Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420150012&lang=pt vol. 105 num. 12 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Climate change, public health and COP21 - a South African perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200001&lng=pt&nrm=iso&tlng=pt http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>A matter of context - time to clinically validate 9-month infant HIV testing in South Africa (?)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Rural district hospitals: Ambulance services, staff attitudes, and other impediments to healthcare delivery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Gonadal pathology in a girl with 45,X/46,XY mosaicism</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>SAMA president, medicopolitical veteran, psychiatrist and treatment pioneer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Attacking 'prejudice' against generics could save SA billions</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200007&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Ebola: Experiences from the field - Liberia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200008&lng=pt&nrm=iso&tlng=pt The experience of all those who have worked with Ebola during the current outbreak has been different, and varied by time and place. I worked with Médicins sans Frontières in Monrovia during October/November 2014. This was the first-ever outbreak of Ebola virus disease in the overcrowded and impoverished areas of a capital city; Ebola was spreading rapidly, and case management had to be upscaled on an unprecedented basis. It was also a time of many questions: for clinicians, these centred on how to optimise survival, and how to maximise care in a resource-limited environment. <![CDATA[<b>Ebola: Personal view from the field - Sierra Leone</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200009&lng=pt&nrm=iso&tlng=pt Experiences of healthcare workers responding to the Ebola epidemic in West Africa vary with the types of facility. Patients suspected of having Ebola virus disease (EVD) must be isolated from each other as well as from the wider community until testing is complete; in Sierra Leone such facilities were called Ebola holding units (EHUs). Once EVD was confirmed, patients were moved to Ebola treatment units, where they could be cohorted together safely and treatment efforts focused on EVD itself. While a number of purpose-built units combined an EHU with an Ebola treatment unit, my personal experience was of working in a number of stand-alone EHUs in Freetown, Sierra Leone. <![CDATA[<b>Is it ever justified for doctors to sue their patients whose allegations against them have been dismissed by the courts or the Health Professions Council of South Africa?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200010&lng=pt&nrm=iso&tlng=pt Doctors should be cautious about suing their patients, because it may generate bad publicity. Where a criminal or civil case or complaint to the Health Professions Council of South Africa by a patient about a doctor's professional conduct is withdrawn or dismissed, a doctor may only sue the patient for defamation if it can be proved that the patient acted from malice, spite or an improper motive. Doctors may only sue patients for malicious prosecution or abuse of civil proceedings if such patients acted with 'malice' and 'without reasonable and probable cause'. If a doctor successfully defends a case against a patient, the court will usually order the patient to pay the doctor's costs. <![CDATA[<b>Reflections on ethical challenges associated with the Ebola epidemic</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200011&lng=pt&nrm=iso&tlng=pt Doctors should be cautious about suing their patients, because it may generate bad publicity. Where a criminal or civil case or complaint to the Health Professions Council of South Africa by a patient about a doctor's professional conduct is withdrawn or dismissed, a doctor may only sue the patient for defamation if it can be proved that the patient acted from malice, spite or an improper motive. Doctors may only sue patients for malicious prosecution or abuse of civil proceedings if such patients acted with 'malice' and 'without reasonable and probable cause'. If a doctor successfully defends a case against a patient, the court will usually order the patient to pay the doctor's costs. <![CDATA[<b>#FeesMustFall and the campaign for universal health coverage</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200012&lng=pt&nrm=iso&tlng=pt Doctors should be cautious about suing their patients, because it may generate bad publicity. Where a criminal or civil case or complaint to the Health Professions Council of South Africa by a patient about a doctor's professional conduct is withdrawn or dismissed, a doctor may only sue the patient for defamation if it can be proved that the patient acted from malice, spite or an improper motive. Doctors may only sue patients for malicious prosecution or abuse of civil proceedings if such patients acted with 'malice' and 'without reasonable and probable cause'. If a doctor successfully defends a case against a patient, the court will usually order the patient to pay the doctor's costs. <![CDATA[<b>Growing genomic research on the African continent: The H3Africa Consortium</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200013&lng=pt&nrm=iso&tlng=pt Doctors should be cautious about suing their patients, because it may generate bad publicity. Where a criminal or civil case or complaint to the Health Professions Council of South Africa by a patient about a doctor's professional conduct is withdrawn or dismissed, a doctor may only sue the patient for defamation if it can be proved that the patient acted from malice, spite or an improper motive. Doctors may only sue patients for malicious prosecution or abuse of civil proceedings if such patients acted with 'malice' and 'without reasonable and probable cause'. If a doctor successfully defends a case against a patient, the court will usually order the patient to pay the doctor's costs. <![CDATA[<b>Climate change is catchy - but when will it really hurt?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200014&lng=pt&nrm=iso&tlng=pt Concern and general awareness about the impacts of climate change in all sectors of the social-ecological-economic system is growing as a result of improved climate science products and information, as well as increased media coverage of the apparent manifestations of the phenomenon in our society. However, scales of climate variability and change, in space and time, are often confused and so attribution of impacts on various sectors, including the health sector, can be misunderstood and misrepresented. In this review, we assess the mechanistic links between climate and infectious diseases in particular, and consider how this relationship varies, and may vary according to different time scales, especially for aetiologically climate-linked diseases. While climate varies in the medium (inter-annual) time frame, this variability itself may be oscillating and/or trending on cyclical and long-term (climate change) scales because of regional and global scale climate phenomena such as the El-Nino southern oscillation coupled with global-warming drivers of climate change. As several studies have shown, quantifying and modelling these linkages and associations at appropriate time and space scales is both necessary and increasingly feasible with improved climate science products and better epidemiological data. The application of this approach is considered for South Africa, and the need for a more concerted effort in this regard is supported. <![CDATA[<b>School students' knowledge and understanding of the Global Solar Ultraviolet Index</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200015&lng=pt&nrm=iso&tlng=pt BACKGROUND: The Global Solar Ultraviolet Index (UVI) is a health communication tool used to inform the public about the health risks of excess solar UV radiation and encourage appropriate sun-protection behaviour. Knowledge and understanding of the UVI has been evaluated among adult populations but not among school students. OBJECTIVES: To draw on previously unpublished data from two school-based studies, one in New Zealand (NZ) and the other in South Africa (SA), to investigate and compare students' knowledge of the UVI and, where possible, report their understanding of UVI. METHODS: Cross-sectional samples of schoolchildren in two countries answered questions on whether they had seen or heard of the UVI and questions aimed at probing their understanding of this measure. RESULTS: Self-report questionnaires were completed by 1 177 students, comprising 472 NZ (264 year 8 (Y8), 214 year 4 (Y4) students) and 705 SA grade 7 primary-school students aged 8 - 13 years. More than half of the NZ Y8 students answered that they had previously heard about or seen the UVI, whereas significantly more SA students and NZ Y4 students replied that they had neither seen nor heard about the UVI. Among the NZ students who had seen or heard of the UVI, understanding of the tool was fairly good. CONCLUSION: The observed lack of awareness among many students in both countries provides an opportunity to introduce an innovative and age-appropriate UVI communication method that combines level of risk with behavioural responses to UVI categories and focus on personal relevance to the UVI message. <![CDATA[<b>Molecular characterisation and epidemiological investigation of an outbreak of <i>bla</i><sub>OXA-181</sub>carbapenemase-producing isolates of <i>Klebsiella pneumoniae </i>in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200016&lng=pt&nrm=iso&tlng=pt BACKGROUND: Klebsiella pneumoniae is an opportunistic pathogen often associated with nosocomial infections. A suspected outbreak of K. pneumoniae isolates, exhibiting reduced susceptibility to carbapenem antibiotics, was detected during the month of May 2012 among patients admitted to a haematology unit of a tertiary academic hospital in Cape Town, South Africa (SA). OBJECTIVES: An investigation was done to determine possible epidemiological links between the case patients and to describe the mechanisms of carbapenem resistance of these bacterial isolates. METHODS: Relevant demographic, clinical and laboratory information was extracted from hospital records and an observational review of infection prevention and control practices in the affected unit was performed. Antimicrobial susceptibility testing including phenotypic testing and genotypic detection of the most commonly described carbapenemase genes was done. The phylogenetic relationship of all isolates containing the blaOXA-181 carbapenemase gene was determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing. RESULTS: Polymerase chain reaction analysis identified a total of seven blaOXA-181-positive, carbapenem-resistant K. pneumoniae isolates obtained from seven patients, all from a single unit. These isolates were indistinguishable using PFGE analysis and belonged to sequence type ST-14. No other carbapenemase enzymes were detected. CONCLUSION: This is the first documented laboratory-confirmed outbreak of OXA-181-producing K. pneumoniae in SA, and highlights the importance of enforcing strict adherence to infection control procedures and the need for ongoing surveillance of antibiotic-resistant pathogens in local hospitals. <![CDATA[<b>Measurement of viral load by the automated Abbott real-time HIV-1 assay using dried blood spots collected and processed in Malawi and Mozambique</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200017&lng=pt&nrm=iso&tlng=pt BACKGROUND: The use of dried blood spots (DBS) for HIV-1 viral load quantification can greatly improve access to viral monitoring for HIV-infected patients receiving treatment in resource-limited settings OBJECTIVES: To evaluate and validate HIV viral load measurement from DBS in sub-Saharan Africa, with a reliable, all-automated, standard commercial assay such as the Abbott m2000 METHODS: A total of 277 DBS were collected in different health centres in Malawi and Mozambique and analysed for viral load determination using the Abbott m2000 assay with the corresponding plasma samples as gold standard. Samples were extracted using the m2000SP automatic extractor and then processed as the plasma samples using the specific 1.0 mL HIV-RNA DBS protocol RESULTS: Among samples with detectable HIV-RNA the correlation between viral load obtained from the paired 131 plasma and DBS samples was high (r=0.946). Overall, viral load values between DBS and plasma differed by less than 0.5 log unit in 90.1% of cases and by less than 1 log unit in 100% of cases. Using a threshold of 1 000 copies/mL (defining virological failure in resource-limited settings), sensitivity was 94.2% and specificity 98.6%, and both positive and negative predictive values were high (98.5% and 94.5%, respectively CONCLUSION: DBS extracted and processed using the Abbott automated system can be reliably used in resource-limited setting to diagnose virological failure. <![CDATA[<b>Time for a culture change? Suboptimal compliance with blood culture standards at a district hospital in Cape Town</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200018&lng=pt&nrm=iso&tlng=pt BACKGROUND: The benchmark for contaminated blood cultures (BCs) is 3%. The South African (SA) guideline aims to optimise BC yield and reduce contamination. Data on BC collection practices in SA since the publication of the 2010 SA guideline are lacking. OBJECTIVE: To evaluate compliance with the national guideline for the optimal use of BCs and determine the BC contamination rate at a local district hospital. METHOD: An audit of compliance with 22 BC standards was conducted at a district hospital in Cape Town, SA. Standards were evaluated by reviewing clinical and laboratory data and by a clinician questionnaire. RESULTS: Of the 425 BCs reviewed, 12.5% had positive growth, and 4.5% grew contaminants. Only 33% of BC bottles contained the recommended fill volume of 8 - 10 mL, and 96.9% of patients had a single BC within a 24-hour period. Of all the BCs, only 7.8% had a combined blood volume of at least 20 mL. The yield of pathogens in BCs collected after antibiotic exposure was 4.9% compared with 7.5% for those cultures with no prior antibiotic exposure (p=0.3). The overall median needle-to-incubator transport time was 11 hours 25 minutes. CONCLUSION: The BC contamination rate was high and compliance with most standards was variable or not met. The findings may not be generalisable to other hospitals, and we recommend that each institution reviews its own BC practices. Recommendations made to hospital staff included a re-audit following implementation of these recommendations. <![CDATA[<b>Diagnosing childhood pulmonary tuberculosis using a single sputum specimen on Xpert MTB/RIF at point of care</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200019&lng=pt&nrm=iso&tlng=pt BACKGROUND. The GeneXpert MTB/RIF (Cepheid, USA) (Xpert) has proved successful for pulmonary tuberculosis (TB) diagnosis on decontaminated/concentrated induced sputum specimens from children. Capacity to perform induction in many settings is limited. OBJECTIVE: To Assess: (i) volumes of 'routinely obtained' sputum in a district-level academic hospital; (ii) whether sputum specimens not meeting Xpert-required testing volumes could still be tested; and (iii) performance of Xpert on a single paediatric sputum specimen at point of care (POC METHODS. Two sputa were collected from paediatric TB suspects (<14 years) at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa. One specimen was weighed at POC; if the volume was &gt;0.1 mL but <0.5 mL, it was increased to 0.5 mL using saline. On-site Xpert testing (G3 cartridge) was performed by a dedicated laboratory technician. The second specimen was referred for TB smear microscopy and culture as per standard of care (SOC). RESULTS. A total of 484 patients presumed to have TB (median age 24 months) were eligible for this study, performed between June 2011 and May 2012. Xpert could not be used on 4.1% of specimens because of volumes <0.1 mL, and 62.8% required addition of saline prior to Xpert testing. Xpert generated a 2.2% error and 3.7% invalid rate, compared with the SOC that rejected 2.3% because of insufficient volume and 2.3% that were contaminated. The diagnostic performance compared with culture was 62.5% (95% confidence interval (CI) 24.7 - 91) and 99.1% (95% CI 97.4 - 99.8) sensitivity and specificity, respectively, for Xpert (n=345) and 33.3% (7.9 - 69.9) and 99.5% (98.1 - 99.9) sensitivity and specificity, respectively, for smear microscopy (n=374). CONCLUSIONS. Up to 67% of 'routinely obtained' sputum specimens from children (<14 years) are below the required volume for Xpert testing but can be 'topped up' with saline. Xpert MTB/RIF performed better than microscopy and generated clinically relevant, timeous results, but sensitivity did not reach the same levels as culture in children. <![CDATA[<b>The diagnostic accuracy of integrated positron emission tomography/computed tomography in the evaluation of pulmonary mass lesions in a tuberculosis-endemic area</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200020&lng=pt&nrm=iso&tlng=pt BACKGROUND: Integrated positron emission tomography/computed tomography (PET-CT) is a well-validated modality for assessing pulmonary mass lesions and specifically for estimating risk of malignancy. Tuberculosis (TB) is known to cause false-positive PET-CT findings. OBJECTIVE: To investigate the utility of PET-CT in the evaluation of pulmonary mass lesions and nodules in a high TB prevalence setting. METHODS: All patients referred for the evaluation of a solitary pulmonary nodule or mass and who underwent PET-CT scanning over a 3-year period were included. The PET-CT findings, including maximum standardised uptake value (SUVmax), were compared with the gold standard (tissue or microbiological diagnosis). The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy for malignant disease were calculated according to the SUVmax cut-off of 2.5 and a proposed cut-off obtained from a receiver operating characteristic (ROC) curve. RESULTS: Forty-nine patients (mean (standard deviation) age 60.1 (10.2) years; 29 males) were included, of whom 30 had malignancy. Using an SUVmax cut-off of 2.5, PET-CT had a sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for malignancy of 93.3%, 36.8%, 70.0%, 77.8% and 71.4%, respectively. After a ROC curve analysis, a suggested SUVmax cut-off of 5.0 improved the specificity to 78.9% and the diagnostic accuracy to 86.7%, with a small reduction in sensitivity to 90.0%. CONCLUSIONS: The diagnostic accuracy of PET-CT in the evaluation of pulmonary mass lesions using the conventional SUVmax cut-off of 2.5 was reduced in a TB-endemic area. An SUVmax cut-off of 5.0 has a higher specificity and diagnostic accuracy for malignancy, with a comparable sensitivity. <![CDATA[<b>Diabetes mellitus and non-traumatic lower extremity amputations in four public sector hospitals in Cape Town, South Africa, during 2009 and 2010</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200021&lng=pt&nrm=iso&tlng=pt BACKGROUND. Diabetes mellitus (DM) is the most commonly reported cause of non-trauma-related lower extremity amputations (LEAs) worldwide, but there is a dearth of such information for South Africa (SA). OBJECTIVES. To examine the proportion of LEAs due to diabetes and to describe the associated characteristics of these patients. METHODS. A retrospective analysis of all LEAs was performed in four public sector hospitals in Cape Town, SA, for 2009 and 2010. Operating theatre records were reviewed to identify all patients who had an LEA. Patient records were perused and information extracted using a structured questionnaire. RESULTS. Records for 941 of 1 134 patients identified as having an LEA were found (recovery rate 82.9%). Of the 867 patients with 1 280 LEAs included in the study, 925 LEAs were in 593 patients with DM and 355 LEAs in 274 non-DM patients. Therefore 72.3% (95% confidence interval (CI) 69.8 - 74.7) of LEAs were in people with DM, while 68.4% (95% CI 65.2 - 71.4) of the total patients had DM. The DM group underwent more multiple LEAs (42.0% v. 23%; p<0.001) and had more multiple admissions (14.3% v. 7.7%; p<0.005) than the non-DM group. Infection (85.7% v. 63.5%,; p<0.001) and ulcer (25.3% v. 15.3%; p=0.001) were the leading causes for LEA in the DM group compared with the non-DM group. Ischaemia was the dominant cause in the non-DM patients (49.3% v. 23.3%; p<0.001), as was smoking (69.7% v. 43.5%, p<0.001), compared with the DM patients. CONCLUSIONS: These data demonstrate an alarming burden of LEAs due to DM in the public sector in Cape Town. Given that the majority of LEAs are preventable with adequate education, screening, treatment and follow-up, effective interventions are needed. <![CDATA[<b>Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200022&lng=pt&nrm=iso&tlng=pt BACKGROUND: Diabetes mellitus (DM) may increase the risk of depression as a result of a sense of threat of debilitating complications or because of associated lifestyle changes. Depression may increase the risk of type 2 diabetes as a result of poor health behaviours. OBJECTIVE: To determine the association between diabetes mellitus, depression and psychological distress in a cohort of South African (SA) teachers. METHODS: Teachers from 111 public schools in the Metro South District of the Cape Metropolitan area, SA, were invited to participate in this study. The Center for Epidemiologic Studies Depression Scale (CES-D) and the Kessler Psychological Distress Scale (K10) were used to assess depression and psychological distress, respectively. A professional nurse completed a physical examination and collected blood for measurement of glucose, cholesterol and serum creatinine. RESULTS: Of the 388 teachers who completed the questionnaires, 67.5% were female and the average age was 46.2 years (standard deviation 8.7). Psychological distress was identified in 28.1% of the cohort and depression in 15.5%, and 7.7% were found to fulfil criteria for DM. A diagnosis of DM was associated with an increased risk of depression (adjusted odds ratio (AOR) 3.90; 95% confidence interval (CI) 1.33 -11.37) and psychological distress (AOR 3.62; 95% CI 1.31 - 10.00). CONCLUSION: The high prevalence of obesity and DM in this cohort of SA teachers is of concern. A diagnosis of DM was strongly associated with an increased risk of depression and psychological distress. <![CDATA[<b>An electronic colonoscopy record system enables detailed quality assessment and benchmarking of an endoscopic service</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200023&lng=pt&nrm=iso&tlng=pt BACKGROUND: Competence in colonoscopy, which is a technically difficult procedure, requires adequate exposure to it and the maintenance of a detailed logbook. Without an electronic record this is difficult to achieve. By implementing an electronic medical record system we aimed to perform a detailed quality assessment audit of colonoscopy, to benchmark our results and generate accurate logbooks for individual endoscopists. METHODS: We reviewed the prospectively maintained Hybrid Electronic Medical Registry (HEMR). Colonoscopies performed between March 2013 and March 2014 were reviewed, and for competency, quality metrics were derived from the guidelines of the American Society of Gastroenterology. RESULTS: A total of 843 colonoscopies were performed. Seven hundred and seventy procedures were performed by three staff endoscopists who each performed over the required 150 procedures annually (n=197, 338 and 235). The remaining 73 (8.7%) were performed by other staff. In 105 cases (12.5%), bowel preparation was deemed to be inadequate, which caused the procedure to be abandoned in 34 cases. A total of 64 cases were deemed to be incomplete because of obstructing lesions (n=26), extensive diverticulosis (n=4), technical difficulty (n=31) and patient discomfort (n=3). There were two complications recorded: perforation (n=1) and bleeding (n=1). CONCLUSIONS: The HEMR system enabled the audit of experiences with colonoscopy in our institution. Our results are broadly compatible with the international literature and with a number of guidelines. The development of an electronic record system is a major advance, as it enables meaningful benchmarking and the generation of accurate procedural logbooks. <![CDATA[<b>Dyspepsia prevalence and impact on quality of life among Rwandan healthcare workers: A cross-sectional survey</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200024&lng=pt&nrm=iso&tlng=pt BACKGROUND: Dyspepsia has been demonstrated worldwide to have major personal and societal impacts, but data on the burden of this disease in Africa are lacking. OBJECTIVE: To document the prevalence of dyspepsia and its quality-of-life impact among healthcare workers (HCWs) at Butare University Teaching Hospital (BUTH), Rwanda. METHODS: A cross-sectional survey among consenting HCWs at BUTH was conducted. Multilingual interviewers guided participants through validated questionnaires, including the Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ), to detect the presence and frequency of dyspeptic symptoms, and the Short-Form Nepean Dyspepsia Index (SF-NDI), to examine the impact of dyspepsia on quality of life. RESULTS: The study included 378 enrolled HCWs, all of whom provided responses to the SF-LDQ and 356 of whom responded to the SF-NDI. The prevalence of dyspepsia in the study population was 38.9% (147/378). Of these 147 HCWs, 79 (53.7%) had very mild dyspepsia, 33 (22.4%) had mild dyspepsia, 20 (13.6%) had moderate dyspepsia and 15 (10.2%) had severe dyspepsia. Females were more likely to complain of dyspepsia than males (98/206 v. 49/172; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.5 - 3.5; p<0.001). Participants with dyspepsia of at least mild severity had SF-NDI scores reflecting reduced quality of life when compared with non-dyspeptic participants (OR 17.0; 95% CI 5.0 - 57.1; p<0.001), with most marked effects on the 'tension' and 'eating and drinking' subdomains of the SF-NDI. CONCLUSION: The prevalence of dyspepsia among HCWs in Rwanda is high and is associated with lowered quality of life. <![CDATA[<b>Musculoskeletal disorders - disease burden and challenges in the developing world</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200025&lng=pt&nrm=iso&tlng=pt BACKGROUND: Dyspepsia has been demonstrated worldwide to have major personal and societal impacts, but data on the burden of this disease in Africa are lacking. OBJECTIVE: To document the prevalence of dyspepsia and its quality-of-life impact among healthcare workers (HCWs) at Butare University Teaching Hospital (BUTH), Rwanda. METHODS: A cross-sectional survey among consenting HCWs at BUTH was conducted. Multilingual interviewers guided participants through validated questionnaires, including the Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ), to detect the presence and frequency of dyspeptic symptoms, and the Short-Form Nepean Dyspepsia Index (SF-NDI), to examine the impact of dyspepsia on quality of life. RESULTS: The study included 378 enrolled HCWs, all of whom provided responses to the SF-LDQ and 356 of whom responded to the SF-NDI. The prevalence of dyspepsia in the study population was 38.9% (147/378). Of these 147 HCWs, 79 (53.7%) had very mild dyspepsia, 33 (22.4%) had mild dyspepsia, 20 (13.6%) had moderate dyspepsia and 15 (10.2%) had severe dyspepsia. Females were more likely to complain of dyspepsia than males (98/206 v. 49/172; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.5 - 3.5; p<0.001). Participants with dyspepsia of at least mild severity had SF-NDI scores reflecting reduced quality of life when compared with non-dyspeptic participants (OR 17.0; 95% CI 5.0 - 57.1; p<0.001), with most marked effects on the 'tension' and 'eating and drinking' subdomains of the SF-NDI. CONCLUSION: The prevalence of dyspepsia among HCWs in Rwanda is high and is associated with lowered quality of life. <![CDATA[<b>Lupus nephritis: An approach to diagnosis and treatment in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200026&lng=pt&nrm=iso&tlng=pt Lupus nephritis (LN) is a significant cause of morbidity and mortality in patients with systemic lupus erythematosus. Delayed recognition and diagnosis of LN may be a common cause of chronic kidney disease among South Africans. Renal biopsy is the gold standard of diagnosing LN; however, this service is not available in many centres and the use of urinalysis, urine microscopic examination and other serological tests can be useful in identifying patients with proliferative LN. Proliferative types of LN (class III, class IV and mixed class V) comprise the larger proportion of patients with this condition. Patients receiving immunosuppressive therapy need to be monitored closely for side-effects and drug-related toxicities. LN patients with end-stage renal disease (class VI) need to be prepared for renal replacement therapy (dialysis and renal transplantation). In all patients, treatment should include adjunctive therapies such as renin angiotensin aldosterone system blockade, bone protection (with calcium supplements and vitamin D), blood pressure control and chloroquine - all of which help to retard the progression of kidney disease. <![CDATA[<b>Evidence-based treatment of systemic lupus erythematosus and its complications</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200027&lng=pt&nrm=iso&tlng=pt Outcomes for patients with systemic lupus erythematosus (SLE) have improved during the last two decades as our understanding of the disease expands. In particular, the importance of antimalarial therapy for addressing and preventing a host of complications in SLE has emerged. Furthermore, evidence is mounting that corticosteroids, while offering excellent control of disease activity, are responsible for many of the late complications of SLE and need to be prescribed in modest doses for the shortest time possible. To achieve this, an understanding of the available 'steroid-sparing' immunosuppressants is useful. Specific attention needs to be paid to the two most important complications of SLE, i.e. infections and atherosclerotic cardiovascular events. Awareness of, screening for and aggressive management of risk factors for these comorbidities are paramount. <![CDATA[<b>A clinical update on paediatric lupus</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200028&lng=pt&nrm=iso&tlng=pt Systemic lupus erythematosus in children is a life-threatening chronic disease that is being increasingly recognised. More black African children are being diagnosed and the proportion of males affected is much higher than in adult-onset lupus. The presenting manifestations of childhood-onset lupus are variable and many systems are involved. Children with lupus often present late with severe disease, and in South African (SA) children severe lupus nephritis occurs commonly at presentation. The investigations for lupus should be performed in a three-step process - initial essential investigations, antibody and serological tests, and supplementary investigations. The most important factor in the management is to involve a multidisciplinary team as soon as possible. All cases of lupus in SA should be discussed with a paediatric specialist so that a tailored management plan can be made, depending on the presenting features and course of the disease. <![CDATA[<b>Infections in the management of rheumatic diseases: An update</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200029&lng=pt&nrm=iso&tlng=pt Patients with inflammatory rheumatic conditions have an increased risk of infection. While this could be the result of the underlying disease, it may also be caused by the use of immunosuppressive therapies, which are needed to treat these disorders. An increasing number of patients with rheumatoid arthritis or other rheumatic diseases are using biologic therapies (biologics) in addition to the synthetic disease-modifying anti-rheumatic drugs. The side-effects and complications of these relatively new agents are unknown to many specialists (outside of rheumatology) and general practitioners. This article highlights updates on the most important infections encountered in the daily management of patients with rheumatic diseases and discusses how these may be prevented. <![CDATA[<b>Meeting the challenges in the diagnosis of inflammatory myopathies</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200030&lng=pt&nrm=iso&tlng=pt Inflammatory myopathy (IM) is a rubric term to describe a heterogeneous group of muscle diseases typified by dermatomyositis and polymyositis. The current classifications are unsatisfactory, but IM associated with other connective tissue diseases (CTDs), such as systemic lupus erythematosus, underlying malignancy and HIV, should also be included. Although uncommon, IM should always be considered in a patient who presents with proximal weakness of gradual onset and has raised serum muscle enzymes. The diagnosis may be obvious if the patient has diagnostic skin signs such as heliotropic rash (peri-orbital discoloration) and Gottron's lesions (typically on the extensor surfaces of the fingers). In the absence of obvious skin manifestations, other features of a CTD such as Raynaud's phenomenon, abnormal capilloroscopy and the presence of serum antinuclear factor antibody should be searched for. Conditions that mimic IM include other causes of myopathy such as endocrine disorders, adverse effects of medication, metabolic myopathies and muscle dystrophies. Atypical features suggesting an alternative diagnosis are acute onset, severe pain, assymmetrical involvement, distal weakness and wasting. Appropriate investigations include a chest radiograph indicating interstitial lung disease or malignancy. Electromyography and muscle biopsy are useful in cases where other diagnoses are suspected. <![CDATA[<b>Juvenile idiopathic arthritis - an update on its diagnosis and management</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200031&lng=pt&nrm=iso&tlng=pt Juvenile idiopathic arthritis (JIA) is the most common form of chronic arthritis in children and the most common cause of musculoskeletal disability in children. Early diagnosis may be challenging, but it is essential to ensure good outcomes. This review proposes an approach to the investigation and diagnosis of JIA. It also gives a summary of the latest available evidence-based treatment for this disease. <![CDATA[<b>Approach to lower back pain</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200032&lng=pt&nrm=iso&tlng=pt Lower back pain is one of the most common symptoms - and the most common musculoskeletal problem - seen by general practitioners. It is also a common cause of disability and an expensive condition in terms of economic impact because of absenteeism. This article discusses an approach to this common symptom and how to distinguish the benign, mechanical type of back pain from the more sinister, but less frequently encountered, inflammatory back pain. <![CDATA[<b>Gout and hyperuricaemia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015001200033&lng=pt&nrm=iso&tlng=pt Gout is the most common crystal arthritis and its prevalence is rising. It is associated with the metabolic syndrome, and hyperuricaemia may be an independent risk factor for cardiovascular disease. The acute presentation of gout is easily managed, but the underlying cause is seldom addressed. Indications for initiating uric acid therapy have been clearly established. The classification criteria for gout have been reviewed and are presented here. Lifestyle modification is key to the management of gout. The clinician must screen for diabetes, hypertension and hypercholesterolaemia when the diagnosis of gout is made. The management of asymptomatic hyperuricaemia is still being researched. As yet, there is no indication to start urate-lowering therapy in such patients. Allopurinol remains the first line of treatment, but there are newer drugs being researched in various clinical trials. Probenecid is the alternative in patients with preserved renal function, who do not have a history of renal calculi.