SAMJ: South African Medical Journal

Euthanasia: no dignity in death in the absence of an ethos of respect for human lifes

Imprisonment and torture of doctors in Bahrain

SAMA speaks out about the victimisation of doctors in Bahrain

Legal imperatives for consent for children participating in research

Stem cell therapy and amyotrophic lateral sclerosis

Hydatid cysts of the breast and parotid gland

Silicosis: 10 000 gold miners getting set to sue

Ubuntu research values needed for Africa

'Formulaic' gender-abuse guidelines seldom followed

Govt steps up to stop corrosion of health research

Willem Abraham Cronjé

Transplantation of the heart: an overview of 40 years' clinical and research experience at Groote Schuur Hospital and the University of Cape Town. Part I. Surgical experience and clinical studies

Transplantation of the heart: an overview of 40 years' clinical and research experience at Groote Schuur Hospital and the University of Cape Town.Part II. Laboratory research experience

Hospital-acquired infections : when are hospitals legally liable?

A community officer's perspective of a rural hospital in KwaZulu-Natal

Dermatological manifestations of measles infection in hospitalised paediatric patients observed in the 2009 - 2011: Western Cape epidemic

INTRODUCTION: Measles is an acute vaccine-preventable infection common in childhood. In this study, the common dermatological signs of measles were designated the 'classic dermatological measles syndrome'. METHODS: We attempted to ascertain the prevalence of 'non-classic' dermatological measles presentation in 69 paediatric patients admitted to New Somerset Hospital, Western Cape, during the recent South African measles outbreak. The patients were examined and photographed, after informed consent had been obtained, and findings were assessed by 1 dermatology consultant and 6 dermatology registrars. Measles infection was confirmed in 38 of the patients by means of IgM testing. The data were analysed using Stata version 11.1 statistical software. OUTCOMES: Of the group, 17.4% (95% confidence interval (CI) 8.2 - 26.6%) displayed a 'classic' measles dermatological picture, although all had been clinically diagnosed and admitted as complicated measles cases. Of those serologically confirmed to have measles (N=38), 26.3% (95% CI 11.6 - 40.9%) conformed to the 'classic' dermatological picture. Therefore, a significant majority of these patients presented with what was considered in this study to be a 'non-classic' dermatological picture. CONCLUSIONS: Measles infection in a paediatric population requiring admission may frequently present without a full-house 'classic' dermatological picture. Recognised signs in isolation may be of greater value than the classically described syndrome as a whole. 'Non-classic' dermatological forms may occur more frequently than anticipated in complicated cases needing admission. Skin necrosis may be associated with measles

Delay in commencing treatment for MDR TB at a specialised TB treatment centre in KwaZulu-Natal

BACKGROUND: According to the National Department of Health (NDoH) guidelines, patients diagnosed with multidrug-resistant tuberculosis (MDR TB) must be referred to a specialised treatment centre for initiation of effective therapy. MDR TB is difficult to diagnose and the centralised referral model is beset with challenges that contribute to treatment delays, increased patient morbidity and mortality, and MDR TB nosocomial transmission. Culture and drug sensitivity testing (DST) takes 8 weeks or longer to obtain results while line probe assays (LPAs) can give a result in hours. LPAs and the GeneXpert MTB/Rif (GX) are ground-breaking discoveries for TB diagnosis. However, they are not easily accessible or available to those needing it, so culture and sensitivity testing remains the gold standard for diagnosis. AIM: This study aimed to assess the delay in the initiation of MDR TB treatment and profiled the patients being referred to a specialised drug-resistant treatment centre in KwaZulu-Natal. RESULTS: Of all the patients, 75% referred showed a mean delay of 12.4 weeks from the date of sputum collection for culture and drug sensitivity testing to the start of treatment. Most of the patients were symptomatic for TB and HIV-positive. DISCUSSION: Our findings suggest that current policy on the initiation of effective treatment needs urgent revision. Staff should be appropriately trained in LPA and GX technology to reduce delays in initiating treatment for MDR TB. The NDoH's plans for rapid diagnosis and reducing the treatment burden on centralised MDR TB management facilities are in the early phases of implementation and will take years to achieve favourable and significant outcomes. CONCLUSION: There is a significant delay in initiating definitive management for MDR TB

Aminoglycoside: induced hearing loss in HIV-positive and HIV-negative multidrug-resistant tuberculosis patients

BACKGROUND: Ototoxicity following aminoglycoside treatment for multidrug-resistant tuberculosis (MDR-TB), is a significant problem. This study documents the incidence of ototoxicity in HIV-positive and HIV-negative patients with MDR-TB and presents clinical guidelines relating to ototoxicity. METHODS: A prospective cohort study of 153 MDR-TB patients with normal hearing and middle ear status at baseline controlling for 6 mitochondrial mutations associated with aminoglycosiderelated ototoxicity, at Brooklyn Chest Hospital in Cape Town. Pure tone audiometry was performed monthly for 3 months to determine hearing loss. HIV status was recorded, as was the presence of 6 mutations in the MT-RNR1 gene. RESULTS: Fifty-seven per cent developed high-frequency hearing loss. HIV-positive patients (70%) were more likely to develop hearing loss than HIV-negative patients (42%). Of 115 patients who were genetically screened, none had MT-RNR1 mutations. CONCLUSION: Ototoxic hearing loss is common in MDR-TB patients treated with aminoglycosides. HIV-positive patients are at increased risk of ototoxicity. Auditory monitoring and auditory rehabilitation should be an integral part of the package of care of MDR-TB patients.

Fresh-frozen plasma use in a South African tertiary hospital

Despite available guidelines on indications for fresh-frozen plasma (FFP) transfusion, inappropriate use is increasing worldwide. We evaluated FFP administration to patients admitted to the Steve Biko Academic Hospital over 4 months, including indications for use and completeness of requisition forms. Transfusions were considered inappropriate for 39.5% of units administered. Of request forms submitted, only 22% had sufficient information for the blood transfusion services of the indication for transfusion. Transfusion with FFP is a medical intervention that carries risks and should be undertaken with care. Although this study was conducted in one centre, it is evident that clinicians' lack of knowledge of the indications for administration of FFP is widespread. Intervention is necessary to improve patient outcomes and reduce expenditure.

Helicobacter pylori eradication: a randomised comparative trial of 7-day versus 14-day triple therapy

BACKGROUND: Helicobacter pylori is associated with several upper gastrointestinal conditions including chronic gastritis, peptic ulcer disease, and gatric malignancy. Proton pump inhibitor-based triple therapies are considered the standard regimens for H. pylori eradication, but the optimal duration of therapy is controversial. To prevent infection and complications, local studies should be undertaken to evaluate H. pylori eradication rates in a country. OBJECTIVES: We compared 7-day and 14-day regimens to determine the optimum duration of triple therapy for H. pylori eradication. We undertook a prospective randomised comparative trial of 7-day and 14-day triple therapy regimen for H. pylori eradication at the Aga Khan University Hospital, Nairobi; 120 patients with dyspepsia and H. pylori infection were randomised to receive esomeprazole, amoxicillin and clarithromycin for either 7 days (EAC 7) or 14 days (EAC 14). Compliance and side-effects were assessed 2 weeks after the start of therapy and H. pylori eradication was assessed by stool antigen tests 4 weeks after treatment. RESULTS: Both the intention-to-treat (ITT; N=120) and per protocol (PP; N=97) analyses showed no significant differences between the eradication rates of EAC 7 (ITT 76.7%; PP 92%) and EAC 14 (ITT 73.3%; PP 93.6%) (ITT p=0.67; PP p=0.76). Poor compliance was reported in one patient in the EAC 14 group. The incidence of adverse events was comparable in the two groups. CONCLUSION: One-week and 2-week triple treatments for H. pylori eradication are similar in terms of efficacy, safety and patient compliance

Suicidal ideation and attempt among South African medical students

International data reveal that medical students are at higher risk of attempting suicide than the general population. We aimed to determine the prevalence of suicidal ideation and attempt among South African medical students from three universities and identify key predisposing risk factors. Data were collected via a questionnaire to medical students on demographics, mental health history, depressive symptoms, suicidal ideation and attempt. A total of 874 medical students from three universities were enrolled. We found a high prevalence of suicidal ideation (32.3%) and suicidal attempt (6.9%), which is three times higher than the general age-appropriate South African population. Simple screening questionnaires can identify such students, enabling universities to provide targeted and improved support for at-risk students

A randomised controlled trial of suture materials used for caesarean section skin closure: Do wound infection rates differ?

OBJECTIVE: The aim of this study was to determine wound complication rates following the use of suture materials and staples for skin closure at caesarean section (CS). STUDY DESIGN: A randomised, controlled, prospective study was undertaken. RESULTS: A total of 1 100 women was assigned randomly into 3 groups: polyglycolic acid (PGA) suture group (N=361), skin staple (SS) group (N=373) and nylon suture group (N=366). The overall wound infection rate was 7%. There was no difference in respect of number of patients, age, parity and gestation between the study groups. Those who had nylon sutures as opposed to PGA sutures were 9.5 times more likely to experience wound infection (p=0.055). Women who had SS were at 6.93 times higher risk of wound infection than those who had PGA sutures (p=0.014). Other factors influencing wound infection rates included: rupture of membranes >12 hours were 13.7 times (95% confidence interval (CI) 3.9 - 47.9, p<0.0001) more likely to have wound infection than those with rupture of membranes <12 hours. For every 1-minute increase of surgery duration, the risk of infection increased 1.094 times (95% CI 1.046 - 1.145; p<0.0001). HIV-infected women were 53.4% less likely to develop wound infection than their uninfected counterparts (odds ratio 0.466, 95% CI 0.238 - 0.913; p=0.026). As the time period of observation increased from baseline to day 3 and from day 3 to day 10, wound infection risk increased by 35 times (95% CI 8.155 - 150.868; p<0.001). CONCLUSION: The use of SS for CS wound closure is associated with a significantly greater risk of wound infections. SS for wound closure at CS is not recommended for use in South African district hospitals.

Centenary of the UCT Faculty of Health Sciences

UCT@100.great!

100 years of UCT's Faculty of Health Sciences

Contributions of the University of Cape Town to medical science in the first 100 years: personal reflections

The contributions of the University of Cape Town's Faculty of Health Sciences to medical science through research over the past 100 years are reviewed. The application of contemporary techniques to common medical problems in the developing world had important implications globally. The Faculty can be proud of its achievements in many areas important to the health of people in South Africa, Africa and beyond.

The University of Cape Town's Medical Faculty and Groote Schuur Hospital

A relationship has existed between the University of Cape Town’s Medical Faculty (MF) and Groote Schuur Hospital (GSH) since the MF was established in 1912. However, this was not formalised until the first Joint Staff Agreement was signed in 1951. This close and rewarding association achieved outstanding results and produced significant benefits for both institutions over many years, despite intermittent problems and disputes. More recently, difficulties have been experienced, but it is hoped that these will be overcome.

The place and the person: named buildings, rooms and places on the campus of the Faculty of Health Sciences, University of Cape Town

The University of Cape Town's Faculty of Health Sciences, in its hundredth year, carries a strong current of its development in the inscriptions on its pediments, doorways and notice boards. These names describe the Faculty in each of its stages of evolution, and evoke a rich history. The named look down from their portraits with pride at the passing students, the staff, and the flourishing Faculty.

The Students' Health and Welfare Centres Organisation (SHAWCO) of the University of Cape Town: a review of the past 69 years

The Students' Health and Welfare Centres Organisation (SHAWCO) is a student-run non-profit community development organisation based at the University of Cape Town (UCT). In 2012 SHAWCO celebrates its 69th anniversary, making it the oldest active student-run free clinic in South Africa. Over the past 7 decades, SHAWCO has become an integral part of UCT's Faculty of Health Sciences. This article reviews its history, current activities, and plans for the future.

Health activism in Cape Town: a case study of the Health Workers Society

The Health Workers Society (HWS), founded in 1980, was one of several progressive health organisations that fought for a democratic health system in South Africa. We document the sociopolitical context within which it operated and some of its achievements. HWS, many of whose members were staff and students of the University of Cape Town, provided a forum for debate on health-related issues, politics and society, and worked closely with other organisations to oppose the apartheid state's health policies and practices. They assisted with the formation of the first dedicated trade union for all healthcare workers and were one of the first to pioneer the primary healthcare approach in an informal settlement in Cape Town.

From medical manners to moral reasoning: an historical overview of bioethics in the University of Cape Town's Faculty of Health Sciences

The history of bioethics in the Faculty of Health Sciences of the University of Cape Town follows a similar pattern to elsewhere. At first, bioethics received little formal attention, but there has been a flowering of interest over the last few decades. There has also been a shift from a professionally insular view of bioethics to one informed by non-medical disciplines. While this pattern is to be found in many parts of the world, there are some distinctive, but not unique, features of bioethics at South Africa's oldest Medical School.

Our surgical heritage: the role of the Department of Paediatric Surgery in the development of paediatric surgery in Cape Town, in Africa, and around the world

The Department of Paediatric Surgery at the University of Cape Town has made a remarkable contribution to the academic body of knowledge of Paediatric Surgery both in South Africa and around the world. It has played a key role in the development of the specialty in South Africa and through the South African diaspora has trained many paediatric surgeons who have made their mark internationally. More recently it has become a major focus of teaching and training for African paediatric surgeons. This article traces this legacy through its origins in the early 1920s to its current prominent position in the world paediatric surgical community.

The state and future of research at the University of Cape Town's Faculty of Health Sciences

The nature of research has continued to change considerably over the last century. Our Faculty's challenge has been to keep abreast of those changes to remain at the cutting edge, while contributing meaningfully to the scientific literature which informs clinical and public health practice in South Africa and beyond. The Faculty must possess an agreed-on research strategy that is dynamic and responsive. Over the years our Faculty has 'grown' such a strategy document. This article, summarising its main thrusts, is offered because we feel that while it applies specifically to the University of Cape Town, the issues raised surely apply to all similar faculties in our country and on the continent, to varying degrees

Anaesthesia: what has the University of Cape Town contributed?

From humble beginnings, the Department of Anaesthesia of the University of Cape Town has played a major role in the development of anaesthesia as a speciality, in South Africa and internationally. We highlight these contributions in clinical service, teaching and research, with particular emphasis on the department's leading role in the evolution of anaesthetic safety in adults and children: from the development of the treatment of malignant hyperthermia, to unique studies in mortality associated with anaesthesia, and modern contributions to improved drug safety. Innovations in anaesthetic techniques have contributed to significant surgical developments, including the first heart transplant. Furthermore, our research has contributed to major advances in obstetric and endocrine anaesthesia, and training in the department is recognised as being among the best in the world.

The gynaecological subspecialties: Advances in women's health

Under Professor Dennis Davey's leadership, the Department of Obstetrics and Gynaecology recognised the need for subspecialist expertise and training. Thus, the gynaecological subspecialties were developed, the first of which was gynaecological oncology. We review the research, and subsequent clinical application, which has evolved from the subspecialist units.

Fifty years of porphyria at the University of Cape Town

The porphyrias are a group of disorders resulting from defective haem biosynthesis. One form, variegate porphyria, is common in South Africa as a result of a founder effect. Over the past 50 years, the Faculty of Health Sciences of the University of Cape Town has built and maintained an international reputation for excellence in the field of porphyria. The porphyria group is respected for its research and for its accumulated experience in the management of these disorders. Equally important has been the comprehensive and holistic care offered to patients with porphyria, and to their families.

From the pursuit of excellence to the quest for significance: Promotion of a Childsafe South Africa

Trauma represents a major burden of disease in South Africa. Children are disproportionately affected by trauma; rightly, childhood trauma can be referred to as 'the neglected childhood killer disease'. Unlike the field of infectious diseases, where vaccinations and prevention are the norm, paediatric trauma is usually ignored and prevention strategies are scarce. In this article, we review paediatric trauma and its effect on our society in light of the development of more effective child safety promotion strategies.

The University of Cape Town taught me how to challenge beliefs

The world's first successful human heart transplantation on 2 December 1967 inspired me to study medicine at the University of Cape Town's Faculty of Health Sciences. There I learned 5 key elements for a successful career in either medicine or science or both - perfectionism, passion, compassion, the dispassionate investigation of all the available evidence, and the need to challenge established beliefs for which the scientific evidence appears imperfect. Challenging such beliefs enabled us to prove that hyponatraemic encephalopathy was caused by persistent and heroic over-drinking during prolonged exercise, usually lasting more than 4 hours, and was unrelated to salt losses in sweat and urine; to understand that the brain not the muscles must regulate the exercise performance, and thus develop the Central Governor Model of Exercise; and to reconsider the dietary causes of the obesity and diabetic epidemic.

A rural perspective: four stories

These brief reflections from 4 University of Cape Town (UCT) medical graduates who chose to make their careers in rural practice are written in narrative style to try to capture something of the lived experience of working in rural areas. Although still the career choice of a minority of UCT graduates, those who have chosen to practise in rural areas have found a solid base of competence and confidence in their clinical skills, that has enabled them to tackle challenges in areas beyond anything that they or their teachers might have anticipated.

The Surgical Society of the University of Cape Town: a society on the cutting edge

The Surgical Society of the University of Cape Town is a student-run society established in 2006 and is affiliated with the Department of Surgery. The aims of the society are to supplement undergraduate training, to promote medical and surgical research, and to motivate students to pursue a career in surgery. Regular monthly lectures and surgical skills courses are offered, as well as weekly anatomy workshops. A recently launched Surgery Shadow Programme enables students to interact with practising surgeons in theatre, thereby gaining insight into the advantages and challenges involved in a future career in surgery

SATVI: after 10 years closing in on a new and better vaccine to prevent tuberculosis

The vision of the South African Tuberculosis Vaccine Initiative (SATVI) (http://www.satvi.uct.ac.za) is 'A World Without TB' and our mission is 'Innovative and high-quality TB vaccine research in Africa, to impact the global epidemic'. Over the last 10 years, our focus has been two-fold: first, clinical trials of BCG and of new candidate vaccines, and second, complementary research that addresses critical questions in tuberculosis (TB) vaccine development. SATVI is now widely regarded as the leading TB vaccine clinical research site in the world.

From comprehensive medicine to public health at the University of Cape Town: A 40-year journey

We explore the history of the School of Public Health at the University of Cape Town and its relationship to changes in the understanding of the role of public health both nationally and internationally. We draw from primary and secondary sources to trace the emergence, growth and development of the School, and to situate these processes within the socio-political, clinical and public health contexts in South Africa and internationally

The University of Cape Town's contribution to medical genetics in Africa : from the past into the future

The Division of Human Genetics (DHG) of the Faculty of Health Sciences, University of Cape Town (UCT) - established in 1972 - recently celebrated its 40th anniversary. We review its history, current status and future objectives. Dr Stuart Saunders, former Professor of Medicine and Vice-Chancellor of UCT, played a pivotal role in initiating the DHG. Dr Peter Beighton served as Professor of Human Genetics from 1972 to 1999. In this period, the initial focus was on medical genetics and the development of cytogenetic, biochemical and molecular laboratories, with the help of Professor Jacquie Greenberg. Fourteen clinical and scientific DHG members obtained doctorates; of these, 8 achieved full professorial status. Current Head of the Department, Professor Raj Ramesar, succeeded to the Chair in 1999. Expansion of the molecular laboratories followed. The DHG now has comprehensive programmes for postgraduate scientific training, research and service. Publications during the lifetime of the DHG include more than 540 articles in peer-reviewed medical, genetic and scientific journals, 20 books and contributions to over 40 chapters/editorials in scientific and medical genetic books

No health without mental health: Establishing psychiatry as a major discipline in an African Faculty of Health Sciences

Psychiatry has not always been a major clinical discipline in medical schools. Although the Faculty of Health Sciences of the University of Cape Town (UCT) celebrates its Centenary in 2012, a closely aligned major psychiatric hospital is older than the Medical School, while the Department of Psychiatry is only 50 years old. These differing dates reflect the history of and challenge for psychiatry; mental disorders contribute a major portion of the burden of disease, while appropriate recognition and resourcing of services and training has been delayed. There are ongoing challenges in aligning the visions of an old state-run system that focused on those with severe psychotic illness, a newer governmental vision of the importance of treating mental disorders in the community, the realities of current under-resourcing, and the international aspiration that psychiatry is one of the clinical neurosciences. Nevertheless, considerable strides have been made towards moving psychiatry from the periphery of society and medicine to a central discipline within the Faculty of Health Sciences at UCT

South African HIV-1 vaccine candidates : the journey from the bench to clinical trials

Around 2.5 million people become infected with human immunodeficiency virus (HIV) each year. This extraordinary toll in human life and public health worldwide will only be reversed with effective prevention. Vaccination is regarded as the most effective way to prevent infectious disease. However, there are many challenges to overcome before a successful prophylactic HIV vaccine will be available. We are participating in a global effort to develop and test candidate HIV vaccines. Two candidate prophylactic HIV vaccines that were designed and developed at the University of Cape Town (UCT) entered phase 1 clinical trials in the USA and South Africa in 2009, after a 9-year development period. In addition to the vaccines in clinical trial, there is a pipeline of candidate HIV-1 subtype C vaccines including virus-like particles, novel DNA vaccines, capripoxvirus and Bacillus Calmette-Guerin (BCG)-vectored vaccines. This article describes the history of HIV vaccine research at UCT, and the partnerships that made the project possible.

Biomedical engineering at the University of Cape Town : challenges and opportunities

The biomedical engineering programme at the University of Cape Town has the potential to address some of South Africa's unique public health challenges and to contribute to growth of the local medical device industry, directly and indirectly, through research activities and postgraduate education. Full realisation of this potential requires engagement with the clinical practice environment and with industry

Approaches to target identification and validation for tuberculosis drug discovery: A University of Cape Town perspective

Tuberculosis (TB) disproportionately affects a few high-burden countries including South Africa. In these regions, basic TB research is rare, endemic countries being valued primarily as sites for drug trials and clinical studies. Our basic mycobacterial research focuses on current approaches to drug target identification and validation within the context of international trends in TB drug discovery. Increased funding for TB drug development globally prompted a significant shift in the composition of drug discovery consortia, with academic laboratories assuming a major role in collaboration with industrial partners. This hybrid model holds promise for the expansion of local programmes, especially where actively supported by government. However, the application of industry-standard business practices to research projects involving biology and chemistry expertise demands a greater appreciation of the differences between a chemically, versus biologically, validated drug target, and of the factors informing these differences.

Shedding the load of hypertension: The proteolytic processing of angiotensin-converting enzyme

A number of membrane proteins are enzymatically cleaved or ‘shed’ from the cell surface, resulting in the modulation of biological events and opening novel pharmaceutical approaches to diverse diseases by targeting shedding. Our focus has been on understanding the shedding of angiotensin-converting enzyme (ACE), an enzyme that plays a pivotal role in blood pressure regulation. The identification of novel hereditary ACE mutations that result in increased ACE shedding has advanced our understanding of the role of ACE shedding in health and disease. Extensive biochemical and molecular analysis has helped to elucidate the mechanism of ACE shedding. These findings point to the potential therapeutic role of targeting shedding in regulating tissue ACE levels in cardiovascular disease.

Haematological complications of HIV infection

South Africa is in the midst of the world’s largest human immune deficiency virus (HIV) epidemic with an estimated 5.6 million people infected. Haematological manifestations of HIV are common and diverse, occurring at all stages of infection. Haematological emergencies occurring in this setting include the high-grade lymphomas, particularly Burkitt lymphoma, and thrombotic thrombocytopenic purpura (TTP). Immune thrombocytopenic purpura (ITP), opportunistic infections and drug side-effects are also frequent causes of cytopenias. A bone marrow biopsy has a high diagnostic utility in HIV patients presenting with unexplained cytopenias and/or fevers. It is not widely realised that HIV is also a prothrombotic state with an increased incidence of thromboembolic disease. Highly active antiretroviral therapy (HAART) is now widely available in South Africa and is a crucial adjunct to therapy of haematological complications. Medical professionals across all disciplines need to be alert to the haematological complications of HIV infection.

Masithethe: Speech and language development and difficulties in isiXhosa

IsiXhosa is the second most spoken language in South Africa and one of its official languages. Spoken mainly in the Eastern and Western Cape regions it is fitting that much of the research focusing on children’s isiXhosa speech and language acquisition has been carried out at the University of Cape Town. We describe what is known about children’s acquisition of isiXhosa, and highlight studies which inform our knowledge of the typical development of the language in relation to the acquisition of consonants including clicks and the isiXhosa noun class system. Little is known about the specific nature of speech and language difficulties in isiXhosa, and the development of isiXhosa resources for speech and language assessment and therapy is in its infancy. Suggestions are made for advancing knowledge and practice which is needed to provide a relevant and quality service to isiXhosa speakers.

Herpetic ulcer of the eyelids in an immunocompromised patient

A 24-year-old black female (HIV-positive) was referred to our clinic with a 4-week history of an ulcerative lesion of the right upper and lower eyelids. She was on treatment for pulmonary tuberculosis and had been admitted to a secondary level hospital. She had no other ocular symptoms or signs. A tissue biopsy of the lesion revealed multinucleate squamous cells with ground glass viral nuclear inclusion bodies, indicative of herpes simplex virus (HSV) infection. The ulcer healed with oral and topical acyclovir therapy, confirming a herpetic origin. There is only one other reported case of this type of ulcerative eyelid lesion caused by HSV; the patient in this case was also immunocompromised.

The complexity of HIV vasculopathy

We present a case and discuss stroke related to human immunodeficiency virus (HIV) infection and the difficulties of reaching a firm diagnosis of the cause of the aneurysmal vasculopathy. In the absence of a clear aetiology we suggest looking for varicella zoster virus (VZV) replication in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) and treating with intravenous acyclovir, aiming for HIV control with appropriate antiretroviral therapy and providing suitable antiplatelet agents. If there is a high index of suspicion of VZV, therapy with acyclovir may be prudent even if the CSF PCR is negative (as may occur after the first 2 weeks of reactivation of infection). Determination of a VZV plasma:CSF IgG ratio is not readily available and would only provide surrogate support for a previous VZV infection in the central nervous system compartment.

Health Sciences undergraduate education at the University of Cape Town: A story of transformation

Undergraduate education and training in the Faculty of Health Sciences at the University of Cape Town has become socially responsive. A story of transformation that is consonant with wider societal developments since the 1994 democratic elections, outlining the changes in undergraduate curricula across the Faculty, is presented.

Polyglutamine disease: From pathogenesis to therapy

Polyglutamine diseases are inherited neurodegenerative conditions arising from expanded trinucleotide CAG repeats in the diseasecausing gene, which are translated into polyglutamine tracts in the resultant protein. Although these diseases share a common type of mutation, emerging evidence suggests that pathogenesis is complex, involving disruption of key cellular pathways, and varying with the disease context. An understanding of polyglutamine disease mechanisms is critical for development of novel therapeutics. Here we summarise theories of molecular pathogenesis, and examine ways in which this knowledge is being harnessed for therapy, with reference to work under way at the University of Cape Town. Despite a plethora of preclinical data, clinical trials of therapies for polyglutamine diseases have had only limited success. However, recently initiated trials, including those using gene silencing approaches, should provide valuable insights into the safety and efficacy of therapiesdirectly targeting polyglutamine pathogenesis. This is particularly relevant in the South African context, where the frequencies of 2 polyglutamine diseases, spinocerebellar ataxia types 1 and 7, are among the highest globally.

Improving poisoning diagnosis and surveillance of street pesticides

An effective surveillance system is required to reduce pesticide exposures and poisonings, especially from street pesticides (illegal, unlabelled, and decanted agricultural pesticides used predominately for urban household purposes). Poisoning from any pesticide class, not only organophosphates, constitutes a medically notifiable condition in South Africa. Current practice, however, is to report only organophosphate cases, resulting in severe under-reporting. The lack of data concerning the link between poisonings and street pesticides has led to the mistaken assumption that urban populations are not at risk from significant pesticide exposures and poisonings. Without accurate statistics, healthcare professionals and policy makers are unaware of the contribution of street pesticide poisonings to the overall health burden. Accurate diagnosis is a prerequisite for notification and subsequent surveillance. An algorithm has been developed to enable healthcare professionals to improve the diagnosis and notification of pesticide poisonings.

What healthcare financing changes are needed to reach universal coverage in South Africa?

The national health insurance proposed for South Africa aims to achieve a universal health system. The best way to identify the financing mechanism that is best suited to achieving this goal is to consider international evidence on funding in universal health systems. The evidence from Organisation for Economic Cooperation and Development countries and a number of middleincome countries that have achieved universal coverage clearly indicates that mandatory pre-payment financing mechanisms (i.e. general tax funding, in some cases supplemented by mandatory health insurance) must dominate, with a clearly specified, complementary role for voluntary or private health insurance.

Cardioprotection from metabolism to molecules to certainties

Starting millions of years ago, the heart developed metabolic and molecular cardioprotective paths. The concept of metabolic protection includes the recent successful early provision of glucose-insulin-potassium (GIK) to patients with acute coronary syndromes in the ambulance to inhibit high harmful free-fatty acid levels. Molecular cardioprotective pathways also developed in primeval times. The 2 major paths are the RISK (Reperfusion Injury Salvage Kinases) path and the SAFE (Survival Activating Factor Enhancement) path, on which our group in Cape Town has focused. These paths help to lessen ischaemic-perfusion damage, and may, hypothetically, also be activated by intense exercise.

Inflammatory pathways in cervical cancer - the University of Cape Town's contribution

Cervical cancer is the leading gynaecological malignancy in southern Africa. The main causal factor for development of the disease is infection of the cervix with human papillomavirus. It is a multi-step disease with several contributing co-factors including multiple sexual partners, a compromised immune system and cervical inflammation caused by infections with Chlamydia trachomatis or Neisseria gonorrhoeae. Inflammation involves extensive tissue remodelling events which are orchestrated by complex networks of cytokines, chemokines and bio-active lipids working across multiple cellular compartments to maintain tissue homeostasis. Many pathological disorders or diseases, including cervical cancer, are characterised by the exacerbated activation and maintenance of inflammatory pathways. In this review we highlight our findings pertaining to activation of inflammatory pathways in cervical cancers, addressing their potential role in pathological changes of the cervix and the significance of these findings for intervention strategies.

Renal transplantation between HIV-positive donors and recipients justified

HIV infection was previously an absolute contraindication to renal transplantation. However, with the advent of highly active antiretroviral therapy (HAART), renal transplantation using HIV-negative donor kidneys has successfully been employed for HIV-infected patients with end-stage renal failure. In resource-limited countries, places on dialysis programmes are severely restricted; HIV-infected patients, like many others with co-morbidity, are often denied treatment. Kidneys (and other organs) from HIV-infected deceased donors are discarded. The transplantation of HIV-positive donor kidneys to HIV-infected recipients is now a viable alternative to chronic dialysis or transplantation of HIV-negative donor kidneys. This significantly increases the pool of donor kidneys to the advantage of HIV-positive and -negative patients. Arguments are presented that led to our initiation of renal transplantation from HIV-positive deceased donors to HIV-positive recipients at Groote Schuur Hospital, Cape Town.

The prevalence and burden of pain and other symptoms among South Africans attending HAART clinics

BACKGROUND: Since the advent of antiretrovirals, HIV disease has largely come to be considered a chronic disease for those able to access treatment. As such, the concept of ‘living well’ with HIV is important. Increasing evidence suggests a high symptom burden in HIV that persists in the presence of treatment. OBJECTIVES: Our study aimed to measure the prevalence and burden of pain and other physical and psychological symptoms among South African HIV-positive patients attending highly active antiretroviral therapy (HAART) clinics. METHODS: The study design was a cross-sectional survey. Simple random sampling was used to recruit 385 adult participants. RESULTS: The sample had a median age of 40 years (Q1 - Q3=33 - 46) and 98.4% were receiving HAART. The mean latest CD4 count for the participants was 355.06±219/mm³. The mean number of symptoms of the 32 symptoms on the MSAS-SF experienced by participants was 10.24±5.71 (range 1 - 28). All 4 psychological symptoms were in the top 10 most prevalent symptoms, with feeling sad being the most prevalent symptom overall. CONCLUSIONS: The high prevalence of symptoms and the high symptom burden experienced by the participants in this survey suggest inadequate symptom control and highlight the palliative care needs of an ambulant patient population already receiving HAART. Extension of life without reasonable efforts to also address the patient’s quality of life is not ethically justifiable. In addition, more research appears to be required to answer whether these findings are associated with sub-optimal HAART adherence.

Remote sensing of HIV care programmes using centrally collected laboratory results: Can we monitor ART programme effectiveness?

AIMS: We describe a monitoring system at population level of patients on antiretroviral therapy (ART) using centrally collected laboratory data. We demonstrate an analogous process of remote sensing using a large set of laboratory results and illustrate the tremendous density of information stored. We moved from an individual to a community view of ART rollout, similar to remote sensing used in the earth and biological sciences when the spatial scale of the investigation is too large to be performed at ground level. METHODS: This was a retrospective cohort study of patients from January 2004 to June 2011. A total of 188 759 individual laboratory results representing 26 445 patients were analysed for average CD4 and viral load by year. RESULTS: The data showed an increasing state of health of the population and allowed for hypothesis generation when the trends did not follow expected paths. CONCLUSION: In this analysis we moved away from individual-centred data to population-level data in order to assess ART programme performance. Routine patient-monitoring data had great utility in assessment of population health. These methods are useful in monitoring and evaluation and effectiveness studies as they are easy to collect, reliable (not requiring much human matching or interventions) and scalable from a single clinic to an entire population. The larger the sample size, the more reliable the results, as confounders (such as incorrectly identified transfers out, lost-to-follow-up patients and transfers in) would be removed.

Burden of antituberculosis and antiretroviral drug-induced liver injury at a secondary hospital in South Africa

BACKGROUND: G F Jooste Hospital (GFJH) is a secondary-level referral hospital in a high HIV and tuberculosis (TB) co-infection setting. AIMS: To assess the proportion of significant drug-induced liver injury (DILI) due to tuberculosis treatment (TBT) and/or antiretroviral therapy (ART) among patients presenting with liver dysfunction at GFJH and to describe management and outcomes. METHODS: A retrospective observational study was performed of all cases referred to GFJH with significant liver dysfunction from 1 January to 30 June 2009. Significant liver dysfunction was defined by alanine transaminase (ALT)=200 U/l or total bilirubin (TBR)=44 µmol/l. TBT- or ART-associated DILI was defined as significant liver dysfunction attributed to TBT and/or ART and which resulted in the halting of treatment or the adjustment thereof. Outcome measures included case numbers, descriptive data, and in-hospital and 3-month mortality. RESULTS: A total of 318/354 cases of significant liver dysfunction were reviewed: 71 were classified as TBT- or ART-associated DILI, while liver dysfunction was attributed to other causes in the remainder. In-hospital and 3-month mortality of TBT- or ART-associated DILI patients was 27% (n=19) and 35% (n=25), respectively. The majority of deaths were related to sepsis or sepsis complicating liver dysfunction. Twenty-three patients (32%) were lost to follow-up; 23 (32%) were alive and in outpatient care 3 months after presentation. CONCLUSIONS: TBT- or ART-associated DILI is a common reason for presentation at a referral hospital in South Africa. In-hospital and 3-month mortality are high. Prospective studies are needed to define optimal management.

Immunological characterisation of an unmasking TB-IRIS case

BACKGROUND: Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an early complication of combination antiretroviral therapy (cART). Two forms are recognised: (i) paradoxical - recurrent or new TB symptoms develop after cART initiation in patients receiving TB treatment prior to cART; and (ii) unmasking TB-IRIS - active TB presents within 3 months of cART in patients not receiving TB treatment at cART initiation. The latter has heightened clinical manifestations and a marked inflammatory presentation. AIM: To gain insight into the immune pathogenesis of a case of unmasking TB-IRIS. Methods. The patient was recruited when starting cART and followed up at 4, 12 and 24 weeks of treatment. Peripheral blood mononuclear cells were used for flow cytometry. RESULTS: Immunological analysis indicated increased CD4+ T-cell proportions from 1.1% at baseline to 14% at 24 weeks (the CD4 count increased from 4 cells/ìl at baseline to 41 cells/ìl at 24 weeks). HIV viral load fell from 460 774 to 1 405 copies/ml during the same period. The proportion of TB antigen (PPD)-specific CD4+IFN-ã+ cells increased from 0.4% at baseline and 4 weeks (IRIS onset) to 7.8% at 12 weeks (after resolution of the IRIS episode); this fell to 0.7% at 24 weeks. The surface phenotype of CD4+IFN-ã+ cells during the episode was CD45RO+, CD45RA-, CCR7-, CD62L-, CCR5+/- and CD69-. We found a distorted balance between central memory and effector memory T-cells at cART commencement that might have predisposed the patient to unmasking TB-IRIS. We showed that this might have reflected compromised thymic output. DISCUSSION: While it has been suggested that tuberculin-specific Th1-responses induce TB-IRIS in HIV co-infected patients, our data in this case indicated that these cells were expanded only after IRIS onset and were therefore not inducing TB-IRIS. CONCLUSION: We describe, in hitherto unpublished detail, the immunological characterisation of an unmasking TB-IRIS case; we show that thymic output may be compromised at IRIS onset.

Advances in childhood tuberculosis - contributions from the University of Cape Town

Childhood tuberculosis (TB) is common in high TB burden countries, contributing a substantial proportion to the TB caseload. The HIV epidemic has had a large impact on the incidence, diagnosis and management of childhood TB. AIM: To review the contributions from researchers at the University of Cape Town to the field of childhood TB over the past decades. METHODS: Review of published literature on studies of childhood TB done by investigators from the University of Cape Town. RESULTS: Important advances have been made, especially in the areas of epidemiology, diagnosis and prevention of childhood TB. Epidemiological research has led to improved understanding of the large burden of childhood TB in Cape Town. Advances in diagnosis include use of improved specimens, particularly induced sputum and better diagnostic tests. The efficacy of GeneXpert, a rapid polymerase chain reaction (PCR)-based diagnostic test, on induced sputum specimens, has potential to enable a confirmed diagnosis in children of all ages at a range of healthcare facilities, and represents an important advance in management of children presenting with suspected TB. Advances in prevention include the establishment of a vaccine study site and several studies on immunisation, and on the use of primary isoniazid prophylaxis as an effective preventive strategy in symptomatic HIV-infected children. CONCLUSION: Research in childhood TB has led to important advances in diagnosis and management, enabling better care for HIV-infected and uninfected children.

The effect of physiological concentrations of bile acids on the in vitro growth of Mycobacterium tuberculosis

BACKGROUND: Intestinal tuberculosis occurs mainly in the terminal ileum and caecum, where the concentration of bile acids is lowest, and rarely in the upper digestive tract. OBJECTIVES: We examined the effect of physiological concentrations of bile acids on the in vitro growth of Mycobacterium tuberculosis (MTB). METHODS: The 4 major bile acids, lithocolic acid, cholic acid, deoxycholic acid and chenodeoxycholic acid, were added to individual Lowenstein-Jensen (LJ) culture media at physiological concentrations. A combined LJ medium was also prepared using all 4 bile acids. These were double-diluted 4 times by the addition of LJ media. Each culture medium was inoculated with the H37Rv strain of MTB and incubated at 37°C for 8 weeks. MTB growth was measured at 2 and 8 weeks in a semiquantitative fashion using cut-offs of >5, >10, >20, >100 colony-forming units. RESULTS: All lithocolic acid cultures showed uninhibited TB growth at 2 and 8 weeks. Chenodeoxycholic acid, deoxycholic acid and cholic acid alone, and in combination, showed concentration-dependent inhibition of MTB growth at 2 and 8 weeks. Four cultures were lost to contamination. CONCLUSIONS: Certain bile acids alone and in combination, at physiological concentrations, inhibit the growth of MTB in vitro. This might explain why intestinal TB occurs in the ileocaecum in the majority of cases and why gallbladder TB is very rare.

Complement component C5 and C6 mutation screening indicated in meningococcal disease in South Africa

BACKGROUND: Invasive meningococcal disease (MD), caused by Neisseria meningitidis infection, is endemic in South Africa, with a seasonal peak in winter and spring. There were 2 432 laboratory-confirmed cases between 2006 and 2010. Human deficiency of the fifth complement component (C5D) or complete absence of the sixth component (C6Q0) leads to increased risk of MD, which is often recurrent. All attacks are serious and can lead to death or severe long-term consequences. OBJECTIVE: To determine the frequency of specific disease-associated C5 and C6 gene mutations in patients presenting with MD in the Western Cape. RESULTS: In 109 patients with confirmed invasive MD investigated for local mutations known to cause C5D and C6Q0, 3 were C5D and 11 were C6Q0. In 46 black patients tested, 3 were C5D and 7 were C6Q0. In 63 coloured patients, none were C5D and 4 were C6Q0. All deficient patients were followed up and offered prophylaxis. CONCLUSION: C5D and C6Q0 are not rare genetic diseases in South Africa and affected patients are susceptible to repeated MD; 12.8% of MD patients tested were C5D or C6Q0. Blacks were at greatest risk with 21.7% being either C5D or C6Q0. We strongly recommend diagnostic testing for complement C5 and C6 deficiency in the routine work-up of all MD cases in South Africa. Prophylactic treatment should be started in susceptible individuals.

The role of the Infectious Diseases Unit at Groote Schuur Hospital in addressing South Africa's greatest burden of disease

BACKGROUND: The greatest burden of disease in South Africa (SA) comes from infectious diseases (ID), with human immunodeficiency virus (HIV) and tuberculosis (TB) dominating the health landscape. However, other infections including community-acquired and imported infections and the rise in hospital-acquired infections pose a considerable threat to public health. METHODS AND OBJECTIVES: We used a prospective cross-sectional study to examine the profile of patients referred to the Infectious Diseases Unit at Groote Schuur Hospital (GSH) between 2008 and 2011. RESULTS: A total of 2 142 patient consultations were performed, the majority at the request of secondary hospital level medical teams; 80% of patients were HIV-infected (with a median CD4 count of 128/mm3). Approximately half of antiretroviral-naïve, HIV-infected patients started antiretroviral therapy in hospital. TB, predominantly extrapulmonary, was the most common diagnosis. Imported infections, notably severe falciparum malaria, accounted for a large number of the 81 different diagnoses in HIV-seronegative patients. Over half of all patients had co-morbidity complicating their clinical presentation. In-hospital mortality was 5.8%, with overwhelming sepsis the cause in 40% of deaths, largely due to hospital-acquired infection, particularly in the HIV-infected cohort. CONCLUSION: The overwhelming burden of ID in SA is revealed in this experience at GSH, a tertiary level referral hospital serving the Cape metropolitan area. The needs of the population warrant a reappraisal of human resource capacity and training in ID in SA.

The characteristics of juvenile myasthenia gravis among South Africans

OBJECTIVES: To report the characteristics of juvenile-onset (<20 years) myasthenia gravis (MG) in Africa. SUBJECTS AND METHODS: Six South African centres collected data which included acetylcholine receptor-antibody (AChR-ab) status, delay before diagnosis, MG Foundation of America grade at onset, maximum severity and severity at last visit, therapies, outcomes and complications. RESULTS: We report on 190 individuals with a 4-year median follow-up (interquartile range (IQR) 1 - 8). The median age at symptom onset was 7 years (IQR 4 - 14). Ocular MG (26%) occurred among younger children (mean 5.1 years) compared with those developing generalised MG (74%) (mean 10.2 years) (p=0.0004). Remissions were obtained in 45% of generalised and 50% of ocular MG patients, of whom the majority received immunosuppressive treatment, mainly prednisone. Children with post-pubertal onset had more severe MG, but deaths were infrequent. Thymectomies were performed in 43% of those with generalised MG who suffered greater maximum disease severity (p=0.002); there was a trend towards more remissions in the thymectomy group compared with the non-thymectomy group (p=0.057). There was no racial variation with respect to AChR-ab status, maximum severity, or use of immunosuppression. However, 23% of children of African genetic ancestry developed partial or complete ophthalmoplegia as a complication of generalised MG (p=0.002). CONCLUSION: Younger children developed ocular MG and older children generalised MG. Persistent ophthalmoplegia developing as a MG complication is not uncommon among juveniles of African genetic ancestry. A successful approach to the management of this complication that causes significant morbidity is, as yet, unclear.

Phaco-emulsification versus manual small-incision cataract surgery in South Africa

OBJECTIVES: To compare the results of phaco-emulsification cataract surgery and manual small-incision cataract surgery. METHODS: Consecutive patients aged >50 years undergoing surgery for age-related cataract were recruited into a randomised prospective clinical trial. Randomisation was done using opaque sequentially numbered envelopes opened by the surgeon immediately prior to surgery. The patients were seen after 1 day, 2 weeks, and 8 weeks. OUTCOME MEASURES: The primary outcome measure was the uncorrected visual acuity at week 8. The secondary outcome measures were the uncorrected visual acuity on day 1, the best corrected visual acuity at week 8, the refraction at week 8, and the intra- and postoperative complications. RESULTS: One hundred patients were recruited into each arm of the study. There was no difference in the incidence of intraocular complications (p=0.19). There was no difference in the day 1 visual acuities (p=0.28). However, both the uncorrected and the corrected week 8 visual acuities were better in the eyes that had phaco-emulsification (p=0.02 and p=0.03), and there was less astigmatism (p=0.001) at week 8 in the eyes that had phacoemulsification. CONCLUSIONS: While manual small-incision surgery has been recommended as an acceptable alternative to phaco-emulsification in middle- and low-income countries, we have found that the results of phaco-emulsification are better. Where appropriate, consideration should be given to encouraging a transition to phaco-emulsification in our Vision 2020 programmes in Africa.

Early outcomes of thrombolysis for acute ischaemic stroke in a South African tertiary care centre

BACKGROUND: Stroke is an important cause of death and disability in sub-Saharan Africa. Recombinant tissue plasminogen activator (tPA) thrombolysis is effective in treating acute ischaemic stroke, but may not be a viable option in developing countries. METHODS: We assessed the short-term outcomes and safety of tPA for the treatment of stroke at Groote Schuur Hospital from the year 2000. Patients with a clinical diagnosis of acute stroke with onset of stroke symptoms within 4.5 hours of receiving thrombolysis were included. Exclusion criteria were based on the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial protocol (upper age limit was 75 years). Primary outcomes were the proportion of patients achieving significant early neurological recovery defined as an improvement of 4 or more points on the National Institutes of Health stroke scale (NIHSS) score and functional independence defined as a modified Rankin score of 2 or less at discharge. The primary safety measures were the rates of symptomatic intracranial haemorrhage (SICH) and death. RESULTS: From January 2000 to February 2011 42 patients were thrombolysed, with a mean time to tPA infusion of 160 minutes (standard deviation (SD) 50; range 60 - 270). By discharge the median NIHSS score fell from 14 (interquartile range (IQR) 10.5 - 17) to 7.5 (IQR 1 - 15); 28 (66.7%) achieved significant neurological improvement, and 17 (40.5%) were functionally independent. Two patients (4.8%) suffered SICH and there were 3 (7.1%) deaths. CONCLUSION: Thrombolysis in routine clinical practice in a South African setting has similar safety and early efficacy outcomes to controlled trials and open-label studies in developing and developed countries.

Functioning at 6 months post stroke following discharge from inpatient rehabilitation

OBJECTIVES: To determine activity limitations, participation restrictions, health-related quality of life and caregiver strain in community-dwelling stroke survivors discharged from an intensive inpatient rehabilitation programme at 6 months post stroke. METHODS: Fifty-one consecutive stroke patients admitted to a Western Cape rehabilitation centre were included. Community-dwelling participants (N=46) at 6 months post stroke were assessed using the Modified Rankin Scale (MRS), Barthel index (BI), Nottingham extended activities of daily living (NEADL) scale, Euroqol (EQ-5D) instrument and caregiver strain index (CSI). RESULTS: Most participants (73.9%) were independent in activities of daily living or had minimal disability (BI 75 - 100). However, according to the NEADL, many participants were not independent in housework (60.9%), food preparation (52.2%), shopping (80.4%) and public transport use (65.2%), implying the need for caregiver assistance. According to the MRS, 29% of participants were severely disabled, requiring caregiver assistance for basic needs, and 20% could not be left alone. Feelings of anxiety or depression were felt in 50% of participants and 59% reported pain or discomfort, according to the EQ-5D. High levels of caregiver strain were reported in 56% of caregivers (CSI). Follow-up after discharge was reported in few participants. CONCLUSIONS: Consideration should be given to support for stroke survivors and caregivers after discharge and whether targeted programmes can improve specific aspects of functioning, such as community mobility.

Twelve-month outcomes of patients admitted to the acute general medical service at Groote Schuur Hospital

OBJECTIVES: Hospitalisation for medical illness has ongoing impact on individuals, healthcare services and society beyond discharge. This study’s objective was to determine the 12-month mortality and functional outcomes of patients admitted to the acute medical service at Groote Schuur Hospital (GSH). METHODS: Follow-up, using the hospital records system and provincial death registry, together with telephonic interviews or home visits, was attempted for 465 medical inpatients admitted to GSH between 14 September and 16 November 2009. Functional outcomes were assessed using the Katz activities of daily living (ADL) score and Barthel index (BI). OUTCOME MEASURES: The major study outcomes included: 12-month mortality (overall and unexpected), changes in functional status and pre- and post-admission employment rates. RESULTS: Inpatient mortality was 11%. At 12-month follow-up, 35% (145/415) were deceased and 30% (125/415) could not be traced; 38% (55/145) of deaths were considered expected and unexpected mortality was associated with age >40 years (p=0.02) and an admission urea >7.0 mmol/l (p=0.004). Katz ADL deteriorated in 15% (21/143) of interviewed patients and was associated with age >50 years (p=0.005); 23% (33/143) had improved Katz ADL associated with admission human immunodeficiency virus (HIV) (p=0.01), tuberculosis (TB) infection (p=0.05) and sepsis (p=0.02). Employment rates declined from 41% (59/145) pre-admission to 18% (26/145) at 12 months (p<0.001), with little increase in the number of persons receiving disability grants. Twenty per cent (29/145) of patients required hospital readmission and this was associated with ADL functional decline (p=0.01). CONCLUSIONS: There was a very high overall mortality of 42% in patients admitted to the general medical wards. Significant employment decline and readmission rates highlight the additional economic and societal burdens of hospitalisation due to medical illness in the survivors.

Outcome in decompensated alcoholic cirrhotic patients with acute variceal bleeding

BACKGROUND: Variceal bleeding (VB) is the leading cause of death in cirrhotic patients with oesophageal varices. We evaluated the efficacy of emergency endoscopic intervention in controlling acute variceal bleeding and preventing rebleeding and death during the index hospital admission in a large cohort of consecutively treated alcoholic cirrhotic patients after a first variceal bleed. METHODS: From January 1984 to August 2011, 448 alcoholic cirrhotic patients (349 men, 99 women; median age 50 years) with VB underwent endoscopic treatments (556 emergency, 249 elective) during the index hospital admission. Endoscopic control of initial bleeding, variceal rebleeding and survival after the first hospital admission were recorded. RESULTS: Endoscopic intervention alone controlled VB in 394 patients (87.9%); 54 also required balloon tamponade. Within 24 hours 15 patients rebled; after 24 hours 61 (17%, n=76) rebled; and 93 (20.8%) died in hospital. No Child-Pugh (C-P) grade A patients died, while 16 grade B and 77 grade C patients died. Mortality increased exponentially as the C-P score increased, reaching 80% when the C-P score exceeded 13. CONCLUSION: Despite initial control of variceal haemorrhage, 1 in 6 patients (17%) rebled during the first hospital admission. Survival (79.2%) was influenced by the severity of liver failure, with most deaths occurring in C-P grade C patients.

Treatment of carcinoma of the anal canal at Groote Schuur Hospital

OBJECTIVES: Chemoradiation is the treatment of choice for squamous carcinoma of the anal canal, resulting in the same local control rates as surgery but with the advantage of organ function preservation. We aimed to review all cases of anal canal carcinoma treated at Groote Schuur Hospital between 2000 and 2004 and to assess treatment outcome. METHODS: The records for 31 patients presenting during this period were reviewed. Patient and tumour characteristics were recorded. Twenty-six patients were treated with chemoradiation. Local failure-free, colostomy-free and overall survival were calculated using the Kaplan-Meier method. RESULTS: Compared with the literature, the median patient age was younger and the stage was more advanced in this study. The complete response rate for all stages with chemoradiation was 80%. The local failure-free survival at 5 years was 60.7%. Colostomy-free and overall survival at 5 years were 59.2% and 65.6%, respectively. CONCLUSIONS: The patients presented with locally advanced disease. Chemoradiation is effective treatment for this group of patients and the majority avoid a permanent colostomy as they preserve anal sphincter function.

Diagnosing breast cancer: An opportunity for innovative engineering

BACKGROUND: In an ancient papyrus, dating back to 2500 BC, an Egyptian named Imhotep, thought to be the first physician and engineer in history, offers a glimpse into the earliest recorded case of breast cancer. Treatment has evolved over the years, from radical mastectomy to radiation by X-rays, and from adjuvant chemotherapy to hormonal therapy. A key challenge in fighting the ‘war’ on breast cancer is early diagnosis and here innovative engineers play a vital role. AIMS: While full-field digital mammography has emerged in the past decade, this technique suffers from relatively high dose levels and poor sensitivity when the breasts are dense. We aimed to develop a diagnostic imaging system that exposes the patient to lower ionising radiation and improves the sensitivity and specificity for women with dense breasts. RESULTS: Our PantoScanner platform has been designed to implement slot scanning digital X-rays, thereby lowering the dose and increasing signal-to-noise ratio, while also accommodating automated ultrasound and digital tomosynthesis. Early results based on mammographic phantoms are encouraging while the PantoScanner is undergoing clinical testing prior to commercial release. CONCLUSION: Since breast cancer kills 500 000 people globally every year, early diagnosis by breast screening could save the lives of many women. Our fervent hope is that the PantoScanner system will significantly contribute to this effort in South Africa and around the world.

Lowering the alcohol content of red wine does not alter its cardioprotective properties

BACKGROUND: Many epidemiological, clinical and laboratory studies suggest that chronic and moderate consumption of red wine benefits cardiovascular health, because of the alcoholic content or the polyphenols/flavonoids. Aims. The antioxidant and cardioprotective properties of a French red wine (cabernet sauvignon, 12% alcohol by volume) were compared with those of the same wine subjected to reverse osmosis for partial removal of alcohol (6% alcohol by volume). METHODS: Antioxidant capacity was assessed in vitro using the oxygen radical absorbance capacity (ORAC) assay. To test the cardioprotective effect of 12% v. 6% wine, the drinking water of rats used for controls was supplemented with red wine (12% or 6%). After 10 days, hearts were isolated on a Langendorff system and subjected to 30 minutes of global ischaemia plus 30 minutes of reperfusion (I/R). RESULT: No differences in antioxidant capacity were observed between wine of 12% and 6% alcohol content (n=8 per group). Control hearts subjected to I/R presented a rate pressure product (heart rate x left ventricular developed pressure, expressed as a percentage of baseline value) of 16±4% (mean±standard error). Pretreatment with wine 12% or 6% improved the rate pressure product to 40±6% and 43±6%, respectively (p<0.05 v. control). CONCLUSION: Our findings suggest that the reduction of alcohol content from 12% to 6% in wine did not alter its antioxidant and cardioprotective properties. Moderate and regular consumption of lower alcohol content wines may confer beneficial effects without the risks associated with traditional wines of higher alcohol content.

Trauma and violence in the later stone age of southern Africa

BACKGROUND: Antemortem and perimortem fractures in skeletons recovered from Later Stone Age burials in southern Africa demonstrate that people were, on occasion, the victims of severe trauma attributable to interpersonal violence. METHODS: Case studies are presented of cranial vault depression fractures on 4 different individuals and a young adult female who had 2 bone arrowheads embedded in the lower vertebrae. These are compared with other cases from the literature. RESULTS: The evidence from the archaeological skeletons suggests that interpersonal violence was a regular occurrence among prehistoric foragers. Additional cases show healed fractures of other bones, but these probably represent injuries from day-to-day activities rather than violent conflict. DISCUSSION: The ethnographic depiction of the San as ‘harmless people’ is probably inaccurate, or, at best, only representative of the situation in northern Botswana in the 1960s. Damage to the bones indicates that the cause of the trauma was intentional violence. Explanatory models that suggest intense competition between hunter-gatherer groups are probably more accurate than ones that suggest that the groups were non-aggressive. CONCLUSION: Historical references to the San as aggressive and dangerous adversaries may be more accurate than revisionist historians have argued.

Low acceptability of medical male circumcision as an HIV/AIDS prevention intervention within a South African community that practises traditional circumcision

BACKGROUND: Traditional circumcision is practised among some indigenous tribes in South Africa (SA) such as the Xhosa. Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of HIV infection in heterosexual men. The acceptability of circumcision as a biomedical intervention mirroring an ingrained cultural practice, as well as the age and extent of the procedure, are poorly understood. METHODS: Men aged 15 - 42 years were recruited in a peri-urban settlement near Cape Town. Participants completed an interviewer-administered questionnaire assessing self-reported circumcision status, context and reasons for previous or planned circumcision, and willingness to undergo medical circumcision for themselves or their sons. Results were confirmed by clinical examination. The most recent HIV test result was compared with circumcision status. RESULTS: Of the 199 men enrolled, 148 (74%) reported being traditionally circumcised; of the 51 not circumcised, 50 were planning the traditional procedure. Among men self-reporting circumcision, 40 (27%) had some or all of the foreskin remaining. The median age at traditional circumcision was 21 years (interquartile range 19 - 22 years). While knowledge of the preventive benefit of circumcision was reported by 128 men (66%), most were unwilling to undergo medical circumcision or allow their sons to do so, because of religion/culture, notions of manhood, and social disapproval. CONCLUSION: Almost all men in this study had undergone or were planning to undergo traditional circumcision and were largely opposed to the medically performed procedure. In the majority, traditional circumcision had occurred after the mean age of sexual debut and almost a quarter were found to have only partial foreskin removal. To ensure optimal HIV prevention benefits, strategies to facilitate complete foreskin removal prior to sexual debut within traditional circumcision practices require further attention.

Racial discrimination: Experiences of black medical school alumni at the University of Cape Town, 1945 - 1994

OBJECTIVE: Reflecting on its role during apartheid, the Faculty of Health Sciences of the University of Cape Town (UCT) undertook a study to explore the experiences of black alumni who trained in the period 1945 - 1994. DESIGN: Seventy-five black alumni were selected through purposive and snowball recruitment, resulting in 52 face-to-face and 23 telephonic or postal interviews. RESULTS: Experiences of racial discrimination were widely reported and respondents believed the quality of their training was adversely affected. Until 1985, black students were required to sign a declaration agreeing to excuse themselves from classes where white patients were present. Black students were denied access to white patients in wards, and the university admitted that it could not guarantee their clinical training. Tutorial groups were racially segregated. Black students were also excluded from university facilities, events and extramural activities. Themes that emerged were: lack of social contact with white staff and students during training, belief that white staff members actively or tacitly upheld discriminatory regulations, and resistance by black students. Efforts of some white staff to resist discrimination were acknowledged. CONCLUSION: Racism was entrenched explicitly and implicitly. Perceptions of the attitudes of white staff to apartheid legislation on the part of black alumni were diverse, ranging from claims of active support for racial discrimination to recognition of attempts to resist racist rules. These findings provided the basis for Faculty transformation initiatives based on human rights, respect for human dignity and non-discrimination.

Access to livelihood assets among youth with and without disabilities in South Africa: Implications for health professional education

PURPOSE: This study compared access to 5 livelihood assets among significantly more NDY received support from extended family, disabled and non-disabled youth, to inform health professionals on friends, partners, and neighbours. They spent significantly more inequities related to disability and to monitor the transformation time engaging in all free-time activities. NDY reported more access agenda aimed at creating an inclusive society. METHODS: Fieldworkers interviewed 989 youth (18 - 35 years;523 (52.9%) disabled youth (DY), 466 (47.1%) non-disabled youth (NDY)) at 9 sites in 5 South African provinces. Descriptive statistics were used to describe demographic characteristics and livelihood assets. Chi-squared and t-tests were used for comparisons. RESULTS: Doctors at hospitals and nurses at clinics are health professionals most frequently seen. Far fewer DY than NDY attended and completed school. Unemployment was markedly more common among DY than among NDY. Barriers to accessing employment for DY were poor health and lack of skills development, and a lack of job opportunities for NDY. Both groups received the same amount of support from immediate household members, but significantly more NDY received support from extended family, friends, partners, and neighbours. They spent significantly more time engaging in all free-time activities. NDY reported more access to bathrooms, phone, and newspapers, as well as public services and the business sector. Participation and access were limited for both groups because of inaccessible public transport. CONCLUSION: This paper shows that DY have a greater struggle to access livelihood assets than non-disabled peers. The Disability Studies Academic Programme at the University of Cape Town is an initiative that seeks to take specific focused action with disability organisations in order to address the inequities faced by disabled youth to ensure their inclusion in development to the same degree as their non-disabled peers.

Infant-parent psychotherapy at primary care level: Establishment of a service

BACKGROUND: Access to infant and child psychiatric care in South Africa is limited. With focus on maternal and infant mental health, early identification and management of developmental, behavioural and psychosocial parent-child problems can be initiated. OBJECTIVES: To establish a mental health service for children aged 0 - 3 years, for delivery of infant-parent psychotherapy in a community setting. METHODS: The DC: 0-3R Classification for Mental Health and Development Disorders of Infancy and Early Childhood was used for diagnosis and standard multi-modal parent-infant psychotherapy methods for short-term interventions. RESULTS: A total of 179 infants and their maternal caregivers were seen. The primary referral symptom was faltering weight. The most frequent psychiatric diagnosis made was 'feeding disorder of caregiver-infant reciprocity'. Seventy two per cent of caregivers were exposed to more than 4 stress factors; 75% proved compliant with treatment with resultant improvement in the relationship between caregiver and child (78%) and in the age-appropriated functioning of the infant (76%). CONCLUSION: This study confirms that a psychotherapeutic service for infants and mothers can be established at a primary healthcare level. Infant-parent psychotherapy was effective and readily accepted by the community. This service offers a training model for mental health providers enabling early recognition of mental health problems in children and psychotherapeutic intervention.