On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.3 Cape Town Mar. 2009
Rough community justice
Newspapers run horrendous stories of communities taking actions against unpunished criminals, but we rarely appreciate the scale of the severe beatings, termed community assault (CA). Proctor and colleagues1 describe their experiences with 19 consecutive patients at Ngwelenzane Hospital in northern KwaZulu-Natal.
Violent crime pervades South Africa, with murder, rape and serious assault directly affecting around 1 in 50 people per annum. Law enforcement in areas with high rates of poverty and violent crime is challenging. Unpunished criminals and an inadequate justice system have led communities to take matters into their own hands.
Significant morbidity was experienced by most patients, with 3 deaths. Seven patients developed renal dysfunction secondary to rhabdomyolysis, 3 of these progressing to acute renal failure requiring haemodialysis. Delayed presentation due to the accused hiding for long periods after the assault and delayed referral from other hospitals contributed to the severity of the patients' conditions. Medical practitioners should be aware that CA is life-threatening and treat patients aggressively.
Until such rural populations feel suitably supported, they will continue to implement this flawed and dubious form of retribution.
Circumcision: Tara KLamp technique adverse events
Male circumcision is by far the most prevalent procedure worldwide, with about 10 million performed each year, mostly in non-medical settings. Since the protective effects of male circumcision against HIV infection are likely to increase circumcision rates it is necessary to assess current male circumcision procedures for safety. Lagarde et al.2 compared forceps-guided (FG) circumcision with the Tara KLamp (TK) technique in a randomised trial in young male adults.
While trials among children had positive results with the TK technique, the trial in young adults was discontinued early because the TK method compared unfavourably with the FG method. While haemorrhage and sepsis are the main causes of morbidity, in this study the most frequent complications were swelling and haematoma. The authors caution against the use of the TK for young adults and recommend careful evaluation of the procedure when performed on children.
Growth hormone guidelines
Sporting stars all too often take performance-enhancing steroids. Older women (and men) are also often encouraged by advertisements and practitioners claiming expertise in 'antiageing' to take hormones of all kinds. Why not then provide growth hormone to any young lass or laddy who seems a little behind on the growth curve? Guidelines for the use of growth hormone (GH) in paediatric patients in South Africa are provided on behalf of the Paediatric and Adolescent Endocrine and Diabetes Society of South Africa.3
The current accepted evidence-based indications for GH are GH deficiency, Turner syndrome, Prader-Willi syndrome, small-for-gestational-age children who fail to show catch-up growth, idiopathic short stature, and chronic renal failure.
Action should not be deferred until puberty in the hope that catch-up growth will occur - only 18% of growth remains after entry into puberty.
PAEDS-SA recognises the financial limitations in the state sector and recommends that GH use be limited to tertiary hospitals managing individuals with short stature, with patients being treated by paediatric endocrinologists or paediatricians in consultation with regional paediatric endocrinologists. Neonatal GH deficiency with hypoglycaemia is an absolute indication for GH therapy if life expectancy is normal and there are no major congenital malformations or syndromes that would limit the benefit. GH is also advocated for managing short stature in children with proven GH deficiency, where there is expected benefit based on age at presentation and growth plate potential.
Drugs via nasogastric tubes
Crushing tablets and opening capsules before administering via nasogastric tubes is a widespread practice. Eric Decloedt and Gary Maartens4 highlight the problems associated with administering drugs via this route. They note that patients may be harmed if the bioavailability of drugs is either impaired, resulting in reduced efficacy, or enhanced, resulting in toxicity. Mechanical failure of nasogastric tubes may occur as a consequence of administering drugs. There are also important medico-legal implications of administering altered oral drug formulations (drugs are registered to be administered as particular formulations, and altering the formulation before administration renders their use off-label).
Examples are crushing of enteric-coated tablets that protect the active ingredient against degradation by gastric acid, which would reduce bioavailability; and reduction of serum concentrations of phenytoin by 72% when it is administered with enteral feeds. Crushing different medications in the same receptacle should be avoided owing to possible drug interactions.
1. Proctor M, Carter N, Barker P. Community assault - the cost of rough justice. S Afr Med J 2009; 99: 160-161. [ Links ]
2. Lagarde E, Taljaard D, Puren A, Auvert B. High rates of adverse events following circumcision of young male adults with the Tara KLamp technique: A randomized trial in South Africa. S Afr Med J 2009; 99: 163-169. [ Links ]
3. Segal D. Guidelines for Using Growth Hormone in Paediatric Patients in South Africa: Treatment of Growth Hormone Deficiency and Other Growth Disorders. S Afr Med J 2009; 99: 185-195. [ Links ]
4. Decloedt E, Maartens G. Pitfalls of administering drugs via nasogastric tubes. S Afr Med J 2009; 99: 148-149. [ Links ]