Deeply rooted in clinical neurology, neurosurgery emerged as a special branch of surgery early in the 20th century and evolved swiftly with developments in anaesthesia, critical care, imaging and a host of surgical innovations. Today, the treatment of patients with diseases of the nervous system is one of the most rapidly advancing areas of medical practice and neurosurgery remains at the forefront, with new insights and advances transforming the management of diseases such as subarachnoid haemorrhage, traumatic brain injury, degenerative disc disease and hydrocephalus. This is an exciting time to be a neurosurgeon.
ACEIs v. ARBs: A cost-benefit analysis
Acute porphyria: Unusual presentation
Breast cancer screening in SA
Risks associated with magnetic bead ingestion
SciELO (SA): Enhancing SA research
Hereditary haemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu disease is an autosomal-dominant inherited vascular disease, characterised by the presence of mucocutaneous telangiectasia and visceral arteriovenous malformations (AVMs). Three main causative genes are known: ENG, ACVRL1 and SMAD4. BMP9 has also been shown to be involved in a small number of cases. We report two cases of HHT in North African and sub-Saharan patients.
In his recent article in the SAMJ, Prof. Steve Reid questions whether inclusion of art and humanities in the medical curriculum can improve the flexibility and skill of a graduate. As a writer and a general practitioner, I have struggled with the split between my artistic life and that of working with the ill, the injured and the emotionally hurt. As a student, I developed a chronic condition; although medication helped limit morbidity, it was my practise of taking emotional difficulty to the page that helped me manage stressors that adversely impacted on my health.
The convergent distribution of HIV/AIDS and neglected tropical diseases (NTDs), particularly helminthiasis, in sub-Saharan Africa has been described and associated with accelerated HIV/AIDS and tuberculosis (TB) epidemics in the region.
Euthanasia is defined as 'conduct that brings about an easy and painless death for persons suffering from an incurable or painful disease or condition'. Active euthanasia is the intentional killing of a person suffering from an incurable disease, and fulfils the legal criteria for murder. There is intent, causation, a human is the victim, and the act, whether by omission or commission, is unlawful. Motive, albeit the altruistic desire to relieve unnecessary suffering in the face of futility, is irrelevant to criminal intent. The term passive euthanasia includes withholding extreme medical measures or removing life support in the presence of futile or non-beneficial treatment. McQuoid-Mason outlines the reason why, in the eyes of the law, passive euthanasia is not a criminal offence, and withholding or withdrawing life-sustaining treatment or administering sufficient analgesia and sedation during the latter cannot be construed as murder. Of the four legal prerequisites for the definition of murder, namely intent, causation, a human victim and contravention of the law, only the last-mentioned is not fulfilled and spares the doctor from a conviction. Although reassuring to those working in critical care, where withholding or withdrawing support is a fact of life (or death), the fact that only one component of the legal definition spares us from being labelled criminals is somewhat disconcerting. We would argue that in addition to the lack of unlawfulness, neither intent nor causation applies, and furthermore that the term 'passive euthanasia' is an oxymoron and should be abandoned.
McQuoid-Mason's statement that 'Doctors who hasten the termination of the lives of their patients by withholding or withdrawing treatment or prescribing a potentially fatal palliative dose of medication satisfy the elements of intention and causation of a charge of murder against them' is of great concern. It highlights a disconnect between the professions of law and medicine and misconceptions regarding the practice of palliative care. Such statements influence professional and public perceptions and create barriers to patient and family access to quality end-of-life care that focuses on relief of suffering and improving quality of life.
Rossouw and Howard's response to my article confirms that it is they and not I who miss the point. My key focus was not whether the Women's Health Initiative Dietary Modification Trial (WHIDMT) supports the use of carbohydrate-restricted diets. Nor did my key points focus 'on subgroup findings rather than the robust overall findings' of the study. By introducing these arguments, Rossouw and Howard neatly sidestep the single most important question I raised.
A Constitutional Court (ConCourt) challenge to South Africa's health authorities by a community-service doctor conscript, outraged by his 'slave-like' working conditions (including excessive overtime and arbitrary posting), has been turned down amid strong, and mixed, collegial emotion.
The pivotal players in the Immutides Spray roll-out drama say they were either victims of bad government communication, pawns of more senior officials or simply ignorant of what was going on. These were the themes to emerge when Izindaba put the allegations to them.
Hessel Utian was born on 18 February 1932 and passed away on 26 February 2012. After matriculating, at the age of 16 years, from Jeppe High School for Boys, Hessel enrolled at Wits Medical School, graduating with an MB BCh in 1954.
Dr Ivan J Nurick was born on 25 August 1934 in Queenstown, after which his family moved to Indwe in the Eastern Cape. In 1952, when I arrived at Driekoppen (Belsen) residence at the University of Cape Town (UCT), the first person I ran into was Ivan and our long friendship began. We later both moved into the Medical Residence. We both married in 1959, within weeks of each other, and spent two years at Edendale Hospital outside Pietermaritzburg.
Vanessa Noble has pulled a rabbit out of a hat by weaving what is essentially a scholarly monograph into an extraordinarily vibrant narrative on the history of black medical training in South Africa, specifically at the University of Natal Medical School, now the Nelson Mandela School of Medicine of the University of KwaZulu-Natal. The book is exceptionally well researched from primary sources, with numerous references and footnotes, and yet written in a style that makes it a page-turner.
This is an excellent book. It took about 10 years for the author to collect and collate the material, in the course of which she interviewed many of the graduates of the medical school and those who provided years of service to it, and the book is interesting, factual and unbiased.
Pompe disease (PD) is an autosomal-recessively inherited neuromuscular disease that, if not diagnosed and treated early, can be fatal. It can present from early infancy into adulthood. Due to the lack of acid α-glucosidase, there is progressive intracellular accumulation of glycogen. The severity of the disease is determined by age of onset, organ involvement including the degree of severity of muscle involvement, as well as rate of progression. PD is classified into two groups: infantile and late-onset, each having two subgroups. The need for two tests performed by separate methods (screening and confirmatory) is outlined. It is imperative to try to reduce the time to diagnosis and to recognise the possibilities of false-positive results. A multidisciplinary team approach to treatment of affected patients is optimum with, as team leader, a physician who has experience in managing this rare disorder. In this article, we present a brief overview of the disease and provide guidelines for diagnosis and management of this condition in South Africa.
The Constitutional Court in the Teddy Bear Clinic appeal case held that the sections of the Sexual Offences Act that impose criminal liability for sexual offences on adolescent children under 16 years of age are invalid. The invalidity was suspended for 18 months to allow Parliament to correct the Act's defects. A moratorium was imposed on all investigations into, arrests in, prosecutions in, and criminal and ancillary proceedings regarding such section 15 and 16 offences. This includes the duty to report consensual sexual conduct between children under 16 years of age in terms of section 54 of the Act - pending Parliament's correction. However, it is submitted that the 'best interests of the child' principle in the Children's Act and the Constitution should guide all obligatory reporting situations involving sexual and other conduct of children, irrespective of whether they are adolescents under 16 years old or between 16 and 17 years old.
Accidental ingestion of foreign bodies is a common problem in children. Magnetic bead toys are hazardous, having potentially lethal consequences if ingested. These magnets conglomerate in different segments of bowel, causing pressure necrosis, perforation and/or fistula formation anywhere along the gastrointestinal tract. A clinical diagnostic pitfall is that the appearance on the initial abdominal radiograph may be misinterpreted by the uninitiated as a single metallic object without any intervening intestinal wall. Symptoms do not occur until complications have developed, and even then, unless magnet ingestion is suspected, treatment may initially be mistakenly expectant, as with any other foreign body. After observing a case of multiple magnet ingestion that led to the rapid onset of small-bowel inter-loop fistulas and peritonitis, we attempted to reproduce the likely sequence of events in a laboratory setting using fresh, post-mortem porcine bowel as an animal model and placing magnetic toy beads within the bowel lumen. Pressure-induced perforation appeared extremely rapidly, replicating the operative findings in two of our cases. We propose that if magnet ingestion is suspected, early endoscopic or surgical retrieval is mandatory. Appropriate, rapid surgical intervention is indicated. Laparoscopy offers a minimally invasive therapeutic option.
Osteoporosis is a common, costly and serious disease, which is still too often regarded as an inevitable part of the normal ageing process and therefore sub-optimally treated, especially in the elderly - in fact, only two out of every 10 patients who sustain a hip fracture receive any form of assessment or prophylactic therapy for osteoporosis. One out of five patients die within 1 year after a hip fracture, and <50% are capable of leading an independent life. Yet very effective anti-fracture therapy, capable of reducing fracture risk by 35 - 60%, is available. A number of publications have recently questioned the safety of drugs routinely used to treat patients with osteoporosis. This paper attempts to put the situation into perspective and expresses the National Osteoporosis Foundation of South Africa's view on the safety of these drugs. Their efficacy in preventing skeletal fractures and their cost-effectiveness are not addressed in any detail. The paper emphasises the fact that all osteoporosis medications have side-effects, some of which are potentially life-threatening.
Acute intermittent porphyria, the most common porphyria affecting the nervous system, typically presents with neurovisceral crises followed by a motor neuropathy. We describe a 23-year-old black South African man presenting with a progressive stuttering, lower motor neuron syndrome developing over months. He had not experienced pain or neuropsychiatric symptoms. One year after symptom onset he was bed-bound with a flaccid quadriparesis. There was marked amyotrophy, but without fasciculations. Sensation was intact apart from a hypo-aesthetic patch over the thigh. Electrophysiological investigations showed an active motor axonopathy. Urinary porphyrins, δ-aminolaevulinic acid and porphobilinogen were elevated. Mutation analysis revealed the c445C>T (R149X) mutation in the porphobilinogen deaminase gene. The patient responded dramatically to haem arginate and could walk with assistance 2 weeks later. We identified the first molecularly confirmed acute intermittent porphyria in a black South African. The clinical presentation mimicked a progressive lower motor neuron syndrome.