South African Medical Journal - Volume 104, Issue 10, 2014
Volumes & issues
Volume 104, Issue 10, 2014
Author Karen HofmanSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8727More Less
The economic development of a nation depends in part on the health of its population. Addressing the non-communicable disease (NCD) epidemic is critical to a virtuous cycle of improved public health outcomes and better economic growth. Decreasing premature mortality from NCDs is now on the post-2015 development agenda. The accumulated losses to South Africa (SA)'s gross domestic product between 2006 and 2015 from diabetes, stroke and coronary heart disease alone are estimated to cost the country US$1.88 billion. Employers face additional costs in the form of high staff turnover and absenteeism, because these conditions are not only a source of morbidity but a leading cause of death in our working-age population. Obese workers cost their employers 49% more in paid time off than their non-obese colleagues. Workplace wellness programmes are growing and show promise, but the urban poor, who are particularly vulnerable, have little access to them. Families of the deceased suffer catastrophic costs, with two-thirds of poor households being underinsured against funeral costs, and are dependent on either a regular wage earner or a grant recipient. The NCD epidemic in SA is an even greater burden because it is occurring concurrently with an ageing HIV-positive population.
Author Daan Den HollanderSource: South African Medical Journal 104, pp 650 –651 (2014) http://dx.doi.org/10.7196/SAMJ.8897More Less
The Medicines Control Council of South Africa recently lifted the suspension on the use of all medicines containing hydroxyethyl starch (HES), with the exclusion of, among other contraindications, patients with severe burns. A circular from the KwaZulu-Natal Department of Health furthermore restricts the use of HES-containing products to specialist anaesthetists, advising the use of Gelofusine for the 'general resuscitation of hypovolaemic patients in intensive care' or for the 'acute resuscitation of patients with severe, source-controlled haemorrhagic shock in theatre by a specialist anaesthetist'.
Use of the Xpert MTB/RIF assay in the diagnosis of tuberculous meningitis : a cautionary note : correspondenceAuthor Ahmed I. BhigjeeSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8735More Less
The Xpert MTB/RIF (Cepheid) assay is a nucleic acid amplification test developed to detect mycobacterial tuberculosis (MTB) infection and rifampicin resistance. It is a closed system, requires minimal training to use, and produces a result in a few hours. When used as an initial diagnostic test replacing smear microscopy for pulmonary tuberculosis, the Xpert MTB/RIF has a pooled sensitivity of 88%. The application of this test has been extended to extrapulmonary samples, including cerebrospinal fluid (CSF).
Author Raymond P. AbrattSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8808More Less
Logbooks of procedures are helpful in determining the professional competence of trainees. There has been correspondence in the SAMJ on aspects of their use in South Africa - for example, the value of specifying the number of surgical operations in the logbook.
However, experience does not automatically translate into learning. Reflection is needed to turn experience into learning. Logbooks of procedures may be complemented by case reports that are structured so as to contain a reflective element.
Source: South African Medical Journal 104, pp 653 –655 (2014) http://dx.doi.org/10.7196/SAMJ.8894More Less
South Africa (SA)'s record in handling the initial HIV/AIDS pandemic (without antiretroviral drugs) and the rapid spread of extensively drug-resistant tuberculosis (XDR TB) are major red flags warning that it may not have the capacity to face the deadly drug-defiant West African Ebola virus.
Source: South African Medical Journal 104, pp 656 –657 (2014) http://dx.doi.org/10.7196/SAMJ.8905More Less
The local standard of training in obstetrics and gynaecology has dropped so dramatically that 'an ordinary caesarean section is now like brain surgery for most interns', says national health minister Dr Aaron Motsoaledi. His claim, made at the South African Medical Association (SAMA)'s Millennium Development Goals (MDGs) conference in Durban at the end of August, was bolstered by one of the world's top maternal mortality researchers, Prof. Jack Moodley, Chairperson of the National Committee on Confidential Enquiries into Maternal Deaths in South Africa (SA) and editor of ten local 'Saving Mothers' reports.
Source: South African Medical Journal 104, pp 658 –659 (2014) http://dx.doi.org/10.7196/SAMJ.8887More Less
Two of several health innovations that could save the lives of millions of mothers and babies will probably reach the South African (SA) market first - years ahead of schedule - because of a new partnership between the government, the South African Medical Research Council (MRC) and a leading international NGO.
Source: South African Medical Journal 104, pp 659 –660 (2014) http://dx.doi.org/10.7196/SAMJ.8886More Less
While government and private healthcare funders urged one another to make internal changes to enable faster progress towards a more equitable healthcare system, some concrete evidence of vitally needed partnership did emerge from the 15th annual Board of Healthcare Funders (BHF) conference.
Source: South African Medical Journal 104, pp 661 –662 (2014) http://dx.doi.org/10.7196/SAMJ.8580More Less
The prevalence of diabetes in South Africa is increasing rapidly, and diabetes is a significant cause of blindness. Diabetic complications can induce a cycle of poverty for affected families. Early detection of retinopathy and appropriate management can prevent blindness. Screening for retinopathy using a mobile retinal camera is highly cost-effective, with costs of screening and follow-up treatment being less than the expense of one year of a disability grant. Such a programme is a prime example of a 'best buy' that should be part of the national diabetes care package.
Healthy migration : a public health and development imperative for south(ern) Africa : forum - opinionAuthor J. VeareySource: South African Medical Journal 104, pp 663 –664 (2014) http://dx.doi.org/10.7196/SAMJ.8569More Less
South Africa (SA), like the rest of the Southern African Development Community, has a high prevalence of communicable diseases, an increasing non-communicable disease burden, and diverse internal and cross-border population movements. Healthy migration is good for development, but current prevention, testing and treatment responses within public health systems - particularly for chronic conditions - fail to engage with migration. Understanding of migration is poor within sectors responsible for developing appropriate responses; negative, unsupported assumptions relating to the prevalence of cross-border migration, the spread of disease, and the burden on receiving health systems prevail. In SA, public health responses fail to address internal and cross-border mobilities, and non-nationals face challenges in accessing healthcare. Of particular concern is the lack of nationally and regionally co-ordinated strategies to ensure treatment continuity for chronic conditions. Co-ordinated, evidence-informed responses to migration, mobility and health are urgently needed. These will have developmental and public health benefits for all.
Low levels of physical activity in female adolescents cause overweight and obesity : are our schools failing our children? : forum - issues in public healthSource: South African Medical Journal 104, pp 665 –667 (2014) http://dx.doi.org/10.7196/SAMJ.8577More Less
The increasing prevalence of overweight and obesity among female adolescents is a global health problem. In developing countries such as South Africa, this increase is often associated with urbanisation and the adoption of a Western lifestyle. Two aspects of the Western lifestyle that contribute to the development of overweight and obesity are a decrease in physical activity levels and an increase in the consumption of energy-dense food, high in fats and refined sugar. Information on the prevalence of increased body fatness in populations in transition is scarce, but necessary for effective planning and intervention. Current indications are that there is a trend towards unhealthy behaviour among high-school girls, globally and in South Africa. Schools can play an important role in the prevention of overweight and obesity among schoolgirls. It is recommended that school governing bodies institute remedial action to prevent weight gain in children, especially girls.
Varicose veins : look before you strip - the occluded inferior vena cava and other lurking pathologies : forum - clinical alertSource: South African Medical Journal 104, pp 668 –670 (2014) http://dx.doi.org/10.7196/SAMJ.8395More Less
Lower limb varicose veins are a common complication of bipedal human movement and deep-vein thrombosis. However, they may have unusual causes, e.g. forming as collaterals around an obstruction or resulting from vascular malformations. Surgery in these cases can be inappropriate or harmful. Five cases of lower limb varicose veins in which there was underlying pathology highlight the fact that cursory examination of patients with varicose veins and inappropriate special investigations can miss rare but significant underlying pathology. Patients should be examined systematically, and varicose veins in unusual situations should alert the clinician. Inappropriate surgery can be harmful.
The influence of glucocorticoids on lipid and lipoprotein metabolism and atherosclerosis : forum - clinical alertSource: South African Medical Journal 104, pp 671 –674 (2014) http://dx.doi.org/10.7196/SAMJ.7979More Less
Glucocorticoids have multiple therapeutic uses, but their impact on lipid metabolism and cardiovascular disease risk is not always considered during long-term treatment. Genetic variations, environmental factors and the reasons for glucocorticoid treatment all influence the lipid profile and atherosclerosis. Responses to glucocorticoid treatment may therefore be variable and unpredictable. Despite the frequency with which pharmacological doses of glucocorticoids are used, surprisingly few publications examine their effects on lipid metabolism and atherosclerosis. Patients managed with glucocorticoids should have their cardiovascular risk assessed, especially if long-term treatment is planned. While some apparent favourable changes have been reported in high-density lipoprotein metabolism, very-low-density lipoprotein and low-density lipoprotein responses seem unfavourable. The impact of glucocorticoids on atherosclerosis, which is often viewed as an inflammatory process, is unclear. Glucocorticoid treatment should be undertaken for appropriate indications, but in some instances special attention should be given to management of dyslipidaemia, as long-term survivors of treatment are likely to encounter atherosclerosis.
Source: South African Medical Journal 104, pp 675 –676 (2014) http://dx.doi.org/10.7196/SAMJ.8842More Less
Non-communicable diseases (NCDs), mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, represent a leading threat to human health and development. According to World Health Organization (WHO) statistics, these four preventable diseases are the world's biggest killers, causing an estimated 35 million deaths each year - 60% of all deaths globally - with 80% in low- and middle-income countries. Up to 80% of heart disease, stroke and type 2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors, mainly tobacco use, an unhealthy diet, physical inactivity and the harmful use of alcohol. Unless addressed with urgency, the mortality and disease burden from these health problems will continue to increase. The WHO projects that, globally, NCD deaths will increase by 17% over the next 10 years, and the greatest increase will be seen in the African region (27%).
Source: South African Medical Journal 104, pp 676 –678 (2014) http://dx.doi.org/10.7196/SAMJ.8809More Less
Adolescence is a time of rapid transition, of significant emotional, physical and psychological changes. These changes influence behaviour, in particular decisions to engage in risky behaviour, including sexual activity, alcohol consumption, smoking and taking drugs. Eighty-eight per cent of the 1.2 billion adolescents worldwide live in developing countries where access to sexual and reproductive health (SRH) services that could support them are often inadequate and fragmented. Unplanned pregnancies can affect the health and wellbeing of adolescents, placing them at risk for morbidity and mortality related to unsafe abortion and childbirth, as well as limiting their educational and employment opportunities.
Source: South African Medical Journal 104, pp 678 –679 (2014) http://dx.doi.org/10.7196/SAMJ.8274More Less
Since 2004, substantial numbers of South African (SA) children have benefited from antiretroviral treatment. Untreated children are at risk of central nervous system (CNS) sequelae, with prevalence rates of 20 - 60%. HIV-1 invades the developing CNS earlier and with greater severity than in adults, resulting in the condition known as HIV encephalopathy (HIVE). In addition, patients on highly active antiretroviral therapy (HAART) may remain vulnerable to the effects of HIV on the brain, because the CNS may be a reservoir for persistent viral replication. The concept of a 'milder' form of neurocognitive disturbance in HIV-infected children, akin to the adult condition of HAND (HIV-associated neurocognitive disorder), is recognised but has yet to be defined.
Monitoring of non-communicable diseases such as hypertension in South Africa : challenges for the post-2015 global development agenda : researchSource: South African Medical Journal 104, pp 680 –687 (2014) http://dx.doi.org/10.7196/SAMJ.7868More Less
Background. Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs.
Objective. To review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example.
Methods. Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010.
Results. The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ≥25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled.
Conclusion. Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential.
Meeting the sexual and reproductive health needs of high-school students in South Africa : experiences from rural KwaZulu-Natal : researchSource: South African Medical Journal 104, pp 687 –690 (2014) http://dx.doi.org/10.7196/SAMJ.7841More Less
Background. Adolescents in South Africa (SA) have a huge unmet need for sexual and reproductive health (SRH) services. Integrating such services into schools may overcome many of the current barriers to access.
Objectives. We describe an SRH service model developed for high-school students and its implementation in 14 high schools in rural SA.
Methods. Following consultation with community and other key stakeholders about the demand for and acceptability of adolescent-targeted SRH services, a three-tier school-based model was developed that included: (i) in-school group SRH information and awareness sessions; (ii) in-school individual SRH counselling and customised HIV counselling and testing (CCT); and (iii) referrals to in-school fixed, in-school mobile or public sector primary SRH clinics.
Results. From October 2011 to June 2012, 70 consultative meetings were held. There was overwhelming support for the pilot founded on concerns about the high HIV prevalence and teenage pregnancy rates among adolescents in the community. SRH information was provided to 8 867 high-school students, 4 171 (47.0%) of whom accessed on-site CCT services for HIV. The gender-specific prevalence of HIV in these students was 3.3% (64/1 962) and 1.1% (24/2 209) for females and males, respectively. Two hundred and thirty-nine students (5.7%) were referred for clinical services at in-school fixed, in-school mobile or public sector primary SRH clinics.
Conclusions. The SRH service provision pilot was acceptable in the community and seems feasible for scale-up. Further work is required to understand inter-school variability in uptake, identify additional service needs of students, and characterise SRH demand dynamics.
Comparability of total cardiovascular disease risk estimates using laboratory and non-laboratory based assessments in urban-dwelling South Africans : the CRIBSA study : researchSource: South African Medical Journal 104, pp 691 –696 (2014) http://dx.doi.org/10.7196/SAMJ.8125More Less
Objectives. To establish the prevalence and determinants of the 10-year risk of a cardiovascular disease (CVD) event in 25 - 74-year-old black Africans in Cape Town, South Africa, using Framingham laboratory- and non-laboratory-based and National Health and Nutrition Examination Survey (NHANES) I non-laboratory-based equations.
Methods. CVD risk factors were determined by questionnaires, clinical measurements and biochemical analyses. Survey logistic regression analyses assessed the sociodemographic determinants of CVD risk ≥20%.
Results. There were 1 025 participants, 369 men and 656 women. Mean 10-year risk for a CVD event by Framingham laboratory- and non-laboratory-based and NHANES I non-laboratory-based equations for men was 9.0% (95% confidence interval 7.7 - 10.3), 11.1% (9.6 - 12.6) and 9.0% (7.6 - 10.3), and for women 5.4% (4.7 - 6.1), 6.8% (5.9 - 7.7) and 8.7% (7.6 - 9.8). Correlations between laboratory- and non-laboratory-based scores were high (0.915 - 0.963). The prevalence of laboratory-based CVD risk ≥20% was 13.0% in men and 6.1% in women. In the logistic model for men, ≤7 years of education (odds ratio 3.09; 95% CI 1.67 - 5.71) and being unemployed (3.44; 1.21 - 9.81) compared with employed were associated with laboratory-based high risk. In women, high risk was associated with ≤7 years of education (4.20; 1.96 - 9.01), living in formal v. informal housing (2.74; 1.24 - 6.06) and being poor (middle v. lowest tertile 0.29; 0.13 - 0.66). In the Framingham non-laboratory-based logistic models there were no changes in the direction or significance of the variables except for housing, which was no longer significant in women.
Conclusions. Comparability of laboratory- and non-laboratory-based CVD risk estimates illustrates the utility of the latter in resource-constrained settings.