South African Medical Journal - Volume 101, Issue 11, November 2011

Complaints of sexual impropriety against health care practitioners are escalating. Professionalism in the practitioner-patient relationship and the role-based trust in health care do not allow crossing of sexual boundaries. Communication with patients is key to prevent erroneous allegations of sexual misconduct. The intimate examination is difficult to define. A chaperone present during an intimate examination protects the patient and practitioner and should be considered a risk reduction strategy in practice.

Anthropogenic climate change and anticipated adverse effects on human health as outlined by the Intergovernmental Panel on Climate Change (IPCC) are taken as givens. A conceptual model for thinking about the spectrum of climate-related health risks ranging from distal and infrastructural to proximal and behavioural and their relation to the burden of disease pattern typical of sub-Saharan Africa is provided. The model provides a tool for identifying modifiable risk factors with a view to future research, specifically into the performance of interventions to reduce the impact of climate change.

Projections show that the effects of climate change in Africa will not be uniform over the region. The region is extremely vulnerable to climate change because of poverty, a high pre-existing disease burden, fragmented health services and water and food insecurity. Despite the consensus that locally relevant information is necessary to inform policy and practice related to climate change, very few studies assessing the association between climate change and health in southern Africa have been conducted. More comprehensive information is therefore urgently needed for the southern African region to estimate the health risks from projected future changes in climate.

Background. Aspirin should not be used in children except for specific therapeutic reasons. We report on a severely ill infant who had ingested aspirin contained in a traditional medicine and review 21 other patients with pre-admission non-therapeutic salicylate exposure.

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Objectives and methods. We reviewed laboratory, clinical and poisons unit records to determine how many children were admitted to our hospital over an 18-month period with evidence of salicylate ingestion not prescribed for therapeutic reasons. We determined the source of the salicylate, elapsed time between ingestion and laboratory assay, morbidity and mortality and final diagnosis.

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Results. Twenty-one children meeting our criteria, including 9 under 6 months of age, were admitted during this period. The most prevalent source of salicylate was over-the-counter (OTC) aspirin, but some had reportedly only been given traditional medicines. Nineteen were seriously ill, 4 died and 3 had severe brain injury. Two, initially diagnosed with Reye's syndrome, probably had inherited metabolic disorders. Only 2 patients had salicylate levels that at the time of measurement are normally considered toxic; however, the literature suggests that lower levels may exacerbate illness severity in young children.

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Conclusions. We found inappropriate use of OTC aspirin in children that requires explanation. There may be policy implications for the content and presentation of patient information; the incorporation of pharmaceuticals in traditional medicines merits further study. Salicylate toxicity should be considered in children with unexplained metabolic acidosis out of keeping with the severity of their acute illness.

Background. South Africa's HIV mortality is primarily due to pulmonary disease. No evidence exists regarding a correlation between specific chest radiographic patterns and CD4 levels of immunity in HIV-infected children.

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Objectives. We aimed to determine the prevalence of specific radiographic features in HIV-infected children initiating antiretroviral therapy (ART) to develop a guideline of expected baseline radiographic appearances, and the radiographic features that predominate at specific levels of immune suppression (defined by CD4 percentage ranges), which would narrow the radiological differential diagnosis.

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Method. Retrospective review of the baseline chest radiographs of 92 consecutive paediatric outpatients initiating ART.

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Results. Normal radiographs were reported in 54% of patients. Those with radiographic abnormalities had parenchymal disease (34%), mediastinal disease (22%) and pleural disease (1%). Parenchymal disease was predominantly air space (28%), and mediastinal disease was predominantly cardiomegaly (21%); lymphadenopathy was rare (1%). Radiological appearances of TB were seen in 9% of patients. A statistically significant association was shown between immune suppression and air space disease (p=0.049) with a relative risk of 0.46 (95% CI 0.24 - 0.88) for air space disease in immune-suppressed children. This association was independent of age.

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Conclusion. Baseline chest radiographs in paediatric outpatients presenting for initiation of ART are predominantly normal, but also demonstrate a significant number of pathological radiological features - primarily air space disease and cardiomegaly. The only statistically significant association between radiographic features and immune suppression was air space disease, which correlated with a higher level of immunity.

Intentional and unintentional injuries were reported to be the second leading cause of Disability Adjusted Life Years in South Africa in 2000. We present household experiences of such injuries in 5 impoverished housing settlements in Johannesburg, Gauteng Province. Data for this study were extracted from the database of the Health, Environment and Development (HEAD) project. The incidence of reported intentional injuries was determined to be double that of unintentional injuries. Households in the Hospital Hill and Riverlea settlements reported the highest prevalence of stabbing and gunshot incidents. We concluded that impoverished South African neighbourhoods bear a high burden of intentional injury; surveillance mechanisms are required to inform prevention strategies at an individual, a community and a societal level.

Introduction. Chronic myeloid leukaemia (CML) is a chronic myeloproliferative disorder characterised by a chromosomal translocation between the long arms of chromosomes 9 and 12 resulting in the formation of the BCR-ABL fusion gene. The management of CML has undergone major changes over the past decade. Novel treatment approaches have had a dramatic impact on patient outcomes and survival. Nevertheless, these outcomes can only be achieved in the context of expert management, careful monitoring of disease response, appropriate management of adverse events and timeous adjustments to therapy when responses are not achieved within stated time frames.

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Aim. With the advent of novel treatments providing molecular responses, both the monitoring and management of CML have become more complicated. The aim of these recommendations was to provide a pragmatic yet comprehensive roadmap to negotiate these complexities.

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Methods. Recommendations were developed based on local expert opinion from both the academic and private medical care arenas after careful review of the relevant literature and taking into account the most widely used international guidelines. About five meetings were held at which these recommendations were discussed and debated in detail.

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Results. A comprehensive set of recommendations was compiled with an emphasis on diagnosis, investigation, treatment and monitoring of disease. Careful attention was given to circumstances unique to South Africa, funding constraints, availability and access to laboratory resources, as well as the effects of concurrent HIV infection.

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Conclusion. Most patients with CML can live a reasonably normal life if their disease is appropriately managed. These recommendations should be of value to all specialists involved in the treatment of haematological disorders.