Obamacare achieves its three objectives to expand health care insurance coverage, to end unfair insurance industry practices, and to curb spiralling health care costs. Given the parallels between the US and South African private health care systems, there are lessons to be learnt from the US experience, but that is a topic for another day.
To the Editor : I was much interested in the report by Tiemensma et al. Considering the extent of the tension pneumothorax as seen in Fig. 1, one would have thought that the doctors on board should have diagnosed it - was the clinical examination done properly? Was the position of the trachea palpated, the thoracic cage percussed, auscultation of lung and heart sounds done?
To the Editor : The last few months have been awkward for a few reasons. The first was that Ralph's illness and subsequent passing seemed so sudden. The second was that when one is not close family appropriate behaviour is elusive, and finally because there are things I felt were left unsaid.
In the article by A J Okwi et al. which appeared on pp. 887 - 891 of the December 2009 SAMJ, the first part of the title should have read 'Sickling and solubility tests and the peripheral blood film method for screening for sickle cell disease' and not 'Solubility tests and the peripheral blood film method for screening for sickle cell disease'.
Public sector doctor relations with their employer, soured by clumsy, inconsistent provincial implementation of long-awaited occupation-specific dispensation (OSD) pay hikes and further delayed mid-level category doctors pay talks, are on a knife edge.
The dysfunctional Medicines Control Council (MCC), which has registered less than half of all medicine applications to it over the past 7 years, has become a life-threatening risk to patients and is now under legal threat from stakeholders.
The hugely welcome government-led initiative to pro-actively offer 'opt-out' HIV testing to patients at its clinics and hospitals needs hefty back-up resources to ensure patient retention and earlier presentation.
Only time - and new senior management intervention - will tell whether the Eastern Cape health department's financial rescue package will fully honour its R1.6 billion accumulated debt, including occupation-specific dispensation (OSD) pay hikes.
Cells and engineered tissue can be used to treat an increasing number of diseases. This development, together with promising pre-clinical data in regenerative medicine, has raised the expectations of many patients. However, this situation tends to make people vulnerable to the lures of companies that abuse the stem cell promise. The problem is compounded by people's propensity to believe that the healing powers of positive thinking, large sums of money and foreign institutions are greater than those of therapies developed through well-tested, properly constructed clinical trials.
An 11-month-old child, brought to hospital by his 16-year-old mother, had allegedly fallen from a bed while unsupervised. He had multiple traumatic skin lesions (Fig. 1) and radiographs revealed multiple fractures (Figs 2 - 4). Retinoscopy and a computed tomography scan of the brain revealed no haemorrhages. The fractures were managed according to standard orthopaedic protocols and social workers were consulted.
Allogeneic stem cell transplantation has become a curative treatment option for many patients with haematological malignancies, bone marrow failure syndromes, thalassaemia, sickle-cell disease and some rare disorders of the blood and bone marrow. Ideally, stem cells from the peripheral blood or bone marrow are sourced from sibling donors or from a matched unrelated donor if a sibling donor is not available. Alternatively, stem cells may be obtained from umbilical cord blood (UCB). The advantages of the latter over conventional sources of stem cells include that tissue matching requirements are less stringent, healthy donors are not exposed to invasive procedures, and transplants can be performed without delay.
Clinical trials provide the best evidence for which health care interventions work, which do not, and which may be harmful. Ideally we aim to base our clinical practice on the results from well-conducted trials. For us to be able to do so, all trial reports must be available in the public domain and accurately reflect the methods and the results of clinical trials.
To the Editor : Ritonavir is a protease inhibitor used in combination therapy for advanced HIV infection. In South Africa lopinavir/ritonavir is first-line therapy for children under 3 years of age where there is a history of perinatal exposure to the non-nucleoside reverse transcriptase inhibitor (NNRTI) nevirapine. Ritonavir is a potent inhibitor of hepatic cytochrome P450-CYP3A4 iso-enzyme activity.
To the Editor : Smoking of hookahs (also known as water-pipes) represents an emerging trend in tobacco use. Hookah smokers are at risk for the same diseases caused by cigarette smoking - cancer, respiratory and heart diseases, and pregnancy-related complications. Globally, the highest rates occur in the North African and East Mediterranean regions and among young people in the USA and European countries. There has been little research on hookah smoking in southern Africa.
Objectives. To describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease.
Design. We conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006.
Outcome measures. Malaria frequency, severity, and treatment.
Results. We identified 1 701 malaria cases; 1 548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals; 1 149 (68%) patients were male. Median age was 27 years (range 1 month - 89 years). Most (84%) infections were presumed to be acquired in Mozambique. Disease severity did not differ by age or sex. Patients who were South African born were more likely to have severe disease (OR=1.43 (1.08 - 1.91)), as were patients who experienced a delay >48 hours between onset of symptoms and diagnosis or treatment (OR=1.98 (1.48 - 2.65)). While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose.
Conclusions. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. Providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
Background. Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers.
Methods. We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) ≤50 ml per minute per 1.73 m2, were identified. In-patient prescriptions were captured if they were written after clinical notes indicated impaired renal function, or ≥1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted.
Results. We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted.
Conclusion. Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment.