Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 99 num. 6 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Dieting</b>: <b>a fat lot of use?</b>]]> <![CDATA[<b>Off-label drug use</b>]]> <![CDATA[<b>Treat the patient, not the result</b>]]> <![CDATA[<b>(ARV-) Free State?</b> <b>The moratorium's threat to patients' adherence and the development of drug-resistant HIV</b>]]> <![CDATA[<b>Are investigators satisfied with contract clinical research in South Africa?</b>]]> <![CDATA[<b>Kebble or quibble?</b>]]> <![CDATA[<b>GVT shifts duty of care to underpaid public sector doctors</b>]]> <![CDATA[<b>McCord</b>: <b>100-year-old beacon of hope in turbulent health care seas</b>]]> <![CDATA[<b>MCC 'tardy' as couple suffer Mefliam 'nightmare'</b>]]> <![CDATA[<b>Surprises of off-label drug use</b>: <b>where had all the Prostin gone?</b>]]> <![CDATA[<b>Santa Claus or grandfather clause?</b>]]> <![CDATA[<b>Perforation of the colon by high-pressure water inserted via the anal canal</b>]]> <![CDATA[<b>The off-label use of medication in South Africa</b>: <b>what about some information for medical practitioners?</b>]]> <![CDATA[<b>Aminoglycoside-induced hearing loss</b>: <b>South Africans at risk</b>]]> <![CDATA[<b>The costs of a bullet</b>: <b>inpatient costs of firearm injuries in South Africa</b>]]> <![CDATA[<b>Health care waste management at an academic hospital</b>: <b>knowledge and practices of doctors and nurses</b>]]> <![CDATA[<b>Clinical, legal and ethical implications of the intra-ocular (off-label) use of bevacizumab (Avastin)</b>: <b>a South African perspective</b>]]> Choroidal neovascularisation is a potentially visually devastating element of various forms of eye pathology. Recent research has focused on neurovascular age-related macular degeneration (AMD) as a cause. AMD can be classified as being exudative (wet) or atrophic (dry). Wet AMD is characterised by a pathological process in which new blood vessels develop in the choroids, causing leakage of fluid and haemorrhage under the retina and leading to localised serous detachment and loss of central vision. Vascular endothelial growth factor (VEGF) stimulates growth of neovascular membranes. Treatments have until recently yielded disappointing results. Ophthalmologists are using intra-ocular injections of bevacizumab (Avastin), an anti-VEGF, to treat AMD. Avastin appears to be safe and effective in the short term, but its intra-ocular administration is entirely off-label. Avastin is registered for treating metastatic colorectal and breast cancer. The off-label use of medication is an important part of mainstream, legitimate medical practice worldwide. Lawyers representing plaintiffs injured by drugs increasingly encounter off-label use claims. From a legal/ethical point of view the off-label use of medication represents a delicate balance between the statutory regulation of medication and a physician's prerogative to prescribe medication that in his or her medical opinion will be beneficial to the patient. The main reason for the controversy created by the off-label use of Avastin is that there are anti-VEGF drugs on the market that have formal approval for the treatment of AMD (and other eye conditions). Lucentis, for example, is extremely expensive, with treatment cost approximately 50 times that of Avastin. Many patients suffering from AMD and macular oedema cannot afford the registered product. The off-label use of Avastin has passed the innovative or experimental stages, as ophthalmologists have used it regularly and openly for a long time, with good success. Such use therefore cannot be considered careless, imprudent or unprofessional. We submit that an ophthalmologist who omits to inform a patient of the availability of Avastin for this form of treatment may be found to be negligent. Protocols developed by the South African Vitreoretinal Society and endorsed by the Ophthalmological Society of South Africa for administering Avastin and other intra-ocular medication intravitreally should be strictly adhered to. <![CDATA[<b>Socio-economic predictors of stunting in preschool children</b>: <b>a population-based study from Johannesburg and Soweto</b>]]> BACKGROUND: Stunting continues to be a child public health concern in many African countries, including South Africa. This study uses data from the Birth to Twenty study, held in Johannesburg, to investigate a range of household-level socio-economic and social support predictors of stunting in children aged less than 30 months. DESIGN: Logistical regression models were constructed using a conceptual framework to investigate the association between early life measures of socio-economic status and stunting (<-2 standard deviations from the WHO (2006) standard), using data collected in the Birth to Twenty study. RESULTS: Stunting prevalence was 18.0% (213/1 186). In unadjusted analyses, numerous socio-economic status exposures showed significant associations with stunting; however, in final multivariable models, decreased likelihood of stunting was seen in children born to mothers who were employed (adjusted odds ratio (AOR)=0.60, 95% confidence interval (CI) 0.40 - 0.88), those with fathers who had completed secondary school (AOR=0.59, 95% CI 0.40 - 0.85), and whose parents employed a domestic worker (AOR=0.40, 95% CI 0.19 - 0.83), while increased likelihood of stunting was seen in male children (AOR=1.40, 95% CI 1.03 - 1.91), and those born of low birth weight (AOR=2.56, 95% CI 1.54 - 4.26). CONCLUSIONS: Stunting and child malnutrition remain policy priorities for the South African Department of Health, and this study suggests that policies that aim to increase parental education level and reduce unemployment or target additional support to families with low education or unemployed parents may reduce stunting in preschool-age children in this setting. <![CDATA[<b>A simple clinical formula for predicting fetal weight in labour at term</b>: <b>derivation and validation</b>]]> OBJECTIVES: To derive and validate a simple formula for birth weight based on symphysis-fundal height (SFH) measurement during labour, and to determine a useful SFH cut-off value for prediction of birth weight >4 000 g. METHODS: In a derivation study, SFH was measured in women at term in the active phase of labour. A simplified formula for birth weight was derived from a regression equation. The best cut-off SFH measurement was obtained for prediction of birth weight >4 000 g. After this, a similar study was done to validate these findings. RESULTS: In the derivation study (N=504), birth weight was predicted by the equation: birth weight in g=301+78 (SFH in cm). This was transformed to the simplified formula: birth weight in g=100 ([SFH in cm]-5). Using this formula for the data set, 68.1% of birth weight estimates were correct to within 10% of the birth weight. For prediction of birth weight >4 000 g, an SFH measurement of 40 cm had a sensitivity of 82% and a specificity of 80%. In the validation study (N=294), the derived simplified formula gave 65.0% of estimates correct to within 10% of the birth weight. The predictive values of the 40 cm SFH cut-off were similar to those in the derivation study. CONCLUSION: The derived simplified formula was validated in the second study. The formula may be useful for intrapartum use in term pregnancies. A cut-off SFH measurement of 40 cm may identify labours at risk for cephalopelvic disproportion or shoulder dystocia. <![CDATA[<b>Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL)</b>]]> BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leuco-encephalopathy (CADASIL) is a hereditary autosomal dominant non-atherosclerotic non-amyloid cerebral arteriopathy. The disease was identified in 1993. We are not aware of reports in the literature of its occurrence in South Africa, and we present the clinical and laboratory features of 5 patients with CADASIL. METHODS: Patients with the characteristic radiological white matter disease and typical features (family history, ischaemic events, migraine or dementia) were evaluated for possible CADASIL by means of clinical examination, routine investigations for strokes, magnetic resonance imaging, skin biopsy electron microscopy, evoked potentials and electro-encephalography. RESULTS: The clinical and laboratory features of our study largely correlate with reported studies. However, all of the skin biopsies were positive, and the onset of migraine in our patients was considerably earlier. A new finding, to our knowledge, was the normality of visual, somatosensory and auditory evoked potentials. CONCLUSION: Our study confirms the existence of CADASIL in South Africa, and also suggests that skin electron microscopy is useful, despite recent reports of its low sensitivity, and that evoked potentials in CADASIL are likely to be normal. <![CDATA[<b>Venous thromboembolism</b>: <b>prophylactic and therapeutic practice guideline</b>]]> BACKGROUND: Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed, which unfortunately results in unacceptable morbidity and mortality in a substantial number of patients. METHOD: The Southern African Society of Thrombosis and Haemostasis reviewed the available literature as well as guidelines from other societies. Specialties represented on the committees included anaesthetics, cardiology, clinical haematology, critical care, gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery, pulmonology and vascular surgery. A draft document was produced, which was revised by consensus agreement. To avoid local bias, the guidelines were adjudicated by recognised independent international external experts. RESULTS AND CONCLUSION: A concise, practical guideline for thrombo-prophylaxis and treatment in medical and surgical patients has been produced for South African conditions. These guidelines will hopefully lead to improved anticoagulation practice in this country, which we believe will directly benefit patient outcomes.