Showing papers in "South African Medical Journal in 1994"

Withholding and withdrawing life-sustaining therapy.

Abstract: Preface American Thoracic Society (ATS) members who practice pulmonary and critical care medicine commonly care for patients receiving mechanical ventilation and other lifesustaining therapy. They not only participate in decisions to withhold and withdraw such therapy but are also professionally and personally involved in the medical, ethical, and legal issues arising from those decisions. Recognizing the importance of these issues to its membership, the ATS Board of Directors approved formation of an ad hoc Bioethics Task Force to develop an official ATS statement related to withholding and withndrawing life-sustaining therapy. The purpose of this statement is to define acceptable standards of medical practice and make recommendations related to withholding and withdrawing life-sustaining therapy in the same manner that previous ATS statements have done for other clinical and ethical issues. This statement has three specific objectives: (I) to enhance the understanding of physicians and other health care providers of the issues involved in withholding and withdrawing life support; (2) to promote medically and ethically sound decision making in clinical practice related to withholding and withdrawing life support; and (3) to assist in the development of institutional and public policies related to these issues. This statement was specifically written to apply to the medical care of adults with or without decision-making capacity. In addition, it may also be useful in caring for children who have variable degrees of ethical and legal autonomy (1). On the other hand, because of the unique ethical, medical, and legal issues involved in their care, the Task Force decided to exclude neonates from its consideration.

The impact of child-resistant containers on the incidence of paraffin (kerosene) ingestion in children

Abstract: The commonest cause of accidental poisoning in the South African black paediatric population is paraffin ingestion. In this intervention study a specifically designed child-resistant container (CRC) was introduced to evaluate whether its use would decrease the incidence of paraffin ingestion. CRCs were distributed to 20,000 households in the study area (Gelukspan district). No CRCs were distributed in the control area (Lehurutshe district). Health education about paraffin poisoning prevention was given in both the control and the study areas. The monthly incidence rates of paraffin ingestion were monitored during the 14-month intervention period after the distribution and were compared with the pre-intervention incidence rates in the study and control areas. The main finding was that the incidence of paraffin ingestion dropped by 47% in the study area during the intervention period. The circumstances surrounding the cases of paraffin ingestion that still occurred in the study and control areas were investigated by means of a questionnaire. We recommend that paraffin be sold in CRCs, and suggestions are made for improving health education to prevent paraffin poisoning.

The Pholela Health Centre: the origins of community-oriented primary health care (COPC): an appreciation of the work of Sidney and Emily Kark

Abstract: The health centre practice pioneered by Sidney and Emily Kark and their colleagues at Pholela during the 1940s was a forerunner of and direct contributor to what later emerged as 'the primary health care approach'. This article gives a detailed account of the context, work and methodologies used at the Pholela Health Centre, emphasising the development of concepts that are now well recognised and described as community-oriented primary health care (COPC). COPC remains highly relevant to health service development in South Africa today.

Duchenne and Becker muscular dystrophy prevalence in South Africa and molecular findings in 128 persons affected

Abstract: A genetic service for Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) was initiated in Cape Town in 1987. Of the 143 DMD patients diagnosed during the period 1987-1992, 66 had a familial pattern of inheritance and 77 were apparently sporadic. Twenty BMD patients were identified, of whom 12 had other affected relatives and 8 were sporadic. Overall minimum prevalence rates of 1/100,000 for DMD and 1/755,000 for BMD were calculated. A markedly low DMD prevalence in the indigenous black population (1/250,000) contributed to the overall low DMD prevalence in South Africa when compared with that in the UK (1/40,000). By means of molecular methods, the diagnosis in 42% of the affected DMD males was confirmed by detection of deletions in the dystrophin gene. Deletions were identified in 50% of Indian, white and mixed ancestry patients. In contrast, only 22% of blacks had identifiable deletions. DMD appears to be underrepresented in the black population; the low deletion frequency in this group suggests that unique mutations not detectable by methods used in this study may be more frequent in these patients than in the other populations. The increased DMD frequency in Indians corroborates findings reported from the UK.

Kaposi's sarcoma in renal transplant recipients. Experience at Johannesburg Hospital, 1966-1989.

Abstract: Between August 1966 and December 1989, 989 renal transplant recipients were followed up at the Renal Transplant Unit of Johannesburg Hospital. Seventy-five (7%) patients developed a total of 95 malignancies of which 5 (6%) were Kaposi's sarcoma. All patients received immunosuppressive agents; steroids, azathioprine and/or cyclosporin A. Clinical presentations included both limited skin involvement (1 patient) and disseminated forms of the disease: necrotic oral lesions (1 patient); disseminated skin involvement and lung metastases (1 patient); and widespread skin lesions with lymphadenopathy (2 patients). Four patients responded with complete tumour regression at all sites upon withdrawal of the immunosuppressive drugs. One patient suffered disease progression, and immunosuppression was continued, albeit at reduced dosages. These cases illustrate a relatively rare complication of immunosuppressive therapy. However, complete withdrawal of iInmunosuppressive drugs may result in sustained complete regression, despite the presence of advanced KS.

Agrichemical safety practices on farms in the western Cape.

Abstract: In order to study agrichemical safety practices in a rural farming area in the western Cape, an audit of 45 randomly sampled farms was performed over 3 months in 1992. A response rate of 87% was achieved, and the survey results suggest that approximately 9% of permanent and 14% of seasonal farm workers are employed in jobs with potential exposure to agrichemicals. While protective equipment was widely available, gloves and masks were seldom used, with little enforcement or commercial support from the suppliers of the equipment. Farm workers receive little training on pesticide safety, but interest in the possibility of further training for workers was high. In the absence of a system of pesticide disposal, the presence of residual, unwanted and outdated stocks of pesticides in farmers' stores, and to a lesser extent the presence of empty containers, are identified as important problems. Current pesticide storage practices require improvement by simple industrial hygiene measures. Health facilities available to workers on most farms are extremely limited, particularly in the light of statutory requirements for occupational safety and health under the Machinery and Occupational Safety Act. It is argued that collective solutions to problems of pesticide safety are possible within the ambit of a public health response, particularly given the willingness of the farming community to identify and address potential health problems. As a result, initiatives to meet these needs are currently under way in the region.

Paraffin (kerosene) poisoning in childhood--is prevention affordable in South Africa?

Abstract: Paraffin (known in some Western countries as kerosene) ingestion is the most common form of acute childhood poisoning in most developing countries. South African black communities reflect a similar pattern, yet the true size and cost of the problem are not known. Without such baseline data the effect of interventions cannot be evaluated. The aim of the study was to determine the incidence and treatment cost of paraffin poisoning in the Cape Peninsula, to identify high-risk areas and to discuss which measures offered the most economical and best preventive potential for this paediatric hazard. A 12-month retrospective study was undertaken in 1990. Relevant patient data were extracted from the files of 6 major Cape Peninsula hospitals. Treatment costs were calculated based on differential hospital costs per inpatient per day, with outpatient costs at one-third of the costs per day. Age-specific rates for affected residential areas were calculated to identify high-risk areas. A total of 436 children (62,5% male), mostly between the ages of 12 and 36 months, were treated at an estimated cost of R111 673. This amount would have been sufficient to provide 95% of households in the 8 identified high-risk areas with child-resistant paraffin containers. In these areas age-specific paraffin poisoning rates ranged from 1,8/1,000 to 7,7/1,000. Strategically planned interventions can be cost-effective when weighed against the treatment cost of cases of paraffin poisoning.

Monogenic primary hypercholesterolaemia in South Africa.

Abstract: Familial hypercholesterolaemia (FH) and familial defective apolipoprotein B-100 (FDB) are the two major causes of monogenic primary hypercholesterolaemia. In this review, FH and FDB are defined in relation to normal lipoprotein metabolism. In South Africa FH affects about 1% of Afrikaners, Jews and Indians, while FDB is probably a much rarer disorder. In Afrikaners, three 'founder' mutations are responsible for more than 80% of FH. The population genetics that created the exceptionally high frequency of FH and comparatively low frequency of FDB in various South African populations are described. The genetic organisation and itinerary of the normal low-density lipoprotein (LDL) receptor are reviewed, with particular emphasis on the structure-function relationships in the LDL receptor that have been clarified by the mutations found in South Africa. Finally, the clinical relevance of research into FH in South Africa is discussed.

Hepatitis viruses and hepatocellular carcinoma.

Abstract: Of the hepatitis viruses that have been identified and their pathological consequences characterised, three - hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus (HDV) - have been implicated as risk factors for hepatocellular carcinoma (HCC) in humans. Sufficient evidence is now available to justify the conclusions that chronic infection with HBV and HCV, but not HDV, are causes of HCC. Hepatocellular carcinogenesis is a complex step-wise process that evolves over many years, and the precise way(s) in which these two viruses induce malignant transformation remain uncertain. The observation that HBV DNA is integrated into cellular DNA in the great majority of, and perhaps all, HBV-related HCCs, whereas replicative intermediates of HCV do not insert into host DNA in HCVrelated HCC, makes it very likely that different pathogenic mechanisms operate in HBV- and HCV-induced HCC. Indeed, evidence is mounting that both direct and indirect mechanisms, and often the two together, are involved in the genesis of HBV-related HCC, but that HCV appears only to induce HCC indirectly by causing chronic necroinflammatory hepatic disease which in turn is responsible for tumour formation. There is some evidence that the two viruses may interact in the development of HCC, but this remains to be proven. Animal models - other members of the hepadnavirus family (to which HBV belongs) that also cause HCC in their respective animal hosts, and transgenic mice into which sequences of HBV DNA have been inserted - are proving useful in elucidating putative mechanisms of HBV-related hepatocellular carcinogenesis, but no models for studying HCV-induced HCC are yet available. Whatever the pathogenesis of HBV-induced and HCV-induced HCC, the viruses do not act alone but in conjunction with other environmental carcinogens and a number of host factors.

Paraffin ingestion - the problem

Abstract: Paraffin ingestion is the commonest cause of accidental childhood poisoning in South Africa. Children from the lower socio-economic group are affected most. They drink paraffin in the summer months from bottles or intermediate containers, mistaking it for water or cold-drink. The children are predominantly male with a mean age of 24 months. The clinical picture is one of respiratory distress with a hospital case fatality rate of 0.74%. The use of paraffin as a source of household energy in South Africa is on the increase. Based on a modernisation index it would seem that this trend will continue into the next century. It can therefore be expected that the number of cases of paraffin ingestion will steadily increase if no active steps are taken to address the problem. Prevention should entail a wide spectrum of measures, the basis of which should be a child-resistant container. An effective durable, low-cost child-resistant container which is easy to pour from should be made available by petroleum companies and/or entrepreneurs and distributed through their network. This should be combined with health education on the danger of paraffin. Health care workers and administrators should be made more aware of the problem and become involved in health education and prevention. Further research should be undertaken on the effect a change in the colour of paraffin and the use of child-resistant caps would have on the incidence of paraffin ingestion in South Africa.

Notification of pesticide poisoning in the western Cape, 1987-1991.

Abstract: There is a paucity of data on pesticide-related morbidity and mortality in South Africa. A review of notifications to the western Cape office of the Department of National Health and Population Development from 1987 to 1991 was undertaken to describe the epidemiological profile of pesticide poisoning in the region. Two hundred and twenty-five cases of pesticide poisoning were identified, of which the majority were from rural areas. Farmers, farm workers and their families were most frequently involved in poisoning events, which included accidents arising outside of workplace production (44%), self-inflicted injury (35%) and direct occupational contamination (11%). Farm pesticide stores were the most frequent source of pesticide and a seasonal variation in the trend of poisoning events could be discerned; this corresponded to agricultural spraying practices in the region. The mortality rate was significantly higher among those with self-inflicted injury, particularly farm workers. A concurrent review of hospital admissions for 1991 found that 78% of cases had not been notified. In view of the key role of surveillance in reducing pesticide-related morbidity and mortality, a call is made to improve notification of pesticide poisoning so as to facilitate control of an important potential public health problem.

Stress and burnout in junior doctors

Abstract: Questionnaires were sent to doctors who had graduated 2 1/2 years previously from two English-medium universities in South Africa. Findings showed that 77.8% of doctors had experienced symptoms consistent with burnout since graduating. Incidence of burnout was found to be related to an inability to communicate freely with patients in their own language. Although those doctors who saw more than forty patients a day reported more burnout, the difference was not statistically significant. The highest incidence of burnout was among doctors working in day hospitals and clinics, followed by those in hospital posts. Doctors working in their own practices experienced least burnout. Sixty-three per cent of doctors felt that a support group would be helpful.

Quinsy tonsillectomy or interval tonsillectomy - a prospective randomised trial

Abstract: Fifty-one patients with peritonsillar abscesses were randomised to undergo either quinsy tonsillectomy (aT) or interval tonsillectomy (IT), and the two groups were compared. The aT group lost fewer (10,3 v. 17,9) working days and less blood during the operation (158,6 ml v. 205,7 ml); haemostasis was easier and the operation was technically simpler in this group. There was no significant difference in length of hospital stay and neither group had intra- or postoperative complications. Only 64% of the IT group returned for tonsillectomy. In this study aT had distinct advantages over drainage and IT in the management of peritonsillar abscesses. S AIr Med J 1994; 84: 689-690.

'Atypical' bacteria are a common cause of community-acquired pneumonia in hospitalised adults.

Abstract: Objectives . To assess the proportion of cases of community· acquired pneumonia caused by 'atypical' bacteria, inclUding the recently discovered Chlamydia pneumoniae , and to compare the clinical, radiographic and laboratory features of patients with and without 'atypical' bacteria. Methods . A prospective serological study was carried out on consecutive adult pneumonia patients from July 1987 to July 1988. Acute and convalescent sera were tested in batches for antibodies against Legionella pneumophila serogroup 1, C. pneumoniae, Chlamydia psittaci, Coxiella burnetii (phase-2 antigen) and Mycoplasma pneumoniae (lgG and IgM). Records and chest radiographs were examined retrospectively. Results . Acute and convalescent sera were available from 113 patients. The records of 4 patients could not be traced and 17 patients did not fulfil the inclusion criteria. Thirty-two of these 92 patients (35,9%) were found to be infected with 'atypical' bacteria. The two most common organisms were C. pneumoniae (20,7%) and L. pneumophila (8,7%). There. were no differences in the clinical and radiographic features of patients with and without 'atypical' bacteria. Clinicians prescribed erythromycin or tetracyclines with equal frequency in the two groups. Conclusions . 'Atypical' bacteria, especially C. pneumoniae , are a common cause of community-acquired pneumonia in adults in South Africa. This is the first demonstration of an aetiological role of C. pneumoniae in this country. We confirmed the finding of other studies that there are no clinical, radiographic or laboratory features characteristic of 'atypical' bacterial infection in hospitalised patients. This has major implications for therapy, as these organisms respond to erythromycin and tetracyclines, but· not to β-lactam antibiotics.

Risk factors for coronary heart disease in the white community of Durban

Abstract: Coronary heart disease (CHD) is the leading cause of death among the white and Indian populations of Durban. This was a community-based study of the white population of Durban, which is predominantly English-speaking. There were 396 subjects (194 men, 202 women) aged 15 - 69 years. A history of CHD was present in 9,3% of the subjects. The important risk factors were hypercholesterolaemia, hypertension and smoking. The minor risk factors were obesity, hypertriglyceridaemia, hypeuricaemia, a sedentary occupation and a history of CHD in the immediate family. Electrocardiograph abnormalities denoting CHD were present in 17% of subjects. A study of the major risk factors showed that 35,1% (age and sex adjusted) had at least one major risk factor at the higher level (level A) and 33,8% (age and sex adjusted) at the lower risk levels (level B). When the combination of risk factors was taken into account, 15,2% and 28% had two major risk factors, one each at levels A and B respectively. On average the percentage of men and women with one risk factor or more increased with age. A protective high-density lipoprotein/total cholesterol ratio≥20% was present in 53,5% of the respondents. Because of the severe nature of CHD, an intensive programme for the primary prevention of CHD risk factors should be instituted.

National HIV surveillance - South Africa, 1990 - 1992

Abstract: The findings of three annual surveys of women attending antenatal clinics (at the end of 1990, 1991 and 1992) are presented here. These surveys form part of the National HIV Surveillance Programme. This programme is probably the most useful means of monitoring the trend and distribution of the epidemic. In all strata, a consistent rise in the HIV prevalence rate was found; it doubled almost every 12 months. The point prevalence rate in antenatal clinic attenders in South Africa increased from 0.76% in 1990 to 1.49% in 1991 and 2.69% in 1992. The prevalence rate was found to vary widely geographically: Natal/KwaZulu formed the spearhead of the epidemic with a 4.77% rate of HIV infection in 1992. Venda and the Cape appeared to be the least affected with rates of 0.64% and 0.66% respectively.

Retrospective analysis of snakebite at a rural hospital in Zululand.

Abstract: Aspects of the epidemiology and clinical features of 81 consecutive patients admitted with snakebite to a rural hospital in Zululand are reviewed. Most bites occurred during the hot season, 40% in children under 10 years of age. Thirty per cent of bites occurred at night. Most bites showed features of local envenoming only, but systemic features (neurotoxicity and haemorrhage) were encountered. Snakebite caused significant morbidity and mortality. Thirty-one per cent of admissions needed surgery; almost 50% needed more than one operation. Five per cent, all children, died. The extent of local envenoming on admission proved to be a highly sensitive indicator of risk of worsening of local envenoming, and of the development of systemic signs. The analysis has allowed the development of rational guidelines on the management of snakebite in this hospital which, it is hoped, will reduce mortality rates, and has identified several areas warranting further research.

The effects of a single treatment of an acaricide, Acarosan, and a detergent, Metsan, on Der p 1 allergen levels in the carpets and mattresses of asthmatic children.

Abstract: Baseline levels of the house-dust mite allergen, Der p 1, were measured on the carpets and mattresses of 60 pure-mite-sensitive asthmatic children in the Cape Peninsula, by means of an enzyme-linked immunosorbent assay (ELISA). High levels of mite allergens were recorded (range 2-50 micrograms Der p 1/g dust). In order to investigate the efficacy of the application of acaricides to carpets and bedding, 3 groups of 20 children were studied. Carpets and mattresses in group A were treated with a detergent, Metsan (Snowchem), and in group B with Metsan combined with the acaricide, Acarosan (Noristan). Group C was a control group in which no treatment was applied. The level of airway hyperreactivity (PC20) to histamine was measured at the beginning of the study and again 3 months after acaricide treatment. Significant reductions in carpet Der p 1 levels were achieved in group A (22.83 v. 13.26 micrograms Der p 1/g dust; P = 0.04) and group B (21.76 v. 13.26 micrograms Der p 1/g dust; P = 0.01), but mite levels were not reduced in any of the mattresses treated. There was also no improvement in airway hyperreactivity in any of the groups. This study clearly demonstrates that at present it is not possible to reduce Der p 1 antigen levels in mattresses in the Cape Peninsula with the available acaricides, even when one of these is combined with a detergent solution. Until strategies are developed which will significantly reduce Der p 1 levels in the bedding of sensitive individuals, a reduction in ongoing airway inflammation and airway hyperreactivity cannot be expected.

Haematological condition of the San (Bushmen) relocated from Namibia to South Africa.

Abstract: A cross-sectional study was undertaken to assess the haematological condition of the San (Bushmen) relocated from Namibia to South Africa. We studied 238 subjects 145 men and 93 women; none of the women was pregnant. We performed full blood counts and estimations of serum vitamin B 12 , folate, ferritin and erythrocyte folate concentrations. The mean haemoglobin concentration among the men was 14,7 g/dl and 19 (13%) were anaemic; among the women it was 13,8 g/dl and 18 (19%) were anaemic. Thirteen (9%) of the men and 22 (24%) of the women had low concentrations of serum ferritin, and 38 (26%) of the men and 22 (24%) of the women had erythrocyte folate concentrations of less than 270 nmol/l

Intravenous and intramuscular magnesium sulphate regimens in severe pre-eclampsia.

Abstract: Patients with severe pre-eclampsia were randomised to receive magnesium sulphate according to an intramuscular (IM) (N = 9) or an intravenous (i.v.) (N = 8) regimen. The IM regimen consisted of a loading dose of 14 g (4 g i.v. and 10 g IM) followed by 5 g 4-hourly. Patients given the IV regimen received a 6 g i.v. loading dose followed by a maintenance infusion of 2 g/h. Clinical outcome, laboratory parameters and serum magnesium levels were recorded for both groups. There were no significant differences between groups with regard to clinical outcome of either mother or child. Similar average serum magnesium concentrations were produced by the regimens the only significant difference was that fluctuations in magnesium levels were greater with the IM than the i.v. regimen. None of the patients had seizures despite levels mostly below 2 mmol/l.

Inequalities in South African health care. Part I. The problem--manifestations and origins

Abstract: This exposition analyses and contextualizes the complex problem of structural inequality in South African health care. Socio-economic conditions, racial divisions and geographical location are isolated as the main determinants of inequality in the provision, allocation and distribution of health care; the prevailing inequalities are attributed to a wide range of underlying causes, including the absence of a central, binding health policy, the prominent role of apartheid and white domination, the free market and the medical profession, as well as the unique sociocultural set-up of the country. The urgent need for deliberate strategies to equalize the prevailing disparities and discrepancies is posed.

Visual function and long-term chloroquine treatment

Abstract: Ophthalmic examinations and selected tests of visual function were perfonned on 64 patients with rheumatoid arthritis who had received daily doses of 200 mg chloroquine sulphate for periods ranging from 3 to 11 months. Visual fields were determined by Humphrey automated perimetry and Amsler grids and a further battery of four tests of macular function (visual evoked potentials, critical flicker fusion threshold, Cambridge contrast sensitivity and the macular dazzle test) were administered. No case of retinal pigmentary abnormalities plus visual loss was found, but 2 patients were advised to cease chloroquine therapy on the basis of funduscopic findings. A small group of patients with relatively poor scores on one or more tests had normal visual fields and ophthalmic findings. There were no significant partial correlations between test results and the cumulative dose of chloroquine. These results support the opinion that currently recommended doses of chloroquine pose a minimal risk of retinal toxicity.

Risk factors for the development of osteoporosis in a South African population. A prospective analysis.

Abstract: CITATION: Blaauw, R. et al. 1994. Risk factors for the development of osteoporosis in a South African population. A prospective study. South African Medical Journal, 84:328-332.