Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420140001&lang=pt vol. 104 num. 1 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>A South African decade of antiretrovirals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>A 'new-look' <i>SAMJ</i></b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>'A new dietary paradigm?' - prove it</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>LCHF</b>: <b>Look at the full picture</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100004&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>No sacred cows as private sector embraces society-wide solutions</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100005&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Universal coverage possible - with private sector support</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100006&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>A first step towards transparency in pricing of medicines and scheduled substances - publication of guidelines for pharmaco-economic submissions</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100007&lng=pt&nrm=iso&tlng=pt The National Department of Health of South Africa recently published guidelines for pharmaco-economic (PE) submissions in accordance with the Medicines and Related Substances Act (Act 101 of 1965), which came into effect on 1 April 2013. These guidelines relate to the compilation of PE submissions for evidence of cost-effectiveness of medicine or scheduled substances. The PE guidelines are a first step towards the creation of a mechanism whereby the value of medicine can be quantified in a transparent manner. The 'voluntary' nature of PE submissions speaks to the current lack of knowledge, understanding and capacity related to pharmaco-economics that exists in the private healthcare market. The current disconnect between the PE guidelines and the Medical Schemes Act should be addressed as a matter of urgency to provide a mechanism whereby guidance in terms of cost-effectiveness from a PE evaluation will be supported by guaranteed reimbursement by medical schemes. <![CDATA[<b>Surrogacy commissioning fathers and HIV</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100008&lng=pt&nrm=iso&tlng=pt Surrogacy is not regulated by a single legal instrument only, nor is confirmation of a surrogacy agreement by the High Court an unqualified green light for the surrogacy process to proceed. In the context of the HIV status of the commissioning father, whose gametes are to be used for the conception of the child in pursuance of a surrogacy agreement, the intended in vitro fertilisation of the surrogate mother may only take place on condition that the commissioning father, and his semen, have been tested for HIV; that he has consented to his HIV status being made available to the surrogate mother, and if he is HIV-positive, that sperm washing will be used to minimise the risk of infection and that the surrogate mother has been informed of his HIV status, and given her informed consent. <![CDATA[<b>Disposal of medical waste</b>: <b>A legal perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100009&lng=pt&nrm=iso&tlng=pt The Constitution of the Republic of South Africa provides that everyone has the right to an environment that is not harmful to their health and well-being. The illegal dumping of hazardous waste poses a danger to the environment when pollutants migrate into water sources and ultimately cause widespread infection or toxicity, endangering the health of humans who might become exposed to infection and toxins. To give effect to the Constitution, the safe disposal of hazardous waste is governed by legislation in South Africa. Reports of the illegal disposal of waste suggest a general lack of awareness and training in regard to the safe disposal of medical waste. <![CDATA[<b>Traditional male circumcision</b>: <b>Balancing cultural rights and the prevention of serious, avoidable harm</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100010&lng=pt&nrm=iso&tlng=pt The right to participate in cultural practices should be protected. However, it is a limited right, and does not entail a right to activities that cause serious and avoidable harms. I argue that the harms currently resulting from traditional circumcision are very serious, and that we have an obligation to ensure that the practice is effectively regulated so as to minimise them. <![CDATA[<b>Adult circumcision in the prevention of HIV/AIDS</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100011&lng=pt&nrm=iso&tlng=pt The right to participate in cultural practices should be protected. However, it is a limited right, and does not entail a right to activities that cause serious and avoidable harms. I argue that the harms currently resulting from traditional circumcision are very serious, and that we have an obligation to ensure that the practice is effectively regulated so as to minimise them. <![CDATA[<b>Charting a path along the continuum of PMTCT of HIV-1, to elimination, and finally to eradication</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100012&lng=pt&nrm=iso&tlng=pt The right to participate in cultural practices should be protected. However, it is a limited right, and does not entail a right to activities that cause serious and avoidable harms. I argue that the harms currently resulting from traditional circumcision are very serious, and that we have an obligation to ensure that the practice is effectively regulated so as to minimise them. <![CDATA[<b>Challenging times for environmental health in South Africa</b>: <b>The role of the Environmental Health Research Network</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100013&lng=pt&nrm=iso&tlng=pt The right to participate in cultural practices should be protected. However, it is a limited right, and does not entail a right to activities that cause serious and avoidable harms. I argue that the harms currently resulting from traditional circumcision are very serious, and that we have an obligation to ensure that the practice is effectively regulated so as to minimise them. <![CDATA[<b>Extrapulmonary tuberculosis among adults</b>: <b>Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100014&lng=pt&nrm=iso&tlng=pt BACKGROUND: Extrapulmonary tuberculosis (EPTB) occurs in 15 - 20% of immunocompetent and 20 - 70% of HIV-infected patients with tuberculosis. There are few recent incidence data for EPTB. METHODS: Adults (N=2 963) with culture-proven EPTB seen over 2 years at Chris Hani Baragwanath Academic Hospital, the main referral hospital serving Soweto, Johannesburg, South Africa, were retrospectively studied for pattern and incidence. RESULTS: The commonest sites of EPTB were the pleura (39.1%), lymph nodes (31.0%), blood (21.8%), meninges (7.3%), and peritoneum (2.9%). Disseminated tuberculosis occurred in 25.0%. The median age was 33 years (range 18 - 87 years). Males comprised 53.2% overall, with a female majority in the peritonitis group. For Soweto, the incidence of adult EPTB was 88.6/100 000 population, rising to 139.4/100 000 and 125.7/100 000 in the 25 - 34-year and 35 - 44-year age groups, respectively. There was no secondary peak in the elderly (17.9/100 000). CONCLUSIONS: This retrospective cohort showed a high incidence of EPTB, most marked in the 25 - 44-year age group. Culture of extrapulmonary sites is of importance to confirm diagnosis of tuberculosis and to ensure antituberculosis drug susceptibility testing. <![CDATA[<b>Prevalence and incidence of symmetrical symptomatic peripheral neuropathy in patients with multidrug-resistant TB</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100015&lng=pt&nrm=iso&tlng=pt BACKGROUND: Symptomatic symmetrical peripheral neuropathy (SSPN) is common in patients with HIV infection. It is also a common adverse event associated with both tuberculosis (TB) treatment and antiretroviral therapy (ART), particularly stavudine. While tenofovir is the one of recommended first-line nucleotide reverse transcriptase inhibitors (NRTIs), there is a risk of nephrotoxicity when using tenofovir together with the aminoglycosides needed to treat multidrug-resistant (MDR) TB. Thus, stavudine is often chosen as a treatment option for the HIV-infected MDR TB patient. OBJECTIVE: To assess whether use of stavudine both before and during treatment for MDR TB increased the prevalence and incidence of SSPN. METHOD: MDR TB patients at Sizwe Tropical Disease Hospital were examined for signs of prevalent SSPN. Age, gender, HIV status, alcohol use, TB and HIV treatment regimens both prior to admission and current, and concomitant medications were recorded. RESULTS: In this cohort of 246 patients, we found that 24.4% of patients with MDR TB had SSPN at time of admission for treatment of MDR TB. They were more likely to be HIV-infected (odds ratio (OR) 3.21; 95% CI 1.25 - 8.21) and tended to have longer (>7 months) exposure to stavudine (OR 1.81; 95% CI 0.90 - 3.63). Incident SSPN occurred in 17% of patients and was associated with older age (hazard ratio (HR) 3.00; 95% CI 1.30 - 6.89) and exposure to terizidone (HR 2.98; 95% CI 0.94 to 4.61) or, to a lesser extent, with stavudine (crude HR 1.62; 95% CI 0.65 - 4.01) in the first 6 months of MDR TB treatment. This common adverse event emphasises the need for the development of less toxic drugs for the treatment of MDR TB. <![CDATA[<b>Diagnostic yield of fine needle aspiration biopsy in HIV-infected adults with suspected mycobacterial lymphadenitis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100016&lng=pt&nrm=iso&tlng=pt BACKGROUND: Fine needle aspiration biopsy (FNAB) has been shown to be the diagnostic procedure of choice for superficial lymphadenitis in tuberculosis endemic regions. METHODS: We conducted a retrospective laboratory-based study to determine the bacteriological yield of clinically suspected mycobacterial tuberculous lymphadenitis following FNAB in adults, and specifically HIV-positive patients, to determine the need for the introduction of automated nucleic acid amplification tests (NAATs) such as the Xpert MTB/RIF assay as the initial diagnostic modality. RESULTS: A diagnostic yield of 80% was achieved, significantly higher in HIV-positive v. HIV-negative patients (84% v. 52%, respectively; p<0.001). CONCLUSION: The results justify using automated NAATs such as the Xpert MTB/RIF assay as the initial diagnostic modality to expedite management in HIV-infected patients. <![CDATA[<b>Percutaneous core needle biopsies: The yield in spinal tuberculosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100017&lng=pt&nrm=iso&tlng=pt BACKGROUND: Current recommendations for spinal tuberculosis (TB) not requiring open surgery include core needle biopsy to confirm TB and determine drug sensitivity. International figures show the positive culture yield from core needle biopsies is 50 - 83%. OBJECTIVES: To (i) assess the yield of percutaneous needle biopsies; (ii) identify factors that may lead to a negative result; and (iii) determine whether, TB being suspected, needle biopsy is justified. METHODS: We conducted a multicentre retrospective review of 44 patients treated for suspected spinal TB between January 2009 and April 2012, who did not require open surgery. Data captured included demographics, relevant history, outcome of investigations and histopathological findings in patients. RESULTS: The overall positive TB culture rate was 59%. Age, duration of symptoms, HIV and neurological status, erythrocyte sedimentation rate and core size had no statistical influence. Of the 7 patients receiving TB treatment at the time of biopsy, 3 were culture-positive. Multidrug resistance was evident in 12% of positive cultures. The positive culture yield was 40% at Tygerberg Hospital and 75% at Groote Schuur Hospital, with no difference in histological yield. This was attributed to the practice of decontaminating specimens prior to culture at Tygerberg Hospital. The highest culture yield (32%) came from samples showing non-necrotising chronic inflammatory changes. CONCLUSION: Percutaneous biopsy remains an important tool to diagnose and manage spinal TB. The yield of transpedicular biopsies in this study was comparable with international figures. Specimen decontamination prior to culture had a direct negative influence on biopsy culture yield, as did prior TB treatment. <![CDATA[<b>The attitudes of medical students to research</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100018&lng=pt&nrm=iso&tlng=pt BACKGROUND: The workforce of 'physician-scientists' is ageing and decreasing in numbers. The responsibility to combat this trend rests on future generations of healthcare professionals and it is therefore valuable to evaluate medical students' attitudes towards research. OBJECTIVE: To establish the attitudes of University of Cape Town (UCT) medical students towards research and to investigate the factors influencing these attitudes. METHODS: An anonymous, cross-sectional, self-administered questionnaire was administered to medical students from years 1 to 6 studying medicine at UCT in 2011. Questions were primarily closed-ended and consisted of Likert scales. RESULTS: Out of a population of 1 195 medical students, 733 were sampled (63%); 65% were female, 53% were preclinical students (years 1 - 3) and 47% were in their clinical years (year 4 - 6). Overall, 61% of students had a positive attitude towards research and 74% felt that participation in research was important to their medical school education; 22% had been involved in voluntarily extracurricular research, 4% had presented at a scientific meeting and 3% had published in peer-reviewed journals. A number of perceived barriers to student research were identified including a lack of adequate training, time and research opportunities. CONCLUSION: Students believed that research was important and had a positive attitude towards it. However, few had been involved in voluntary research and produced work worthy of presentation and/or publication. Addressing identified barriers and improving students' attitudes may begin to reverse the trend in declining numbers of physician-scientists. <![CDATA[<b>Diabetes mellitus in HIV-infected patients receiving antiretroviral therapy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100019&lng=pt&nrm=iso&tlng=pt BACKGROUND: There is little in the literature on HIV and diabetes mellitus (DM) in sub-Saharan Africa. OBJECTIVE: To assess the characteristics of HIV and DM in patients receiving antiretroviral therapy (ART) in Botswana. METHODS: A retrospective case-control study was conducted at 4 sites. Each HIV-infected patient with DM (n=48) was matched with 2 HIV-infected controls (n=108) by age (±2 years) and sex. Primary analysis was conditional logistic regression to estimate univariate odds and 95% confidence intervals (CIs) for each characteristic. RESULTS: There was no significant association between co-morbid diseases, tuberculosis, hypertension or cancer and risk of diabetes. DM patients were more likely to have higher pre-ART weight (odds ratio (OR) 1.09; 95% CI 1.04 - 1.14). HIV-infected adults >70 kg were significantly more likely to have DM (OR 12.30; 95% CI 1.40 - 107.98). Participants receiving efavirenz (OR 4.58; 95% CI 1.44 - 14.57) or protease inhibitor therapy (OR 20.7; 95% CI 1.79 - 240.02) were more likely to have DM. Neither mean pre-ART CD4 cell count (OR 1.0; 95% CI 0.99 - 1.01) nor pre-ART viral load >100 000 copies/ml (OR 0.71; 95% CI 0.21 - 2.43) were associated with a significant risk of diabetes. CONCLUSIONS: These findings suggest a complex interrelation among traditional host factors and treatment-related metabolic changes in the pathogenesis of DM inpatients receiving ART. Notably, pre-ART weight, particularly if >70 kg, is associated with the diagnosis of diabetes in HIV-infected patients in Botswana. <![CDATA[<b>Parents' perceptions of HIV counselling and testing in schools: Ethical, legal and social implications</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100020&lng=pt&nrm=iso&tlng=pt In view of the high prevalence of HIV and AIDS in South Africa, particularly among adolescents, the Departments of Health and Education have proposed a school-based HIV counselling and testing (HCT) campaign to reduce HIV infections and sexual risk behaviour. Through the use of semi-structured interviews, our qualitative study explored perceptions of parents regarding the ethico-legal and social implications of the proposed campaign. Despite some concerns, parents were generally in favour of the HCT campaign. However, they were not aware of their parental limitations in terms of the Children's Act. Their views suggest that the HCT campaign has the potential to make a positive contribution to the fight against HIV and AIDS, but needs to be well planned. To ensure the campaign's success, there is a need to enhance awareness of the programme. All stakeholders, including parents, need to engage in the programme as equal partners. <![CDATA[<b>Patient-initiated sexual partner notification in Botswana and time taken for sexual contacts to report for treatment</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100021&lng=pt&nrm=iso&tlng=pt BACKGROUND: Sexually transmitted infections (STIs) are an important public health concern because of their impact on reproductive and other health problems. Initiating treatment at an early stage for both index patients and their partners reduces the risk of reinfections and prevents serious short- or long-term complications for the infected individuals. Sexual partner tracing is one of the means available for reaching and treating asymptomatic sexual partners of index patients. OBJECTIVES: To determine the time taken by sexual partners to report to a health facility after they had been notified by the index patient, and the distribution of STI syndromes among the treated index patients who had their sexual partners treated. METHODS: All available contact slips of the treated sexual partners from 19 health districts in Botswana were reviewed. The study period was July 2010 to June 2011 inclusive. RESULTS: The partner notification slips showed that 77.9% (1 238/1 590) of sexual contacts sought medical attention at government health facilities within 7 days of treating the index patient. Records showed that 47.3% (752/1590) of the index patients were treated for vaginal discharge syndrome. CONCLUSION: A high proportion of sexual contacts were treated within 7 days of treating the index patient. Considering this short period, we conclude that Botswana's recommended 30-day period for consulting sexual partners needs to be revised downwards, so as to reduce the chances of reinfections, complications and transmission of STIs in the community. <![CDATA[<b>The use of the full blood count and differential parameters to assess immune activation levels in asymptomatic, untreated HIV infection</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100022&lng=pt&nrm=iso&tlng=pt BACKGROUND: A feature of HIV/AIDS is chronic immune activation, which results in a number of complications including inflammation-related disorders and blood cytopaenias. Immune activation status is not routinely tested in HIV infection. However, the full blood count (FBC) is a commonly performed test. OBJECTIVE: We hypothesised that FBC parameters would be significantly different in HIV-infected v. -uninfected individuals, and that some of these parameters would correlate with markers of immune activation (i.e. percentage CD38 expression on CD8+ T cells (%CD38onCD8)) and disease progression (i.e. CD4+ counts) in HIV infection. METHODS: This was a cross-sectional study with 83 HIV-infected adults who were antiretroviral therapy-naive and clinically well, and 51 HIV-uninfected adults. The %CD38onCD8 and CD4+ counts were determined by flow cytometry and the FBC was performed on a Siemens ADVIA 2120 system. FBC parameters investigated were total white cell count (WCC), haemoglobin (Hb) concentration, platelet count, absolute neutrophil count, absolute lymphocyte count, and percentage of large unstained cells (%LUCs). RESULTS: Significant differences were found between the HIV-infected and -uninfected groups for total WCC, Hb, neutrophil count, lymphocyte count and %LUCs. The mean ± standard deviation (SD) for the total WCC (5.3±1.3 v. 6.9±2.2; p<0.001) and the %LUCs (2.5±0.9 v. 2.0±0.9; p=0.001) both showed correlations with CD4+ counts and %CD38onCD8. CONCLUSION: The total WCC and %LUCs showed significant differences in HIV-infected individuals and correlated with markers of immune activation and disease progression. This suggests the potential use of these parameters as markers of immune activation in HIV infection. <![CDATA[<b>Sexual lubricants in South Africa may potentially disrupt mucosal surfaces and increase HIV transmission risk among men who have sex with men</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100023&lng=pt&nrm=iso&tlng=pt BACKGROUND: Men who have sex with men (MSM) are at high risk for HIV acquisition and transmission. There is a high HIV-transmission potential associated with unprotected anal intercourse (UAI), which requires sexual lubrication for comfortable, non-traumatic anal sex. Lubricant distribution remains poor in many developing nations and MSM have been known to substitute a number of common household or food products to ensure comfortable anal sex. Concern has been raised about the potential toxicity of lubricants used during anal sex. Epithelial injury is related to the osmolality of the lubricant product. OBJECTIVE: To analyse commercially available water-based sexual lubricant products to ascertain their osmolality and potential to cause rectal epithelial damage. METHODS: The osmolality and glycerol concentration was determined for eight of the most frequently purchased water-based sexual lubricants and some commonly used household/food products. RESULTS: Osmolality ranged from 270 - 9 440 mosmol/l (Lubrimaxxx Premium, containing phytosqualane, and JO H2O Water Based Lubricant, respectively). Seven (88%) of the commercial lubricants had high osmolalities, with two products approaching 10 000 mosmol/l, far in excess of serum which has an osmolality of ~280 mosmol/l. CONCLUSION: The results of this study show that many of the top-selling brands of water-based sexual lubricants available in SA are hyperosmolar. Given that hyperosmolar products have been shown in vitro and in vivo to cause epithelial injury, they may have the potential to increase HIV acquisition and transmission, if they are used during UAI. Awareness needs to be raised about the mucosal safety of lubricants designed for use during anal sex. <![CDATA[<b>Rapid, minimally invasive adult voluntary male circumcision: A randomised trial of Unicirc, a novel disposable device</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100024&lng=pt&nrm=iso&tlng=pt BACKGROUND: Voluntary medical male circumcision (VMMC) is a priority HIV preventive intervention. To facilitate VMMC scale-up, the World Health Organization is seeking circumcision techniques that are faster, easier, and safer than open surgical methods. OBJECTIVE: To compare open surgical circumcision with suturing v. the Unicirc disposable instrument plus tissue adhesive. METHODS: We conducted a non-blinded randomised controlled trial at an outpatient primary healthcare clinic in Cape Town, South Africa, with 2:1 allocation ratio of 150 male volunteers who were at least 18 years of age. Our primary outcome was intraoperative time and secondary outcomes were ease of performance, post-operative pain, adverse events, time to healing, patient satisfaction and cosmetic result. RESULTS: The intraoperative time was less with the Unicirc/adhesive technique (median 13 v. 22.6 min, respectively; p<0.001). The intraoperative suturing rate was 17% using the Unicirc device. Other adverse events and wound healing outcomes were similar in both groups, but the cosmetic result was superior in the Unicirc group. Doctors found the Unicirc procedure easier to perform and preferred it to the open surgical technique. CONCLUSIONS: This study has important implications for the scale-up of VMMC services. Excising the foreskin with the Unicirc instrument and sealing the wound with cyanoacrylate tissue adhesive in adults is quicker, easier to learn, and is potentially safer than open surgical VMMC. Further studies should be conducted with the optimised device. This new instrument has the potential to facilitate more rapid scale-up and save costs. <![CDATA[<b>Surgical outreach in rural South Africa: Are we managing to impart surgical skills?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100025&lng=pt&nrm=iso&tlng=pt BACKGROUND: The Department of Health in KwaZulu-Natal (KZN) has run a surgical outreach programme for over a decade. OBJECTIVE: To quantify the impact of the outreach programme by analysing its effect on the operative capacity of a single rural health district. METHODS: During 2012, investigators visited each district hospital in Sisonke Health District (SHD), KZN, to quantify surgery undertaken by resident staff between 1998 and 2013. Investigators also reviewed the operative registers of the four district hospitals in SHD for a 6-month period (March - August 2012) to document the surgery performed at each hospital. The number of staff who attended specialist-based teaching was recorded in an attempt to measure the impact of each visit. RESULTS: From 1998 to 2013, 35 385 patients were seen at 1 453 clinics, 5 199 operations were performed and 1 357 patients were referred to regional hospitals. A total of 3 027 staff attended teaching ward rounds and teaching sessions. In the four district hospitals, 2 160 operations were performed in the 6-month period. There were 653 non-obstetric operations and the obstetric cases comprised 1 094 caesarean sections, 55 sterilisations and 370 evacuations of the uterus. CONCLUSION: The infrastructure is well established and the outreach programme is well run and reliable. The clinical outputs of the programme are significant. However, the impact of this programme on specific outcomes is less certain. This raises the question of the future strategic choices that need to be made in our attempts to improve access to surgical care. <![CDATA[<b>Relationship between firewood usage and urinary Cr, Cu and As in informal areas of Cape Town</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100026&lng=pt&nrm=iso&tlng=pt OBJECTIVES: The study investigated whether wood usage by informal food vendors and household residents in Cape Town results in the absorption of arsenic (As), chromium (Cr) and copper (Cu) owing to release of these metals in the burning of chromated copper arsenate (CCA)-treated wood. METHODS: The participants (N=78) selected included an equal number of food vendors and non-vendors from 2 informal settlements. All participants answered a questionnaire concerning exposure and were tested for urinary Cr, Cu and As, while the urine of 29 participants was also tested for toxic As (As(tox)). RESULTS: Multivariate analysis showed that the time spent in close proximity to the wood, as well as the quantity of wood used for cooking and for household use, was weakly positively associated with urinary levels of As, Cr and the sum of As, Cr and Cu. CONCLUSIONS: The study provides evidence that use of wood likely to contain CCA as a fuel for informal food outlets and household purposes may increase the absorption of inorganic As, Cu and Cr. <![CDATA[<b>Critical value reporting</b>: <b>A survey of 36 clinical laboratories in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100027&lng=pt&nrm=iso&tlng=pt OBJECTIVE: Critical value policies are used by clinical laboratories to decide when to notify caregivers of life-threatening results. Despite their widespread use, critical value policies have not been published locally. A survey was designed to determine critical value policies for haematology tests in South Africa. METHODS: A survey was carried out on 136 identified laboratories across South Africa in January 2013. Of these, 36 responded. Data collected included critical value policies, critical values for haematology parameters, and critical value reporting. RESULTS: Of the 36 laboratories surveyed, 11.1% (n=4) were private, 33.3% (n=12) were affiliated to academic institutions and 55.6% (n=20) were peripheral or regional National Health Laboratory Service laboratories. All the laboratories confirmed that they had a critical value policy, and 83.3% of such policies were derived from local clinical opinion. Mean low and high critical limits for the most frequently listed tests were as follows: haemoglobin <6 and &gt;20 g/dl, platelet count <41 and &gt;1 000 x10(9)/l, white cell count <2 and &gt;46x10(9)/l, activated partial thromboplastin time &gt;101 seconds, and international normalised ratio &gt;6. In almost all cases critical value reporting was performed by the technologist on duty (97.2%). The majority of laboratories required that the person notified of the critical value be the doctor who ordered the test or the caregiver directly involved in the patient's care (83.3%); 73.3% of laboratories indicated that they followed an algorithm if the doctor/caregiver could not be reached. CONCLUSION: Each laboratory is responsible for establishing clinically relevant critical limits. Clinicians should be involved in developing the laboratory's critical value policy. The findings of this survey may be of value to local laboratories that are in the process of establishing or reviewing critical value policies. <![CDATA[<b>Mental healthcare in the community</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100028&lng=pt&nrm=iso&tlng=pt OBJECTIVE: Critical value policies are used by clinical laboratories to decide when to notify caregivers of life-threatening results. Despite their widespread use, critical value policies have not been published locally. A survey was designed to determine critical value policies for haematology tests in South Africa. METHODS: A survey was carried out on 136 identified laboratories across South Africa in January 2013. Of these, 36 responded. Data collected included critical value policies, critical values for haematology parameters, and critical value reporting. RESULTS: Of the 36 laboratories surveyed, 11.1% (n=4) were private, 33.3% (n=12) were affiliated to academic institutions and 55.6% (n=20) were peripheral or regional National Health Laboratory Service laboratories. All the laboratories confirmed that they had a critical value policy, and 83.3% of such policies were derived from local clinical opinion. Mean low and high critical limits for the most frequently listed tests were as follows: haemoglobin <6 and &gt;20 g/dl, platelet count <41 and &gt;1 000 x10(9)/l, white cell count <2 and &gt;46x10(9)/l, activated partial thromboplastin time &gt;101 seconds, and international normalised ratio &gt;6. In almost all cases critical value reporting was performed by the technologist on duty (97.2%). The majority of laboratories required that the person notified of the critical value be the doctor who ordered the test or the caregiver directly involved in the patient's care (83.3%); 73.3% of laboratories indicated that they followed an algorithm if the doctor/caregiver could not be reached. CONCLUSION: Each laboratory is responsible for establishing clinically relevant critical limits. Clinicians should be involved in developing the laboratory's critical value policy. The findings of this survey may be of value to local laboratories that are in the process of establishing or reviewing critical value policies. <![CDATA[<b>A broad diagnostic framework to simplify the approach to mental disorders in primary care</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100029&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>An update on attention deficit hyperactivity disorder (ADHD)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100030&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>Outpatient management of adult alcoholism</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100031&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>Psychiatry in primary care using the three-stage assessment</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100032&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>Recovery in mental health</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100033&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>De-institutionalisation in psychiatry - both sides of the coin</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100034&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>Adapting the psychiatric assessment for primary care</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100035&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation. <![CDATA[<b>South African guideline for the use of chronic opioid therapy for chronic non-cancer pain</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014000100036&lng=pt&nrm=iso&tlng=pt Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation.