South African Medical Journal - Volume 105, Issue 7, 2015
Volumes & issues
Volume 105, Issue 7, 2015
Author J. CloeteSource: South African Medical Journal 105, pp 1 –4 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7782More Less
Malnutrition remains a global health concern and contributes significantly to childhood mortality. Nearly half of all deaths in children < 5 years of age are attributed to undernutrition, especially in developing countries. It is important to differentiate between acute and chronic malnutrition, as the management and mortality for these two conditions differ. Management should follow integrative management protocols to ensure that mortality and morbidity are minimised. General principles for inpatient management of acute malnutrition can be divided into two phases, i.e. the initial stabilisation phase (usually in the first week) for acute complications, and the much longer rehabilitation phase. The initial phase lasts approximately 1 week and involves intensive monitoring and treatment. Severe acute malnutrition remains a problem in public health, especially in developing countries. Adhering to programmatic approaches for diagnosis and management ensures lower mortality rates and better outcomes.
Author A. WestwoodSource: South African Medical Journal 105, pp 5 –8 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7784More Less
Long-term health conditions (LTHCs) in children may affect nutrition and growth by means of multiple mechanisms. Both undernutrition and overweight/obesity are risk factors. Direct effects of the condition that may cause undernutrition include increased resting energy expenditure, excess losses through malabsorption, difficulty ingesting food, and decreased appetite. Indirect effects of LTHCs may be mediated by learnt or adaptive behaviours, secondary anorexia, inappropriate diets, or conditions that aggravate existing social nutritional risks to the child. Undernutrition may have significant consequences for the child, including reduced life expectancy. Overweight is a particular risk in children with neurological LTHCs. Regular clinical assessment, including anthropometry, is required to prevent and detect malnutrition. Anticipatory nutritional guidance to the child and caregivers is required and must be adapted to the specific LTHC. Controlling the disease processes that contribute to malnutrition and optimising energy intake are fundamental elements of prevention and management. Interventional feeding regimens, such as surgical approaches, may be required. A mutidisciplinary team, which includes a dietitian, should manage complex LTHCs and LTHC-associated malnutrition.
Source: South African Medical Journal 105, pp 9 –13 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7783More Less
Anorexia, malabsorption and metabolic derangements contribute to the malnutrition that occurs in most children with chronic liver disease. Nutritional support should be started early in the management of these children with the co-operation of a paediatric dietitian to improve quality of life and decrease post-transplant mortality.
Nutritional assessment entails a detailed dietary history, physical examination and anthropometry. Weight-based anthropometric measures are unreliable while mid-upper-arm circumference and skinfold thickness provide more reliable estimates of nutritional status. Special investigations such as serum vitamin levels and skeletal X-rays further guide management.
High energy (130 - 150% of recommended daily intake (RDI)) and protein (3 - 4 g/kg/day) intakes are recommended. Diets are usually enriched with medium-chain fatty acids because of their better absorption in cholestatic liver disease. High-dose fat-soluble vitamin supplements are given while care is taken to avoid toxicity. Initial doses are two to three times the RDI and then adjusted according to serum levels or international normalised ratio (INR) in the case of vitamin K.
Children with good appetites are fed orally. Feeds should be more regular than for other children to avoid prolonged periods of fasting and improve energy intake. Some children require supplementary nasogastric feeds to increase energy intake and avoid overnight fasting.
Author R. ThejpalSource: South African Medical Journal 105, pp 14 –16 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7781More Less
A search (MEDLINE/PubMed) was conducted of recent and relevant articles on iron deficiency in childhood. Iron deficiency remains a global health problem. In South Africa, multiple interventions, including mandatory fortification and a programme for deworming and supplementation, have significantly reduced the prevalence of anaemia. Studies continue to show that iron deficiency in infancy and early childhood is associated with negative neurocognitive, motor and behavioural effects, some of which persist despite treatment. Maternal iron deficiency has negative effects during pregnancy and in the postpartum period, which affects maternal health (e.g. depression, stress, interaction) and has negative effects on the baby (e.g. behavioural and immunological effects).
Newer tests include the soluble transferrin receptor, reticulocyte haemoglobin and hepcidin assays. The hepcidin level is useful in differentiating iron deficiency from anaemia of chronic disease with and without iron deficiency. Screening is a challenge and no firm recommendations have been made. The mainstay of treatment remains oral iron (commonly ferrous sulphate). Failure to respond totreatment, refractory iron deficiency and use of parenteral iron are briefly covered.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7968More Less
The facts seem to indicate that South Africa (SA) is one of the more violent places on earth. We have been, and continue to be, a country with significant levels of political violence, criminal violence and domestic violence. And now, we are witnessing violence against fellow Africans. While many have termed this 'xenophobia', a more accurate term may well be 'Afrophobia'. For clinician-scientists, many questions arise. In this editorial, we briefly consider a few of the most pertinent.
Author J. V. LarsenSource: South African Medical Journal 105, pp 513 –514 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7706More Less
To the Editor: Following the Stransham-Ford case in the Pretoria High Court, the South African Medical Association (SAMA) has stated clearly that it does not support the right to die in law, and opposes euthanasia and doctor-assisted suicide in line with the Health Professions Council of South Africa's policies and the World Medical Association's guidelines and codes on the subject. Yet this is an emotive issue, and this letter is written in the hope of clarifying the issues that are at stake in South Africa (SA) for the sake of those who do not agree with SAMA.
Author Kathleen BatemanSource: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8022More Less
To the Editor: Antel et al. have drawn attention to the acute encephalopathy caused by thiamine deficiency in non-alcohol-related settings. I would like to highlight a different clinical presentation that ought to be readily recognised as a possible manifestation of this deficiency, namely rapidly progressive leg weakness, by briefly describing a woman currently under our care at the Neurology Division, Groote Schuur Hospital, Cape Town, South Africa.
Author H. RodeSource: South African Medical Journal 105, pp 514 –515 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7807More Less
To the Editor: Visible skin defects in adults, and especially those in the developing child, are frequently very unsightly, stigmatising the person and often leading to severe psychological sequelae. This situation can result from surgical treatment of vitiligo, congenital pigmented naevi, vascular hamartomas and skin cancer, and from burn scars and contractures. Many affected people are ostracised from society because of our inability to restore the defect to normality after excision, or at least to an acceptable functional and cosmetic end result. The obvious solution is to replace the excised tissue with a functional and cosmetic substitute similar to the surrounding area.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7809More Less
To the Editor: Lead exposure through mining processes contributes significantly to environmental and human contamination worldwide. Studies have shown that there is no safe level of exposure, and very low levels (blood lead levels < 5 μg/dL) have resulted in neurocognitive and behavioural abnormalities in children. This has detrimental economic and social consequences, especially in low- and middle income countries where resources to mitigate the effects of lead exposure are limited. In 1991, 2002 and 2008, cross-sectional surveys assessing lead exposure were conducted in grade 1 children in a remote lead-mining town (Aggeneys) and a control town (Pella) about 40 km away in the Northern Cape Province, South Africa (SA). Blood lead levels (BLLs) were assessed in whole-blood samples using atomic absorption spectrophotometry in 1991 and 2002 and in capillary blood using the LeadCare 1 analyser system in 2008.
William Guybon Atherstone : his 8-day and 1 600 km house call to Oudtshoorn in 1890 : correspondenceAuthor S.A. CravenSource: South African Medical Journal 105 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7817More Less
To the Editor: William Guybon Atherstone (1814 - 1898) became well known because for six decades he and his father, John Atherstone, practised medicine in Grahamstown in the Eastern Cape during the turbulent Frontier Wars. When not attending patients, he pursued his interests in geology and botany. He is best known for having performed the first successful surgical procedure under general ether anaesthetic, and for having identified the first diamond found in the Cape Colony.
Source: South African Medical Journal 105, pp 517 –520 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7838More Less
'Smooth seas do not make skilful sailors.' (African proverb) For 3 stormy years from the time Tugela Ferry's doctors first uncovered what turned out to be an alarming countrywide extensively drug-resistant tuberculosis (XDR-TB) prevalence (2005 - 2007), they diagnosed 110 new XDR-TB cases per year. Yet by implementing a combination of interventions with a remarkable team, the tap was turned down to less than 10 cases in 2012, making the Church of Scotland Hospital (CoSH) an international beacon of best practice. Izindaba returned there after 6 years to find out how they are helping to quell the general TB epidemic itself.
Source: South African Medical Journal 105, pp 520 –521 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7955More Less
The protagonists in the latest clash of the dieting titans (conventional v. Banting diets) agree on one thing - that asking an esteemed panel of Prof. Tim Noakes's medical peers to rule on whether his cyber-advice on breastfeeding babies was 'unprofessional conduct' may prove a turning point for nutritional guidance.
Source: South African Medical Journal 105, pp 522 –524 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7835More Less
Death cafés - the concept sounds ghoulish, but they could soon become as much a reality in South Africa (SA) as they are in North America, Europe and Australia. This follows a groundbreaking local judgment that has the best legal and medical minds debating whether euthanasia can ever be justified in this country.
Source: South African Medical Journal 105 (2015)More Less
The career of Harry Stein, who died at 89 on 31 December 2014, touched the lives of countless babies at Baragwanath Hospital in some of South Africa's darkest years during apartheid. In a career spanning 37 years, Harry became Head of Neonatology and later Head of Paediatrics at Baragwanath Hospital and Professor of Paediatrics at the University of the Witwatersrand until he retired in 1987. Baragwanath (now Chris Hani Baragwanath) was a national referral centre and the only hospital serving Soweto at the time, then with a population estimated to be in excess of 1.5 million people. Running paediatrics was a formidable task. Baragwanath had 400 children's beds and treated 100 000 child outpatients a year; 17 000 babies were delivered each year. There were very high rates of low birth weight and premature delivery, with over 3 000 babies a year weighing less than 2 500 g at birth and often premature.
The bronchiolitis season is upon us - recommendations for the management and prevention of acute viral bronchiolitis : forum - clinical alertSource: South African Medical Journal 105, pp 525 –526 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8040More Less
Doctor-assisted suicide : what is the present legal position in South Africa? : forum - medicine and the lawAuthor D.J. McQuoid-MasonSource: South African Medical Journal 105, pp 526 –727 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7895More Less
In the recent case of Stransham-Ford v. the Minister of Justice and Correctional Services, the North Gauteng High Court held that a terminally ill patient who was experiencing intractable suffering was entitled to commit suicide with the assistance of his doctor and that the doctor's conduct would not be unlawful. The court was careful to state that it was not making a general rule about doctor-assisted suicide. The latter should be left to the Parliament, the Constitutional Court and 'future courts'. The judge dealt specifically with the facts of the case at hand. In order to understand the basis of the decision it is necessary to consider: (i) the facts of the case; (ii) the question of causation; (iii) the paradox of 'passive' and 'active' euthanasia; (iv) the test for unlawfulness in euthanasia cases; and (v) the meaning of doctor-assisted suicide. It is also necessary to clarify the present legal position regarding doctor-assisted suicide.
The importance of identified cause-of-death information being available for public health surveillance, actions and research : forum - healthcare deliverySource: South African Medical Journal 105, pp 528 –530 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.8019More Less
An amendment to the South African Births and Deaths Registration Act has compromised efforts to strengthen local mortality surveillance to provide statistics for small areas and enable data linkage to provide information for public health actions. Internationally it has been recognised that a careful balance needs to be kept between protecting individual patient confidentiality and enabling effective public health intelligence to guide patient care and service delivery and prevent harmful exposures. This article describes the public health benefits of a local mortality surveillance system in the Western Cape Province, South Africa (SA), as well as its potential for improving the quality of vital statistics data with integration into the national civil registration and vital statistics system. It also identifies other important uses for identifiable cause-of-death data in SA that have been compromised by this legislation.
Social franchising primary healthcare clinics - a model for South African national health insurance? : forum - healthcare deliveryAuthor A.K.L. RobinsonSource: South African Medical Journal 105, pp 531 –534 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAMJnew.7814More Less
This article describes the first government social franchise initiative in the world to deliver a 'brand' of quality primary healthcare (PHC) clinic services. Quality and standards of care are not uniformly and reliably delivered across government PHC clinics in North West Province, South Africa, despite government support, numerous policies, guidelines and in-service training sessions provided to staff. Currently the strongest predictor of good-quality service is the skill and dedication of the facility manager. A project utilising the social franchising business model, harvesting best practices, has been implemented with the aim of developing a system to ensure reliably excellent healthcare service provision in every facility in North West. The services of social franchising consultants have been procured to develop the business model to drive this initiative. Best practices have been benchmarked, and policies, guidelines and clinic support systems have been reviewed, evaluated and assessed, and incorporated into the business plan. A pilot clinic has been selected to refine and develop a working social franchise model. This will then be replicated in one clinic to confirm proof of concept before further scale-up. The social franchise business model can provide solutions to a reliable and recognisable 'brand' of quality universal coverage of healthcare services.