South African Medical Journal
The South African Medical Journal (SAMJ) is published under the auspices of the South African Medical Association, though it enjoys full editorial autonomy. The SAMJ :
- Provides a premier vehicle for the publication of medical research in South Africa and beyond;
- Provides high quality educational material for doctors;
- Informs the medical profession and the public on relevant health issues;
- Provides a forum for members of the profession to voice their opinions;
- Influences opinion and policy through the authority, relevance and quality of its contents;
- Is an important source for advertising and obtaining information about professional appointments.
This journal continues CME : Your SA Journal of CPD
|Publisher||Health and Medical Publishing Group (HMPG)|
|Coverage||Vol 93 Issue 1 2003 - current|
Readiness to adopt a performance measurement system for substance abuse treatment : findings from the Service Quality Measures initiative
Background. A performance measurement system – the Service Quality Measures (SQM) initiative – has been developed to monitor the quality of South Africa (SA)’s substance abuse treatment services. Identifying factors associated with readiness to adopt this system may inform strategies to facilitate its robust implementation.
Objective. To examine factors associated with readiness to adopt a performance measurement system among SA substance abuse treatment providers.
Methods. We surveyed 81 treatment providers from 13 treatment sites in the Western Cape, SA. The survey examined awareness, resources, organisational climate, leadership support and readiness to adopt the SQM system. Regression analysis was used to identify factors associated with readiness to adopt this system.
Results. Readiness to adopt the SQM initiative was high (M=5.64, standard deviation 1.63). In bivariate analyses, caseload size (F=3.73 (degrees of freedom (df)=3.70), p=0.015), awareness (r=0.78, p<0.0001), leadership support (r=0.70, p<0.0001), resources (r=0.65, p<0.0001), openness to change (r=0.372, p=0.001), and external pressure to change were associated with readiness to adopt the SQM. In multivariate analyses, only awareness of the SQM initiative (B=0.34, standard error (SE) 0.08, t=4.4, p<0.0001) and leadership support (B=0.45, SE 0.11, t=4.0, p<0.0001) were significantly associated with readiness to adopt this system.
Conclusion. While treatment providers report high levels of readiness to adopt the SQM system, findings show that the likelihood of adoption can be further increased through improved provider awareness and enhanced leadership support for this health innovation.
Is it possible to differentiate tuberculous and cryptococcal meningitis in HIV-infected patients using only clinical and basic cerebrospinal fluid characteristics?
Background. Tuberculous and cryptococcal meningitis (TBM and CM) are the most common causes of opportunistic meningitis in HIVinfected patients from resource-limited settings, and the differential diagnosis is challenging.
Objective. To compare clinical and basic cerebrospinal fluid (CSF) characteristics between TBM and CM in HIV-infected patients.
Methods. A retrospective analysis was conducted of clinical, radiological and laboratory records of 108 and 98 HIV-infected patients with culture-proven diagnosis of TBM and CM, respectively. The patients were admitted at a tertiary centre in São Paulo, Brazil. A logistic regression model was used to distinguish TBM from CM and derive a diagnostic index based on the adjusted odds ratio (OR) to differentiate these two diseases.
Results. In multivariate analysis, TBM was independently associated with: CSF with neutrophil predominance (odds ratio (OR) 35.81, 95% confidence interval (CI) 3.80 - 341.30, p=0.002), CSF pleocytosis (OR 9.43, 95% CI 1.30 - 68.70, p=0.027), CSF protein >1.0 g/L (OR 5.13, 95% CI 1.38 - 19.04, p=0.032) and Glasgow Coma Scale <15 (OR 3.10, 95% CI 1.03 - 9.34, p=0.044). Nausea and vomiting (OR 0.27, 95% CI 0.08 - 0.90, p=0.033) were associated with CM. Algorithm-related area under the receiver operating characteristics curve was 0.815 (95% CI 0.758 - 0.873, p<0.0001), but an accurate cut-off was not derived.Conclusion. Although some clinical and basic CSF characteristics appear useful in the differential diagnosis of TBM and CM in HIV
Burden, genotype and phenotype profiles of adult patients with sickle cell disease in Cape Town, South AfricaBackground. An exponential increase in the number of sickle cell disease (SCD) patients in paediatric services in Cape Town, South Africa,has been reported. The trend in adult/adolescent services has not been investigated.
Objectives. To evaluate epidemiological trends of SCD and the profile of patients affected by SCD attending the Haematology Clinic at Groote Schuur Hospital (GSH), Cape Town.
Methods. (i) A retrospective review of the number of SCD patients over the past 20 years; (ii) a cross-sectional analysis of clinical and haematological characteristics of SCD patients; and (iii) molecular analysis of the haemoglobin S mutation, the haplotype in the β-globinlike genes cluster, the 3.7 kb α-thalassaemia gene deletion and 19 selected single-nucleotide polymorphisms (SNPs) associated with fetal haemoglobin (HbF) levels.
Results. From 1995 to 2016, 81 adolescent/adult patients with SCD were registered, mostly originating from other African countries (n=61, 75.3%). There was an increase of over 200% in new cases (n=47) during the last quarter of the two decades investigated. Data from 34 of 58 regular attendees (58.6%) were analysed. The mean age of the patients was 26.1 years (standard deviation (SD) 9.8), and 70.6% were male. With the exception of four patients with sickle/β-thalassaemia, all the patients had SCD (haemoglobin SS). The co-inheritance of a single 3.7 kb α-globin deletion was found in 42.3% of cases (n=11). The Bantu haplotype was the most observed (65.4% of chromosomes). Most HbF-promoting SNPs were not associated with variable levels of haematological indices.
Conclusions. There is an increasing burden of adult SCD patients at GSH. National health and academic institutions need to adapt policies and healthcare professional training accordingly.
Analysis of mutations causing familial hypercholesterolaemia in black South African patients of different ancestryBackground. Familial hypercholesterolaemia (FH) is usually caused by mutations in three genes (LDLR, APOB and PCSK9).Objective. To identify the spectrum of FH-causing mutations in black South African (SA) patients.
Methods. DNA samples of 16 unrelated South African FH patients with elevated low-density lipoprotein cholesterol levels, tendon xanthomas and corneal arcus (3 clinically homozygous FH and 13 heterozygous FH) of ethnic African origin were screened for mutations in the LDLR (coding region, promoter and intron/exon boundaries), APOB (part of exon 26) and PCSK9 genes (exon 7), using high-resolution melting.
Results. Eight LDLR mutations were identified, for an overall detection rate of 8/19 predicted FH-causing alleles (42.1%). The previously reported six base pair deletion p.(D47_G48del) was found in two patients, and two novel variants (c.1187-25T>C and c.1664T>G p.(L555R)) were found, both predicted to be pathogenic using in silico web-based predictive algorithms. No pathogenic variants in APOB or PCSK9 were found.
Conclusions. These findings contribute to the knowledge of allelic heterogeneity in the spectrum of FH-causing mutations in black SA patients, signifying their ancestral diversity. The relatively low overall detection rate may reflect locus heterogeneity of the FH phenotype in black SA FH patients.
Background. Calcific uraemic arteriolopathy (calciphylaxis) is an unusual and potentially fatal condition characterised by small-vessel calcification and ischaemic skin necrosis. It mainly affects patients with end-stage renal disease (ESRD) on haemodialysis, but may rarely occur in the absence of ESRD in conditions such as primary hyperparathyroidism, malignancy, alcoholic liver disease and connective tissue disease.
Methods. We reviewed the records of all patients diagnosed with calciphylaxis while on renal replacement therapy at Tygerberg Hospital, Cape Town, South Africa, between 1990 and 2014, to describe its presentation, course and final outcome.
Results. Nineteen patients developed calciphylaxis over this period. Their median age was 34 years and 13 (68.4%) were female. Fifteen (78.9%) had received a kidney transplant. All patients had painful skin lesions that rapidly progressed to infarction. Small-vessel calcification was seen on skin biopsy in 13 patients. Twelve patients had hyperparathyroidism. Several of the transplanted patients had been treated for graft rejection in the year preceding the diagnosis. Treatment consisted of good wound care and efforts to normalise serum calcium and phosphate levels. Five patients received an urgent parathyroidectomy. The outcome was fatal in 17 patients, with sepsis being the main cause of death.
Conclusions. In our patients, calciphylaxis carried a worse prognosis than previously reported internationally. It should always be considered in the differential diagnosis of painful skin lesions in the dialysis or transplant patient.