Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420150008&lang=pt vol. 105 num. 8 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>SA's happiness - and misery - index</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Cost awareness on the part of health professionals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Myasthenia gravis is a rare but treatable disease</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>'Changing sides' - SAMA unionist now Limpopo's Health MEC</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Pain management - the global sound of silence</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Snipping away at the HIV pandemic, one foreskin at a time</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800007&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Pharmaceuticals, Corporate Crime and Public Health</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800008&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Cochrane Corner</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800009&lng=pt&nrm=iso&tlng=pt 'Cochrane Corner' in the August SAMJ offers evidence relating to articles published in this issue, namely 'Improving access to antiretrovirals in rural South Africa - a call to action, 'Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa' and 'Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey, and the editorial by Yach and Alexander, 'Turbo-charging tobacco control in South Africa'. <![CDATA[<b>Anterior chamber paracentesis to improve diagnosis and treatment of infectious uveitis in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800010&lng=pt&nrm=iso&tlng=pt Infectious uveitis is a significant cause of blindness in South Africa, especially among HIV-infected individuals. The visual outcome of uveitis depends on early clinical and laboratory diagnosis to guide therapeutic intervention. Analyses of aqueous humor obtained by anterior chamber paracentesis direct the differential diagnosis in infectious uveitis. However, although safe and potentially cost-effective, diagnostic anterior chamber paracentesis is not common practice in ophthalmic care across Africa. We draw attention to this important procedure, which could improve the diagnosis and prognosis of infectious uveitis. <![CDATA[<b>Patient support interventions to improve adherence to drug-resistant tuberculosis treatment: A counselling toolkit</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800011&lng=pt&nrm=iso&tlng=pt In response to the growing burden of drug-resistant tuberculosis (DR-TB) in South Africa (SA), Médecins Sans Frontières (MSF), with local government health departments, piloted a decentralised model of DR-TB care in Khayelitsha, Western Cape Province, in 2007. The model takes a patient-centred approach to DR-TB treatment that is integrated into existing TB and HIV primary care programmes. One essential component of the model is individual and family counselling to support adherence to and completion of treatment. The structured and standardised adherence support sessions have been compiled into a DR-TB counselling toolkit. This is a comprehensive guide that focuses on DR-TB treatment literacy, adherence strategies to encourage retention in care, and provision of support throughout the patient's long treatment journey. Along with other strategies to promote completion of treatment, implementation of a strong patient support component of DR-TB treatment is considered essential to reduce rates of loss from treatment among DR-TB patients. We describe our experience from the implementation of this counselling model in a high DR-TB burden setting in Khayelitsha, Cape Town, SA. <![CDATA[<b>The first black doctors and their influence in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800012&lng=pt&nrm=iso&tlng=pt The early black doctors who qualified from foreign medical schools between 1883 and 1940 were pioneers in the history of South Africa. They made seminal contributions to the struggle against colonialism and apartheid, established the principle of fighting against racism in healthcare through the courts, and were trailblazers in academic medicine. They have bequeathed a remarkable legacy to the new South Africa. <![CDATA[<b>Turbo-charging tobacco control in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800013&lng=pt&nrm=iso&tlng=pt The early black doctors who qualified from foreign medical schools between 1883 and 1940 were pioneers in the history of South Africa. They made seminal contributions to the struggle against colonialism and apartheid, established the principle of fighting against racism in healthcare through the courts, and were trailblazers in academic medicine. They have bequeathed a remarkable legacy to the new South Africa. <![CDATA[<b>Improving access to antiretrovirals in rural South Africa - a call to action</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800014&lng=pt&nrm=iso&tlng=pt The early black doctors who qualified from foreign medical schools between 1883 and 1940 were pioneers in the history of South Africa. They made seminal contributions to the struggle against colonialism and apartheid, established the principle of fighting against racism in healthcare through the courts, and were trailblazers in academic medicine. They have bequeathed a remarkable legacy to the new South Africa. <![CDATA[<b>Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800015&lng=pt&nrm=iso&tlng=pt BACKGROUND: South Africa (SA) is facing a heavy burden of non-communicable diseases (NCDs). Few studies address multimorbidity, control and treatment of NCDs in patients attending primary healthcare (PHC) clinics. OBJECTIVES: To describe multimorbidity, related risk factors, disease severity and treatment status of patients with four important NCDs attending public sector PHC clinics in two districts in SA. METHODS: A cross-sectional sample of patients completed baseline data collection for a randomised controlled trial of a health systems intervention. The study population comprised adults attending PHC clinics in the Eden and Overberg districts of the Western Cape in 2011. Four subgroups of patients were identified: hypertension, diabetes, chronic respiratory disease and depression. A total of 4 393 participants enrolled from 38 clinics completed a baseline structured questionnaire and had measurements taken. Prescription data were recorded. RESULTS: Of participants with hypertension, diabetes, respiratory disease and depression, 80%, 92%, 88% and 80%, respectively, had at least one of the other three conditions. There were low levels of control and treatment: 59% of participants with hypertension had a blood pressure >140/90 mmHg, the mean haemoglobin A1c (HbA1c) value in participants with diabetes was 9%, 12% of participants in the depression group were prescribed an antidepressant at a therapeutic dose, and 48% of respiratory participants were prescribed a β2-agonist and 34% an inhaled corticosteroid. CONCLUSION: Considerable multimorbidity and unmet treatment needs exist among patients with NCDs attending public sector PHC clinics. Improved strategies are required for diagnosing and managing NCDs in this sector. <![CDATA[<b>Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800016&lng=pt&nrm=iso&tlng=pt BACKGROUND: Data on tobacco use have informed the effectiveness of South Africa (SA)'s tobacco control strategies over the past 20 years. OBJECTIVE: To estimate the prevalence of tobacco use in the adult SA population according to certain demographic variables, and identify the factors influencing cessation attempts among current smokers. METHODS: A multistage disproportionate nationally representative stratified cluster sample of households was selected for the South African National Health and Nutrition Examination Survey, conducted in 2012. A sample of 10 000 households from 500 census enumerator areas was visited. A detailed questionnaire was administered to all consenting adults in each consenting household. RESULTS: Of adult South Africans, 17.6% (95% confidence interval (CI) 6.3 - 18.9) currently smoke tobacco. Males (29.2%) had a prevalence four times that for females (7.3%) (odds ratio 5.20, 95% CI 4.39 - 6.16; p<0.001). The provinces with the highest current tobacco smoking prevalence were the Western Cape (32.9%), Northern Cape (31.2%) and Free State (27.4%). Among current tobacco smokers, 29.3% had been advised to quit smoking by a healthcare provider during the preceding year, 81.4% had noticed health warnings on tobacco packages, and 49.9% reported that the warning labels had led them to consider quitting. CONCLUSION: A large proportion of adult South Africans continue to use tobacco. While considerable gains have been made in reducing tobacco use over the past 20 years, tobacco use and its determinants need to be monitored to ensure that tobacco control strategies remain effective. <![CDATA[<b>Carcinogenic nitrosamines in traditional beer as the cause of oesophageal squamous cell carcinoma in black South Africans</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800017&lng=pt&nrm=iso&tlng=pt BACKGROUND: Before the 1930s, squamous cell carcinoma (SCC) of the oesophagus was almost unknown among black South Africans. From the 1930s the annual frequency rose. A dietary cause was sought, the staple diet of black people having changed from sorghum to maize (corn), with traditional beer being brewed from maize. Carcinogenic N-nitrosamines in traditional beer were suggested as a cause of SCC of the oesophagus, with Fusarium moniliforme, a corn saprophyte, thought to play a role. OBJECTIVES: To confirm the presence of N-nitrosamines in traditional beer and demonstrate a mechanism for the oncogenesis of oesophageal carcinoma. METHODS: Analysis by high-performance liquid chromatography was conducted for the identification of nitrosamines in traditional beer samples, and molecular docking studies were employed to predict the affinity between N-nitrosamines and the S100A2 protein. RESULTS: Carcinogenic N-nitrosamines were identified in all six samples of traditional beer examined (N=18 analyses), and docking studies confirmed a high affinity of the nitrosamine N-nitrosopyrrolidone with the S100A2 protein. This may result in the altered expression of the S100A2 protein, leading to tumour progression and prognosis. CONCLUSION: It is suggested that carcinogenic N-nitrosamines in traditional beer are a major factor in the causation of SCC of the oesophagus in black South Africans. N-nitrosamines have been shown to produce cancer experimentally, but there has not been conclusive epidemiological evidence that N-nitrosamines are carcinogenic to humans. This study is the first to demonstrate the potential link between N-nitrosamines and a human tumour. <![CDATA[<b>Do low levels of physical activity in female adolescents cause overweight and obesity? Objectively measured physical activity levels of periurban and rural adolescents</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800018&lng=pt&nrm=iso&tlng=pt BACKGROUND: The increase in obesity levels in South African adolescents is attributed to an energy imbalance such that physical inactivity is causally related to adiposity. However, in some settings obesity occurs in spite of high physical activity levels. OBJECTIVES: To examine objectively measured physical activity levels of rural black female and male adolescents from periurban to rural settings in relation to weight status, and specifically the direction and strength of the associations. METHODS: Seven-day accelerometry-derived pedometry data (step counts and activity energy expenditure) were collected for 17 adolescents (85 females, 93 males; age 13.7 - 18.0 years) living in six demographic surveillance site villages. Anthropometric measures were body mass index (kg/m²), waist circumference (cm) and sum of skinfolds (mm). Weight status was determined using international growth standards for stunting, underweight (UW), normal weight (NW), overweight (OW) and obesity (OB). RESULTS: Females had greater adiposity and lower 7-day average step counts and activity energy expenditure, and achieved fewer day at &gt;10 000 steps and more days at <5 000 steps (p<0.05). The age and gender-weighted prevalence for female/male stunting, UW-NW OW-OB, <5 000 steps/day and &gt;12 500 steps/day were 12.4%/20.7%, 74.3%/99.1%, 25.8%/0.9%, 12.3%/0.9% and 50%/64.9%, respectively (females v. males, p<0.05). In multivariate models (weighted and adjusting for age, gender, village, season), step counts and activity energy expenditure were positively related to adiposity measures (p<0.05). CONCLUSION: Both UW-NW and OW-OB perturbing to rural adolescents were active to highly active on most days of the week. Physical activity was directly associated with adiposity measures. <![CDATA[<b>The case for expanding the definition of 'key populations' to include high-risk groups in the general population to improve targeted HIV prevention efforts</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800019&lng=pt&nrm=iso&tlng=pt BACKGROUND: Two additional key populations within the general population in South Africa (SA) that are at risk of HIV infection are black African women aged 20 - 34 years and black African men aged 25 - 49 years. OBJECTIVE: To investigate the social determinants of HIV serostatus for these two high-risk populations. METHODS: Data from the 2012 South African National HIV Prevalence, Incidence, and Behaviour Survey were analysed for black African women aged 20 - 34 years and black African men aged 25 - 49 years. RESULTS: Of the 6.4 million people living with HIV in SA in 2012, 1.8 million (28%) were black women aged 20 - 34 years and 1.9 million (30%) black men aged 25 - 49 years. In 2012, they constituted 58% of the total HIV-positive population and 48% of the newly infected population. Low socioeconomic status (SES) was strongly associated (p<0.001) with being HIV-positive among black women aged 20 - 34 years, and was marginally significant among black men aged 25 - 49 years (p<0.1). CONCLUSION: Low SES is a critical social determinant for HIV infection among the high-risk groups of black African women aged 20 -34 years and black African men aged 25 - 49 years. Targeted interventions for these key populations should prioritise socioeconomic empowerment, access to formal housing and services, access to higher education, and broad economic transformation. <![CDATA[<b><i>K-ras </i></b><b>codon 12 and not <i>TP53 </i>mutations are predominant in advanced colorectal cancers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800020&lng=pt&nrm=iso&tlng=pt BACKGROUND: Colorectal cancer (CRC) is one of the most common types of cancer, affecting 3 - 5% of the global population. K-ras proto-oncogene and TP53 tumour suppressor gene mutations are among the most common genetic alterations detected in advanced colorectal tumours. OBJECTIVE: To investigate the role of K-ras codon 12 and TP53 exons 5 - 9 mutations in late-stage CRC patients. METHODS: Blood samples were collected from 249 CRC patients, of whom 147 presented with advanced carcinoma. K-ras codon 12 mutations were analysed using polymerase chain reaction-restriction fragment length polymorphism, while direct sequencing was used in screening for TP53 exons 5 - 9 mutations. RESULTS: No significant changes were observed in TP53 exons 5 - 9, except for two cases in which nucleotide replacements were observed in the non-coding regions in intron 4 (c.376-19C>T) and intron 9 (c.993+12T>C). Heterozygous mutations in K-ras codon 12 were observed in 79 individuals suffering from advanced CRC (53.7%). Colon and rectal tumours were equally distributed among the heterozygotes, but colon tumours were mostly present in wild-type homozygotes (84.6%). There was also a predominance of Caucasians among heterozygotes and a predominance of Asians among the wild-type homozygotes. CONCLUSION: Analysis of peripheral blood samples of CRC patients suffering from advanced carcinoma has prognostic value only for K-ras codon 12 mutations, and not for TP53 mutations. <![CDATA[<b>Chromosomal radiosensitivity of lymphocytes in South African breast cancer patients of different ethnicity: An indirect measure of cancer susceptibility</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800021&lng=pt&nrm=iso&tlng=pt BACKGROUND: Breast cancer is the leading cancer among South African (SA) women. SA has citizens from diverse ethnic groups, and the lifetime risk of breast cancer differs according to ethnicity. Candidate genes for increased breast cancer risk are those involved in DNA damage repair pathways, and mutations in these genes are characterised by increased chromosomal radiosensitivity. Several European studies have shown that breast cancer patients are more sensitive to ionising radiation than healthy individuals. OBJECTIVES: To investigate the in vitro chromosomal radiosensitivity of SA women with breast cancer and the possible influence of ethnicity and clinical parameters on chromosomal radiosensitivity. METHODS: Chromosomal radiosensitivity was analysed with the micronucleus assay using lymphocytes of breast cancer patients and healthy individuals of different ethnic groups. Lymphocytes were irradiated in vitro with 2 Gy or 4 Gy, and micronuclei (MN) were scored 70 hours after irradiation. These MN frequencies were correlated with the ethnicity and clinical parameters of the breast cancer patients. RESULTS: MN values were higher in breast cancer patients than in healthy controls. This was noted for black and white breast cancer patients at the different radiation doses. No correlations could be demonstrated between MN values and clinical parameters of the breast cancer, except that MN values were significantly higher in oestrogen receptor (ER)-positive breast cancers. CONCLUSION: SA breast cancer patients have elevated chromosomal radiosensitivity compared with healthy controls. ER positivity also influences chromosomal radiosensitivity. <![CDATA[<b>Human papillomavirus genotypes and clinical management of genital warts in women attending a colposcopy clinic in Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800022&lng=pt&nrm=iso&tlng=pt BACKGROUND: Genital human papillomavirus (HPV) infection is the most common sexually transmitted viral disease in the world. HPV infection of the genital epithelium is associated with genital warts and malignancies of the lower genital tract. OBJECTIVES: To describe the distribution, phenotypic appearance and HPV type associated with genital warts in women. METHODS: This was a prospective observational study of all women with genital warts who attended the Colposcopy Clinic, Groote Schuur Hospital, Cape Town, South Africa, during 2010 and fulfilled the inclusion and exclusion criteria. One hundred and thirteen women were tested for HPV using the Roche Linear Array HPV genotyping kit to determine the HPV genotypes causing genital warts. RESULTS: The median age of the women was 27 years (range 15 - 53); 90 (79.6%) were HIV-positive, and two-thirds were on antiretroviral treatment. Treatment involved ablation with topical agents, cauterisation or carbon dioxide laser. At 3 months' follow-up after treatment, 56.6% of the women, the majority of whom were HIV-positive, had recurrent/persistent disease. In both HIV-positive and HIV-negative women, HPV was detected in over 90% of cases. However, over half the HIV-positive women as opposed to 2/18 of the HIV-negative women were infected with multiple HPV genotypes. The commonest HPV genotypes in HIV-positive and HIV-negative women were types 11, 6, 89, 61, 55 and 62 and types 11 and 6, respectively. CONCLUSIONS: The majority of the patients were HIV-positive and had multiple HPV infections. While this did not alter the phenotypic appearance of the warts, recurrence/persistence after treatment was more common. <![CDATA[<b>The mental health experiences and needs of methamphetamine users in Cape Town: A mixed-methods study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800023&lng=pt&nrm=iso&tlng=pt BACKGROUND: South Africa (SA) has a burgeoning problem of methamphetamine use, particularly in the Western Cape Province. Although methamphetamine has been associated with elevated psychological distress, there has been little examination of the mental health needs of out-of-treatment methamphetamine users in SA. OBJECTIVE: To describe the mental health experiences and needs of out-of-treatment methamphetamine users in Cape Town. METHODS: Active methamphetamine users were recruited using respondent-driven sampling techniques. Eligible participants (N=360) completed a computer-assisted assessment and clinical interview, where they provided data on mental health symptoms and treatment-seeking behaviour. A subset of 30 participants completed qualitative in-depth interviews in which they provided narrative accounts of their mental health experiences and needs. Analysis of the mixed-methods data was conducted using a concurrent triangulation strategy whereby both methods contributed equally to the analysis and were used for cross-validation. RESULTS: About half of the participants met screening criteria for depression and traumatic stress, and there were some indications of paranoia. Using substances to cope with psychological distress was common, with participants talking about using methamphetamine to numb their feelings or forget stressful memories. One-third of women and 13% of men had previously tried to commit suicide. Despite the huge mental health burden in this population, very few had ever received mental health treatment. CONCLUSION: The data indicate a need for integrated care that addresses both substance use and psychiatric needs in this population. Mental health and drug treatment services targeting methamphetamine users should include a concerted focus on suicide prevention. <![CDATA[<b>Fits, faints and funny turns</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800024&lng=pt&nrm=iso&tlng=pt BACKGROUND: South Africa (SA) has a burgeoning problem of methamphetamine use, particularly in the Western Cape Province. Although methamphetamine has been associated with elevated psychological distress, there has been little examination of the mental health needs of out-of-treatment methamphetamine users in SA. OBJECTIVE: To describe the mental health experiences and needs of out-of-treatment methamphetamine users in Cape Town. METHODS: Active methamphetamine users were recruited using respondent-driven sampling techniques. Eligible participants (N=360) completed a computer-assisted assessment and clinical interview, where they provided data on mental health symptoms and treatment-seeking behaviour. A subset of 30 participants completed qualitative in-depth interviews in which they provided narrative accounts of their mental health experiences and needs. Analysis of the mixed-methods data was conducted using a concurrent triangulation strategy whereby both methods contributed equally to the analysis and were used for cross-validation. RESULTS: About half of the participants met screening criteria for depression and traumatic stress, and there were some indications of paranoia. Using substances to cope with psychological distress was common, with participants talking about using methamphetamine to numb their feelings or forget stressful memories. One-third of women and 13% of men had previously tried to commit suicide. Despite the huge mental health burden in this population, very few had ever received mental health treatment. CONCLUSION: The data indicate a need for integrated care that addresses both substance use and psychiatric needs in this population. Mental health and drug treatment services targeting methamphetamine users should include a concerted focus on suicide prevention. <![CDATA[<b>An approach to the clinical assessment and management of syncope in adults</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800025&lng=pt&nrm=iso&tlng=pt Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medical presentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implement a mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease, rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains the most important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised into vasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope (from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope that cannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural (mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined as a decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes of orthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should be managed urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medication and provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to be the cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to remember that in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and prevent recurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequently referred to a cardiologist for appropriate management. <![CDATA[<b>An approach to epilepsy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800026&lng=pt&nrm=iso&tlng=pt Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medical presentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implement a mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease, rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains the most important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised into vasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope (from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope that cannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural (mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined as a decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes of orthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should be managed urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medication and provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to be the cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to remember that in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and prevent recurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequently referred to a cardiologist for appropriate management. <![CDATA[<b>An approach to acute vertigo</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800027&lng=pt&nrm=iso&tlng=pt There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that their patient's complaint is giddiness. This frequently means that after exhaustive enquiry it will still not be entirely clear what it is that the patient feels wrong and even less so why he feels it. (W B Mathews)[1] Contrary to this prevalent view, in recent years advances in the diagnosis and management of common vestibular disorders have made the clinical evaluation of the dizzy patient more rewarding. An accurate diagnosis may be possible in the majority of patients presenting with acute vertigo when a directed history is taken and an examination is performed. Specific and effective treatments are available for many patients. This article describes the clinical evaluation of a patient with acute vertigo, and highlights selected common and important conditions. <![CDATA[<b>An approach to balance problems and falls in elderly persons</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000800028&lng=pt&nrm=iso&tlng=pt Gait instability and falls are common in elderly persons and have devastating consequences, with substantial morbidity and mortality. Furthermore, they are a precipitant for functional decline, increasing frailty and institutionalisation. The rate of falls and severity of complications increase with age and frailty. A consequence of falls with or without injury is that at least a third of persons develop a fear of falling, which leads to functional decline and a progressive decline in gait. The causes of falls in elderly persons are multifactorial and include physiological changes of ageing, frailty, pathologies, and environmental and situational factors. Maintaining postural control requires a complex integration of sensory input, central processing, motor co-ordination and musculoskeletal function, which decrease with ageing. This change, combined with sarcopenia, leads to slowed and weakened postural control and muscle responses, resulting in gait instability and falls. The assessment and management of a patient who is at risk of falls or who has fallen require a multidisciplinary approach to identify and address factors contributing to the fall. The assessment, which includes history, physical examination, and evaluation of gait, postural control and mental function, is aimed at identifying situational and associated factors surrounding a fall, intrinsic impairments in gait or pathologies that increase the risk of falls. The components of the assessment comprise a full medical evaluation for pathologies, including vision, medication review (including over-the-counter medication) with regard to polypharmacy and high-risk medications, psychogeriatric review, functional status (instrumental activities of daily living (IADLs) and activities of daily living (ADLs)), functional assessment of gait and balance, and assessment of environmental hazards in the home. Laboratory investigations are guided by clinical suspicions or diagnoses arising from the medical assessment and screening for common conditions that may increase the risk of falls. Management and prevention of falls focus on maintaining mobility and balance, and identifying those at risk of a fall for multidisciplinary assessment and intervention. Intervention to reduce the risk of subsequent falls is targeted at modification of the contributory factors. Intervention includes management of underlying pathologies, strength and balance training by a physiotherapist, assessment and modification of environmental hazards in the home by an occupational therapist, medication review and rationalisation of high-risk medications and polypharmacy, and supplementation of vitamin D where indicated.