Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 100 num. 5 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<B>Obamacare - a stunning legacy</B>]]> <link></link> <description/> </item> <item> <title><![CDATA[<B>A personal tribute to Ralph Kirsch</B>]]> <![CDATA[<B>Sudden death on an aeroplane</B>]]> <![CDATA[<B>Pathology request guidelines</B>: <B>haematology questioned</B>]]> <![CDATA[<B>Errata</B>]]> <![CDATA[<B>Withdrawal of published paper</b>]]> <![CDATA[<B>Occupation-specific dispensation - a hapless tale</B>]]> <![CDATA[<B>Dysfunctional MCC under legal threat</B>]]> <![CDATA[<B>'Opt-out' testing lacks patient-friendly system</B>]]> <![CDATA[<B>Eastern Cape health bail-out set to 'fall short'-analyst</B>]]> <![CDATA[<B>Cell-based therapy - navigating troubled waters</B>]]> <![CDATA[<B>Non-accidental injury - 'the silent pandemic'</B>]]> <![CDATA[<B>A Pan-African clinical trials registry for the specific needs of triallists on the continent</B>]]> <![CDATA[<B>The role of the state in establishing a public cord blood stem cell bank</B>]]> <![CDATA[<B>Adrenal suppression and Cushing's syndrome secondary to ritonavir and budesonide</B>]]> <![CDATA[<B>High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg</B>]]> <![CDATA[<B>The burden of imported malaria in Gauteng province</B>]]> OBJECTIVES: To describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. DESIGN: We conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. OUTCOME MEASURES: Malaria frequency, severity, and treatment. RESULTS: We identified 1 701 malaria cases; 1 548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals; 1 149 (68%) patients were male. Median age was 27 years (range 1 month - 89 years). Most (84%) infections were presumed to be acquired in Mozambique. Disease severity did not differ by age or sex. Patients who were South Africanborn were more likely to have severe disease (OR=1.43 (1.08 - 1.91)), as were patients who experienced a delay >48 hours between onset of symptoms and diagnosis or treatment (OR=1.98 (1.48 - 2.65)). While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. CONCLUSIONS: The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. Providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered. <![CDATA[<B>Dosage adjustment in medical patients with renal impairment at Groote Schuur hospital</B>]]> BACKGROUND: Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers. METHODS: We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) <50 ml per minute per 1.73 m², were identified. In-patient prescriptions were captured if they were written after clinical notes indicated impaired renal function, or >1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted. RESULTS: We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted. CONCLUSION: Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment. <![CDATA[<B>Endogenous heparin levels in the controlled asthmatic patient</B>]]> BACKGROUND: Since heparin possesses anti-inflammatory properties, it is hypothesised that asthmatic patients have decreased levels of circulating heparin compared with healthy individuals. DESIGN: We compared endogenous heparin levels in controlled asthmatic patients (53 adults) from the Asthma Clinic at Johannesburg General Hospital with those of healthy controls (26 adults) from the general population. Heparin levels in the blood samples were tested using the Chromogenix Coatest Heparin kit. RESULT: The blood of the patients contained significantly lower levels of endogenous heparin compared with that of the healthy individuals, indicating that the anti-inflammatory properties afforded by heparin are absent in these patients. <![CDATA[<B>Primary care morbidity in Eastern Cape province</B>]]> BACKGROUND: Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. AIM: To describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. DESIGN: Cross-sectional survey. SETTING: A rural clinic, health centre and district hospital in Eastern Cape Province, South Africa. METHODS: The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. RESULTS: Altogether, 4 383 patient encounters were recorded across all three sites. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. CONCLUSION: Of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. The ICPC-2 can be successfully used to monitor encounters at similar African health care facilities. <![CDATA[<B>Caesarean section wound infiltration with local anaesthetic for postoperative pain relief - any benefit?</B>]]> Delivery by caesarean section (CS) is becoming more frequent. Childbirth is an emotion-filled event, and the mother needs to bond with her baby as early as possible. Any intervention that leads to improvement in pain relief is worthy of investigation. Local anaesthetics have been employed as an adjunct to other methods of postoperative pain relief, but reports on the effectiveness of this strategy are conflicting. This review attempted to assess the effects of local anaesthetic agent wound infiltration and/or abdominal nerve blocks on pain after CS and the mother's well-being and interaction with her baby. METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009).The selection criteria were randomised controlled trials of local analgesia during CS to reduce pain afterwards. Twenty studies (1 150 women) were included. RESULTS: Women who had wound infiltration after CS performed under regional analgesia had a decrease in morphine consumption at 24 hours compared with placebo (morphine dose -1.70 mg; 95% confidence interval (CI) -2.75 to -0.94). Women who had wound infiltration and peritoneal spraying with local anaesthetic after CS under general anaesthesia (1 study, 100 participants) had a reduced need for opioid rescue (risk ratio (RR) 0.51; 95% CI 0.38 to 0.69). The numerical pain score (0 -10) within the first hour was also reduced (mean difference (MD) -1.46; 95% CI -2.60 to -0.32). Women with regional analgesia who had local anaesthetic and non-steroidal anti-inflammatory cocktail wound infiltration consumed less morphine (1 study, 60 participants; MD -7.40 mg; 95% CI -9.58 to -5.22) compared with those who had local anaesthetic control. Women who had regional analgesia with abdominal nerve blocks had decreased opioid consumption (4 studies, 175 participants; MD -25.80 mg; 95% CI -50.39 to -5.37). For outcome in terms of the visual analogue pain score (0 - 10) over 24 hours, no advantage was demonstrated in the single study of 50 participants who had wound infiltration with a mixture of local analgesia and narcotics versus local analgesia. CONCLUSIONS: Local anaesthetic infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anaesthesia are of benefit in CS by reducing opioid consumption. Non-steroidal anti-inflammatory drugs may provide additional pain relief. <![CDATA[<B>South African guideline for the diagnosis, management and prevention of acute viral bronchiolitis in children</B>]]> ENDORSEMENT: South African Thoracic Society, South African Society of Paediatric Infectious Diseases, United South African Neonatal Association. OBJECTIVE: To develop and publish a guideline for doctors managing acute viral bronchiolitis, because this condition is extremely common in South Africa, it is responsible for significant morbidity in the population, and subsequently a great deal of patient and parental distress, and the disease is costly, since many children are unnecessarily subjected to investigations and treatment strategies that are of no proven benefit. The main aims of the guideline are to promote an improved standard of treatment based on understanding of the disease and its management, and to encourage costeffective and appropriate management. EVIDENCE: A detailed literature review was conducted and summarised into this document by a selected working group of paediatricians from around the country. RECOMMENDATIONS: These include the appropriate diagnostic and management strategies for acute viral bronchiolitis.