Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 103 num. 4 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Rape in South Africa - a call to action</b>]]> <![CDATA[<b>Eastern Cape dysfunction set to continue</b>]]> <![CDATA[<b>Western Cape academic hospitals</b>]]> <![CDATA[<b>A labour of love</b>: <b>'No schools for medical editors'</b>]]> <![CDATA[<b>Doctors' lifestyles vital for SA's health -global expert</b>]]> <![CDATA[<b>Eastern Cape's corruption-busting DG finally ousted</b>]]> <![CDATA[<b>Inspanning all the oxen - new Health Foundation</b>]]> <![CDATA[<b>Much ado over the new South African PMTCT guidelines</b>]]> <![CDATA[<b>Peter (Polly) Perrot</b>]]> <![CDATA[<b>Reuben Silberman</b>]]> <![CDATA[<b>Philip Palmer</b>]]> <![CDATA[<b>Handbook of Family Medicine</b>]]> <![CDATA[<b>Emergency medical treatment and 'do not resuscitate' orders</b>: <b>When can they be used?</b>]]> <![CDATA[<b>Biobank research</b>: <b>Time for discussion and debate</b>]]> <![CDATA[<b>Africa's roads - the deadliest in the world</b>]]> <![CDATA[<b>Ten years on ART - where to now?</b>]]> <![CDATA[<b>Thrombosis - prevention is better than cure</b>]]> <![CDATA[<b>NIMART rollout to primary healthcare facilities increases access to antiretrovirals in Johannesburg</b>: <b>An interrupted time series analysis</b>]]> INTRODUCTION: South Africa has made remarkable progress in rolling out antiretroviral therapy (ART), with the largest number of people (more than 1.4 million) enrolled on antiretrovirals in the world. Decentralisation of services to primary health centres (PHCs) has strengthened retention of patients on ART and reduced the burden of managing uncomplicated cases at referral hospitals. METHODS: This was a ten-step Nurse Initiatied Management of Antiretroviral Treatment (NIMART) rollout intervention in which nurses from 17 primary healthcare facilities of Region F, City of Johannesburg, South Africa, were trained and mentored in NIMART by the Wits Reproductive Health and HIV Research Institute (WRHI) to commence patients on ART in their PHCs. A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. To test the statistical significance of the impact of NIMART rollout on the referral hospital initiations and Region F monthly initiations, interrupted time series analysis was applied. FINDINGS: Ten-step NIMART rollout was applied, with the first step being establishment of NIMART as a priority in order to obtain primary buy-in by the Department of Health (DoH) and City of Johannesburg (CoJ). Forty-five professional nurses were trained in NIMART by WRHI quality improvement mentors. By the end of September 2011, all 17 PHCs in Region F were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout (p=0.013) and continued to increase by an average of 9 every month (p=0.013), while referral facility initiations decreased by 12 (p=0.791) immediately after NIMART and then decreased by an average of 18 every month (p=0.01). CONCLUSION: In this study, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients. Engaging and having buy-in from DoH/CoJ partners in rolling out NIMART was crucial in increasing outputs as well as for sustainability of the NIMART programme. <![CDATA[<b>An integrated approach to improving the availability and utilisation of tuberculosis healthcare in rural South Africa</b>]]> BACKGROUND: Patients with tuberculosis (TB) face several challenges in accessing care, and an integrated service that includes HIV testing could be preferable for them and ensure timely HIV treatment initiation and optimal TB care. OBJECTIVES:To investigate factors, including uptake of HIV testing, associated with availability and utilisation of healthcare by TB patients in a rural programme devolved to primary care in Hlabisa sub-district, KwaZulu-Natal. METHODS: Three hundred TB patients were randomly selected in a two-stage-sampling scheme with five primary healthcare clinic (PHC) sampling units selected with probability proportional to size. Data were collected using a structured questionnaire. We describe key availability and utilisation factors and analyse factors associated with being offered an HIV test in multiple regressions controlling for sex, age, education, employment and marital status. RESULTS: Most patients (75.2%) received care for a first episode of TB, mainly pulmonary. Nearly all (94.3%) were offered an HIV test during their current TB treatment episode, patients using their closest clinic being substantially more likely to have been offered HIV testing than those not using their closest clinic (adjusted odds ratio 12.79, p=0.05). About one-fifth (20.3%) of patients did not take medication under observation, and 3.4% reported missing taking their tablets at some stage. Average travelling time to the clinic and back was 2 hours, most patients (56.8%) using minibus taxis. CONCLUSION: We demonstrate high HIV testing rates among TB patients in a rural public programme, suggesting appropriate management of HIV-TB co-infected patients. We describe healthcare availability and utilisation factors that can inform the proposed district management teams for PHC re-engineering on areas needing improvement. <![CDATA[<b>Economic appraisal of dabigatran as first-line therapy for stroke prevention in atrial fibrillation</b>]]> BACKGROUND: Dabigatran is an oral anticoagulant direct thrombin inhibitor recently registered in South Africa (SA) to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation (AF). Owing to the price disparity between warfarin (the current gold standard for treatment of patients with AF) and dabigatran, we conducted an economic appraisal of the use of dabigatran compared with warfarin from a payer perspective in the South African private healthcare setting. OBJECTIVES: To estimate the cost-effectiveness (CE) and budget impact of dabigatran compared with warfarin for the prevention of stroke in AF patients. METHODS: A previously published Markov model was populated with SA cost and mortality data to estimate the CE and budget impact analysis of dabigatran over a lifetime horizon. The model population consisted of a cohort of patients of whom those aged younger than 80 years used dabigatran 150 mg twice daily and those older than 80 years 110 mg twice daily. Modelled outcomes included total cost, quality-adjusted life years (QALYs) and incremental CE ratio (ICER), with the effectiveness measured by QALYs gained. RESULTS: Dabigatran compared with warfarin as first-line treatment was estimated to have an ICER of R93 290 and an average incremental cost per beneficiary per month of R0.39 over a 5-year period. Conservative assumptions were made regarding the number of international normalised ratio monitoring tests for patients on warfarin, and the ICER is estimated to decrease by as much as 15.7% under less stringent assumptions. A robust sensitivity analysis was also performed. CONCLUSION: Dabigatran as first-line treatment compared with warfarin for the use of stroke prevention in patients with AF is deemed cost-effective when used in accordance with its registered indication in the SA private sector. <![CDATA[<b>Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa</b>]]> BACKGROUND: In South Africa, information on sex workers' characteristics, sexual behaviour and health needs is limited. Current social, legal and institutional factors impede a safe working environment for sex workers and their clients. OBJECTIVES: To describe characteristics and sexual behaviour of female, male and transgender sex workers, and assess their risk factors for unprotected sex. METHODS:Repeat cross-sectional surveys among sex workers were conducted in Hillbrow, Sandton, Rustenburg and Cape Town in 2010. Sex workers were interviewed once; any re-interviews were excluded from analysis. Unprotected sex was defined as any unprotected penetrative vaginal or anal sex with last two clients. RESULTS: Trained sex worker-research assistants interviewed 1 799 sex workers. Sex work was a full-time profession for most participants. About 8% (126/1 594) of women, 33% (22/75) of men, and 25% (12/50) of transgender people had unprotected sex. A quarter of anal sex was unprotected. Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; p=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers. Male sex workers were 2.9 times (AOR, 95% CI 1.6 - 5.3; p<0.001) more likely, and transgender people 2.4 times (AOR, 95% CI 1.1 - 4.9; p=0.021) more likely, than females to have unprotected sex. Sex workers in Hillbrow, where the only sex work-specific clinic was operational, were less likely to have unprotected sex than those in other sites. CONCLUSION: Tailored sex work interventions should explicitly include male and transgender sex workers, sex work-specific clinics, focus on the risks of unprotected anal sex, and include interventions to reduce harm caused by alcohol abuse. <![CDATA[<b>Evaluation and correlation of mammographically suspicious lesions with histopathology at Addington Hospital, Durban</b>]]> BACKGROUND: Stereotactic core-needle biopsies (SCNBs) are a reliable alternative to surgical biopsy for microcalcifications. The positive predictive value (PPV) of SCNB has been shown to be reproducible in several studies using the Breast Imaging Reporting and Data System (BIRADS) classification, which is the current gold standard in mammographic reporting. At this stage, no study has been done in KwaZulu-Natal to assess local outcomes against BIRADS. The current standard of care utilises vacuum-assisted breast biopsy, but is not available in a resource-constrained environment such as ours. The need, therefore, is for constant evaluation of existing practice to ensure that it is optimised for the challenges and limitations facing local radiologists. OBJECTIVE: To assess the PPV of SCNB in Addington Hospital, and to compare it with that of BIRADS. MATERIAL AND METHODS: Mammographically detected lesions were assigned to 3 categories: benign, indeterminate and suspicious. A retrospective review of 67 SCNBs was performed for lesions falling within the suspicious category, and the PPV and rates of ductal carcinoma in situ (DCIS) were determined. RESULTS: Our study demonstrated a PPV of 20.9%. This correlated well with international studies for BIRADS 4 and 5 lesions. DCIS accounted for 21.4% of detected malignancies, which is in keeping with current literature. CONCLUSION: Despite resource limitations, local outcomes were comparable with those of BIRADS. Given our fairly general categorisation of lesions, however, it should be emphasised that BIRADS allows better organisation, consistency and clarity in breast imaging reporting, as well as accurate data comparison between centres facing limitations similar to our own. <![CDATA[<b>Gastric adenocarcinoma in Zambia</b>: <b>A case-control study of HIV, lifestyle risk factors, and biomarkers of pathogenesis</b>]]> BACKGROUND: Gastric cancer is a leading cause of cancer deaths worldwide but there are few data from Africa. We recently observed a trend towards diagnosis in younger patients. OBJECTIVE: To test the hypothesis that HIV might have altered risk factors for acquisition of gastric cancer, in a case-control study in the University Teaching Hospital, Lusaka, Zambia. METHODS: Patients (n=52) with confirmed gastric adenocarcinoma and controls (n=94) undergoing endoscopy but with no macroscopic gastric pathology. Established risk factors and HIV status were compared. RESULTS: HIV status did not differ significantly between cases and controls (odds ratio 1.03; 95% CI 0.2 - 4.3; p=1.00) and seroprevalence in cases was similar to that of the Zambian population. Smoking, regular alcohol intake, and gastric atrophy were all associated with cancer in univariate and multivariate analysis. Helicobacter pylori serology was positive in 84% of patients studied and cytotoxin-associated gene A (cagA) serology in 66%; neither serological marker was associated with cancer. Atrophy was common in cases (57%) and controls (30%) and associated with both smoking and alcohol use. Intestinal metaplasia was present in 17% of the controls, but was not associated with atrophy. CONCLUSIONS: HIV was not associated with gastric cancer and does not explain the apparent younger age distribution. Atrophy was common and was not essential for the development of intestinal metaplasia, suggesting that gastric carcinogenesis in Africa does not always follow the pathway from atrophy to intestinal metaplasia to gastric carcinoma (the so-called Correa pathway). <![CDATA[<b>Venous thromboembolism</b>: <b>Prophylactic and therapeutic practice guideline</b>]]> BACKGROUND: Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed. This has resulted in unacceptable rates of morbidity and mortality. METHOD: The Southern African Society of Thrombosis and Haemostasis held a meeting to update the previous guideline and review new literature including guidelines from other societies. The following specialties were represented on the committees: anaesthetics, cardiology, clinical haematology, critical care, obstetrics and gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery and pulmonology. A draft document was presented at the meeting, which was then revised by consensus agreement. To avoid local bias, the guideline was adjudicated by recognised international external experts. RESULTS AND CONCLUSION: A concise, practical updated guideline for thromboprophylaxis and treatment in medical and surgical patients has been produced for South African conditions. It is hoped that this guideline will continue to improve anticoagulation practice in this country, which we believe will directly benefit patient outcomes.