Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420130003&lang=en vol. 103 num. 3 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Our canine carers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Cold comfort for NHI-wary GPs?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Overmedicalising - again!</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Underreporting child abuse deaths</b>: <b>Experiences from a national study on child homicide</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Underreporting child abuse deaths</b>: <b>Not all is rosy with PinkDrive</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300005&lng=en&nrm=iso&tlng=en <![CDATA[<b>One doctor's misfortune boosts TB treatment activism</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300006&lng=en&nrm=iso&tlng=en <![CDATA[<b>PinkDrive intervention 'over-rated' - experts</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300007&lng=en&nrm=iso&tlng=en <![CDATA[<b>The PPP 'without the GP' - a Western Cape story</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Provincial policy death-knell for iconic McCord Hospital?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Edward John (Ed) Immelman</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300010&lng=en&nrm=iso&tlng=en <![CDATA[<b>John Emile Cosnett</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Common Medical Problems in the Tropics</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300012&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rethinking Aging</b>: <b>Growing Old and Living Well in an Overtreated Society</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300013&lng=en&nrm=iso&tlng=en <![CDATA[<b>Daily Drug Use</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300014&lng=en&nrm=iso&tlng=en <![CDATA[<b>Risks identified in implementation of district clinical specialist teams</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300015&lng=en&nrm=iso&tlng=en The District Clinical Specialist Team (DCST) is a strategy implemented by the South African National Department of Health to strengthen district health systems. An amount of R396 million per annum will be required to fund posts in all 52 districts. During implementation, numerous risks were identified, the major one being the most expensive category of DCST personnel, i.e. Head of Clinical Unit. Similar risks will probably apply to other categories of personnel within the DCST. To achieve the objectives of the DCST strategy, risk reduction strategies need to be promptly applied. <![CDATA[<b>Establishing a Health Promotion and Development Foundation in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300016&lng=en&nrm=iso&tlng=en South Africa has a 'quadruple burden of disease'. One way to reduce this burden, and address the social determinants of health and social inequity, could be through health promotion interventions driven by an independent Health Promotion and Development Foundation (HPDF). This could provide a framework to integrate health promotion and social development into all government and civil society programmes. On priority issues, the HPDF would mobilise resources, allocate funding, develop capacity, and monitor and evaluate health promotion and development work. Emphasis would be on reducing the effects of poverty, inequity and unequal development on disease rates and wellbeing. The HPDF could also decrease the burden on the proposed National Health Insurance (NHI) system. We reflect on such foundations in other countries, and propose a structure for South Africa's HPDF and a dedicated funding stream to support its activities. In particular, an additional 2% levy on alcohol and tobacco products is proposed to be utilised to fund the HPDF. <![CDATA[<b>Clinical pharmacology becomes a specialty in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300017&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>The pilgrim's prognosis - medical aspects of a <i>camino</i></b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300018&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>So many years ago</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300019&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>The challenges of health disparities in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300020&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>National Health Insurance</b>: <b>The first 18 months</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300021&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>Triaging children - keep it simple, swift and safe</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300022&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>Acute asthma treatment guidelines</b>: <b>Reducing morbidity and mortality in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300023&lng=en&nrm=iso&tlng=en South Africa recently became the first African country where clinical pharmacology has been approved as a specialty. This article outlines the need for clinical pharmacologists, their role in advancing public health, the potential benefits to the country, and recommendations for ensuring a healthy future for the discipline. <![CDATA[<b>An adapted triage tool (ETAT) at Red Cross War Memorial Children's Hospital Medical Emergency Unit, Cape Town</b>: <b>An evaluation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300024&lng=en&nrm=iso&tlng=en OBJECTIVE: To evaluate the efficacy of an adapted Emergency Triage Assessment and Treatment (ETAT) tool at a children's hospital. DESIGN: A two-armed descriptive study. SETTING: Red Cross War Memorial Children's Hospital, Cape Town, South Africa. METHODS: Triage data on 1 309 children from October 2007 and July 2009 were analysed. The number of children in each triage category red (emergency), orange (urgent or priority) and green (non-urgent)) and their disposal were evaluated. RESULTS: The October 2007 series: 902 children aged 5 days - 15 years were evaluated. Their median age was 20 (interquartile range (IQR) 7 -50) months, and 58.8% (n=530) were triaged green, 37.5% (n=338) orange and 3.8% (n=34) red. Over 90% of children in the green category were discharged (478/530), while 32.5% of children triaged orange (110/338) and 52.9% of children triaged red (18/34) were admitted. There was a significant increase in admission rate for each triage colour change from green through orange to red after adjustment for age category (risk ratio (RR) 2.6; 95% confidence interval (CI) 2.2 - 3.1). The July 2009 cohort: 407 children with a median age of 22 months (IQR 7 - 53 months) were enrolled. Twelve children (2.9%) were triaged red, 187 (45.9%) orange and 208 (51.1%) green. A quarter (101/407) of the children triaged were admitted: 91.7% (11/12) from the red category and 36.9% (69/187) from the orange category were admitted, while 89.9% of children in the green category (187/208) were discharged. After adjusting for age category, admissions increased by more than 300% for every change in triage acuity (RR 3.2; 95% CI 2.5 - 4.1). CONCLUSIONS: The adapted ETAT process may serve as a reliable triage tool for busy paediatric medical emergency units in resource-constrained countries and could be evaluated further in community emergency settings <![CDATA[<b>Is the golden hour optimally used in South Africa for children presenting with polytrauma?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300025&lng=en&nrm=iso&tlng=en BACKGROUND: The major paediatric public health problem worldwide is injury or trauma. In 2004, 950 000 children died as a result of injury. OBJECTIVE: The aim of this study was to evaluate the logistics of medical care after paediatric polytrauma within the first hours after arrival into a trauma unit - the so-called Golden Hour. METHODS: Children presenting with polytrauma to the Trauma Unit at the Red Cross War Memorial Children's Hospital between May 2011 and August 2011 were considered for inclusion in the study. RESULTS: Fifty-five children were included in the final analysis. The median duration of stay in the Trauma Unit was 205 minutes (interquartile range 135 - 274). CONCLUSION: Several factors were identified that unnecessarily prolonged the time that patients stayed in the trauma unit following arrival in hospital for polytrauma management. <![CDATA[<b>The <i>Clostridium difficile</i> problem</b>: <b>A South African tertiary institution's prospective perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300026&lng=en&nrm=iso&tlng=en BACKGROUND AND OBJECTIVES: The aim of this study is to report the incidence of Clostridium difficile-associated disease (CDAD) in a tertiary-care hospital in South Africa and to identify risk factors, assess patient outcomes and determine the impact of the hypervirulent strain of the organism referred to as North American pulsed-field type 1 (NAP1). METHODS: Adults who presented with diarrhoea over a period of 15 months were prospectively evaluated for CDAD using stool toxin enzyme immunoassay (EIA). Positive specimens were evaluated by PCR. Patient demographics, laboratory parameters and outcomes were analysed. RESULTS: CDAD was diagnosed in 59 (9.2%) of 643 patients (median age 39 years, IQR 30 - 55). Thirty-four (58%) were female. Recent antibiotic exposure was reported in 39 (66%), 27 (46%) had been hospitalised within 3 months, and 14 (24%) had concomitant inflammatory bowel disease (IBD). Nineteen (32%) had community-acquired CDAD (CA-CDAD). The annual incidence of hospital-acquired CDAD (HA-CDAD) was 8.7 cases/10 000 hospitalisations. Two cases of the hypervirulent strain NAP1 were identified. Seven (12%) patients underwent colectomy (OR 6.83; 95% CI 2.41 - 19.3). On logistic regression, only antibiotic exposure independently predicted for CDAD (OR 2.9; 95% CI 1.6 - 5.1). Three (16%) cases of CA-CDAD reported antibiotic exposure (v. 90% of HA-CDAD, p<0.0001). Twelve (86%) patients had concomitant IBD (p<0.0001 v. HA-CDAD). CA-CDAD was significantly associated with antibiotic exposure (OR 0.04, 95% CI 0.01 - 0.24) and IBD (OR 9.6, 95% CI 1.15 - 79.8). CONCLUSION: The incidence of HA-CDAD in the South African setting is far lower than that reported in the West. While antibiotic use was a major risk factor for HA-CDAD, CA-CDAD was not associated with antibiotic therapy. Concurrent IBD was a predictor of CA-CDAD. <![CDATA[<b>Malaria control aimed at the entire population in KwaZulu-Natal negates the need for policies to prevent malaria in pregnancy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300027&lng=en&nrm=iso&tlng=en BACKGROUND: South Africa has no policy to prevent malaria in pregnancy, despite the adverse effects of the disease in pregnancy. However, malaria control measures consisting of indoor residual spraying and specific antimalarial treatment have been in place since the 1970s. Information on the burden of malaria in pregnancy in South Africa is needed to indicate whether a specific policy for malaria prevention in pregnancy is necessary. OBJECTIVE: To determine the burden of malaria in pregnancy in KwaZulu-Natal (KZN) province, South Africa. METHODS: Pregnant women were enrolled at their first antenatal care visit to three health facilities in Umkhanyakude health district in northern KZN during May 2004 - September 2005 and followed up until delivery. Data collection included demographic details, current and previous malaria infection during pregnancy, haemoglobin concentrations and birth outcomes. RESULTS: Of the 1406 study participants, more than a quarter were younger than 20 years of age, and more than 90% were unemployed and unmarried. Although 33.2% of the women were anaemic, this was not related to malaria. The prevalence and incidence of malaria were very low, and low birth weight was only weakly associated with malaria (1/10). CONCLUSION: The low burden of malaria in these pregnant women suggests that they have benefited from malaria control strategies in the study area. The implication is that additional measures specific for malaria prevention in pregnancy are not required. However, ongoing monitoring is needed to ensure that malaria prevalence remains low. <![CDATA[<b>Tuberculosis in medical doctors - a study of personal experiences and attitudes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300028&lng=en&nrm=iso&tlng=en BACKGROUND: The concurrent TB and HIV epidemics in sub-Saharan Africa place all healthcare workers (HCWs) at increased risk of exposure to Mycobacterium tuberculosis. AIM: This study explores personal experiences, attitudes and perceptions of medical doctors following treatment for TB within the healthcare system. METHOD: Sixty-two medical doctors who were diagnosed with and treated for TB during 2007 - 2009 agreed to participate and complete a semi-structured questionnaire. RESULTS: The response rate was 64.5% (N=40). The mean age of participants was 33.7 years (standard deviation ±10.6). A correct diagnosis of TB was made within 7 days of clinical presentation in 20% of participants, and was delayed beyond 3 weeks in 52.5%. Non-routine special investigations and procedures were performed in 26 participants. Complications following invasive procedures were reported by 8 participants. Multi-drug resistant TB (MDR-TB) was diagnosed in 4 participants. Nineteen considered defaulting on their treatment because of drug side-effects. The majority (n=36) expressed concerns regarding lack of infection control at the workplace, delays in TB diagnosis and negative attitudes of senior medical colleagues and administrators. Ninety per cent of participants indicated that their personal illness experiences had positively changed their professional approach to patients in their current practice. CONCLUSION: The inappropriate delays in diagnosis in a large number of participants, coupled with a number of negative personal perceptions towards their treatment, are cause for concern. The results further amplify the need for improved educational and awareness programmes among all healthcare personnel (including hospital administrators), adherence to national health guidelines, effective infection control measures, pre- and post-employment screening in all HCWs, and changes in attitudes on the part of senior medical colleagues and administrators. <![CDATA[<b>Measles vaccination coverage in high-incidence areas of the Western Cape, following the mass vaccination campaign</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300029&lng=en&nrm=iso&tlng=en BACKGROUND: Despite significant advances in measles control, large epidemics occurred in many African countries in 2009 - 2011, including South Africa. South Africa's control strategy includes mass vaccination campaigns about every 4 years, the last of which was conducted nationally in April 2010 and coincided with the epidemic. AIM: A community survey was conducted in the Western Cape to assess measles vaccination coverage attained by routine and campaign services, in children aged 6 to 59 months at the time of the mass campaign, from high-incidence areas. METHODS: Households were consecutively sampled in high-incidence areas identified using measles epidemic surveillance data. A caregiver history of campaign vaccination and routine vaccination status from the child's Road to Health card were collected. Pre- and post-campaign immunity was estimated by analytical methods. RESULTS: Of 8 332 households visited, there was no response at 3 435 (41.2%); 95.1% (1 711/1 800) of eligible households participated; and 91.2% (1 448/1 587; 95% confidence interval 86 - 94%) of children received a campaign vaccination. Before the campaign, 33.0% (103/312) of 9 - 17-month-olds had not received a measles vaccination, and this was reduced to 4.5% (14/312) after the campaign. Of the 1 587 children, 61.5% were estimated to have measles immunity before the campaign, and this increased to 94.0% after the campaign. DISCUSSION: Routine services had failed to achieve adequate herd immunity in areas with suspected highly mobile populations. Mass campaigns in such areas in the Western Cape significantly increased coverage. Extra vigilance is required to monitor and sustain adequate coverage in these areas. <![CDATA[<b>Prevalence of human immunodeficiency virus, hepatitis C virus, hepatitis B virus and syphilis among individuals attending anonymous testing for HIV in Luanda, Angola</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300030&lng=en&nrm=iso&tlng=en BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis remain major infections around the world. In Angola, about 166 000 individuals are living with HIV, representing a prevalence of 1.98% in adults between 15 and 49 years of age. In a 2003 study in Luanda, 4.5% of pregnant women had antibodies to HIV and 8.1% to HBV, and 5.4% were infected with Treponema pallidum. OBJECTIVES: The aim of this study was to determine the prevalence of HIV-1 and 2, HBV, HCV and T. pallidum serological markers, and hence the prevalence of these infections, in individuals attending a sexually transmitted disease clinic in Luanda, Angola, and the burden of these infections in the Angolan population. METHODS: Individuals attending a centre for anonymous testing for HIV were randomly included in the study. All samples were tested for HBV surface antigen (HBsAg), anti-HCV and anti-HIV-1 and 2 antibodies and antibodies to T. pallidum. RESULTS: A total of 431 individuals (262 women and 169 men) were studied, of whom 10.0% (43/431) were seropositive for T. pallidum and 4.6% had active syphilis; 8.8% (38/431) were seropositive for HIV-1 and/or HIV-2 (of these, 78.9% were HIV-1-positive, 2.6% HIV-2-positive and 18.4% co-infected); 9.3% (40/431) were HBsAg-positive, while 8.1% (35/431) had antibodies to HCV. Of 102 patients with positive results, 26 (25.5%, or 6.0% of the total of 431 patients) were positive for more than one of the organisms studied. Rates of co-infection were as follows: 2.3% (10/431) for HIV/HBV, 0.9% (4/431) for HIV/HCV, and 0.9% (4/431) for HCV/HBV. Three individuals with active syphilis had viral co-infection, hepatitis B in 1 case and HIV in 2. Five individuals (1.2% of the total) were seropositive for 3 infections: HIV, hepatitis B and hepatitis C in 3 cases and HIV, hepatitis C and syphilis in 2. CONCLUSIONS: A high prevalence of co-infection with the infections studied was found in this population, including HIV infection (8.8%). These results demonstrate the need to improve screening for and treatment of HIV and other sexually transmitted infections in Angola, and for educational campaigns to prevent not only the morbidity and mortality associated with these diseases, but also their further transmission <![CDATA[<b>Guideline for the management of acute asthma in adults</b>: <b>2013 update - Part 2: March 2013</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300031&lng=en&nrm=iso&tlng=en Acute asthma attacks (asthma exacerbations) are increasing episodes of shortness of breath, cough, wheezing or chest tightness associated with a decrease in airflow that can be quantified and monitored by measurement of lung function (peak expiratory flow (PEF) or forced expiratory volume in the 1st second) and requiring emergency room treatment or admission to hospital for acute asthma and/or systemic glucocorticosteroids for management. The goals of treatment are to relieve hypoxaemia and airflow obstruction as quickly as possible, restore lung function, and provide a suitable plan to avoid relapse. Severe exacerbations are potentially life-threatening and their treatment requires baseline assessment of severity, close monitoring, and frequent reassessment using objective measures of lung function (PEF) and oxygen saturation. Patients at high risk of asthma-related death require particular attention. First-line therapy consists of oxygen supplementation, repeated administration of inhaled short-acting bronchodilators (beta-2-agonists and ipratropium bromide), and early systemic glucocorticosteroids. Intravenous magnesium sulphate and aminophylline are second- and third-line treatment strategies, respectively, for poorly responding patients. Intensive care is indicated for severe asthma that is not responsive to first-line treatment. Antibiotics are only indicated when there are definite features of bacterial infection. Factors that precipitated the acute asthma episode should be identified and preventive measures implemented. Acute asthma is preventable with optimal control of chronic asthma. <![CDATA[<b>Guideline for the management of acute asthma in children</b>: <b>2013 update - Part 3: March 2013</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300032&lng=en&nrm=iso&tlng=en BACKGROUND: Acute asthma exacerbations remain a common cause of hospitalisation and healthcare utilisation in South African children. AIM: To update the South African paediatric acute asthma guidelines according to current evidence, and produce separate recommendations for children above and below 2 years of age. METHODS: A working group of the South African Childhood Asthma Group was established to review the published literature on acute asthma in children from 2000 to 2012, and to revise the South African guidelines accordingly. RECOMMENDATIONS: Short-acting inhaled bronchodilators remain the first-line treatment of acute asthma. A metered dose inhaler with spacer is preferable to nebulisation for bronchodilator therapy to treat mild to moderate asthma. Two to four puffs of a short-acting bronchodilator given every 20 - 30 minutes, depending on clinical response, should be given for mild attacks; up to 10 puffs may be needed for more severe asthma. Children with severe asthma or oxygen saturation (SpO2) <92% should receive oxygen and frequent doses of nebulised β2-agonists, and be referred to hospital. Nebulised ipratropium bromide (via nebulisation or multidosing via pMDI-spacer combination) should be added if there is a poor response to three doses of β2-agonist or if the symptoms are severe. Early use of corticosteroids reduces the need for hospital admission and prevents relapse; oral therapy is preferable. Assessment of acute asthma in children below the age of 2 years can be difficult, and other causes of wheezing must be excluded. Treatment of acute asthma in this age group is similar to that of older children. CONCLUSION: Effective therapy for treatment of acute asthma - primarily inhaled short-acting β2-agonists, oral corticosteroids and oxygen with appropriate delivery systems - should be available in all healthcare facilities and rapidly instituted for treatment of acute asthma in children. ENDORSEMENT: The guideline document is endorsed by the Allergy Society of South Africa (ALLSA), the South African Thoracic Society (SATS), the National Asthma Education Programme (NAEP), the South African Paediatric Association (SAPA) and the South African Academy of Family Practice.