Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420130005&lang=es vol. 103 num. 5 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Screening - benefits or harms?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500001&lng=es&nrm=iso&tlng=es http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500002&lng=es&nrm=iso&tlng=es <![CDATA[<b>Triage - keep it simple, swift, safe and scientific</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500003&lng=es&nrm=iso&tlng=es <![CDATA[<b>An adapted triage tool (ETAT) at Red Cross War Memorial Children's Hospital Medical Emergency Unit, Cape Town, South Africa</b>: <b>An evaluation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500004&lng=es&nrm=iso&tlng=es <![CDATA[<b>Artesunate v. quinine for severe malaria</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500005&lng=es&nrm=iso&tlng=es <![CDATA[<b>Asthma guidelines</b>: <b>Why aminophylline?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500006&lng=es&nrm=iso&tlng=es <![CDATA[<b>Late termination of pregnancy</b>: <b>Maternal counselling and fetal rights</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500007&lng=es&nrm=iso&tlng=es <![CDATA[<b>Autism - mitigating a global epidemic</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500008&lng=es&nrm=iso&tlng=es <![CDATA[<b>Whistle blast on private healthcare's 'zero sum game'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500009&lng=es&nrm=iso&tlng=es <![CDATA[<b>'Jack-knife' scrum victim</b>: <b>8 years on, no payout</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500010&lng=es&nrm=iso&tlng=es <![CDATA[<b>Karabus' 'Argo moment' a long time coming</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500011&lng=es&nrm=iso&tlng=es <![CDATA[<b>Is the mass circumcision drive in KwaZulu-Natal involving neonates and children less than 16 years of age legal? What should doctors do?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500012&lng=es&nrm=iso&tlng=es <![CDATA[<b>Private theatre utilisation in South Africa</b>: <b>A case study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500013&lng=es&nrm=iso&tlng=es INTRODUCTION: A large private operating theatre complex was investigated to address the lack of published South African benchmarks for utilisation. All major theatres were staffed during normal working hours (07h00 - 19h00), emergency cases being provided for on an ad hoc basis through spare capacity. METHODS: An extensive billing database, amounting to 28 991 records of procedures performed during normal working hours and spanning the period October 2007 - February 2010, was data-mined using Visual Basic for Applications (VBA) scripts. Theatre utilisation was analysed per day, per theatre. RESULTS: The results showed an average utilisation of 43% with significant variation in day-to-day operations. If the very underutilised minor theatre was excluded from the analysis, overall utilisation rose to 48%. Individual theatre utilisation ranged from 14% to 61%. An analysis of change in utilisation with time during a day showed that peak utilisation of 71% was achieved at 09h30 (90 minutes after lists start). Utilisation dropped to 25% at the end of the working day and was sustained for some time after hours. CONCLUSION: The 48% utilisation observed was significantly lower than the global benchmark of between 70% and 80%. <![CDATA[<b>Toxicovigilance</b>: <b>Experience of the Tygerberg Poison Information Centre in context</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500014&lng=es&nrm=iso&tlng=es INTRODUCTION: A large private operating theatre complex was investigated to address the lack of published South African benchmarks for utilisation. All major theatres were staffed during normal working hours (07h00 - 19h00), emergency cases being provided for on an ad hoc basis through spare capacity. METHODS: An extensive billing database, amounting to 28 991 records of procedures performed during normal working hours and spanning the period October 2007 - February 2010, was data-mined using Visual Basic for Applications (VBA) scripts. Theatre utilisation was analysed per day, per theatre. RESULTS: The results showed an average utilisation of 43% with significant variation in day-to-day operations. If the very underutilised minor theatre was excluded from the analysis, overall utilisation rose to 48%. Individual theatre utilisation ranged from 14% to 61%. An analysis of change in utilisation with time during a day showed that peak utilisation of 71% was achieved at 09h30 (90 minutes after lists start). Utilisation dropped to 25% at the end of the working day and was sustained for some time after hours. CONCLUSION: The 48% utilisation observed was significantly lower than the global benchmark of between 70% and 80%. <![CDATA[<b>Screening for chronic diseases in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500015&lng=es&nrm=iso&tlng=es INTRODUCTION: A large private operating theatre complex was investigated to address the lack of published South African benchmarks for utilisation. All major theatres were staffed during normal working hours (07h00 - 19h00), emergency cases being provided for on an ad hoc basis through spare capacity. METHODS: An extensive billing database, amounting to 28 991 records of procedures performed during normal working hours and spanning the period October 2007 - February 2010, was data-mined using Visual Basic for Applications (VBA) scripts. Theatre utilisation was analysed per day, per theatre. RESULTS: The results showed an average utilisation of 43% with significant variation in day-to-day operations. If the very underutilised minor theatre was excluded from the analysis, overall utilisation rose to 48%. Individual theatre utilisation ranged from 14% to 61%. An analysis of change in utilisation with time during a day showed that peak utilisation of 71% was achieved at 09h30 (90 minutes after lists start). Utilisation dropped to 25% at the end of the working day and was sustained for some time after hours. CONCLUSION: The 48% utilisation observed was significantly lower than the global benchmark of between 70% and 80%. <![CDATA[<b>Paradigm shift needed for cervical cancer</b>: <b>HPV infection is the real epidemic</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500016&lng=es&nrm=iso&tlng=es INTRODUCTION: A large private operating theatre complex was investigated to address the lack of published South African benchmarks for utilisation. All major theatres were staffed during normal working hours (07h00 - 19h00), emergency cases being provided for on an ad hoc basis through spare capacity. METHODS: An extensive billing database, amounting to 28 991 records of procedures performed during normal working hours and spanning the period October 2007 - February 2010, was data-mined using Visual Basic for Applications (VBA) scripts. Theatre utilisation was analysed per day, per theatre. RESULTS: The results showed an average utilisation of 43% with significant variation in day-to-day operations. If the very underutilised minor theatre was excluded from the analysis, overall utilisation rose to 48%. Individual theatre utilisation ranged from 14% to 61%. An analysis of change in utilisation with time during a day showed that peak utilisation of 71% was achieved at 09h30 (90 minutes after lists start). Utilisation dropped to 25% at the end of the working day and was sustained for some time after hours. CONCLUSION: The 48% utilisation observed was significantly lower than the global benchmark of between 70% and 80%. <![CDATA[<b>Toxicovigilance I</b>: <b>A survey of acute poisonings in South Africa based on tygerberg poison information centre data</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500017&lng=es&nrm=iso&tlng=es BACKGROUND: The incidence and spectrum of acute poisonings in South Africa are unknown. Poisoning data can be derived from sources such as hospital admission records and poison information centre (PIC) records. OBJECTIVES: This study was conducted to examine the extent of the problem and to identify trends and toxicovigilance issues using PIC data. METHODS: A survey was conducted based on Tygerberg Poison Information Centre (TPIC) consultations over 1 year. TPIC consultation forms were analysed for patient demographics and causes of poisoning. RESULTS: The TPIC dealt with 4 771 consultations related to human exposures to poisonous substances. The study showed that accidental exposure was more common than intentional poisoning (65.2% v. 34.8%); that 55.8% of cases were adults, of which 57.6% were females; and that 61.4% of adult cases were intentional exposures, and of these 64.3% were females. There was a predominance of accidental exposures (98.8%) and a male predominance (59.7%) in children. Categories of poisoning exposures across all age groups were non-drug chemicals (52.7%), medicines (35.2%) and biological toxins (12.6%). Pesticides (34.8%), irritant/corrosive substances (27.7%) and volatile hydrocarbons (8.3%) were the most common classes of non-drug chemical exposures. Cholinesterase inhibitors (8.8%), anticoagulant rodenticides (7.1%) and pyrethroids (5.0%) were the most commonly ingested non-drug chemicals. Aldicarb and amitraz poisoning were identified as toxicovigilance targets. Analgesics (26.1%) were the most common class of medicine-related exposure, and paracetamol (15.8%), benzodiazepines (9.2%) and antihistamines (5.2%) were the most common medicine-related exposures. CONCLUSION: The study provided information on evolving trends and identified toxicovigilance targets and the need for continuing toxicology education programmes. <![CDATA[<b>Toxicovigilance II</b>: <b>A survey of the spectrum of acute poisoning and current practices in the initial management of poisoning cases admitted to South African hospitals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500018&lng=es&nrm=iso&tlng=es BACKGROUND: Initial management of acute poisoning in South African (SA) hospitals such as gastric decontamination and use of antidotes has not been evaluated relevant to current international guidelines. OBJECTIVES: The objective of this study was to conduct a toxicovigilance survey of SA hospital admissions to assess the spectrum of acute poisonings, current practices in gastric decontamination, and use of antidotes in the management of acute poisoning. METHODS: A survey was undertaken based on acute poisoning admissions to Tygerberg Academic Hospital (TAH) as well as hospital-based poisoning consultations with the Tygerberg Poison Information Centre (TPIC) over 1 year to investigate trends in admissions and the initial management of hospital admissions for acute poisoning. TAH admission details and TPIC consultation forms for hospital-based cases were analysed for patient demographics, causes of poisoning, gastric decontamination measures and use of antidotes. RESULTS: There were 662 admissions to TAH and 2 459 hospital-based TPIC consultations. Paracetamol and cholinesterase inhibitors were the most common exposures in both studies. Gastric decontamination measures were employed at TAH in 47.7% of cases and in 5.3% of hospital cases reported to the TPIC. Of these, 67.4% in the TAH study and 26.1% in the TPIC study did not comply with international guidelines. N-acetylcysteine was administered inappropriately in 22.1% of the paracetamol poisoning cases at TAH and in 1.6% in the TPIC study. Atropine was administered unnecessarily in 12 of 30 TPIC cases. CONCLUSION: This study has identified the need for directed training on gastric decontamination measures and use of antidotes and, combined with the previous study, has identified national trends in poisoning. <![CDATA[<b>Vital signs for children at triage</b>: <b>A multicentre validation of the revised South African Triage Scale (SATS) for children</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500019&lng=es&nrm=iso&tlng=es OBJECTIVE: To validate a revised version of the paediatric South African Triage Scale (SATS) against admission as a reference standard and compare the sensitivity of triage using: (i) clinical discriminators; (ii) an age-appropriate physiological composite score; and (iii) a combination of both. METHODS: A prospective cohort study was undertaken validating the revised paediatric SATS against outcome markers of children at six emergency centres during a 2-month period in 2011. The primary outcome marker was the proportion of children admitted. Validity indicators including sensitivity (Se), specificity, positive predictive value and negative predictive value (NPV) were used to estimate the validity. Associated percentages for over-/under-triage were used to further assess practical application of the paediatric SATS. RESULTS: A total of 2 014 children were included. The percentage of hospital admissions increased with an increase in the level of urgency from 5% in the non-urgent patients to 73% in the emergency patients. The data demonstrated that sensitivity increased substantially when using the SATS, which is a combination of clinical discriminators and the Triage Early Warning Score (TEWS) (Se 91.0%, NPV 95.3%), compared with use of clinical discriminators in isolation (Se 57.1%, NPV 86.3%) or the TEWS in isolation (Se 75.6%, NPV 89.1%). CONCLUSION: The results of this study illustrate that the revised paediatric SATS is a safe and robust triage tool. <![CDATA[<b>Provincial screening rates for chronic diseases of lifestyle, cancers and HIV in a health-insured population</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500020&lng=es&nrm=iso&tlng=es BACKGROUND: Screening for asymptomatic diseases can reduce the burden of morbidity and mortality in all population groups. There is widespread geographical variation in the quality of care. Few data are available on national screening rates in South Africa and how these vary across the provinces. OBJECTIVE: To examine screening rates for chronic diseases of lifestyle (CDL), HIV and cancer in a privately insured population for a single insurer across all nine provinces in South Africa, and to determine whether or not there are any differences between the provinces. METHOD: Screening rates were calculated as the proportion of eligible members who had received screening tests during 2011 in each province. Mean screening rates were compared between Gauteng and the other eight provinces. RESULTS: Nationwide screening rates were 20.5% for CDL, 8.2% for HIV and 31.9% for cancer. Despite similar insurance coverage, screening rates ranged from 0.3% to 0.95% lower in other provinces compared with Gauteng. Of all the provinces, Gauteng had the highest annual screening rates for CDL, breast cancer, prostate cancer and HIV (p<0.001), while the Western Cape had the highest rate for cervical cancer (p<0.001). CONCLUSION: There is much variation in preventive care utilisation across the provinces within this health-insured population. Provinces with more abundant healthcare resources have higher screening rates. Further research is required to understand the reasons for the variation, given equal payment access. <![CDATA[<b>Age-specific prevalence of cervical human papillomavirus infection and cytological abnormalities in women in Gauteng Province, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500021&lng=es&nrm=iso&tlng=es BACKGROUND: Women accessing the public health system in Gauteng province, South Africa are largely unscreened for cervical cancer and have a high background prevalence of human immunodeficiency virus (HIV) infection. OBJECTIVES: This cross-sectional study describes the age-specific prevalence of human papillomavirus (HPV) infection and cytological abnormalities among this urban and peri-urban population. METHOD: Over the period March 2009 - September 2011, 1 524 women attending public sector primary healthcare clinics were invited to participate in a cervical cancer screening study. All participants were screened with conventional cytology and HPV testing undertaken using the HPV linear array genotyping kit (Roche Molecular Systems). RESULTS: Of 1 472 women with valid cytology results, abnormalities were detected in 17.3% (n=255), of which 9.1% (n=134) were high-grade squamous intraepithelial lesions, and 0.5% (n=8) suggestive of squamous carcinoma. Of the 1 445 women with complete data, the overall and high-risk HPV DNA prevalences were 74.6% (n=1 078) and 54.3% (n=784), respectively. HPV type 16 and/or 18 were detected in 19.5% (n=282) of women. Age-specific prevalence of HPV showed a plateau-shaped curve. CONCLUSIONS: The prevalences of HPV infection and abnormal cytology were much higher than previously reported in general populations in South Africa and elsewhere. Higher age-specific prevalence and similar plateau-like age-specific epidemiological curves have previously only been described in studies among HIV-positive women. These findings have implications for planning and development of cervical screening programmes in developing countries with largely unscreened populations with a high background prevalence of HIV. <![CDATA[<b>High uptake of Gardasil vaccine among 9 - 12-year-old schoolgirls participating in an HPV vaccination demonstration project in KwaZulu-Natal, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500022&lng=es&nrm=iso&tlng=es BACKGROUND: Cervical cancer is linked to infection of the cervix by oncogenic human papillomavirus (HPV) subtypes. The quadrivalent Gardasil vaccine (against HPV types 6, 11, 16, 18), recommended in girls 9 - 12 years of age, has been shown to be safe, immunogenic and efficacious, with minimal or no side-effects. AIM: To demonstrate the capacity of school health teams to carry out vaccinations within a school environment. OBJECTIVES: To assess the uptake of 3 doses of the vaccine, document lessons learnt and provide recommendations for a national rollout of school-based HPV vaccination for learners. METHODS: Female learners (age 9 - 12 years) from 31 primary schools in Nongoma and Ceza districts (KwaZulu-Natal province, South Africa) were identified for inclusion in the vaccination programme. The 3 doses of vaccine were administered by existing school health teams. Education and training sessions were held with all stakeholders: provincial departments of health and education; school health teams; primary healthcare nurses; hospital doctors and nurses; private practitioners; school principals, teachers and governing bodies; parents; and community and traditional leaders. RESULTS: The overall uptake of the vaccine was found to be high: 99.7%, 97.9% and 97.8% for the first, second and third doses respectively ( N=963). No adverse events were attributed to the HPV vaccine. CONCLUSION: This project demonstrated the successful implementation of HPV vaccination among learners (ages 9 - 12 years) using school health teams. <![CDATA[<b>Risk of nevirapine-associated Stevens-Johnson syndrome among HIV-infected pregnant women</b>: <b>The Medunsa National Pharmacovigilance Centre, 2007 - 2012</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500023&lng=es&nrm=iso&tlng=es BACKGROUND: Stevens-Johnson syndrome (SJS) is an acute life-threatening condition often elicited by drugs. The government's indecisiveness in deciding to stop the use of nevirapine (NVP) in HIV-infected pregnant women owing to the increase of SJS among this population group in South Africa prompted this investigation. OBJECTIVES: To investigate if pregnancy is a risk factor for SJS among HIV-infected women taking NVP-containing regimens and registered within the Medunsa National Pharmacovigilance Centre database. METHODS: A matched case-control study with 5:1 matching was conducted. Women with SJS (cases) taking NVP-containing regimens were matched with women without SJS (controls) taking NVP-containing regimens. Controls were randomly selected and matched to cases by hospital, age, treatment duration and CD4 count. Conditional logistic regression was used to determine if pregnancy was a risk factor forSJS. RESULTS: Six SJS cases were identified and 30 controls selected. The median age of both cases and controls was 29 years and the average CD4 counts were 237 and 234 cells/┬Ál respectively. Subjects were on NVP treatment for 18 - 31 days before the onset of SJS. Controls did not develop SJS after treatment of between 1 and 365 days. Pregnancy increased the chances of developing SJS 14-fold (OR 14.28, p=0.006, 95% CI 1.54 - 131.82). CONCLUSIONS: NVP-containing ARV regimens taken during pregnancy increase the risk of developing SJS. Healthcare workers are advised to offer informed consent to patients and recommend effective contraception methods if NVP treatment is considered. In the light of our findings, further studies of the association between NVP, pregnancy and SJS are necessary before general conclusions can be reached. <![CDATA[<b>Bone marrow morphological features and diagnostic value in paediatric disseminated tuberculosis in the setting of increased HIV prevalence</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500024&lng=es&nrm=iso&tlng=es BACKGROUND: Disseminated tuberculosis (TB) is a life-threatening condition which is often a challenge to diagnose. When to use bone marrow biopsies to diagnose disseminated TB in paediatrics is always a dilemma, from both a clinical and laboratory perspective, as there are no clear guidelines. Our study primarily aims to evaluate the role of routine bone marrow biopsies, and to compare peripheral blood cultures to aspirate cultures in the diagnosis of disseminated TB, in a paediatric population at Tygerberg Hospital. In addition, we set out to assess the morphology of bone marrow biopsies in this study. METHODS: A prospective study, consisting of 35 paediatric patients, was conducted from October 2007 to November 2008. Bone marrow aspirate and trephine biopsies were performed on all patients and examined. Granulomas with Ziehl-Neelsen (ZN) positivity were sought on the trephine biopsy for the presence of acid-fast bacilli (AFB). RESULTS: Of the 35 children in this study, 25 were eventually diagnosed with TB on the basis of a multitude of clinical and laboratory parameters. The remaining 10 had alternative diagnoses. Peripheral blood TB cultures were positive in less than 1%. Bone marrow aspirate cultures were positive in less than 5%. Bone marrow trephine biopsies showed granulomas with ZN positivity in 11% of the 35 patients. CONCLUSION: Our results, generally, agree with the current evidence. Bone marrow biopsies in children should be performed if there is a strong clinical suspicion of disseminated TB, when no alternative non-invasive confirmatory test is available. <![CDATA[<b>Hepatitis B virus in HIV-infected patients in northeastern South Africa</b>: <b>Prevalence, exposure, protection and response to HAART</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500025&lng=es&nrm=iso&tlng=es OBJECTIVE: Hepatitis B virus (HBV) and HIV are endemic infections in many African countries. The objectives of this study were to determine the levels of exposure to, and protection from, HBV, as well as the prevalence of HIV/HBV co-infection and the response of HBV to highly active anti-retroviral therapy (HAART) in a cross-section of HIV-infected patients in north-eastern South Africa. STUDY DESIGN: This was a laboratory-based, unmatched study. Three hundred and eighty patients were screened by ELISA for HBsAg, anti-HBc and anti-HBs. Samples non-reactive for HBsAg but reactive for anti-HBc were examined for occult HBV infection. Response to HAART was assessed by measuring HBV viral loads, seroconversion from HBeAg to anti-HBe, and levels of aminotransferase. RESULTS: Of the study population of 380, 60% (95% CI 54.8 - 64.9) were exposed to HBV based on HBsAg, anti-HBs or anti-HBc; 20%(95% CI 16.1 - 24.4) had active HBV infection, based on HBsAg serology, and 30% (95% CI 25.2 - 35.2) were protected, based on anti-HBs levels >10 IU/l. Of 181 HBsAg-negative individuals, 61 had HBV occult infection (33.7%, 95% CI 26.9 - 41.1). The differences in prevalence were not statistically significant when gender, marital status and CD4+ cell counts were considered. Of 21 patients analysed, 80% showed adequate response to the first-line HAART regimen (stavudine/lamivudine/efavirenz or nevirapine) after 12 months of use. CONCLUSION: The study confirms the higher level (60%) of exposure to HBV in HIV patients in Limpopo Province, as well as the high (20%) prevalence of HBsAg positivity and occult hepatitis B (33.7%). However, further studies are warranted to corroborate the benefit of lamivudine-containing HAART regimens, as HIV/HBV co-infected patients have a higher liver-related mortality if hepatitis B is not treated. <![CDATA[<b>South African guideline for the management of chronic hepatitis B: 2013</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000500026&lng=es&nrm=iso&tlng=es Hepatitis B remains a significant yet preventable health issue in South Africa. The introduction of the hepatitis B vaccine into the country some 18 years ago has demonstrated benefit, but the exposure to, and prevalence of chronic HBsAg positivity remain unacceptably high. Those with chronic hepatitis B virus infection have an elevated risk of developing cirrhosis with end-stage liver disease and a markedly elevated risk of hepatocellular carcinoma, independent of the presence of cirrhosis. The challenge in South Africa remains prevention through the universal vaccination coverage of all children and the identification of those with chronic hepatitis B virus infection. Over the last decade our understanding of hepatitis B and its behaviour and natural history in those with chronic infection has significantly improved. This understanding is key to identifying those who warrant further evaluation and therapy. A number of global societies have updated their guidelines in recent years. This document draws on these guidelines and serves to contextualise, for South Africa, practice guidelines for the management of chronic hepatitis B.