Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 107 num. 8 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Seeing through another's eyes</b>]]> <![CDATA[<b>Paraffin ingestion in children: Rationalising antibiotic treatment</b>]]> <![CDATA[<b>Human dignity and the future of the voluntary active euthanasia debate in South Africa</b>]]> <![CDATA[<b>What can we expect from the leadership of the recently elected World Health Organization Director-General, Dr Tedros?</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>The ECG Atlas of Cardiac Rhythms</b>]]> <![CDATA[<b>Darwin's Hunch: Science, Race and the Search for Human Origins</b>]]> <![CDATA[<b>Short-course adjuvant trastuzumab will increase cure rates in patients with human epidermal growth factor receptor 2-positive breast cancer</b>]]> <![CDATA[<b>Growing wilderness and expedition medicine education in southern Africa</b>]]> <![CDATA[<b>Expedition medicine: A southern African perspective</b>]]> A growing number of people are undertaking expeditions and adventure travel to previously inaccessible areas. The risks posed by increasing accessibility of remote regions and interest in extreme sports have not been fully obviated by modern equipment and communications. Therefore, there remains a requirement for medical care during wilderness expeditions, for which expectations and formal standards continue to increase. Expedition medicine should take cognisance of the predicted problems, plan for contingencies, and be practised pragmatically in austere settings. Southern African medics have a broad skill set, which makes them ideally suited to the field, but they should seek to understand the epidemiology of expeditions in different environments, undergo specialised training, and become involved in all phases of planning and execution of an expedition. Routine general practice complaints and accidental trauma are ubiquitous; travel medical issues such as blisters, diarrhoea, insomnia, sunburn and dehydration occur commonly; area/activity-specific issues such as infectious disease risks and altitude illnesses must be addressed; and women's health and dental problems are frequently overlooked. The expedition medic plays a wide range of roles, and should have knowledge and skills to match the requirements of the expedition. Fortunately, many resources exist to assist medics in becoming competent in the field. <![CDATA[<b>Heat-related illness in the African wilderness</b>]]> Wilderness heat-related illnesses span a variety of conditions caused by excessive or prolonged heat exposure, and/or the inability to compensate adequately for increased endogenous production during strenuous outdoor activities. Despite management of well-known risk factors, such as lack of fitness or acclimatisation, dehydration, underlying illness and certain medications, even highly trained individuals may exceed their physiological capability to dissipate increased core temperature. Heat illnesses range from benign cramps to the more concerning heat syncope and exercise-associated collapse (with or without hyperthermia), and culminate in life-threatening heat stroke. The differential diagnosis in the wilderness is broad and should include exercise-associated hyponatraemia with or without encephalopathy. Clinical guidelines for wilderness and hospital management of these conditions are available. Field management and evacuation are based on severity, and include cooling, rehydration and assessment of core temperature and serum sodium, if possible. Hyponatraemia should be corrected with the use of oral or intravenous hypertonic saline, depending on whether the patient can safely take oral fluids. Hospital management may include aggressive and potentially invasive cooling, careful assessment for organ dysfunction, and intensive multi-organ support, if required. Paracetamol, non-steroidal anti-inflammatory drugs and dantrolene should not be used. <![CDATA[<b>Human factors: Predictors of avoidable wilderness accidents?</b>]]> A common misconception is that wilderness adventure travel is risky owing to the nature of the objective dangers that are encountered, such as avalanches, rock falls, flash floods, failure of technical equipment and so forth. However, when one critically examines the proximal causes of wilderness accidents, even those caused by such 'objective dangers', it is apparent that many are due to 'human factors' or nontechnical skills. These are broadly defined as the continuous process of identifying and avoiding the activities, interactions and decisions that may jeopardise safe and effective response to adverse events. Objective dangers and adverse events are unavoidable, but the response to them is governed by how team dynamics, leadership and followership modes, situational awareness and experience may mitigate these risks or manage their consequences effectively. On the other hand, ignoring human factors during wilderness travel is predictive of wilderness accidents. This article outlines how an awareness of human factors may be used to reduce the risks of adventure travel significantly. <![CDATA[<b>A retrospective study evaluating the efficacy of identification and management of sepsis at a district-level hospital internal medicine department in the Western Cape Province, South Africa, in comparison with the guidelines stipulated in the 2012 Surviving Sepsis Campaign</b>]]> BACKGROUND. Currently there is little information on the identification, management and outcomes of patients with sepsis in developing countries. Simple cost-effective measures such as accurate identification of patients with sepsis and early antibiotic administration are achievable targets, within reach without having to make use of unsustainable protocols constructed in developed countries. OBJECTIVES. To assess the ability of clinicians at a district-level hospital to identify and manage sepsis, and to assess patient outcome in terms of in-hospital mortality and length of hospital stay given the above management. METHODS. A retrospective descriptive study design was used, analysing data from the routine burden of disease audit done on a 3-monthly basis at Karl Bremer Hospital (KBH) in the Western Cape Province, South Africa. RESULTS. The total sample size obtained was 70 patients, of whom 18 (25.7%) had an initial triage blood pressure indicative of sepsis-induced hypotension. However, only 1 (5.5%) of these 18 patients received an initial crystalloid fluid bolus of at least 30 mL/kg. The median time that elapsed before administration of antibiotics in septic shock was 4.25 hours. Furthermore, a positive delay in antibiotic administration (p=0.0039) was demonstrated. The data also showed that 8/12 patients (66.7%) with septic shock received inappropriate amounts of fluids. The in-hospital mortality rate for sepsis was 4/24 (16.7%), for severe sepsis 11/34 (32.3%) and for septic shock a staggering 9/12 (75.0%). CONCLUSIONS. The initial classification process and management of sepsis by clinicians at KBH is flawed. This inevitably leads to an increase in in-hospital mortality. <![CDATA[<b>Enrolling HIV-positive adolescents in mental health research: A case study reflecting on legal and ethical complexities</b>]]> BACKGROUND. Adolescents living with HIV are an emerging group in the global HIV/AIDS epidemic. Mental health in this population affects HIV care, treatment, consequential morbidity and secondary transmission. There is a paucity of research regarding these youth in South Africa (SA), partly because section 71 of the National Health Act of 2003 (NHA) requires parental or guardian's consent. OBJECTIVE. To explore legal and ethical issues related to conducting adolescent mental health research in SA. METHODS. After obtaining a High Court order permitting research on minors aged <18 years without prior parental or guardian's consent, we used qualitative and quantitative methods to interview adolescents in five clinics serving HIV-positive adolescents in Johannesburg. RESULTS. Our study enrolled 343 participants; 74% were orphaned and did not have legal guardians, 27% were symptomatic for depression, anxiety or post-traumatic stress disorder, 24% were suicidal, and almost 90% did not feel that they belonged in the family with which they lived. Without court intervention, most of the participants could not have participated in this research because parental consent was impossible to obtain. This case study argues for exceptions to the parental consent requirement, which excludes orphaned and vulnerable children and youth from research. CONCLUSIONS. Recommendations are made to promote ethical integrity in conducting mental health research with adolescents. A balance is needed between protecting adolescents from exploitation and permitting access to benefits of research. Requiring parental consent for all research does not necessarily give effect to policy. For the vast majority of SA HIV-positive adolescents, parental consent is not possible. Section 71 of the NHA ought to be amended to facilitate valuable and necessary research concerning HIV-positive orphan children and adolescents. <![CDATA[<b>Confidentiality and fitness to drive: Professional, ethical, and legal duties in the case of the diabetic bus driver</b>]]> Patients who pose a risk of serious accidents present a difficult ethical problem for medical practitioners. The duty to maintain confidentiality is an ancient and weighty obligation and has many beneficial consequences for patients and society generally. Similarly, the duty of care towards a patient militates against disclosing details that could remove his or her source of income and imperil physical and mental wellbeing. However, in cases where maintaining confidentiality can result in severe harm to the patient and the public, the benefits of confidential practice may be outweighed. While many publications on this topic provide clinical criteria for determining the unfitness of a diabetic patient to drive, the focus in this article is on ethical, professional, and legal responsibilities after a practitioner has decided that a driver poses a significant danger. <![CDATA[<b>Does access to private healthcare influence potential lung cancer cure rates?</b>]]> BACKGROUND. Numerous studies show a link between poor socioeconomic status (SES) and late-stage cancer diagnosis. However, this has not been consistently shown looking at non-small-cell lung cancer (NSCLC) in isolation. Despite the extremely high prevalence of lung cancer and disparities in access to healthcare based on health insurance in South Africa, there is a paucity of data on the influence of health insurance (as a surrogate for SES) on stage at presentation of NSCLC. OBJECTIVE. To assess the relationship between health insurance status (and invariably SES) and staging (and therefore resectability) of patients with primary NCSLC at the time of initial presentation. METHODS. Health-insured patients with NSCLC (n=51) were retrospectively compared with NSCLC patients with no health insurance (n=532) with regard to demographics, tumour node metastasis (TNM) staging, and cell type at initial presentation. RESULTS. Patients with no health insurance were younger (mean (standard deviation (SD)) 59.9 (10.1) years) than those with private health insurance (64.2 (9.6) years) (p=0.03). Poorly differentiated NSCLC was significantly more common in the privately health-insured group (23.6%) than among those with no health insurance (4.6%) (p<0.01). Six of 51 NSCLC patients (11.8%) with private health insurance presented with early-stage, potentially curable disease (up to stage IIIA), compared with 55 patients (10.3%) in the uninsured group (p=0.75). CONCLUSIONS. Access to private health insurance did not have a significant impact on stage at initial presentation. The only significant differences were the relatively advanced age at presentation and relatively higher percentage of poorly differentiated NSCLC seen in patients with health insurance. <![CDATA[<b>A method for determining when the superficial scalp arteries are the source of migraine pain</b>]]> In some patients the pain of migraine originates in the extracranial cranial arteries. This article describes the location and a logical examination sequence of the vessels most frequently involved in migraine pain. <![CDATA[<b>Ocular metastasis as initial presentation in breast cancer</b>]]> Two patients presented to their ophthalmologists with vision disturbances. On ocular examination, retinopathic lesions were observed. On subsequent examination, these lesions were diagnosed as metastases of breast cancer. Neither patient had a history of breast cancer. In patients with breast cancer and multiple metastases, ocular metastases are well described. However, the latter is uncommon as a presenting complaint. <![CDATA[<b>Corneal donations in South Africa: A 15-year review</b>]]> BACKGROUND. Corneal pathology is one of the leading causes of preventable blindness in South Africa (SA). A corneal transplant can restore or significantly improve vision in most cases. However, in SA there is a gross shortage of corneal tissue available to ophthalmologists. Little has been published describing the magnitude of the problem. OBJECTIVES. To describe trends in the number of corneal donors per year in SA, the number of corneal transplants performed each year, the origin of donors, the allocation of corneas to the public or private sector, and the demographics of donors. METHODS. This was a retrospective review of all corneal donations to SA eye banks over the 15-year period 1 January 2002 - 31 December 2016. RESULTS. There was a progressive year-on-year decline in corneal donors over the study period, from 565 per year in 2002 to 89 in 2016. As a direct result, there has been an 85.5% decrease in the number of corneal transplants performed per year using locally donated corneas, from 1 049 in 2002 to 152 in 2016. Of the donors, 48.8% originated from mortuaries, 39.0% from private hospitals and 12.2% from government hospitals; donors from mortuaries showed the most significant decline over the 15-year period, decreasing by 94.8%. Of donated corneas, 79.3% were allocated to the private sector and 21.7% to the public sector. Males comprised 69.1% of donors, while 77.2% were white, 14.0% coloured, 6.3% black and 2.5% Indian/Asian. Donor age demonstrated a bimodal peak at 25 and 55 years. CONCLUSIONS. The number of corneal donations in SA has declined markedly, causing the burden of corneal disease requiring transplantation to rise steadily. Population groups with a low donor rate may have cultural and other objections to corneal donation, which should be a major focus of future research and initiatives aimed at reversing the current trends. <![CDATA[<b>The effect of HIV status on clinical outcomes of surgical sepsis in KwaZulu-Natal Province, South Africa</b>]]> BACKGROUND. KwaZulu-Natal Province, South Africa (SA), has long been the epicentre of the HIV epidemic, but the impact of HIV co-infection on the clinical outcomes of emergency surgical patients with sepsis remains largely unknown. OBJECTIVE. To review our experience with the management of patients with HIV co-infection and to compare the disease spectrum and outcome with those without HIV infection. METHODS. A retrospective study was undertaken at the Pietermaritzburg Metropolitan Surgical Service (PMSS), SA over a 5-year period from January 2010 to December 2014. RESULTS. A total of 675 patients with a documented surgical source of sepsis were reviewed. Of these, 332 (49%) were male, and the mean age was 46 (standard deviation 19) years. HIV status was known in 237 (35%) patients, 146 (62%) were HIV-positive and the remaining 91 (38%) were HIV-negative. Other than tuberculosis of the abdomen being significantly more common in HIV-positive than HIV-negative patients (10% v. 2%, p=0.033), there were no differences in the spectrum of diseases between the two groups. There were no significant differences in overall morbidity or mortality. When adjusted for CD4 counts, the mortality in HIV-positive patients with a CD4 count <200 cells/μL was 60% (15/25) and in those with a CD4 count &gt;200 cells/μL it was 2% (2/101) (p<0.001). CONCLUSION. The clinical presentation and the spectrum of surgical sepsis in patients with HIV co-infection were not markedly different to those in patients who were not HIV-infected. HIV-infected patients with a CD4 count <200 cellsμL had a significantly higher mortality. Management approaches should not differ based solely on the HIV status of patients with surgical sepsis. <![CDATA[<b>Pancreatitis in a high HIV prevalence environment</b>]]> BACKGROUND. Acute pancreatitis is common in HIV-positive individuals in reports from regions with a low incidence of HIV infection. This association has not been reported in areas with a high incidence of HIV infection. OBJECTIVE. To examine the prevalence and outcomes of HIV-associated acute pancreatitis in a high HIV prevalence environment, and trends over the period May 2001 - November 2010. METHODS. The records of patients admitted with acute pancreatitis from 2001 to 2010 were reviewed, looking for HIV status, CD4 counts and medications at presentation. The Glasgow criteria, organ failure, local complications and mortality were assessed. RESULTS. One hundred and six (16.9%) of 627 patients admitted with acute pancreatitis during the study period were infected with HIV. Most were female (65.1%) and black African (91.5%). The serum amylase level was used to confirm acute pancreatitis in 50 patients, with a mean of 1 569 IU/L (range 375 - 5 769), and urinary amylase in 56 patients, with a mean of 4 083 IU/L (range 934 - 36 856). Alcohol was a less frequent cause of pancreatitis in the HIV-positive group than in patients who were HIV-negative (24.5% v. 68.3%), and the prevalence of gallstones as a cause was similar (23.6% v. 17.9%). Antiretroviral therapy was associated with pancreatitis in 35.8%, and 6 (5.7%) had abdominal malignancies. Sixteen (15.1%) had pancreatic necrosis, 20 (18.9%) had septic complications, and 6 (5.7%) died. CONCLUSIONS. HIV-associated acute pancreatitis was most frequent in females and black Africans and was associated with malignancy. Mortality was similar in HIV and non-HIV pancreatitis. <![CDATA[<b>Cardiovascular risk factors and mortality in children with chronic kidney disease</b>]]> BACKGROUND. Cardiovascular disease (CVD) begins early in children with chronic kidney disease (CKD), and its progression is determined by the presence of single or multiple cardiovascular risk factors (CVRFs). OBJECTIVE. To determine the prevalence of CVRFs in children with CKD and their association with mortality in children on chronic dialysis. METHODS. This comparative cross-sectional study recruited children aged 5 - 18 years with all stages of CKD. All patients had a short history taken along with a physical examination, and their blood samples were assessed for serum creatinine, urea, albumin, calcium, phosphorus, parathyroid hormone, alkaline phosphatase, total cholesterol (TC), haemoglobin and C-reactive protein. Urine samples were also assessed for proteinuria. RESULTS. One hundred and six children who met the study criteria were recruited, 34 with CKD I, 36 with CKD II - IV and 36 with CKD V (dialysis). The overall median age was 11 years (range 8 - 14), and the male/female ratio was 2.1:1. The most common CVRF was anaemia (39.6%). The rate of anaemia was higher in the dialysis group than in the CKD II - IV and CKD I groups (77.8%, 33.3% and 5.9%, respectively). Other CVRFs detected were hypertension, proteinuria, hypercholesterolaemia and dysregulated mineral bone metabolism. Seven deaths were recorded in the dialysis group during the study period. Severe hypertension and intracranial bleeding were the most common causes of death. Modifiable risk factors such as increased TC and decreased albumin levels were more common than other CVRFs in the dialysis patients who died. CONCLUSIONS. CVRFs may be present in early CKD, even before the decline in GFR. Routine screening for CVRFs, along with timely intervention, may prevent the progression of CVD and mortality later in life. <![CDATA[<b>Suicide in Pretoria: A retrospective review, 2007 - 2010</b>]]> BACKGROUND. The World Health Organization has declared suicide a global health crisis, predicting that ~1.53 million people will commit suicide annually by 2020. OBJECTIVE. A study from South Africa reviewed 1 018 suicide cases in Pretoria over 4 years (1997 - 2000). Our study was undertaken to establish whether there have been substantial changes in the profile of suicide victims who died in Pretoria a decade later. METHODS. Case records at the Pretoria Medico-Legal Laboratory were reviewed retrospectively from 2007 to 2010. RESULTS. A total of 957 suicide cases were identified. Hanging was the most common method of suicide, followed by self-inflicted firearm injury. The true incidence of suicidal intake of prescription drugs/medication was difficult to determine, because of a backlog at the state toxicology laboratories. White males and females appeared to be over-represented among suicide victims, but there has been an increase in suicide among blacks. There seems to have been a substantial decrease in the use of firearms to commit suicide - possibly reflecting a positive outcome of gun control legislation that has been introduced in the interim. CONCLUSION. Suicide continues to constitute almost 10% of all fatalities admitted to the Pretoria Medico-Legal Laboratory, confirming suicide as a major cause of mortality in our society. Further research is needed to clarify the profile of suicidal deaths, with a view to informing resource allocation and to improve preventive strategies.