South African Medical Journal - Volume 106, Issue 4, 2016
Volumes & issues
Volume 106, Issue 4, 2016
Author Bridget FarhamSource: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10764More Less
As the new year started, this caught my eye in my daily trawl of online news: 'Potato-rich diet "may increase pregnancy diabetes risk"'. This BBC news item, based on an article in the British Medical Journal, suggests that women who eat potatoes in any form most days of the week have an increased risk of diabetes during pregnancy. The risk is probably triggered by the massive rise in blood sugar levels that all starchy carbohydrates cause. But the interesting thing about the news item was not so much the potentially increased risk of gestational diabetes caused by eating potatoes daily, but the comment of 'British experts' who said the 'proof was lacking' and that people need to eat lots of starchy foods for fibre, as well as fresh fruit (known to be high in sugars) and vegetables. The UK advice is that people should get about one-third of their daily intake from starchy foods such as potatoes, and there is no limit to how much carbohydrate people should eat.
Author Hannah KikayaSource: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10817More Less
Medical journals, unlike their basic science cousins, are the link between medical science and practice. Not only do they seek to disseminate new knowledge, but they also intend to influence outcomes - the application of new knowledge to the treatment of patients. But this laudable goal creates a dilemma: who are medical journals actually for? The scientists or the doctors? Or perhaps the small group of specialists who are both?
Source: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10634More Less
To the Editor: We read with great interest the article on the public health issue of 'The simple bread tag - a menace to society?' in the May 2015 issue of the SAMJ.
We are delighted that the authors have directed the medical fraternity to one of the most common public health problems in early childhood, and agree that these bread tags should be removed from use.
Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin : correspondenceSource: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016v106i4.10711More Less
To the Editor: In October 2014, a communication from the Department of Health substituted azithromycin for erythromycin for penicillin-allergic patients. This was for certain conditions including acute rheumatic fever and prophylaxis of rheumatic fever.
It has recently been suggested that owing to the challenges with the availability of oral penicillin, azithromycin should be used as a penicillin substitute for patients who are not allergic to penicillin.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10765More Less
Source: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10763More Less
Longstanding critical staff shortages in the maternity unit at Port Elizabeth's Dora Nginza Hospital came to a head in mid-February with a 3-day nurses' strike, the enforced departure of the CEO, and nearly burnt-out doctors being prevented from doing ward rounds by strikers.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10762More Less
The ranks of senior public healthcare administrators swelled by 12% over the past 3 years v. a 3.5% growth among all physicians, pharmacists and pathologists over the same period. This previously unpublicised skewed progression has further bolstered appeals by healthcare professional groups to stop the wide-scale, debilitating freezing of clinical posts.
Author Marika SborosSource: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10764More Less
The Health Professions Council of South Africa (HPCSA) this February closed its case against University of Cape Town emeritus professor Tim Noakes on a charge of unprofessional conduct and will resume with cross-examination of the controversial A-rated scientist on 17 October.
Author D. BenatarSource: South African Medical Journal 106, pp 323 –324 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10569More Less
Unpacking the new proposed regulations for South African traditional health practitioners : editorialSource: South African Medical Journal 106, pp 325 –326 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10623More Less
Traditional health practitioners (THPs) are an integral part of the history and culture of South Africa (SA). Many traditional healers and users of traditional medicine agree that there is a need to regulate the system. To this end, over the years, healers have initiated over 100 different traditional healer associations countrywide. More recently, however, steps have been taken to regulate the estimated 200 000 THPs under one professional statutory body.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10704More Less
This issue of CME profiles acute viral bronchiolitis - a common condition that is often not serious. Nonetheless, each year a number of infants, particularly those with an underlying susceptibility to severe disease, are admitted to hospital or even to paediatric intensive care units. This series of articles highlights the diagnostic principles involved, and emphasises the principles of management and prevention.
Source: South African Medical Journal 106, pp 328 –329 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10441More Less
Bronchiolitis may be diagnosed on the basis of clinical signs and symptoms. In a young child, the diagnosis can be made on the clinical pattern of wheezing and hyperinflation.
Clinical symptoms and signs typically start with an upper respiratory prodrome, including rhinorrhoea, low-grade fever, cough and poor feeding, followed 1 - 2 days later by tachypnoea, hyperinflation and wheeze as a consequence of airway inflammation and air trapping.
The illness is generally self limiting, but may become more severe and include signs such as grunting, nasal flaring, subcostal chest wall retractions and hypoxaemia. The most reliable clinical feature of bronchiolitis is hyperinflation of the chest, evident by loss of cardiac dullness on percussion, an upper border of the liver pushed down to below the 6th intercostal space, and the presence of a Hoover sign (subcostal recession, which occurs when a flattened diaphragm pulls laterally against the lower chest wall).
Measurement of peripheral arterial oxygen saturation is useful to indicate the need for supplemental oxygen. A saturation of < 92% at sea level and 90% inland indicates that the child has to be admitted to hospital for supplemental oxygen. Chest radiographs are generally unhelpful and not required in children with a clear clinical diagnosis of bronchiolitis.
Blood tests are not needed routinely. Complete blood count tests have not been shown to be useful in diagnosing bronchiolitis or guiding its therapy. Routine measurement of C-reactive protein does not aid in management and nasopharyngeal aspirates are not usually done. Viral testing adds little to routine management.
Risk factors in patients with severe bronchiolitis that require hospitalisation and may even cause death, include prematurity, congenital heart disease and congenital lung malformations.
Source: South African Medical Journal 106, pp 330 –332 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10437More Less
Management of acute viral bronchiolitis is largely supportive. There is currently no proven effective therapy other than oxygen for hypoxic children. The evidence indicates that there is no routine benefit from inhaled, rapid short-acting bronchodilators, adrenaline or ipratropium bromide for children with acute viral bronchiolitis. Likewise, there is no demonstrated benefit from routine use of inhaled or oral corticosteroids, inhaled hypertonic saline nebulisation, montelukast or antibiotics. The last should be reserved for children with severe disease, when bacterial co-infection is suspected.
Prevention of respiratory syncytial virus (RSV) disease remains a challenge. A specific RSV monoclonal antibody, palivizumab, administered as an intramuscular injection, is available for children at risk of severe bronchiolitis, including premature infants, young children with chronic lung disease, immunodeficiency, or haemodynamically significant congenital heart disease. Prophylaxis should be commenced at the start of the RSV season and given monthly during the season. The development of an RSV vaccine may offer a more effective alternative to prevent disease, for which the results of clinical trials are awaited.
Education of parents or caregivers and healthcare workers about diagnostic and management strategies should include the following: bronchiolitis is caused by a virus; it is seasonal; it may start as an upper respiratory tract infection with low-grade fever; symptoms are cough and wheeze, often with fast breathing; antibiotics are generally not needed; and the condition is usually self limiting, although symptoms may occur for up to 4 weeks in some children.
A call to action : addressing the reproductive health needs of women with drug-resistant tuberculosis : in practice - healthcare deliverySource: South African Medical Journal 106, pp 333 –334 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016v106i4.10205More Less
Although there is substantial risk to maternal and neonatal health in the situation of pregnancy during treatment for rifampicin-resistant tuberculosis (RR-TB), there is little evidence to guide clinicians as to how to manage this complexity. Of the 49 680 patients initiated on RR-TB treatment from 2009 to 2014 in South Africa, 47% were women and 80% of them were in their reproductive years (15 - 44). There is an urgent need for increased evidence of the safety of RR-TB treatment during pregnancy, increased access to contraception during RR-TB treatment, and inclusion of reproductive health in research on the prevention and treatment of TB.
Source: South African Medical Journal 106, pp 335 –341 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10671More Less
Background. Hand hygiene is an important and basic practice that should be used by all healthcare staff to protect both themselves and their patients against infection. Unfortunately hand hygiene compliance remains poor.
Objective. To show an improvement in hand hygiene compliance using a multifaceted approach.
Methods. This was a quasi-experimental pre-post intervention study design with a number of standardised interventions to promote hand hygiene. The World Health Organization hand hygiene multimodal (five-step) intervention approach was used. The study ran from June2015 to August 2015 in 11 selected wards of a 975-bed tertiary and quaternary care public hospital (Groote Schuur Hospital, Cape Town, South Africa). The outcome was to assess improvement in hand hygiene compliance monthly over the 3 months, compared with non-intervention wards and compared with the wards' own performance measured in 2014. The study included both descriptive and analyticalcomponents.
Results. Post intervention, hand hygiene compliance showed a statistically significant improvement for before patient contact from 34% in 2014 to 76% in 2015 (p< 0.05) and for after patient contact from 47% in 2014 to 82% in 2015 (p< 0.05).
Conclusion. The intervention improved hand hygiene compliance and can easily be replicated in other wards, resulting in sustaining a culture of hand hygiene improvement and behavioural change throughout the hospital.
Intracranial complications of Serratia marcescens infection in neonates : in practice - clinical alertSource: South African Medical Journal 106, pp 342 –344 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10206More Less
Even though Serratia marcescensis not one of the most common causes of infection in neonates, it is associated with grave morbidity and mortality. We describe the evolution of brain parenchymal affectation observed in association with S. marcescens infection in neonates. This retrospective case series details brain ultrasound findings of five neonates with hospital-acquired S. marcescens infection. Neonatal S. marcescens infection with or without associated meningitis can be complicated by brain parenchymal affectation, leading to cerebral abscess formation. It is recommended that all neonates with this infection should undergo neuro-imaging more than once before discharge from hospital; this can be achieved using bedside ultrasonography.
Biofilms associated with bowel necrosis : a newly recognised phenomenon in infants : in practice - clinical alertSource: South African Medical Journal 106, pp 345 –347 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10425More Less
Background. A biofilm is defined as a collection of organisms attached to a surface and surrounded by a matrix.
Objective.To present three cases in which bowel necrosis coexisted with biofilm.
Methods.The medical records, bacteriological findings and tissue biopsies from three infants with bowel necrosis who subsequently died from sepsis were analysed. Tissue sent for histological evaluation was prepared for light microscopy. Haematoxylin and eosin (H&E), Sandiford and Alcian blue/periodic acid Schiff (ABPAS) stains were performed. Tissue samples were ex-waxed for electron microscopy in one case.
Results.The three patients described all had necrotic bowel at laparotomy, all cultured Klebsiella pneumoniae from peritoneal pus swabs, and all died despite appropriate antibiotics. All specimens showed varying degrees of bowel necrosis and an organising acute peritoneal reaction. In addition, all showed colonies of Gram-negative bacteria within a mucopolysaccharide matrix.
Conclusions.The identification of biofilms in necrotic bowel has raised questions regarding their clinical implications. Further studies are needed to evaluate all resected necrotic bowel for biofilms and the clinical implications of this finding.
A child's potential claim for negligent misdiagnosis : the case of H v. Fetal Assesment Centre : in practice - medicine and the lawAuthor P. MaherySource: South African Medical Journal 106, pp 348 –349 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016v106i4.9724More Less
South African law recognises a financial claim against a health provider for negligently failing to advise an expectant mother that she might give birth to a child suffering from a severe health condition or congenital disability. In December 2014, the Constitutional Court handed down a judgment that could lead to financial claims by the child, who was subsequently born with a severe health condition or disability. This judgment thus creates a framework to legally recognise a claim by a child whose current health condition was negligently misdiagnosed before birth. The contents and effects of the judgment are discussed in this article.
The impact of the Medicines Control Council backlog and fast-track review system on access to innovative and new generic and biosimilar medicines of public health importance in South Africa : in practice - issues in public healthSource: South African Medical Journal 106, pp 350 –353 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016.v106i4.10237More Less
The fast-track registration policy of the South African (SA) National Department of Health (DoH) allows for rapid registration of new medicines of public health importance and of all medicines on the Essential Medicines List, most of which are generics. No limit is placed on the number of generic brands of a medicine that can be submitted for fast-track registration. This, together with resource constraints at the regulator, may delay access to important new medicines, new fixed-dose combinations of critical medicines or affordable versions of biological medicines (biosimilars). One reason for not limiting the number of fast-track generic applications was to promote price competition among generic brands. We found this not to be valid, since market share correlated poorly with price. Generic brands with high market share were, mostly, those that were registered first. We propose that the number of generic brands accepted for fast-tracking be limited to not more than seven per medicine.
Orbital apex syndrome caused by aspergilloma in an immunocompromised patient with cutaneous lymphoma : a case report of a rare entity : in practice - case reportSource: South African Medical Journal 106, pp 354 –355 (2016) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJ.2016v106i4.9936More Less
A 57-year-old man with a history of chemotherapy because of cutaneous lymphoma presented with an orbital apex syndrome. The cranial computed tomography scan revealed a tumour in the orbital apex, extending intradurally. With a suspected diagnosis of a neoplastic lesion, the patient underwent orbital surgery with optic nerve decompression. Histology revealed an aspergilloma. No other foci were seen and treatment with antifungals was started. In immunocompromised patients with intracranial tumours, infection is always a major consideration in the differential diagnosis, even if the reason for immunosuppression (in this case chemotherapy) dates back several months. Misdiagnosing an orbital apex lesion as a cancer and treating patients primarily with corticosteroids can be life threatening. Removal or biopsy of such lesions is essential in further treatment since antifungals have to be administered as fast as possible.