South African Medical Journal - Volume 102, Issue 4, 2012
Volumes & issues
Volume 102, Issue 4, 2012
Author Daniel J. NcayiyanaSource: South African Medical Journal 102 (2012)More Less
Sixty-two years after the much reviled and now repealed Population Registration Act of 1950 was enacted, and 18 years into our new non-racial democracy, it continues to haunt South African public life. The Act classified South Africans into 'race' categories, thus creating the framework for the differentiated allocation of opportunity and privilege, and resulted in severe inequalities between the white elite and the black underclass. The historical inequalities continue to manifest themselves in all aspects of daily living such as housing, health, wealth, employment, skills, assets, education and more. Democratic South Africa has chosen to redress these inequalities through 'affirmative action', a concept that is perhaps best expressed in the Afrikaans equivalent of regstellende aksie. It was US President John F Kennedy who coined the phrase 'affirmative action' back in 1961. But it fell to his successor, Lyndon B Johnson, to implement the concept, declaring that 'We seek ... not just equality as a right and a theory, but equality as a fact and as a result.' Since that time five decades ago, affirmative action has found wide application in all spheres of life in the USA, including preferential admission to university of African Americans, Hispanics and Native Americans.
Responding to the evidence for improved treatment for cryptococcal meningitis in resource-limited settings : correspondenceSource: South African Medical Journal 102, pp 196 –198 (2012)More Less
The World Health Organization (WHO) issued the first evidence-based treatment guidelines for cryptococcal meningitis in December 2011. Although its incidence has decreased with increased access to antiretroviral therapy, cryptococcal meningitis remains a major cause of death in people with HIV/AIDS, with over 500 000 deaths every year in sub-Saharan Africa. It is a leading cause of death in the Médecins sans Frontières (MSF) HIV/AIDS programmes in Africa.
Acute urinary retention as a complication of primary varicella-zoster infection of childhood - a second reported case : correspondenceSource: South African Medical Journal 102 (2012)More Less
Author Robert Ian CaldwellSource: South African Medical Journal 102 (2012)More Less
Issues in medicine
Violence, violence prevention, and safety : a research agenda for South Africa : forumSource: South African Medical Journal 102, pp 215 –218 (2012)More Less
Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: (i) violence must be understood better to develop effective interventions; and (ii) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.
Issues in medicine
Regulatory crackdown on stem cell therapy : what would the position be in South Africa? : forumSource: South African Medical Journal 102, pp 219 –220 (2012)More Less
This article attempts to answer the question of whether stem cell therapy falls within the current South African regulatory framework, using the Regenexx case in the USA as an example. The USA regulator, the Federal Drug Administration (FDA), is seeking to regulate the Regenexx autologous stem cell therapy as a 'drug' and a 'biological product'. The opposing position taken by the inventors of the Regenexx therapy is that re-implantation of one's own body parts can in principle not be a 'drug' and that the FDA is exceeding its mandate. In this article arguments are presented that the Regenexx therapy would qualify as a 'biological medicinal product' in the South African regulatory framework established in terms of the Medicines and Related Substances Control Act. As such, the Regenexx therapy would be subject to registration with the Medicines Control Council (MCC) as a legal precondition for its commercialisation. Furthermore, in order to convince the MCC of the safety, efficacy and quality of the Regenexx therapy, such therapy must - similar to any other new medicine - first be subjected to clinical trials. It is therefore concluded that stem cell therapy is indeed comprehensively regulated in South Africa, and that a recent opinion expressed in this journal that there exists a 'legislative vacuum' with relation to the regulation of stem cell therapy in South Africa is plainly incorrect.
Author Dan J. NcayiyanaSource: South African Medical Journal 102 (2012)More Less
This self-published autobiography presents a fascinating and in-depth account of the life story of a black South African doctor who was born and raised in poverty-stricken rural Transkei, became an anti-apartheid activist in his teenage years and was relentlessly hounded by the security police. He was educated at Fort Hare and at the University of Natal Medical School in Durban where he graduated with an MB ChB degree in 1966. At university, Edmund gradually came to embrace an evangelical Christian faith, something that comes out strongly in this narrative.
Source: South African Medical Journal 102, pp 223 –224 (2012)More Less
The initial clinical presentation of amitraz and organophosphate poisoning may be similar. Reduced serum pseudocholinesterase supports a diagnosis of organophosphate toxicity, but there is no similar laboratory test for amitraz poisoning. A 'mothball-like' odour associated with poisoned patients may have diagnostic potential. In a blinded controlled trial, 83% (95% confidence interval, 63 - 93%) of 23 healthcare workers were able to distinguish between the odours of amitraz and organophosphates. Awareness of this simple component of bedside examination may allow earlier recognition of this potentially fatal poisoning.
Source: South African Medical Journal 102, pp 224 –225 (2012)More Less
Knowledge of local antibiotic sensitivities is crucial to creating appropriate empiric antibiotic guidelines. The new National Health Laboratory Service (NHLS) Data Warehouse allows clinicians to access collated spreadsheets of culture isolates and antimicrobial susceptibility patterns for their facilities. We used this service to study the trends in blood culture (BC) results at GF Jooste Hospital from 2005 to 2010. We investigated the BC contamination rate and changes in the antibiotic sensitivity profiles of selected organisms, and estimated the proportion of infections that were hospital-acquired. Over 3000 BCs were performed per year in this period. A very high contamination rate was observed (7 - 9%) in 2005 - 2007, with a gratifying reduction by 2010. Ceftriaxone resistance increased from 16% to 62% in Klebsiella pneumoniae (p<0.0001), and from 33% to 100% in Enterobacter spp. (p=0.053).
Source: South African Medical Journal 102, pp 226 –227 (2012)More Less
Background. Feeding schemes based on school garden produce have been proposed as an effective solution to food insecurity and hunger among learners in South Africa. However, few studies have looked at the potential contamination of school food gardens when situated near mine tailing dams.
Objectives. The aim of the study was to evaluate the potential heavy metal contamination in a school vegetable garden in Johannesburg.
Methods. Twenty soil samples were collected from the study school and a comparison school. Surface and deep (~10 cm beneath the surface) soil samples were analysed using X-ray fluorescence for levels of arsenic, chromium, copper, lead and zinc. Thirteen vegetables samples were collected from the school garden, and compared with six samples from a national retailer and four obtained from a private organic garden. The heavy metal concentrations of the vegetable samples were analysed in the laboratories of the South African Agricultural Research Council.
Results. High levels of arsenic were found in the school soil samples, and elevated concentrations of lead and mercury in the school vegetables. Calculation of the estimated daily intake for a child of 30 kg, however, indicated that levels of lead, mercury and arsenic in vegetables were within acceptable limits. However, the levels of lead in the vegetable samples were high across all three sites.
Conclusion. Further investigation and research should be undertaken to assess the source/s and extent of public exposure to heavy metals in vegetables in South Africa.
Source: South African Medical Journal 102, pp 228 –233 (2012)More Less
Building the skills for doing, managing and delivering health research is essential for every country's development. Yet human resources for health research (HRHR) are seldom considered in Africa and elsewhere. Africa's health research capacity has grown considerably, with potential to increase this growth. However, a systemic way of defining, co-ordinating and growing the HRHR needed to support health systems development is missing. Reviewing the status of HRHR in Africa, we assert that it consists of unco-ordinated, small-scale activities, primarily driven from outside Africa. We present examples of ongoing HRHR capacity building initiatives in Africa.
There is no overarching framework, strategy or body for African countries to optimise research support and capacity in HRHR. A simple model is presented to help countries plan and strategise for a comprehensive approach to research capacity strengthening. Everyone engaged with global, regional and national research for health enterprises must proactively address human resource planning for health research in Africa. Unless this is made explicit in global and national agendas, Africa will remain only an interested spectator in the decisions, prioritisation, funding allocations, conduct and interpretation, and in the institutional, economic and social benefits of health research, rather than owning and driving its own health research agendas.
Source: South African Medical Journal 102, pp 233 –236 (2012)More Less
Background. The Wits Donald Gordon Medical Centre paediatric liver transplant programme is the second such unit in sub-Saharan Africa. Initiated in November 2005, it forms part of the centre's solid organ transplant unit, comprising kidney, liver and simultaneous kidney-pancreas arms. Initially established in the private sector, we recently received government approval to expand our programme into the provincial sector and have performed transplants on several provincial-sector patients. Current challenges relate to the lack of appropriately trained paediatric sub-specialists, specifically critical care practitioners and hepatologists.
Methods. Subsequent to institutional approval, a retrospective chart analysis of all paediatric liver transplants performed at our facility to date was conducted.
Results. Defining children as those under 18 years of age, 29 patients have received a cadaveric liver transplant since 2005, using 16 whole livers, 10 reduced-size grafts, and 3 split segments; 13 were transplanted with biliary atresia, 3 hyperoxalurea, 3 autosomal recessive polycystic disease, 2 alpha-1 antitrypsin deficiency, and 2 idiopathic, with the remainder for a wide spectrum of other pathologies. Seven patients received combined liver-kidney transplants. There were 3 in-hospital mortalities. The remaining 26 patients are all long-term survivors. We describe 7 acute surgical morbidities in 6 patients, and 8 long-term surgical morbidities. One patient was subsequently re-transplanted in Cape Town.
Conclusions. Despite a shortage of organs, we have overcome a steep learning curve, with results comparable with other early series. The current threat to the continued viability of our unit is the lack of appropriately trained paediatric hepatologists and intensivists.
Correlation between a new visual prostate symptom score (VPSS) and uroflowmetry parameters in men with lower urinary tract symptomsSource: South African Medical Journal 102, pp 237 –240 (2012)More Less
Objective. A visual prostate symptom score (VPSS) compared with the international prostate symptom score (IPSS) for evaluation of lower urinary tract symptoms (LUTS) can be completed without physician assistance by a significantly larger proportion of men with limited education. We aimed to evaluate the correlation of the VPSS and IPSS with uroflowmetry parameters.
Methods. Men with LUTS were requested to complete the IPSS and VPSS, consisting of pictograms to evaluate urinary frequency, nocturia, force of the stream and quality of life. The maximum (Qmax) and average urinary flow rate (Qave), voided volume (VV) and post-void residual (PVR) urine volumes were measured. Statistical analysis was performed using the Mann-Whitney and Spearman's tests.
Results. The study included 93 men (mean age 64 years, range 33 - 85), with VV >150 ml in 66 (71%) and <150 ml in 27 (29%) subjects. In the group with VV >150 ml there were significant negative correlations between the IPSS and Qmax (r=-0.30, p=0.016), the IPSS and Qave (r=-0.29, p=0.018), the VPSS and Qmax (r=-0.38, p<0.002) and the VPSS and Qave (r=-0.37, p<0.003). The VPSS question on the subject's assessment of his urinary stream showed a significant negative correlation with the Qmax (r=-0.37, p=0.002) and Qave (r=-0.31, p=0.011), but the IPSS question on the subject's urinary stream did not correlate significantly with the Qmax or Qave.
Conclusions. The VPSS is equivalent to the IPSS in terms of correlation with Qmax and Qave and can therefore be used instead of the IPSS to evaluate LUTS in men with limited education.
Source: South African Medical Journal 102, pp 241 –244 (2012)More Less
Objectives. To determine the current door-to-needle time for the administration of fibrinolytics for acute myocardial infarction (AMI) in emergency centres (ECs) at three hospitals in Cape Town, and to compare it with the American Heart Association/American College of Cardiology (AHA/ACC) recommendation of 30 minutes as a marker of quality of care.
Methods. A retrospective review of case notes from January 2008 to July 2010 of all patients receiving thrombolytics for AMI in the ECs of three Cape Town hospitals. The total door-to-needle time was calculated and patient demographics and presentation, physician qualification, clinical symptomology and reasons for delays in thrombolytic administration were analysed.
Results. A total of 372 patients with acute ST elevation myocardial infarction (STEMI) were identified; 161 patients were eligible for the study. The median door-to-needle time achieved was 54 minutes (range 13 - 553 mins). A door-to-needle time of 30 minutes or less was achieved in 33 (20.5%) patients; 51.3% of the patients arrived by ambulance; 34% of patients had a pre-hospital 12-lead ECG; and 88.8% had typical symptoms of myocardial infarction. Medical officers administered thrombolytics to 44.7% of the patients. The predominant infarct location on ECG was inferior (55.9%).
Conclusion. A significant number of patients were not thrombolysed within 30 minutes of presentation. The lack of senior doctors, difficulty interpreting ECGs, atypical presentations and EC system delays prolonged the door-to-needle time in this study.
Acceptability, feasibility and impact of routine screening to detect undiagnosed HIV infection in 17 - 24-month-old children in the western sub-district of Cape TownSource: South African Medical Journal 102, pp 245 –248 (2012)More Less
Objectives. To explore the acceptability and feasibility of routine HIV screening in children at primary healthcare clinics and ascertain the prevalence of previously undiagnosed HIV infection in 17 - 24-month-old children accessing curative and routine services.
Methods. A survey was conducted in 4 primary health clinics in the western sub-district of Cape Town. Rapid HIV screening of 17 - 24-month-old children was performed for consenting caregiver-child pairs. Data on demographics, child health and antenatal history were collected using questionnaires.
Results. During recruitment, 358 children (72%) were tested for HIV infection. Most of the children (95.8%) were accompanied by a parent. The prevalence of reported HIV exposure among children was 21% (107/499). Of these, 3 had previously confirmed HIV infection; 1 was reportedly confirmed by a 6-week HIV test, and the other 2 probably contracted the virus via late postpartum transmission. The overall transmission rate was 3.5% (3/86) and the confirmed proportion of HIV-infected children was 0.8% (3/361). No previously unknown HIV infection was detected.
Conclusions. Programmes to prevent mother-to-child transmission are effective, but at-risk infants who test negative at 6 weeks should be monitored for subsequent seroconversion. Parents of HIV-exposed infants are more likely to permit (re)testing of their infants than those whose offspring are not at risk. Routine HIV testing of children is feasible and acceptable at primary level, but may require additional resources to achieve universal coverage. Routine screening at an earlier age may detect previously undiagnosed HIV infection.
Source: South African Medical Journal 102, pp 249 –251 (2012)More Less
Background. The shortage of doctors in all specialties in Malawi is particularly severe in rural areas. Contributory factors are the low number of students graduating each year, migration of doctors, and the preference of new graduates for practising in urban areas. Attempts to increase the output from Malawi's only medical school are insufficient to meet the country's healthcare needs.
Methods. We studied the factors influencing career choices of medical undergraduates of the College of Medicine in Blantyre, Malawi, who were surveyed by means of a self-administered questionnaire (N=205) and individual interviews (N=17).
Results. Most respondents (89.4%) indicated that they intend to specialise abroad, predominantly to study in 'better institutions' and to get the 'experience' of a different country; 87.0% indicated that they intend to live in Malawi long-term. Although, in general, the rural lifestyle was unattractive to medical students, respondents from rural areas and small towns, and whose parents were 'non-professionals', were more likely to intend working in rural areas and small towns, and to settle in Malawi, than students from urban and professional families.
Conclusions. The College of Medicine should consider increasing its intake of students with lower socio-economic backgrounds and from rural areas/small towns to increase the number of doctors working in rural areas and settling in Malawi. However, the Ministry of Health may need a multipronged approach to reduce the mismatch between doctors' career expectations and the country's healthcare needs.
Author Roger StewartSource: South African Medical Journal 102, pp 252 –255 (2012)More Less
Two hundred years ago, the naturalist William John Burchell departed from Cape Town on extensive travels in South Africa 'solely for the purpose of acquiring knowledge'. An intelligent observer who was exceptionally skilled at recording his observations in words and pictures, he is remembered for numerous contributions to the country as scientist, artist and ethnographer. The medical perspective on his travels has yet to receive attention. He identified and recorded illnesses of the indigenous peoples with whom he came into contact. He also described the medical care he administered to his companions and to himself; in doing so, he revealed a profound care for his 'fellow creatures'. His vivid and sometimes poignant descriptions remind us of some of the health risks endured by early travellers in the country. One of the most riveting is his successful care of an assistant whose left hand was severely mutilated when a firearm exploded in his hands. Burchell was probably the first person to include the materia medica of the Khoi in an essentially European approach to the non-surgical management of such a serious condition.