South African Medical Journal - Volume 103, Issue 8, 2013
Volumes & issues
Volume 103, Issue 8, 2013
Source: South African Medical Journal 103, pp 529 –533 (2013)More Less
Background. Genetic testing for BRCA mutations has been available in the Western Cape of South Africa since 2005, but practical implementation of genetic counselling and testing has been challenging.
Objective. To describe an approach to breast cancer genetic counselling and testing developed in a resource-constrained environment at Tygerberg Hospital in Cape Town, Western Cape.
Methods. Genetic counselling is offered in a stepwise manner to our diverse patient population, with a focus on affected probands, and subsequent cascade testing. A record review of BRCA testing between 2005 and 2011 was performed.
Results. During this period 302 probands received genetic testing, with increasing numbers tested over time. Of 1 520 women treated for breast cancer since 2008, 226 (14.9%) accepted BRCA testing, and 39 tested positive (17.3% of those tested, and 2.6% of all women). Common founder mutations were detected in 11.9% of women (36/302), and comprised 73% (36/49) of mutations detected. Cascade testing increased after 2010: 16 female and 4 male family members of 19 probands accepted testing, with 6 positives being detected.
Conclusion. A protocol-driven approach focusing on probands, with initial pre-test counselling by primary care staff has proven effective in establishing the service. Involvement of a clinical geneticist/genetic counsellor has permitted more detailed post-test counselling and increased use of cascade testing.
Author M.G. SchoonSource: South African Medical Journal 103, pp 534 –537 (2013)More Less
Aim. In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. We probed the role of inter-facility transport in effecting this reduction in mortality.
Methods. A before-after analysis was performed of data from 2 separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Data were compared for a 12-month prior- and 10-month post-intervention period using descriptive and correlation statistics.
Results. The maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7% (p<0.0001). Monthly mean dispatch interval curves closely mirrored the maternal mortality curve.
Conclusion. Effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.
Source: South African Medical Journal 103, pp 537 –542 (2013)More Less
Background. In Botswana the maternal mortality ratio in 2010 was 163 per 100 000 live births. It is a priority to reduce this ratio to meet Millennium Development Goal 5 target of 21 per 100 000 live births.
Objective. To investigate the underlying circumstances of maternal deaths in Botswana.
Method. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death.
Results. Sixty-six percent of deaths occurred in Botswana's two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care: better teamwork, communication and supportive supervision of health professionals; earlier recognition of the seriousness of complication(s) with more aggressive case-management; joint management between HIV and obstetric clinicians; screening for, and treatment of, opportunistic infections throughout the antenatal to postnatal periods; and better supply management of medications, fluids, blood for transfusion and laboratory tests.
Conclusion. Integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.
Maternal and fetal outcomes of HIV-infected and noninfected pregnant women admitted to two intensive care units in Pietermaritzburg, South Africa : researchSource: South African Medical Journal 103, pp 543 –548 (2013)More Less
Background. Outcomes of HIV-positive pregnant patients admitted to intensive care units (ICUs) are controversial.
Objective. To determine maternal and fetal outcomes of HIV-positive patients admitted to ICUs.
Methods. Pregnant patients admitted to ICUs were enrolled in the study. On admission, they were classified as having low (<50%) or high (≥50%) risk of death by GRAMPT stratification score. The primary maternal outcome was death or hypoxic-ischaemic brain injury (HIBI), while fetal outcomes recorded were Apgar score, birth weight, and delivery of the fetus to facilitate maternal care.
Results. There were 84 admissions to the ICUs: 66 (78.6%) were post-partum and 18 (21.4%) antepartum. The HIV sero-status was as follows: 11 (13.1%) HIV status unknown; 42 (50%) HIV-negative and 31 (36.9%) HIV-positive. The most common pre-ICU admission diagnoses were pneumonia (19.4%) in HIV-positive patients and eclampsia (31%) in HIV-negative patients. Maternal outcomes showed a worsening trend among the HIV-positive women when compared with those who were HIV-negative (high GRAMPT, 1.91 relative risk of death/HIBI in HIV-positive; 95% CI 0.57 - 6.44). Forty-two patients gave birth within 24 hours prior to ICU admission; 3 gave birth while in ICU and none gave birth within 24 hours following ICU discharge. Outcomes of the 45 infants born to HIV-positive women were worse than for those born to HIV-negative patients (except for Apgar scores 1 - 6). Performance of the GRAMPT model for prediction of maternal mortality/HIBI was best in hypertensive patients (ROC: AUC 0.72; 95% CI 0.48 - 0.96).
Conclusion. With the exception of Apgar scores 1 - 6, all outcomes showed worsening trends among infants born to HIV-positive mothers. Large multicentre studies are needed to confirm our findings.
An assessment of the implementation of the National Therapeutic Programme for pregnant women within the City of Cape Town district : researchSource: South African Medical Journal 103, pp 549 –551 (2013)More Less
Background. An integrated Nutritional Supplementation Programme (NSP), now termed the National Therapeutic Programme (NTP), was initiated in 1995 to address South Africa's pressing nutritional problems. It specifically focuses on maternal health, including iron deficiency anaemia and underweight among pregnant women, but its implementation and efficacy for pregnant women has not been evaluated.
Objectives. To determine (i) whether pregnant women qualified for both the food and micronutrient (folate and iron) supplementation offered by the programme; (ii) whether those who qualified received such supplementation; and (iii) whether those who qualified were aware of the rationale for the supplementations.
Methods. A cross-sectional descriptive study was conducted in all primary healthcare antenatal clinics in the City of Cape Town district, involving 114 women. All were interviewed using a questionnaire, their mid-upper arm circumference was measured, and their symphysis-fundus measurements (where documented) were obtained from their medical files.
Results. Only 5% of the women qualified for the food supplementation, while all qualified for the micronutrient supplementation. Only 1 of the 6 participants who qualified for food supplementation was registered and received it. Seventy (61%) of the participants received the micronutrient supplementation and used it correctly. Twenty-nine (25%) participants had heard about the food supplementations for pregnant women and 54 (47%) had heard about the micronutrient supplementations.
Conclusion. The food supplementation was not successfully implemented among pregnant women. The strategy requires further attention within the antenatal clinics.
A comparison of pregnancy dating methods commonly used in South Africa : a prospective study : researchSource: South African Medical Journal 103, pp 552 –556 (2013)More Less
Background. Pregnancy dating in the South African public healthcare setting is mainly based on clinical assessment. However, the accuracy of this approach is unknown.
Aim. To compare the accuracy of different pregnancy dating methods.
Methods. We performed a prospective comparison of 2 ultrasound policies involving consecutive low-risk women in a midwife clinic in the Metro East region, Cape Town, Western Cape. Information on the last menstrual period (LMP), the 1st symphysis-to-fundal height measurement (FH) and average gestation by ultrasonographic (US) fetal biometry was recorded. Five dating methods: LMP, FH, US and their combinations, were assessed against the actual day of delivery (ADD). The main outcome measures were: (i) the days between the ADD and estimated date of delivery in pregnancies where spontaneous labour occurred and the baby had a normal birth weight; (ii) the incidence of gestational age-related outcomes; and (iii) the influence of clinical variables on dating discrepancies.
Results. A total of 1 342 pregnancies were analysed. The accuracy of dating was similar for certain and uncertain LMP. FH was less accurate with increasing obesity. US-based dating was most accurate (for 85% of predictions within 14 days) and similarly accurate at 20 - 24 weeks and at >24 weeks. US reduced the number of assumed pre- and post-term deliveries and, in addition, was better at detecting small-for-gestational age infants (p<0.001).
Conclusion. Pregnancy dating by US, including those in more advanced pregnancies than currently permitted, is recommended since all non-ultrasound-based estimations of gestational age were considerably less accurate.
Safety, feasibility and efficacy of a rapid ART initiation in pregnancy pilot programme in Cape Town, South Africa : researchSource: South African Medical Journal 103, pp 557 –562 (2013)More Less
Background. Antiretroviral therapy (ART) in pregnancy is a crucial intervention in the prevention of mother-to-child transmission (PMTCT) of HIV. It is recognised that mother-to-child transmission is reduced with each week on ART. However, in most South African settings, ART initiation is delayed owing to slow determination of treatment eligibility and separation of HIV and antenatal care services.
Objective. The rapid initiation of an ART in pregnancy programme is a model of care designed to expedite treatment initiation in ART-eligible pregnant women. This study evaluated the performance of the programme.
Methods. Participants enrolled in the ART programme in the same week as their first ANC visit throughout 2011, and had outcome data available by March 2012. Treatment eligibility was determined or confirmed via point-of-care CD4+ testing. Eligible women were offered ART immediately, with concurrent counselling and safety laboratory blood testing. Women attended until 6 - 8 weeks after delivery. Data were collected from clinical records with infant polymerase chain reaction (PCR) results at 6 weeks.
Results. Of 134 ART-eligible (CD4+ count <350 cells/µl or WHO stage III/IV) pregnant women, 130 (97.0%) started ART, 118 (90.8%) initiating treatment the same day that treatment eligibility was determined. There were no abnormal laboratory blood results or adverse events that required medical intervention. Pre-delivery retention in care and infant mortality were comparable to those in similar settings. Of the 107 pregnancies with PCR outcomes available, there was 1 positive HIV result in an infant (0.9%). Maternal viral load suppression in this mother was not achieved by the time of delivery.
Conclusions. This pilot programme provides evidence that rapid ART initiation in pregnancy is safe, feasible and effective in reducing PMTCT. Further follow-up is required to monitor long-term outcomes.
Functional MRI language mapping in pre-surgical epilepsy patients : findings from a series of patients in the Epilepsy Unit at Mediclinic Constantiaberg : researchSource: South African Medical Journal 103, pp 563 –567 (2013)More Less
Background. Functional magnetic resonance imaging (fMRI) is commonly applied to study the neural substrates of language in clinical research and for neurosurgical planning. fMRI language mapping is used to assess language lateralisation, or determine hemispheric dominance, and to localise regions of the brain involved in language. Routine fMRI has been introduced in the Epilepsy Unit at Mediclinic Constantiaberg to contribute to the current functional mapping procedures used in pre-surgical planning.
Method. In this paper we describe the language paradigms used in these routine studies as well as the results from 22 consecutive epilepsy patients. Multi-subject analyses were performed to assess the reliability of activation patterns generated by two language mapping paradigms, namely a verb generation task and passive listening task. Results from a finger-tapping task are also presented.
Results. The paradigms generate reliable and robust signal changes, enabling both the lateralisation of language and localisation of expressive and receptive language cortex.
Conclusion. The fMRI results are meaningful at the group and individual level and can be recommended for language mapping in pre-surgical patients.
Source: South African Medical Journal 103, pp 568 –575 (2013)More Less
Disease presentation and clinical course in black, coloured and white Crohn's disease patients in the Western Cape, South Africa
Prediction of treatment outcomes from manometric subtypes in achalasia patients
Endoscopic ultrasound in the drainage of symptomatic pancreatic and peri-pancreatic fluid collections
The sero-prevalence of hepatitis C infection in an HIV-infected male population of heterosexual and men who have sex with men (MSM) in Cape Town
Oesophageal cancer in Pietermaritzburg: The shocking timeline to diagnosis and definitive management
Pneumatic balloon dilatation v. laparoscopic Heller myotomy: A teaching hospital experience
Comparison of the diagnostic yield and clinical outcomes of an approach based on initial double balloon enteroscopy v. initial capsule endoscopy in patients with obscure gastrointestinal bleeding
A prospective review of the endoscopic management of large bile duct calculi using controlled radial expansion (CRE) balloon dilatation v. sphincterotomy
Solitary extramedullary plasmacytoma of the colon, rectum and anus: A collective review
The impact of biological therapy in patients with inflammatory bowel disease at Groote Schuur Hospital
Triad of dysregulated signalling in human hepatocellular carcinoma suggests a multipronged approach is needed for therapeutic targeting
Characteristics of hepatitis B-associated hepatocellular carcinoma (HCC) in Cape Town
Randomised clinical trial: Effect of Lactobacillus plantarum 299v on symptoms of irritable bowel syndrome
Predicting poor-outcome Crohn's Disease at the time of first diagnosis
Cold snare polypectomy for colonic polyps >10 mm
Bile duct perforation in an infant
Assessment of the critical flicker frequency measuring machine in diagnosis of minimal hepatic encephalopathy
Duodenal eosinophil count in patients with functional dyspepsia at Chris Hani Baragwanath Academic Hospital
Resistant Clostridium difficile infection and faecal transplantation in patients with inflammatory bowel disease at Wits Donald Gordon Medical Centre
Adult nesidioblastosis: A problematic diagnosis and a treatment challenge
Normal values of 24-hour ambulatory oesophageal multichannel intraluminal impedance-pH monitoring in a rural black African population
'Downhill' oesophageal varices
Untreated hypopituitarism-causing cirrhosis in adulthood
Successful pregnancy on anti-TNF-α therapy
South African recommendations for the management of rheumatoid arthritis : an algorithm for the standard of care in 2013 : guidelineSource: South African Medical Journal 103, pp 576 –585 (2013)More Less
Updated treatment recommendations for the therapy of rheumatoid arthritis (RA) in South Africa advocate early diagnosis, prompt initiation of disease-modifying anti-rheumatic drugs (DMARDs), and an intense treatment strategy where disease activity is assessed with a composite score such as the Simplified Disease Activity Index (SDAI). Frequent assessments and escalation of therapy are necessary until low disease activity (LDA) (SDAI ≤11) or ideally remission (SDAI ≤3.3) is achieved. Synthetic DMARDs may be used as monotherapy or in combination, and can be co-prescribed with low-dose corticosteroids if necessary. Biologic DMARD therapy should be considered for patients who have failed a 6-month trial of at least 3 synthetic DMARDs. All RA patients in SA are at increased risk of tuberculosis (TB), in particular patients using anti-tumour necrosis factor (TNF) biologic therapy. These recommendations provide practical suggestions for the screening and management of TB and other comorbidities, and offer an approach to monitoring of RA patients.