South African Medical Journal - Volume 105, Issue 7, 2015
Volumes & issues
Volume 105, Issue 7, 2015
Source: South African Medical Journal 105, pp 535 –539 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7923More Less
Background. Medical internship is designed to bridge the gap between the theoretical knowledge learned as a student and the skills required as a competent medical practitioner. In South Africa (SA) it is a 2-year structured programme incorporating experience in key domains of medicine selected by the Health Professions Council of South Africa (HPCSA). HPCSA guidelines state that the clinical experience should include teaching, supervision and competency in selected logbook procedures. After concerns were raised over some accredited intern facilities, we investigated whether these guidelines were being met for interns across SA.
Methods. An electronic survey was sent to 150 SA doctors who had completed their internship between 2010 and 2013. The questions covered supervision, workload and rest, teaching and perception of patient safety. All responses were anonymous and there was opportunity to comment at the end of each question.
Results. The respondents (n=90) included graduates from all eight SA medical schools. Supervision was ranked as the aspect of internship that respondents would change the most, with 33.0% performing an interventional procedure for the first time without supervision and 25.6% experiencing an adverse event where senior help was not available. More than half the interns had an entire shift supervised by a medical officer with less than 3 years' clinical training in that specialty.
Conclusions. This survey identified deficiencies of supervision as directed by the HPCSA. It also highlighted difficulties with workload and teaching opportunities. A significant proportion of interns did not feel that patients were safe under their care. A national annual HPCSA survey would highlight hospitals where closer investigation may be required.
A South African family with oculopharyngeal muscular dystrophy : clinical and molecular genetic characteristics : forum - geneticsSource: South African Medical Journal 105, pp 540 –543 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7880More Less
Autosomal dominantly inherited oculopharyngeal muscular dystrophy (OPMD) is caused by a trinucleotide repeat expansion in exon 1 of the polyadenylate binding protein nuclear 1 (PABPN1) gene on chromosome 14q. A large family with OPMD was recently identified in Pretoria, South Africa (SA). Molecular studies revealed a (GCG)11(GCA)3GCG or (GCN)15 mutant allele. The (GCN)15 mutation detected in this family has been described previously in families from Uruguay and Mexico as a founder effect. To our knowledge, this is the first report of an SA Afrikaner family with molecularly confirmed OPMD. The proband, a 64-year-old woman, presented to the neurology outpatient department at Steve Biko Academic Hospital, Pretoria. A sibship of 18 individuals was identified, of whom eight had OPMD. Four patients were interviewed and examined clinically, and electromyographic studies were performed. Molecular analysis of the PABPN1 gene was performed by polymerase chain reaction amplification and direct sequencing of exon 1 in three of the patients. Patients presented with ptosis, external ophthalmoplegia, dysphagia, dysarthria and mild proximal weakness. High foot arches and absent ankle reflexes raised the possibility of peripheral neuropathy, but electromyography showed only mildly low sensory amplitudes, and myopathic units in two patients.
Author Amanda KrauseSource: South African Medical Journal 105, pp 544 –545 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8041More Less
The diverse nature of the peoples living in South Africa (SA) and their history has offered unique opportunities over the years to its researchers, particularly those working in the field of human and medical genetics. Many genetic conditions and/or genetic causative mutations have been demonstrated to have interesting population-specific distributions. This is well demonstrated by two articles in this issue of the SAMJ. Apart from research opportunities, this diversity of genetic disease has major relevance when offering diagnostic testing. Frequencies of disease may differ between groups, and the mutational basis may be different. Unless clinicians and laboratories are aware of these differences, and offer testing appropriate to the origins of patients, inappropriate testing may be performed and important diagnoses may be missed. Different mutation-specific therapies may also be required in the future.
Author Michael F. UrbanSource: South African Medical Journal 105, pp 545 –547 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7894More Less
The culmination of the Human Genome Project, with the publication of two 'reference' genomes, introduced the genomic era.
Before this, human genetics concerned itself with techniques to analyse the chromosomes (cytogenetics) and to detect the genes causing Mendelian diseases such as cystic fibrosis or sickle cell anaemia (molecular genetics), and was largely the preserve of human geneticists. Genetic testing was accurate, but slow and costly. Chromosome analysis was limited by its low resolution (a DNA deletion of 5 million base pairs of DNA may be undetectable), and molecular genetics by the inability to sequence more than a few hundred DNA bases ata time.
The Cochrane corner in the SAMJ : summaries of Cochrane systematic reviews for evidence-informed practice : editorialSource: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8035More Less
Despite substantial gains in the implementation of evidence-based practice in the past few decades, it has recently been referred to as a 'movement in crisis'. This is not because the principle of using rigorous relevant evidence to inform healthcare decisions is in doubt, but rather that the ethos of evidence-based healthcare (EBHC) is being misrepresented or subverted by groups with vested interests, such as the pharmaceutical industry. The overwhelming volume of information from research and guidelines, which is difficult for practitioners to digest, as well as the notion that an evidence-based approach may undermine clinical judgement or experience, are additional barriers to the adoption of EBHC. These challenges notwithstanding, the principles of EBHC must continue to be promoted as the basis for honestly appraising the strengths and limitations of existing evidence and making informed healthcare decisions. Key to the success of EBHC is the integration of the best available, up-to-date research evidence with clinical judgement, and the incorporation of information regarding patient preferences and values.
Source: South African Medical Journal 105, pp 549 –553 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7796More Less
Background. Childhood pneumonia is common in all countries, and empyema is one of the commonest complications. The role of routine intrapleural fibrinolytics in the management of childhood empyema is not well established in low- and middle-income countries.
Methods. We did a prospective observational study of children sequentially hospitalised with empyema between December 2006 and December 2011 in South Africa (SA). Intrapleural tissue plasminogen activator (TPA), administered according to a standard protocol, was introduced in September 2009. Outcomes in children treated with TPA after 2009 were compared with the historical cohort not treated with TPA who met the treatment criteria.
Results. One hundred and forty-two children with empyema, median age 17 months (interquartile range 8 - 43), were admitted during the study period. Excluding children who did not have a chest tube inserted and those in whom fibrinolysis was contraindicated, there were 99 patients, 52 of whom received fibrinolytics. Clinical characteristics and empyema aetiology were similar in those who received fibrinolysis and those who did not. Eighteen children (38.3%) not treated with TPA required surgery v. 5 (9.6%) treated with TPA (relative risk 0.25; 95% confidence interval 0.1 - 0.6). The median duration of hospitalisation was similar in both groups. Complications occurred rarely and with a similar incidence in both groups. In-hospital mortality was low, with two deaths in each group.
Conclusion. Intrapleural TPA resulted in a four-fold reduction in surgery. Fibrinolytics should be used for management of empyema in children in SA.
The impact of highly active antiretroviral therapy on the burden of bacterial lower respiratory tract infections in children : researchSource: South African Medical Journal 105, pp 554 –557 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7820More Less
Background. Respiratory diseases are common and associated with significant morbidity and mortality in children.
Objective. To evaluate the prevalence and outcome of bacterial lower respiratory tract infections (LRTIs) in HIV-infected and uninfected children at a primary level hospital.
Methods. A cross-sectional descriptive study of children aged 6 months - 18 years was conducted. Recruitment included HIV-positive children who had been on highly active antiretroviral therapy (HAART) for at least 6 months. A comparator group of HIV-negative children admitted with bacterial pneumonia was included. Laboratory data collected included CD4+ T-cell counts, HIV viral load and C-reactive protein (CRP). Data collected in both groups included demographic data, immunisation status, zinc supplementation, previous LRTIs, environmental exposures and treatment.
Results. Fifty-nine HIV-infected and 20 uninfected children were enrolled. The HIV-positive children were older, with a mean age of 107.2(standard deviation 50.0) months v. 12.0 (5.8) months (p < 0.005). The HIV-infected group had a mean CD4 percentage of 31.5%, and had had an average of 3.9 visits for bacterial LRTIs. All were treated with amoxicillin with no complications. In the HIV-uninfected group, cough and rapid breathing were the most common presenting symptoms, and the mean CRP level was 463.0 mg/L. The mean hospital stay was 4 days.
Conclusion. HAART is effective in reducing the burden of LRTIs in HIV-positive children, even when the diagnosis is delayed. Cough and fast breathing are still the most reliable presenting symptoms of pneumonia. The majority of children still respond to amoxicillin as first-line therapy, with low complication rates.
Identification of a mutation in the ubiquitin-fold modifier1-specific peptidase 2 gene, UFSP2, in an extended South African family with Beukes hip dysplasia : researchSource: South African Medical Journal 105, pp 558 –563 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7917More Less
Background. Beukes hip dysplasia (BHD) is an autosomal dominant disorder of variable penetrance that was originally identified in a large South African family of European origin. BHD is characterised by bilateral dysmorphism of the proximal femur, which results in severe degenerative osteoarthropathy. Previous studies mapped the disorder to a 3.34 Mb region on chromosome 4q35.
Objective. To fine-map the BHD locus and identify the disease-causing mutation by direct sequencing.
Results. The linked BHD allele was refined to 1.33 Mb, reducing the number of candidate genes from 25 to 16. Analysis of protein coding and invariant splice-site sequences in three distantly related individuals identified a single-candidate disease-causing variant c.868T>C within exon 8 of the ubiquitin-fold modifier 1 (Ufm1)-specific peptidase 2 gene, UFSP2. The presence of this unique mutation was confirmed in all 17 affected members of the BHD family who were genotyped. The mutation segregated with the BHD phenotype in the extended family with a two-point (single marker) LOD score of 10.4 (θ = 0.0 and 80% penetrance). The mutation predicts the substitution of a highly conserved amino acid, p.Tyr290His, in the encoded protein. In vitro functional assays performed using purified recombinant wild-type and mutant UFSP2 protein demonstrated that the BHD mutation abolishes UFSP2-mediated C-terminal cleavage of its substrate, Ufm1.
Conclusion. We report a unique UFSP2 mutation that segregates with the BHD phenotype. The predicted amino acid substitution inactivates UFSP2 proteolytic function, thus implicating the ubiquitin-fold modifier 1 cascade in this form of severe hip osteoarthropathy. The facile polymerase chain reaction-based assay we describe could be used to confirm the diagnosis of BHD, or for presymptomatic testing of members of the extended BHD family.
Impact of an educational intervention and clinical performance dashboard on neonatal bloodstream infections : researchSource: South African Medical Journal 105, pp 564 –566 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7764More Less
Background. Blood cultures are the most direct method of detecting bacteraemia. Reducing contamination rates improves the specificity and positive predictive value of the blood culture. Clinical performance dashboards have been shown to be powerful tools in improving patient care and outcomes.
Objectives. To determine whether prospective surveillance of bloodstream infections (BSIs), introduction of an educational intervention and the use of a clinical performance dashboard could reduce BSIs and blood culture contamination rates in a neonatal nursery.
Methods. We compared two time periods, before and after an intervention. Blood culture data were extracted from the local microbiology laboratory database. The educational intervention included the establishment of hand-washing protocols, blood culture techniques and video tools. A clinical performance dashboard was developed to demonstrate the monthly positive blood culture and contamination rates, and this was highlighted and referred to weekly at the unit staff meeting.
Results. Before the intervention, 1 460 blood cultures were taken; 206 (14.1%) were positive, of which 104 (7.1% of the total) were contaminants. In the period following the intervention, 1 282 blood cultures were taken; 131 (10.2%) were positive, of which 42 (3.3% of the total) were contaminants. The number of positive blood cultures and contamination rates after the intervention were both statistically significantly reduced (p=0.002 and p< 0.001, respectively).
Conclusion. This study demonstrates that adopting a relatively simple educational tool, making use of a clinical performance dashboard indicator and benchmarking practice can significantly reduce the level of neonatal sepsis while also reducing contaminated blood cultures.
Source: South African Medical Journal 105, pp 567 –569 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7786More Less
Background. Asthma and allergic rhinitis affect 15% and 38% of South African (SA) children, respectively. The housedust mite (HDM) is the most significant indoor aeroallergen. Typical HDM species include Dermatophagoides pteronyssinus, D. farinae and Blomia tropicalis. Conventional skin-prick testing (SPT) panels only test for Dermatophagoides. B. tropicalis has been described in the tropical and subtropical regions, but is not routinely tested for in SA.
Objective. To ascertain the significance of B. tropicalis as an aeroallergen in northern coastal KwaZulu-Natal Province (KZN), a tropical environment, and in Johannesburg in the highveld, where the climate is milder and less humid.
Methods. Children aged 1 - 18 years with features of allergic rhinitis and/or asthma were recruited over a 6-month period from Alberlito Hospital in northern KZN and the Clinton Clinic in Johannesburg. SPTs included Dermatophagoides and B. tropicalis. Sensitisation was defined as a wheal 3 mm greater than the negative control.
Results. Eighty-five subjects were included, 50 in northern KZN and 35 in the Johannesburg arm; 52% of subjects in northern KZN and 3% in Johannesburg were sensitised to B. tropicalis, with a significant difference between these centres (p< 0.05). Of the 52% sensitised to B. tropicalis in northern KZN, half were sensitised only to B. tropicalis.
Conclusion. There is a high prevalence of B. tropicalis allergy in the tropical northern KZN region and a much lower prevalence in the Johannesburg region. Routine testing for B. tropicalis allergy should be employed in northern KZN.
Nodular thyroid disease and thyroid malignancy : experience at Polokwane Mankweng Hospital Complex, Limpopo Province, South Africa : researchSource: South African Medical Journal 105, pp 570 –572 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7885More Less
Background. Nodular thyroid disease is common throughout the world. Numbers of patients with goitre are increasing worldwide, as also noted in Limpopo Province, South Africa (SA). Globally, thyroid nodules have been reported in 4 - 7% of the population on neck palpation and in 30 - 50% by ultrasonography.
Objectives. To review the profile of thyroid disease in patients with goitre presenting to the Department of Surgery at Polokwane Mankweng Hospital Complex (PMHC), Limpopo, SA, to characterise the pattern of malignancy in patients with goitre, and to determine the most common thyroid cancer.
Method. A 6-year retrospective study (2003 - 2008) of all patients with thyroid nodules who underwent thyroid surgery at PMHC.
Results. The study group included 90 patients (mean age 45 years, range 4 - 80). The male-to-female ratio was 1:17 (5 men, 85 women). Of these patients, 80 (89.9%) had benign lesions, of which 52 (57.8% of the total) were adenomas, 25 (27.8%) multinodular goitres (MNGs), 2 (2.2%) hyperplastic nodules and 1 (1.1%) Hashimoto's thyroiditis. Ten patients (11.1%) had malignant lesions (7 follicular carcinomas and 3 papillary carcinomas), of which 2 were found in MNGs.
Conclusions. Adenoma and MNG were the predominant non-malignant conditions (85.6%). The prevalence of thyroid cancer in our study was 11.1%, and of all 90 patients, 7.8% had follicular carcinoma. The risk of malignancy in MNG was 8.9%. Rates of thyroid nodules and carcinoma were highest in women aged 41 - 60 years. We advocate that total thyroidectomy be considered for MNG, because MNG can harbour incidental carcinoma.
Household fuel use and child respiratory ill health in two towns in Mpumalanga, South Africa : researchSource: South African Medical Journal 105, pp 573 –577 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7934More Less
Background. This cross-sectional study examined respiratory health outcomes and associated risk factors in children living in a part of South Africa characterised by high levels of air pollution.
Methods. A questionnaire was used to collect self-reported respiratory health and risk factor data from the parents/guardians of children between the ages of 9 and 11 years attending primary schools in the study area. Six government schools were selected based on their location, class size and willingness to participate. Univariate and bivariate analyses as well as logistic regression analysis were performed on the data, using a p-value of 0.25 and biological plausibility.
Results. The overall prevalence of respiratory ill-health symptoms was 34.1%. The prevalence of respiratory ill-health conditions was significantly elevated among children from households using non-electrical fuels v. electricity for cooking (43.9% v. 31.6%; adjusted p-value 0.005). The same was noted among those using non-electrical fuels for heating (37.8% v. 29.0%).
Conclusion. The elevated prevalence of some respiratory health outcomes among schoolchildren, especially in conjunction with domestic fossil fuel burning, is of concern. The data collected in this study may be used to complement or form a basis for future policy regarding indoor or ambient air quality in the area.
Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa : a population-based study : researchSource: South African Medical Journal 105, pp 578 –583 (2015) http://dx.doi.org/http://dx.doil.org/10.7196/SAMJnew.8038More Less
Background. In order to reduce maternal mortality in South Africa (SA), it is important to understand the process of obstetric care, identify weaknesses within the system, and implement interventions for improving care.
Objective. To determine the spectrum of maternal morbidity and mortality in the Pretoria Academic Complex (PAC), SA.
Methods. A descriptive population-based study that included all women delivering in the PAC. The World Health Organization definition, criteria and indicators of near miss and maternal death were used to identify women with severe complications in pregnancy.
Results. Between 1 August 2013 and 31 July 2014, there were 26 614 deliveries in the PAC. The institutional maternal mortality ratio was 71.4/100 000 live births. The HIV infection rate was 19.9%, and 2.7% of women had unknown HIV status. Of the women, 1 120 (4.2%) developed potentially life-threatening conditions and 136 (0.5%) life-threatening conditions. The mortality index was 14.0% overall, 30.0% for non-pregnancy-related infections, 2.0% for obstetric haemorrhage and 13.6% for hypertension. Of the women with life-threatening conditions, 39.3% were referred from the primary level of care. Vascular, uterine and coagulation dysfunctions were the most frequent organ dysfunctions in women with life-threatening conditions. The perinatal mortality rate was 26.9/1 000 births overall, 23.1/1 000 for women with non-life threatening conditions, and 198.0/1 000 for women with life-threatening conditions.
Conclusion. About one in 20 pregnant women in the PAC had a potentially life-threatening condition; 39.3% of women presented to a primary level facility as an acute emergency and had to be transferred for tertiary care. All healthcare professionals involved in maternity care must have knowledge and skills that equip them to manage obstetric emergencies. Review of the basic antenatal care protocol may be necessary.
Intracranial suppuration : review of an 8-year experience at Umtata General Hospital and Nelson Mandela Academic Hospital, Eastern Cape, South Africa : researchAuthor M.A. AnwarySource: South African Medical Journal 105, pp 584 –588 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7881More Less
Background. Intracranial suppuration (ICS) is a life-threatening condition caused by various disease processes and consisting of brain abscess and extradural and subdural empyema. The major causes have changed over the decades. To the author's knowledge, the incidence of ICS in South Africa (SA) has not been established.
Objective. To determine the incidence of ICS, overall and according to age and gender, and to identify the source and distribution of ICS.
Method. The archive of the radiology departments at Umtata General Hospital and Nelson Mandela Academic Hospital in the Transkei region,Eastern Cape Province, SA, was searched retrospectively for computed tomography (CT) reports of patients diagnosed with ICS. Cases in which the CT images, patients' clinical information and CT reports were available for an uninterrupted period of at least 1 year were included.
Results. Five time frames were established, encompassing 8 years of data. The first time frame established an incidence of ICS of 1/100 000/year for the Transkei region. All the time frames were utilised to determine the incidence according to gender and age, and the source and distribution of ICS. The incidence of ICS was higher among males than females, and highest in the age groups 0 - 10 and 11 - 20 years. A seasonal variation in the incidence of sinusitis- and meningitis-related ICS was noted. Numbers of cases declined during the last 3 years of the study period.
Conclusion. Sinusitis, head trauma, ear infection and meningitis were the major sources of ICS. A pulmonary source was not a major feature. In the last 4 years, trauma became the commonest source of ICS. A steady decline in ear infection- and meningitis-related ICS was noted.
Observed full blood count and lymphocyte subset values in a cohort of clinically healthy South African children from a semi-informal settlement in Cape Town : researchSource: South African Medical Journal 105, pp 589 –595 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7914More Less
Background. The paediatric full blood count and lymphocyte subset reference intervals used by the National Health Laboratory Service (NHLS), South Africa (SA), are taken from two international reference interval publications. Differences in reference intervals suggest that international data sets may not be appropriate for use in SA.
Objective. To study immunohaematological values of a group of clinically healthy children from an informal settlement in Cape Town, SA, to assess whether international paediatric reference intervals used by the NHLS are appropriate.
Methods. A cross-sectional study of 207 female and 174 male HIV-uninfected children living in an informal settlement in Cape Town was performed. Full blood counts, automated differential counts and lymphocyte subset analysis were done using internationally accepted technologies. Data were categorised by age and reference intervals compiled using medians and 95% confidence intervals (CIs). Gender comparisons were calculated by non-parametric tests.
Results. Although median and 95% CI values differed slightly, physiological trends for red cell, platelet, white blood cell differential and lymphocyte subsets were similar to international reference intervals currently in use at the NHLS. Benign ethnic neutropenia was not a significant finding, and gender-specific intervals were not necessary until 12 years of age. Lower overall median values for haemoglobin and haematocrit, and higher median values for mean cell volume and red cell distribution width, were noted. Assessment of haemoglobin, red cell distribution width and calculated Mentzer ratios suggested underlying iron deficiency in 14.2% of participants.
Conclusion. Paediatric immunohaematological reference intervals observed in this study are similar to, and support continued use of, international paediatric reference intervals. Underlying iron and related nutritional deficiencies may be contributing to lower haemoglobin levels noted in local children. A larger nationwide study, including all ethnic groups, is recommended.
Evaluation of the diagnostic accuracy of the HemoCue device for detecting anaemia in healthy school-aged children in KwaZulu-Natal, South Africa : researchSource: South African Medical Journal 105, pp 596 –599 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7919More Less
Background. The prevalence of anaemia in school-aged children is reported to be high (>10%), yet neither the onset of anaemia nor the disease causing it is easily established. Any form of anaemia, even if mild, can compromise children's health and survival. This study was conducted to generate data to support or reject use of the HemoCue device as a potential point-of-care method for haemoglobin (Hb) assessment in field and primary healthcare settings.
Objective. To assess the validity of the HemoCue in relation to the gold-standard laboratory method.
Methods. A cross-sectional study of children aged 6 - 8 years, analysing the diagnostic accuracy of the HemoCue in determining Hb levels in venous blood. Agreement between the HemoCue and laboratory techniques was evaluated using the Bland-Altman plot. The intra-class correlation coefficient was used to assess within-subject variability of measured Hb.
Results. A trend of underestimation of Hb values was noted. The mean Hb with the HemoCue was 11.70 g/dL and that with the laboratory method 12.19 g/dL. The mean difference between the two methods was 0.49 g/dL, with a standard deviation of 0.77 g/dL (95% confidence interval -0.59 - -0.38). Discrepancies >1 g/dL were identified in 14.1% of cases. Bias increased with increasing Hb values.
Conclusion. The HemoCue was found to be comparable to the standard laboratory method for determining Hb concentrations in school-aged children. Its usefulness for screening healthy children was demonstrated, although a full blood count is recommended if anaemia or iron deficiency is suspected.
Use of EMLA cream as a topical anaesthetic before venepuncture procedures in field surveys : a practice that helps children, parents and health professionals : researchSource: South African Medical Journal 105, pp 600 –602 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7797More Less
Background. Topical analgesia is becoming essential as the number of invasive screening procedures involving children rises steadily. Little is known about the frequency of these procedures, or about interventions to ease the pain.
Methods. We investigated the use of EMLA cream in 184 school-aged children in KwaZulu-Natal Province, South Africa. Another group of 20 children did not receive any local analgesia and was assessed as a control. Anticipatory anxiety, pain, adverse reactions and ease of procedure were assessed using a subjective visual analogue scale (VAS) pain score generated by the researcher and obtained from each child immediately after the procedure.
Results. The use of EMLA cream resulted in reduced pain and distress. The pain-relieving influence of EMLA was good (91.3% analgesic effect). Participants who received EMLA cream reported significantly lower VAS pain scores (p=0.001). Pain scores generated by the researcher were also significantly lower in the EMLA group than in the control group (p=0.000). No adverse reactions were observed, and the children could continue with other research activities during the application time and after the procedure. Parent or caregiver scores were in favour of EMLA cream.
Conclusion. EMLA cream was safe and effective for alleviating the pain associated with venepuncture in a fieldwork setting. We therefore believe that it merits a place in the routine premedication of children before phlebotomy and cannulation procedures in clinical settings, research studies and field surveys. Further research is recommended to assess whether EMLA cream can be used for immunisations.
Vitamin D deficiency and insufficiency in Africa and the Middle East, despite year-round sunny days : guest editorial - CME reviewSource: South African Medical Journal 105, pp 603 –605 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7785More Less
Exposure to sunlight, specifically ultraviolet B (UVB), is essential for cutaneous vitamin D synthesis. Despite significant daily sunlight availability in Africa and the Middle East, persons living in these regions are frequently vitamin D insufficient or deficient. Vitamin D insufficiency (25-hydroxyvitamin D (25(OH)D) between 15 and 20 ng/mL (37.5 - 50 nmol/L)) has been described in various population groups, ranging from 5% to 80%. Risk factors include traditional dress and avoidance of sunlight exposure, and multiple dietary factors as a result of specific cultural beliefs. Vitamin D resistance due to calcium deficiency mechanisms has been described in similar population groups, which may lead to hypovitaminosis D.
Should the new diseases related to hypovitaminosis D prove to be truly associated, Africa and the Middle East will become an epicentre for many of these conditions. Urgent attention will need to be paid to cultural dress and dietary behaviours if hypovitaminosis D is to be taken seriously. Should such factors not be correctable, new strategies for supplementation or food fortification will have to be devised.
Author R.J. GreenSource: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7915More Less
This issue of CME is dedicated to nutrition and malnutrition in young children. It is an important topic in paediatric medicine and child health, because toddlers start feeding independently and lifelong feeding patterns for health are thus set in motion. Malnutrition as a result of protein or energy deficiency or chronic illness is relatively common in this age group, even in our modern world.