South African Medical Journal - Volume 103, Issue 8, 2013
Volumes & issues
Volume 103, Issue 8, 2013
Author Carol-Ann BennSource: South African Medical Journal 103 (2013)More Less
I was considering material for the privilege of writing this guest editorial on breast cancer in South Africa (SA) while strolling the streets of New York after a whistle-stop visit to premiere breast cancer units in the USA. I wandered past the advert to 'The Lion King' (proudly African) and thought about the circle of breast cancer management seen in the last half-century and how this has affected women in SA diagnosed with the disease.
Author J.V. LarsenSource: South African Medical Journal 103, pp 498 –499 (2013)More Less
Early in May, a friend in her late 70s here in KZN needed investigation and assessment for an abdominal cancer. She was able to access care in the private sector, and had a CT scan within 4 days; the appropriate management plan was begun in 7 days. During the same week, the home-based carers in our small hospice found a 39-year-old mother of 4 children who was in great pain at home. She was on HAART, and had been diagnosed with cancer of the cervix 7 months previously in the district hospital. She was assessed by the Oncology Unit in our tertiary hospital 4 weeks later, and put on the waiting list for radiotherapy.
Author Gerald BaldreySource: South African Medical Journal 103 (2013)More Less
After reading the above-titled editorial, I came to the conclusion that it gave a historical perspective, by and large, to the care of rape victims in South Africa. It contains many criticisms of practitioners who care for such victims:
- 'secondary trauma sometimes suffered at the hands of the SAPS and health services
- many rape survivors feel alone and let down by ... the institutions that ostensibly exist to protect them
- four rape crisis centres ... there has been no significant change to the quality of services offered to rape survivors
- misapprehension ... medical staff ... victims must first lay a charge
- lack of clinical competence in clinical forensic medicine, all compounded by staff apathy, resistance and non-adherence to protocols.'
Author Clint CronningSource: South African Medical Journal 103 (2013)More Less
In the early 1990s, a landmark decision was made by the South African Nursing Council (SANC), and supported by the Department of Health, to close down all adult-education vocational-training nursing colleges in favour of higher education (HE) institutions. Fast-forward 20 years and this 'well-meaning' decision has now plunged South Africa (SA) into its largest shortage of trained nurses in history, referred to in many newspapers and press reports as the 'crisis in nursing'. Even the Minister of Health (MoH) and the Health Professions Council of SA (HPCSA) have admitted that the closing of nursing colleges was a huge mistake. As a result, many previously closed colleges have been reopened in a desperate attempt to supply our hospitals with trained nursing staff, at a multi-million Rand cost to the taxpayer. Emergency medical services (EMS) are about to follow the same disastrous path.
Author Susan GrabeSource: South African Medical Journal 103 (2013)More Less
The editorial entitled 'Rape in South Africa - a call to action' implores me to respond. The author aptly describes the landscape of sexual violence as it intersects with medicine and the limitations in the response. Child sexual abuse (CSA) is included in this lament, and on this I wish to cast some more light. The inherent nature of CSA includes secrecy, serious threats, perpetrators who are part of the extended family, victims who are often preschool children, and a host of other factors that complicate management. The grooming process and access that perpetrators have to children precludes immediate alarm. It is clear that children need specialised services, including psychological, social, medical and legal services, necessitating a multi-professional approach. Currently, these are seldom available outside the private sector, and are often subcontracted by NGOs to protect children. Successful prosecution is also seldom possible.
Source: South African Medical Journal 103 (2013)More Less
In July 2012, Uganda's Minister of Health notified the World Health Organization (WHO) of an outbreak of Ebola. Even though some cases were reported later, the end of the outbreak was declared in October 2012. Current studies have assessed the use of internet tools to identify trends in queries regarding communicable diseases, which have been used for early identification of a potential outbreak.
Source: South African Medical Journal 103, pp 501 –502 (2013)More Less
Her shy, humble demeanour belies the passion and tenacity it took just to keep studying, sitting by the light of a small paraffin lamp late into many nights in her tiny Eastern Cape shack - all so she could achieve the matric marks she knew would one day help her become a doctor. Her Goko (grandmother) chided her for using too much precious paraffin in the small township near Peddie in which she grew up. Today, her Goko would burst with pride to hear that Dr Neliswa Gogela (36) is the country's first recipient of a R2.1 million grant to study liver transplantation at one of the world's top clinical research hospitals.
Source: South African Medical Journal 103, pp 503 –505 (2013)More Less
Sex workers, truckers and young women top a comprehensive new government list of HIV-vulnerable groups identified in specific geographical areas. Now the first two are being considered as targets for pre-exposure prophylactic drug pilot programmes, complementing a successful array of HIV and other healthcare interventions being rolled out, albeit inadequately, to these 'core transmission' groups. This emerged during several expert presentations, and individual interviews conducted by Izindaba, at the sixth South African AIDS Conference held in Durban from 18 to 21 June this year.
Source: South African Medical Journal 103, pp 505 –506 (2013)More Less
The impact of Remunerated Work Outside the Public Service (RWOPS) abuse on the ethical understanding of young doctors is 'devastating' while patient care is 'doubly disadvantaged', through a dearth of teaching and lack of actual physical care. This is how a respected Stellenbosch University medical and legal ethicist and a cutting edge community and primary health care innovator at the University of Pretoria (UP) see the fast-evolving RWOPS abuse saga which took centre stage in public health over the last 3 months.
Source: South African Medical Journal 103, pp 506 –508 (2013)More Less
If a bid by state lawyers succeeds, the minority of state doctors proven to have sacrificed their legal/ethical obligations to public sector patients in favor of private sector extra earnings could end up paying reparation - and some may even be financially crippled. This emerged in the ongoing saga of Remunerated Work Outside the Public Service (RWOPS), which has played out most publicly in KwaZulu-Natal (KZN), Gauteng and the Free State recently. It also threw up a shaky truce between doctors and officials, following slurs on the medical profession and clumsy, sweeping clampdowns by some provincial health ministers.
Author R.O. WiseSource: South African Medical Journal 103 (2013)More Less
It is with great sadness that I report the death on 11 April 2013 of Willie Mukheiber, one of Nature's thorough gentlemen. Born in Ficksburg on 1 August 1925, he was the second of 3 siblings, and attended the local high school. After matriculating in 1942, he enrolled in the medical faculty at UCT.
Direct-to-consumer genetic testing : to test or not to test, that is the question : forum - clinical practiceSource: South African Medical Journal 103, pp 510 –512 (2013)More Less
In direct-to-consumer (DTC) genetic testing, laboratory-based genetic services are offered directly to the public without an independent healthcare professional being involved. The committee of the Southern African Society for Human Genetics (SASHG) appeals to the public and clinicians to be cautious when considering and interpreting such testing. It is important to stress that currently, the clinical validity and utility of genetic tests for complex multifactorial disorders such as type 2 diabetes mellitus and cardiovascular diseases is questionable. The majority of such tests are not scientifically validated and are based on a few preliminary studies. Potential consumers should be aware of the implications of genetic testing that could lead to stigmatisation and discrimination by insurance companies or potential employers of themselves and their family members. Guidelines and recommendations for DTC genetic testing in South Africa (SA) are currently lacking. We provide recommendations that seek to protect consumers and healthcare providers in SA from possible exploitation.
Obstetric risk avoidance : will anyone be offering obstetrics in private practice by the end of the decade? : forum - medicine and the lawAuthor G.R. HowarthSource: South African Medical Journal 103, pp 513 –514 (2013)More Less
Obstetric claims inflation is increasing the cost of covering obstetric risk. This is leading to obstetric risk avoidance by those offering insurance and by practitioners who do not perform enough deliveries to cover the cost of obstetric risk indemnity. By the end of the decade indemnifying obstetric risk will probably be too expensive for doctors in private practice. Non-indemnified doctors will be unable or unwilling to do private deliveries; however, women will still fall pregnant and require delivery. These women will inevitably be forced to deliver in provincial facilities, shifting the workload and liability to the state.
Source: South African Medical Journal 103, pp 515 –516 (2013)More Less
Rates of HIV infection in sub-Saharan Africa remain stubbornly high, despite considerable investment in an array of HIV prevention interventions. The solution to accelerating and sustaining the decline in new infections may be found in the addition of new interventions to the 'tool kit'. These include early antiretroviral (ARV) treatment for prevention, innovative behaviour change methods, 'key population' intervention packages, vaccines and passive immunisation. While all of these have potential, their utility remains unproven.
Source: South African Medical Journal 103 (2013)More Less
Technological advances in genomics are shifting the genetic testing paradigm, from testing targeted mutations in selected genes to testing whole genes and even whole genomes. These exciting developments raise numerous practical pitfalls and ethical issues. Two articles in this issue of the SAMJ address genetic testing for multifactorial diseases.
Source: South African Medical Journal 103, pp 518 –519 (2013)More Less
Worldwide there has been a call for a two-thirds reduction in childhood mortality by 2015. Unfortunately, Millennium Development Goal 4 (MDG4) is unlikely to be reached in 2 years' time. Of the 130 million babies born every year, 4 million will die in the first 28 days of life, with the highest risk on the first day of life. The highest rates are in sub-Saharan Africa, where little progress has been made in the last 15 years towards reducing the number of deaths.
Source: South African Medical Journal 103, pp 520 –521 (2013)More Less
Maternal health is a major health priority for international agencies, the African Union, and the South African Government. In 2000, all United Nations (UN) member states agreed to substantial improvements in maternal health, defined by Millenium Development Goal 5 (MDG5), which includes the specific target of reducing maternal mortality by 75% between 1990 and 2015. While many countries are making progress, maternal mortality in South Africa (SA) has significantly increased during this time. Data from the 2007 Community Survey suggest that maternal mortality in SA, rather than showing evidence of reduction, may have quadrupled from 1998 to 2007. The SA National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) reports, which analyse institutional maternal mortality, have shown an increase in maternal deaths, from the first report in 1998 to the latest triennial report covering the years 2008-2010.
MammaPrint Pre-screen Algorithm (MPA) reduces chemotherapy in patients with early-stage breast cancer : researchSource: South African Medical Journal 103, pp 522 –526 (2013)More Less
Background. Clinical and pathological parameters may overestimate the need for chemotherapy in patients with early-stage breast cancer. More accurate determination of the risk of distant recurrence is now possible with use of genetic tests, such as the 70-gene MammaPrint profile.
Objectives. A health technology assessment performed by a medical insurer in 2009 introduced a set of test eligibility criteria - the MammaPrint Pre-screen Algorithm (MPA) - applied in this study to determine the clinical usefulness of a pathology-supported genetic testing strategy, aimed at the reduction of healthcare costs.
Methods. An implementation study was designed to take advantage of the fact that the 70-gene profile excludes analysis of hormone receptor and human epidermal growth factor receptor 2 (HER2) status, which form part of the MPA based partly on immunohistochemistry routinely performed in all breast cancer patients. The study population consisted of 104 South African women with early-stage breast carcinoma referred for MammaPrint. For the MammaPrint test, RNA was extracted from 60 fresh tumours (in 58 patients) and 46 formalin-fixed, paraffin-embedded (FFPE) tissue samples.
Results. When applying the MPA for selection of patients eligible for MammaPrint testing, 95 of the 104 patients qualified. In this subgroup 62% (59/95) were classified as low risk. Similar distribution patterns for risk classification were obtained for RNA extracted from fresh tumours v. FFPE tissue samples.
Conclusions. The 70-gene profile classifies approximately 40% of early-stage breast cancer patients as low-risk compared with 15% using conventional criteria. In comparison, more than 60% were shown to be low risk with use of the MPA validated in this study as an appropriate strategy to prevent chemotherapy overtreatment in patients with early-stage breast cancer.
Breast cancer clinicopathological presentation,gravity and challenges in Eritrea, East Africa : management practice in a resource-poor setting : researchSource: South African Medical Journal 103, pp 526 –528 (2013)More Less
Background. In Africa, breast cancer closely compares with cervical cancer as the most common malignancy affecting women and the incidence rates appear to be rising. Early detection of breast cancer is a key strategy for a good treatment outcome. However, there is no established protocol or guideline for management of breast cancer in Eritrea, East Africa.
Objective. To assess the clinicopathological presentation, gravity and management challenges presented in breast cancer treatment in Eritrea.
Methods. Our investigation was a retrospective, descriptive study to assess the clinical features and severity of breast cancer at time of presentation. We reviewed the medical records of all patients who presented with breast malignancies over the 2-year period from 1 January 2007 to 31 December 2008.
Results. Eighty-two patients ranging in age from 26 - 80 years (mean 48 years) were included in the study. Of these 51% were premenopausal women; 61% of the patients presented with breast mass only and the remainder with manifestations of local (mass plus discharge, breast pain or breast ulceration) or distant metastatic disease. More than 60% of the patients presented after >2 years following onset of symptoms. Two-thirds of patients had late stage (III or IV) disease. All except one case was managed surgically.
Conclusion. Most cases presented at younger age and advanced stage. These findings call for strengthening health education to promote early health-seeking behaviour and advocacy for the introduction of national screening, implementation of a management protocol and establishment of a radio-chemotherapy centre.