South African Medical Journal - Volume 105, Issue 8, 2015
Volumes & issues
Volume 105, Issue 8, 2015
Author Janet SeggieSource: South African Medical Journal 105, pp 615 –616 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8217More Less
Measuring a nation's happiness - Gross National Happiness (GNH) - in the manner of measuring Gross National Product (GNP) would seem frivolous, but is increasingly being taken seriously. Happiness has come to be considered a measure of social progress. Psychologists, economists and sociologists have shown that people's satisfaction with their lives offers information about a society. National governments have begun to use measures of happiness, or subjective wellbeing, to guide development of policies aimed at improving people's lives.
Source: South African Medical Journal 105, pp 616 –617 (2015)More Less
CME: Fits, faints and funny turns
Non-communicable diseases in South Africa
Anterior chamber paracentesis to improve diagnosis and treatment of infectious uveitis
Human papillomavirus genotypes and clinical management of genital warts
Carcinogenic nitrosamines in traditional beer as the cause of oesophageal squamous cell carcinoma in black South Africans
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7810More Less
The African region bears more than 24% of the global burden of disease, but has access to less than 1% of the financial resources. Access to healthcare is a significant concern in South Africa (SA), and financial cost is a recognised cause of lack of access to adequate healthcare. Furthermore, increasing healthcare costs affect healthcare decisions taken by poorer households, further decreasing their already limited access. Resource scarcity also determines the standard of care, and higher costs have been shown to have a negative impact on patient outcomes. The cost of healthcare can also affect other aspects of living, and for some members of society can mean the choice between medication and essentials of living such as food.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8328More Less
Myasthenia gravis (MG) is a rare but treatable disease. Early recognition and treatment can prevent mortality and morbidity, thereby reducing the burden of the disease. In 85 - 90% of cases, the diagnosis is made with an acetylcholine receptor antibody (AChR) radioimmunoprecipitation assay. As a diagnostic test, the assay is 99.9% specific for the presence of MG. We recently reported the incidence of AChR-positive MG in South Africa (SA) based on all the laboratory data over a 2-year period (2011 - 2012). Here, we highlight two issues emanating from that research of importance to specialist services delivery and MG management.
Source: South African Medical Journal 105, pp 620 –621 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8082More Less
She's known countrywide as the strident public health activist voice of the South African Medical Association (SAMA), slamming national and provincial health departments wherever there's dismal patient care, drug stock-outs or non-payment of doctor salaries - you name the dysfunction. Now suddenly she's the surprise MEC for Health in one of the country's most bankrupt and historically corruption-ridden provinces - Limpopo.
Source: South African Medical Journal 105, pp 621 –623 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8083More Less
Worldwide, and particularly in South Africa (SA), patients are unwittingly forced to suffer in silence because doctor training in formal pain management is almost nonexistent, with the best local medical campus undergraduate pain training consisting of 'about four hours' in a student's fourth or fifth year.
Source: South African Medical Journal 105, pp 623 –625 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8123More Less
Nearly two million South African (SA) men will have been voluntarily circumcised by the end of this year, about half of the government's original target - yet even this will have conservatively prevented 133 333 new HIV infections as a timely new public/private sector initiative kicks in to boost overall efforts. In spite of this, alarm bells continue to ring as interventions for women, twice as vulnerable biologically and culturally, remain in various stages of trial.
Pharmaceuticals, Corporate Crime and Public Health, G. Dukes, J. Braithwaite and J.P. Moloney : izindaba - book reviewAuthor R.S. SummersSource: South African Medical Journal 105 (2015)More Less
This comprehensive, probing and helpful book can be described as 'compulsory reading for all responsible healthcare practitioners'. Its three authors have a long history of association with and analysis of the international pharmaceutical industry, having identified and written about a range of its activities for the past half century. In this book they go one step further than the usual criticisms by offering achievable strategies to improve practices and result in more positive outcomes than those that have beset the industry over so many years. The fact that malpractice appears to be on the increase is adequate reason for updating the picture and offering remedies, as they have done.
Source: South African Medical Journal 105, pp 626 –627 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8271More Less
'Cochrane Corner' in the August SAMJ offers evidence relating to articles published in this issue, namely 'Improving access to antiretrovirals in rural South Africa - a call to action', 'Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa' and 'Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey', and the editorial by Yach and Alexander, 'Turbo-charging tobacco control in South Africa'.
Anterior chamber paracentesis to improve diagnosis and treatment of infectious uveitis in South Africa : forum - healthcare deliverySource: South African Medical Journal 105, pp 628 –630 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7816More Less
Infectious uveitis is a significant cause of blindness in South Africa, especially among HIV-infected individuals. The visual outcome of uveitis depends on early clinical and laboratory diagnosis to guide therapeutic intervention. Analyses of aqueous humor obtained by anterior chamber paracentesis direct the differential diagnosis in infectious uveitis. However, although safe and potentially cost-effective, diagnostic anterior chamber paracentesis is not common practice in ophthalmic care across Africa. We draw attention to this important procedure, which could improve the diagnosis and prognosis of infectious uveitis.
Patient support interventions to improve adherence to drug-resistant tuberculosis treatment : a counselling toolkit : forum - healthcare deliverySource: South African Medical Journal 105, pp 631 –634 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7803More Less
In response to the growing burden of drug-resistant tuberculosis (DR-TB) in South Africa (SA), Médecins Sans Frontières (MSF), with local government health departments, piloted a decentralised model of DR-TB care in Khayelitsha, Western Cape Province, in 2007. The model takes a patient-centred approach to DR-TB treatment that is integrated into existing TB and HIV primary care programmes. One essential component of the model is individual and family counselling to support adherence to and completion of treatment. The structured and standardised adherence support sessions have been compiled into a DR-TB counselling toolkit. This is a comprehensive guide that focuses on DR-TB treatment literacy, adherence strategies to encourage retention in care, and provision of support throughout the patient's long treatment journey. Along with other strategies to promote completion of treatment, implementation of a strong patient support component of DR-TB treatment is considered essential to reduce rates of loss from treatment among DR-TB patients. We describe our experience from the implementation of this counselling model in a high DR-TB burden setting in Khayelitsha, Cape Town, SA.
Source: South African Medical Journal 105, pp 635 –636 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7821More Less
The early black doctors who qualified from foreign medical schools between 1883 and 1940 were pioneers in the history of South Africa. They made seminal contributions to the struggle against colonialism and apartheid, established the principle of fighting against racism in healthcare through the courts, and were trailblazers in academic medicine. They have bequeathed a remarkable legacy to the new South Africa.
Source: South African Medical Journal 105, pp 637 –638 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8032More Less
Tobacco continues to be the leading cause of death and disease worldwide. Globally, the prevalence of smoking among adults decreased between 1980 and 2012 from 41% to 31% for men and from 11% to 6% for women, yet the number of smokers increased to nearly 1 billion by 2012. Tobacco use by girls is increasing in many countries, and unless effectively addressed will result in increased risk for the next generation of women. While media attention to global tobacco has waned, the harm it causes is increasing.
Source: South African Medical Journal 105, pp 638 –640 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8265More Less
South Africa (SA) already has the world's biggest antiretroviral (ARV) programme. With the introduction of extended criteria for initiating ARVs, the National Department of Health (NDoH) wishes to increase the number of people on ARVs by around two million over the next 2 years. Adoption of a chronic disease management model, with extended task shifting, decentralisation and new approaches to distribution of ARVs, must be embraced if this is to be successfully achieved without huge increases in resources. In this editorial we discuss the need for change, and the current substantial blocks to progress (principally in prescribing and dispensing legislation) that contradict national treatment guidance and should be addressed as a matter of urgency. In addition, we draw attention to threatened regulatory changes that may further worsen the situation.
Multimorbidity, control and treatment of noncommunicable diseases among primary healthcare attenders in the Western Cape, South Africa : researchSource: South African Medical Journal 105, pp 642 –647 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7882More Less
Background. South Africa (SA) is facing a heavy burden of non-communicable diseases (NCDs). Few studies address multimorbidity, control and treatment of NCDs in patients attending primary healthcare (PHC) clinics.
Objectives. To describe multimorbidity, related risk factors, disease severity and treatment status of patients with four important NCDs attending public sector PHC clinics in two districts in SA.
Methods. A cross-sectional sample of patients completed baseline data collection for a randomised controlled trial of a health systems intervention. The study population comprised adults attending PHC clinics in the Eden and Overberg districts of the Western Cape in 2011. Four subgroups of patients were identified: hypertension, diabetes, chronic respiratory disease and depression. A total of 4 393 participants enrolled from 38 clinics completed a baseline structured questionnaire and had measurements taken. Prescription data were recorded.
Results. Of participants with hypertension, diabetes, respiratory disease and depression, 80%, 92%, 88% and 80%, respectively, had at least one of the other three conditions. There were low levels of control and treatment: 59% of participants with hypertension had a blood pressure ≥140/90 mmHg, the mean haemoglobin A1c (HbA1c) value in participants with diabetes was 9%, 12% of participants in the depression group were prescribed an antidepressant at a therapeutic dose, and 48% of respiratory participants were prescribed a β2-agonist and 34% an inhaled corticosteroid.
Conclusion. Considerable multimorbidity and unmet treatment needs exist among patients with NCDs attending public sector PHC clinics. Improved strategies are required for diagnosing and managing NCDs in this sector.
Prevalence of tobacco use among adults in South Africa : results from the first South African National Health and Nutrition Examination Survey : researchSource: South African Medical Journal 105, pp 648 –655 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7932More Less
Background. Data on tobacco use have informed the effectiveness of South Africa (SA)'s tobacco control strategies over the past 20 years.
Objective. To estimate the prevalence of tobacco use in the adult SA population according to certain demographic variables, and identify the factors influencing cessation attempts among current smokers.
Methods. A multistage disproportionate nationally representative stratified cluster sample of households was selected for the South African National Health and Nutrition Examination Survey, conducted in 2012. A sample of 10 000 households from 500 census enumerator areas was visited. A detailed questionnaire was administered to all consenting adults in each consenting household.
Results. Of adult South Africans, 17.6% (95% confidence interval (CI) 6.3 - 18.9) currently smoke tobacco. Males (29.2%) had a prevalence four times that for females (7.3%) (odds ratio 5.20, 95% CI 4.39 - 6.16; p< 0.001). The provinces with the highest current tobacco smoking prevalence were the Western Cape (32.9%), Northern Cape (31.2%) and Free State (27.4%). Among current tobacco smokers, 29.3% had been advised to quit smoking by a healthcare provider during the preceding year, 81.4% had noticed health warnings on tobacco packages, and 49.9% reported that the warning labels had led them to consider quitting.
Conclusion. A large proportion of adult South Africans continue to use tobacco. While considerable gains have been made in reducing tobacco use over the past 20 years, tobacco use and its determinants need to be monitored to ensure that tobacco control strategies remain effective.
Carcinogenic nitrosamines in traditional beer as the cause of oesophageal squamous cell carcinoma in black South Africans : researchSource: South African Medical Journal 105, pp 656 –658 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7935More Less
Background. Before the 1930s, squamous cell carcinoma (SCC) of the oesophagus was almost unknown among black South Africans. From the 1930s the annual frequency rose. A dietary cause was sought, the staple diet of black people having changed from sorghum to maize (corn), with traditional beer being brewed from maize. Carcinogenic N-nitrosamines in traditional beer were suggested as a cause of SCC of the oesophagus, with Fusarium moniliforme, a corn saprophyte, thought to play a role.
Objectives. To confirm the presence of N-nitrosamines in traditional beer and demonstrate a mechanism for the oncogenesis of oesophageal carcinoma.
Methods. Analysis by high-performance liquid chromatography was conducted for the identification of nitrosamines in traditional beer samples, and molecular docking studies were employed to predict the affinity between N-nitrosamines and the S100A2 protein.
Results. Carcinogenic N-nitrosamines were identified in all six samples of traditional beer examined (N=18 analyses), and docking studies confirmed a high affinity of the nitrosamine N-nitrosopyrrolidone with the S100A2 protein. This may result in the altered expression of the S100A2 protein, leading to tumour progression and prognosis.
Conclusion. It is suggested that carcinogenic N-nitrosamines in traditional beer are a major factor in the causation of SCC of the oesophagus in black South Africans. N-nitrosamines have been shown to produce cancer experimentally, but there has not been conclusive epidemiological evidence that N-nitrosamines are carcinogenic to humans. This study is the first to demonstrate the potential link between N-nitrosamines and a human tumour.
Do low levels of physical activity in female adolescents cause overweight and obesity? Objectively measured physical activity levels of periurban and rural adolescents : researchAuthor I. CookSource: South African Medical Journal 105, pp 659 –663 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7791More Less
Background. The increase in obesity levels in South African adolescents is attributed to an energy imbalance such that physical inactivity is causally related to adiposity. However, in some settings obesity occurs in spite of high physical activity levels.
Objectives. To examine objectively measured physical activity levels of rural black female and male adolescents from periurban to rural settings in relation to weight status, and specifically the direction and strength of the associations.
Methods. Seven-day accelerometry-derived pedometry data (step counts and activity energy expenditure) were collected for 178 adolescents (85 females, 93 males; age 13.7 - 18.0 years) living in six demographic surveillance site villages. Anthropometric measures were body mass index (kg/m2), waist circumference (cm) and sum of skinfolds (mm). Weight status was determined using international growth standards for stunting, underweight (UW), normal weight (NW), overweight (OW) and obesity (OB).
Results. Females had greater adiposity and lower 7-day average step counts and activity energy expenditure, and achieved fewer days at ≥10 000 steps and more days at < 5 000 steps (p< 0.05). The age and gender-weighted prevalences for female/male stunting, UW-NW, OW-OB, < 5 000 steps/day and ≥12 500 steps/day were 12.4%/20.7%, 74.3%/99.1%, 25.8%/0.9%, 12.3%/0.9% and 50%/64.9%, respectively (females v. males, p< 0.05). In multivariate models (weighted and adjusting for age, gender, village, season), step counts and activity energy expenditure were positively related to adiposity measures (p< 0.05).
Conclusion. Both UW-NW and OW-OB periurban to rural adolescents were active to highly active on most days of the week. Physical activity was directly associated with adiposity measures.
The case for expanding the definition of 'key populations' to include high-risk groups in the general population to improve targeted HIV prevention efforts : researchSource: South African Medical Journal 105, pp 664 –669 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7918More Less
Background. Two additional key populations within the general population in South Africa (SA) that are at risk of HIV infection are black African women aged 20 - 34 years and black African men aged 25 - 49 years.
Objective. To investigate the social determinants of HIV serostatus for these two high-risk populations.
Methods. Data from the 2012 South African National HIV Prevalence, Incidence, and Behaviour Survey were analysed for black African women aged 20 - 34 years and black African men aged 25 - 49 years.
Results. Of the 6.4 million people living with HIV in SA in 2012, 1.8 million (28%) were black women aged 20 - 34 years and 1.9 million (30%) black men aged 25 - 49 years. In 2012, they constituted 58% of the total HIV-positive population and 48% of the newly infected population. Low socioeconomic status (SES) was strongly associated (p< 0.001) with being HIV-positive among black women aged 20 - 34 years, and was marginally significant among black men aged 25 - 49 years (p< 0.1).
Conclusion. Low SES is a critical social determinant for HIV infection among the high-risk groups of black African women aged 20 - 34 years and black African men aged 25 - 49 years. Targeted interventions for these key populations should prioritise socioeconomic empowerment, access to formal housing and services, access to higher education, and broad economic transformation.
Source: South African Medical Journal 105, pp 670 –674 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7886More Less
Background. Colorectal cancer (CRC) is one of the most common types of cancer, affecting 3 - 5% of the global population. K-ras proto-oncogene and TP53 tumour suppressor gene mutations are among the most common genetic alterations detected in advanced colorectal tumours.
Objective. To investigate the role of K-ras codon 12 and TP53 exons 5 - 9 mutations in late-stage CRC patients.
Methods. Blood samples were collected from 249 CRC patients, of whom 147 presented with advanced carcinoma. K-ras codon 12 mutations were analysed using polymerase chain reaction-restriction fragment length polymorphism, while direct sequencing was used in screening for TP53 exons 5 - 9 mutations.
Results. No significant changes were observed in TP53 exons 5 - 9, except for two cases in which nucleotide replacements were observed in the non-coding regions in intron 4 (c.376-19C>T) and intron 9 (c.993+12T>C). Heterozygous mutations in K-ras codon 12 were observed in 79 individuals suffering from advanced CRC (53.7%). Colon and rectal tumours were equally distributed among the heterozygotes, but colon tumours were mostly present in wild-type homozygotes (84.6%). There was also a predominance of Caucasians among heterozygotes and a predominance of Asians among the wild-type homozygotes.
Conclusion. Analysis of peripheral blood samples of CRC patients suffering from advanced carcinoma has prognostic value only for K-ras codon 12 mutations, and not for TP53 mutations.