Scielo RSS http://www.scielo.org.za/rss.php?pid=0256-957420140010&lang=en vol. 104 num. 10 lang. en http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000002&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000003&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000004&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000005&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000006&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000007&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000008&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000009&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000010&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000011&lng=en&nrm=iso&tlng=en The prevalence of diabetes in South Africa is increasing rapidly, and diabetes is a significant cause of blindness. Diabetic complications can induce a cycle of poverty for affected families. Early detection of retinopathy and appropriate management can prevent blindness. Screening for retinopathy using a mobile retinal camera is highly cost-effective, with costs of screening and follow-up treatment being less than the expense of one year of a disability grant. Such a programme is a prime example of a 'best buy' that should be part of the national diabetes care package. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000012&lng=en&nrm=iso&tlng=en South Africa (SA), like the rest of the Southern African Development Community, has a high prevalence of communicable diseases, an increasing non-communicable disease burden, and diverse internal and cross-border population movements. Healthy migration is good for development, but current prevention, testing and treatment responses within public health systems - particularly for chronic conditions -fail to engage with migration. Understanding of migration is poor within sectors responsible for developing appropriate responses; negative, unsupported assumptions relating to the prevalence of cross-border migration, the spread of disease, and the burden on receiving health systems prevail. In SA, public health responses fail to address internal and cross-border mobilities, and non-nationals face challenges in accessing healthcare. Of particular concern is the lack of nationally and regionally co-ordinated strategies to ensure treatment continuity for chronic conditions. Co-ordinated, evidence-informed responses to migration, mobility and health are urgently needed. These will have developmental and public health benefits for all. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000013&lng=en&nrm=iso&tlng=en The increasing prevalence of overweight and obesity among female adolescents is a global health problem. In developing countries such as South Africa, this increase is often associated with urbanisation and the adoption of a Western lifestyle. Two aspects of the Western lifestyle that contribute to the development of overweight and obesity are a decrease in physical activity levels and an increase in the consumption of energy-dense food, high in fats and refined sugar. Information on the prevalence of increased body fatness in populations in transition is scarce, but necessary for effective planning and intervention. Current indications are that there is a trend towards unhealthy behaviour among high-school girls, globally and in South Africa. Schools can play an important role in the prevention of overweight and obesity among schoolgirls. It is recommended that school governing bodies institute remedial action to prevent weight gain in children, especially girls. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000014&lng=en&nrm=iso&tlng=en Lower limb varicose veins are a common complication of bipedal human movement and deep-vein thrombosis. However, they may have unusual causes, e.g. forming as collaterals around an obstruction or resulting from vascular malformations. Surgery in these cases can be inappropriate or harmful. Five cases of lower limb varicose veins in which there was underlying pathology highlight the fact that cursory examination of patients with varicose veins and inappropriate special investigations can miss rare but significant underlying pathology. Patients should be examined systematically, and varicose veins in unusual situations should alert the clinician. Inappropriate surgery can be harmful. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000015&lng=en&nrm=iso&tlng=en Glucocorticoids have multiple therapeutic uses, but their impact on lipid metabolism and cardiovascular disease risk is not always considered during long-term treatment. Genetic variations, environmental factors and the reasons for glucocorticoid treatment all influence the lipid profile and atherosclerosis. Responses to glucocorticoid treatment may therefore be variable and unpredictable. Despite the frequency with which pharmacological doses of glucocorticoids are used, surprisingly few publications examine their effects on lipid metabolism and atherosclerosis. Patients managed with glucocorticoids should have their cardiovascular risk assessed, especially if long-term treatment is planned. While some apparent favourable changes have been reported in high-density lipoprotein metabolism, very-low-density lipoprotein and low-density lipoprotein responses seem unfavourable. The impact of glucocorticoids on atherosclerosis, which is often viewed as an inflammatory process, is unclear. Glucocorticoid treatment should be undertaken for appropriate indications, but in some instances special attention should be given to management of dyslipidaemia, as long-term survivors of treatment are likely to encounter atherosclerosis. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000016&lng=en&nrm=iso&tlng=en Glucocorticoids have multiple therapeutic uses, but their impact on lipid metabolism and cardiovascular disease risk is not always considered during long-term treatment. Genetic variations, environmental factors and the reasons for glucocorticoid treatment all influence the lipid profile and atherosclerosis. Responses to glucocorticoid treatment may therefore be variable and unpredictable. Despite the frequency with which pharmacological doses of glucocorticoids are used, surprisingly few publications examine their effects on lipid metabolism and atherosclerosis. Patients managed with glucocorticoids should have their cardiovascular risk assessed, especially if long-term treatment is planned. While some apparent favourable changes have been reported in high-density lipoprotein metabolism, very-low-density lipoprotein and low-density lipoprotein responses seem unfavourable. The impact of glucocorticoids on atherosclerosis, which is often viewed as an inflammatory process, is unclear. Glucocorticoid treatment should be undertaken for appropriate indications, but in some instances special attention should be given to management of dyslipidaemia, as long-term survivors of treatment are likely to encounter atherosclerosis. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000017&lng=en&nrm=iso&tlng=en Glucocorticoids have multiple therapeutic uses, but their impact on lipid metabolism and cardiovascular disease risk is not always considered during long-term treatment. Genetic variations, environmental factors and the reasons for glucocorticoid treatment all influence the lipid profile and atherosclerosis. Responses to glucocorticoid treatment may therefore be variable and unpredictable. Despite the frequency with which pharmacological doses of glucocorticoids are used, surprisingly few publications examine their effects on lipid metabolism and atherosclerosis. Patients managed with glucocorticoids should have their cardiovascular risk assessed, especially if long-term treatment is planned. While some apparent favourable changes have been reported in high-density lipoprotein metabolism, very-low-density lipoprotein and low-density lipoprotein responses seem unfavourable. The impact of glucocorticoids on atherosclerosis, which is often viewed as an inflammatory process, is unclear. Glucocorticoid treatment should be undertaken for appropriate indications, but in some instances special attention should be given to management of dyslipidaemia, as long-term survivors of treatment are likely to encounter atherosclerosis. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000018&lng=en&nrm=iso&tlng=en Glucocorticoids have multiple therapeutic uses, but their impact on lipid metabolism and cardiovascular disease risk is not always considered during long-term treatment. Genetic variations, environmental factors and the reasons for glucocorticoid treatment all influence the lipid profile and atherosclerosis. Responses to glucocorticoid treatment may therefore be variable and unpredictable. Despite the frequency with which pharmacological doses of glucocorticoids are used, surprisingly few publications examine their effects on lipid metabolism and atherosclerosis. Patients managed with glucocorticoids should have their cardiovascular risk assessed, especially if long-term treatment is planned. While some apparent favourable changes have been reported in high-density lipoprotein metabolism, very-low-density lipoprotein and low-density lipoprotein responses seem unfavourable. The impact of glucocorticoids on atherosclerosis, which is often viewed as an inflammatory process, is unclear. Glucocorticoid treatment should be undertaken for appropriate indications, but in some instances special attention should be given to management of dyslipidaemia, as long-term survivors of treatment are likely to encounter atherosclerosis. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000019&lng=en&nrm=iso&tlng=en BACKROUND: Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs. OBJECTIVO: To review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example. METHODS: Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010. RESULTS: The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ≥25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled. CONCLUSION: Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000020&lng=en&nrm=iso&tlng=en BACKGROUND: Adolescents in South Africa (SA) have a huge unmet need for sexual and reproductive health (SRH) services. Integrating such services into schools may overcome many of the current barriers to access. OBJECTIVES: We describe an SRH service model developed for high-school students and its implementation in 14 high schools in rural SA. Methods. Following consultation with community and other key stakeholders about the demand for and acceptability of adolescent-targeted SRH services, a three-tier school-based model was developed that included: (i) in-school group SRH information and awareness sessions; (ii) in-school individual SRH counselling and customised HIV counselling and testing (CCT); and (iii) referrals to in-school fixed, in-school mobile or public sector primary SRH clinics. RESULTS: From October 2011 to June 2012, 70 consultative meetings were held. There was overwhelming support for the pilot founded on concerns about the high HIV prevalence and teenage pregnancy rates among adolescents in the community. SRH information was provided to 8 867 high-school students, 4 171 (47.0%) of whom accessed on-site CCT services for HIV. The gender-specific prevalence of HIV in these students was 3.3% (64/1 962) and 1.1% (24/2 209) for females and males, respectively. Two hundred and thirty-nine students (5.7%) were referred for clinical services at in-school fixed, in-school mobile or public sector primary SRH clinics. CONCLUSIONS: The SRH service provision pilot was acceptable in the community and seems feasible for scale-up. Further work is required to understand inter-school variability in uptake, identify additional service needs of students, and characterise SRH demand dynamics. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000021&lng=en&nrm=iso&tlng=en OBJECTIVES: To establish the prevalence and determinants of the 10-year risk of a cardiovascular disease (CVD) event in 25 - 74-year-old black Africans in Cape Town, South Africa, using Framingham laboratory- and non-laboratory-based and National Health and Nutrition Examination Survey (NHANES) I non-laboratory-based equations. METHODS: CVD risk factors were determined by questionnaires, clinical measurements and biochemical analyses. Survey logistic regression analyses assessed the sociodemographic determinants of CVD risk ≥20%. RESULTS: There were 1 025 participants, 369 men and 656 women. Mean 10-year risk for a CVD event by Framingham laboratory- and non-laboratory-based and NHANES I non-laboratory-based equations for men was 9.0% (95% confidence interval 7.7 - 10.3), 11.1% (9.6 - 12.6) and 9.0% (7.6 - 10.3), and for women 5.4% (4.7 - 6.1), 6.8% (5.9 - 7.7) and 8.7% (7.6 - 9.8). Correlations between laboratory- and non-laboratory-based scores were high (0.915 - 0.963). The prevalence of laboratory-based CVD risk >20% was 13.0% in men and 6.1% in women. In the logistic model for men,≥7 years of education (odds ratio 3.09; 95% CI 1.67 - 5.71) and being unemployed (3.44; 1.21 - 9.81) compared with employed were associated with laboratory-based high risk. In women, high risk was associated with ≥7 years of education (4.20; 1.96 - 9.01), living in formal v. informal housing (2.74; 1.24 - 6.06) and being poor (middle v. lowest tertile 0.29; 0.13 - 0.66). In the Framingham non-laboratory-based logistic models there were no changes in the direction or significance of the variables except for housing, which was no longer significant in women. CONCLUSIONS: Comparability of laboratory- and non-laboratory-based CVD risk estimates illustrates the utility of the latter in resource-constrained settings. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000022&lng=en&nrm=iso&tlng=en BACKGROUND: The performance of clinical and immunological criteria to predict virological failure in HIV-infected children receiving antiretroviral therapy (ART) is not well documented. OBJECTIVE: To determine the validity of clinical and immunological monitoring in detecting virological failure in children on ART. METHODS: A total of 218 children were included in the study. All were from care and treatment clinics in Dar es Salaam, Tanzania. Their mean age was 10.6 years, 122 (56.0%) were males, and the mean time on ART was 40.9 months. The study was conducted from August 2011 to March 2012. Data on sociodemographic and clinical characteristics and immunological and virological failure were based on World Health Organization definitions. Blood samples were collected for CD4+ T-cell count and viral load tests. RESULTS: Of 217 children with available viral load results, 124 (57.1%) had virological failure (>400 copies/mL), 25.0% immunological failure and 11.5% clinical failure. The sensitivity, specificity, positive predictive value and negative predictive value of clinical criteria were 12.9%, 90.3%, 64.0% and 43.8%, respectively, those for immunological criteria 22.6%, 73.1%, 53.3% and 41.4%, and those for the combination of clinical and immunological monitoring 25.8%, 69.9%, 53.3% and 41.4%. Children who received nevirapine (NVP)-based regimens were two times more likely (odds ratio 2.0; 95% confidence interval 1.20 - 3.64) to have virological failure than those on efavirenz and protease inhibitor-based regimens. CONCLUSIONS: The study demonstrated poor performance of currently recommended clinical and immunological criteria for monitoring HIV-infected children on ART. Moreover, children on NVP-based regimens had a higher risk of developing virological failure than those on other regimens. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000023&lng=en&nrm=iso&tlng=en BACKGROUND: Diabetic retinopathy (DR) is an important biomarker for microvascular disease and blindness. Digital fundus photography is a cost-effective way of screening for DR. Access to DR screening is difficult for many South Africans with diabetes. OBJECTIVE: To perform external quality assurance (EQA) on graders registered in the Ophthalmological Society of South Africa DR screening programme. METHODS: Graders registered on the South African (SA) Diabetic Register website were invited to participate in the study. The Scottish EQA software system was used to enable on-line grading of 100 retinal photographs. Expert National Health Service graders provided the consensus expert grading for the image set. RESULTS: Two hundred and sixty-one participants completed the EQA process, including nine ophthalmologists, 243 optometrists, and nine other graders. A wide range of outcomes were demonstrated, with a mean sensitivity of 0.905 (range 0.286 - 1.000) and mean specificity of 0.507 (0.000 - 0.935). The mean diagnostic odds ratio was calculated to be 12.3 (range 0.147 - 148.2). CONCLUSIONS: This is the first quality assurance study conducted with SA healthcare professionals. The outcomes are of interest to all stakeholders dealing with the diabetes epidemic. The disparity in grader performance indicates room for improvement. The results demonstrate a high referral rate to ophthalmology, suggesting that on average graders are performing safely, but with a high number of inappropriate referrals. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000024&lng=en&nrm=iso&tlng=en BACKGROUND: Diabetic retinopathy (DR) is an important biomarker for microvascular disease and blindness. Digital fundus photography is a cost-effective way of screening for DR. Access to DR screening is difficult for many South Africans with diabetes. OBJECTIVE: To perform external quality assurance (EQA) on graders registered in the Ophthalmological Society of South Africa DR screening programme. METHODS: Graders registered on the South African (SA) Diabetic Register website were invited to participate in the study. The Scottish EQA software system was used to enable on-line grading of 100 retinal photographs. Expert National Health Service graders provided the consensus expert grading for the image set. RESULTS: Two hundred and sixty-one participants completed the EQA process, including nine ophthalmologists, 243 optometrists, and nine other graders. A wide range of outcomes were demonstrated, with a mean sensitivity of 0.905 (range 0.286 - 1.000) and mean specificity of 0.507 (0.000 - 0.935). The mean diagnostic odds ratio was calculated to be 12.3 (range 0.147 - 148.2). CONCLUSIONS: This is the first quality assurance study conducted with SA healthcare professionals. The outcomes are of interest to all stakeholders dealing with the diabetes epidemic. The disparity in grader performance indicates room for improvement. The results demonstrate a high referral rate to ophthalmology, suggesting that on average graders are performing safely, but with a high number of inappropriate referrals. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000025&lng=en&nrm=iso&tlng=en The aetiopathogenesis of atopic dermatitis (AD) is complex and during recent years much has been learnt regarding the genetic predisposition to the development of this condition and how its interaction with the environment influences clinical manifestations. AD is not a simple allergic condition. An inherited stratum corneum barrier defect, transepidermal water loss, early antigen exposure through the skin and over-hygienic care of the young child seem to be the major drivers in the manifestation of the disease. Many other, more specific, environmental factors may influence the clinical picture in individual patients; some of these have an allergic basis, while others do not. In this article, the terminology used in this issue of CME is explained, the evidence for the different aetiopathological factors is presented and the factors that worsen or improve AD are listed. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000026&lng=en&nrm=iso&tlng=en Epidemiological studies on atopic dermatitis, primarily performed in children, have shown that the one-year prevalence rate of symptoms is population and area dependent. The few studies that have been done in South Africa among children of different age groups showed one-year prevalence rates of 1 - 13.3%. In adults, the burden of disease is significant. The prevalence rates and age-related percentages of those affected vary between the countries where studies were undertaken. While about 60% of cases show spontaneous clearing by puberty, the condition may recur in adults. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000027&lng=en&nrm=iso&tlng=en Atopic dermatitis (AD) is essentially diagnosed clinically. In babies and young children, the diagnosis is usually straightforward. Dry, very pruritic dermatitis starts on the cheeks, with the neck and trunk often involved, but the nappy area spared. Limb involvement follows later - first extensoral, later classically flexural. This is mostly the picture of AD. In adults, the presentation may vary widely. Classic flexural dermatitis may persist, but erythroderma (whole-body involvement), head and neck dermatitis, isolated hand dermatitis and nummular dermatitis may be more difficult to identify as AD. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000028&lng=en&nrm=iso&tlng=en Educating patients with atopic dermatitis is an essential and necessary part of therapy and particularly important when young children are involved. Quality of life is seriously impaired if patients or their carers do not understand the chronic and relapsing nature of the disease and how it can be treated. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000029&lng=en&nrm=iso&tlng=en Non-pharmacological measures to improve the management of atopic dermatitis (AD) are as important as pharmacotherapy for true healing of the skin. Skin dryness (which contributes to inflammation, loss of suppleness (leading to fissuring), impaired barrier function, and increased adherence of Staphylococcus aureus organisms) can be overcome by the use of emollients. Ointments and creams provide better barrier function than lotions. Bathing is an important part of the management of AD. Regular, once-daily bathing in warm (not hot) water to hydrate the skin and debride crusts is important. Scented soaps should be avoided and replaced with a moisturising cleanser. After bathing, patients should pat the skin dry and apply emollients immediately. Routine use of topical or systemic antibacterial or antifungal agents is not recommended for AD, but during flares such agents may be invaluable. There is no specific diet for the treatment of AD. Elimination diets are not routine treatment and are potentially harmful. Food elimination should be reserved for those children who have been proven to be allergic to the specific food. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000030&lng=en&nrm=iso&tlng=en Topical corticosteroids (TCSs) continue to be the mainstay of atopic dermatitis (AD) treatment. For more than four decades TCSs have provided effective flare control by means of their anti-inflammatory, antiproliferative, immunosuppressive and vasoconstrictive actions. They suppress the release of inflammatory cytokines and act on a variety of immune cells, including T lymphocytes, monocytes, macrophages, dendritic cells and their precursors. Various strengths and formulations of TCSs are available. The extent to which they induce cutaneous vasoconstriction and inhibit inflammation corresponds to their potency. Topical calcineurin inhibitors (TCIs) (pimecrolimus and tacrolimus) are complex macrocyclic compounds that result in selective inhibition of cytokine transcription in activated T cells. TCIs are registered for short-term and non-continuous chronic treatment of moderate to severe AD in immunocompetent patients aged >2 years. Systemic corticosteroids are frequently used for short-term therapy of severe AD, but their use is controversial. Complementary/alternative therapies have no proven benefit in AD. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001000031&lng=en&nrm=iso&tlng=en Topical corticosteroids (TCSs) continue to be the mainstay of atopic dermatitis (AD) treatment. For more than four decades TCSs have provided effective flare control by means of their anti-inflammatory, antiproliferative, immunosuppressive and vasoconstrictive actions. They suppress the release of inflammatory cytokines and act on a variety of immune cells, including T lymphocytes, monocytes, macrophages, dendritic cells and their precursors. Various strengths and formulations of TCSs are available. The extent to which they induce cutaneous vasoconstriction and inhibit inflammation corresponds to their potency. Topical calcineurin inhibitors (TCIs) (pimecrolimus and tacrolimus) are complex macrocyclic compounds that result in selective inhibition of cytokine transcription in activated T cells. TCIs are registered for short-term and non-continuous chronic treatment of moderate to severe AD in immunocompetent patients aged >2 years. Systemic corticosteroids are frequently used for short-term therapy of severe AD, but their use is controversial. Complementary/alternative therapies have no proven benefit in AD.