The South African Medical Journal (SAMJ) was first published in 1884, and has therefore been in existence for 126 years in one form or another. The journal pays tribute to a journal buff who contributed considerably to its more recent history - for some 42 years, or exactly one-third of its existence. Tributes to Ralph Kirsch have been published in the SAMJ, but we would like to express our appreciation by outlining some of his many contributions to publications in South Africa and to the SAMA stable of journals in particular.
To the Editor : From a clinical perspective, technology is expected to reduce the risk of disease, reduce duration of illness, improve quality of care, increase access and restore, or limit the decay of, a person's quality of life. Technology is also expected to contain costs and improve interventional risk management through enhancement of service efficiency and productivity of health care professionals. As health technology evolves, so does the need to assess its impact on patients' health outcomes, hospital operations, and financial resources. This process leads to the evolution of health technology assessment (HTA), which is a systematic evaluation of properties, effects and other consequences of health care technology. Its purpose is to provide objective information for supporting health care decisions and policy-making at international, national, provincial and health facility levels. An effective HTA programme produces good-quality information and analysis, and then effectively uses this information and knowledge to influence decision-makers in health care systems.
To the Editor : Clarity with regard to what training in clinical haematology in South Africa involves and aims to achieve can be elusive. Clinical haematology trainees can have primary specialties of Internal Medicine or Paediatrics or Pathology (Haematology). I discuss the situation of those with the primary specialty of Internal Medicine.
Are embattled medical aids indulging in bully-boy 'extortion' tactics or merely recouping losses from suspect health care practitioners whom the industry claims cost it R7 - R10 billion (10% of payouts) in fraud, abuse or over-servicing every year?
A second government-commissioned report has concluded that most of South Africa's waste water treatment plants are either dysfunctional or nonfunctional, with millions of litres of sewage illegally discharged daily into rivers by small-town municipalities.
She could have said that sufficient counselling rooms and trained staff exist, that the health system is 'patient friendly' enough to ensure most of the 1.65 million people who'll test HIV positive in the massive new campaign will be treated and retained.
To capitalise on the impending national health insurance (NHI) system, private doctors need to change their mindsets from fee-for-service to capitation, sharpen up business models, practise preventive medicine in groups and outsource some office functions.
Most of the 5 million HIV-positive South Africans are in the reproductive age group. The current infertility rate in this group is 15 - 20%,1 and it is likely that a substantial proportion of offspring are HIV positive. Given the implementation of highly active antiretroviral therapy (HAART), expectancy and quality of life, including reproductive aspirations, are raised. However, the prevalence of infertility among HIV-positive South Africans remains unknown.
J waves can commonly be seen in patients with severe hypothermia. Fig. 1 shows an ECG recording of a patient undergoing coronary artery revascularisation with the use of cardiopulmonary bypass. The purple recording shows the ECG with a small, existing J wave early during the initiation of cooling. The green overlay demonstrates the accentuation of the J wave as the patient was further cooled to 29°C.
Frik Rademan drowned on 6 March 2010 while canoeing near the weir at his farm, Sunnyside, on the Vaal River in the Vredefort Dome. He was 54 years old and riding the crest of the wave of his full and wonderful life.
To the Editor : Figures for the period 2008/2009 indicate a 10% rise in the number of reported sexual offences compared with figures for 2007/2008. The increase may be partly attributable to the recent version of the act regulating sexual offences : the Criminal Law (Sexual Offences and Related Matters) Amendment Act, Act 32 of 2007 (Act). In this Act, the definition of rape has been broadened to include the non-consensual vaginal, oral or anal penetration of any person, regardless of gender, with any object. South Africa has one of the highest incidences of rape in the world and the most violent types of rape in the world, with gang rape and severe physical injury to rape victims commonly occurring.
To the Editor: An estimated 5.7 million people in South Africa live with HIV/AIDS. In 2008, it was estimated that 12.5% of the Limpopo population aged 15 - 49 was HIV-positive, while the national HIV prevalence estimate was 18.8%.
Objectives. To establish whether a specific community in a gold mining area, with potentially associated small-scale gold mining activities, was exposed to mercury.
Methods. The community was situated in Mpumalanga, where some potential sources of mercury emissions may have an impact. Adults ≥18 years were considered eligible. Biological monitoring, supported by questionnaires, was applied. Thirty respondents completed the questionnaire which covered demographics, energy use, food and water consumption, neurological symptoms, and confounders such as alcohol consumption and brain injuries. Mercury levels were determined in 28 urine and 20 blood samples of these respondents.
Results. Three (15%) of the blood samples exceeded the guideline (<10 µg/l) for individuals who are not occupationally exposed, while 14 (50%) of the urine samples exceeded the guideline for mercury in urine (<5.0 µg/g creatinine) for those not exposed occupationally. The cause of these elevated levels is unknown, as only 20% of respondents indicated that they used coal as an energy carrier. Furthermore, nobody from the community was reportedly formally employed in a goldmine. Nineteen (63%) respondents consumed locally caught fish, while 20 (67%) drank water from a river.
Conclusions. Some individuals in this study may be occupationally exposed to mercury through small-scale gold mining activities. As primary health facilities will be the first point of entry for individuals experiencing symptoms of mercury poisoning, South African primary health care workers need to take cognisance of mercury exposure as a possible cause of neurological symptoms in patients.
Background. At the turn of the century, only 300 cases of warfarin-induced skin necrosis (WISN) had been reported. WISN is a rare but potentially fatal complication of warfarin therapy. There are no published reports of WISN occurring in patients with HIV-1 infection or tuberculosis (TB).
Methods. We retrospectively reviewed cases of WISN presenting from April 2005 to July 2008 at a referral hospital in Cape Town, South Africa.
Results. Six cases of WISN occurred in 973 patients receiving warfarin therapy for venous thrombosis (0.62%, 95% CI 0.25 - 1.37%). All 6 cases occurred in HIV-1-infected women (median age 30 years, range 27 - 42) with microbiologically confirmed TB and venous thrombosis. All were profoundly immunosuppressed (median CD4+ count at TB diagnosis 49 cells/µl, interquartile range 23 - 170). Of the 3 patients receiving combination antiretroviral therapy, 2 had TB-IRIS (immune reconstitution inflammatory syndrome). The median interval from initiation of antituberculosis treatment to venous thrombosis was 37 days (range 0 - 150). The median duration of parallel heparin and warfarin therapy was 2 days (range 1 - 6). WISN manifested 6 days (range 4 - 8) after initiation of warfarin therapy. The international normalised ratio (INR) at WISN onset was supra-therapeutic, median 5.6 (range 3.8 - 6.6). Sites of WISN included breasts, buttocks and thighs. Four of 6 WISN sites were secondarily infected with drug-resistant nosocomial bacteria (methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, extended spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae) 17 - 37 days after WISN onset. In 4 patients, the median interval from WISN onset to death was 43 days (range 25 - 45). One of the 2 patients who survived underwent bilateral mastectomies and extensive skin grafting at a specialist centre.
Conclusion. This is one of the largest case series of WISN. We report a novel clinical entity : WISN in HIV-1 infected patients with TB and venous thrombosis. The occurrence of 6 WISN cases in a 40-month period may be attributed to (i) hypercoagulability, secondary to HIV-1 and TB; (ii) short concurrent heparin and warfarin therapy; and (iii) high loading doses of warfarin. Active prevention and appropriate management of WISN are likely to improve the dire morbidity and mortality of this unusual condition.
Objectives.Cryptococcal meningitis is the most common cause of adult meningitis in southern Africa. Much of this disease burden is thought to be due to symptomatic relapse of previously treated infection. We studied the contribution of inadequate secondary fluconazole prophylaxis to symptomatic relapses of cryptococcal meningitis.
Design. A prospective observational study of patients presenting with laboratory-confirmed symptomatic relapse of HIV-associated cryptococcal meningitis between January 2007 and December 2008 at GF Jooste Hospital, a public sector adult referral hospital in Cape Town.
Outcome measures. Relapse episodes were categorised into : (i) patients not taking fluconazole prophylaxis; (ii) immune reconstitution inflammatory syndrome (IRIS); and (iii) relapses occurring prior to ART in patients taking fluconazole. In-hospital mortality was recorded.
Results. There were 69 relapse episodes, accounting for 23% of all cases of cryptococcal meningitis; 43% (N=30) of relapse episodes were in patients not receiving fluconazole prophylaxis, 45% (N=31) were due to IRIS, and 12% (N=8) were in patients pre-ART taking fluconazole. Patients developing relapse due to inadequate secondary prophylaxis had severe disease and high in-hospital mortality (33%). Of the 30 patients not taking fluconazole, 47% (N=14) had not been prescribed secondary prophylaxis by their health care providers. We documented no relapses due to fluconazole resistance in these patients who received amphotericin B as initial therapy.
Conclusions. A large number of relapses of cryptococcal meningitis are due to failed prescription, dispensing and referral for or adherence to secondary fluconazole prophylaxis. Interventions to improve the use of secondary fluconazole prophylaxis are essential.