate quality and one ongoing Cochrane review. In one completed review, general health checks had no effect on total morbidity or mortality or on healthcare services compared with no health checks. In the other, intensive hypertension screening methods were ineffective in increasing screening uptake or detecting new cases compared with less intensive methods. Both reviews included studies in high-income settings. There is insufficient evidence from currently available systematic reviews to confirm a beneficial effect of blanket screening for hypertension and/or diabetes compared with other types of screening methods in low- and middle-income settings. Scarce resources are being mobilised to implement mass screening intervention for diabetes and hypertension without adequate evidence of its effects. A systematic review is needed to assess clinical effectiveness, cost-effectiveness and overall impact on the health system of screening strategies, especially in low- and middle-income settings such as exist in South Africa. Robust evaluation of these outcomes would then be necessary to inform secondary prevention strategies. <![CDATA[<b>Why is cancer not a priority in South Africa?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200016&lng=pt&nrm=iso&tlng=pt To assess the evidence from systematic reviews on the effect on morbidity and mortality of blanket screening for hypertension or diabetes mellitus compared with targeted, opportunistic or no screening, we searched for relevant systematic reviews and conducted duplicate study selection, data extraction and quality appraisal. Results were summarised narratively. We included two completed reviews of moderate quality and one ongoing Cochrane review. In one completed review, general health checks had no effect on total morbidity or mortality or on healthcare services compared with no health checks. In the other, intensive hypertension screening methods were ineffective in increasing screening uptake or detecting new cases compared with less intensive methods. Both reviews included studies in high-income settings. There is insufficient evidence from currently available systematic reviews to confirm a beneficial effect of blanket screening for hypertension and/or diabetes compared with other types of screening methods in low- and middle-income settings. Scarce resources are being mobilised to implement mass screening intervention for diabetes and hypertension without adequate evidence of its effects. A systematic review is needed to assess clinical effectiveness, cost-effectiveness and overall impact on the health system of screening strategies, especially in low- and middle-income settings such as exist in South Africa. Robust evaluation of these outcomes would then be necessary to inform secondary prevention strategies. <![CDATA[<b>Morbidity and mortality of black HIV-positive patients with end-stage kidney disease receiving chronic haemodialysis in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200017&lng=pt&nrm=iso&tlng=pt To assess the evidence from systematic reviews on the effect on morbidity and mortality of blanket screening for hypertension or diabetes mellitus compared with targeted, opportunistic or no screening, we searched for relevant systematic reviews and conducted duplicate study selection, data extraction and quality appraisal. Results were summarised narratively. We included two completed reviews of moderate quality and one ongoing Cochrane review. In one completed review, general health checks had no effect on total morbidity or mortality or on healthcare services compared with no health checks. In the other, intensive hypertension screening methods were ineffective in increasing screening uptake or detecting new cases compared with less intensive methods. Both reviews included studies in high-income settings. There is insufficient evidence from currently available systematic reviews to confirm a beneficial effect of blanket screening for hypertension and/or diabetes compared with other types of screening methods in low- and middle-income settings. Scarce resources are being mobilised to implement mass screening intervention for diabetes and hypertension without adequate evidence of its effects. A systematic review is needed to assess clinical effectiveness, cost-effectiveness and overall impact on the health system of screening strategies, especially in low- and middle-income settings such as exist in South Africa. Robust evaluation of these outcomes would then be necessary to inform secondary prevention strategies. <![CDATA[<b>South African National Cancer Registry: Effect of withheld data from private health systems on cancer incidence estimates</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200018&lng=pt&nrm=iso&tlng=pt BACKGROUND: The National Cancer Registry (NCR) was established as a pathology-based cancer reporting system. From 2005 to 2007, private health laboratories withheld cancer reports owing to concerns regarding voluntary sharing of patient data. OBJECTIVES: To estimate the impact of under-reported cancer data from private health laboratories. METHODS: A linear regression analysis was conducted to project expected cancer cases for 2005 - 2007. Differences between actual and projected figures were calculated to estimate percentage under-reporting. RESULTS: The projected NCR case total varied from 53 407 (3.8% net increase from actual cases reported) in 2005 to 54 823 (3.7% net increase) in 2007. The projected number of reported cases from private laboratories in 2005 was 26 359 (19.7% net increase from actual cases reported), 27 012 (18.8% net increase) in 2006 and 27 666 (28.4% net increase) in 2007. CONCLUSION: While private healthcare reporting decreased by 28% from 2005 to 2007, this represented a minimal impact on overall cancer reporting (net decrease of <4%). <![CDATA[<b>Morbidity and mortality of black HIV-positive patients with end-stage kidney disease receiving chronic haemodialysis in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200019&lng=pt&nrm=iso&tlng=pt INTRODUCTION: There are few published data from South Africa (SA) on the outcomes ofblack HIV-positive patients receiving chronic haemodialysis. METHODS: This retrospective study compared the incidences of vascular and infectious morbidity and mortality in black HIV-positive patients with those in a group of HIV-negative patients matched for ethnicity, age and gender. All the patients were receiving chronic haemodialysis in the medically insured healthcare sector of SA. RESULTS: The incidence of tuberculosis and hospital admission rates for vascular access-related infections were significantly higher in the HIV-positive group than the HIV-negative group. The HIV-positive group had significantly lower albumin (p<0.05) and haemoglobin levels (p<0.01), but this did not impact on mortality. Survival in both groups was excellent. In the HIV-positive group, viral suppression rates were suboptimal with <50% of patients on antiretroviral therapy completely virally suppressed. CONCLUSION: This study has shown that black HIV-positive patients receiving chronic haemodialysis in a healthcare-funded environment in SA have excellent overall survival in spite of higher hospital admission rates and higher infectious morbidity compared with HIV-negative patients. <![CDATA[<b>The Vaccine and Cervical Cancer Screen (VACCS) project: Linking cervical cancer screening to HPV vaccination in the South-West District of Tshwane, Gauteng, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200020&lng=pt&nrm=iso&tlng=pt BACKGROUND: Cervical cancer is preventable, but still highly prevalent in South Africa (SA). Screening strategies in the country have been ineffective, and new ways to prevent the disease are needed. OBJECTIVES: To investigate the feasibility of linking cervical cancer screening in adult women to human papillomavirus (HPV) vaccination in schoolgirls. METHODS: Ten primary schools in the South-West District of Tshwane, Gauteng Province, SA, took part in the study. Cervical cancer and HPV vaccine information was provided to schoolgirls and their parents. Consented schoolgirls were vaccinated and their female parents were invited to participate in self-screening. RESULTS: Among 1 654 girls invited for vaccination, the consented and invited uptake rates were 99.4% and 64.0%, respectively. Vaccine completion rates were higher in schools where the vaccination programme was completed in the same calendar year than in those where it was administered over two calendar years. Of 569 adult females invited, 253 (44.5%) returned screen tests; 169 (66.8%) tested negative and 75 (29.6%) positive for any high-risk HPV (hrHPV). There were no differences in level of education, employment status or access to healthcare between women with positive and those with negative screen results. CONCLUSIONS: Implementation of HPV vaccination in a primary school-based programme was successful, with high vaccine uptake and completion rates. Self-screening reached the ideal target group, and it is possible to link cervical cancer screening to the cervical cancer vaccine by giving women the opportunity of self-sampling for hrHPV testing. This is a novel and feasible approach that would require some adaptive strategies. <![CDATA[<b>Prevalence of gastrointestinal pathogenic bacteria in patients with diarrhoea attending Groote Schuur Hospital, Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200021&lng=pt&nrm=iso&tlng=pt BACKGROUND: Diarrhoea due to gastrointestinal infections is a significant problem facing the South African (SA) healthcare system. Infections can be acquired both from the community and from the hospital environment itself, the latter acting as a reservoir for potential pathogenic bacteria. OBJECTIVES: To examine the prevalence of a panel of potential diarrhoea-causing bacteria in patients attending a tertiary healthcare facility in Cape Town, SA. METHODS: Polymerase chain reaction (PCR) primers specific for Clostridium difficile, Shigella spp., Salmonella spp., Klebsiella oxytoca, enteropathogenic and enterohaemorrhagic Escherichia coli (EPEC/EHEC), Staphylococcus aureus, enterotoxigenic Bacteroides fragilis and Campylobacter spp. were used to screen total bacterial genomic DNA extracted from stool samples provided by 156 patients with diarrhoea attending Groote Schuur Hospital, Cape Town, SA. RESULTS: C. difficile was the most frequently detected pathogen (16% of cases) in the 21 - 87-year-old patient range, but was not present in samples from the 16 - 20-year-old range. K. oxytoca (6%), EPEC/EHEC strains (9%) and S. aureus (6%) were also detected. The remaining pathogens were present at low frequencies (0 - 2.9%), and the occurrence of mixed infections was 5%. The majority of non-C. difficile-related diarrhoeas were community acquired. CONCLUSION: C. difficile was the main cause of infectious diarrhoea in the sampled patients, while K. oxytoca and EPEC/EHEC strains were present as relatively minor but potentially significant pathogens. <![CDATA[<b>Predictors of in-hospital mortality following non-cardiac surgery: Findings from an analysis of a South African hospital administrative database</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200022&lng=pt&nrm=iso&tlng=pt BACKGROUND: Predictors of in-hospital mortality (IHM) following non-cardiac surgery in South African (SA) patients are not well described. OBJECTIVE: To determine the association between patient comorbidity and IHM in a cohort of SA non-cardiac surgery patients. METHODS: Data related to comorbidity and IHM for 3 727 patients aged >45 years were obtained from a large administrative database at a tertiary SA hospital. Logistic regression analysis was used to determine independent predictors of IHM. In addition, population-attributable fractions (PAFs) were calculated for all clinical factors identified as independent predictors of IHM. RESULTS: Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were independently associated with IHM (odds ratios (95% confidence intervals) 7.585 (5.480 - 10.50); 2.604 (1.119 - 6.060); 2.645 (1.414 - 4.950); 1.433 (1.107 -1.853); and 1.646 (1.213 - 2.233), respectively). Ischaemic heart disease, diabetes and hypertension were not identified as independent predictors of IHM in SA non-cardiac surgery patients. Renal dysfunction had the largest contribution to IHM in this study (PAF 0.34), followed by high-risk surgical specialties (PAF 0.15), male gender (PAF 0.08), cerebrovascular disease (PAF 0.03) and congestive heart failure (PAF 0.03). CONCLUSION: Renal dysfunction, congestive heart failure, cerebrovascular disease, male gender and high-risk surgical specialties were major contributors to increased IHM in SA non-cardiac surgery patients. Prospectively designed research is required to determine whether ischaemic heart disease, diabetes and hypertension contribute to IHM in these patients. <![CDATA[<b>Human myiasis in rural South Africa is under-reported</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200023&lng=pt&nrm=iso&tlng=pt BACKGROUND: Myiasis is the infestation of live tissue of humans and other vertebrates by larvae of flies. Worldwide, myiasis of humans is seldom reported, although the trend is gradually changing in some countries. Reports of human myiasis in Africa are few. Several cases of myiasis were recently seen at the Mthatha Hospital Complex, Mthatha, Eastern Cape Province, South Africa (SA). OBJECTIVE: Because of a paucity of literature on myiasis from this region, surgeons and scientists from Walter Sisulu University, Mthatha, decided to document myiasis cases presenting either at Nelson Mandela Academic Hospital or Umtata General Hospital from May 2009 to April 2013. The objective was to determine the incidence, epidemiology, patient age group and gender, and fly species involved. The effect of season on incidence was also investigated. RESULTS: Twenty-five cases (14 men and 11 women) were recorded in the 4-year study period. The fly species involved were Lucilia sericata, L. cuprina, Chrysomya megacephala, C. chloropyga and Sarcophaga (Liosarcophaga) nodosa, the latter being confirmed as an agent for human myiasis for the first time. The patients were 3 - 78 years old (median 56). Cases were most numerous during spring and summer, and were associated with underlying pathologies typical of ageing. CONCLUSION: Myiasis is a more common medical condition than expected in the Mthatha region. The study shows that human myiasis is still frequently encountered in SA, and there is a need to understand its epidemiology better. <![CDATA[<b>Multimorbidity in non-communicable diseases in South African primary healthcare</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200024&lng=pt&nrm=iso&tlng=pt BACKGROUND: Multimorbidity in non-communicable diseases (NCDs) is a complex global healthcare challenge that is becoming increasingly prevalent. In Africa, comorbidity of communicable diseases and NCDs is also increasing. OBJECTIVES: To evaluate the extent of multimorbidity among patients with NCDs in South African (SA) primary healthcare (PHC). METHODS: A dataset obtained from a previous morbidity survey of SA ambulatory PHC was analysed. Data on conditions considered active and ongoing at consultations by PHC providers were obtained. RESULTS: Altogether 18 856 consultations were included in the dataset and generated 31 451 reasons for encounter and 24 561 diagnoses. Hypertension was the commonest NCD diagnosis encountered (13.1%), followed by type 2 diabetes (3.9%), osteoarthritis (2.2%), asthma (2.0%), epilepsy (1.9%) and chronic obstructive pulmonary disease (COPD) (0.6%). The majority of patients (66.9%) consulted a nurse and 33.1% a doctor. Overall 48.4% of patients had comorbidity and 14.4% multimorbidity. Multimorbidity (two or more conditions) was present in 36.4% of patients with COPD, 23.7% with osteoarthritis, 16.3% with diabetes, 15.3% with asthma, 12.0% with hypertension and 6.7% with epilepsy. Only 1.1% also had HIV, 1.0% TB, 0.4% depression and 0.04% anxiety disorders. CONCLUSION: About half of the patients with NCDs had comorbidity, and multimorbidity was most common in patients with COPD and osteoarthritis. However, levels of multimorbidity were substantially lower than reported in high-income countries. Future clinical guidelines, training of PHC nurses and involvement of doctors in the continuum of care should address the complexity of patients with NCDs and multimorbidity. <![CDATA[<b>Prospective analysis of the medicine possession ratio of antidepressants in the private health sector of South Africa, 2006 - 2011</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200025&lng=pt&nrm=iso&tlng=pt BACKGROUND: Major depressive disorder (MDD) is a disabling mental illness with high morbidity and mortality rates. Inadequate treatment efficacy, unfavourable side-effect profiles and consequent shortfalls in compliance are major stumbling blocks in its treatment. Noncompliance data in low- to middle-income countries are lacking. OBJECTIVE: To investigate the prevalence of antidepressant (AD) non-compliance in the private healthcare sector of South Africa (SA). METHODS: We conducted a prospective cohort study analysing AD medicine claims (N=35 175) for 14 135 patients, obtained from a nationally representative pharmaceutical benefit management company, over a 6-year study period (1 January 2006 - 31 December 2011). The medicine possession ratio (MPR) was used as a proxy to determine compliance with AD medication. Only patients &gt;18 years of age whose treatment had been initiated by a psychiatrist following an appropriate International Classification of Diseases (10th edition) (ICD-10) diagnosis of a mood disorder were included. A patient was considered compliant if the MPR was between &gt;80% and <110% over a &gt;4-month treatment period. RESULTS: After the first 4 months, only 34% of patients were compliant. A statistically significant association was found between active ingredient consumed and compliance (p<0.0001). Only 26.2% of patients who received amitriptyline-containing products were compliant, compared with 38.8% and 38.7% for venlafaxine and duloxetine, respectively. CONCLUSION: Compliance data collected from pharmacy claims provide a workable estimate of the broader clinical scenario they represent. Although differences between classes of AD were evident, non-compliance was found to be high in the private healthcare environment of SA, comparable with global trends. <![CDATA[<b>Integrated positron emission tomography/computed tomography for evaluation of mediastinal lymph node staging of non-small-cell lung cancer in a tuberculosis-endemic area: A 5-year prospective observational study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200026&lng=pt&nrm=iso&tlng=pt BACKGROUND: Integrated positron emission tomography/computed tomography (PET-CT) is a well-validated modality for assessing mediastinal lymph node metastasis in non-small-cell lung cancer (NSCLC), which determines management and predicts survival. Tuberculosis (TB) is known to lead to false-positive PET-CT findings. OBJECTIVES: To assess the diagnostic accuracy of PET-CT in identifying mediastinal lymph node involvement of NSCLC in a high TB-endemic area. METHODS: Patients who underwent both PET-CT and lymph node tissue sampling for the investigation of suspected NSCLC were prospectively included in this observational study. Results were analysed per patient and per lymph node stage. A post-hoc analysis was performed to test the validity of a maximum standardised uptake value (SUVmax) cut-off for lymph node positivity. RESULTS: PET-CT had a sensitivity of 92.6%, specificity of 48.6%, positive predictive value of 56.8% and negative predictive value (NPV) of 90.0% in the per-patient analysis. Diagnostic accuracy was 67.2%. Similar values were obtained in the per-lymph node stage analysis. TB was responsible for 21.1% of false-positive results. A SUVmax cut-off of 4.5 yielded an improvement in diagnostic accuracy from 64.0% to 84.7% compared with a cut-off of 2.5, but at the cost of decreasing the NPV from 90.6% to 83.5%. CONCLUSION: In a high TB-endemic area, PET-CT remains a valuable method for excluding mediastinal lymph node involvement in NSCLC. Patients with a negative PET-CT may proceed to definitive management without further invasive procedures. However, PET-CT-positive lymph nodes require pathological confirmation, and the possibility of TB must be considered. <![CDATA[<b>The medical case report</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200027&lng=pt&nrm=iso&tlng=pt BACKGROUND: Integrated positron emission tomography/computed tomography (PET-CT) is a well-validated modality for assessing mediastinal lymph node metastasis in non-small-cell lung cancer (NSCLC), which determines management and predicts survival. Tuberculosis (TB) is known to lead to false-positive PET-CT findings. OBJECTIVES: To assess the diagnostic accuracy of PET-CT in identifying mediastinal lymph node involvement of NSCLC in a high TB-endemic area. METHODS: Patients who underwent both PET-CT and lymph node tissue sampling for the investigation of suspected NSCLC were prospectively included in this observational study. Results were analysed per patient and per lymph node stage. A post-hoc analysis was performed to test the validity of a maximum standardised uptake value (SUVmax) cut-off for lymph node positivity. RESULTS: PET-CT had a sensitivity of 92.6%, specificity of 48.6%, positive predictive value of 56.8% and negative predictive value (NPV) of 90.0% in the per-patient analysis. Diagnostic accuracy was 67.2%. Similar values were obtained in the per-lymph node stage analysis. TB was responsible for 21.1% of false-positive results. A SUVmax cut-off of 4.5 yielded an improvement in diagnostic accuracy from 64.0% to 84.7% compared with a cut-off of 2.5, but at the cost of decreasing the NPV from 90.6% to 83.5%. CONCLUSION: In a high TB-endemic area, PET-CT remains a valuable method for excluding mediastinal lymph node involvement in NSCLC. Patients with a negative PET-CT may proceed to definitive management without further invasive procedures. However, PET-CT-positive lymph nodes require pathological confirmation, and the possibility of TB must be considered. <![CDATA[<b>The unsuspected killer: Liquefied petroleum gas overexposure in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200028&lng=pt&nrm=iso&tlng=pt A 21-year-old woman with no past medical history of note was found unconscious together with five of her family members after prolonged exposure to liquefied petroleum gas. She was admitted to the intensive care unit at Victoria Hospital, Wynberg, Cape Town, South Africa, following resuscitation for pulseless electrical activity. On examination the following was found: coma without focal neurology; shock requiring fluid resuscitation and adrenaline; probable pneumonitis or aspiration pneumonia; acute rhabdomyolysis with severe metabolic acidosis; and raised serum K+. A carboxyhaemoglobin test was unable to confirm or exclude carbon monoxide poisoning. <![CDATA[<b>The utility of urine sulphosalicylic acid testing in the detection of non-albumin proteinuria</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200029&lng=pt&nrm=iso&tlng=pt We report two cases of immunoglobulin light chain proteinuria (Bence Jones proteinuria) detected by simple side-room investigations: urine dipstick negative/1+, but with strong positive precipitation on addition of an equal volume of sulphosalicylic acid (SSA) 3%. We highlight a significant limitation of urine dipstick testing, namely specificity for albumin, and the utility of SSA testing for the detection of urinary free light chain immunoglobulins. <![CDATA[<b>Digoxin therapy in the modern management of cardiovascular disease: An unusual but serious complication</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200030&lng=pt&nrm=iso&tlng=pt A 67-year-old woman presented to the Emergency Unit, Groote Schuur Hospital, Cape Town, South Africa, with a 1-week history of poor appetite, vomiting and fatigue. Her background history was notable for infundibular pulmonary stenosis resection, pulmonary embolism and atrial flutter. Two days before, she complained to her general practitioner of recent-onset, recurrent syncope and worsening gastrointestinal upset. Her medical treatment included warfarin 5 mg daily, enalapril 5 mg twice daily, furosemide 40 mg twice daily, atenolol 50 mg twice daily, amiodarone 200 mg daily and digoxin 0.125 mg daily. The digoxin was added to her therapy 8 months earlier to optimise rate control. <![CDATA[<b>Arthritis mutilans: A rare phenomenon</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200031&lng=pt&nrm=iso&tlng=pt A 67-year-old woman presented to the Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, South Africa, with an incarcerated umbilical hernia and a history of hypertension and psoriasis. Gastroscopy revealed a prepyloric ulcer. She had generalised plaque psoriasis and arthritis of the small joints of the hands, wrist and feet. <![CDATA[<b>For external use only</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200032&lng=pt&nrm=iso&tlng=pt Hair dye poisoning is a common problem in West Africa, in North Africa and on the Indian subcontinent. In Morocco, acute hair dye poisoning is the most frequent reason for hospitalisation for attempted suicide. In adults, 70 - 90% of episodes of hair dye poisoning are suicide attempts. The reported mortality rate range for acute hair dye poisoning is 10.6 - 38.7%. <![CDATA[<b>A tale of two viruses</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200033&lng=pt&nrm=iso&tlng=pt A 30-year-old woman presented to Tshepong Hospital, Klerksdorp, South Africa, with a history of rash with papules and pustules, which started on her face and spread to her entire body. There was a typical varicella lesion on the trunk. She was newly diagnosed as HIV-positive and was not yet on antiretroviral therapy. <![CDATA[<b>Schistosomiasis misdiagnosed as abdominal tuberculosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200034&lng=pt&nrm=iso&tlng=pt Schistosomiasis (also termed bilharzia, after the tropical disease specialist Theodor Bilharz) is a waterborne parasitic infection. It was first described in the appendix in 1909, but despite awareness of the disease for more than a century, few data on its exact incidence are available. <![CDATA[<b>An additional X chromosome</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200035&lng=pt&nrm=iso&tlng=pt A 35-year-old man presented with symmetrical inflammatory polyarthritis of the small and large joints and associated early-morning stiffness. He was assessed as having features in keeping with Klinefelter's syndrome. It is evident from the literature that there is a relationship between Klinefelter's syndrome and developing rheumatic conditions. <![CDATA[<b>Wernicke's encephalopathy as a complication of gastroparesis after emergency partial antrectomy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200036&lng=pt&nrm=iso&tlng=pt Wernicke's encephalopathy is a common complication of malnutrition, alcohol abuse and gastric outlet obstruction. We describe a patient who developed Wernicke's encephalopathy secondary to gastroparesis, with no significant evidence of malnutrition, alcohol abuse, or gastric outlet obstruction. <![CDATA[<b>Fever, sore throat and myalgia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000200037&lng=pt&nrm=iso&tlng=pt A 20-year-old man presented with a severely sore throat and myalgia, which were unresponsive to antibiotics. He was admitted to a regional hospital with an ongoing painful throat, generalised myalgia, fever and a transient, recurring, salmon-pink rash on his hands and trunk. He did not respond to ceftriaxone and had a continual significant fever daily