Fits, faints and funny turns

Fits, faints and funny turns represent a commonreason for presentation – either to the generalpractitioner or to the emergency department. Inmany cases, the consultation is dissatisfying for thedoctor and the patient, as such patients frequentlypresent a diagnostic dilemma for the clinician. Frequently, the keyto a satisfactory evaluation is a structured approach, premised ona clear and comprehensive history focused on prior comorbiditiesand the episode – its context, precipitating factors, prior situationalfactors, onset and evolution, and events occurring afterwards. Adetailed and carefully elicited medical history allows the clinicianto confirm the diagnosis, delineate the underlying mechanism, andidentify features that may suggest high risk of recurrence, injuryor death

Research on COVID-19 in South Africa: Guiding principles for informed consent

Research is imperative in addressing the COVID-19 epidemic, both in the short and long term. Informed consent is a key pillar of research and should be central to the conduct of COVID-19 research. Yet a range of factors, including physical distancing requirements, risk of exposure and infection to research staff, and multiple pressures on the healthcare environment, have added layers of challenges to the consent process in COVID-19 patients. Internationally, the recognition that consent for COVID-19 research may be imperfect has led to a range of suggestions to ensure that research remains ethical. Drawing on these guidelines, we propose a consent process for COVID-19 research in the South African context that combines individual consent with delayed and proxy consent for individuals who may be temporarily incapacitated, combined with key principles that should be considered in the design of a consent process for COVID-19 research.

Digoxin therapy in the modern management of cardiovascular disease: An unusual but serious complication

A 67-year-old woman presented to the Emergency Unit, Groote Schuur Hospital, Cape Town, South Africa, with a 1-week history of poor appetite, vomiting and fatigue. Her background history was notable for infundibular pulmonary stenosis resection, pulmonary embolism and atrial flutter. Two days before, she complained to her general practitioner of recent-onset, recurrent syncope and worsening gastrointestinal upset. Her medical treatment included warfarin 5 mg daily, enalapril 5 mg twice daily, furosemide 40 mg twice daily, atenolol 50 mg twice daily, amiodarone 200 mg daily and digoxin 0.125 mg daily. The digoxin was added to her therapy 8 months earlier to optimise rate control.

An approach to the clinical assessment and management of syncope in adults

Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medicalpresentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implementa mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease,rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains themost important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanismcausing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised intovasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope(from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope thatcannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural(mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined asa decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes oforthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should bemanaged urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medicationand provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to bethe cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to rememberthat in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and preventrecurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequentlyreferred to a cardiologist for appropriate management