Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 106 num. 9 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>The cannabis debate: Let's do the research</b>]]> <![CDATA[<b>Recognising and mitigating the risk of altitude-related illness</b>]]> <![CDATA[<b>Psychoactive substances: Position statement on harm reduction</b>]]> <![CDATA[<b>Position statement on cannabis: A step forwards</b>]]> <![CDATA[<b>Adding to the cannabis debate: Comment on various Central Drug Authority papers</b>]]> <![CDATA[<b>Clarifying the position statements of the Central Drug Authority Executive Committee</b>]]> <![CDATA[<b>Social justice and research using human biological material</b><b>: </b><b>A right to respond</b>]]> <![CDATA[<b>The potential danger of journal summary services</b>]]> <![CDATA[<b>Effects of oestrogen on prepubescent children</b>]]> <![CDATA[<b>'50 for 50': A celebration of 50 years of cancer research at the International Agency for Research on Cancer global conference in Lyon, France</b>]]> <![CDATA[<b>Cutting-edge ZAR120 million boost for SA's surgical skills</b>]]> <![CDATA[<b>'Shamed' Durban doctor claims ZAR20 million</b>]]> <![CDATA[<b>Two fatalities in Durban's multiple hospital strikes</b>]]> <![CDATA[<b>Give us peer educators, not nurses, say sex workers</b>]]> <![CDATA[<b>Child deaths in South Africa: Lessons from the child death review pilot</b>]]> <![CDATA[<b>Functional neurosurgery (part 2)</b>]]> <![CDATA[<b>Surgical management of movement disorders</b>]]> Movement disorders are usually treated by neurologists, and appropriately so. The first-line management of all conditions that are grouped together as movement disorders (e.g. Parkinson's disease, dystonia, essential tremor) is with medication and, in some, with rehabilitative strategies, such as occupational therapy, physiotherapy and even psychotherapy. In general, if these strategies fail or have undesirable consequences, surgery would become an option. Intramuscular injection of botulinum toxin is also very useful in the focal dystonias, such as writer's cramp, and in the occupation-specific dystonias, such as musician's dystonia or hairdresser's dystonia. The limiting factor is the total safe dosage allowed. One cannot inject every muscle involved in all four limbs in a patient with generalised dystonia. This has led to surgery being offered as therapy in certain cases where there have previously not been any alternatives. Surgery does not offer curative procedures for movement disorders, but long-term control with medication is possible, often with significant reduction or complete cessation of symptoms. <![CDATA[<b>Surgical management of pain</b>]]> Severe and intractable pain is one of the most difficult and challenging neurological conditions to deal with and to treat. The entity is not entirely well understood, and the afflicted patients often have significant concomitant neuropsychological problems that obscure the physical issue at hand. Physicians also do not fully understand what pain is. In a sense all pain is neural in origin. From a therapeutic perspective, pain is divided into visceral (dull and poorly localised owing to enteric sensory receptors) and somatosensory (more discreet and localised - often owing to nociceptors being stimulated) pain. It is detected by nociceptors, i.e. sensory reseptors with the ability to interpret and transmit noxious stimuli. Treatment options include medication, physical therapy and psychotherapy. The availability of sophisticated new medication, such as pregabalin, augments the medical arm of therapy. If these therapies fail, and with a thorough multidisciplinary approach involving carefully screened cases, surgery may form part of the management. Generally, surgical pain management is divided into neuro-modulative (enhancing physiological control of the pain system) and neurodestructive (lesioning and destroying the defined pain generator in the central nervous system) surgery. Complex pain management should not focus on cure as the only outcome. Patients often experience pain for years before considering surgery; it would therefore be unwise to expect an immediate cure. Careful psychological support and evaluation is of the utmost importance. This article gives an overview of the neurosurgical management of pain. <![CDATA[<b>Recipes for obstetric spinal hypotension: The clinical context counts</b>]]> Hypotension following obstetric spinal anaesthesia remains a common and important problem. While recent research advances have brought us closer to the perfect recipe for the obstetric spinal anaesthetic, these advances have not been translated into practical guidelines able to reduce the unacceptable number of fatalities that occur in environments where resources are limited. In South Africa, more than half of anaesthetic deaths are still related to spinal hypotension. A gap exists between the 'perfect recipe', developed from a clinical context rooted in resource-rich research environments, and its application and performance in real-world resource-poor environments - conditions experienced by more than 75% of the world's population. This review attempts to define this knowledge gap and proposes a research agenda to address the deficiencies. <![CDATA[<b>'Getting under our skin': Introducing banked allograft skin to burn surgery in South Africa</b>]]> Deceased donor skin possesses many of the properties of the ideal biological dressing, and a well-stocked skin bank has become a critically important asset for the modern burn surgeon. Without it, managing patients with extensive burns and wounds becomes far more challenging, and outcomes are significantly worse. With the recent establishment of such a bank in South Africa, the challenge facing the medical fraternity is to facilitate tissue donation so that allograft skin supply can match the enormous demand. <![CDATA[<b>A biobank to support HIV malignancy research for sub-Saharan Africa</b>]]> Sub-Saharan Africa has one of the highest incidences of infection with HIV globally, but more people in this region are living longer owing to increased access to antiretroviral therapy. However, along with increased care and treatment, this population is expected to have an increase in HIV-associated cancers, as is being seen in the USA and other developed countries. To support translational research in HIV-associated cancers, Stellenbosch University in Cape Town, South Africa, was funded to house the state-of-the-art AIDS and Cancer Specimen Resource Sub-Saharan Africa Regional Biorepository (SSA RBR) to proactively obtain, manage and process biospecimens and associated clinical data representing both AIDS-defining and non-AIDS-defining cancers for research. The SSA RBR furthermore functions as the biorepository for AIDS Malignancy Consortium sub-Saharan clinical trial activities in this region. Although the site had much experience with cryopreservation and storage of specimens, capacity building revolving around operations under International Society for Environmental and Biological Resources/National Cancer Institute best practices took place in such areas as custodianship v. ownership, data sharing and facilities management. The process from selection until launch took 14 months. <![CDATA[<b>CRISPR-Cas: Revolutionising genome engineering</b>]]> The ability to permanently alter or repair the human genome has been the subject of a number of science fiction films, but with the recent advent of several customisable sequence-specific endonuclease technologies, genome engineering looks set to become a clinical reality in the near future. This article discusses recent advancements in the technology called 'clustered regularly interspaced palindromic repeat (CRISPR)-associated genes' (CRISPR-Cas), the potential of CRISPR-Cas to revolutionise molecular medicine, and the ethical and regulatory hurdles facing its application. <![CDATA[<b>Improving the recording of clinical medicolegal findings in South Africa</b>]]> BACKGROUND: The accurate recording of findings in clinical medicolegal cases is important, yet the current J88 form used for this purpose in South Africa has been reported to have many flaws. In addition, there are reports of poor completion of the form, which could in part be due to its poor design and clarity. OBJECTIVE: To describe the process that was undertaken to revise the current J88 form. METHODS: A repetitive consultative process was used to revise the current J88 form and to obtain inputs from relevant government institutions. RESULTS: A brief outline of the changes that have been made to the current J88 form and the reasons why these changes were proposed by national experts is provided. CONCLUSION: The revised J88 form will provide clearer guidance to healthcare providers on the completion of necessary information in an expedited fashion. It is hoped that the form will soon be approved by the necessary government institutions. <![CDATA[<b>Postoperative care: From a legal point of view, whose responsibility is it?</b>]]> An ear, nose and throat surgeon recently asked if anyone else would be responsible postoperatively for removing a patient's throat pack that had been negligently left in place by the anaesthetist. Generally, members of the operating or treatment team such as anaesthetists, surgeons and circulating nurses are not legally liable for one another's negligent acts or omissions in theatre or postoperatively. However, in situations where one or both of the other members of the team could have directly intervened to prevent harm to a patient and failed to do so, such team members could have legal liability imposed on them as joint wrongdoers, e.g. where a throat pack is negligently left in a patient by an anaesthetist. <![CDATA[<b>Invasive carbapenem-resistant Enterobacteriaceae infection at a paediatric hospital: A case series</b>]]> BACKGROUND: There are no paediatric reports of invasive infection caused by carbapenem-resistant Enterobacteriaceae (CRE) from Africa. OBJECTIVES: To document a series of cases of CRE infections at a tertiary children's hospital in Cape Town, South Africa, describing the clinical and microbiological findings in these children. METHODS: A retrospective, descriptive study was completed using data from a series of children with invasive CRE infection between 2010 and 2015, sourced from their clinical notes and microbiology results. RESULTS: The first of 10 invasive CRE infections during the study period occurred in November 2012. Nine CRE infections were caused by Klebsiella pneumoniae, and one by both K. pneumoniae and Escherichia coli. The median age was 25 months (interquartile range (IQR) 5 - 60). All 10 CRE infections were hospital acquired. The median length of hospitalisation before CRE infection was 28.5 days (IQR 20 -44). Eight of the children were exposed to carbapenems during the 12-month period prior to invasive CRE infection. Six were treated with colistin and carbapenem combination therapy, of whom 2 died, including 1 of a non-CRE event. The other 4 children received colistin monotherapy. All these children died, including 2 from non-CRE events. CONCLUSIONS: Children with invasive CRE infection and severe underlying disease must be treated with combination antibiotic therapy. Strict infection control practice and antibiotic stewardship are necessary to contain the spread of CRE and limit the number of new infections. <![CDATA[<b>Human brucellosis in South Africa: Public health and diagnostic pitfalls</b>]]> Human brucellosis in South Africa (SA) is under-diagnosed and under-reported. This is because many clinicians have little or no experience in managing affected patients, and in part because of the nonspecific and insidious nature of the disease. A case of human brucellosis caused by Brucella melitensis in a patient from the Western Cape Province of SA is described, and the resulting exposure of staff members at two medical microbiology laboratories, as well as the public health investigation that was conducted, are discussed. The objective of this article is to highlight the need for strengthening integration between public health, medical and veterinary services and exposing deficiencies in public health, veterinary and laboratory practices. <![CDATA[<b>Sirolimus-induced lymphoedema</b>]]> Sirolimus is an inhibitor of the mammalian target of rapamycin (mTOR), used as an immunosuppressant for solid-organ transplant recipients and patients with autoimmune disorders. We report a case of lymphoedema, a rare complication of sirolimus, and discuss the mechanism of drug action, the adverse effects and the challenges of treating a kidney transplant recipient with this complication in a resource-limited environment. Lymphoedema is a rare complication of sirolimus, and the mechanisms are not completely understood; however, early recognition can prevent permanent disfiguration. This case highlights the need for early recognition of adverse drug effects and further research into their pathophysiology and management. <![CDATA[<b>Neonatal tetanus associated with skin infection</b>]]> A 1-week-old infant was brought to a regional hospital with a history of recurrent seizures following lower abdominal septic skin infection. She was found to have neonatal tetanus, and a spatula test was positive. The tetanus infection was associated with a superficial skin infection, common in neonates. Treatment included sedatives (diazepam, chlorpromazine, phenobarbitone and morphine), muscle relaxants, antibiotics and ventilation in the neonatal intensive care unit. Intrathecal and intramuscular immunoglobulin were given, and the wound was treated. The infant recovered, with no seizures by the 16th day from admission, and was off the ventilator by the 18th day. This was shorter than the usual 3 - 4 weeks for neonates with tetanus at the hospital. The question arises whether tetanus immunisation should be considered in infants with skin infections, which frequently occur in the neonatal period. <![CDATA[<b>Three cases of intentional isoniazid overdose - a life-threatening condition</b>]]> Currently, isoniazid (INH) overdose seems to be a growing and life-threatening problem, partly due to the recent national roll-out of INH preventive therapy (IPT) for HIV-positive adults. We present three cases, two of which were fatal, seen at Frere and Cecilia Makiwane hospitals, East London, South Africa over the past 16 months. <![CDATA[<b>Primary ethmoid sinus squamous cell carcinoma in a young adult man</b>]]> In this case report we describe an aggressive primary ethmoid squamous cell carcinoma in an unusually young patient. <![CDATA[<b>The South African child death review pilot: A multiagency approach to strengthen healthcare and protection for children</b>]]> BACKGROUND: Child mortality trends in South Africa (SA) show a decrease, but remain high and appear to have plateaued. To attain the new sustainable development goals, we need a better understanding of causes of death and the associated factors. OBJECTIVES: To describe the SA child death review (CDR) pilot, the pattern of child deaths reviewed and the factors associated with these deaths. METHODS: CDR teams were established at two pilot sites, Salt River mortuary (Western Cape Province) and Phoenix mortuary (KwaZulu-Natal Province). All child deaths were reviewed by a multidisciplinary team at the pilot sites for the period 1 January 2014 - 31 December 2014. RESULTS: The CDR pilot reviewed 711 cases. Over half (53.3%) were natural deaths, as opposed to 42.6% non-natural deaths. Most infant deaths (83.9%) were due to natural causes, while 91.7% of deaths in the 15 - 17-year-old age group were due to injuries. The leading cause of deaths reviewed (30.8%) was respiratory tract infection (RTI), mainly among infants (51.6%). Homicide was the second most common cause of death and affected children of all ages, with the highest burden (52.8%) in the 15 - 17-year age group. Child abuse and neglect accounted for 11.3% of deaths. RTI was shown to be more likely after the neonatal period (odds ratio (OR) 2.92; p<0.000) and in preterm infants (OR 1.98; p=0.005). CONCLUSIONS: CDR teams have been effective in improving identification of the causes of out-of-hospital deaths, as well as by identifying remediable factors critical to reducing child deaths further. <![CDATA[<b>A cross-sectional study of socioeconomic status and cardiovascular disease risk among participants in the Prospective Urban Rural Epidemiological (PURE) Study</b>]]> BACKGROUND: Cardiovascular diseases (CVDs) are a challenge to populations and health systems worldwide. It is projected that by 2020 about a third of all deaths globally will be caused by CVDs, and that they will become the single leading cause of death by 2030. Empirical evidence suggests that there is socioeconomic patterning in the distribution and prevalence of risk factors for CVD, but the exact nature of this relationship in South Africa remains unclear. OBJECTIVE: To examine the association between socioeconomic status (SES) and risk factors for CVD in a cohort of adult South Africans living in rural and urban communities. METHOD. This was a cross-sectional analytical study of baseline data on a population-based cohort of 1 976 SA men and women aged 35 - 70 years who were part of the Cape Town arm of the Prospective Urban and Rural Epidemiology (PURE) Study. RESULTS: We found a complex association between SES and CVD risk factors, its pattern differing between urban and rural participants. Marital status showed the most consistent association with CVD risk in both groups: widowed participants living in urban communities were more likely to be hypertensive as well as diabetic, while single participants in both locations were more likely to use alcohol and tobacco products. Level of education was the only SES variable that had no significant association with any CVD risk factor in either study group. All measured SES variables were significantly different between urban and rural participants (p<0.05), with diabetes, obesity and alcohol use significantly more prevalent in urban than in rural participants (p<0.05) while hypertension and tobacco use were not (p&gt;0.05). CONCLUSIONS: In this cohort of South Africans, there were significant associations between SES and CVD risk, with marked differences in these associations between rural and urban locations. These findings highlight the need to consider SES and area of residence when designing interventions for CVD prevention and control. <![CDATA[<b>The histological significance of atypical glandular cells on cervical cytology: Experience at Groote Schuur Hospital, Cape Town, South Africa</b>]]> BACKGROUND: Atypical glandular cells (AGC) identified on Pap tests may be markers for potentially significant pathology. OBJECTIVES: Primarily, to correlate AGC findings at Groote Schuur Hospital (GSH), Cape Town, South Africa, with subsequent histological investigations and attempt to identify predictors of pathology relevant to the clinical management of women with a cytological diagnosis of AGC. Secondly, to compare the GSH data with data from similar international studies. METHODS: Records of AGC Pap tests were retrieved from the laboratory database in the anatomical pathology laboratory at GSH and clinically relevant information was summarised based on the available information. Standard descriptive statistics were used to summarise the study data, and Fisher's exact test was used to compare categorical outcomes, where possible. RESULTS: Of the 237 women with a cytological diagnosis of AGC and who had subsequent histological diagnoses, 120 (50.6%) had significant pathology (cervical intraepithelial neoplasia (CIN) 2 or worse). Significant cervical pathology was most common in women aged <50 years, while significant endometrial pathology predominated in women aged &gt;50 years. The results of the GSH study were largely consistent with international findings, but the risk of malignancy was six times higher in the GSH population than in a comparable international group. CONCLUSION: AGC identified on Pap tests may be markers for potentially significant pathology. Human papillomavirus DNA testing is recommended for younger women diagnosed with AGC to reduce invasive investigations and minimise expenses in a resource-poor setting. <![CDATA[<b>Missed appointments among rifampicin-resistant tuberculosis (RR-TB) patients at a decentralised RR-TB outpatient clinic in Johannesburg, South Africa</b>]]> BACKGROUND: With the implementation of outpatient (ambulatory) decentralised rifampicin-resistant tuberculosis (RR-TB) treatment in South Africa (SA) since late 2011, the high rates of loss from treatment are a significant concern. Missed appointments lead to treatment interruptions and may contribute to amplification of resistance, ongoing transmission of RR-TB and an increased risk of morbidity and mortality to the patient. OBJECTIVE: To describe characteristics of patients who missed scheduled appointments during ambulatory RR-TB treatment. Methods: The study was a retrospective, deidentified electronic medical record review of RR-TB patients at an outpatient clinic in Johannesburg, SA, from March 2013 to December 2014. Associations between missed appointments and clinical and demographic characteristics were analysed using time-to-event Cox proportional hazards regression. RESULTS: Of 172 patients who met the eligibility criteria, 53.5% missed at least one appointment and 39.5% missed three or more. More than half (59.8%) of first missed appointments occurred within the first 3 months after treatment initiation. The median number of days from initiation until the first missed appointment was 82 (interquartile range 52 - 260.5). HIV-infected patients with a CD4 count of <100 cells/ μL. (adjusted hazard ratio (aHR) 4.25, 95% confidence interval (CI) 1.49 - 12.18), patients referred from an inpatient facility (aHR 1.96, 95% CI 1.18 - 3.25) and patients aged 18 - 24 years as opposed to those aged 35 - 44 years (aHR 3.26, 95% CI 1.20 - 8.84) were all more likely to miss one or more appointments. CONCLUSION: HIV-infected patients with a low CD4 count, patients referred from inpatient care and young patients are at high risk of missing appointments and should receive interventions targeted at improving retention. <![CDATA[<b>Effects of diabetes mellitus on health-related quality of life at a tertiary hospital in South Africa: A cross-sectional study</b>]]> BACKGROUND: Diabetes mellitus (DM) is a chronic metabolic disease that potentially causes debilitating and life-threatening complications, demands a lifestyle change, and has important implications with regard to wellbeing and health-related quality of life (HRQOL). TO: OBJECTIVES: (i) determine the HRQOL of a sample of patients with type 2 diabetes; (ii) describe the demographics (age, gender, and smoking and alcohol use) of the population studied; (iii) document the following parameters, which are important in determining the control and severity of type 2 diabetes: (a) glycosylated haemoglobin (HbA1c), (b) total amount of insulin required per day (if on insulin therapy), (c) body mass index (BMI), and (d) exercise compliance; (iv) determine whether there was an association between any or all of the above parameters and the HRQOL of these patients; and (v) determine whether coexisting diseases (hypertension (HT) and dyslipidaemia) were present, and compare HRQOL between diabetic patients with and without these diseases. METHODS: This was a cross-sectional and descriptive study of 200 patients attending the diabetes clinic at Helen Joseph Hospital, Johannesburg, South Africa. HRQOL assessments were made using the Diabetes 39 (D-39) questionnaire, which patients filled in once consent had been obtained and if they fulfilled the inclusion criteria. Patients' questionnaire forms were then analysed with regard to their demographics (age and gender), exercise regimen, smoking and alcohol history, employment status, living arrangements, age of diagnosis of DM, and concurrent use of antihypertensive and cholesterol-lowering drugs. The patients' files were analysed and various clinical parameters were noted (HbA1c, lipogram, BMI, number of insulin units used per day, and whether any antihypertensive and/or lipid-lowering drugs were used). RESULTS: There was an association between HRQOL and HbA1c, and between HRQOL and HT and dyslipidaemia. CONCLUSIONS: No association was found between HRQOL and other clinical parameters, namely number of insulin units used per day, exercise, BMI, lipogram and the use of oral hypoglycaemic agents. Demographic parameters (age, gender, age at diagnosis, employment status and living arrangements) were also shown to have no impact on HRQOL. We found no association between HRQOL in patients who consumed alcohol and smoked cigarettes and in those who did not. <![CDATA[<b>A follow-up study of a large group of children struck by lightning</b>]]> BACKGROUND: On 11 November 1994, 26 preadolescent girls, 2 adult supervisors and 7 dogs were sleeping in a tent in rural South Africa when the tent was struck by lightning. Four of the girls and 4 of the dogs were killed. The 2 adults were unharmed, but all but 3 of the children suffered significant injuries. An article in 2002 detailed the event and examined the medical and psychological changes in the surviving girls. OBJECTIVE: To understand the medical and psychological changes secondary to lightning strike years after injury. METHODS: An online questionnaire was prepared that included a checklist of physical and psychological symptoms. Participants were asked to report on both initial and current symptoms. Eleven of the 22 survivors were contacted, and 10 completed the survey. RESULTS: Participants reported that initial physical symptoms generally resolved over time, with ~10 - 20% continuing to experience physical symptoms. Vision problems persisted in 50% of respondents. Psychological symptoms, overall, had a later onset and were more likely to be chronic or currently experienced. Depression and anxiety, specifically, were higher among the survivors than the reported incidence in South Africa. CONCLUSIONS: Initial and current/chronic physical and psychological symptoms following lightning strike are reported, adding to the body of literature on the long-term after-effects of lightning strike on survivors. A brief discussion on post-traumatic stress disorder symptomatology and post-lightning shock syndrome is provided. <![CDATA[<b>The PAWPER tape and the Mercy method outperform other methods of weight estimation in children at a public hospital in South Africa</b>]]> BACKGROUND: A rapid, accurate weight-estimation method is essential in paediatric emergency care, when it may not be possible to weigh a child, as drug dose calculations cannot be completed without weight. OBJECTIVES: To determine and compare the performance of the Broselow tape, PAWPER (Paediatric Advanced Weight Prediction in the Emergency Room) tape, Mercy method, Wozniak method and three age-based formulae in estimating the weight of children. A secondary objective was to assess whether the addition of a figural rating scale to assess body habitus improved the performance of the PAWPER tape. METHODS: We estimated the weights of children between the ages of 1 month and 12 years using the Broselow tape, PAWPER tape, Mercy method and Wozniak method. The performance of the four methods was evaluated, and they were compared with one another and with three aged-based formulae. RESULTS: Three hundred children were enrolled in the study. The PAWPER tape and Mercy method performed the best, estimating weight within 10% of actual weight (PW10) in 88% and 80% of cases, respectively. The Broselow tape and Wozniak method fared significantly worse (PW10 54% for Broselow, 71% for the ulna length method and 63% for the tibia length method). The use of a figural rating scale to assess body habitus did not significantly improve the overall performance of the PAWPER tape. The age-based formulae performed poorly. CONCLUSIONS: The PAWPER tape and Mercy method outperformed the Wozniak method and Broselow tape in estimating weight of children. The Broselow tape and the age-based formulae were very poor weight-estimation methods and should no longer be used, given the availability of better methods. <![CDATA[<b>What are the communication skills and needs of doctors when communicating a poor prognosis to patients and their families? A qualitative study from South Africa</b>]]> BACKGROUND: Thousands of South Africans are diagnosed with life-threatening illness every year. Research shows that, globally, of the 20 million people who need palliative care at the end of life every year, <10% receive it. OBJECTIVES: To explore communication skills and practices of medical practitioners when conveying a poor prognosis to patients and families, and to identify their communication skills, needs and understanding of palliative care. METHODS: This was an exploratory qualitative study of practising doctors, using a grounded theory approach. The study was conducted at a government-funded public hospital in Cape Town, South Africa, which is a referral centre for various illnesses, including cancer. Face-to-face, one-on-one interviews using a semistructured interview guide were conducted, using audio recording. RESULTS: The emerging theory from this study is that doctors who understand the principles of palliative care and who have an established working relationship with a palliative care team feel supported and express low levels of emotional anxiety when conveying a poor prognosis. CONCLUSION: Having hospital-based palliative care teams in all public hospitals will provide support for patients and doctors handling difficult conversations. All healthcare professionals should be trained in palliative care so that they can effectively communicate concerns related to poor prognosis with patients and their families. Communication, loss and grief issues should be part of the curriculum in all disciplines and throughout training in medical school.