Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 101 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Feminisation of the South African medical profession</b>: <b>not yet nirvana for gender equity</b>]]> <![CDATA[<b>South African ischaemic stroke guideline, 2010</b>]]> <![CDATA[<b>Will national health insurance ensure the national health?</b>]]> <![CDATA[<b>South African transplantation</b>: <b>where are we now and where should we go next?</b>]]> <![CDATA[<b>Reflections on then and now</b>]]> <![CDATA[<b>HIV prevalence in Zimbabwe dropping like a stone</b>]]> <![CDATA[<b>Smartphones improving clinical outcomes</b>]]> <![CDATA[<b>Health corruption busters reveal the monster in our midst</b>]]> <![CDATA[<b>Burns disasters</b>: <b>a plan for South Africa</b>]]> <![CDATA[<b>Ethical decision making in severe paediatric burn victims</b>]]> <![CDATA[<b>Vaginal deliveries</b>: <b>is there a need for documented consent?</b>]]> <![CDATA[<b>Mphako Charles Martin Modiba</b>]]> <![CDATA[<b>HIV/AIDS in South Africa</b>: <b>2nd ed.</b>]]> <![CDATA[<b>Fit for purpose?</b> <b>The appropriate education of health professionals in South Africa</b>]]> <![CDATA[<b>Down syndrome in paediatric outpatient wards at Durban hospitals</b>]]> <![CDATA[<b>Educational factors that influence the urban-rural distribution of health professionals in South Africa</b>: <b>a case-control study</b>]]> SETTING: The influence of undergraduate and postgraduate training on health professionals’ career choices in favour of rural and underserved communities has not been clearly demonstrated in resourceconstrained settings. OBJECTIVES: This study aimed to evaluate the influence of educational factors on the choice of rural or urban sites of practice of health professionals in South Africa. METHODS: Responses to a questionnaire on undergraduate and postgraduate educational experiences by 174 medical practitioners in rural public practice were compared with those from 142 urban public hospital doctors. Outcomes measured included specific undergraduate and postgraduate educational experiences, and noneducational factors such as family and community influences that were likely to affect the choice of the site of practice. RESULTS: Compared with urban doctors, rural respondents were significantly less experienced, more likely to be black, and felt significantly more accountable to the community that they served. They were more than twice as likely as the urban group to have been exposed to rural situations during their undergraduate training, and were also five times more likely than urban respondents to state that exposure to rural practice as an undergraduate had influenced their choice of where they practise. Urban respondents were significantly more attracted to working where they do by professional development and postgraduate education opportunities and family factors than the rural group. CONCLUSIONS: Evidence is provided that rural exposure influences the choice of practice site by health professionals in a developing country context, but the precise curricular elements that have the most effect deserve further research. <![CDATA[<b>The contribution of South African curricula to prepare health professionals for working in rural or under-served areas in South Africa</b>: <b>a peer review evaluation</b>]]> SETTING: The Collaboration for Health Equity through Education and Research (CHEER) was formed in 2003 to examine strategies that would increase the production of health professionals who choose to practise in rural and under-served areas in South Africa. OBJECTIVES: We aimed to identify how each faculty is preparing its students for service in rural or under-served areas. METHODS:Peer reviews were conducted at all nine participating universities. A case study approach was used, with each peer review constituting its own study but following a common protocol and tools. Each research team comprised at least three reviewers from different universities, and each review was conducted over at least 3 days on site. The participating faculties were assessed on 11 themes, including faculty mission statements, resource allocation, student selection, first exposure of students to rural and under-served areas, length of exposure, practical experience, theoretical input, involvement with the community, relationship with the health service, assessment of students and research and programme evaluation. RESULTS: With a few exceptions, most themes were assessed as inadequate or adequate with respect to the preparation of students for practice in rural or under-served areas after qualification, despite implicit intentions to the contrary at certain faculties. CONCLUSIONS: Common challenges, best practices and potential solutions have been identified through this project. Greater priority must be given to supporting rural teaching sites in terms of resources and teaching capacity, in partnership with government agencies. <![CDATA[<b>Abdominal and pericardial ultrasound in suspected extrapulmonary or disseminated tuberculosis</b>]]> OBJECTIVE: Tuberculosis (TB) in patients with or without advanced HIV infection may present as smear-negative, extrapulmonary and/or disseminated forms. We studied the role of pericardial and abdominal ultrasound examinations in the determination of extrapulmonary or disseminated TB. METHODS: A prospective descriptive and analytic cross-sectional study design was used to determine the ultrasound findings of value in patients with subsequently proven TB. Ultrasound examinations were performed on 300 patients admitted to G F Jooste Hospital with suspected extrapulmonary or disseminated TB. OUTCOME MEASURES: The presence of hepatomegaly, splenomegaly, lymphadenopathy (location, size and appearance), ascites, pleural effusions, pericardial effusions and/or splenic micro-abscesses was noted. Clinical findings, microbiological and serological data were also recorded, correlated and analysed. RESULTS: Complete data sets were available for 267 patients; 91.0% were HIV positive, and 70.0% had World Health Organization clinical stage 4 disease. Active TB (determined by smear or culture) was present in 170 cases (63.7%). Ultrasonically visible abdominal lymphadenopathy over 1 cm in minimum diameter correlated with active TB in 55.3% of cases (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.5 - 4.6, p=0.0002). Ultrasonographically detected pericardial effusions (OR 2.8, 95% CI 1.6 - 5.0, p<0.0001), ascites (OR 2.2, 95% CI 1.2 - 4.2, p=0.005) and splenic lesions (OR 1.9, 95% CI 1.0 - 3.5, p=0.024) also predicted active TB. CONCLUSION: Pericardial and abdominal ultrasound examinations are valuable supplementary investigations in the diagnosis of suspected extrapulmonary or disseminated TB. <![CDATA[<b>Postgraduate palliative care education</b>: <b>evaluation of a South African programme</b>]]> AIM: We aimed to assess the postgraduate palliative care distance education programme of the University of Cape Town (UCT) in terms of its perceived ability to influence palliative care delivery. METHODS: A mixed-methods approach, consisting of two surveys using open-ended and multiple-choice options, was conducted from January to December 2007 at the UCT School of Public Health and Family Medicine. All students registered in the programme from 2000 - 2007 were invited to participate; 83 (66.4% of all eligible participants) completed the general survey, and 41 (65.7%) of the programme’s graduates completed the graduate survey. The survey scores and open-ended data were triangulated to evaluate UCT’s palliative care postgraduate programme. RESULTS: General survey scores of graduates were significantly higher in 5 of the 6 categories in comparison with current students. The graduate survey indicated that curriculum and teaching strengths were in communication and dealing with challenging encounters. Graduates also stressed the need to develop a curriculum that incorporated a practical component. CONCLUSIONS: In addition to current postgraduate training, palliative care education in South Africa should be extended to undergraduate medical students, as the benefits of UCT’s programme were limited to a small cohort of practitioners. <![CDATA[<b>Effectiveness of prenatal screening for Down syndrome on the basis of maternal age in Cape Town</b>]]> OBJECTIVE: The prenatal screening programme for Down syndrome (DS) in the South African public health sector remains primarily based on advanced maternal age (AMA). We assessed the changes over time and effectiveness of this screening programme within a Cape Town health district. METHODS: Retrospective analysis of the Groote Schuur Hospital Cytogenetic Laboratory and Pregnancy Counselling Clinic databases and audit of maternal delivery records at a primary health care facility. RESULTS The number of amniocenteses performed for AMA in consecutive 5-year periods reduced progressively from 786 in 1981 - 1985 to 360 in 2001 - 2005. Comparing prenatal with neonatal diagnoses of DS, the absolute number and the proportion diagnosed prenatally have remained relatively constant over time. The Pregnancy Counselling Database showed that, of 507 women receiving genetic counselling for AMA in 2008 - 2009, 158 (31.1%) accepted amniocentesis - uptake has reduced considerably since the early 1990s. The audit of women delivering at a primary care facility found that only 10 (16.4%) of 61 AMA women reached genetic counselling in tertiary care: reasons included late initiation of antenatal care and low referral rates from primary care. CONCLUSION: Prenatal screening and diagnosis for DS based on AMA is working ineffectively in the Cape Town health district assessed, and this appears to be representative of a broader trend in South Africa. Inclusion of fetal ultrasound in the process of prenatal screening for DS should be explored as a way forward. <![CDATA[<b>Validity of oral mucosal transudate specimens for HIV testing using enzyme-linked immunosorbent assay in children in Chimanimani district, Zimbabwe</b>]]> OBJECTIVE: To assess the validity of oral mucosal transudate (OMT) specimens for HIV testing in children using enzyme-linked immunosorbent assay (ELISA). METHODS: A cross-sectional descriptive study was conducted asThe overall sensitivity of OMT specimens for HIV part of a community-based behavioural and HIV sero-status survey testing in children using ELISA was low. Stratifying the analysis of adults and children in the Chimanimani district of Zimbabwe. by sector showed that OMT samples are good specimens for HIV Dried blood spot (DBS) and OMT samples were collected from testing. It is important to note that factors such as the low HIV children aged between 2 and 14 years, inclusive. Both samples were prevalence in our study population, quality of the OMT, diet and tested for HIV using the Vironostika Uniform II plus O kits. The oral hygiene could have influenced the results. main study outcomes were the sensitivity and specificity of OMT samples, with DBS as the gold-standard specimen. RESULTS: Paired DBS and OMT specimens were available from 1 274 (94.4%) of the 1 350 children enrolled. Using the DBS, HIV prevalence was 3.2%. Overall sensitivity of OMT was 48.8% (95% confidence interval (CI) 33.3 - 64.5), and specificity was 98.5% (95% CI 97.7 - 99.1). CONCLUSION: The overall sensitivity of OMT specimens for HIV testing in children using ELISA was low. Stratifying the analysis by sector showed that OMT samples are good specimens for HIV testing. It is important to note that factors such as the low HIV prevalence in our study population, quality of the OMT, diet and oral hygiene could have influenced the results. <![CDATA[<b>Ecological determinants of blindness in Nigeria</b>: <b>the Nigeria national blindness and visual impairment survey</b>]]> OBJECTIVE: To determine the prevalence and causes of visual loss in different ecological zones across Nigeria. METHODS: A population-based survey using multi-stage, stratified, cluster random sampling with probability proportional to size comprising a nationally representative sample of adults aged &gt;40 years from six ecological zones. OUTCOME MEASURES: Distance vision was measured using reduced logMAR charts. Clinical examination included basic eye examination for all respondents and a detailed examination including visual fields, gonioscopy and fundus photography for those who were visually impaired or blind (i.e. presenting vision <20/40 in the better eye). A principal cause of visual loss was assigned to all respondents with presenting vision <20/40 in the better eye. RESULTS: A total of 15 122 persons aged &gt;40 years were enumerated, 13 599 (89.9%) of whom were examined. The prevalence of blindness varied according to ecological zone, being highest in the Sahel region (6.6%; 95% confidence interval (CI) 4.2 - 10.4) and lowest in the rain forest region (3.23%; 95% CI 2.6 - 3.9). Age/gender-adjusted analyses showed that risk of blindness was highest in Sahel (odds ratio (OR) 3.4; 95% CI 2.1 - 5.8). More than 80% of blindness in all ecological regions was avoidable. Trachoma was a significant cause only in the Sudan savannah belt. The prevalence of all major blinding conditions was highest in the Sahel. CONCLUSIONS: The findings of this national survey may be applicable to other countries in West and Central Africa that share similar ecological zones. Onchocerciasis and trachoma are not major causes of blindness in Nigeria, possibly reflecting successful control efforts for both these neglected tropical diseases. <![CDATA[<b>Guideline for the management of chronic obstructive pulmonary disease</b>: <b>2011 update</b>]]> OBJECTIVE: To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations. KEY POINTS: 1. Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. 2. Spirometry is essential for the diagnosis and staging of COPD. 3. COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. 4. Oral corticosteroids are no longer recommended for maintenance treatment of COPD. 5. A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. 6. Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. 7. Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. 8. A cute exacerbations of COPD significantly affect morbidity, health care units and mortality. 9. Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. 10. COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes. OPTIONS:Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease (GOLD), initiative, that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost. OUTCOME:Holistic management utilising pharmacological and nonpharmacological options are put in perspective. EVIDENCE: Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. BENEFITS, HARMS AND COSTS:The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction. RECOMMENDATIONS: These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery. VALIDATION: The COPD Working Group comprised experienced pulmonologists representing all University departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. GUIDELINE SPONSOR:The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith- Kline.