South African Medical Journal - Volume 103, Issue 7, 2013
Volumes & issues
Volume 103, Issue 7, 2013
Otorhinolaryngology - not just tonsils and grommets : insights into the ENT scene in South Africa : editorialSource: South African Medical Journal 103, pp 455 –457 (2013)More Less
Ear, nose and throat (ENT) surgery may be the oldest surgical specialty, but it certainly has not lost its lustre with age. It encompasses a wide variety of pathology, spanning all age groups regardless of gender, ethnicity or socio-economic status. The field of ENT (otorhinolaryngology) includes a broad range of procedures, often using advanced technology both at the bedside and in theatre. Recent decades have seen the discipline expand to include subspecialties like head and neck surgery, neuro-otology, anterior and lateral skull base surgery, allergology and paediatrics.
The Biosulin equivalence in standard therapy (BEST) study - a multicentre, open-label, non-randomised, interventional, observational study in subjects using Biosulin 30/70 for the treatment of insulin-dependent type 1 and type 2 diabetes mellitus : researchSource: South African Medical Journal 103, pp 458 –460 (2013)More Less
Introduction. The need for more cost-effective insulin therapy is critical in reducing the burden on patients and health systems. Biosimilar insulins have the potential to dramatically lower healthcare costs by delivering insulin with a similar anti-glycaemic effect and adverse reaction profile.
Objectives. The purpose of this study was to confirm equivalence in glycaemic outcomes and side-effect profiles between Biosulin 30/70 and other human premixed insulin preparations on the South African market in a clinical practice setting.
Methods. Subjects in this interventional, observational, multicentre, open-label, prospective study were switched from their existing human premix insulin (Actraphane, Humulin 30/70 or Insuman) to the study insulin Biosulin 30/70. The primary endpoint was the change in HbA1c from baseline to 6 months.
Results. Seventy-seven adult patients with type 1 (n=18) or type 2 (n=59) diabetes were enrolled. The baseline HbA1c in the overall cohort was 7.9%, 8.0% at 3 months (p=0.50) and 7.6% at 6 months (p=0.14).There was a small increase in the total daily dose of insulin used in both the type 1 and type 2 cohort, from 0.62 to 0.65 units/kg/day (p=0.0004). There was no significant difference in weight in the study subjects during the 6-month period on Biosulin 30/70 (p=0.67).
Conclusion. Biosulin 30/70 achieved at least equivalent glycaemic control to existing human premix insulins, with no reported new or severe adverse events. Increased use of biosimilar insulins has the potential for significant cost savings.
Exponential increase in postprandial blood-glucose exposure with increasing carbohydrate loads using a linear carbohydrate-to-insulin ratio : researchSource: South African Medical Journal 103, pp 461 –463 (2013)More Less
Background. Postprandial glucose excursions contribute significantly to average blood glucose, glycaemic variability and cardiovascular risk. Carbohydrate counting is a method of insulin dosing that balances carbohydrate load to insulin dose using a fixed ratio. Many patients and current insulin pumps calculate insulin delivery for meals based on a linear carbohydrate-to-insulin relationship. It is our hypothesis that a non-linear relationship exists between the amounts of carbohydrate consumed and the insulin required to cover it.
Aim. To document blood glucose exposure in response to increasing carbohydrate loads on fixed carbohydrate-to-insulin ratios.
Methods. Five type 1 diabetic subjects receiving insulin pump therapy with good control were recruited. Morning basal rates and carbohydrate-to-insulin ratios were optimised. A Medtronic glucose sensor was used for 5 days to collect data for area-under-the-curve (AUC) analysis, during which standardised meals of increasing carbohydrate loads were consumed.
Results. Increasing carbohydrate loads using a fixed carbohydrate-to-insulin ratio resulted in increasing glucose AUC. The relationship was found to be exponential rather than linear. Late postprandial hypoglycaemia followed carbohydrate loads of >60 g and this was often followed by rebound hyperglycaemia that lasted >6 hours.
Conclusion. A non-linear relationship exists between carbohydrates consumed and the insulin required to cover them. This has implications for control of postprandial blood sugars, especially when consuming large carbohydrate loads. Further studies are required to look at the optimal ratios, duration and type of insulin boluses required to cover increasing carbohydrate loads.
Otolaryngological and head and neck manifestations in HIV-infected patients seen at Steve Biko Academic Hospital in Pretoria, South Africa : researchSource: South African Medical Journal 103, pp 464 –466 (2013)More Less
Background. Sub-Saharan Africa has the highest incidence of HIV infection. According to recent census statistics, 5.6 million people in South Africa (SA) are HIV-positive, the highest number of infected individuals worldwide. Over 80% of HIV-infected individuals will present with ear, nose and throat (ENT) manifestations. Previous studies show that oral diseases seem to be the most common ENT-related manifestation, reported in about 40 - 50% of HIV-infected patients. In SA, there is lack of local information regarding the otolaryngological and head and neck manifestations in HIV-infected individuals.
Objective. To ascertain our local trends of ENT and head and neck manifestations in HIV-infected patients seen at our specialised ENT-HIV Clinic, Steve Biko Academic Hospital, Pretoria, Gauteng Province, SA.
Methods. A 1-year prospective study involving 153 HIV-infected patients was conducted in the clinic from January to December 2011. Patient history was taken and examinations were performed based on the World Health Organization (WHO) HIV/AIDS classification system. Data analysis was performed using Epi Info 7 software.
Results. The most common manifestations were adenoid hypertrophy/hyperplasia followed by cervical lymphadenopathy, chronic suppurative otitis media, otitis media with effusion and sensory-neural hearing loss.
Conclusion. Patients typically presented with early manifestations during symptomatic WHO stages I and II in contrast to results reported in similar developing world studies from Iran, Nigeria and India. A possible explanation may lie in the SA government HIV Counselling and Testing campaign and the antiretroviral rollout programme, the effectiveness of which is becoming evident.
Paediatric chronic suppurative otitis media in the Free State Province : clinical and audiological features : researchSource: South African Medical Journal 103, pp 467 –470 (2013)More Less
Background. Chronic suppurative otitis media (CSOM) is a chronic infection of the middle ear cleft. In sub-Saharan Africa >50% of cases occur in children <10 years of age.
Objectives. To describe the otological, audiological and bacteriological findings in children with CSOM.
Methods. We conducted a prospective study at the Ear, Nose and Throat (ENT) Clinic at Universitas Academic Hospital between August 2009 and December 2010. We included all children with CSOM over this period. Patients underwent ENT and paediatric examination, and were tested for HIV. Pus swabs were taken after an ear toilet for routine microbiology, fungal and Mycobacterium tuberculosis culture. We performed audiological testing after the otorrhoea had resolved.
Results. Eighty-six children (113 ears) were included, with a median age of 4.6 years (range 1 - 12 years). The mean duration of otorrhoea was 161.7 weeks (range 4 - 572 weeks). Nine patients (10.5%) presented with coalescent mastoiditis and/or intracranial complications of CSOM. Of the 153 organisms identified, Gram-negative bacteria were present in 93 (82.3%) ears, with 94.8% of these being sensitive to quinolones. Only 1 case of tuberculous otitis media was identified. HIV infection was present in 54.6% of patients tested. There was a hearing loss in 44 (66.7%) of the tested affected ears.
Conclusions. There was a long delay between the onset of symptoms and accessing ENT services. Most cases of CSOM were due to quinolone-sensitive Gram-negative aerobes. There was a high prevalence of cholesteatoma, hearing loss and other complications in children in this study.
Chronic otorrhoea : spectrum of microorganisms and antibiotic sensitivity in a South African cohort : researchSource: South African Medical Journal 103, pp 471 –473 (2013)More Less
Background. Chronic otorrhoea is difficult to treat, with treatment in South Africa (SA) being protocol driven and generally initiated at the primary healthcare level. There is a lack of local studies that focus on the bacteriology and antimicrobial sensitivities of chronic otorrhoea, which underpins the management advice offered.
Aims. To determine the microbiological profile and antimicrobial susceptibility of patients with chronic otorrhoea and the validity of the Department of Health's (DoH) current guideline.
Methods. We conducted a prospective study at Groote Schuur Hospital from 2005 to 2009. We included patients with chronic otorrhoea classified as either otitis media or otitis externa, according to our definitions. Pus swabs were taken, from which microorganisms were cultured and tested for antimicrobial susceptibility.
Results. Of 79 patients with otorrhoea, 50 had otitis media, 21 had otitis externa and the condition was not determined in 8 patients. The most common organism isolated with otitis media was Proteus mirabilis (18/50; 36%) and with otitis externa, Pseudomonas aeruginosa (7/21; 33%). Otorrhoea had a different microbial spectrum compared with international reports, with methicillin-resistant Staphylococcus aureus infection in a single patient. The organisms isolated were susceptible mainly to fluoroquinolones (96%) and aminoglycosides (81%).
Conclusion. Amoxicillin is a poor choice of antibiotic due to its low sensitivity, which calls into question the current DoH guideline for otorrhoea. Antimicrobial treatment protocols should be based on local data and be revisited from time to time. This study suggests that, should first-line treatment fail, an antibiotic with Gram-negative cover, e.g. a topical fluoroquinolone, should be considered.
Source: South African Medical Journal 103, pp 474 –475 (2013)More Less
Background. Congenital hearing loss affects 3 - 6/1 000 children worldwide. The benefits of early identification of hearing loss and early intervention have been clearly established. There are no previous studies reporting on the age of diagnosis of congenital hearing loss in the Free State province.
Objectives. To determine the age of diagnosis of congenital hearing loss in the Otorhinolaryngology Clinic at Universitas Hospital. Secondary aims included determining age at first visit, as well as the time delay between first visit and diagnosis, and documenting any interventions which took place.
Methods. A retrospective, descriptive study was undertaken, analysing data from 2001 to 2010.
Results. A total of 260 cases of congenital hearing loss were analysed. The median age of diagnosis of hearing loss was 44.5 months. The median age of first visit was 40.9 months, and the median delay between first visit and diagnosis was 49 days.
Conclusions. The median age of diagnosis far exceeds national and international benchmarks. This has a profoundly negative impact on the development and outcomes of children with hearing loss. These results have been used to motivate for the expansion of hearing screening and diagnostic services in the province.
Source: South African Medical Journal 103, pp 476 –478 (2013)More Less
Carbapenem-resistant Enterobacteriaceae have been increasingly reported throughout the world. The first South African report of a New Delhi metallo-beta-lactamase was from Gauteng in August 2011. Despite maintaining a high degree of vigilance, the first such case was seen in KwaZulu-Natal almost a year later. Other cases have been unable to confirm a definite link to any other affected areas; this is the first case in South Africa showing this direct epidemiological link.
Source: South African Medical Journal 103, pp 478 –480 (2013)More Less
Background and objectives. The purpose of this report is to describe the changing trends in adolescent treatment admissions for methamphetamine in Cape Town, and to discuss possible implications.
Method. Data were collected on admissions for drug abuse treatment through a regular monitoring system involving drug treatment centres and programmes in Cape Town, every 6 months as part of the South African Community Epidemiology Network on Drug Use (SACENDU). A one-page form was completed by treatment centre personnel for each patient to collect demographic and substance abuse data.
Results. The results indicate that between 2004 and 2006, a significant increase in the proportion of adolescent treatment admissions for methamphetamine abuse occurred, while a significant decrease occurred between 2006 and 2011.
Conclusions. The initial increase in adolescent treatment admissions for methamphetamine abuse from 2004 to 2006, and subsequent decrease between 2006 and 2011, may suggest a change in methamphetamine abuse patterns among adolescents in Cape Town.
Health conditions and support needs of persons living in residential facilities for adults with intellectual disability in Western Cape Province : researchSource: South African Medical Journal 103, pp 481 –484 (2013)More Less
Background. Intellectual disability (ID) is a relatively high-incidence disability, with an increased risk of poor physical and mental health. Persons with ID also have lifelong support needs that must be met if they are to achieve an acceptable quality of life. Little is known about these health conditions and support needs in the African context. This study examines persons over the age of 18 years with ID in residential facilities in Western Cape Province.
Objective. To analyse the health conditions and support needs of persons with ID in Western Cape Province.
Method. A survey of residents' health conditions and support needs was conducted in face-to-face interviews with the managers of 37 out of 41 identified facilities.
Results and conclusion. The survey comprised 2 098 residents (54% of them female), representing less than 2% of the estimated population of persons with ID in the province. The survey suggests that such persons experience a wide range of health conditions (notably mental health and behavioural issues) but have limited access to general healthcare and rehabilitation services. Furthermore, the daily living supports required for an acceptable quality of life are limited. The findings highlight the need for better health and support provision to persons with ID.
A case for revising the strength of the relationship between childhood asthma and atopy in the developing world : researchSource: South African Medical Journal 103, pp 485 –488 (2013)More Less
Introduction. Asthma is the commonest chronic condition of children. Diagnosis remains difficult and many surrogate markers are used, such as documenting evidence of atopy.
Method. Two studies investigated the role of atopy in childhood asthma. The first documented the prevalence and nature of allergy sensitivities in a group of asthmatic children compared with non-asthmatic children in Pretoria, South Africa. The second enrolled a random sample of asthmatic children and their mothers attending the Children's Chest and Allergy Clinic at Steve Biko Academic Hospital, Pretoria. Children were classified as having atopic or non-atopic asthma. Mothers completed a questionnaire to reveal atopic features.
Results. In the first study, only 45.0% of asthmatic children had a positive skin-prick test (SPT), as opposed to 16.2% of control children. This is a lower proportion than in many reported international studies. In the second study, 64 children with atopic asthma and 36 with non-atopic asthma were studied, along with their mothers. The proportion of children with atopic asthma did not differ for mothers with and without a positive SPT (p=0.836), a history of asthma (p=0.045) or symptoms suggestive of an allergic disease (p=1.000), or who were considered to be allergic (p=0.806). The odds ratio (OR) of a child having atopic asthma when he or she had a mother with a doctor-diagnosed history of asthma was 4.76, but the sensitivity was low (21.9%).
Conclusion. The data demonstrate that fewer asthmatic children in South Africa are atopic than was previously thought. Also, all maternal allergic or asthmatic associations are poor predictors of childhood atopic asthma. Despite the increased risk of atopic asthma in a child of a mother who has a doctor diagnosis of asthma (OR 4.76; p=0.045), this is a poor predictor of atopic asthma (sensitivity 21.9%).
Source: South African Medical Journal 103, pp 489 –490 (2013)More Less
The clean-shave haircut known locally as the chiskop is rare among females but popular with black South African men, who are also predisposed to folliculitis keloidalis nuchae (FKN) (keloids on the back of the head). During a previous study, participants described an unexpected symptom of haircut-associated bleeding. As this is not a widely recognised entity, we conducted the present study at an HIV clinic servicing the same population, with the objective of comparing the prevalences of haircut-associated bleeding and FKN in 390 HIV-positive subjects with published data for Langa (Western Cape, South Africa). The results for HIV-positive participants were similar to the population data, but in both groups the prevalence of haircut-associated bleeding (24.5% v. 32%; p=0.17) was much higher than that of FKN (10.2% v. 10.5%), suggesting that the hairstyle increases the risk of bleeding even in people with healthy scalps without folliculitis. This study does not (and was not intended to) prove a higher HIV prevalence in chiskop wearers or in FKN sufferers, but it confirms a history of haircut-associated bleeding in at least a quarter of our male study participants. The risk of transmission of blood-borne infection via haircuts is likely to be low, but requires formal quantification. Public education on adequate sterilisation of barber equipment between haircuts and promotion of individual hair-clipper ownership for chiskop clients should not be delayed. Depilatory creams formulated for African hair offer a non-mechanical means of achieving clean-shave hairstyles.
Source: South African Medical Journal 103, pp 491 –493 (2013)More Less
Background. As KwaZulu-Natal Province is the epicentre of the HIV epidemic both in South Africa (SA) and globally, it is an ideal location to conduct HIV prevention and therapeutic trials. Numerous prevention trials are currently being conducted here; the potential for participant co-enrolment may compromise the validity of these studies and is therefore of great concern.
Aim. To report the development and feasibility of a digital, fingerprint-based participant identification method to prevent co-enrolment at multiple clinical trial sites.
Methods. The Medical Research Council (MRC) HIV Prevention Research Unit (HPRU) developed the Biometric Co-enrolment Prevention System (BCEPS), which uses fingerprint-based biometric technology to identify participants. A trial website was used to determine the robustness and usability of the system. After successful testing, the BCEPS was piloted in July 2010 across 7 HPRU clinical research sites. The BCEPS was pre-loaded with study names and clinical trial sites, with new participant information loaded at first visit to a trial site.
Results. We successfully implemented the BCEPS at the 7 HPRU sites. Using the BCEPS, we performed real-time 'flagging' of women who were already enrolled in another study as they entered a trial at an HPRU site and, where necessary, excluded them from participation on site.
Conclusion. This system has promise in reducing co-enrolment in clinical trials and represents a valuable tool for future implementation by all groups conducting trials. The MRC is currently co-ordinating this effort with clinical trial sites nationally.