Background. Breast cancer is the leading cancer among South African (SA) women. SA has citizens from diverse ethnic groups, and the lifetime risk of breast cancer differs according to ethnicity. Candidate genes for increased breast cancer risk are those involved in DNA damage repair pathways, and mutations in these genes are characterised by increased chromosomal radiosensitivity. Several European studies have shown that breast cancer patients are more sensitive to ionising radiation than healthy individuals.
Objectives. To investigate the in vitro chromosomal radiosensitivity of SA women with breast cancer and the possible influence of ethnicity and clinical parameters on chromosomal radiosensitivity.
Methods. Chromosomal radiosensitivity was analysed with the micronucleus assay using lymphocytes of breast cancer patients and healthy individuals of different ethnic groups. Lymphocytes were irradiated in vitro with 2 Gy or 4 Gy, and micronuclei (MN) were scored 70 hours after irradiation. These MN frequencies were correlated with the ethnicity and clinical parameters of the breast cancer patients.
Results. MN values were higher in breast cancer patients than in healthy controls. This was noted for black and white breast cancer patients at the different radiation doses. No correlations could be demonstrated between MN values and clinical parameters of the breast cancer, except that MN values were significantly higher in oestrogen receptor (ER)-positive breast cancers.
Conclusion. SA breast cancer patients have elevated chromosomal radiosensitivity compared with healthy controls. ER positivity also influences chromosomal radiosensitivity.
Background. Genital human papillomavirus (HPV) infection is the most common sexually transmitted viral disease in the world. HPV infection of the genital epithelium is associated with genital warts and malignancies of the lower genital tract.
Objectives. To describe the distribution, phenotypic appearance and HPV type associated with genital warts in women.
Methods. This was a prospective observational study of all women with genital warts who attended the Colposcopy Clinic, Groote Schuur Hospital, Cape Town, South Africa, during 2010 and fulfilled the inclusion and exclusion criteria. One hundred and thirteen women were tested for HPV using the Roche Linear Array HPV genotyping kit to determine the HPV genotypes causing genital warts.
Results. The median age of the women was 27 years (range 15 - 53); 90 (79.6%) were HIV-positive, and two-thirds were on antiretroviral treatment. Treatment involved ablation with topical agents, cauterisation or carbon dioxide laser. At 3 months' follow-up after treatment, 56.6% of the women, the majority of whom were HIV-positive, had recurrent/persistent disease. In both HIV-positive and HIV-negative women, HPV was detected in over 90% of cases. However, over half the HIV-positive women as opposed to 2/18 of the HIV-negative women were infected with multiple HPV genotypes. The commonest HPV genotypes in HIV-positive and HIV-negative women were types 11, 6, 89, 61, 55 and 62 and types 11 and 6, respectively.
Conclusions. The majority of the patients were HIV-positive and had multiple HPV infections. While this did not alter the phenotypic appearance of the warts, recurrence/persistence after treatment was more common.
Background. South Africa (SA) has a burgeoning problem of methamphetamine use, particularly in the Western Cape Province. Although methamphetamine has been associated with elevated psychological distress, there has been little examination of the mental health needs of out-of-treatment methamphetamine users in SA.
Objective. To describe the mental health experiences and needs of out-of-treatment methamphetamine users in Cape Town.
Methods. Active methamphetamine users were recruited using respondent-driven sampling techniques. Eligible participants (N=360) completed a computer-assisted assessment and clinical interview, where they provided data on mental health symptoms and treatment-seeking behaviour. A subset of 30 participants completed qualitative in-depth interviews in which they provided narrative accounts of their mental health experiences and needs. Analysis of the mixed-methods data was conducted using a concurrent triangulation strategy whereby both methods contributed equally to the analysis and were used for cross-validation.
Results. About half of the participants met screening criteria for depression and traumatic stress, and there were some indications of paranoia. Using substances to cope with psychological distress was common, with participants talking about using methamphetamine to numb their feelings or forget stressful memories. One-third of women and 13% of men had previously tried to commit suicide. Despite the huge mental health burden in this population, very few had ever received mental health treatment.
Conclusion. The data indicate a need for integrated care that addresses both substance use and psychiatric needs in this population. Mental health and drug treatment services targeting methamphetamine users should include a concerted focus on suicide prevention.
Fits, faints and funny turns represent a common reason for presentation - either to the general practitioner or to the emergency department. In many cases, the consultation is dissatisfying for the doctor and the patient, as such patients frequently present a diagnostic dilemma for the clinician. Frequently, the key to a satisfactory evaluation is a structured approach, premised on a clear and comprehensive history focused on prior comorbidities and the episode - its context, precipitating factors, prior situational factors, onset and evolution, and events occurring afterwards. A detailed and carefully elicited medical history allows the clinician to confirm the diagnosis, delineate the underlying mechanism, and identify features that may suggest high risk of recurrence, injury or death.
Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medical presentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implement a mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease, rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains the most important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised into vasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope (from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope that cannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural (mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined as a decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes of orthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should be managed urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medication and provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to be the cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to remember that in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and prevent recurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequently referred to a cardiologist for appropriate management.
The key to understanding and managing epilepsy is to decide whether seizures are genetic/idiopathic or caused by focal brain pathology. The classification of seizures was modified in 2010 after many variations of the original 1981 system and inconclusive debate. Major changes included abandoning many entrenched words and complete rejection of the Focal subsystem. While most of the reasoning is rational, the focal system is described in a long list of terms; general clinicians are therefore faced with a more challenging task than that required for understanding the old classification system. Some of the difficulties include using common words with non-intuitive neurological definitions, ambiguous words and the tendency to merge seizure categorisation with epilepsy. This article highlights some of the fundamental principles in trying to categorise seizures and offers a simplified way of using descriptive words to structure the organisation of Focal seizures. Focal seizures are broken down to A, B and C - an easy-to-remember schema for general clinicians, patients and carers. Words such as 'Aura' and 'Blank stare' are strategically used to represent old seizure types and how they may be linked in the same patient. Awareness or the lack thereof is explained and how the same patient may have different seizure types and combinations of these. There is less change in the Generalised seizures category, but these are often confused with Focal seizures. Absences are confused with blank stares, while Generalised Tonic-Clonic seizures (GTCSs) are confused with 'Focal-onset evolving rapidly to GTCSs'. Diagrams to illustrate the concepts of Generalised and Focal are included, as well as tables to demonstrate the differences between seizures that appear similar and points to consider in separating them. Focal seizures may mimic almost any human behaviour. Sorting and grouping the symptoms of Focal seizures with awareness (auras) is covered, along with sorting both the former and those without awareness seizures (As and Bs) by brain lobes. Distinguishing between Generalised and Focal seizures is not merely an academic exercise. It assists in determining the aetiology and has a material impact on the choice of management. Appropriate management of seizures starts with identifying the various seizure types. Time will tell whether or not this new descriptive approach to organisation of seizures makes the task easier and more effective.
There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that their patient's complaint is giddiness. This frequently means that after exhaustive enquiry it will still not be entirely clear what it is that the patient feels wrong and even less so why he feels it. (W B Mathews)
Contrary to this prevalent view, in recent years advances in the diagnosis and management of common vestibular disorders have made the clinical evaluation of the dizzy patient more rewarding. An accurate diagnosis may be possible in the majority of patients presenting with acute vertigo when a directed history is taken and an examination is performed. Specific and effective treatments are available for many patients. This article describes the clinical evaluation of a patient with acute vertigo, and highlights selected common and important conditions.
Gait instability and falls are common in elderly persons and have devastating consequences, with substantial morbidity and mortality. Furthermore, they are a precipitant for functional decline, increasing frailty and institutionalisation. The rate of falls and severity of complications increase with age and frailty. A consequence of falls with or without injury is that at least a third of persons develop a fear of falling, which leads to functional decline and a progressive decline in gait. The causes of falls in elderly persons are multifactorial and include physiological changes of ageing, frailty, pathologies, and environmental and situational factors. Maintaining postural control requires a complex integration of sensory input, central processing, motor co-ordination and musculoskeletal function, which decrease with ageing. This change, combined with sarcopenia, leads to slowed and weakened postural control and muscle responses, resulting in gait instability and falls.
The assessment and management of a patient who is at risk of falls or who has fallen require a multidisciplinary approach to identify and address factors contributing to the fall. The assessment, which includes history, physical examination, and evaluation of gait, postural control and mental function, is aimed at identifying situational and associated factors surrounding a fall, intrinsic impairments in gait or pathologies that increase the risk of falls. The components of the assessment comprise a full medical evaluation for pathologies, including vision, medication review (including over-the-counter medication) with regard to polypharmacy and high-risk medications, psychogeriatric review, functional status (instrumental activities of daily living (IADLs) and activities of daily living (ADLs)), functional assessment of gait and balance, and assessment of environmental hazards in the home. Laboratory investigations are guided by clinical suspicions or diagnoses arising from the medical assessment and screening for common conditions that may increase the risk of falls.
Management and prevention of falls focus on maintaining mobility and balance, and identifying those at risk of a fall for multidisciplinary assessment and intervention. Intervention to reduce the risk of subsequent falls is targeted at modification of the contributory factors. Intervention includes management of underlying pathologies, strength and balance training by a physiotherapist, assessment and modification of environmental hazards in the home by an occupational therapist, medication review and rationalisation of high-risk medications and polypharmacy, and supplementation of vitamin D where indicated.