South African Medical Journal - Volume 104, Issue 1, 2014
Volumes & issues
Volume 104, Issue 1, 2014
Patient-initiated sexual partner notification in Botswana and time taken for sexual contacts to report for treatment : researchSource: South African Medical Journal 104, pp 42 –44 (2014)More Less
Background. Sexually transmitted infections (STIs) are an important public health concern because of their impact on reproductive and other health problems. Initiating treatment at an early stage for both index patients and their partners reduces the risk of reinfections and prevents serious short- or long-term complications for the infected individuals. Sexual partner tracing is one of the means available for reaching and treating asymptomatic sexual partners of index patients.
Objectives. To determine the time taken by sexual partners to report to a health facility after they had been notified by the index patient, and the distribution of STI syndromes among the treated index patients who had their sexual partners treated.
Methods. All available contact slips of the treated sexual partners from 19 health districts in Botswana were reviewed. The study period was July 2010 to June 2011 inclusive.
Results. The partner notification slips showed that 77.9% (1 238/1 590) of sexual contacts sought medical attention at government health facilities within 7 days of treating the index patient. Records showed that 47.3% (752/1 590) of the index patients were treated for vaginal discharge syndrome.
Conclusion. A high proportion of sexual contacts were treated within 7 days of treating the index patient. Considering this short period, we conclude that Botswana's recommended 30-day period for consulting sexual partners needs to be revised downwards, so as to reduce the chances of reinfections, complications and transmission of STIs in the community.
The use of the full blood count and differential parameters to assess immune activation levels in asymptomatic, untreated HIV infection : researchSource: South African Medical Journal 104, pp 45 –48 (2014)More Less
Background. A feature of HIV/AIDS is chronic immune activation, which results in a number of complications including inflammation-related disorders and blood cytopaenias. Immune activation status is not routinely tested in HIV infection. However, the full blood count (FBC) is a commonly performed test.
Objective. We hypothesised that FBC parameters would be significantly different in HIV-infected v. -uninfected individuals, and that some of these parameters would correlate with markers of immune activation (i.e. percentage CD38 expression on CD8+ T cells (%CD38onCD8)) and disease progression (i.e. CD4+ counts) in HIV infection.
Methods. This was a cross-sectional study with 83 HIV-infected adults who were antiretroviral therapy-naive and clinically well, and 51 HIV-uninfected adults. The %CD38onCD8 and CD4+ counts were determined by flow cytometry and the FBC was performed on a Siemens ADVIA 2120 system. FBC parameters investigated were total white cell count (WCC), haemoglobin (Hb) concentration, platelet count, absolute neutrophil count, absolute lymphocyte count, and percentage of large unstained cells (%LUCs).
Results. Significant differences were found between the HIV-infected and -uninfected groups for total WCC, Hb, neutrophil count, lymphocyte count and %LUCs. The mean ± standard deviation (SD) for the total WCC (5.3±1.3 v. 6.9±2.2; p≤0.001) and the %LUCs (2.5±0.9 v. 2.0±0.9; p=0.001) both showed correlations with CD4+ counts and %CD38onCD8.
Conclusion. The total WCC and %LUCs showed significant differences in HIV-infected individuals and correlated with markers of immune activation and disease progression. This suggests the potential use of these parameters as markers of immune activation in HIV infection.
Sexual lubricants in South Africa may potentially disrupt mucosal surfaces and increase HIV transmission risk among men who have sex with men : researchSource: South African Medical Journal 104, pp 49 –51 (2014)More Less
Background. Men who have sex with men (MSM) are at high risk for HIV acquisition and transmission. There is a high HIV-transmission potential associated with unprotected anal intercourse (UAI), which requires sexual lubrication for comfortable, non-traumatic anal sex. Lubricant distribution remains poor in many developing nations and MSM have been known to substitute a number of common household or food products to ensure comfortable anal sex. Concern has been raised about the potential toxicity of lubricants used during anal sex. Epithelial injury is related to the osmolality of the lubricant product.
Objective. To analyse commercially available water-based sexual lubricant products to ascertain their osmolality and potential to cause rectal epithelial damage.
Methods. The osmolality and glycerol concentration was determined for eight of the most frequently purchased water-based sexual lubricants and some commonly used household/food products.
Results. Osmolality ranged from 270 - 9 440 mosmol/l (Lubrimaxxx Premium, containing phytosqualane, and JO H2O Water Based Lubricant, respectively). Seven (88%) of the commercial lubricants had high osmolalities, with two products approaching 10 000 mosmol/l, far in excess of serum which has an osmolality of ~280 mosmol/l.
Conclusion. The results of this study show that many of the top-selling brands of water-based sexual lubricants available in SA are hyperosmolar. Given that hyperosmolar products have been shown in vitro and in vivo to cause epithelial injury, they may have the potential to increase HIV acquisition and transmission, if they are used during UAI. Awareness needs to be raised about the mucosal safety of lubricants designed for use during anal sex.
Rapid, minimally invasive adult voluntary male circumcision : a randomised trial of Unicirc, a novel disposable device : researchSource: South African Medical Journal 104, pp 52 –57 (2014)More Less
Background. Voluntary medical male circumcision (VMMC) is a priority HIV preventive intervention. To facilitate VMMC scale-up, the World Health Organization is seeking circumcision techniques that are faster, easier, and safer than open surgical methods.
Objective. To compare open surgical circumcision with suturing v. the Unicirc disposable instrument plus tissue adhesive.
Methods. We conducted a non-blinded randomised controlled trial at an outpatient primary healthcare clinic in Cape Town, South Africa, with 2:1 allocation ratio of 150 male volunteers who were at least 18 years of age. Our primary outcome was intraoperative time and secondary outcomes were ease of performance, post-operative pain, adverse events, time to healing, patient satisfaction and cosmetic result.
Results. The intraoperative time was less with the Unicirc/adhesive technique (median 13 v. 22.6 min, respectively; p<0.001). The intraoperative suturing rate was 17% using the Unicirc device. Other adverse events and wound healing outcomes were similar in both groups, but the cosmetic result was superior in the Unicirc group. Doctors found the Unicirc procedure easier to perform and preferred it to the open surgical technique.
Conclusions. This study has important implications for the scale-up of VMMC services. Excising the foreskin with the Unicirc instrument and sealing the wound with cyanoacrylate tissue adhesive in adults is quicker, easier to learn, and is potentially safer than open surgical VMMC. Further studies should be conducted with the optimised device. This new instrument has the potential to facilitate more rapid scale-up and save costs.
Source: South African Medical Journal 104, pp 57 –60 (2014)More Less
Background. The Department of Health in KwaZulu-Natal (KZN) has run a surgical outreach programme for over a decade.
Objective. To quantify the impact of the outreach programme by analysing its effect on the operative capacity of a single rural health district.
Methods. During 2012, investigators visited each district hospital in Sisonke Health District (SHD), KZN, to quantify surgery undertaken by resident staff between 1998 and 2013. Investigators also reviewed the operative registers of the four district hospitals in SHD for a 6-month period (March - August 2012) to document the surgery performed at each hospital. The number of staff who attended specialist-based teaching was recorded in an attempt to measure the impact of each visit.
Results. From 1998 to 2013, 35 385 patients were seen at 1 453 clinics, 5 199 operations were performed and 1 357 patients were referred to regional hospitals. A total of 3 027 staff attended teaching ward rounds and teaching sessions. In the four district hospitals, 2 160 operations were performed in the 6-month period. There were 653 non-obstetric operations and the obstetric cases comprised 1 094 caesarean sections, 55 sterilisations and 370 evacuations of the uterus.
Conclusion. The infrastructure is well established and the outreach programme is well run and reliable. The clinical outputs of the programme are significant. However, the impact of this programme on specific outcomes is less certain. This raises the question of the future strategic choices that need to be made in our attempts to improve access to surgical care.
Relationship between firewood usage and urinary Cr, Cu and As in informal areas of Cape Town : researchSource: South African Medical Journal 104, pp 61 –64 (2014)More Less
Objectives. The study investigated whether wood usage by informal food vendors and household residents in Cape Town results in the absorption of arsenic (As), chromium (Cr) and copper (Cu) owing to release of these metals in the burning of chromated copper arsenate(CCA)-treated wood.
Methods. The participants (N=78) selected included an equal number of food vendors and non-vendors from 2 informal settlements. All participants answered a questionnaire concerning exposure and were tested for urinary Cr, Cu and As, while the urine of 29 participants was also tested for toxic As (As(tox)).
Results. Multivariate analysis showed that the time spent in close proximity to the wood, as well as the quantity of wood used for cooking and for household use, was weakly positively associated with urinary levels of As, Cr and the sum of As, Cr and Cu.
Conclusions. The study provides evidence that use of wood likely to contain CCA as a fuel for informal food outlets and household purposes may increase the absorption of inorganic As, Cu and Cr.
Source: South African Medical Journal 104, pp 65 –67 (2014)More Less
Objective. Critical value policies are used by clinical laboratories to decide when to notify caregivers of life-threatening results. Despite their widespread use, critical value policies have not been published locally. A survey was designed to determine critical value policies for haematology tests in South Africa.
Methods. A survey was carried out on 136 identified laboratories across South Africa in January 2013. Of these, 36 responded. Data collected included critical value policies, critical values for haematology parameters, and critical value reporting.
Results. Of the 36 laboratories surveyed, 11.1% (n=4) were private, 33.3% (n=12) were affiliated to academic institutions and 55.6% (n=20) were peripheral or regional National Health Laboratory Service laboratories. All the laboratories confirmed that they had a critical value policy, and 83.3% of such policies were derived from local clinical opinion. Mean low and high critical limits for the most frequently listed tests were as follows: haemoglobin <6 and >20 g/dl, platelet count <41 and >1 000 x 109/l, white cell count <2 and >46 x 109/l, activated partial thromboplastin time >101 seconds, and international normalised ratio >6. In almost all cases critical value reporting was performed by the technologist on duty (97.2%). The majority of laboratories required that the person notified of the critical value be the doctor who ordered the test or the caregiver directly involved in the patient's care (83.3%); 73.3% of laboratories indicated that they followed an algorithm if the doctor/caregiver could not be reached.
Conclusion. Each laboratory is responsible for establishing clinically relevant critical limits. Clinicians should be involved in developing the laboratory's critical value policy. The findings of this survey may be of value to local laboratories that are in the process of establishing or reviewing critical value policies.
Author John ParkerSource: South African Medical Journal 104 (2014)More Less
During the last decade or so, there has been a growing international recognition of the high burden of disease associated with mental health problems, with local research that supports this view. The most comprehensive study of common mental disorders in South Africa, the South African Stress and Health Study, carried out in 1999, showed a lifetime prevalence for these disorders of 30.3%. Of those who had had a mental disorder in the past year, only 25.2% sought treatment and a tiny number, 5.7%, used any formal mental health service. In the years since that study, the HIV/AIDS and substance abuse epidemics have contributed further to this burden, while at the same time mental health services have seen a reduction in hospital beds with de-institutionalisation, yet little growth in community-based services.
A broad diagnostic framework to simplify the approach to mental disorders in primary care : CME - reviewSource: South African Medical Journal 104, pp 69 –71 (2014)More Less
Overemphasis on detailed classification of a psychiatric disorder at a primary level assessment may be unhelpful and prone to error. True rigour demands a continuous process of hypothesis formation that guides further enquiry. A simple categorisation of priority conditions provides a useful framework for such a process. This approach has been set out by the World Health Organization (WHO) Mental Health Gap Action Program (MHGAP) Intervention Guide, which can then be adapted for use in the South African context. This then provides the basis for further enquiry and risk assessment at the initial consultation.
Source: South African Medical Journal 104, pp 72 –74 (2014)More Less
Although the diagnosis of attention deficit hyperactivity disorder (ADHD) attracts much media attention and is seen by many to be a disorder of the 20th century, it was already described in the 18th century. This article highlights the latest recommendations in the assessment and treatment of ADHD across the age range. It gives an update on the diagnostic criteria for ADHD, which have been revised in the updated Diagnostic and Statistical Manual of Mental Disorders (DSM 5).
Author M.F. WilliamsSource: South African Medical Journal 104, pp 75 –78 (2014)More Less
Alcohol consumption is responsible for an estimated 3.8% of all deaths and 4.6% of disability-adjusted life-years (DALYs) globally.
In 2000, 7.1% of all deaths and 7.0% of total DALYs were attributable to alcohol. Alcohol remains South Africa's most abused substance. Fourteen per cent of the population are thought to receive lifetime diagnoses for alcohol abuse and/or dependence, while 28 - 39% of South African adults consume alcohol.
This article outlines the outpatient management of adult alcoholism and emphasises a primary healthcare approach.
Source: South African Medical Journal 104 (2014)More Less
Source: South African Medical Journal 104, pp 77 –79 (2014)More Less
A particular challenge in primary healthcare is that the time available for consultations is extremely limited owing to high workloads. This can be particularly difficult in the detection and management of mental health problems. Traditionally, the mental health assessment has been taught as a very comprehensive psychiatric history and examination, which can take as long as an hour. While the value of thorough assessment cannot be denied, such an imperative becomes self-defeating if it discourages any assessment at all, or results in one that misses the most critical information.
Source: South African Medical Journal 104 (2014)More Less
Traditionally, recovery has referred to absence of disease, or cure. This makes sense when applied to a short-lived condition such as tonsillitis, but its relevance in more enduring or chronic conditions, such as high blood pressure, an amputated limb or mental disorders, is questionable.
South African guideline for the use of chronic opioid therapy for chronic non-cancer pain : guidelineSource: South African Medical Journal 104, pp 79 –89 (2014)More Less
Chronic pain may have a significant impact on health-related quality of life and can be difficult to manage. In carefully selected patients, and as part of a comprehensive pain management strategy, opioid analgesia may help to achieve long-term pain control with a manageable side-effect profile and a low risk of serious adverse effects. However, appropriate evaluation, including biopsychosocial screening and risk screening is essential before initiating an opioid and during continued therapy. This guideline aims to assist practitioners in screening and selecting appropriate patients with chronic non-cancer pain to initiate, monitor and continue pain management with opioid therapy.
Source: South African Medical Journal 104, pp 79 –82 (2014)More Less
The burden imposed by mental illness on local services is immense and cannot be borne exclusively by psychiatrists based in specialist clinics and institutions. To address the massive demands for health services in the country the National Department of Health has adopted a strategy that prioritises a model of integrated district-based primary care. Among the many challenges that have to be confronted when efforts are made to integrate psychiatry into primary care, and one that this paper seeks to address, is the need to develop a model of assessment and treatment that is accessible, yet effective, and responsive to the particular needs of psychiatric patients who access these services.