SAMJ - Africa's top open access medical journal

A revolution is taking place in the world of scientific publishing. In the traditional model of publishing scientific articles, the author raised money to conduct the research project, then submitted the paper to a scientific journal for consideration for publication; if the manuscript survived the brutal peer review process, the author would be required to assign copyright to the publisher and pay 'page charges' for publication of the article. Finally, the author (as reader) had to pay a subscription fee to the publisher of the journal in order to have access to his or her published paper! Authors, members of the public and funders of research are understandably in revolt against this apparent exploitation of authors and readers by traditional publishers who extract substantial profits from the production of scientific knowledge through the efforts and investments of others. This unfavourable situation has led to the rise of the 'open access' movement in scientific publishing

A proposal for the eradication of rheumatic fever in our lifetime

The Pan African Society of Cardiology (PASCAR) convened the 1st All Africa Workshop on Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD) on 15 - 16 October 2005 at the Champagne Sports Resort, Drakensberg, South Africa. The purpose of the Workshop was to formulate an action plan for the prevention of RF and RHD in Africa. The gathering was a response to the new guideline on the control of RF and RHD by the World Health Organization (WHO) in 2004.1 The meeting (and this supplement) was made possible by the generous sponsorship of the national Department of Health of South Africa, the Medical Research Council of South Africa, the WHO Regional Office for Africa (WHO-AFRO) and the World Heart Federation, and endorsed by the Heart Foundation of South Africa, the Paediatric Cardiac Society of South Africa, and the South African Heart Association. The other organisations represented at the meeting included the Africa Heart Network, the Nigerian Heart Foundation, and academics from the universities of Alexandria, Cape Town, Ghana, Ibadan, KwaZulu-Natal, Libreville, Limpopo, Nairobi, Pretoria, and Eduardo Mondlane University

Protocols for antibiotic use in primary and secondary prevention of rheumatic fever

Several guidelines and studies that address the issue of ‘best practice’ in the primary and secondary prevention of rheumatic fever (RF) have been published recently.1-4 Here I present a summary of the latest recommendations for the prevention of RF that have been distilled from these sources

Pentoxifylline for heart failure: A systematic review

Background. Recent trials have indicated a beneficial effect of pentoxifylline on measures of inflammation and markers of cardiac dysfunction in people with heart failure. However, it is uncertain whether pentoxifylline should be used routinely in the management of heart failure. Objective. To determine the effectiveness of pentoxifylline in heart failure. Design. Systematic review of randomised controlled trials. Methods. We searched MEDLINE (1 January 1966 - 20 November 2004), the Cochrane Controlled Trials Register (issue 4, 2004), and reference lists of related papers, for randomised controlled trials of pentoxifylline in the treatment of heart failure. Prospective, randomised, double-blind controlled trials were sought for inclusion in the study. The two reviewers independently assessed trial quality and extracted data, which were analysed using RevMan statistical software. The following outcome measures were evaluated: (i) New York Heart Association (NYHA) functional class; (ii) left ventricular ejection fraction (LVEF); (iii) frequency of hospitalisation; and (iv) death from all causes. Results. Four studies with a total of 144 participants met the inclusion criteria. Statistical pooling (or meta-analysis) was not performed owing to the significant clinical heterogeneity and differences in reporting of the outcomes in the included studies; instead, the trials were analysed separately for the outcomes of interest. The four studies tested the use of pentoxifylline versus placebo in patients with heart failure of varying aetiology (idiopathic dilated cardiomyopathy, 3 studies; ischaemic cardiomyopathy, 1 study). In 2 of the idiopathic dilated cardiomyopathy studies, patients were classified as NYHA class II or III, while the study population in another idiopathic cardiomyopathy study was in NYHA class IV. The trial of patients with ischaemic cardiomyopathy included patients in NYHA functional classes I - IV. The use of pentoxifylline was associated with significant improvement in symptoms (i.e. NYHA functional class) and cardiac function (i.e. LVEF) in 3 out of 4 studies. The beneficial effect on symptoms of heart failure and cardiac function was seen in all grades of severity of heart failure and in patients with ischaemic and idiopathic dilated cardiomyopathy. All 4 studies showed a trend towards reduction of mortality, but this effect was not statistically significant. The effect of pentoxifylline on the frequency of hospitalisation has not been tested in randomised controlled trials. Interpretation. Pentoxifylline may have a beneficial effect on NYHA functional class, ejection fraction and mortality in heart failure, but published trials are too small to provide conclusive evidence. There is a need for large, placebocontrolled trials of pentoxifylline in heart failure, involving a diverse group of patients with regard to cause and severity of heart failure

The challenge of screening for asymptomatic rheumatic heart disease in South Africa

Acute rheumatic fever and rheumatic heart disease remain common in the population of South Africa. A recent screening study of asymptomatic schoolchildren in Mozambique and Cambodia makes a compelling case for a shift in the approach to screening for rheumatic heart disease from auscultation to portable echocardiography. Rheumatic heart disease meets all the epidemiological criteria for screening in the South African population. The incorporation of echocardiographic screening programmes into the school health system and in antenatal clinics for the pre-symptomatic diagnosis of rheumatic heart disease could result in the reduction of morbidity and mortality through the early and wide application of secondary antibiotic prophylaxis

Intramuscular penicillin is more effective than oral penicillin in secondary prevention of rheumatic fever - a systematic review

Background. People with a history of rheumatic fever (RF) are at high risk of recurrent attacks and of developing rheumatic heart disease following a streptococcal throat infection. Giving penicillin to these people can prevent recurrent attacks of RF and subsequent rheumatic heart disease. However, there is no agreement on the most effective method of giving penicillin. Objectives. To assess the effects of different penicillin regimens and formulations for preventing streptococcal infection and RF recurrence. Search strategy. We searched the Controlled Trials Register (Cochrane Library Issue 2, 2001), Medline (January 1966 - July 2000), Embase (January 1985 - July 2000), reference lists of articles, and contacted experts in the field. Selection criteria. Randomised and quasi-randomised studies comparing: (i) oral with intramuscular penicillin; and (ii) 2- or 3-weekly with 4-weekly intramuscular penicillin in patients with previous RF. Data collection and analysis. Two reviewers independently assessed trial quality and extracted data. Main results. Six studies were included (1 707 patients). Data were not pooled because of clinical and methodological heterogeneity of the trials. Four trials (1 098 patients) compared intramuscular with oral penicillin and all showed that intramuscular penicillin was more effective in reducing RF recurrence and streptococcal throat infections than oral penicillin. One trial (360 patients) compared 2-weekly with 4-weekly intramuscular penicillin. Penicillin given every 2 weeks was better at reducing RF recurrence (relative risk (RR) 0.52, 95% confidence interval (CI): 0.33 - 0.83) and streptococcal throat infections (RR 0.60, 95% CI: 0.42 - 0.85). One trial (249 patients) showed that 3-weekly intramuscular penicillin injections reduced streptococcal throat infections (RR 0.67, 95% CI: 0.48 - 0.92) compared with 4-weekly intramuscular penicillin. Conclusions. Intramuscular penicillin seemed to be more effective than oral penicillin in preventing RF recurrence and streptococcal throat infections. Two-weekly or 3-weekly injections appeared to be more effective than 4-weekly injections. However, the evidence is based on poor-quality trials and the use of outdated formulations of oral penicillin. (South African Medical Journal: 2003 93(3): 212-218

Clinical and epidemiological aspects of streptococcus pyogenes pharyngitis and carriage in Africa

Infection with Group A β-haemolytic Streptococcus, also known as Streptococcus pyogenes, results in various mucosal and skin diseases including pharyngitis. An exaggerated immune response to a single or repeated group A streptococcal (GAS) infection subsequently results in acute rheumatic fever (ARF) and, in the absence of intervention, repeated bouts of ARF may in turn result in progression to RHD, particularly in those ARF patients with cardiac involvement. Addressing GAS pharyngitis through appropriate primary prevention measures and treating all symptomatic GAS sore throats with a course of oral or parenteral penicillin presents an opportunity for the primary intervention of RHD. Failure to eradicate streptococci from the pharynx occurs in about one third of non-treated cases, giving rise to carrier status in those individuals harbouring intracellular GAS and thus representing a potential source of the acquisition of infections for other children and adults. Improved living conditions and access to healthcare during the last century are credited for the considerable decline in the prevalence of ARF and RHD in developed countries. However, a few studies have been reported from within Africa, and in these GAS carriage ranged around 9.0%. In South African studies GAS carriage isolation rates, which range from 1.62% to16.8%, were reported. As regards the prevalence of GAS pharyngitis, it is generally higher in developing countries and impoverished communities withinindustrialised nations. The most-up-to-date data from South Africa was collected more than 30 years ago with rates then ranging from 23.2% to 45.5%. There are no incidence data on GAS pharyngitis in Africa. This review found that there is a need to document the epidemiology of GAS carriage and GAS pharyngitis in school children of all ages within Africa. Molecular characterisation of strains harboured in the pharynx of carriers and of those isolated during bouts of pharyngitis, will help to identify risk factors associated with carriage in school-aged children and infl uence the planning and evaluation of management programmes in the screening of pharyngeal carriers and treatment of GAS pharyngitis

2016 National Rheumatic Fever Week: The status of rheumatic heart disease in South Africa

There is evidence of early progress in the efforts to eliminate acute rheumatic fever (ARF) and control rheumatic heart disease (RHD) in South Africa. The caseload of ARF and RHD in paediatric units appears to be falling in some provinces such as Gauteng, and the mortality attributed to rheumatic heart disease at a population level has fallen from 1.3/100 000 in 2001 to 0.7/100 000 in 2012. However, the incidence of congestive heart failure due to RHD in adults remains high (~25/100 000/year) in Gauteng Province, and is associated with a high case fatality rate of up to 35% in 6 months. There is a need to intensify the application of comprehensive interventions to enhance the primary and secondary prevention and treatment of ARF/RHD in a registry-based national programme