SAMJ: South African Medical Journal

Medunsa's rebirth would do well to start with a truth and reconciliation process

Stroke and atrial fibrillation

Changes to parental consent procedures in South Africa: implications for school-based adolescent sexual health research

Where have all the flowers gone?

Erratum

Academics appeal to State: 'help us train where the needs are'

Tygerberg Burns chief wins global award

Motsoaledi declares war on disease-causing products

Mothers and babies: widening the HIV safety net

Revitalising professionalism

South Africa's cataract surgery rates: why are we not meeting our targets?

Breast cancer in antiquity

Phoebus Perdikis

South Africa needs more doctors and dentists

Lessons from the 2009 measles epidemic in South Africa

Overdose with HAART: are we managing these patients adequately?

Operative surgery at the district hospital

More doctors and dentists are needed in South Africa

BACKGROUND: An aim of the Colleges of Medicine of South Africa (CMSA) project 'Strengthening Academic Medicine and Specialist Training' was to research the number and needs of specialists and subspecialists within South Africa. METHODS: Data were collected from several sources: Deans of the 8 Faculties of Health Sciences and the Presidents of the 27 constituent Colleges of the CMSA completed a survey; and the HPCSA's Register of Approved Registrar Posts for Faculties of Health Sciences was examined and the results tabulated. RESULTS: South Africa compares unfavourably with middleincome countries on the ratios of medical and dental professionals; many districts have limited access to specialists and subspecialists. The unacceptable ratio of doctors, dentists and other health professionals per capita needs to be remedied, given South Africa's impressive reputation for its output of health professionals, including the areas of medical training, clinical practice and clinical research. The existing output from South Africa's 8 medical schools of MB ChB and specialist graduates is not being absorbed into the public health system, and neither are other health professionals. CONCLUSION: Dynamic leadership and policy interventions are required to advocate and finance the planned increase of medical, dental and other health professionals in South Africa.

High prevalence of comorbidity and need for up-referral among inpatients at a district-level hospital with specialist tuberculosis services in South Africa: the need for specialist support

OBJECTIVES: To define the patient population at Cape Town's district-level hospital offering specialist tuberculosis (TB) services, concerning the noted increase in complex, sick HIV-TB co-infected patients requiring increased levels of care. METHODS: A cross-sectional study of all hospitalised adult patients in Brooklyn Chest Hospital (a district-level hospital offering specialist TB services) from 27 to 30 October 2008. Outcome measures were: type of TB and drug sensitivity, HIV co-infection, comorbidity, Karnofsky performance score, and frequency and reason for referral to other health care facilities. RESULTS: More than two-thirds of patients in the acute wards were HIV-co-infected, of whom 98% had significant comorbidities and 60% had a Karnofsky performance score <30. Twenty-eight per cent of patients did not have a confirmed diagnosis of TB. In contrast, long-stay patients with multidrug-resistant (MDR), pre-extensively (pre-XDR) and extensively drug-resistant (XDR) TB had a lower prevalence of HIV co-infection, but manifested high rates of comorbidity. Overall, one-fifth of patients required up-referral to higher levels of care. CONCLUSIONS: District-level hospitals such as Brooklyn Chest Hospital that offer specialist TB services share the increasing burden of complex, sick, largely HIV-co-infected TB patients with their secondary and tertiary level counterparts. To support these hospitals effectively, outreach, skills transfer through training, and improved radiology resources are required to optimise patient care.

Evaluation of pain incidence and pain management in a South African paediatric trauma unit

OBJECTIVES: To evaluate pain incidence and pain management in a South African paediatric trauma unit, and to compare the usefulness of 5 different assessment tools. DESIGN: A prospective observational study, using the Numerical Rating Scale for pain (NRS pain), Numerical Rating Scale for anxiety (NRS anxiety), the Alder Hey Triage Pain Score (AHTPS), the COMFORT behaviour scale and the Touch Visual Pain Scale (TVPS). All patients were assessed at admission; those who were hospitalised were again assessed every 3 hours until discharge. RESULTS: A total of 165 patients, with a mean age of 5.3 years (range 0 - 13), were included. NRS scores were indicative of moderate to severe pain in 13.3% of the patients, and no pain in 24% at admission. Two-thirds of the patients received no analgesics; for them, NRS pain, AHTPS and TVP scores were lower than the scores for the other children. CONCLUSION: Pain and anxiety incidences in this paediatric trauma unit are relatively low. Implementation of a standard pain assessment tool in the emergency department triage system can improve pain management. The AHTPS is the most promising for use in non-Western settings.

The effectiveness of the South African Triage Score (SATS) in a rural emergency department

BACKGROUND: The Modified Early Warning Score (MEWS) is used to monitor medical inpatients in hospitals in the developed world. The South African Triage Score (SATS) was developed from the MEWS, and its use throughout South Africa has been proposed. OBJECTIVES: We aimed to assess the effectiveness of the SATS in an emergency department (ED) in a rural setting in KwaZulu-Natal (KZN). METHODS: A prospective cross-sectional study undertaken over a 1-month period in June 2009 of patients in the ED of a government hospital in rural KZN, the referral centre for 22 peripheral hospitals. Data capture included physiological parameters, mobility and trauma scores, a list of selected clinical conditions (physician discriminator list), MEWS and SATS scores, final clinical diagnosis, and outcome in the ED (death, hospital admission or discharge). Outcome measures were under- and over-triage rates according to both systems. RESULTS: Over the study period, 589 patients were triaged and their data analysed. The MEWS under-triaged 15.1% (over-triaged 8.3%) of cases that needed admission, compared with an undertriage rate of 4.4% (over-triage rate 4.3%) when the SATS was used. CONCLUSION: Our study supports use of the SATS as a primary triage score in South African urban and rural hospitals. The SATS is superior to the MEWS as a triage scoring system in a rural hospital ED in KZN, its rates of under- and over-triage falling within the limits of the American College of Surgeons Committee on Trauma (ACSCOT) guidelines.

**Acute haemorrhagic conjunctivitis epidemics and outbreaks of Paederus spp. keratoconjunctivitis ('Nairobi red eyes') and dermatitis**

An epidemic of acute conjunctivitis in Dar es Salaam in 2010 demonstrated the importance of a strong infectious diseases epidemiological surveillance network to minimise disease outbreaks. Misunderstanding of the causes and management of diseases explains the repetitive nature of acute haemorrhagic conjunctivitis (AHC) in Dar es Salaam. This paper discusses AHC and Paederus spp. keratoconjunctivitis and periorbital oedema ('Nairobi red eyes') that are confused as being associated with recurrent epidemics of conjunctivitis in Dar es Salaam.

Will the new Consumer Protection Act prevent harm to nutritional supplement users?

BACKGROUND: There is no clear distinction between the regulation of food, supplements and medicines in South Africa. Consequently, grey areas exist in implementing the legislation, particularly in the supplement industry. The increase in supplement sales in South Africa can be attributed to aggressive marketing by manufacturers whose claims are not always supported by published peer-reviewed evidence. Such claims often go unchecked, resulting in consumers being mislead about the role of supplements. As a result of poor regulation, contaminants or adulterants in supplements may also cause insidious effects unrelated to the listed ingredients. AIM: To assess the regulations, legislation, and claims associated with nutritional supplement products in South Africa. METHOD: Peer-reviewed literature and the relevant South African statutes were consulted. RESULTS: The National Health Act incorporates the Medicine Control Council, which is charged with ensuring the safety, quality and effectiveness of medicines, and related matters, including complementary/alternative medicines. The South African Institute for Drug-Free Sport and Amendment Act provides for testing athletes for using banned substances, but currently does not concern itself with monitoring nutritional supplements for contaminants or adulterants that may cause a positive drug test, which has implications for sports participants and also the health of the general population. The implementation of the Consumer Protection Act 68 of 2008 (CPA) could protect consumer rights if it is administered and resourced appropriately. CONCLUSION: The CPA should promote greater levels of policy development, regulatory enforcement, and consumer education of South Africa's supplement industry.

Reference intervals for serum total cholesterol, HDL cholesterol and non-HDL cholesterol in Batswana adults

Reference intervals of total cholesterol, HDL cholesterol and non- HDL cholesterol concentrations were determined on 309 blood donors from an urban and peri-urban population of Botswana. Using non-parametric methods to establish 2.5th and 97.5th percentiles of the distribution, the intervals were: total cholesterol 2.16 - 5.52 mmol/l; non-HDL cholesterol 1.22 - 4.48 mmol/l; and HDL cholesterol 0.67 - 1.65 mmol/l and 0.59 - 1.59 mmol/l for females and males, respectively.