South African Medical Journal - Volume 105, Issue 12, 2015
Volumes & issues
Volume 105, Issue 12, 2015
Review - Lupus nephritis : an approach to diagnosis and treatment in South Africa : continuing medical educationSource: South African Medical Journal 105, pp 1 –4 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10224More Less
Lupus nephritis (LN) is a significant cause of morbidity and mortality in patients with systemic lupus erythematosus. Delayed recognition and diagnosis of LN may be a common cause of chronic kidney disease among South Africans. Renal biopsy is the gold standard of diagnosing LN; however, this service is not available in many centres and the use of urinalysis, urine microscopic examination and other serological tests can be useful in identifying patients with proliferative LN. Proliferative types of LN (class III, class IV and mixed class V) comprise the larger proportion of patients with this condition. Patients receiving immuno suppressive therapy need to be monitored closely for side-effects and drug-related toxicities. LN patients with end-stage renal disease (class VI) need to be prepared for renal replacement therapy (dialysis and renal transplantation). In all patients, treatment should include adjunctive therapies such as renin angiotensin aldosterone system blockade, bone protection (with calcium supplements and vitamin D), blood pressure control and chloroquine - all of which help to retard the progression of kidney disease.
Article - evidence-based treatment of systemic lupus erythematosus and its complications : continuing medical educationSource: South African Medical Journal 105, pp 5 –9 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10221More Less
Outcomes for patients with systemic lupus erythematosus (SLE) have improved during the last two decades as our understanding of the disease expands. In particular, the importance of antimalarial therapy for addressing and preventing a host of complications in SLE has emerged. Furthermore, evidence is mounting that corticosteroids, while offering excellent control of disease activity, are responsible for many of the late complications of SLE and need to be prescribed in modest doses for the shortest time possible. To achieve this, an understanding of the available 'steroid-sparing' immunosuppressants is useful. Specific attention needs to be paid to the two most important complications of SLE, i.e. infections and atherosclerotic cardiovascular events. Awareness of, screening for and aggressive management of risk factors for these comorbidities are paramount.
Source: South African Medical Journal 105, pp 10 –14 (2015) http://dx.doi.org/10.7196/SAMJ.v105i12.10341More Less
Systemic lupus erythematosus in children is a life-threatening chronic disease that is being increasingly recognised. More black African children are being diagnosed and the proportion of males affected is much higher than in adult-onset lupus. The presenting manifestations of childhood-onset lupus are variable and many systems are involved. Children with lupus often present late with severe disease, and in South African (SA) children severe lupus nephritis occurs commonly at presentation. The investigations for lupus should be performed in a three-step process - initial essential investigations, antibody and serological tests, and supplementary investigations. The most important factor in the management is to involve a multidisciplinary team as soon as possible. All cases of lupus in SA should be discussed with a paediatric specialist so that a tailored management plan can be made, depending on the presenting features and course of the disease.
Article - infections in the management of rheumatic diseases : an update : continuing medical educationSource: South African Medical Journal 105, pp 15 –17 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10220More Less
Patients with inflammatory rheumatic conditions have an increased risk of infection. While this could be the result of the underlying disease, it may also be caused by the use of immuno-suppressive therapies, which are needed to treat these disorders. An increasing number of patients with rheumatoid arthritis or other rheumatic diseases are using biologic therapies (biologics) in addition to the synthetic disease modifying anti-rheumatic drugs. The side-effects and complications of these relatively new agents are unknown to many specialists (outside of rheumatology) and general practitioners. This article highlights updates on the most important infections encountered in the daily management of patients with rheumatic diseases and discusses how these may be prevented.
Article - Meeting the challenges in the diagnosis of inflammatory myopathies : continuing medical educationAuthor M. ManieSource: South African Medical Journal 105, pp 18 –20 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10226More Less
Inflammatory myopathy (IM) is a rubric term to describe a heterogeneous group of muscle diseases typified by dermatomyositis and polymyositis. The current classifications are unsatisfactory, but IM associated with other connective tissue diseases (CTDs), such as systemic lupus erythematosus, underlying malignancy and HIV, should also be included. Although uncommon, IM should always be considered in a patient who presents with proximal weakness of gradual onset and has raised serum muscle enzymes. The diagnosis may be obvious if the patient has diagnostic skin signs such as heliotropic rash (peri-orbital discoloration) and Gottron's lesions (typically on the extensor surfaces of the fingers). In the absence of obvious skin manifestations, other features of a CTD such as Raynaud's phenomenon, abnormal capilloroscopy and the presence of serum antinuclear factor antibody should be searched for. Conditions that mimic IM include other causes of myopathy such as endocrine disorders, adverse effects of medication, metabolic myopathies and muscle dystrophies. Atypical features suggesting an alternative diagnosis are acute onset, severe pain, as symmetrical involvement, distal weakness and wasting. Appropriate investigations include a chest radiograph indicating interstitial lung disease or malignancy. Electromyography and musclebiopsy are useful in cases where other diagnoses are suspected.
Article - juvenile idiopathic arthritis - an update on its diagnosis and management : continuing medical educationSource: South African Medical Journal 105, pp 20 –25 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10223More Less
Juvenile idiopathic arthritis (JIA) is the most common form of chronic arthritis in children and the most common cause of musculoskeletal disability in children. Early diagnosis may be challenging, but it is essential to ensure good outcomes. This review proposes an approach to the investigation and diagnosis of JIA. It also gives a summary of the latest available evidence-based treatment for this disease.
Source: South African Medical Journal 105, pp 27 –29 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10249More Less
Lower back pain is one of the most common symptoms - and the most common musculoskeletal problem - seen by general practitioners. It is also a common cause of disability and an expensive condition in terms of economic impact because of absenteeism. This article discusses an approach to this common symptom and how to distinguish the benign, mechanical type of back pain from the more sinister, but less frequently encountered, inflammatory back pain.
Author M.N. AbrahamsSource: South African Medical Journal 105, pp 30 –32 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10225More Less
Gout is the most common crystal arthritis and its prevalence is rising. It is associated with the metabolic syndrome, and hyperuricaemia may be an independent risk factor for cardiovascular disease. The acute presentation of gout is easily managed, but the underlying cause is seldom addressed. Indications for initiating uric acid therapy have been clearly established. The classification criteria for gout have been reviewed and are presented here. Lifestyle modification is key to the management of gout. The clinician must screen for diabetes, hypertension and hypercholesterolaemia when the diagnosis of gout is made. The management of asymptomatic hyperuricaemia is still being researched. As yet, there is no indication to start urate-lowering therapy in such patients. All opurinol remains the first line of treatment, but there are newer drugs being researched in various clinical trials. Probenecid is the alternative in patients with preserved renal function, who do not have a history of renal calculi.
Source: South African Medical Journal 105, pp 997 –998 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10232More Less
Climate change and health in South Africa
Observed climate trends and projections for South Africa (SA) suggest important directional changes, with annual average temperatures likely to increase by approximately 2°C more than the predicted average global increase of 2°C by 2100. Extreme temperature events, such as heat waves and continuous stretches of very hot days, will probably become more common. The ability to predict temperature has improved in recent years, providing sound opportunities for assessing emperaturerelated health impacts in SA. There is less certainty regarding future rainfall, but spatial and temporal changes are expected, with some western areas of SA having less rain and more wind, while eastern areas will have more rain. These climatic changes place SA among one of the most vulnerable countries in the world, especially given the current high incidence of several life-threatening diseases, combined with poverty and inequality of access to health.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9935More Less
December's CME focuses on musculoskeletal (MSK) disorders, which represent a major disease burden and challenges in the developing world, mainly because of lack of resources and poor training in diagnosis and management. Many patients with diseases such as systemic lupus erythematosus and rheumatoid arthritis have reduced life expectancy and face a lifetime of pain and other problems. The advent of the synthetic disease-modifying anti-rheumatic drugs has significantly improved outcomes, but the challenge of early diagnosis and initiation of treatment remains in the developing world - and these drugs are expensive.
Source: South African Medical Journal 105, pp 1000 –1001 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10160More Less
A matter of context - time to clinically validate 9-month infant HIV testing in South Africa(?)
To the Editor: In their recent article, Fairlie et al. rightly point out the need for increased identification and early treatment of postnatally HIV-infected infants, and suggest that testing at 9 months of age using HIV rapid tests (HRTs) will assist in this regard. While I agree with them on this point, I am less certain that such a practice will reduce the number of HIV polymerase chain reaction (PCR) tests done with resultant cost savings, as they have concluded. All HRTs that are positive at 9 months will have to be confirmed with HIV PCR testing, as maternal antibodies may persist well beyond this time point. Delayed seroreversion at >18 months of age in HIV-uninfected infants has been described in Malawi, Vietnam, Brazil and the USA. The US study detected anti-HIV antibodies by enzymelinked immunosorbent assay (ELISA) testing in 14% of uninfected infants >18 months of age, with the median time to seroreversion occurring at >13 months of age. The slower time to seroreversion from previously established cut-offs appears to be related to the introduction of combination antiretroviral therapy for prevention of mother to-child transmission during pregnancy, although the exact mechanisms of anti-HIV antibody clearance remain unclear.
Author J. Du T ZaaijmanSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10174More Less
Rural district hospitals: Ambulance services, staff attitudes, and other impediments to healthcare delivery
To the Editor: I was pleased to note the recent article and correspondence in the SAMJ dealing with the revival of rural district hospitals. However,many problems have to be overcome before this essential 'hub' of rural medical services will be restored. Two such problem areas were recently highlighted in our local and regional newspapers. I live in the rural Eastern Cape (EC), so my comments pertain only to this area.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10176More Less
Gonadal pathology in a girl with 45,X/46,XY mosaicism
To the Editor: A 13-year-old girl presented with short stature and clitoromegaly. The clitoromegaly had been noticed at birth, but medical attention was only sought at age 13. She had not experienced menarche and had a female gender identity. She had no learning disability.
Source: South African Medical Journal 105, pp 1003 –1004 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10301More Less
Keeping a cool head and listening and communicating while being 'relevant and realistic' is what the new President of the South African Medical Association (SAMA), top psychiatrist Prof. Denise White, a 12-year veteran of SAMA leadership, hopes to bring to her executive and council.
Source: South African Medical Journal 105, pp 1004 –1005 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10317More Less
Author R. BurtonSource: South African Medical Journal 105, pp 1006 –1008 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10239More Less
The experience of all those who have worked with Ebola during the current outbreak has been different, and varied by time and place. I worked with Médicins sans Frontiéres in Monrovia during October/November 2014. This was the first-ever outbreak of Ebola virus disease in the overcrowded and impoverished areas of a capital city; Ebola was spreading rapidly, and case management had to be up-scaled on anunprecedented basis. It was also a time of many questions : for clinicians, these centred on how to optimise survival, and how to maximise care in a resource-limited environment.
Author T.H. BoylesSource: South African Medical Journal 105, pp 1008 –1009 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.9935More Less
Experiences of healthcare workers responding to the Ebola epidemic in West Africa vary with the types of facility. Patients suspected of having Ebola virus disease (EVD) must be isolated from each other as well as from the wider community until testing is complete; in Sierra Leone such facilities were called Ebola holding units (EHUs). Once EVD was confirmed, patients were moved to Ebola treatment units, where they could be cohorted together safely and treatment efforts focused on EVD itself. While a number of purpose-built units combined an EHU with an Ebola treatment unit, my personal experience was of working in a number of stand-alone EHUs in Freetown, Sierra Leone.
Medicine and the law - Is it ever justified for doctors to sue their patients whose allegations against them have been dismissed by the courts or the Health Professions Council of South Africa? : forumAuthor D.J. McQuoid-MasonSource: South African Medical Journal 105, pp 1010 –1011 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10238More Less
Doctors should be cautious about suing their patients, because it may generate bad publicity. Where a criminal or civil case or complaint to the Health Professions Council of South Africa by a patient about a doctor's professional conduct is withdrawn or dismissed, a doctor may only sue the patient for defamation if it can be proved that the patient acted from malice, spite or an improper motive. Doctors may only sue patients for malicious prosecution or abuse of civil proceedings if such patients acted with 'malice' and 'without reasonable and probable cause'. If a doctor successfully defends a case against a patient, the court will usually order the patient to pay the doctor's costs.
Author Solomon R. BenatarSource: South African Medical Journal 105, pp 1012 –1013 (2015) http://dx.doi.org/10.7196/SAMJ.2015.v105i12.10247More Less
The recent tragic, horrifying and extensively reported Ebola epidemic must surely lead us to question why, despite major medical progress, such epidemics continue to emerge. We should also consider their implications for our global collective future. Seeking to understand the Ebola epidemic requires viewing it in the broadest historical and sociopolitical contexts that have shaped health globally, and specifically in West Africa.