South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde (SAMJ S AFR MED J)

Publications in this journal

• Article: Thrombosis - prevention is better than cure.

  B F Jacobson
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):231.
• Article: Economic appraisal of dabigatran as first-line therapy for stroke prevention in atrial fibrillation.

  M Bergh, C A Marais, H Miller-Jansön, F Salie, M P Stander
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  ABSTRACT: Background. Dabigatran is an oral anticoagulant direct thrombin inhibitor recently registered in South Africa (SA) to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation (AF). Owing to the price disparity between warfarin (the current gold standard for treatment of patients with AF) and dabigatran, we conducted an economic appraisal of the use of dabigatran compared with warfarin from a payer perspective in the South African private healthcare setting. Objectives. To estimate the cost-effectiveness (CE) and budget impact of dabigatran compared with warfarin for the prevention of stroke in AF patients. Methods. A previously published Markov model was populated with SA cost and mortality data to estimate the CE and budget impact analysis of dabigatran over a lifetime horizon. The model population consisted of a cohort of patients of whom those aged younger than 80 years used dabigatran 150 mg twice daily and those older than 80 years 110 mg twice daily. Modelled outcomes included total cost, quality-adjusted life years (QALYs) and incremental CE ratio (ICER), with the effectiveness measured by QALYs gained. Results. Dabigatran compared with warfarin as first-line treatment was estimated to have an ICER of R93 290 and an average incremental cost per beneficiary per month of R0.39 over a 5-year period. Conservative assumptions were made regarding the number of international normalised ratio monitoring tests for patients on warfarin, and the ICER is estimated to decrease by as much as 15.7% under less stringent assumptions. A robust sensitivity analysis was also performed. Conclusion. Dabigatran as first-line treatment compared with warfarin for the use of stroke prevention in patients with AF is deemed cost-effective when used in accordance with its registered indication in the SA private sector.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):241-5.
• Article: Evaluation and correlation of mammographically suspicious lesions with histopathology at Addington Hospital, Durban.

  B D Cupido, F Vawda, A Sabri, C T Sikwila
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  ABSTRACT: Background. Stereotactic core-needle biopsies (SCNBs) are a reliable alternative to surgical biopsy for microcalcifications. The positive predictive value (PPV) of SCNB has been shown to be reproducible in several studies using the Breast Imaging Reporting and Data System (BIRADS) classification, which is the current gold standard in mammographic reporting. At this stage, no study has been done in KwaZulu-Natal to assess local outcomes against BIRADS. The current standard of care utilises vacuum-assisted breast biopsy, but is not available in a resource-constrained environment such as ours. The need, therefore, is for constant evaluation of existing practice to ensure that it is optimised for the challenges and limitations facing local radiologists. Objective. To assess the PPV of SCNB in Addington Hospital, and to compare it with that of BIRADS. Material and methods. Mammographically detected lesions were assigned to 3 categories: benign, indeterminate and suspicious. A retrospective review of 67 SCNBs was performed for lesions falling within the suspicious category, and the PPV and rates of ductal carcinoma in situ (DCIS) were determined. Results. Our study demonstrated a PPV of 20.9%. This correlated well with international studies for BIRADS 4 and 5 lesions. DCIS accounted for 21.4% of detected malignancies, which is in keeping with current literature. Conclusion. Despite resource limitations, local outcomes were comparable to those of BIRADS. Given our fairly general categorisation of lesions, however, it should be emphasised that BIRADS allows better organisation, consistency and clarity in breast imaging reporting, as well as accurate data comparison between centres facing limitations similar to our own.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):251-4.
• Article: Inspanning all the oxen - new Health Foundation.

  Chris Bateman
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  ABSTRACT: The Western Cape is pioneering an independent fund-raising foundation that will help its provincial health department to reduce the regional burden of disease through wellness programmes, infrastructure upgrades and mutually beneficial public-private partnerships. Initially aimed at reducing, among other things, what Health MEC Theuns Botha estimates as a R1 billion backlog in infrastructure maintenance, the multi-faceted strategy (as embodied by the new Health Foundation) is a 'holistic, all hands on deck' approach. Speaking at the opening of the Foundation's offices in Stellenbosch on 4 February this year, its CEO, Dr Joshua Fisher, said accelerating and spreading wellness programmes through employer programmes at the workplace and at schools, replicating the hugely successful Red Cross Children's War Memorial Hospital fund-raising model at other facilities, and up-skilling (or merely rendering functional) health facility boards would be pivotal. The Foundation was also positioning itself to broker 'significant deals with private companies' to enable the generation of rental income and fees.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):217-8.
• Article: Much ado over the new South African PMTCT Guidelines.

  Chris Bateman
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  ABSTRACT: A group of well-respected South African academics and HIV experts have started a national debate by questioning the 'dangerously hasty' acceptance and implementation of lifelong antiretroviral therapy (ART) for HIV-positive pregnant women in resource-constrained settings. The South African National Department of Health will introduce updated prevention of mother-to-child transmission (PMTCT) guidelines this month, based in part on the World Health Organization (WHO)'s recommendations on the use of ART for treating pregnant women and preventing HIV infection in infants. The guideline update will recommend a standardised triple-drug regimen to treat HIV-infected pregnant women (regardless of CD4 count) during pregnancy and breastfeeding, with continuation of ART after breastfeeding for women with CD4 counts less than 350 (Option B). HIV-exposed infants will receive nevirapine prophylaxis for 4 - 6 weeks and should be tested for HIV at 6 weeks of age. The new treatment guidelines are expected to further enhance the success of the PMTCT programme in South Africa (HIV transmission from mother to child is down from 8.0 - 20.2% prior to 2007, to 3.5% in 2010), with the goal being the complete elimination of preventable HIV infection in infants. More critically, it will bolster a concerted effort to reduce high maternal morbidity and mortality figures; HIV, complicated by accompanying infections such as tuberculosis, pneumonia and meningitis, is responsible for 40% of maternal deaths in South Africa. Further guidance on treatment options for pregnant women, including a stronger recommendation to offer all pregnant women lifelong ART irrespective of CD4 count (Option B+) is expected in the form of revised WHO guidelines in June.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):218-21.
• Article: NIMART rollout to primary healthcare facilities increases access to antiretrovirals in Johannesburg: An interrupted time series analysis.

  J C Y Nyasulu, E Muchiri, S L Mazwi, M Ratshefola
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  ABSTRACT: Introduction. South Africa has made remarkable progress in rolling out antiretroviral therapy (ART), with the largest number of people (more than 1.4 million) enrolled on antiretroviral in the world. Decentralisation of services to primary health centres (PHCs) has strengthened retention of patients on ART and reduced the burden of managing uncomplicated cases at referral hospitals. Methods. This was a ten-step Nurse Initiation Management of Antiretroviral Treatment (NIMART) rollout intervention in which nurses from 17 primary healthcare facilities of Region F, City of Johannesburg, South Africa, were trained and mentored in NIMART by the Wits Reproductive Health and HIV Research Institute (WRHI) to commence patients on ART in their PHCs. A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. To test the statistical significance of the impact of NIMART rollout on the referral hospital initiations and Region F monthly initiations, interrupted time series analysis was applied. Findings. Ten-step NIMART was applied, with the first step being establishment of NIMART as a priority in order to obtain primary buy-in by the Department of Health (DoH) and City of Johannesburg (CoJ). Forty-five professional nurses were trained in NIMART by WRHI quality improvement mentors. By the end of September 2011, all 17 PHCs in Region F were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout (p=0.013) and continued to increase by an average of 9 every month (p=0.013), while referral facility initiations decreased by 12 (p=0.791) immediately after NIMART and then decreased by an average of 18 every month (p=0.01). Conclusion. In this study, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients. Engaging and having buy-in from DoH/CoJ partners in rolling out NIMART was crucial in increasing outputs as well as for sustainability of the NIMART programme.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):232-6.
• Article: Ten years on ART - where to now?

  D Evans
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):229-31.
• Article: Doctors' lifestyles vital for SA's health - global expert.

  Chris Bateman
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  ABSTRACT: Overweight, smoking doctors 'make terrible counselors', says Dr Derek Yach, the South African former tobacco-control activist who rose to lead the World Health Organization (WHO)'s Framework Convention on Tobacco Control and its strategy on diet and physical activity. He says research shows that doctors who smoke and present as overweight or obese are 'far less likely' to counsel their patients or become effective disease prevention agents, let alone engage in any public discourse on legislative health measures.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):214-5.
• Article: Africa's roads: the deadliest in the world.

  M Peden, O Kobusingye, M E Monono
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):228-9.
• Article: Emergency medical treatment and 'do not resuscitate' orders: When can they be used?

  D J McQuoid-Mason
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  ABSTRACT: The Constitution and the National Health Act provide that nobody shall be refused emergency medical treatment. 'Do not resuscitate' (DNR) orders require that certain patients should not be given cardiopulmonary resuscitation to save their lives. Whether there is a conflict between these two requirements is answered by considering: (i) the meaning of emergency medical treatment; (ii) the relationship between emergency medical treatment and DNR orders; (iii) the meaning of futile medical treatment; (iv) the relationship between DNR orders and euthanasia; and (v) when DNR orders may be lawfully used.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):223-5.
• Article: Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa.

  M L Richter, M Chersich, M Temmerman, S Luchters
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  ABSTRACT: Background. In South Africa, information on sex workers' characteristics, sexual behaviour and health needs is limited. Current social, legal and institutional factors impede a safe working environment for sex workers and their clients. Objectives. To describe characteristics and sexual behaviour of female, male and transgender sex workers, and assess their risk factors for unprotected sex. Methods. Repeat cross-sectional surveys among sex workers were conducted in Hillbrow, Sandton, Rustenburg and Cape Town in 2010. Sex workers were interviewed once; any re-interviews were excluded from analysis. Unprotected sex was defined as any unprotected penetrative vaginal or anal sex with last two clients. Results. Trained sex workers interviewed 1 799 sex workers. Sex work was a full-time profession for most participants. About 8% (126/1 594) of women, 33% (22/75) of men, and 25% (12/50) of transgender people had unprotected sex. A quarter of anal sex was unprotected. Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; p=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers. Male sex workers were 2.9 times (AOR, 95%CI 1.6 - 5.3; p<0.001) more likely, and transgender people 2.4 times (AOR, 95% CI 1.1 - 4.9; p=0.021) more likely, than females to have unprotected sex. Sex workers in Hillbrow, where the only sex work-specific clinic was operational, were less likely to have unprotected sex than those in other sites. Conclusion. Tailored sex work interventions should explicitly include male and transgender sex workers, sex work-specific clinics, focus on the risks of unprotected anal sex, and include interventions to reduce alcohol harm.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):246-51.
• Article: Gastric adenocarcinoma in Zambia: A case-control study of HIV, lifestyle risk factors, and biomarkers of pathogenesis.

  V Kayamba, A W Asombang, V Mudenda, M M Lisulo, E Sinkala, S Mwanamakondo, I Mweemba, P Kelly
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  ABSTRACT: Background. Gastric cancer is a leading cause of cancer deaths worldwide but there are few data from Africa. We recently observed a trend towards diagnosis in younger patients. Objective. To test the hypothesis that HIV might have altered risk factors for acquisition of gastric cancer, in a case-control study in the University Teaching Hospital, Lusaka, Zambia. Methods. Patients (n=52) with confirmed gastric adenocarcinoma and controls (n=94) undergoing endoscopy but with no macroscopic gastric pathology. Established risk factors and HIV status were compared. Results. HIV status did not differ significantly between cases and controls (odds ratio 1.03; 95% CI 0.2 - 4.3; p=1.00) and seroprevalence in cases was similar to that of the Zambian population. Smoking, regular alcohol intake, and gastric atrophy were all associated with cancer in univariate and multivariate analysis. Helicobacter pylori serology was positive in 84% of patients studied and cagA serology in 66%; neither serological marker was associated with cancer. Atrophy was common in cases (57%) and controls (30%) and associated with both smoking and alcohol use. Intestinal metaplasia was present in 17% of the controls, but was not associated with atrophy. Conclusions. HIV was not associated with gastric cancer and does not explain the apparent younger age distribution. Atrophy was common and was not essential for the development of intestinal metaplasia, suggesting that gastric carcinogenesis in Africa does not always follow the pathway from atrophy to intestinal metaplasia to gastric carcinoma (the so-called Correa pathway).
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):255-9.
• Article: E Cape's corruption-busting DG finally ousted.

  Chris Bateman
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  ABSTRACT: Dr Siva Pillay, the IT-savvy, corruption-busting Nelson Mandela Bay doctor and millionaire businessman, has been edged out as Superintendent-General of the controversy-riddled Eastern Cape Health Department, after a long-standing feud with his Health MEC, Sicelo Gqobana. His (acting) replacement is Mahlubandile Qwase, a teacher, former MEC for Education, former chair of the provincial health portfolio committee and former deputy director-general in Premier Noxolo Kieviet's office. Counting MEC Gqobana, this puts two teachers at the helm of the provincial health department.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):215-7.
• Article: Biobank research: Time for discussion and debate.

  A Dhai, S Mahomed
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  ABSTRACT: The establishment of biobanks is gaining prominence globally. The open and evolving nature of biobanks has profound ethical, legal and social implications for individual and group autonomy, informed consent, privacy, confidentiality, secondary use of samples and data over time, return of results, data sharing, benefit sharing with communities, and premature or unplanned closure. Complexities also emerge because of increasing international collaborations, and differing national positions. Public consultation and involvement are very necessary to the success of biobanks. Implementing national laws in an internationally consistent manner is problematic.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):225-7.
• Article: An integrated approach to improving the availability and utilisation of tuberculosis healthcare in rural South Africa.

  N Z Chimbindi, T Bärnighausen, M-L Newell
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  ABSTRACT: Background. Patients with tuberculosis (TB) face several challenges in accessing care, and an integrated service that includes HIV testing could be preferable for them and ensure timely HIV treatment initiation and optimal TB care. Objectives. To investigate factors, including uptake of the offer of HIV testing, associated with availability and utilisation of healthcare by TB patients in a rural programme devolved to primary care in Hlabisa sub-district, KwaZulu-Natal. Methods. Three hundred TB patients were randomly selected in a two-stage-sampling scheme with five primary healthcare clinic (PHC) sampling units selected with probability proportional to size. Data were collected using a structured questionnaire. We describe key availability and utilisation factors and analyse factors associated with being offered an HIV test in multiple regressions controlling for sex, age, education, employment and marital status. Results. Most patients (75.2%) received care for a first episode of TB, mainly pulmonary. Nearly all (94.3%) were offered an HIV test during their current TB treatment episode, patients using their closest clinic being substantially more likely to have been offered HIV testing than those not using their closest clinic (adjusted odds ratio 12.79, p=0.05). About one-fifth (20.3%) of patients did not take medication under observation, and 3.4% reported missing taking their tablets at some stage. Average travelling time to the clinic and back was 2 hours, most patients (56.8%) using minibus taxis. Conclusion. We demonstrate high HIV testing rates among TB patients in a rural public programme, suggesting appropriate management of HIV-TB co-infected patients. We describe healthcare availability and utilisation factors that can inform the proposed district management teams for PHC re-engineering on areas needing improvement.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):237-40.
• Article: Venous thromboembolism: Prophylactic and therapeutic practice guideline.

  B F Jacobson, S Louw, H Büller, M Mer, P R De Jong, P Rowji, E Schapkaitz, D Adler, A Beeton, H-C Hsu, P Wessels, S Haas
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  ABSTRACT: Background. Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed. This has resulted in unacceptable rates of morbidity and mortality. Method. The Southern African Society of Thrombosis and Haemostasis held a meeting to update the previous guideline and review new literature including guidelines from other societies. The following specialties were represented on the committees: anaesthetics, cardiology, clinical haematology, critical care, obstetrics and gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery and pulmonology. A draft document was presented at the meeting, which was then revised by consensus agreement. To avoid local bias, the guideline was adjudicated by recognised international external experts. Results and conclusion. A concise, practical updated guideline for thromboprophylaxis and treatment in medical and surgical patients has been produced for South African conditions. It is hoped that this guideline will continue to improve anticoagulation practice in this country, which we believe will directly benefit patient outcomes.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):260-71.
• Article: Peter (polly) perrot.

  Roy O Wise
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 04/2013; 103(4):221.
• Article: The pilgrim's prognosis - medical aspects of a camino.

  R-I Caldwell
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  ABSTRACT: Medical aspects of an 800 km pilgrimage, the Camino de Santiago de Compostela.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 03/2013; 103(3):152-3.
• Article: Prevalence of human immunodeficiency virus, hepatitis C virus, hepatitis B virus and syphilis among individuals attending anonymous testing for HIV in Luanda, Angola.

  H Guimarães Nebenzahl, A Lopes, R Castro, F Pereira
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  ABSTRACT: Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis remain major infections around the world. In Angola there are about 166 000 individuals living with HIV, representing a prevalence of 1.98% in adults between 15 and 49 years of age. In a 2003 study in Luanda, 4.5% of pregnant women had antibodies to HIV and 8.1% to HBV, and 5.4% were infected with Treponema pallidum. Objectives. The aim of this study was to determine the prevalence of HIV-1 and 2, HBV, HCV and T. pallidum serological markers, and hence the prevalence of these infections, in individuals attending a sexually transmitted disease clinic in Luanda, Angola, and the burden of these infections in the Angolan population. Methods. Individuals attending a centre for anonymous testing for HIV were randomly included in the study. All samples were tested for HBV surface antigen (HBsAg), anti-HCV and anti-HIV-1 and 2 antibodies and antibodies to T. pallidum. Results. A total of 431 individuals (262 women and 169 men) were studied, of whom 10.0% (43/431) were seropositive for T. pallidum and 4.6% had active syphilis; 8.8% (38/431) were seropositive for HIV-1 and/or HIV-2 (of these, 78.9% were HIV-1-positive, 2.6% HIV-2-positive and 18.4% co-infected); 9.3% (40/431) were HBsAg-positive, while 8.1% (35/431) had antibodies to HCV. Of 102 patients with positive results, 26 (25.5%, or 6.0% of the total of 431 patients) were positive for more than one of the organisms studied. Rates of co-infection were as follows: 2.3% (10/431) for HIV/HBV, 0.9% (4/431) for HIV/HCV, and 0.9% (4/431) for HCV/HBV. Three individuals with active syphilis had viral co-infection, hepatitis B in 1 case and HIV in 2. Five individuals (1.2% of the total) were seropositive for three infections, HIV, hepatitis B and hepatitis C in 3 cases and HIV, hepatitis C and syphilis in 2. Conclusions. A high prevalence of co-infection with the infections studied was found in this population, including HIV infection (8.8%). These results demonstrate the need to improve screening for and treatment of HIV and other sexually transmitted infections in Angola, and for educational campaigns to prevent not only the morbidity and mortality associated with these diseases, but also their further transmission.
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 03/2013; 103(3):186-8.
• Article: Dr Farham responds.

  Bridget Farham
  South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 03/2013; 103(3):132.