South African Medical Journal - Volume 104, Issue 4, 2014
Volumes & issues
Volume 104, Issue 4, 2014
Source: South African Medical Journal 104, pp 285 –286 (2014) http://dx.doi.org/10.7196/SAMJ.7782More Less
The porphyrias are a group of eight metabolic disorders, each of which is associated with a specific enzymatic alteration in the haem biosynthetic pathway. In general, the porphyrias share one or both of two clinical symptom complexes: cutaneous photosensitivity, which results from the interaction of light and photoactive porphyrin molecules in the skin; and the acute attack, a serious complication associated with a phase of accelerated hepatic porphyrin synthesis. The acute attack is a feature of four porphyrias: acute intermittent porphyria (AIP); variegate porphyria; hereditary coproporphyria; and aminolaevulinic acid (ALA) dehydratase porphyria. All four are so-called 'hepatic' porphyrias, in which the haem synthetic defect is expressed in non-erythroid cells, notably hepatocytes.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.7934More Less
Editors, publishers and researchers gathered in São Paulo, Brazil, in October 2013 to celebrate the 15th anniversary of the Scientific Electronic Library Online (SciELO), a significant developing-country, openaccess publishing project. This subsidised collection of mainly Latin American journals was joined by SciELO South Africa (SA) as its first African extension in 2009.
Source: South African Medical Journal 104, pp 288 –291 (2014) http://dx.doi.org/10.7196/SAMJ.7389More Less
Background. Cisplatin is administered as the first-line treatment of soft-tissue cancers. It has a reported cure rate of up to 85%, but is associated with a high incidence of ototoxicity, characterised by irreversible bilateral hearing loss and affecting 23 - 50% of adults who receive the drug.
Objectives. To determine the incidence of cisplatin-induced ototoxicity at Groote Schuur Hospital (GSH), Cape Town, South Africa.
Methods. A retrospective cross-sectional study of cisplatin-receiving cancer patients attending GSH between January 2006 and August 2011.
Results. A total of 377 patients were recorded as receiving cisplatin therapy during the study period. A 300% increase in new cisplatin-receiving patients receiving audiological monitoring was observed between 2006 and 2010. However, only patients with all clinical data as well as baseline and follow-up audiometric analyses were investigated. One hundred and seven such patients were identified, 55.1% of whom developed cisplatin-induced ototoxicity while receiving high-dose (≥60 mg/m2) cisplatin treatment. Higher cumulative cisplatin dosages were associated with development of significant hearing loss (p=0.027). The odds of developing cisplatin-induced hearing loss were elevated for patients with head and neck tumours and lymphoma (p=0.0465 and p=0.0563, respectively) and were significantly lower for those with reproductive cancers (p=0.0371).
Conclusion. Comprehensive audiological monitoring should be available for every patient during cisplatin treatment to minimise the development of disabling hearing loss.
Angiotensin converting enzyme inhibitors v. angiotensin receptor blockers in the management of hypertension : a funder's perspective : researchSource: South African Medical Journal 104, pp 292 –294 (2014) http://dx.doi.org/10.7196/SAMJ.7593More Less
Background. Hypertension poses a huge financial risk to any funder/medical aid, including the risk-mitigating strategies provided by the managed care organisations that are required to manage patients with hypertension. The South African Hypertension Guideline states that the choice of therapy - an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) - should be based on cost and tolerability.
Objective. To assess the costs of ACEIs v. ARBs in the management of hypertensive patients and the prevention of cardiovascular complications for a private medical aid scheme in South Africa.
Method. A Phase IV observational, retrospective cohort study of over 480 000 beneficiaries between 2010 and 2011 was undertaken. Hypertensive patients were identified by their chronic medication authorisation and were categorised into three groups: ACEI, ARB and combined groups. A cost-benefit analysis was performed on the claims data, comparing the input costs in rand against the downstream costs using analysis of variance.
Results. Data from 28 165 patients were included in the study. Based on the health economic analysis that was performed, there was no statistically significant difference in the input costs between the ACEI and the ARB groups. However, a statistically significant reduction in the downstream costs was observed in the ACEI group v. the ARB and combined groups (p<0.0001).
Conclusion. It is more cost beneficial to treat chronic hypertensive patients with an ACEI than ARBs in preventing cardiovascular-related complications. It is recommended that managed care companies continue recommending ACEIs rather than ARBs in the treatment of hypertensive patients.
Source: South African Medical Journal 104, pp 294 –296 (2014) http://dx.doi.org/10.7196/SAMJ.7246More Less
Background. Mammographic screening is carried out at public sector hospitals as part of clinical practice.
Objective. We report the experience of such screening at Tygerberg Academic Hospital (TBAH), a tertiary referral hospital in the Western Cape Province, South Africa.
Methods. All mammograms performed between 2003 and 2012 at TBAH were analysed regarding patient demographics, clinical data, indication and outcome according to the American College of Radiology Breast Imaging Reporting and Data System (BIRADS). Screening mammography was offered to patients >40 years of age and mammograms were read by experienced breast surgeons. Patients with BIRADS 3 and 4 lesions were recalled for short-term follow-up, further imaging or tissue acquisition. Patients with BIRADS 5 lesions were recalled for tissue acquisition. Further imaging, method of tissue acquisition, histology results and use of neo-adjuvant therapy were also recorded.
Results. Of 16 105 mammograms, 3 774 (23.4%) were carried out for screening purposes. The median age of patients undergoing screening was 54 years. Of 407 women with mammograms that were reported as BIRADS 3 - 5 (10.8% of screening mammograms), 187 (46% of recalled women) went on to have further imaging only. Tissue was acquired in 175 patients (43% of recalled women), comprising a biopsy rate of 4.6% of the total series. The malignancy rate in cases in which tissue acquisition was done was 25%. Forty-three breast cancers were diagnosed (11.4/1 000 examinations). Of the cancers, nine (31%) were ductal carcinomas in situ. Of 20 invasive cancers, nine (45%) were < 10 mm in size. Of the invasive cancers, 40% were node-positive.
Conclusions. The cancer diagnosis rate indicates a high breast cancer load in an urbanised population.
Source: South African Medical Journal 104, pp 297 –298 (2014) http://dx.doi.org/10.7196/SAMJ.7242More Less
Background. Mammographic screening programmes are now established in developing countries. We present an analysis of the first screening programme in sub-Saharan Africa.
Methods. Women aged ≥40 years were identified at three primary healthcare centres in the Western Cape Province, South Africa, and after giving informed consent underwent mammography at a mobile unit. After a single reading, patients with American College of Radiology Breast Imaging Reporting and Data System (BIRADS) 3 - 5 lesions were referred to a tertiary centre for further management.
Results. Between 1 February 2011 and 31 August 2012, 2 712 screening mammograms were performed. A total of 261 screening mammograms were reported as BIRADS 3 - 5 (recall rate 9.6%). Upon review of the 250 available screening mammograms, 58 (23%) were rated benign or no abnormalities (BIRADS 1 and 2) and no further action was taken. In 32 women, tissue was acquired (biopsy rate for the series 1.2%); 10 cancers were diagnosed (biopsy malignancy rate 31%). For the entire series of 2 712 screening mammograms, the cancer diagnosis rate was 3.7/1 000 examinations. Of 10 cancers diagnosed at screening, 5 were TNM clinical stage 0, 2 stage I and 3 stage II.
Conclusions. The low cancer detection rate achieved, and the technical and multiple administrative problems experienced do not justify installation of a screening programme using the model utilised in this series.
Community v. non-community assault among adults in Khayelitsha, Western Cape, South Africa : a case count and comparison of injury severity : researchSource: South African Medical Journal 104, pp 299 –301 (2014) http://dx.doi.org/10.7196/SAMJ.7615More Less
Background. Community assault (CA) or vigilantism is widespread in the township of Khayelitsha, Cape Town, South Africa (SA). Anecdotal evidence suggests that victims of CA are worse off than other assault cases. However, scientific data on the rate and severity of CA cases are lacking for SA.
Objectives. To contribute to CA prevention and management strategies by estimating the rate of CA among adults in Khayelitsha and comparing the injury severity and survival probability between cases of CA and other assault (non-CA) cases.
Methods. We studied four healthcare centres in Khayelitsha during July - December 2012. A consecutive case series was conducted to capture all CA cases during this period. A retrospective folder review was performed on all cases of CA and on a control group of non-CA cases to compare injury severity and estimate survival probability.
Results. A total of 148 adult cases of CA occurred (case rate 1.1/1 000 person-years) over the study period. The Injury Severity Scores (ISSs) in the CA group were significantly higher than in the non-CA group (p<0.001), with a median (interquartile range) ISS of 3 (2 - 6) in CA cases v. 1 (1 - 2) in non-CA cases. Comparison between the CA v. non-CA groups showed that a Glasgow Coma Scale <15 (20.1% v. 5.4%, respectively), referral to the tertiary hospital (33.8% v. 22.6%, respectively), and crush syndrome (25.7% v. 0.0%, respectively) were all more common in CA cases. Survival probabilities were similar in both groups (CA v. non-CA 99.2% v. 99.3%, respectively).
Conclusion. The rate of CA among adults in Khayelitsha is high, and the severity of injuries sustained by CA victims is substantially higher than in other assault cases.
Self-induction of abortion among women accessing second-trimester abortion services in the public sector, Western Cape Province, South Africa : an exploratory study : researchSource: South African Medical Journal 104, pp 302 –305 (2014) http://dx.doi.org/10.7196/SAMJ.7408More Less
Background. Despite South Africa's liberal abortion law permitting abortion on request in the first trimester and under restricted conditions for second-trimester pregnancies, the practice of unsafe self-induced abortion persists. However, the prevalence of this practice, the methods used and the reasons behind it are relatively under-researched. As part of a larger study seeking to improve abortion services in the Western Cape Province, we explored reports of prior attempts to self-induce abortion among women undergoing legal second-trimester abortion.
Objectives. To describe the prevalence and methods of and factors related to unsuccessful attempts at self-induction of abortion by women presenting without complications and seeking second-trimester abortion at public health facilities in the Western Cape.
Methods. In a cross-sectional study from April to August 2010, 194 consenting women undergoing second-trimester abortion were interviewed by trained fieldworkers using structured questionnaires at four public sector facilities near Cape Town.
Results. Thirty-four women (17.5%; 95% confidence interval 12.7 - 23.4) reported an unsuccessful attempt to self-induce abortion during the current pregnancy before going to a facility for second-trimester abortion. No factors were significantly associated with self-induction, but a relatively high proportion of this small sample were unemployed and spoke an indigenous African language at home. A readily available herbal product called Stametta was most commonly used; other methods included taking tablets bought from unlicensed providers and using other herbal remedies. No use of physical methods was reported.
Conclusions. The prevalence of unsafe self-induction of abortion is relatively high in the Western Cape. Efforts to inform women in the community about the availability of free services in the public sector and to educate them about the dangers of self-induction and unsafe providers should be strengthened to help address this public health issue.
Clinicians ignore best practice guidelines : prospective audit of cardiac injury marker ordering in patients with chest pain : researchAuthor J.C. StanflietSource: South African Medical Journal 104, pp 305 –306 (2014) http://dx.doi.org/10.7196/SAMJ.7381More Less
Background. Chest pain is a frequent presenting symptom and is a diagnostic challenge. Recent recommendations state that high-sensitivity cardiac troponin assays are the only biochemical test required in the diagnosis of acute coronary syndrome (ACS) and that other biomarkers such as myoglobin or creatine kinase (CK)-MB isoform are not indicated.
Objective. To establish whether clinician ordering in the setting of suspected ACS was in keeping with recent recommendations.
Methods. A prospective audit was undertaken of all requests for cardiac troponin I (cTnI) and CK-MB received at a large tertiary hospital in Durban, South Africa, during a 20-day period in December 2012.
Results. A total of 193 cardiac marker requests were received: 12 (6.2%) requests were for cTnI alone; 8 (4.1%) were for CK-MB alone; and the remaining 173 (89.7%) were for both cTnI and CK-MB. Therefore, a total of 181 (93.8%) incorrect requests were received during this period. A total of 103 (53.4%) patients had values below the cut-off point of 40 ng/l for cTnI, i.e. ACS was ruled out. Of these, 15 had CK-MB values above the reference interval. A total of 12 (6.2%) patients had cTnI values >500 ng/l, i.e. ACS was ruled in; 33.3% of this group had normal CK-MB values.
Conclusion. Ordering patterns in the setting of ACS did not reflect current recommendations and were wasteful and potentially dangerous.
Hepatitis B and HIV co-infection in pregnant women : indication for routine antenatal hepatitis B virus screening in a high HIV prevalence setting : researchSource: South African Medical Journal 104, pp 307 –309 (2014) http://dx.doi.org/10.7196/SAMJ.7299More Less
Background. Sub-Saharan Africa is endemic for hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections. HBV/HIV co-infection in women of reproductive age is of clinical and public health importance because these women constitute a significant reservoir for horizontal and perinatal HBV transmission. Childhood HBV vaccination from 6 weeks of age protects most children against chronic HBV infection. However, infants born to HBV/HIV co-infected women are more likely to be infected perinatally, with an increased risk of chronic hepatitis, than infants born to HBV mono-infected women.
Objectives. The aim of our study was to establish the prevalence of HBV infection and HBV/HIV co-infection in pregnant women in KwaZulu-Natal, South Africa, to inform antenatal HBV screening and childhood immunisation policies in South Africa.
Methods. Stored plasma specimens obtained from 570 pregnant women were tested for hepatitis B surface antigen (HBsAg) and HBV infectivity, as characterised by the presence of hepatitis B e antigen (HBeAg) and/or HBV DNA load.
Results. The antenatal HIV prevalence and HBsAg prevalence in this study were 41.6% and 5.3% (95% confidence interval (CI) 3.4 - 7.1), respectively. Overall, 3.1% (95% CI 1.7 - 4.6) of pregnant women were HBV/HIV co-infected, with HBeAg positivity and the HBV DNA load being significantly higher in co-infected women.
Conclusion. We report a 5.3% HBV prevalence and a 3.1% HBV/HIV co-infection prevalence in pregnant women from this HIV-endemic region. Routine antenatal HBV screening will allow early identification of neonates who require HBV active-passive immunoprophylaxis at birth. This strategy, together with antenatal antiretrovirals, will reduce the risk of perinatal HBV transmission, especially in high-risk HBV/HIV co-infected pregnant women.
Transition from child- to adult-orientated care for children with long-term health conditions : a process, not an event : continuing medical education - reviewSource: South African Medical Journal 104, pp 310 –313 (2014) http://dx.doi.org/10.7196/SAMJ.8201More Less
This month's CME component contains the second of a two-part series of continuing medical education articles on various aspects of spina bifida, with the focus on some of the longer-term management issues such as hydrocephalus and limb deformity, as well as quality of life.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8160More Less
Despite improvement in antenatal care and screening, myelomeningocele remains the most common congenital birth defect, with a reported incidence of 1 - 2.5/1000 patients in the Western Cape, South Africa. The multidisciplinary team involved in the Spinal Defects Clinic at Red Cross War Memorial Children's Hospital, Cape Town, South Africa consists of neurosurgeons, urologists, orthopaedic surgeons, stomatherapists and orthotists. Orthopaedic surgeons have a protean involvement in the management of myelomeningocele.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8194More Less
Hydrocephalus is one of the most common complications of spinal dysraphism. Although few patients require cerebrospinal fluid diversion immediately at birth or within the first few days of life, most patients with myelomeningocele, which comprises the most prevalent, clinically significant form of spina bifida, will eventually need surgical treatment for hydrocephalus at some point following closure of the spinal defect. Furthermore, symptomatic hydrocephalus needs to be dealt with timeously, as these patients not only face the usual ill-effects of raised intracranial pressure (ICP), but also have an increased risk of breakdown of the myelomeningocele repair. Poorly treated ICP may also cause the Chiari II malformation to become symptomatic.
Source: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8196More Less
Beyond the operating theatre : long-term quality of life in spina bifida : continuing medical educationAuthor Z. ToefySource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8148More Less
The International Federation for Spina Bifida and Hydrocephalus : priorities in developing countries : continuing medical educationAuthor L. BauwensSource: South African Medical Journal 104, pp 318 –319 (2014) http://dx.doi.org/10.7196/SAMJ.8202More Less
The International Federation for Spina Bifida and Hydrocephalus (IF) is the global umbrella organisation for national and regional spina bifida and hydrocephalus associations. Currently, IF has 50 members, representing people with spina bifida and hydrocephalus from 46 countries. IF's mission is to increase the quality of life of persons living with disabilities associated with these conditions and to decrease the incidence of these impairments by primary prevention. IF members share this mission and work locally to achieve these goals.