Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420130001&lang=es vol. 103 num. 1 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The health of mine(r)s</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100001&lng=es&nrm=iso&tlng=es <![CDATA[<b>Alien justice - the pitfalls of foreign work</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100002&lng=es&nrm=iso&tlng=es <![CDATA[<b>Stem cells on South African shores</b>: <b>Proposed guidelines for comprehensive informed consent</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100003&lng=es&nrm=iso&tlng=es <![CDATA[<b>Poor maternal outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100004&lng=es&nrm=iso&tlng=es <![CDATA[<b>Can a new paediatric sub-specialty improve child health in South Africa?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100005&lng=es&nrm=iso&tlng=es <![CDATA[<b>When will we escape from the medical funding industry's 'spin'?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100006&lng=es&nrm=iso&tlng=es <![CDATA[<b>'Pioneer' Paarl neuro sets alarm bells ringing</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100007&lng=es&nrm=iso&tlng=es <![CDATA[<b>No 'walk in the park' - new social compact</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100008&lng=es&nrm=iso&tlng=es <![CDATA[<b>Flesh rendered 'immortal' - Body Worlds hits Cape Town</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100009&lng=es&nrm=iso&tlng=es <![CDATA[<b>Karabus trial - a cautionary tale</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100010&lng=es&nrm=iso&tlng=es <![CDATA[<b>Lack of clinical notes angered UAE judge in Karabus case</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100011&lng=es&nrm=iso&tlng=es <![CDATA[<b>A new class of stem cells in South Africa</b>: <b>iPS cells</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100012&lng=es&nrm=iso&tlng=es Created from adult rather than embryonic cells, induced pluripotent stem (iPS) cells represent a breakthrough in stem cell science, and their pioneers have been recognised with the 2012 Nobel Prize in Medicine. These cells offer new hope in the treatment of pathogenetic diseases, but there is still a way to go on the road to effective therapeutic applications. <![CDATA[<b>Stem cell transplantation - a collegial conversation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100013&lng=es&nrm=iso&tlng=es Created from adult rather than embryonic cells, induced pluripotent stem (iPS) cells represent a breakthrough in stem cell science, and their pioneers have been recognised with the 2012 Nobel Prize in Medicine. These cells offer new hope in the treatment of pathogenetic diseases, but there is still a way to go on the road to effective therapeutic applications. <![CDATA[<b>Effectively addressing the health needs of South Africa's population</b>: <b>The role of health professions education in the 21st century</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100014&lng=es&nrm=iso&tlng=es The causes of the poor health status of the South African population are probably multifactorial, but to be socially accountable we must ensure that the education and training of health professionals continue to be aligned with the population's health needs. The authors of a seminal report published in the Lancet in 2010 provide guidelines for the future training of health professionals. Since November 2010, this report, together with other guiding publications, informed a series of strategic initiatives undertaken by the Undergraduate Education and Training subcommittee of the Medical and Dental Professions Board of the Health Professions Council of South Africa (HPCSA). These initiatives seek to ensure alignment of the training of health professionals in South Africa (SA) with the health needs of the population and with international educational norms and standards. These initiatives are described and the role of the HPCSA in guiding the education and training of SA's health professionals is explored. <![CDATA[<b>Re-launch of the South African Society of Medical Managers (previously known as the Medical Administrators Group)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100015&lng=es&nrm=iso&tlng=es Medical management is a recognised specialty in many developing and developed countries, including Australia, India, New Zealand, Pakistan and Sri Lanka. In South Africa it was recognised as a sub-specialty in the 1990s, but this is no longer the case. The South African Society of Medical Managers, in close collaboration with the Division of Medical Management of the College of Public Health Medicine of South Africa, has been working to re-establish the specialty of medical management in South Africa. Well-trained specialist medical managers would play a significant role in the effective and efficient implementation of National Health Insurance and primary healthcare re-engineering through the practice of evidence-based health care, clinical economics and administrative medicine. <![CDATA[<b>Containing costs in the era of National Health Insurance - the need for and importance of demand management in laboratory medicine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100016&lng=es&nrm=iso&tlng=es Medical management is a recognised specialty in many developing and developed countries, including Australia, India, New Zealand, Pakistan and Sri Lanka. In South Africa it was recognised as a sub-specialty in the 1990s, but this is no longer the case. The South African Society of Medical Managers, in close collaboration with the Division of Medical Management of the College of Public Health Medicine of South Africa, has been working to re-establish the specialty of medical management in South Africa. Well-trained specialist medical managers would play a significant role in the effective and efficient implementation of National Health Insurance and primary healthcare re-engineering through the practice of evidence-based health care, clinical economics and administrative medicine. <![CDATA[<b>Professionalism in the intimate examination</b>: <b>How healthcare practitioners feel about having chaperones present during an intimate consultation and examination</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100017&lng=es&nrm=iso&tlng=es BACKGROUND: Despite the clear prohibition against sexual relations with one's patients, complaints of a sexual nature against practitioners registered with the Health Professions Council of South Africa (HPCSA) have been increasing. The HPCSA does not provide ethical guidelines regarding the use of a chaperone during intimate examinations. AIMS: (i) To ascertain how a group of medical practitioners felt about the presence of chaperones during the consultation and intimate examination of patients; (ii) to determine whether they currently engage the services of chaperones; (iii) to assess how they felt about consensual sexual relationships between medical practitioners and their patients. METHODS: A self-administered, questionnaire-based survey was distributed to gynaecologists and medical practitioners. RESULTS: There was a 43% response rate with 72% of practitioners in favour of using a chaperone during an intimate examination, although only 27% always do so. Most practitioners felt that consensual sexual relationships with patients are unacceptable; 83% felt that ethical guidelines on this topic were needed. CONCLUSION: The HPCSA should develop guidelines on the use of chaperones to assist practitioners. With medical litigation increasing, using chaperones will benefit patients and practitioners. <![CDATA[<b>Medical inpatient mortality at Groote Schuur Hospital, Cape Town, 2002 - 2009</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100018&lng=es&nrm=iso&tlng=es BACKGROUND: Despite the challenges facing healthcare in South Africa, empirical insights into the performance of healthcare services over time are scarce. METHODS: We analysed first admissions of adult medical inpatients to Groote Schuur Hospital, Cape Town, from January 2002 to July 2009. Data included age, sex, medical specialty, and date of admission and discharge. We used population group and hospital billing codes as proxy measures for socio-economic status (SES). We calculated the duration of stay in days from the date of admission to discharge, and inpatient mortality rates per 1 000 patient days. Poisson regression was used to estimate mortality rate ratios (MRR) in unadjusted analysis and after adjusting for potential confounders. RESULTS: There were 42 582 first admissions. Patient demographics shifted towards a lower SES. Median age decreased from 52 years in 2002 to 49 years in 2009, while patients aged 20 - 39 years increased in proportion from 26% to 31%. The unadjusted proportion of admissions which resulted in in-hospital deaths increased from 12% in 2002 to 17% in 2009. Corresponding mortality rates per 1 000 patient days were 17.0 (95% confidence interval (CI) 15.9 - 18.3) and 23.4 (95% CI 21.6 - 25.4), respectively (unadjusted MRR 1.37; 95% CI 1.23 - 1.53). Annual increases in mortality rates were highest during the first 2 days following admission (increasing from 30.1 to 50.3 deaths per 1 000), and were associated with increasing age, non-paying patient status, black population group and male sex, and were greatest in the emergency ward (adjusted MRR 1.73, comparing 2009 with 2002; 95% CI 1.49 - 2.01). DISCUSSION: Increasing medical inpatient mortality rates at a large South African academic hospital were most marked during the first 2 days after admission and appeared greatest among emergency medical inpatients. <![CDATA[<b>Misdiagnosis of tuberculosis in patients with lymphoma</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100019&lng=es&nrm=iso&tlng=es BACKGROUND: Since 1970, the incidence of lymphoma, a potentially curable disease, has risen by 80% in the general population and in HIV-positive patients. Given its clinical similarities to tuberculosis (TB), lymphoma may be misdiagnosed and patients treated unnecessarily with potentially harmful TB medication. OBJECTIVES: (i) To identify patients with a histological diagnosis of lymphoma who were previously misdiagnosed with TB; and (ii) to raise awareness of lymphoma as a differential diagnosis when TB has not been confirmed. METHOD: A retrospective study was conducted at Ngwelezane Hospital in rural KwaZulu-Natal, which serves an estimated population of 3 million. Using clinic notes and a questionnaire for patients attending the lymphoma clinic, we identified patients who had undergone failed TB treatment in the 12 months before their histological confirmation of lymphoma. RESULTS: Twenty-one patients were included; 18 had been diagnosed with TB in the 12 months preceding the histological confirmation of lymphoma. All these patients subjectively reported TB treatment failure. CONCLUSIONS: Delay in diagnosing lymphoma or its misdiagnosis is an important clinical problem in South Africa, with the condition often misdiagnosed as TB. This subjects patients to incorrect treatment and potential harm. We propose an algorithm for the work-up of patients presenting with lymphadenopathy +/- constitutional symptoms, to assist diagnosis and management in resource-poor settings. <![CDATA[<b>Incidence of cytological abnormalities within 24 months of a normal cervical smear in Soweto, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100020&lng=es&nrm=iso&tlng=es BACKGROUND: A screening programme for cervical cancer has been implemented in South Africa (SA) with intervals of 10 years after a normal cytological result. There are no studies that evaluate repeat screening at a shorter interval in SA. OBJECTIVES: (i) To find the incidence of cytological abnormalities on a repeat test after a report of normal cytology or an inadequate Pap smear; and (ii) to explore the factors associated with an abnormal cytology on repeat testing. METHODS: This was a secondary data analysis of a randomised controlled trial of diaphragm, lubricant gel and condoms v. condoms in the prevention of HIV infection. HIV-negative women were recruited between November 2003 and December 2005, with a normal Pap smear at entry. Observation time was from the first Pap smear to the date of the repeat Pap smear. Explanatory variables used were baseline, excepting any new HIV infection. RESULTS: The incidence of cytological abnormalities was 6.48% yearly in women with a previously normal Pap smear and 11.71% yearly in women with an inadequate smear result (p=0.03). The incidence of high-grade squamous intra-epithelial lesions (HSILs) was <0.5%. Factors associated with abnormal cytology were a history of ectopic pregnancy (odds ratio (OR) 9.25; confidence interval (CI) 1.78 - 48.02; p=0.01), number of male partners (OR 1.12; CI 1.03 - 1.22; p=0.01), history of vaginal discharge (OR 13.95; CI 1.18 - 164.47; p=0.04), and incident HIV infection (OR 6.56; CI 1.14 - 38.16; p=0.04). CONCLUSION: The incidence of HSILs is low in the first 2 years after a normal or inadequate Pap smear, even in a setting with a high prevalence of cytological abnormalities. <![CDATA[<b>The burden of deliberate self-harm on the critical care unit of a peri-urban referral hospital in the Eastern Cape</b>: <b>A 5-year review of 419 patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100021&lng=es&nrm=iso&tlng=es BACKGROUND: Buffalo City Municipality (BCM) in the Eastern Cape (EC) has the highest susceptibility to deliberate self-harm (DSH) of any South African city. The EC also has a shortage of critical care beds. OBJECTIVE: This study reviewed DSH admissions over 5 years to the critical care unit (CCU) of Cecilia Makiwane Hospital (CMH), a large peri-urban hospital in the EC. It also examined the financial burden that DSH exerts on public-sector critical care. METHODS: DSH cases admitted to CMH's CCU between January 2006 and December 2010 were retrospectively reviewed. Patients under 13 years of age were excluded. Age, gender, admission duration, agent used, outcome and toxicology results were recorded. Cost was estimated using the Department of Health 2012 fee schedule. RESULTS: A total of 419 patients, comprising 17% of total CCU admissions, were included in the study. Cholinesterase inhibitors (CIs) were the most common agents ingested (55%). Compared with non-CI groups, CI patients where admitted for twice as long from admission to discharge (p<0.0001), but had a lower mortality rate (p=0.0344). No significant difference was found between gender and survival (p=0.5725) and between the yearly DSH CCU admission means (p=0.052). CI cases cost a minimum of R15 966.29 per admission and DSH CCU cases cost over R1 million per annum. CONCLUSION: DSH imposes an appreciable burden on the CCU services in the EC. There is a need to better control the unregulated availability of CIs (and related public education) as well as to improve psychiatric and psychological services in the EC rural areas. <![CDATA[<b>Comparison of HTLV-associated myelopathy (HAM) in HIV-positive and HIV-negative patients at a tertiary South African hospital</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100022&lng=es&nrm=iso&tlng=es BACKGROUND: HTLV-1 associated myelopathy (HAM), or tropical spastic paraparesis, is caused by a retrovirus, the human T-cell lymphotropic virus (HTLV). Although patients with HAM and HIV infection have been described, to our knowledge no direct comparison has been made between patients who are HIV positive and suffering from HAM (HHAM) v. those who are HIV negative and suffering from HAM. AIM: We aimed to compare clinical and radiological findings in HIV-positive and -negative patients with HAM. METHODS: Adult patients who presented to the Neurology Unit at the Steve Biko Academic Hospital from May 2005 to June 2012 with a progressive myelopathy and HTLV seropositivity were retrospectively identified and their clinical and radiological data were collected and reviewed. RESULTS: 21 patients with HAM were identified, of whom 9 were HIV-positive and 11 HIV-negative. One patient, whose HIV status had not been established, was not included in the study. Although the trend did not reach statistical significance, co-infected patients tended to present at an earlier age (HHAM 6/9 (66%) <40 years old; HAM 2/11 (18%) <40 years old) and presented to hospital earlier (HHAM 6/9 (66%) < 3 years symptomatic; HAM 7/11 (63%) &gt; 3 years symptomatic). Cord atrophy occurred in 7/8 dually infected patients and 8/10 HIV-negative patients. CONCLUSION: Although the study is limited by the small number of patients, co-infected patients tended to have a younger age of onset and to present to hospital sooner, and thoracic cord atrophy was very common. <![CDATA[<b>Late termination of pregnancy by intracardiac potassium chloride injection</b>: <b>5 years' experience at a tertiary referral centre</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100023&lng=es&nrm=iso&tlng=es OBJECTIVES: To report our experience with intracardiac potassium chloride (KCl) injection as a method of feticide for severe congenital abnormalities beyond 24 weeks' gestation. METHOD: A retrospective chart review. Patient demographics and types of fetal anomalies were analysed according to the groups that accepted or declined late termination of pregnancy (LTOP, >24 weeks) for severe congenital abnormalities. RESULTS: Of 3 896 women referred to the Fetal Medicine Unit at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, 2 209 (56.7%) were at >24 weeks' gestation at their first visit. LTOP for severe congenital abnormalities was offered to 253 (11.5%), of whom 191 (75.5%) accepted. Differences in maternal age, parity, race and religion were not statistically significant. The type of fetal abnormalities and gestational age at diagnosis influenced the decision-making process in >80% of the women. The most frequent indications for LTOP were brain and spinal abnormalities (53.0%), and aneuploidy (20.6%). Feticide by ultrasound-guided intracardiac KCl injection was performed in 138/191 cases (72.2%); 53 women who accepted LTOP did not undergo feticide for a variety of reasons. The mean interval between diagnosis and performance of feticide was 10 days (range 0 - 42 days). Fetal asystole was achieved in all cases within 2 minutes by a single-needle injection of intracardiac KCl; the mean duration of the procedure was 12 minutes (range 6 - 25 minutes). There were no maternal complications, and stillbirths occurred in all cases. CONCLUSION: Feticide by ultrasound-guided intracardiac KCl injection was an acceptable, safe and effective method for LTOP. Further studies are needed to determine the minimum dosage of KCl required to achieve the desired effect. <![CDATA[<b>Guideline for office spirometry in adults, 2012</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000100024&lng=es&nrm=iso&tlng=es BACKGROUND: Office spirometry remains an integral part of a comprehensive respiratory evaluation and is used to categorise the nature, severity and progression of respiratory diseases and to measure response to treatment. These updated guidelines are aimed at improving the quality, standardisation and usefulness of office spirometry in South Africa. RECOMMENDATIONS: All equipment should have proof of validation regarding resolution and the system's linearity (consistency). Moreover, equipment must be calibrated daily and quality controlled. It is also important to have standard operating procedures in place, including the documentation of ambient conditions and infection control measures. Adequate spirometry relies on a competent operator, accurate equipment, standardised operating procedures, quality control and patient co-operation. The indication for spirometry in a particular patient should be unambiguous and should be documented. Subjects should be appropriately prepared for testing, and patient details must be documented. Forced vital capacity (FVC) manoeuvres (either closed or open circuit) must be performed strictly according to guidelines, and strict quality assurance methods should be in place, including acceptability criteria (for any given effort) and repeatability (between efforts). Testing should continue until at least 3 acceptable curves are produced (with 2 fulfilling repeatability criteria). Other indices are derived from these efforts. CONCLUSION: Test results must be categorised and graded according to current guidelines, taking into account the indication for the test and the appropriateness of reference values.