Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420130008&lang=pt vol. 103 num. 8 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The circle of life</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>(The genetics of) breast cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Rape in South Africa - call to action</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Carcinoma of the cervix - the hopeless disease</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Child sexual abuse exacerbated by inadequate services</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Will the Department of Health and the Minister make the same mistake twice?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Ebola outbreak in Uganda</b>: <b>What we can and can not see from query trends</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800007&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Epitomising hope</b>: <b>From poverty to world-class healer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800008&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Neglected high-risk groups a top priority in AIDS prevention/treatment</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800009&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>RWOPS abuse 'eroding ethical standards of juniors'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800010&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>RWOPS abuse could cost, or even ruin, offenders</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800011&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Willie Mukheiber</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800012&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Direct-to-consumer genetic testing</b>: <b>To test or not to test, that is the question</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800013&lng=pt&nrm=iso&tlng=pt In direct-to-consumer (DTC) genetic testing, laboratory-based genetic services are offered directly to the public without an independent healthcare professional being involved. The committee of the Southern African Society for Human Genetics (SASHG) appeals to the public and clinicians to be cautious when considering and interpreting such testing. It is important to stress that currently, the clinical validity and utility of genetic tests for complex multifactorial disorders such as type 2 diabetes mellitus and cardiovascular diseases is questionable. The majority of such tests are not scientifically validated and are based on a few preliminary studies. Potential consumers should be aware of the implications of genetic testing that could lead to stigmatisation and discrimination by insurance companies or potential employers of themselves and their family members. Guidelines and recommendations for DTC genetic testing in South Africa (SA) are currently lacking. We provide recommendations that seek to protect consumers and healthcare providers in SA from possible exploitation. <![CDATA[<b>Obstetric risk avoidance</b>: <b>Will anyone be offering obstetrics in private practice by the end of the decade?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800014&lng=pt&nrm=iso&tlng=pt Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state. <![CDATA[<b>Pre-exposure prophylaxis for HIV prevention</b>: <b>Ready for prime time in South Africa?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800015&lng=pt&nrm=iso&tlng=pt Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state. <![CDATA[<b>Clinical issues in genetic testing for multifactorial diseases</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800016&lng=pt&nrm=iso&tlng=pt Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state. <![CDATA[<b>Neonatal mortality in South Africa</b>: <b>How are we doing and can we do better?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800017&lng=pt&nrm=iso&tlng=pt Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state. <![CDATA[<b>Maternal health</b>: <b>There is cause for optimism</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800018&lng=pt&nrm=iso&tlng=pt Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state. <![CDATA[<b>MammaPrint Pre-screen Algorithm (MPA) reduces chemotherapy in patients with early-stage breast cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800019&lng=pt&nrm=iso&tlng=pt BACKGROUND: Clinical and pathological parameters may overestimate the need for chemotherapy in patients with early-stage breast cancer. More accurate determination of the risk of distant recurrence is now possible with use of genetic tests, such as the 70-gene MammaPrint profile. OBJECTIVES: A health technology assessment performed by a medical insurer in 2009 introduced a set of test eligibility criteria - the MammaPrint Pre-screen Algorithm (MPA) - applied in this study to determine the clinical usefulness of a pathology-supported genetic testing strategy, aimed at the reduction of healthcare costs. METHODS: An implementation study was designed to take advantage of the fact that the 70-gene profile excludes analysis of hormone receptor and human epidermal growth factor receptor 2 (HER2) status, which form part of the MPA based partly on immunohistochemistry routinely performed in all breast cancer patients. The study population consisted of 104 South African women with early-stage breast carcinoma referred for MammaPrint. For the MammaPrint test, RNA was extracted from 60 fresh tumours (in 58 patients) and 46 formalin-fixed, paraffin-embedded (FFPE) tissue samples. RESULTS: When applying the MPA for selection of patients eligible for MammaPrint testing, 95 of the 104 patients qualified. In this subgroup 62% (59/95) were classified as low risk. Similar distribution patterns for risk classification were obtained for RNA extracted from fresh tumours v. FFPE tissue samples. CONCLUSIONS: The 70-gene profile classifies approximately 40% of early-stage breast cancer patients as low-risk compared with 15% using conventional criteria. In comparison, more than 60% were shown to be low risk with use of the MPA validated in this study as an appropriate strategy to prevent chemotherapy overtreatment in patients with early-stage breast cancer. <![CDATA[<b>Breast cancer clinicopathological presentation, gravity and challenges in Eritrea, East Africa: Management practice in a resource-poor setting</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800020&lng=pt&nrm=iso&tlng=pt BACKGROUND: In Africa, breast cancer closely compares with cervical cancer as the most common malignancy affecting women and the incidence rates appear to be rising. Early detection of breast cancer is a key strategy for a good treatment outcome. However, there is no established protocol or guideline for management of breast cancer in Eritrea, East Africa. OBJECTIVE: To assess the clinicopathological presentation, gravity and management challenges presented in breast cancer treatment in Eritrea. METHODS: Our investigation was a retrospective, descriptive study to assess the clinical features and severity of breast cancer at time of presentation. We reviewed the medical records of all patients who presented with breast malignancies over the 2-year period from 1 January 2007 to 31 December 2008. RESULTS: Eighty-two patients ranging in age from 26 - 80 years (mean 48 years) were included in the study. Of these 51% were premenopausal women; 61% of the patients presented with breast mass only and the remainder with manifestations of local (mass plus discharge, breast pain or breast ulceration) or distant metastatic disease. More than 60% of the patients presented after >2 years following onset of symptoms. Two-thirds of patients had late stage (III or IV) disease. All except one case was managed surgically. CONCLUSION: Most cases presented at younger age and advanced stage. These findings call for strengthening health education to promote early health-seeking behaviour and advocacy for the introduction of national screening, implementation of a management protocol and establishment of a radio-chemotherapy centre. <![CDATA[<b>Implementation of a breast cancer genetic service in South Africa - lessons learned</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800021&lng=pt&nrm=iso&tlng=pt BACKGROUND: Genetic testing for BRCA mutations has been available in the Western Cape of South Africa since 2005, but practical implementation of genetic counselling and testing has been challenging. OBJECTIVE: To describe an approach to breast cancer genetic counselling and testing developed in a resource-constrained environment at Tygerberg Hospital in Cape Town, Western Cape. METHODS: Genetic counselling is offered in a stepwise manner to our diverse patient population, with a focus on affected probands, and subsequent cascade testing. A record review of BRCA testing between 2005 and 2011 was performed. RESULTS: During this period 302 probands received genetic testing, with increasing numbers tested over time. Of 1 520 women treated for breast cancer since 2008, 226 (14.9%) accepted BRCA testing, and 39 tested positive (17.3% of those tested, and 2.6% of all women). Common founder mutations were detected in 11.9% of women (36/302), and comprised 73% (36/49) of mutations detected. Cascade testing increased after 2010: 16 female and 4 male family members of 19 probands accepted testing, with 6 positives being detected. CONCLUSION: A protocol-driven approach focusing on probands, with initial pre-test counselling by primary care staff has proven effective in establishing the service. Involvement of a clinical geneticist/genetic counsellor has permitted more detailed post-test counselling and increased use of cascade testing. <![CDATA[<b>Impact of inter-facility transport on maternal mortality in the Free State Province</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800022&lng=pt&nrm=iso&tlng=pt AIM: In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. We probed the role of inter-facility transport in effecting this reduction in mortality. METHODS: A before-after analysis was performed of data from 2 separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Data were compared for a 12-month prior- and 10-month post-intervention period using descriptive and correlation statistics. RESULTS: The maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7% (p<0.0001). Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. CONCLUSION: Effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies. <![CDATA[<b>Review of causes of maternal deaths in Botswana in 2010</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800023&lng=pt&nrm=iso&tlng=pt BACKGROUND: In Botswana the maternal mortality ratio in 2010 was 163 per 100 000 live births. It is a priority to reduce this ratio to meet Millennium Development Goal 5 target of 21 per 100 000 live births. OBJECTIVE: To investigate the underlying circumstances of maternal deaths in Botswana. METHOD: Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. RESULTS: Sixty-six percent of deaths occurred in Botswana's two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care: better teamwork, communication and supportive supervision of health professionals; earlier recognition of the seriousness of complication(s) with more aggressive case-management; joint management between HIV and obstetric clinicians; screening for, and treatment of, opportunistic infections throughout the antenatal to postnatal periods; and better supply management of medications, fluids, blood for transfusion and laboratory tests. CONCLUSION: Integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death. <![CDATA[<b>Maternal and fetal outcomes of HIV-infected and non-infected pregnant women admitted to two intensive care units in Pietermaritzburg, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800024&lng=pt&nrm=iso&tlng=pt BACKGROUND: Outcomes of HIV-positive pregnant patients admitted to intensive care units (ICUs) are controversial. OBJECTIVE: To determine maternal and fetal outcomes of HIV-positive patients admitted to ICUs. METHODS: Pregnant patients admitted to ICUs were enrolled in the study. On admission, they were classified as having low (<50%) or high (≥50%) risk of death by GRAMPT stratification score. The primary maternal outcome was death or hypoxic-ischaemic brain injury (HIBI), while fetal outcomes recorded were Apgar score, birth weight, and delivery of the fetus to facilitate maternal care. RESULTS: There were 84 admissions to the ICUs: 66 (78.6%) were post-partum and 18 (21.4%) antepartum. The HIV sero-status was as follows: 11 (13.1%) HIV status unknown; 42 (50%) HIV-negative and 31 (36.9%) HIV-positive. The most common pre-ICU admission diagnoses were pneumonia (19.4%) in HIV-positive patients and eclampsia (31%) in HIV-negative patients. Maternal outcomes showed a worsening trend among the HIV-positive women when compared with those who were HIV-negative (high GRAMPT, 1.91 relative risk of death/HIBI in HIV-positive; 95% CI 0.57 - 6.44). Forty-two patients gave birth within 24 hours prior to ICU admission; 3 gave birth while in ICU and none gave birth within 24 hours following ICU discharge. Outcomes of the 45 infants born to HIV-positive women were worse than for those born to HIV-negative patients (except for Apgar scores 1 - 6). Performance of the GRAMPT model for prediction of maternal mortality/HIBI was best in hypertensive patients (ROC: AUC 0.72; 95% CI 0.48 - 0.96). CONCLUSION: With the exception of Apgar scores 1 - 6, all outcomes showed worsening trends among infants born to HIV-positive mothers. Large multicentre studies are needed to confirm our findings. <![CDATA[<b>An assessment of the implementation of the National Therapeutic Programme for pregnant women within the City of Cape Town district</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800025&lng=pt&nrm=iso&tlng=pt BACKGROUND: An integrated Nutritional Supplementation Programme (NSP), now termed the National Therapeutic Programme (NTP), was initiated in 1995 to address South Africa's pressing nutritional problems. It specifically focuses on maternal health, including iron deficiency anaemia and underweight among pregnant women, but its implementation and efficacy for pregnant women has not been evaluated. OBJECTIVES: To determine (i) whether pregnant women qualified for both the food and micronutrient (folate and iron) supplementation offered by the programme; (ii) whether those who qualified received such supplementation; and (iii) whether those who qualified were aware of the rationale for the supplementations. METHODS: A cross-sectional descriptive study was conducted in all primary healthcare antenatal clinics in the City of Cape Town district, involving 114 women. All were interviewed using a questionnaire, their mid-upper arm circumference was measured, and their symphysis-fundus measurements (where documented) were obtained from their medical files. RESULTS: Only 5% of the women qualified for the food supplementation, while all qualified for the micronutrient supplementation. Only 1 of the 6 participants who qualified for food supplementation was registered and received it. Seventy (61%) of the participants received the micronutrient supplementation and used it correctly. Twenty-nine (25%) participants had heard about the food supplementations for pregnant women and 54 (47%) had heard about the micronutrient supplementations. CONCLUSION: The food supplementation was not successfully implemented among pregnant women. The strategy requires further attention within the antenatal clinics. <![CDATA[<b>A comparison of pregnancy dating methods commonly used in South Africa</b>: <b>A prospective study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800026&lng=pt&nrm=iso&tlng=pt BACKGROUND: Pregnancy dating in the South African public healthcare setting is mainly based on clinical assessment. However, the accuracy of this approach is unknown. AIM: To compare the accuracy of different pregnancy dating methods. METHODS: We performed a prospective comparison of 2 ultrasound policies involving consecutive low-risk women in a midwife clinic in the Metro East region, Cape Town, Western Cape. Information on the last menstrual period (LMP), the 1st symphysis-to-fundal height measurement (FH) and average gestation by ultrasonographic (US) fetal biometry was recorded. Five dating methods: LMP, FH, US and their combinations, were assessed against the actual day of delivery (ADD). The main outcome measures were: (i) the days between the ADD and estimated date of delivery in pregnancies where spontaneous labour occurred and the baby had a normal birth weight; (ii) the incidence of gestational age-related outcomes; and (iii) the influence of clinical variables on dating discrepancies. RESULTS: A total of 1 342 pregnancies were analysed. The accuracy of dating was similar for certain and uncertain LMP. FH was less accurate with increasing obesity. US-based dating was most accurate (for 85% of predictions within 14 days) and similarly accurate at 20 - 24 weeks and at &gt;24 weeks. US reduced the number of assumed pre-and post-term deliveries and, in addition, was better at detecting small-for-gestational age infants (p<0.001). CONCLUSION: Pregnancy dating by US, including those in more advanced pregnancies than currently permitted, is recommended since all non-ultrasound-based estimations of gestational age were considerably less accurate. <![CDATA[<b>Safety, feasibility and efficacy of a rapid ART initiation in pregnancy pilot programme in Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800027&lng=pt&nrm=iso&tlng=pt BACKGROUND: Antiretroviral therapy (ART) in pregnancy is a crucial intervention in the prevention of mother-to-child transmission (PMTCT) of HIV. It is recognised that mother-to-child transmission is reduced with each week on ART. However, in most South African settings, ART initiation is delayed owing to slow determination of treatment eligibility and separation of HIV and antenatal care services. OBJECTIVE: The rapid initiation of an ART in pregnancy programme is a model of care designed to expedite treatment initiation in ART-eligible pregnant women. This study evaluated the performance of the programme. METHODS: Participants enrolled in the ART programme in the same week as their first ANC visit throughout 2011, and had outcome data available by March 2012. Treatment eligibility was determined or confirmed via point-of-care CD4+ testing. Eligible women were offered ART immediately, with concurrent counselling and safety laboratory blood testing. Women attended until 6 - 8 weeks after delivery. Data were collected from clinical records with infant polymerase chain reaction (PCR) results at 6 weeks. RESULTS: Of 134 ART-eligible (CD4+ count <350 cells/┬Ál or WHO stage III/IV) pregnant women, 130 (97.0%) started ART, 118 (90.8%) initiating treatment the same day that treatment eligibility was determined. There were no abnormal laboratory blood results or adverse events that required medical intervention. Pre-delivery retention in care and infant mortality were comparable to those in similar settings. Of the 107 pregnancies with PCR outcomes available, there was 1 positive HIV result in an infant (0.9%). Maternal viral load suppression in this mother was not achieved by the time of delivery. CONCLUSIONS: This pilot programme provides evidence that rapid ART initiation in pregnancy is safe, feasible and effective in reducing PMTCT. Further follow-up is required to monitor long-term outcomes. <![CDATA[<b>Functional MRI language mapping in pre-surgical epilepsy patients: Findings from a series of patients in the Epilepsy Unit at Mediclinic Constantiaberg</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800028&lng=pt&nrm=iso&tlng=pt BACKGROUND: Functional magnetic resonance imaging (fMRI) is commonly applied to study the neural substrates of language in clinical research and for neurosurgical planning. fMRI language mapping is used to assess language lateralisation, or determine hemispheric dominance, and to localise regions of the brain involved in language. Routine fMRI has been introduced in the Epilepsy Unit at Mediclinic Constantiaberg to contribute to the current functional mapping procedures used in pre-surgical planning. METHOD: In this paper we describe the language paradigms used in these routine studies as well as the results from 22 consecutive epilepsy patients. Multi-subject analyses were performed to assess the reliability of activation patterns generated by two language mapping paradigms, namely a verb generation task and passive listening task. Results from a finger-tapping task are also presented. RESULTS: The paradigms generate reliable and robust signal changes, enabling both the lateralisation of language and localisation of expressive and receptive language cortex. CONCLUSION: The fMRI results are meaningful at the group and individual level and can be recommended for language mapping in pre-surgical patients. <![CDATA[<b>SAGES Congress, 16 - 18 August 2013, Drakensberg, South Africa. Oral presentations</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800029&lng=pt&nrm=iso&tlng=pt BACKGROUND: Functional magnetic resonance imaging (fMRI) is commonly applied to study the neural substrates of language in clinical research and for neurosurgical planning. fMRI language mapping is used to assess language lateralisation, or determine hemispheric dominance, and to localise regions of the brain involved in language. Routine fMRI has been introduced in the Epilepsy Unit at Mediclinic Constantiaberg to contribute to the current functional mapping procedures used in pre-surgical planning. METHOD: In this paper we describe the language paradigms used in these routine studies as well as the results from 22 consecutive epilepsy patients. Multi-subject analyses were performed to assess the reliability of activation patterns generated by two language mapping paradigms, namely a verb generation task and passive listening task. Results from a finger-tapping task are also presented. RESULTS: The paradigms generate reliable and robust signal changes, enabling both the lateralisation of language and localisation of expressive and receptive language cortex. CONCLUSION: The fMRI results are meaningful at the group and individual level and can be recommended for language mapping in pre-surgical patients. <![CDATA[<b>South African recommendations for the management of rheumatoid arthritis: An algorithm for the standard of care in 2013 - Part 2</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000800030&lng=pt&nrm=iso&tlng=pt Updated treatment recommendations for the therapy of rheumatoid arthritis (RA) in South Africa advocate early diagnosis, prompt initiation of disease-modifying anti-rheumatic drugs (DMARDs), and an intense treatment strategy where disease activity is assessed with a composite score such as the Simplified Disease Activity Index (SDAI). Frequent assessments and escalation of therapy are necessary until low disease activity (LDA) (SDAI <11) or ideally remission (SDAI <3.3) is achieved. Synthetic DMARDs may be used as monotherapy or in combination, and can be co-prescribed with low-dose corticosteroids if necessary. Biologic DMARD therapy should be considered for patients who have failed a 6-month trial of at least 3 synthetic DMARDs. All RA patients in SA are at increased risk of tuberculosis (TB), in particular patients using anti-tumour necrosis factor (TNF) biologic therapy. These recommendations provide practical suggestions for the screening and management of TB and other comorbidities, and offer an approach to monitoring of RA patients.