South African Medical Journal - Volume 104, Issue 3, 2014
Volumes & issues
Volume 104, Issue 3, 2014
Author Bridget FarhamSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8060More Less
A couple of weekends ago a friend, Richard, popped in for a cup of tea - a very fit, active septuagenarian who rides the Cape Argus Pick 'n Pay Cycle Tour every year and has recently started running. A few years ago he had a triple bypass. At the time, his cardiologist told him that, 'From today, you become a vegetarian ... '. According to Richard, the cardiologist told him to cut out eggs, butter, red meat and any source of saturated fats from his diet; standard advice that we have all given at some stage in our careers. Richard's problem, though, was this: 'Now' he says, 'I am told that margarine is actually bad for me, eggs are fine and there are even people saying that it is OK to eat saturated fats - who is right? What do I do?'
Source: South African Medical Journal 104, pp 154 –155 (2014) http://dx.doi.org/10.7196/SAMJ.7740More Less
We read with interest the edition of SAMJ (November 2013) dedicated to smoking, arguably the most significant modifiable cause of death and disease. One of the areas not addressed relates to the impact of smoking in the context of surgery. It is well recognised that smoking increases the risk of overall complications, arrhythmias, thrombotic episodes, pneumonia, infection, wound healing complications and prolonged hospital stays, as well as the need for further surgery. As surgeons we are frequently held responsible for these complications, and yet the decision to undertake the procedure at all should often be scrutinised, especially in the elective setting, rather than just the technical execution thereof.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.5978More Less
Evidence of the futility of mass circumcision campaigns to reduce HIV sexual transmission in sub-Saharan Africa (SSA) has been outlined in the SAMJ by former Editor-in-Chief, Prof. Ncayiyana. The claim is based on three randomised controlled trials (RCTs) in South Africa, Uganda, and Kenya that circumcision reduces men's risk for HIV by ~60%.
A path to full-service contracting with general practitioners under National Health Insurance : correspondenceAuthor Shabir MoosaSource: South African Medical Journal 104, pp 155 –156 (2014) http://dx.doi.org/10.7196/SAMJ.7719More Less
National Health Insurance (NHI) is important in South Africa (SA). On 27 November 2013, during a lecture at the University of the Witwatersrand, the National Minister of Health spoke about the 'Americanisation' of healthcare. In discussing service contracts for general practitioners (GPs), he was open but cautious: 'How will we monitor them?' There is a perception that GPs are poorly equipped and badly trained, and will limit patient access when they are faced with high volumes. There is also concern that the current public service will be 'destroyed' by competition with GPs.
Source: South African Medical Journal 104, pp 156 –157 (2014) http://dx.doi.org/10.7196/SAMJ.7880More Less
We applaud the efforts by Irlam et al. to conduct a cost-effectiveness analysis of primary prevention of rheumatic fever (RF) in children. The authors used a Markov decision analysis cohort model to assess seven different treatment strategies for children presenting with sore throat. A particular strength of the study was the inclusion of costs relating to secondary prevention and development of chronic rheumatic heart disease (RHD). The authors concluded that using clinical criteria for the diagnosis of pharyngitis without culturing for group A streptococci is the most cost-effective intervention for the prevention of RF and RHD in settings where these diseases are endemic. However, we believe that they have not fully considered several important issues.
Author Patrick B. WilsonSource: South African Medical Journal 104, pp 157 –158 (2014) http://dx.doi.org/10.7196/SAMJ.7839More Less
I read with interest the critique of the Women's Health Initiative Randomized Controlled Dietary Modification Trial (WHIRCDMT) by Prof. Tim Noakes. His critique focused on the varying incidence of cardiovascular outcomes between women with and without a history of cardiovascular disease (CVD), and justly called for more discussion and transparency with respect to these findings. The latter half of the critique, however, unfairly portrays the low-fat dietary intervention as deleterious for weight gain and the development of diabetes mellitus (DM).
Source: South African Medical Journal 104, pp 159 –160 (2014) http://dx.doi.org/10.7196/SAMJ.7997More Less
Two young Cape Town-based doctors, evoked by the overwhelm they've seen at struggling public hospitals, have custom-educated themselves to facilitate pioneering, inclusive healthcare solutions, bringing local patients, healthcare workers and technicians together for the first time.
Source: South African Medical Journal 104, pp 160 –162 (2014) http://dx.doi.org/10.7196/SAMJ.7998More Less
Author Y.K. SeedatSource: South African Medical Journal 104 (2014)More Less
Prof. Dennis Pudifin passed away on 3 December 2013. He was born on 13 May 1934. Dennis qualified from the University of Cape Town in 1957 as a medical doctor. He did his internship at Edendale Hospital in Pietermaritzburg and then trained in the same hospital under Dr John Cosnett, a well-known physician who was skilled in clinical medicine and whose obituary Dennis provided a few months ago.
Author Norman A. BlumbergSource: South African Medical Journal 104 (2014)More Less
It was with great sadness that I learned of Hymie's death at age 92 in San Diego, in early December 2013. He and I were among the last surviving residents of Resdoc from 1951. He was a groomsman at my wedding and we remained close friends for more than 60 years. Maureen and I spent a quality week with Hymie and Rhoda in San Diego just a few months ago.
Clinical Access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis : forum - clinical practiceSource: South African Medical Journal 104, pp 164 –166 (2014) http://dx.doi.org/10.7196/SAMJ.7263More Less
While clinical disease caused by drug-sensitive Mycobacterium tuberculosis (MTB) can usually be treated successfully, clinical disease caused by drug-insensitive MTB is associated with a poorer prognosis. In December 2012, a new drug, bedaquiline, was approved by the US Food and Drug Administration. This article documents the process whereby the National Department of Health, Right to Care and Médecins Sans Frontières obtained access to this medication for South Africans who might benefit from subsequent implementation of the Clinical Access to Bedaquiline Programme.
Author S. WalazaSource: South African Medical Journal 104, pp 166 –167 (2014) http://dx.doi.org/10.7196/SAMJ.8010More Less
Here we provide recommendations for the use of viral vaccines in anticipation of the 2014 southern hemisphere influenza season. For a review of the 2013 influenza season, please refer to the National Institute for Communicable Diseases, National Health Laboratory Service website (http://www.nicd.ac.za).
Source: South African Medical Journal 104, pp 168 –173 (2014) http://dx.doi.org/10.7196/SAMJ.7942More Less
Favourable lifestyles promote cardiovascular protection. Exercise can induce beneficial changes in the genome that decrease low-density lipoprotein cholesterol (LDL-C) and increase anti-inflammatory markers. The Mediterranean dietary pattern, fortified by nuts, while not reducing weight, reduces mortality. Lifestyle changes combined with statin therapy provide potent protection against coronary heart disease, especially when used for secondary prevention after cardiovascular events. Decisions regarding the initiation of statin therapy for primary prevention are more difficult, requiring consideration of both the LDL-C level and the degree of cardiovascular risk for dyslipidaemic patients. Combining intensive exercise and statin therapy substantially reduces the mortality risk, and thus is potentially the ideal risk-reducing combination.
Isoniazid preventive therapy for tuberculosis in South Africa : an assessment of the local evidence base : forum - reviewSource: South African Medical Journal 104, pp 174 –177 (2014) http://dx.doi.org/10.7196/SAMJ.7968More Less
Worldwide, South Africa (SA) has the worst tuberculosis (TB) epidemic. In SA, there are >6.1 million people living with HIV (PLWH) and the country now has the largest antiretroviral treatment programme with >2 million people receiving combination therapy. While there has been a marked recent decline in HIV-associated deaths, >50% of TB cases still continue to be diagnosed in PWLH. The current TB control strategy based on passive case finding, chemotherapy of childhood TB contacts and directly observed therapy has clearly failed to control endemic TB in SA. Two recent meta-analyses have shown a >60% reduction in TB in HIV-infected adults after isoniazid preventive therapy (IPT). SA has implemented the World Health Organization policy and IPT is now recommended for HIV-positive people for up to 36 months. Originally, there was only one SA study included in the evidence base supporting this policy, but subsequently four randomised controlled trials have been conducted in SA populations. These studies, together with local observational studies, are the subject of this local, evidence-based review.
Author A. DhaiSource: South African Medical Journal 104, pp 178 –180 (2014) http://dx.doi.org/10.7196/SAMJ.7864More Less
Health research sets out to acquire not only theoretical knowledge but also benefits for many people and often society as a whole, and is therefore justified. The quandary, though, is how such an important, shared purpose can be pursued with full protection of individuals and communities, in particular those with vulnerabilities. Abuses in the field surfaced in the early 1800s, and by the 1890s, anti-vivisectionists were calling for laws to protect children because of the increasing numbers of institutionalised children being subjected to unethical research. When read together, the Nuremberg Code and the Universal Declaration of Human Rights can be interpreted as establishing a basis for underpinning the principles of free and informed consent and avoiding harms and exploitation in scientific experiments involving human participants. The Declaration of Helsinki has been recognised as one of the most authoritative statements on ethical standards for human research in the world.
Source: South African Medical Journal 104, pp 181 –182 (2014) http://dx.doi.org/10.7196/SAMJ.7984More Less
In South Africa (SA), childhood tuberculosis (TB) still accounts for considerable morbidity and mortality. The incidence of TB disease and risk of progression to severe or disseminated forms are especially high in young children or those with HIV infection. Childhood TB presents most commonly as primary TB, often with non specific signs and symptoms; TB may also present as acute pneumonia. The clinical diagnosis can therefore be challenging. Furthermore, due to difficulty in obtaining good-quality specimens and the paucibacillary nature of childhood TB, microbiological confirmation is only achieved in a minority of children, especially in settings where there is limited capacity for microbiological confirmation.
Source: South African Medical Journal 104, pp 183 –186 (2014) http://dx.doi.org/10.7196/SAMJ.7011More Less
Background. There is an alarming global increase in the incidence of nosocomial infections with multidrug-resistant Gram-negative bacteria, which are often only susceptible to colistin. Colistin was developed prior to current methods of establishing dosing using pharmacokinetic-pharmacodynamic relationships. Dosing regimens differ in package inserts from different manufacturers and in different guidelines. It is imperative to avoid under-dosing with colistin in order to limit the development of resistance, as it is the last line of defence.
Methods. We conducted a systematic review of the literature to develop guidelines for rational dosing of intravenous colistin, with a particular focus on critically ill patients.
Results. Colistin is administered as the inactive pro-drug colistimethate sodium. Colistin demonstrates concentration-dependent bacterial killing, suggesting that higher doses should be administered less frequently to achieve higher peak concentrations. Dose-related nephrotoxicity occurs, making it impossible to safely achieve concentrations that prevent the selection of resistant mutants or the effective eradication of bacteria with higher minimum inhibitory concentrations. Theoretically, combination therapy should be used to reduce the risk of selection of resistant bacteria. In critically ill patients, a loading dose should be given to rapidly achieve therapeutic concentrations, followed by maintenance doses of 4.5 MU 12-hourly. Maintenance dose adjustment is necessary with renal impairment.
Conclusion. Easier access to colistin is needed in South Africa, where it is not a registered medicine. Further research is needed to better characterise colistin's pharmacokinetic-pharmacodynamic relationships in humans and to establish whether combinations of colistin with other antimicrobials result in improved clinical outcomes or a reduction in selection of resistant bacteria.
Determinants, outcomes and costs of ceftriaxone v. amoxicillin-clavulanate in the treatment of community-acquired pneumonia at Witbank Hospital : researchSource: South African Medical Journal 104, pp 187 –191 (2014) http://dx.doi.org/10.7196/SAMJ.7243More Less
Background. Community-acquired pneumonia (CAP) is a major cause of death and morbidity worldwide. Treatment is centred on antibiotics with ceftriaxone and amoxicillin-clavulanate being some of the most commonly prescribed agents.
Objective. To compare treatment outcomes and costs in patients receiving either of these two antibiotics at Witbank Hospital (WH).
Methods. A total of 200 randomly selected adult patient files (100 receiving ceftriaxone and 100 amoxicillin-clavulanate) recording a diagnosis of CAP were studied to determine the length of hospital stay, comorbid conditions and treatment outcomes. A descriptive and comparable analysis was performed.
Results. Male gender, higher CURB-65 scores and death were associated with the use of ceftriaxone. Severity of disease and previous antibiotic exposure influenced the duration of hospital admission.
Conclusion. Gender and severity of disease (based on the CURB-65 score) were the determinants of antibiotic choice at WH. Male gender increased the likelihood of being treated with ceftriaxone, as did a CURB-65 score of >2. There were no differences in the outcomes of CAP patients treated with ceftriaxone compared with those treated with amoxicillin-clavulanate. Irrespective of antibiotic used, gender and severity of disease influenced treatment outcomes. Male gender was associated with a higher mortality and longer hospital stay. The average duration of stay for both antibiotics was not significantly different. Thus, only level 1 and 2 costs need to be considered when comparing the two regimens. On this basis, ceftriaxone was cheaper than amoxicillin-clavulanate.
The impact of chronic pseudomonal infection on pulmonary function testing in individuals with cystic fibrosis in Pretoria, South Africa : researchSource: South African Medical Journal 104, pp 191 –194 (2014) http://dx.doi.org/10.7196/SAMJ.7222More Less
Background. Colonisation of the airway by Pseudomonas spp. in cystic fibrosis has been reported to be an important determinant of decline in pulmonary function.
Objective. To assess pulmonary function decline and the presence of bacterial colonisation in patients with cystic fibrosis (CF) attending a CF clinic in a developing country.
Methods. A retrospective audit of patients attending the CF clinic at Steve Biko Academic Hospital, Pretoria, South Africa, was performed. The data included spirometric indices and organisms routinely cultured from airway secretions (Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA)).
Results. There were 29 study subjects. Analysis of variance for ranks (after determining that baseline pulmonary function, age, gender and period of follow-up were not contributing to pulmonary function decline) revealed a median decline in forced expiratory volume in 1 second, forced vital capacity and forced expiratory flow over 25 - 75% expiration of 12%, 6% and 3%, respectively, for individuals colonised by PA. There was no pulmonary function decline in individuals not colonised by PA, or in individuals colonised by SA.
Conclusion. Pulmonary function decline in this South African centre is significantly influenced by chronic pseudomonal infection. Other influences on this phenomenon should be explored.