Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 106 num. 4 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Where are we now?</b>]]> <![CDATA[<b>A new vision for the <i>SAMJ </i>- and a call for papers</b>]]> <![CDATA[<b>The simple bread tag - a menace to society? More warnings in our digital era</b>]]> <![CDATA[<b>Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin</b>]]> <![CDATA[<b>Vaccines: SA's immunisation programme debunked</b>]]> <![CDATA[<b>PE hospital turmoil: CEO leaves, nurses snore in patient beds</b>]]> <![CDATA[<b>Budget squeeze: Cutting clinicians hurts patients</b>]]> <![CDATA[<b>'My advice was evidence based' - Noakes</b>]]> <![CDATA[<b>Where are the males? Diversity, proportionality and Health Sciences admissions</b>]]> <![CDATA[<b>Unpacking the new proposed regulations for South African traditional health practitioners</b>]]> <![CDATA[<b>Acute viral bronchiolitis in South Africa: Diagnosis and current management</b>]]> <![CDATA[<b>Acute viral bronchiolitis in South Africa: Diagnostic flow</b>]]> Bronchiolitis may be diagnosed on the basis of clinical signs and symptoms. In a young child, the diagnosis can be made on the clinical pattern of wheezing and hyperinflation. Clinical symptoms and signs typically start with an upper respiratory prodrome, including rhinorrhoea, low-grade fever, cough and poor feeding, followed 1 - 2 days later by tachypnoea, hyperinflation and wheeze as a consequence of airway inflammation and air trapping. The illness is generally self limiting, but may become more severe and include signs such as grunting, nasal flaring, subcostal chest wall retractions and hypoxaemia. The most reliable clinical feature of bronchiolitis is hyperinflation of the chest, evident by loss of cardiac dullness on percussion, an upper border of the liver pushed down to below the 6th intercostal space, and the presence of a Hoover sign (subcostal recession, which occurs when a flattened diaphragm pulls laterally against the lower chest wall). Measurement of peripheral arterial oxygen saturation is useful to indicate the need for supplemental oxygen. A saturation of <92% at sea level and 90% inland indicates that the child has to be admitted to hospital for supplemental oxygen. Chest radiographs are generally unhelpful and not required in children with a clear clinical diagnosis of bronchiolitis. Blood tests are not needed routinely. Complete blood count tests have not been shown to be useful in diagnosing bronchiolitis or guiding its therapy. Routine measurement of C-reactive protein does not aid in management and nasopharyngeal aspirates are not usually done. Viral testing adds little to routine management. Risk factors in patients with severe bronchiolitis that require hospitalisation and may even cause death, include prematurity, congenital heart disease and congenital lung malformations. <![CDATA[<b>Acute viral bronchiolitis in South Africa: Strategies for management and prevention</b>]]> Management of acute viral bronchiolitis is largely supportive. There is currently no proven effective therapy other than oxygen for hypoxic children. The evidence indicates that there is no routine benefit from inhaled, rapid short-acting bronchodilators, adrenaline or ipratropium bromide for children with acute viral bronchiolitis. Likewise, there is no demonstrated benefit from routine use of inhaled or oral corticosteroids, inhaled hypertonic saline nebulisation, montelukast or antibiotics. The last should be reserved for children with severe disease, when bacterial co-infection is suspected. Prevention of respiratory syncytial virus (RSV) disease remains a challenge. A specific RSV monoclonal antibody, palivizumab, administered as an intramuscular injection, is available for children at risk of severe bronchiolitis, including premature infants, young children with chronic lung disease, immunodeficiency, or haemodynamically significant congenital heart disease. Prophylaxis should be commenced at the start of the RSV season and given monthly during the season. The development of an RSV vaccine may offer a more effective alternative to prevent disease, for which the results of clinical trials are awaited. Education of parents or caregivers and healthcare workers about diagnostic and management strategies should include the following: bronchiolitis is caused by a virus; it is seasonal; it may start as an upper respiratory tract infection with low-grade fever; symptoms are cough and wheeze, often with fast breathing; antibiotics are generally not needed; and the condition is usually self limiting, although symptoms may occur for up to 4 weeks in some children. <![CDATA[<b>A call to action: Addressing the reproductive health needs of women with drug-resistant tuberculosis</b>]]> Although there is substantial risk to maternal and neonatal health in the situation of pregnancy during treatment for rifampicin-resistant tuberculosis (RR-TB), there is little evidence to guide clinicians as to how to manage this complexity. Of the 49 680 patients initiated on RR-TB treatment from 2009 to 2014 in South Africa, 47% were women and 80% of them were in their reproductive years (15 - 44). There is an urgent need for increased evidence of the safety of RR-TB treatment during pregnancy, increased access to contraception during RR-TB treatment, and inclusion of reproductive health in research on the prevention and treatment of TB. <![CDATA[<b>A multifaceted hospital-wide intervention increases hand hygiene compliance</b>]]> BACKGROUND: Hand hygiene is an important and basic practice that should be used by all healthcare staff to protect both themselves and their patients against infection. Unfortunately hand hygiene compliance remains poor. OBJECTIVE: To show an improvement in hand hygiene compliance using a multifaceted approach. METHODS: This was a quasiexperimental pre-post intervention study design with a number of standardised interventions to promote hand hygiene. The World Health Organization hand hygiene multimodal (five-step) intervention approach was used. The study ran from June 2015 to August 2015 in 11 selected wards of a 975-bed tertiary and quaternary care public hospital (Groote Schuur Hospital, Cape Town, South Africa). The outcome was to assess improvement in hand hygiene compliance monthly over the 3 months, compared with non-intervention wards and compared with the wards' own performance measured in 2014. The study included both descriptive and analytical components. RESULTS: Post intervention, hand hygiene compliance showed a statistically significant improvement for before patient contact from 34% in 2014 to 76% in 2015 (p<0.05) and for after patient contact from 47% in 2014 to 82% in 2015 (p<0.05). CONCLUSION: The intervention improved hand hygiene compliance and can easily be replicated in other wards, resulting in sustaining a culture of hand hygiene improvement and behavioural change throughout the hospital. <![CDATA[<b>Intracranial complications of <i>Serratia marcescens </i>infection in neonates</b>]]> Even though Serratia marcescens is not one of the most common causes of infection in neonates, it is associated with grave morbidity and mortality. We describe the evolution of brain parenchymal affectation observed in association with S. marcescens infection in neonates. This retrospective case series details brain ultrasound findings of five neonates with hospital-acquired S. marcescens infection. Neonatal S. marcescens infection with or without associated meningitis can be complicated by brain parenchymal affectation, leading to cerebral abscess formation. It is recommended that all neonates with this infection should undergo neuro-imaging more than once before discharge from hospital; this can be achieved using bedside ultrasonography. <![CDATA[<b>Biofilms associated with bowel necrosis: A newly recognised phenomenon in infants</b>]]> BACKGROUND: A biofilm is defined as a collection of organisms attached to a surface and surrounded by a matrix OBJECTIVE: To present three cases in which bowel necrosis coexisted with biofilm METHODS: The medical records, bacteriological findings and tissue biopsies from three infants with bowel necrosis who subsequently died from sepsis were analysed. Tissue sent for histological evaluation was prepared for light microscopy. Haematoxylin and eosin (H), Sandiford and Alcian blue/periodic acid Schiff (ABPAS) stains were performed. Tissue samples were ex-waxed for electron microscopy in one case RESULTS: The three patients described all had necrotic bowel at laparotomy, all cultured Klebsiella pneumoniae from peritoneal pus swabs, and all died despite appropriate antibiotics. All specimens showed varying degrees of bowel necrosis and an organising acute peritoneal reaction. In addition, all showed colonies of Gram-negative bacteria within a mucopolysaccharide matrix CONCLUSIONS: The identification of biofilms in necrotic bowel has raised questions regarding their clinical implications. Further studies are needed to evaluate all resected necrotic bowel for biofilms and the clinical implications of this finding <![CDATA[<b>A child's potential claim for negligent misdiagnosis: The case of H v. Fetal Assesment Centre</b>]]> South African law recognises a financial claim against a health provider for negligently failing to advise an expectant mother that she might give birth to a child suffering from a severe health condition or congenital disability. In December 2014, the Constitutional Court handed down a judgment that could lead to financial claims by the child, who was subsequently born with a severe health condition or disability. This judgment thus creates a framework to legally recognise a claim by a child whose current health condition was negligently misdiagnosed before birth. The contents and effects of the judgment are discussed in this article. <![CDATA[<b>The impact of the Medicines Control Council backlog and fast-track review system on access to innovative and new generic and biosimilar medicines of public health importance in South Africa</b>]]> The fast-track registration policy of the South African (SA) National Department of Health (DoH) allows for rapid registration of new medicines of public health importance and of all medicines on the Essential Medicines List, most of which are generics. No limit is placed on the number of generic brands of a medicine that can be submitted for fast-track registration. This, together with resource constraints at the regulator, may delay access to important new medicines, new fixed-dose combinations of critical medicines or affordable versions of biological medicines (biosimilars). One reason for not limiting the number of fast-track generic applications was to promote price competition among generic brands. We found this not to be valid, since market share correlated poorly with price. Generic brands with high market share were, mostly, those that were registered first. We propose that the number of generic brands accepted for fast-tracking be limited to not more than seven per medicine. <![CDATA[<b>Orbital apex syndrome caused by aspergilloma in an immunocompromised patient with cutaneous lymphoma: A case report of a rare entity</b>]]> A 57-year-old man with a history of chemotherapy because of cutaneous lymphoma presented with an orbital apex syndrome. The cranial computed tomography scan revealed a tumour in the orbital apex, extending intradurally. With a suspected diagnosis of a neoplastic lesion, the patient underwent orbital surgery with optic nerve decompression. Histology revealed an aspergilloma. No other foci were seen and treatment with antifungals was started. In immunocompromised patients with intracranial tumours, infection is always a major consideration in the differential diagnosis, even if the reason for immunosuppression (in this case chemotherapy) dates back several months. Misdiagnosing an orbital apex lesion as a cancer and treating patients primarily with corticosteroids can be life threatening. Removal or biopsy of such lesions is essential in further treatment since antifungals have to be administered as fast as possible. <![CDATA[<b>Autoimmune progesterone dermatitis: Case report with history of urticaria, petechiae and palpable pinpoint purpura triggered by medical abortion</b>]]> Autoimmune progesterone dermatitis (APD) is a rare autoimmune response to raised endogenous progesterone levels that occur during the luteal phase of the menstrual cycle. Cutaneous, mucosal lesions and other systemic manifestations develop cyclically during the luteal phase of the menstrual cycle when progesterone levels are elevated. APD symptoms usually start 3 - 10 days before menstruation and resolve 1 - 2 days after menstruation ceases. A 30-year-old woman presented with urticaria, petechiae and palpable pinpoint purpura lesions of the legs, forearms, neck and buttocks 1 week prior to her menses starting and 2 months after a medical abortion. She was diagnosed with allergic contact dermatitis and topical steroids were prescribed. Her skin conditions did not improve and were associated with her menstrual cycle. We performed an intradermal test using progesterone, which was positive. She was treated with oral contraceptive pills and the symptoms were resolved. This is a typical case of APD triggered by increased sensitivity to endogenous progesterone induced a few months after medical abortion. <![CDATA[<b>Where do children die and what are the causes? Under-5 deaths in the Metro West geographical service area of the Western Cape, South Africa, 2011</b>]]> BACKGROUND: Accurate child mortality data are essential to plan health interventions to reduce child deaths OBJECTIVES: To review the deaths of children aged <5 years during 2011 in the Metro West geographical service area (GSA) of the Western Cape Province (WC), South Africa, from routine data sources METHODS: A retrospective study of under-5 deaths in the Metro West GSA was done using the WC Local Mortality Surveillance System (LMSS), the Child Healthcare Problem Identification Programme (Child PIP) and the Perinatal Problem Identification Programme (PPIP), and linking where possible RESULTS: The LMSS reported 700 under-5 deaths, Child PIP 99 and PPIP 252, with an under-5 mortality rate of 18 deaths per 1 000 live births. The leading causes of death were pneumonia (25%), gastroenteritis (10%), prematurity (9%) and injuries (9%). There were 316 in-hospital deaths (45%) and 384 out-of-hospital deaths (55%). Among children aged <1 year, there were significantly more pneumonia deaths out of hospital than in hospital (144 (49%) v. 16 (6%); p<0.001). Among children aged 1 - 4 years there were significantly more injury-related deaths out of hospital than in hospital (43 (47%) v. 4 (9%); p<0.001). In 56 (15%) of the cases of out-of-hospital death the child had visited a public healthcare facility within 1 week of death. Thirty-six (64%) of these children had died of pneumonia or gastroenteritis CONCLUSIONS: Health interventions targeted at reducing under-5 deaths from pneumonia, gastroenteritis, prematurity and injuries need to be implemented across the service delivery platform in the Metro West GSA. It is important to consider all routine data sources in the evaluation of child mortality <![CDATA[<b>Antiretroviral therapy programme outcomes in Tshwane district, South Africa: A 5-year retrospective study</b>]]> BACKGROUND: Scaling up of antiretroviral therapy (ART) in South Africa (SA) has resulted in an increase in the number of patients on the national ART programme and an increased workload for ART service providers nationwide OBJECTIVES: To ascertain patient retention on ART after 5 years on treatment in one district of Gauteng Province, SA, establish the number of patients who remained alive on ART after 5 years of treatment, and identify patient-related factors that contributed towards the outcome of each indicator METHODS: A retrospective cohort study of patients initiated on highly active antiretroviral therapy (HAART) between January and March 2007 was carried out. A sample of 381 patients was randomly selected from 1 004 records, and their records were reviewed for visits over the previous 60 months. Summary statistics, Pearson's χ² test and linear regression tests were performed RESULTS: Of 381 patients, 156 (40.9%) remained alive and active on HAART at their initial sites. The overall mortality rate was 5.0% and the rate of long-term retention in care was 57.4%, excluding those transferred to another site. After 6 months on HAART the mean rise in CD4 count was 113 cells/μL, and after 60 months it was 288 cells/μL. Viral load suppression to <400 copies/mL was achieved in 74.0% of patients at 6 months and 91.0% at 60 months CONCLUSIONS: Immunological and virological outcomes after 5 years on treatment were good. Both these positive outcomes showed that the ART programme was a success. Improved data quality and patient follow-up will further strengthen programme outcomes <![CDATA[<b>Clinician compliance with laboratory monitoring and prescribing guidelines in HIV 1-infected patients receiving tenofovir</b>]]> BACKGROUND: Tenofovir is part of the preferred first-line regimen for HIV-infected patients in South Africa (SA), but is associated with kidney toxicity. SA antiretroviral therapy (ART) guidelines recommend creatinine monitoring at baseline (ART start) and at 3, 6 and 12 months, and substituting tenofovir with zidovudine, stavudine or abacavir should creatinine clearance (CrCl) decrease to <50 mL/min OBJECTIVE: To assess clinician compliance with tenofovir monitoring and prescribing guidelines METHODS: We described the proportion of adult patients on tenofovir-based first-line ART who were screened for baseline renal impairment, were monitored according to the SA antiretroviral treatment guidelines, and were switched from tenofovir if renal function declined RESULTS: We included 13 168 patients who started ART from 2010 to 2012. Creatinine concentrations were recorded in 11 712 (88.9%) patients on tenofovir at baseline, 9 135/11 657 (78.4%) at 3 months, 5 426/10 554 (51.4%) at 6 months, and 5 949/ 8 421 (70.6%) at 12 months. At baseline, 227 (1.9%) started tenofovir despite a CrCl <50 mL/min. While on tenofovir, 525 patients had at least one CrCl of <50 mL/min. Of 382 patients with &gt;3 months' follow-up after a CrCl <50 mL/min, 114 (29.8%) stopped tenofovir within 3 months. Clinicians were more likely to stop tenofovir in patients with lower CrCl and CD4 count. Of 226 patients who continued to receive tenofovir and had further CrCls available, 156 (69.0%) had a CrCl &gt;50 mL/min at their next visit CONLUSIONS: Creatinine monitoring is feasible where access to laboratory services is good. Kidney function recovered in most patients who continued to receive tenofovir despite a CrCl <50 mL/min. Further research is needed to determine how best to monitor renal function with tenofovir in resource-limited settings <![CDATA[<b>The S'Khokho 'bushcan' initiative: Kick a bush and condoms fall out</b>]]> BACKGROUND: People living in rural areas have limited access to condoms owing to distance, cost and time involved in travelling to public health facilities, around which most condom distribution efforts are centralised. OBJECTIVE: In an effort to increase access to condoms in these areas, we explored the feasibility and efficacy of condom distribution by placing 'condocans' on trees along informal footpaths used by residents. METHODS: From October 2012, steel condocans, typically seen in clinic settings, were erected on trees along pathways in bushy areas with high levels of foot traffic at several rural locations in the uMgungundlovu district of KwaZulu-Natal Province, South Africa (SA). Because of their location, the condocans were referred to as 'bushcans'. Condom uptake was closely monitored, and the bushcans were restocked when necessary. RESULTS: Following the introduction of the bushcans, male condom distribution increased by 237% from October 2012 to December 2012. Condom distribution in these areas increased on average by 187% from October 2012 to October 2015, with more than 408 000 condoms distributed over the 3-year period using the bushcans alone. Discussions with residents revealed that they were pleased about the increased access to condoms via the bushcans, and they recommended other areas for potential implementation of this initiative. CONCLUSIONS: The bushcan initiative highlighted the fact that condoms are not as easily accessible to all South Africans as is often thought. By providing access to condoms in a discreet and convenient manner, the bushcans have the potential to increase access to condoms in other rural and periurban areas in SA where communities face similar barriers to access. <![CDATA[<b>Piloting a national laboratory electronic programme status reporting system in Ekurhuleni health district, South Africa</b>]]> BACKGROUND: The National Health Laboratory Service (NHLS) performs ~4 million CD4 tests per annum for the public health sector at 61 CD4 testing laboratories across South Africa. Currently, CD4 laboratory data captured do not differentiate between antiretroviral treatment (ART) and pre-ART care METHODS: A cross-sectional study was undertaken to evaluate a redesigned Comprehensive Care, Management and Treatment of HIV and AIDS (CCMT) request form, incorporating a two-tick collection procedure linking the CD4 test request to patient CCMT programme status. Field testing was undertaken at three health facilities, where healthcare personnel were required to capture whether the CD4 count requested was a 'first-ever CD4', 'CD4 taken previously, not yet in ART care' or 'in ART care'. All data were extracted from the NHLS Corporate Data Warehouse and analysed using Microsoft Excel and Stata-12 RESULTS: A substantial increase in the number of request forms with a CCMT programme status (28.1% v. 84.4%) was reported pre- and post-implementation. Post-implementation data (N=1 004) revealed that 30.8% patients were ART naive ('first-ever CD4'), with 7.4% 'not yet on ART' (median CD4 counts of 150 and 328 cells/μL, respectively). Patients on ART comprised 61.9% of the study group (median CD4 count ~346 cells/μL). Sixty percent of patients were aged between 30 and 44 years, and females predominated (male/ female ratio 0.7:1 CONCLUSIONS: A simple modification to the CCMT request form can successfully facilitate collection of programme status. For national implementation, it would be advantageous to have a unique patient identifier to further enhance laboratory-based programmatic monitoring and evaluation <![CDATA[<b>A deadly combination - HIV and diabetes mellitus: Where are we now?</b>]]> BACKGROUND: The combination of HIV infection and diabetes mellitus (DM) represents a collision of two chronic conditions. Both HIV and DM increase the risk of developing tuberculosis (TB). Health resources in developing countries are already under strain as a result of the TB epidemic and poor diabetic control would further worsen this epidemic. Optimal diabetic control provides one avenue of curbing the TB epidemic in developing countries OBJECTIVES: To establish if there is a difference in blood pressure, lipid and glycaemic control and complications between HIV-infected and uninfected diabetic patients; and to compare characteristics among HIV-infected diabetic patients between those with optimal and sub-optimal glycaemic control METHODS: This was a retrospective chart review of all patients who visited the Edendale Hospital diabetic clinic, Pietermaritzburg, from 1 October 2012 to 30 September 2013 RESULTS: There were statistically significant differences noted in the following parameters between HIV-infected and uninfected diabetic patients: (i) mean HbA1c% (11.08% v. 10.14%, respectively); (ii) nephropathy defined by proteinuria (25.66% v. 15.43%); (iii) neuropathy (48.68% v. 42.10%); and (iv) Kidney Disease Outcomes Quality Initiative (KDOQI) stage >2 chronic kidney disease (30.87% v. 41.67%). There were no significant differences noted in the percentage of patients achieving the following target parameters between the two cohorts: (i) blood pressure (42.11% v. 35.62%); (ii) total cholesterol (36.84% v. 34.67%); and (iii) triglycerides (42.76% v. 40.19%). Within the HIV-infected diabetic cohort 85.23% displayed suboptimal glycaemic control. A significant percentage of HIV-infected diabetic patients on antiretroviral (ARV) therapy (89.36%) had suboptimal glycaemic control. HIV-infected female diabetic patients showed a significant increased waist circumference when compared with their HIV-uninfected counterparts CONCLUSION: HIV-infected diabetic patients had significantly poorer blood sugar control and a higher incidence of neuropathy and nephropathy (when defined by overt proteinuria). There was a non-significant difference noted between the HIV-infected and uninfected diabetic patients with regard to blood pressure and lipid control. The majority of HIV-infected patients on ARVs failed to achieve target glycaemic control. Obesity remains a global challenge, as noted in both the HIV-infected and uninfected diabetic patients <![CDATA[<b>The burden of diabetes mellitus in KwaZulu-Natal's public sector: A 5-year perspective</b>]]> BACKGROUND: Diabetes mellitus (DM), together with its devastating complications, has a huge impact on both the patients it affects and the global economy as a whole. The economies of developing countries are already under threat from communicable diseases. More needs to be done to stem the tide of non-communicable diseases like DM. In order for us to develop new strategies to tackle this dread disease we need to obtain and analyse as many data as possible from the geographical area where we work OBJECTIVE: To describe the burden of DM in the public sector of the province of KwaZulu-Natal (KZN), South Africa (SA METHOD: Data on the number of diabetes visits, DM patients that were initiated on treatment, defaulters and DM-related amputations were accessed from the Department of Health records for the period 2010 - 2014 inclusive RESULTS: There was a decline in the number of patients initiated on treatment per 100 000 population from 2010 to 2014 inclusive (265.9 v. 197.5 v. 200.7 v. 133.4 v. 148.7). Defaulter rates for 2013 compared with 2014 were 3.31% v. 1.75%, respectively and amputation rates were 0.09% v. 0.05% for 2013 and 2014, respectively. There was a strong proportional relationship observed between the number of defaulters and number of diabetes-related amputations (r=0.801; p=0.000) (Pearson correlation). A notable percentage of DM patients ranging between 63% and 80% were commenced on pharmacological therapy at their local clinics rather than at hospitals in the province CONCLUSION: Strategies directed towards detection and treatment of DM, together with decreasing defaulter rates and thereby decreasing diabetes-related amputations, need to be addressed urgently. The majority of patients were initiated on therapy at the clinic level. This emphasises the need to strengthen our clinics in terms of resources, staffing, and nursing and clinician education, as this is where diabetes control begins. Although this study was based solely in KZN, the second most populous province in SA, it probably reflects the current situation regarding DM in other provinces of SA as well <![CDATA[<b>Distribution, incidence, prevalence and default of patients with diabetes mellitus accessing public healthcare in the 11 districts of KwaZulu-Natal, South Africa</b>]]> BACKGROUND: The global increase in the prevalence of diabetes mellitus is most marked in African countries. The District Health Information System (DHIS) is the primary data collection system of the Department of Health in KwaZulu-Natal Province (KZN), South Africa. Data are routinely collected at all public healthcare facilities in the province and are aggregated per facility OBJECTIVE: To investigate the distribution, incidence and prevalence of diabetes in the public healthcare sector of KZN METHODS: Data collected by the DHIS for all patients with diabetes in KZN from 1 January 2010 to 31 December 2014 inclusive were analysed. Additional open-source databases were accessed to enable further exploration of the data collected RESULTS: The study showed that the majority (38.7%) of patients with diabetes on the public sector register were from the district of eThekwini. Positive correlations were found between the prevalence of diabetes, the mortality rate and the number of defaulters (patients with diabetes who did not return for regular treatment CONCLUSIONS: Provincial estimates of the prevalence of diabetes in this study were higher than the known national prevalence. This may be due to the large proportion of Indians in KZN, who have a genetic predisposition to diabetes mellitus. However, allowance must be made for possible inaccurate data collection at source with miscounting of individuals. This study supports the global trend of an association between diabetes and urbanisation and highlights the need for regular diabetes screening and education, particularly in the public healthcare domain <![CDATA[<b>The other side of surveillance: Monitoring, application, and integration of tuberculosis data to guide and evaluate programme activities in South Africa</b>]]> BACKGROUND: The importance of using surveillance data to monitor and evaluate programme activities has been emphasised in international policies for tuberculosis (TB) control OBJECTIVES: A survey was conducted to assess the use of TB surveillance data to monitor and guide TB programme activities in South Africa (SA METHODS: As part of an evaluation of the SA national TB surveillance system, semi-structured interviews were conducted among TB staff at health facilities and offices in three provinces. At each site, all persons involved with TB care, management and surveillance were invited to participate RESULTS: At least one person (range 1 - 4) was interviewed at 47/54 health facilities (87.0%), 11/13 subdistrict and district TB offices (84.6%), 2/3 provincial TB offices (66.7%), and at the national level (1/1, 100.0%). Of 119 TB staff, 64.7% recognised the purpose of TB surveillance as guiding programme planning, implementation and evaluation. However, only 16.0% reported using data to measure disease burden, 8.4% to monitor trends, and 9.2% to inform resource allocation. The majority reported using TB management tools provided by the national programme, but 44.5% also described using additional tools. Personnel mentioned the need for dedicated surveillance staff, training on recording and reporting, improved computer access, and methods to apply information from surveillance data to the programme CONCLUSIONS: The majority of TB staff understood the purpose of surveillance but did not routinely use data to guide programme planning, implementation and evaluation. Training and supporting TB staff to utilise surveillance data will help improve the TB surveillance system <![CDATA[<b>A randomised controlled trial comparing oxytocin and oxytocin + ergometrine for prevention of postpartum haemorrhage at caesarean section</b>]]> BACKGROUND: Globally 166 000 women die annually as a result of obstetric haemorrhage. More than 50% of these deaths occur in sub-Saharan Africa. Uterine atony is the commonest cause of severe postpartum haemorrhage (PPH). Bleeding at or after caesarean section (CS) is responsible for >30% of maternal deaths due to obstetric haemorrhage in South Africa (SA OBJECTIVE: To compare oxytocin alone with oxytocin + ergometrine in terms of primary prophylaxis for PPH at the time of CS METHODS: This was a double-blind randomised controlled interventional study comparing oxytocin with oxytocin + ergometrine administered during CS. Patients were randomised to receive oxytocin alone intravenously as a bolus or oxytocin + ergometrine intramuscularly, with the placebo being an injection of sterile water. The study population consisted of women undergoing CS at Kalafong Provincial Tertiary Hospital in Atteridgeville, Gauteng, SA RESULTS: Five hundred and forty women were randomised and data for 416 women, of whom 214 received oxytocin and 202 oxytocin + ergometrine, were available for analysis. In the oxytocin group 19 women (8.9%) required blood transfusion, compared with seven (3.5%) in the oxytocin + ergometrine group (p=0.01; relative risk = 2.78; 95% confidence interval 1.21 - 6.4). There were no statistically significant differences in the mean estimated visual and mean calculated blood loss CONCLUSIONS: The overall need for blood transfusion was significantly reduced by about two-thirds in women receiving the oxytocin + ergometrine combination. Consideration should be given to using oxytocin + ergometrine for prophylaxis of PPH at CS <![CDATA[<b>Evaluating current knowledge of legislation and practice of obstetricians and gynaecologists in the management of fetal remains in South Africa</b>]]> BACKGROUND: In the clinical setting, the main legislative provisions governing the management and 'disposal' of fetal remains in South Africa are the Choice on Termination of Pregnancy Act 92 of 1996 and the Births and Deaths Registration Act 51 of 1992 OBJECTIVES: To determine obstetricians' and gynaecologists' current knowledge of this legislation. Current practice with regard to certification of death and methods of disposal of fetal material was also reviewed METHODS: A questionnaire-based study was conducted. The data collected included demographic details, qualifications, years of experience, working environment (public/private practice), responses to general questions reviewing knowledge of current legislation, and practical experience RESULTS: Seventy-six questionnaires were returned, with practitioners from the private and public sectors nearly equally represented. It was found that there is a concerning gap in obstetricians' and gynaecologists' knowledge of the law, and that some practitioners are acting outside the scope of the law. The study further revealed that patients' needs are not properly accommodated under the current legislative provisions, because the law prevents certain remains from being respectfully managed CONCLUSIONS: The study findings suggest that improved training of practitioners, together with possible law reform, are required to better serve the needs of patients <![CDATA[<b>Socioeconomic factors associated with asthma prevalence and severity among children living in low-income South African communities</b>]]> BACKGROUND: Rates of asthma, poverty and social deprivation are high among young people in South Africa (SA), yet asthma interventions largely remain focused on biomedical factors OBJECTIVE: To investigate associations between socioeconomic factors and childhood asthma METHODS: We recruited 6 002 children aged 10 - 17 years from six low-income urban and rural sites in three SA provinces. Self-report questionnaires measured health status, sociodemographics and socioeconomic factors. Logistic regression and mediation analyses were used to test models of risk factors for asthma prevalence and severity (frequency of attacks RESULTS: Child anxiety (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.04 - 1.12) and community violence (OR 1.14; 95% CI 1.00 -1.30) were associated with increased odds of having asthma. Children doing more outdoor housework (OR 0.83; 95% CI 0.71 - 0.98) and living in greater poverty (OR 0.93; 95% CI 0.88 - 0.99) had lower odds of having asthma. Severe asthma was predicted by child depression (OR 1.14; 95% CI 1.03 - 1.26) and greater household poverty (OR 1.14; 95% CI 1.01 - 1.28). Most socioeconomic factors operated in 'risk pathways', wherein structural factors (e.g. urban living) were associated with individual factors (e.g. fewer outdoor tasks), which predicted greater odds of having asthma or severe exacerbations CONCLUSIONS: This study suggests the need to consider the context of childhood asthma in SA for improved prevention and treatment. A multidisciplinary approach may be more effective than a biomedical model, given the plausible effects of psychosocial stress and poverty on asthma outcomes <![CDATA[<b>Parasitaemia and haematological changes in malaria-infected refugees in South Africa</b>]]> BACKGROUND: Haematological changes associated with malaria are well recognised, but may vary with level of malaria endemicity and patient background, haemoglobinopathy, nutritional status, demographic factors and malaria immunity. Although malaria in South Africa (SA) has been reduced dramatically in endemic areas, little is known about the haematological changes associated with malaria infection among refugee populations who live in SA cities OBJECTIVE: To describe haematological alterations among malaria-infected refugees living in Durban, SA METHODS: A cross-sectional study was conducted from September 2012 to July 2013 inclusive at a refugee centre in central Durban. Blood samples from 102 adult black African refugees were examined for infection with malaria parasites, and haematological profiles were compared with standard normal values RESULTS: Malaria infection was detected in 16 (15.7%) of the 102 participants. The mean haemoglobin (Hb) value was reduced (mean 9.2 g/dL) in the participants with malaria, who also had an extremely low mean packed cell volume (PCV) of 28.3%. The mean Hb value in the non-malaria-infected participants was normal (12.6 g/dL), and the mean PCV was slightly low (38.0% CONCLUSIONS: Anaemia was more common among participants with malaria infection than among those who were uninfected. Other haematological changes were common in both infected and uninfected participants, suggesting that infections other than malaria, or other underlying factors that cause haematological alterations, may be present. This research needs to be expanded to include a large sample and other areas and infections <![CDATA[<b>Use of the nested polymerase chain reaction for detection of <i>Toxoplasma gondii </i>in slaughterhouse workers in Thika District, Kenya</b>]]> BACKGROUND: The widely used methods of diagnosis of Toxoplasma gondii are serological. Current reports indicate a high seroprevalence of T. gondii in humans in Kenya. There is a need for more sensitive diagnostic tests, especially when the specific antibody titres are below detectable threshold levels. Use of the polymerase chain reaction (PCR) targeting the repetitive 529 base pair loci has been reported to be sensitive and specific OBJECTIVE: To detect T. gondii in a high-risk group of public health workers in Thika District, Kenya METHODS: In total, 87 human blood samples were collected from male slaughterhouse workers between 1 March 2013 and 25 June 2013. The DNA extracted was amplified by the nested PCR RESULTS: T. gondii was detected in 39.1% (34/87) of the workers. In the cow-sheep-goat slaughterhouses the prevalence ranged between 20% and 60%, while all the chicken slaughterhouse workers (6/6, 100%) tested positive. The difference in T. gondii positivity between the workers in the chicken slaughterhouse and those in the cattle-sheep-goat slaughterhouses was statistically significant (p=0.003 CONCLUSION: This study shows the presence of T. gondii in an asymptomatic high-risk group in Thika District, indicating the need for enhancement of public health awareness