Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420120001&lang=en vol. 102 num. 1 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The job chooses the (wo)man</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Blazing carrots/cracking whips - the HIV prevention answer?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100002&lng=en&nrm=iso&tlng=en <![CDATA[<b>The story of drotrecogin alfa - evidence-based or evidence-biased?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100003&lng=en&nrm=iso&tlng=en <![CDATA[<b>PSA screening reduces prostate cancer mortality</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Dying with dignity - advance directives</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100005&lng=en&nrm=iso&tlng=en <![CDATA[<b>Malignant persecution of doctors by the HPCSA</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100006&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Critics 'chew' furiously on Zille's HIV/drug-testing 'carrots'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Cape Health ups the innovation bar</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rural E-Cape award winner</b>: <b>'my motivation - seeing medicine change lives'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100010&lng=en&nrm=iso&tlng=en <![CDATA[<b>The Hamilton Naki Clinical Scholarship, 2007 - 2011</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Pre-implantation diagnosis to create 'saviour siblings'</b>: <b>a critical discussion of the current and future legal frameworks in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100012&lng=en&nrm=iso&tlng=en Pre-implantation genetic diagnosis (PGD) is a technology used in conjunction with in vitro fertilisation to screen embryos for genetic conditions prior to transfer. It was initially developed to screen mutations for severe, irreversible, genetic conditions. Currently, PGD makes it possible to select against more than 100 different genetic conditions. It has been proposed as a method for creating a tissue-matched child who can in turn serve as a compatible stem cell donor to save a sick sibling in need of a stem cell transplant. The advantage of this method is that it provides genetic information before implantation of an embryo into the womb, making it possible to ensure that only tissue-matched embryos are transferred to the uterus. A couple can therefore avoid the difficult choice of either terminating the pregnancy at a later point if the fetus is not a match, or extending their family again in the hope that their next child will be tissue compatible. Many people have expressed disapproval of the use of PGD for this purpose, and it is associated with many conflicting interests including religion, ethics as well as legal regulation. In order to manage these issues some jurisdictions have created legal frameworks to regulate the use of this technology. Many of these are modelled on the UK's Human Fertilisation and Embryology Authority and its guardian legislation. This paper critiques the current and future South African legal framework to establish whether it is able to adequately regulate the use of PGD as well as guard against misuse of the technology. It concludes that changes are required to the future framework in order to ensure that it regulates the circumstances in which PGD may occur and that the Minister of Health should act expediently in finalising draft regulations which will regulate PGD in the future. <![CDATA[<b>Control of hypertension in South Africa</b>: <b>time for action</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100013&lng=en&nrm=iso&tlng=en Pre-implantation genetic diagnosis (PGD) is a technology used in conjunction with in vitro fertilisation to screen embryos for genetic conditions prior to transfer. It was initially developed to screen mutations for severe, irreversible, genetic conditions. Currently, PGD makes it possible to select against more than 100 different genetic conditions. It has been proposed as a method for creating a tissue-matched child who can in turn serve as a compatible stem cell donor to save a sick sibling in need of a stem cell transplant. The advantage of this method is that it provides genetic information before implantation of an embryo into the womb, making it possible to ensure that only tissue-matched embryos are transferred to the uterus. A couple can therefore avoid the difficult choice of either terminating the pregnancy at a later point if the fetus is not a match, or extending their family again in the hope that their next child will be tissue compatible. Many people have expressed disapproval of the use of PGD for this purpose, and it is associated with many conflicting interests including religion, ethics as well as legal regulation. In order to manage these issues some jurisdictions have created legal frameworks to regulate the use of this technology. Many of these are modelled on the UK's Human Fertilisation and Embryology Authority and its guardian legislation. This paper critiques the current and future South African legal framework to establish whether it is able to adequately regulate the use of PGD as well as guard against misuse of the technology. It concludes that changes are required to the future framework in order to ensure that it regulates the circumstances in which PGD may occur and that the Minister of Health should act expediently in finalising draft regulations which will regulate PGD in the future. <![CDATA[<b>Pathogens chipping away at our last line of defence - the rise of the metallo-beta-lactamases</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100014&lng=en&nrm=iso&tlng=en We describe the first known report of a VIM1 metallo-betalactamase-producing Klebsiella pneumonia outside Europe - confirmed by our colleagues in Canada. The patient had no travel history, and surveillance failed to identify additional cases. The importance of healthcare professionals being diligent in identifying these multi-drug resistant isolates is emphasised. <![CDATA[<b>Twinning in paediatric oncology - an African experience</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100015&lng=en&nrm=iso&tlng=en Developing twinning programmes in paediatric oncology between African countries is possible, encouraging and rewarding. The development of centres of excellence in Africa could serve as a means of disseminating the knowledge and channelling international support for the surrounding countries in their effort to cure children's cancer. <![CDATA[<b>Hypertension in goldminers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100016&lng=en&nrm=iso&tlng=en BACKGROUND: Reliable information about the prevalence of hypertension, which is a major contributor to cardiovascular disease in general and to coronary heart disease in particular, in different geographical regions is essential for its prevention and optimal control. In the mining industry, which comprises mainly urbanised black African men, the prevalence, impact, treatment and control of hypertension remains unexplored. METHODS: We conducted a retrospective, descriptive 1-year hypertension prevalence study in Gauteng Harmony Mine Operations in South Africa. Patient profiles and blood pressure (BP) measurements were retrieved from the company electronic data systems. Follow-up entries made at all the different health facilities that serve this population were examined. Continuous variables were summarised using means or medians with standard deviations. Categorical deviations, including ethnicity, were summarised using percentages and/or frequencies. RESULTS: Of the 4 297 subjects (100% of the mining population in the study period), 4 286 (99%) were black Africans; 90% were men; mean age was 44.62 years; and 39.5% (N=1 696) had hypertension, for which 42% (N=719) received pharmacological treatment, of which 31% (13% of the total hypertensive population) achieved an adequate BP control target of <140/90 mmHg. Pharmacological treatment included diuretics (38.5%), angiotensin-converting enzyme inhibitors (30.16%), calcium channel blockers (26%), beta-blockers (4.47%), angiotensin-receptor blockers (0.17%) and centrally acting agents (0.07%), usually taken in combination. CONCLUSION: We confirmed that hypertension is an important health challenge for the mining industry in South Africa. Detection, treatment and adequate control of hypertension should receive high priority from the mining authorities. <![CDATA[<b>HIV management by nurse prescribers compared with doctors at a paediatric centre in Gaborone, Botswana</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100017&lng=en&nrm=iso&tlng=en OBJECTIVES: To compare compliance with national paediatric HIV treatment guidelines between nurse prescribers and doctors at a paediatric referral centre in Gaborone, Botswana METHODS: A cross-sectional study was conducted in 2009 at the Botswana-Baylor Children's Clinical Centre of Excellence (COE), Gaborone, Botswana, comparing the performance of nurse prescribers and physicians caring for HIV-infected paediatric patients. Selected by stratified random sampling, 100 physician and 97 nurse prescriber encounters were retrospectively reviewed for successful documentation of eight separate clinically relevant variables: pill count charted; chief complaint listed; social history updated; disclosure reviewed; physical exam; laboratory testing; World Health Organization (WHO) staging documented; paediatric dosing. RESULTS: Nurse prescribers and physicians correctly documented 96.0% and 94.9% of the time, respectively. There was a trend towards a higher proportion of social history documentation by the nurses, but no significant difference in any other documentation items. CONCLUSION: Our findings support the continued investment in programmes employing properly trained nurses in southern Africa to provide quality care and ART services to HIV-infected children who are stable on therapy. Task shifting remains a promising strategy to scale up and sustain adult and paediatric ART more effectively, particularly where provider shortages threaten ART rollout. Policies guiding ART services in southern Africa should avoid restricting the delivery of crucial services to doctors, especially where their numbers are limited. <![CDATA[<b>Traumatic rhabdomyolysis (crush syndrome) in the rural setting</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100018&lng=en&nrm=iso&tlng=en BACKGROUND: Patients with traumatic rhabdomyolysis (crush syndrome)(CS) secondary to community beatings commonly present to a rural emergency department that has limited access to dialysis services. We describe a retrospective study of patients admitted with a diagnosis of CS to the emergency department of a government hospital in rural KwaZulu-Natal, between November 2008 and June 2009. OBJECTIVES: We assessed identification and management of these patients, considering: (i) early adverse parameters used to identify poor prognosis, (ii) the importance of early recognition, and (iii) appropriate management with aggressive fluid therapy and alkaline diuresis to prevent progression to renal failure. METHODS: Diagnosis was based on clinical suspicion and haematuria. Exclusion criteria included a blood creatine kinase level <1 000 U/l on admission. Data captured included demographics, the offending weapon, time of injury and presentation to hospital, and admission laboratory results. Outcome measures included length of time in the resuscitation unit, and subsequent movement to the main ward or dialysis unit, discharge from hospital, or death. RESULTS: Forty-four patients were included in the study (41 male, 3 female), all presenting within 24 hours of injury: 27 were assaulted with sjamboks or sticks, 43 were discharged to the ward with normal or improving renal function, and 1 patient died. CONCLUSION: Serum potassium, creatinine, and creatine kinase levels were important early parameters for assessing CS severity; 43 patients (98%) had a favourable outcome, owing to early recognition and institution of appropriate therapy - vital in the absence of dialysis services. <![CDATA[<b>Luminex-based virtual crossmatching for renal transplantation in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100019&lng=en&nrm=iso&tlng=en BACKGROUND: Current practice in the Johannesburg renal transplantation programme is to perform a transplant when the patient's complement-dependent cytotoxicity and flow cytometric crossmatches are negative. However, even in patients with negative crossmatches early graft rejections have occurred. We retrospectively evaluated the use of Luminex anti-human leukocyte antigen (HLA) antibody detection technology, often termed 'virtual crossmatching', compared with the flow cytometric crossmatch, for predicting graft outcome in renal transplant patients. METHODS: Sixty-four recipients were crossmatched against multiple donors during their routine work-up for transplant (111 crossmatches); 17 of these patients received transplants during the study period. Anti-HLA antibody detection was performed using Luminex technology and the results were compared with the flow cytometric crossmatch results and with short-term graft success. RESULTS: Compared with flow cytometric crossmatch results, the sensitivity and specificity of Luminex virtual crossmatching was 85.7% and 90.7% for the T-cell crossmatch and 100% and 87.2% for the B-cell crossmatch. Both the sensitivity and specificity of Luminex for predicting short-term graft success were 100%. CONCLUSION: Strong evidence is provided that single-antigen assays provide improved sensitivity to detect clinically relevant anti-HLA antibodies and can reliably be used to predict shortterm graft success. We recommend incorporation of single-antigen Luminex methodology into the routine work-up algorithm of renal transplant recipients in South Africa. <![CDATA[<b>Provision and need of HIV/AIDS services in the city of Tshwane Metropolitan Municipality, 2010</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100020&lng=en&nrm=iso&tlng=en OBJECTIVES: To determine the need for HIV/AIDS service provision in the City of Tshwane Metropolitan Municipality (CTMM), especially in municipal areas. METHODS: The Foundation for Professional Development initiated the Compass Project. Using a questionnaire, data were collected during May - June 2010 from organisations providing HIV/AIDS services in the CTMM (organisational information and types of HIV/AIDS services). The need for HIV counselling and testing (HCT), antiretroviral treatment (ART), prevention of mother-tochild transmission (PMTCT), and care for orphans and vulnerable children (OVC) was estimated using data from various sources. RESULTS: A total of 447 service providers was included in the study: 72.3% non-governmental organisations (NGOs); 18.1% in the public sector; 5.1% in the private sector; and 4.5% faithbased organisations. The majority of the prevention- (70.2%) and support-related services (77.4%) were provided by NGOs, while the majority of treatment-related services originated from the public sector (57.3%). Service need estimates included: HCT - 1 435 438 adults aged 15 - 49 years (11 127/service provider); total ART - 75 211 adults aged 15+ years (1 213/service provider); ART initiation - 30 713 adults aged 15+ years (495/service provider); PMTCTHCT - 30 092 pregnant women (510/service provider); PMTCTART - 7 734 HIV+ pregnant women (221/service provider); and OVC care - 54 590 children (258/service provider). CONCLUSION: Service gaps remain in the provision of HCT, PMTCT-ART and OVC care. ART provision must be increased, in light of new treatment guidelines from the Department of Health. <![CDATA[<b>Seroprevalence of hepatitis B surface antigen among pregnant women attending the Hospital for Women & Children in Koutiala, Mali</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100021&lng=en&nrm=iso&tlng=en OBJECTIVES: To establish the rate of seroprevalence of the hepatitis B surface antigen in pregnant women in south-eastern Mali, and to decrease mother-to-child transmission. METHODS: In a descriptive cross-sectional comparison study, 3 659 pregnant women attending a non-governmental hospital in Koutiala, Mali, during 2008 and 2009 were screened for the hepatitis B surface antigen during antenatal clinic attendance or when admitted for delivery. A chart review compared the hepatitis B virus (HBV)-positive women to HBV-negative women used as controls to identify potential risk factors for HBsAg positivity. The variables compared were age, parity, type of genital excision, birthweight of baby and HIV status. RESULTS: A total of 293 (8.0%) pregnant women tested positive for HBsAg. Their average age was 27.6 years, average parity of 2.8 births, 90% had Type 2 genital excision, 21% had low-birthweight infants, and 14 (0.4%) women also tested positive for HIV. Infants born to HbsAg-positive women were immunised with the hepatitis B vaccine in the delivery room. Two hundred and eighty-four HBVnegative women were compared with the HBV-positive women. None of the differences of means or relationships was statistically insignificant. CONCLUSION: In view of the high endemicity and lack of easily identifiable risk factors, free maternal HBV screening should be provided to all women in Mali, and the infants born to HBsAgpositive women should be immunised within 12 hours of birth. <![CDATA[<b>South African Hypertension Guideline 2011</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742012000100022&lng=en&nrm=iso&tlng=en OUTCOME: Extensive data from randomised controlled trials have shown the benefit of treating hypertension. The target blood pressure (BP) for antihypertensive management is systolic <140 mmHg and diastolic <90 mmHg with minimal or no drug sideeffects; however, stricter BP control is required for patients with end-organ damage, co-existing risk factors and co-morbidity, e.g. diabetes mellitus. The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month. Co-existent risk factors should also be controlled. BENEFITS: Benefits of management include reduced risks of stroke, cardiac failure, chronic kidney disease and coronary heart disease. RECOMMENDATIONS: The correct BP measurement procedure is described, and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. The total cardiovascular disease risk profile should be determined for all patients to inform management strategies. Lifestyle modification and patient education are cornerstones in the management of every patient. Major indications, precautions and contraindications to each recommended antihypertensive drug are listed. Combination therapy should be considered ab initio if the BP is >20/10 mmHg above goal. First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics, calcium channel blockers (CCBs) or angiotensin-converting enzyme inhibitors (ACEIs) (or ARBs - angiotensin II receptor blockers). If the target BP is not obtained, a second antihypertensive should be added from the aforementioned list. If the target BP is still not met, the third remaining antihypertensive agent should be used. In black patients either thiazide-like diuretics or CCBs can be used initially, because response rates are better than with ACE-Is or β-blockers. In treating resistant hypertension, a centrally acting drug, vasodilator, α-blocker, spironolactone or β-blocker should be added. This guideline includes management of specific situations, i.e. hypertensive emergency and urgency, severe hypertension with target organ damage, hypertension in diabetes mellitus, resistant hypertension, fixed drug combinations, new trials in hypertension, and interactions of antihypertensive agents with other drugs. VALIDITY: The guideline was developed by the Southern African Hypertension Society.