SAMJ: South African Medical Journal

Good riddance!

Editor's Choice

Crime causes the wealth gap

Time for adolescent medicine units in South Africa?

Medical responsibility at inquests

Training an old-timer as a GP in Britain

New health ministers - so little time, so much to do

Science seals Mbeki/Msimang's AIDS ignominy

Vital breast cancer drugs highlight funding ethics

DoH reviews HIV/TB treatment protocols

Accounting for the full benefits of childhood vaccination in South Africa

Free provision of PEP and medical advice for sexual offence victims: What should doctors do?

Epiploic appendagitis

Primary central nervous system lymphoma: An unusual presentation

Bernard Johnson Meyer

J P (Freddie) van Niekerk (1924 - 2008)

Do you really need back surgery? A surgeon's guide to neck and back pain and how to choose your treatment

Preventing thromboembolism in medical inpatients - time to catch up with the surgeons?

Accuracy of patients' self-reporting of pregnancy and awareness of risks to the fetus from X-ray radiation

Haemodialysis access by inferior vena cava catheterisation

Knowledge of post-rape procedures and guidelines among first-year female resident students at the University of the Free State

Do knees survive the Comrades Marathon?

OBJECTIVE: To detect by magnetic resonance imaging (MRI) the presence and type of knee injuries in non-professional runners after running an ultra-marathon, and to determine whether ultra-marathon running exacerbates pre-existing knee injuries or results in new permanent injuries. DESIGN: A prospective MRI study of one knee of 10 randomly selected participants who completed the Comrades Marathon between 1997 and 2002. Their knees were scanned 48 hours before the race, and 48 hours and 1 month after the race. SETTING: All scans were performed at the Radiology Department, Wentworth Hospital, Durban, and the University of KwaZulu-Natal. MAIN OUTCOME MEASURES: Scores of all knee injuries detected on MRI scans immediately before the race, compared with the scores after the race. RESULTS: All scanned knees demonstrated an abnormal amount of joint fluid before the race; this increased immediately after the race in 5 runners and remained unchanged in another 5. At 1 month, 5 knees showed decreased joint fluid and 5 remained unchanged, but these were not the same runners as in the post-race groups. There was increased signal intensity in the distal patellar and quadriceps tendons in 4 runners before the race, which increased or remained the same on post-race scans in 6 knees. There was a decrease in signal intensity on scans taken 1 month later in 3 runners, with complete resolution in 2 and no change in 1. Old injuries to ligaments, tendons or other knee structures were unaffected by the race. No bone bruising, cartilage defects or meniscal abnormalities were observed. There was no significant difference in the pre- and post-race or 1-month scan scores. CONCLUSIONS: The race appears to have had a detrimental effect on runners who started the ultra-marathon with tendinopathy, which worsened post-race by MRI criteria. One month after the race, the scan appearance of the overuse injury had either improved or resolved completely. Bone bruising or meniscal damage did not appear to occur, and the presence of increased joint fluid probably relates to stress or injury.

Fetal alcohol syndrome among Grade 1 schoolchildren in Northern Cape Province: Prevalence and risk factors

OBJECTIVE: To describe the prevalence, characteristics and risk factors for fetal alcohol syndrome (FAS) and partial FAS among schoolgoing children in Grade 1 in Northern Cape Province, South Africa. DESIGN: A cross-sectional study using a two-tiered method for ascertainment of FAS/partial FAS cases, comprising: screening of growth parameters, diagnostic assessment for screen-positive children using clinical and neurocognitive assessments, and maternal history of drinking during pregnancy. Mothers or caregivers of FAS children and matched controls were interviewed. SETTING: Primary schools in De Aar (8) and Upington (15). SUBJECTS: Grade 1 pupils in 2001 (De Aar, N=536) and 2002 (Upington, N=1 299). OUTCOME MEASURES: FAS or partial FAS. RESULTS: The prevalence of FAS/partial FAS was high: 64/536 (119.4/1 000, 95% CI 93.2 - 149.9) in De Aar, and 97/1 299 (74.7/1 000, 95% CI 61.0 - 90.3) in Upington. Overall, 67.2 per 1 000 children (95% CI 56.2 - 79.7) had full FAS features. Growth retardation was also common in this population: 66.6% (1 181/1 774) were underweight, 48.3% (858/1 776) stunted, and 15.1% had a head circumference <2 SD for age. Mothers of children with FAS were less likely to have full-time employment or have attended secondary school and had lower body mass index, and about 80% currently smoked. Over two-thirds of all pregnancies had been unplanned. CONCLUSIONS: A very high proportion of pupils (nearly 1 in 10) had FAS/partial FAS, the rate in De Aar being the highest yet described in South Africa. FAS/partial FAS may contribute to the extremely high rate of growth retardation in South Africa as a whole and is a major cause of learning disability. These epidemiological features are important in designing preventive interventions.

Clinical profile and predictors of severe illness in young South African infants (<60 days)

BACKGROUND: Most childhood deaths occur within the first 2 months of life. Simple symptoms and signs that reliably indicate the presence of severe illness that would warrant urgent hospital management are of major public health importance. OBJECTIVES: To describe the disease profile of sick young infants aged 0 - 59 days presenting at King Edward VIII Hospital, Durban, and to assess the association between clinical features assessed by primary health workers and the presence of severe illness. METHODS: Specific clinical signs were evaluated in young infants by a health worker (nurse), using a standardised list. These signs were compared with an assessment by an experienced paediatrician for the need for urgent hospital- or clinic-based care. RESULTS: Nine hundred and twenty-five young infants were enrolled; 61 were <7 days old, 477 were 7 - 27 days old, and 387 were 28 - 59 days old. Illnesses needing urgent hospital management in the age group <7 days were hyperbilirubinaemia (43%) and sepsis (43%); in the age group 7 - 27 days they were pneumonia (26%), sepsis (17%) and hyperbilirubinaemia (15%), and in the age group 28 - 59 days they were pneumonia (54%) and sepsis (15%). The clinical sign most consistently predictive of needing urgent hospital care across all groups was not feeding well. Among those over 7 days old, a history of difficult feeding, temperature >37.5ºC and respiratory rate >60 per minute were also important. CONCLUSIONS. The simple features of feeding difficulties, pyrexia, tachypnoea and lower chest in-drawing are useful predictors of severity of illness as well as effective and safe tools for triaging of young infants for urgent hospital management at primary care centres. Neonatal hyperbilirubinaemia, pneumonia and sepsis are the common conditions for which young infants require urgent hospital-based management.

Neuropathic pain in AIDS patients prior to antiretroviral therapy

OBJECTIVE: To measure the prevalence, severity and morbidity of neuropathic pain in AIDS patients, prior to the initiation of antiretroviral (ARV) therapy. DESIGN: A prospective, cross-sectional and descriptive-analytical study. SETTING: The Kalafong Hospital HIV Clinic in Pretoria. SUBJECTS: All patients with confirmed AIDS who were referred to the Kalafong HIV clinic to be initiated on ARV therapy during the period August 2006 to March 2007. OUTCOME MEASURES: Data were collected regarding the presence and severity of neuropathic pain in each subject. Pain of predominantly neuropathic origin (POPNO) was identified using the Neuropathic Pain Diagnostic Questionnaire (DN4). Numerical rating scales (NRS), adapted from the Brief Pain Inventory, were used to measure pain severity and pain-related interference with six aspects of daily living. RESULTS: Of the 354 patients studied, 20.9% (95% confidence interval (CI) 16.8 - 25.2%) had POPNO. This pain was significantly more frequent in patients who were male, had lower CD4+ counts or higher viral load levels, and those on TB treatment. Eighty per cent of patients with POPNO experienced significant pain (worst pain severity >5 out of 10 on a NRS). Pain-related interference was highest for enjoyment of life, mood and ability to work. There was a significant positive correlation between severity of pain and pain-related interference for all domains of daily living evaluated. CONCLUSIONS: POPNO results in significant suffering and impaired functioning in patients with AIDS. It is therefore imperative that clinicians assess patients with AIDS for the presence and severity of neuropathic pain and manage it, using the most recent evidence-based guidelines.