This month's issue of the SAMJ features two important papers that address the management of fever and the analysis of blood cultures in sick children. Fever is a symptom that alarms parents and caregivers alike. Yet, fever in itself poses little to no risk to the child. Rather, it is often a symptom of a minor self-limiting illness, such as viral upper-respiratory infection, and is a positive response of the body. However, it may be a sign of common, major illnesses that carry high morbidity and mortality. Serious bacterial infections such as pneumonia, which is the 4th most common cause of death in children in South Africa, often present with fever. Also, malignancies such as acute lymphoblastic leukaemia and connective tissue diseases such rheumatic disease often present with fever as an initial feature.
To the Editor: Medical communication is often so formal, and one can't help thinking that sometimes a more light-hearted approach would be nice. We recently attended an advanced paediatric life support course in Pretoria (may we suggest that all doctors treating children should think of doing this course?), and on one of the days our group was in a silly mood. Attempting to describe perfusion in a child who isn't shocked but also doesn't have perfect perfusion, we came up with the term 'good-ish'. It felt so right, and everybody could identify with what we meant - '-ish': something that falls outside a medical tick-box; 'normal-ish': something's not quite right but one won't put one's medical head on the block; 'ok-ish': better, but who knows what will happen?
To the Editor: Neurocysticercosis is recognised globally as a major cause of secondary or acquired epilepsy. In southern Africa, it is said to be a common cause of juvenile epilepsy. The prevalence of cysticercosis in endemic areas of the Eastern Cape Province of South Africa (SA) is estimated at 64.6% (Krecek et al. 2008), while that of neurocysticercosis is estimated at 61% (Ocana et al. 2009).
To the Editor: My 85-year-old father has been a life-long smoker, he remains fit and well and writes a blog about the pleasure he gets from smoking and the benefits in terms of weight loss. Another 127 85-year-old lifelong smokers have written to him saying they have also maintained a normal weight throughout their lives; they feel healthy and enjoy smoking. My father would like the SAMJ to publish these letters as evidence of the health benefits of smoking.
To the Editor: We are writing to point out inaccuracies in Professor Noakes' critique of the Women's Health Initiative (WHI) trial of dietary modification. Difficult as it may be for proponents of low carbohydrate, high fat diets to accept, it is an inconvenient truth that the findings from the WHI trial negate their thesis that diets higher in carbohydrates and lower in fats lead to obesity and insulin resistance and increase diabetes risk. Instead, the lower fat diet rigorously tested in a large number of participants in the WHI led to less weight gain, improved insulin resistance (at 1 year), and no increase in diabetes risk compared with the control diet. Diabetes risk appeared to be reduced proportionately to decreases in fat intake and weight. These findings are in agreement with findings from the Diabetes Prevention Trial (of people with pre-diabetes treated with a low-fat, calorie-restricted diet plus exercise) that reduction in diabetes risk was proportional to reduction in fat intake and weight loss.
To the Editor: Point-of-care testing (POCT) is a top agenda item for healthcare providers. What, where, when and how to implement it is under investigation, and a current focus of my research: 'To determine the feasibility of implementing multiple POCT in clinics for HIV ART initiation'.
If medical aids are forced to pay the full fee charged by doctors, as the Council for Medical Schemes (CMS) insists they do, then either medical aid subscriptions will become unaffordable or schemes will collapse, denying people their constitutional rights. This is the view of Dr Humphrey Zokufa of the Board of Healthcare Funders (BHF), which represents over 70% of existing medical aid schemes. He signalled to Izindaba the BHF's intention to forge ahead in securing either a High Court or Constitutional Court interpretation of the contentious Regulation 8 of the Medical Schemes Act.
Jonathan Broomberg, CEO of Discovery Health, and Milton Streak, the Principal Officer of the Discovery Health Medical Scheme said both entities supported the Council for Medical Scheme (CMS) and did not agree with the Board of Healthcare Funders (BHF) on its view of Regulation 8. Discovery Health Medical Scheme and other schemes managed by Discovery Health had 'for several years, had payment arrangements in place allowing members' access to full payment or PMB [Prescribed Member Benefit] conditions'.
The government will hold hospital line managers responsible for ensuring that consultants and doctors deliver at least 56 hours of State work per week - if they are to do any Remunerated Work Outside the Public Service (RWOPS) at all. This will be nationally legislated, Izindaba has learnt.
Imagine trying to mollify 400 municipal health workers who have been told they will be changing employers, job descriptions and possibly workplaces - with only half their senior management in place. Imagine that, and you will have a picture of what the Foundation for Professional Development (FPD) and their partner, the newly formed Nelson Mandela Bay (NMB) health district management, took on - with amazing success so far - in the often strife-torn NMB (Port Elizabeth, Uitenhage and Dispatch) Health District in the Eastern Cape earlier this year.
Last October, a rejuvenated, financially healthier and better-led Medical Research Council (MRC) gave lifetime achievement awards to two local scientists whose applied research has saved tens of thousands of lives in South Africa (SA) and multiples more in other countries, winning international recognition.
This book tells the fascinating story of a philanthropic organisation - Medical Education for South African Blacks (MESAB) - founded in the 1980s; its chief objective was to help improve health and healthcare for black people in South Africa (SA).
When Doctors Don't Listen is a recently published book written by two emergency medicine doctors from Harvard University, USA. Their objective: to improve emergency department diagnostic accuracy while minimising unnecessary (and expensive) testing. There is a surprising catch - the book is aimed primarily at the patient rather than the doctor. That said, clinicians will still find this a fascinating read.
Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in children depends on prompt and effective diagnosis and treatment of pharyngitis at the primary level of care. Cost-effectiveness modeling shows that the most cost-effective strategy for primary prevention in South Africa (SA) is to use a simple symptomatic clinical decision rule (CDR) to diagnose pharyngitis in children presenting at the primary level of care and then to treat them with a single dose of intramuscular penicillin. Treat All and CDR2+ strategies are affordable and simple and miss few cases of streptococcal pharyngitis at the primary level of care. The CDR2+ strategy is the most cost-effective for primary prevention of ARF and RHD in urban SA and should complement primordial and secondary prevention efforts.
In this article, I explore the South African 2003 National School Health Policy (NSHP) and the revised 2012 Integrated School Health Policy (ISHP). I examine whether the shortcomings in the development, content and implementation of the 2003 NSHP, and the context in which it was implemented, have been addressed adequately in the 2012 ISHP. The shortcomings include poorly structured relationships among key policy actors; an absent policy translation process resulting in insufficient understanding and prioritisation of school health by district and facility managers; and poor support and training of nurses. Insufficient capacity and resources, compounded by inadequate referral service capacity, resulted in the inequitable coverage and quality of the service and caused nurses to refer to school health as 'the stepchild of primary healthcare'. The comparison of the 2003 and 2012 policies is guided by the policy analysis framework of the Walt and Gilson policy triangle, which considers the policy context, process of policy development, policy actors and the policy content as key dimensions to successful policy development and implementation. I draw on an evaluation of a six-year implementation period (2003 - 2009) of the 2003 NSHP, which revealed the implementation challenges with the related explanatory factors. I provide lessons from the evaluation of the 2003 NSHP, highlight the policy changes in the new 2012 ISHP and finally highlight key opportunities, and remaining challenges, for the implementation of the new 2012 ISHP.
The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient's problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists - family physicians - are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively.
The development of novel oral anticoagulants that are effective alternatives to warfarin in non-valvular atrial fibrillation (AF) is a welcome advance. However, a variety of unresolved problems with their use, and not least with their cost, make it important to re-evaluate the use of warfarin as it will likely remain the anticoagulant of choice in South African patients with non-valvular AF for the foreseeable future. In this article, we review the correct clinical use of warfarin. Guidance is provided on commencing warfarin treatment, maintenance dosing, the recommended steps when temporary withdrawal of treatment is necessary, the management of bleeding, and the use of warfarin in chronic kidney disease. Techniques for changing from warfarin to one of the new oral anticoagulants and vice versa are included.
The social accountability of institutions which train doctors has attracted increasing attention in recent years. In this context, the World Health Organization (WHO) defines social accountability as 'an obligation to direct education, research and service activities towards addressing the priority health concerns of the community, region and/or nation they have a mandate to serve.' While the 'social accountability debate' has gained considerable momentum, the essential healthcare needs of rural and/or underserved communities continue to be inadequately addressed globally. Unfortunately, the situation in South Africa (SA) is no different.