Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 100 num. 6 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>A tribute to a journal buff</b>]]> <![CDATA[<b>Noise and sports events</b>]]> <![CDATA[<b>Health technology assessment</b>: <b>a new initiative in South Africa</b>]]> <![CDATA[<b>Clinical haematology training in South Africa for fellows with the primary specialty of internal medicine</b>: <b>what's in a name?</b>]]> <![CDATA[<b>Extortion or self-defence?</b><b> - </b><b>tempers rise in claims row</b>]]> <![CDATA[<b>Second report slams crippling neglect of water/sanitation system</b>]]> <![CDATA[<b>Taming the HIV/AIDS monster in our lifetime?</b>]]> <![CDATA[<b>How will NHI affect my practice?</b><b> </b><b>Workshop seeks answers</b>]]> <![CDATA[<b>The burden of infertility among HIV-positive couples in South Africa</b>: <b>the available evidence</b>]]> <![CDATA[<b>The progression of a J wave during induction of hypothermia</b>]]> <![CDATA[<b>Somerset Hospital</b>: <b>South Africa</b><b>'s oldest hospital</b>]]> <![CDATA[<b>Frederik Jacobus Rademan (25 september 1955 - 6 march 2010)</b>]]> <![CDATA[<b>Arthur Charles Keast (30 may 1927 - 12 february 2010)</b>]]> <![CDATA[<b>Reported rapes at a hospital rape centre</b>: <b>demographic and clinical profiles</b>]]> <![CDATA[<b>Barriers to VCT despite 13 years of community-based awareness campaigns in a peri-urban township in northern Limpopo</b>]]> <![CDATA[<b>Mercury exposure in a low-income community in South Africa</b>]]> OBJECTIVES: To establish whether a specific community in a gold mining area, with potentially associated small-scale gold mining activities, was exposed to mercury. METHODS: The community was situated in Mpumalanga, where some potential sources of mercury emissions may have an impact. Adults >18 years were considered eligible. Biological monitoring, supported by questionnaires, was applied. Thirty respondents completed the questionnaire which covered demographics, energy use, food and water consumption, neurological symptoms, and confounders such as alcohol consumption and brain injuries. Mercury levels were determined in 28 urine and 20 blood samples of these respondents. RESULTS: Three (15%) of the blood samples exceeded the guideline (<10 µg/l) for individuals who are not occupationally exposed, while 14 (50%) of the urine samples exceeded the guideline for mercury in urine (<5.0 µg/g creatinine) for those not exposed occupationally. The cause of these elevated levels is unknown, as only 20% of respondents indicated that they used coal as an energy carrier. Furthermore, nobody from the community was reportedly formally employed in a goldmine. Nineteen (63%) respondents consumed locally caught fish, while 20 (67%) drank water from a river. CONCLUSIONS: Some individuals in this study may be occupationally exposed to mercury through small-scale gold mining activities. As primary health facilities will be the first point of entry for individuals experiencing symptoms of mercury poisoning, South African primary health care workers need to take cognisance of mercury exposure as a possible cause of neurological symptoms in patients. <![CDATA[<b>Warfarin-induced skin necrosis in HIV-1-infected patients with tuberculosis and venous thrombosis</b>]]> BACKGROUND: At the turn of the century, only 300 cases of warfarin-induced skin necrosis (WISN) had been reported. WISN is a rare but potentially fatal complication of warfarin therapy. There are no published reports of WISN occurring in patients with HIV-1 infection or tuberculosis (TB). METHODS: We retrospectively reviewed cases of WISN presenting from April 2005 to July 2008 at a referral hospital in Cape Town, South Africa. RESULTS: Six cases of WISN occurred in 973 patients receiving warfarin therapy for venous thrombosis (0.62%, 95% CI 0.25 - 1.37%). All 6 cases occurred in HIV-1-infected women (median age 30 years, range 27 - 42) with microbiologically confirmed TB and venous thrombosis. All were profoundly immunosuppressed (median CD4+ count at TB diagnosis 49 cells/µl, interquartile range 23 - 170). Of the 3 patients receiving combination antiretroviral therapy, 2 had TB-IRIS (immune reconstitution inflammatory syndrome). The median interval from initiation of antituberculosis treatment to venous thrombosis was 37 days (range 0 - 150). The median duration of parallel heparin and warfarin therapy was 2 days (range 1 - 6). WISN manifested 6 days (range 4 - 8) after initiation of warfarin therapy. The international normalised ratio (INR) at WISN onset was supra-therapeutic, median 5.6 (range 3.8 - 6.6). Sites of WISN included breasts, buttocks and thighs. Four of 6 WISN sites were secondarily infected with drug-resistant nosocomial bacteria (methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae) 17 - 37 days after WISN onset. In 4 patients, the median interval from WISN onset to death was 43 days (range 25 - 45). One of the 2 patients who survived underwent bilateral mastectomies and extensive skin grafting at a specialist centre. CONCLUSION: This is one of the largest case series of WISN. We report a novel clinical entity: WISN in HIV-1 infected patients with TB and venous thrombosis. The occurrence of 6 WISN cases in a 40-month period may be attributed to (i) hypercoagulability, secondary to HIV-1 and TB; (ii) short concurrent heparin and warfarin therapy; and (iii) high loading doses of warfarin. Active prevention and appropriate management of WISN are likely to improve the dire morbidity and mortality of this unusual condition. <![CDATA[<b>Symptomatic relapse of HIV-associated cryptococcal meningitis in South Africa</b>: <b>the role of inadequate secondary prophylaxis</b>]]> OBJECTIVES: Cryptococcal meningitis is the most common cause of adult meningitis in southern Africa. Much of this disease burden is thought to be due to symptomatic relapse of previously treated infection. We studied the contribution of inadequate secondary fluconazole prophylaxis to symptomatic relapses of cryptococcal meningitis. DESIGN: A prospective observational study of patients presenting with laboratory-confirmed symptomatic relapse of HIV-associated cryptococcal meningitis between January 2007 and December 2008 at GF Jooste Hospital, a public sector adult referral hospital in Cape Town. OUTCOME MEASURES: Relapse episodes were categorised into: (i) patients not taking fluconazole prophylaxis; (ii) immune reconstitution inflammatory syndrome (IRIS); and (iii) relapses occurring prior to ART in patients taking fluconazole. In-hospital mortality was recorded. RESULTS: There were 69 relapse episodes, accounting for 23% of all cases of cryptococcal meningitis; 43% (N=30) of relapse episodes were in patients not receiving fluconazole prophylaxis, 45% (N=31) were due to IRIS, and 12% (N=8) were in patients pre-ART taking fluconazole. Patients developing relapse due to inadequate secondary prophylaxis had severe disease and high in-hospital mortality (33%). Of the 30 patients not taking fluconazole, 47% (N=14) had not been prescribed secondary prophylaxis by their health care providers. We documented no relapses due to fluconazole resistance in these patients who received amphotericin B as initial therapy. CONCLUSIONS: A large number of relapses of cryptococcal meningitis are due to failed prescription, dispensing and referral for or adherence to secondary fluconazole prophylaxis. Interventions to improve the use of secondary fluconazole prophylaxis are essential. <![CDATA[<b>An evaluation of nutritional practice in a paediatric burns unit</b>]]> INTRODUCTION: Burn injuries evoke a systemic metabolic response with profound effects on organ function, susceptibility to infection, wound healing, growth and development, and mortality. Children are especially vulnerable to nutritional deficiencies owing to their limited energy reserves. METHODS: We evaluated the feeding practice in a paediatric burns unit. All children admitted to the unit were studied for a minimum of 3 consecutive days. Patients were divided into two groups: those with <20% (group 1) and burns >20% of total body surface area (TBSA) (group 2). Dietary prescriptions, intake, compliance with feeding practices, and the use of supplementary nutrition were assessed. Under-feeding and over-feeding were defined when there was a discrepancy between prescribed and actual food intake. RESULTS: Forty children (mean age 5.8 years) were studied. They sustained between 2% and 55% TBSA burns. Inadequate caloric intake was seen in 19 of 29 patients and in 9 of 11 patients in groups 1 and 2, respectively. In contrast, excess protein supplementation was seen in 24 of 29 group 1 patients and 6 of 11 group 2 patients. The dietician's food prescription was followed for 170 of 211 days; prescription compliance was correct in only 39 of 211 days. CONCLUSION: Adequate nutrition is essential for burns patients, but several factors can lead to either under- or over-feeding. A daily dietary consumption chart and evaluation of compliance are essential for each patient. There should be greater acceptability of tube enteral feeding. <![CDATA[<b>Guideline</b>: <b>appropriate use of tigecycline</b>]]> INTRODUCTION: Tigecycline, the first of a new class of antibiotics, the glycylcyclines, was licensed in South Africa for the parenteral treatment of adult patients with complicated intra-abdominal infections (cIAIs) and complicated skin and soft-tissue infections (cSSTIs). METHODS: A multidisciplinary meeting representative of the Association of Surgeons of South Africa, the Critical Care Society of Southern Africa, the Federation of Infectious Diseases Societies of Southern Africa, the South African Thoracic Society and the Trauma Society of South Africa was held to draw up a national guideline for the appropriate use of tigecycline. Background information reviewed included randomised controlled trials, other relevant publications and local antibiotic susceptibility patterns. The initial document was drafted at the meeting. Subsequent drafts were circulated to members of the working group for modification. OUTPUT: The guideline addresses several important aspects of the new agent, summarising key clinical data and highlighting important considerations with the use of the drug. The recommendations in this guideline are based on currently available scientific evidence together with the consensus opinion of the authors. CONCLUSION: This statement was written out of concern regarding the widespread misuse of antibiotics. Its primary intention is to facilitate heterogeneous use of antibiotics as a component of antibiotic stewardship and to highlight