South African Medical Journal - August 2023 Vol 113 No 8 Print Edition

Introduction

Urgent appeal to allow all professional nurses and midwives to prescribe pre-exposure prophylaxis (PrEP) in South Africa

With 1.5 million global incident HIV infections in 2021, of which 210 000 occurred in South Africa (SA), there is an urgent need to reduce barriers to and simplify provision of pre-exposure prophylaxis (PrEP) for those who need it most. SA has the highest number of people living with HIV in the world, with HIV prevalence rates of up to 41% in pregnant women. In SA, daily oral PrEP (tenofovir/ emtricitabine (TDF/FTC)) has been provided to adolescent girls and young women, sex workers, men who have sex with men, pregnant and breastfeeding women and other populations at risk of HIV acquisition, following the 2015 World Health Organization (WHO) recommendations.[5] The national PrEP programme in SA reached >880 000 individuals started on daily oral PrEP between June 2016 and February 2023. However, continuation of PrEP remains low, estimated at only 20% of those who start PrEP (based on national PrEP monitoring and evaluation data presented by the National Department of Health in Johannesburg, 19 - 20 April 2023 – unpublished). Furthermore, integration of PrEP delivery into existing services differs across provinces and facilities, frequently being impeded by resource constraints.

Surgical training and capacity development in the South African internship programme

South Africa (SA)’s health system manages a quadruple burden of disease, consisting of infectious diseases such as HIV/AIDS and tuberculosis; maternal, newborn and child health problems; non-communicable diseases; and trauma due to injury and violence. SA’s disease burden is driven by many systemic factors, one of which is the stark inequalities between the rich and the poor that reflect the legacy of apartheid and colonialism. Mayosi et al.’s argument that these inequalities extend into the quality of healthcare accessed between races and between income classes was supported by a 2015 systematic review on health inequalities in SA. The effects of the provision of inequitable healthcare services throughout the apartheid era in SA are long lasting, and this history must be considered in every analysis of the SA healthcare system.

Potential drug-drug interactions with phentermine among long-term phentermine consumers: A retrospective analysis

Phentermine, an extraordinary amphetamine derivate, is South Africa (SA)’s most popular prescription-only anti-obesity medication used for its appetite-suppressing properties. The drug stimulates the central nervous system (CNS), inhibiting the reuptake and stimulating the release of endogenous neurotransmitters, including dopamine (DA), serotonin (5-HT) and norepinephrine (NE). Consequently, there is an increase in the concentration of these neurotransmitters in the CNS and stimulatory effects. In the brain, the increased DA concentration will provide a constant DA-induced feeling/sensation of reward (associated with eating), which will result in appetite suppression. Persistent 5-HT neurotransmission in the brain may also result in appetite suppression; however, these effects are only achieved at doses higher than the recommended maximum daily dosage, that is >30 mg phentermine. Once NE is released, the hormone cascade of the hypothalamus-pituitary axis (HPA) is activated via the amygdala of the brain. Signals are transmitted from the amygdala to the hypothalamus, then to the pituiary gland, and finally to the adrenal cortex, positioned on top of the kidneys. As a result, DA, NE and epinephrine are released into the bloodstream, where they will bind to adrenergic receptors (α and β receptors) of fat tissue and smooth muscles.

Cavernous sinus thrombosis: A rare and potentially lethal complication of herpes zoster ophthalmicus that can easily be missed

Herpes zoster ophthalmicus (HZO) is a well-recognised opportunistic infection representing reactivation of latent varicella-zoster along the ophthalmic division (V1) of the trigeminal nerve. More commonly known as shingles, it can affect both immunocompetent and immunocompromised individuals, although the disease runs a more severe course in those who are immunocompromised. It is frequently a blinding condition in South Africa (SA) owing to late presentation, often coupled with a delay in initiation of appropriate treatment. The disfiguring facial scarring and chronic pain of postherpetic neuralgia (PHN) that affect many patients add to the burden of psychosocial morbidity associated with this devastating disease. Approximately 20% of patients with herpes zoster may present with HZO, and of these ~50% will have ocular involvement. The presence of Hutchinson’s sign (lesions on the lateral aspect and/or the tip of the nose) indicates nasociliary nerve involvement and has a strong positive predictive value for ocular involvement. Causes of acute vision loss include necrotising retinitis, kerato-uveitis, scleritis, and rarely optic neuritis. Neuro-ophthalmic manifestations such as encephalitis, aseptic meningitis and cranial nerve palsies, although uncommon, have been described. Cavernous sinus thrombosis is a very rare but potentially lethal complication of HZO, with just a few isolated case reports in the literature. However, it is critical that the diagnosis is considered and not missed when dealing with a patient with HZO.

Streamlining regulatory processes for health researchers: To what extent does POPIA apply?

This article starts by examining the specific regulatory framework for health research in South Africa (SA). It then dissects s3(2) of the Protection of Personal Information Act No. 4 of 2013 (POPIA), which is the application provision in the Act. We show that the provisions of the sectoral legislation on health are more extensive than the conditions in chapter 3 of POPIA, meeting the requirements of s3(2)(b) of POPIA. We then explore the implications of this finding, one of which is that the definition of broad consent in the sectoral legislation for health research should be applied to the exclusion of the consent provisions in POPIA.

Cancer mortality trends in South Africa: 1997 - 2016

The National Cancer Registry of South Africa (NCR-SA) has reported that prostate, colorectal, lung, non-Hodgkin’s lymphoma and melanoma cancer are the ‘big five’ cancers that affected men in South Africa (SA) in 2019. In 2019, the NCR-SA also reported that the top five cancers that indiscriminately afflicted women included breast, cervix, colorectal, uterus and non-Hodgkin’s lymphoma cancer in SA. There is a high curability of many cancers if detected early and treated effectively. It is noteworthy that in the reports published by Statistics South Africa (StatsSA) in 2013 and 2015 that cancer did not make it to the top 10 of the most frequent causes of death, which creates the impression that cancer is not a problem in SA. However, the reporting was primarily based on the International Statistical Classification of Diseases and Related Health Problems (10th edition) (ICD-10).

A national retrospective descriptive analysis of critical care transfers in the private sector in South Africa

The growing need for critical care transfers (CCTs) has been necessitated by the growing population of critically ill or injured patients requiring upgrade of care from resource-limited facilities to centralised facilities with multidisciplinary teams. Additional demand for CCTs has also been found to be a result of a lack of access to appropriate healthcare facilities, a growing patient population and an insufficient number of medical specialists, along with an outgrowing demand for intensive care unit and high-care beds. Internationally, specialised critical care retrieval services (CCRS) have been developed to undertake these transfers, owing to the high acuity of patients, the need for specialised training and equipment, and the high rates of adverse events during transport.

Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review

Heart failure is a significant public health challenge, with nearly 65 million people affected globally. It is a heterogenous clinical syndrome with a global prevalence estimated at 2% in the general adult population in high-income countries, with an increase of >10% in patients >70 years of age. Population-based estimates in sub-Saharan Africa are lacking, but the combination of poorer outcomes and an anticipated higher prevalence results in a significant burden on the health system and substantial healthcare expenditure.[6] In contrast to high-income countries, where heart failure is mainly considered a disease of the older population, it affects younger people in sub-Saharan Africa, with predominantly non-ischaemic aetiologies. Acute pulmonary oedema (APE) is a well-defined manifestation  of  acute decompensated heart failure, with an in-hospital mortality of 4 - 7% globally, increasing to 11% 2 - 3 months post discharge. It is a life-threatening emergency that progresses to cardiorespiratory collapse in minutes to hours, if not treated promptly.

Acute angioedema in Cape Town emergency centres and a suggested algorithm to simplify and improve management

Angioedema is paroxysmal, localised and self-limiting swelling of the subcutaneous and/or submucosal tissue due to a temporary increase in vascular permeabilty. The number of acute angioedema cases in high-income countries (HICs) is increasing. However, there is a paucity of data regarding the epidemiology of angioedema in Africa. This is concerning, given that persons of African ancestry are three to five times more likely to have angiotensin converting enzyme inhibitor (ACE-I) angioedema.

The association between cytology and histopathology in thyroid nodules over a 6-year period in an urban hospital in South Africa

Thyroid cancer is prevalent both internationally and locally in South Africa (SA), and is the most common cause of endocrine malignancy in Africa. Rahbari et  al.  found that it is 2.9  times more common in females than males, and is currently on an increasing trend worldwide. This increase may be due to various factors, including improvements in diagnostic methods and changes in iodination of salt in our diets. Internationally, according to the National Cancer Database in the USA, the incidence of thyroid cancer has increased over the last decade from an incidence of 7.1 per 100 000 in 2000 to 17.6 per 100 000 in 2013. This increase was noted predominantly in papillary carcinoma. The 2019 SA National Cancer Registry Guidelines noted that thyroid cancer was the 15th most common cancer among females, compared with the 32nd most common in males, with incidences of 1.28% v. 0.4%, respectively.