Message From The Executive

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Evaluation of fever of unknown origin before starting antiretroviral therapy

A 34-year-old woman tested HIV-positive in December 2005, and was referred to a specialist HIV unit in mid-January 2006. She had presented to her general practitioner with oesophageal candidiasis and a history of a cough and occasional loose stools since November 2005, with an 8 kg weight loss over the past 6 months. She had no history of other opportunistic infections or HIV-related conditions. On examination her temperature was 38.5°C and she had sinus tachycardia. Wasting, pallor and severe oral thrush were noted. There was no lymphadenopathy, hepatomegaly or splenomegaly, and the findings on respiratory examination were normal. Southern African Journal of HIV Medicine Vol. 7 (2) 2006: pp. 45-4

Overview of HIV-related lipodystrophy

Lipodystrophy is a well-recognised adverse effect of HIV and antiretroviral therapy, with certain antiretrovirals, specifically thymidine analogues, implicated in the aetiology and pathogenesis. Lipodystrophy is often accompanied by metabolic complications, such as hyperlipidaemia and insulin resistance, which increase risk for cardiovascular disease. There are limited data on the effect of treatment modification, pharmacological interventions and surgical management on this condition.Here we summarise the latest data on lipodystrophy, with the aim of facilitating informed decision-making in managing this condition. In light of the absence of cost-effective measures to treat lipoatrophy and lipohypertrophy, prevention remains the best option; we recommend targeted annual screening. Healthcare workers should be sensitised to early detection in patients on thymidine-based regimens, and affected patients should be switched to an appropriate regimen as soon as feasible. There is no evidence to support the use of new-generation ARVs, except in patients with significant hypercholesterolaemia, where atazanavir and raltegravir may present better options.S Afr J HIV Med 2013;14(1):29-33. DOI:10.7196/SAJHIVMED.87

Prevalence and incidence of symmetrical symptomatic peripheral neuropathy in patients with multidrug - resistant TB

KMBackground: Symptomatic symmetrical peripheral neuropathy (SSPN) is common in patients with HIV infection. It is also a common adverse event associated with both tuberculosis (TB) treatment and antiretroviral therapy (ART), particularly stavudine. While tenofovir is the one of recommended first-line nucleotide reverse transcriptase inhibitors (NRTIs), there is a risk of nephrotoxicity when using tenofovir together with the aminoglycosides needed to treat multidrug-resistant (MDR) TB. Thus, stavudine is often chosen as a treatment option for the HIV-infected MDR TB patient. Objective: To assess whether use of stavudine both before and during treatment for MDR TB increased the prevalence and incidence of SSPN. Method: MDR TB patients at Sizwe Tropical Disease Hospital were examined for signs of prevalent SSPN. Age, gender, HIV status, alcohol use, TB and HIV treatment regimens both prior to admission and current, and concomitant medications were recorded. Results: In this cohort of 246 patients, we found that 24.4% of patients with MDR TB had SSPN at time of admission for treatment of MDR TB. They were more likely to be HIV-infected (odds ratio (OR) 3.21; 95% CI 1.25 - 8.21) and tended to have longer (>7 months) exposure to stavudine (OR 1.81; 95% CI 0.90 - 3.63). Incident SSPN occurred in 17% of patients and was associated with older age (hazard ratio (HR) 3.00; 95% CI 1.30 - 6.89) and exposure to terizidone (HR 2.98; 95% CI 0.94 to 4.61) or, to a lesser extent, with stavudine (crude HR 1.62; 95% CI 0.65 - 4.01) in the first 6 months of MDR TB treatment. This common adverse event emphasises the need for the development of less toxic drugs for the treatment of MDR TB

Clinical access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis

KMWhile clinical disease caused by drug-sensitive Mycobacterium tuberculosis (MTB) can usually be treated successfully, clinical disease caused by drug-insensitive MTB is associated with a poorer prognosis. In December 2012, a new drug, bedaquiline, was approved by the US Food and Drug Administration. This article documents the process whereby the National Department of Health, Right to Care and Médecins Sans Frontières obtained access to this medication for South Africans who might benefit from subsequent implementation of the Clinical Access to Bedaquiline Programme

New antiretrovirals: What\'s in it for southern Africa

The rise of novel antiretrovirals (ARVs) has introduced a new evolutionary phase in HIV care. In developed countries, the 1980s and early 1990s were characterised by palliative care and opportunistic infection prophylaxis; the late 1990s by an attempt to use a limited and toxic antiretroviral arsenal effectively while cycling through high levels of resistance; and finally, the first half of this decade by working out the easiest-to-take regimens, using the steadily rising number of safer drugs. At present, there are 8 nucleoside analogues (NRTIs), 3 non-nucleoside analogues (NNRTIs), 10 protease inhibitors (PIs), and one each of the fusion, entry and integrase inhibitors to choose from, along with a new drug pipeline that targets both existing and new targets in the viral replicative cycle. The choice may seem quite vast, but the reality is that many of these drugs cannot be used simultaneously or in patients with extensive drug resistance. In addition, some drugs have unacceptable toxicities and are not favoured in current treatment regimens. Southern African Journal of HIV Medicine Vol. 9 (4) 2008: pp. 44-4

The Bible as a problematic text: a critical analysis based on controversies in the Dutch Reformed Church: from Johannes du Plessis to Ferdinand Deist and Willem Vorster (1920–2000)

Text in Afrikaans, with summaries in Afrikaans and EnglishIncludes bibliographical references (leaves 383-403)Die woordestryd oor goddelike inspirasie van alles wat in die Bybel staan, as gevolg van die uitgesproke stellings van Johannes Du Plessis, het tot ‘n krisis gelei wat as baken in die annale van die Ned. Geref. Kerk beskou word. Die meeste van sy standpunte word vandag as waarheid aanvaar en hy het bygedra tot die intellektuele debat oor die Bybel as Woord van God wat vandag nog aangaan. Du Plessis se herkoms, opleiding en verdienste as predikant en saakgelastigde van die Kerk word kortliks bespreek. Hy was die talentvolle seun en enigste kind van 'n Afrikaanse predikant en 'n Engelse vrou, die dogter van 'n sendeling van die LMS. Hy word professor aan die Kweekskool en met kennis opgedoen tydens verdere studie oorsee, het hy gewys op dele van die Bybel wat nie aan goddelike inspirasie toegeskryf kan word nie. Hy het dit ook duidelik gestel dat hy as teoloog en leermeester nie kon glo sonder om te probeer verstaan nie. Hy het sy bevindinge bekend gemaak in Het Zoeklicht, 'n maandblad wat bedoel was om as soeklig te dien om verskillende vorms van “duisternis” in beide godsdiens en die politiek, betref, aan die lig te bring. Oortuig van die waarde van die Hoër Kritiek, het hy dit as sy plig geag om wat hy deur wye leeswerk en kritiese ondersoek rakende die oorsprong, vorm en inhoud van die Ou Testamentiese boeke bekom het, bekend te maak. Artikels van dié aard, eers in De Kerkbode en daarna in Het Zoeklicht, het gelei tot beroering onder behoudende lesers wat gekant was teen enige veranderinge in die prediking. Hulle was veral ontstoke oor sy siening dat die belydenisskrifte wat spruit uit die dae van die Hervorming 500 jaar tevore, oop was vir herformulering. Klagtes dat Du Plessis op 'n gevaarlike pad was, was die begin van wat gelei het tot 'n krisis in die Kerk, en uiteindelik tot 'n buitengewone sinode in 1930 toe hy van sy pos onthef is. Die behoudende reaksie van die meerderheid was dat die Bybel die onfeilbare Woord van God is. Die gevolg was dat 'n groot aantal van die leiers van die Kerk, aanhangers van die Nasionale Party wat in 1948 aan bewind gekom het, tekste uit die Bybel gebruik het om die beleid van Apartheid Skriftuurlik te begrond. Ná byna veertig jaar van 'n onkritiese benadering tot die Bybel, is die geloof in 'n foutlose Bybel weer bevraagteken. Tussen die eerlike teoloë wat dit gewaag het om te wys op foute en inkonsekwenthede, was Ferdinand Deist en Willem Vorster. Albei het hulle opleiding as predikante voltooi maar het hulle nie beroepbaar gestel nie omdat hulle met verdere studie voortgegaan het en hulle openlik uitgespreek het teen die misbruik van Bybelse gegewens om apartheid te regverdig. Geskool aan die Kweekskool in Stellenbosch, het Deist hom onderskei as geleerde wat sy drang na dieper ondersoek gepaar het met 'n piëtisme waarop hy uiting gegee het in 'n stortvloed van akademiese en populêre geskrifte ― wat nie altyd gestrook het met sy stelling dat die Woord van God nie met 'n gelyk-aan-teken aan mekaar verbind kan word nie. Vorster, wat sy opleiding aan die Universiteit van Pretoria ontvang het, het ewe bekend geraak en het internasionale erkenning geniet vir sy toepassing van die semantiek op studies van die Nuwe Testament. Daarby het hy sy kennis van die Nabye Oosterse tale toepaslik gevind in sy bydrae tot The New Quest om meer te wete te kom oor die historiese Jesus, 'n Jood en Galileër wat vir 'n kort periode opgetree het as leermeester en eskatologiese profeet. In die studie van bydraes van die drie geleerdes tot ons verstaan van die Bybel, is ook aandag geskenk aan 'n ander aspek van die Bybel as problematiese teks: Die nadruk wat skrywers en redaktors van die Bybelse gebeure, geplaas het op mans as vaders en seuns ten koste van vroue, moeders en dogters. Die gevolg was dat meeste van die sogenaamde Kerkvaders genoeg in die Bybel kon vind om hulle te identifiseer met die neerhalende beeld wat in Die Openbaring (14:3-4) geskep word van vroue, opvallend in stryd met die inhoud van Genesis 1:26-31.The controversy started by Johannes Du Plessis over the question whether everything in the Bible was inspired by God, caused a crisis in the Dutch Reformed Church, which is listed as a beacon in its history. Most of the points he raised are accepted as truth today, and started an intellectual debate that is still going on. Information relating to Du Plessis’ origins, training, and achievements as a minister and church official is briefly noted. He was the talented son, and only child of an Afrikaner father and minister of religion, and an English mother, the daughter of an LMS missionary. He became a professor at the Seminary in Stellenbosch, after his studies overseas had caused him to question parts of the Old Testament text that could not be regarded as divinely inspired. He also made it quite clear that believing without trying to understand was not possible for him as a theologian and teacher. He proclaimed his findings in Het Zoeklicht, a monthly magazine intended to serve as a searchlight and an organ to reveal the “darkness” that was still prevalent in both religion and politics. Aware of the value of Higher Criticism of the Old Testament, he regarded it his duty to make known what he had found in reading widely and in critical research on the origins, form and content of the books of the Bible. Articles to this effect published first in De Kerkbode and then in Het Zoeklicht, caused an outcry from conservative readers who were opposed to any changes in the teaching of the church. They were especially enraged by his view that the confessions drawn up by Reformers 500 years earlier, were open for review. Complaints that Du Plessis was on a dangerous path, marked the beginning of what was regarded as a crisis in the Church, and in the end led to Du Plessis being relieved of his post by a special Synod convened in 1930. The views of the conservative majority, however, prevailed. As a result, a large number of leading ministers and theologians, who openly supported the Nationalist government that came into power in 1948, provided assurance that the concept of separation of racial groups was in accordance with Scripture. After nearly forty years of an uncritical approach to the Bible, the belief in in-errancy was again questioned. Among the few theologians who dared to point out errors and inconsistencies in various texts, were Ferdinand Deist and Willem Vorster. Both trained as ministers, they chose to continue their studies and openly expressed themselves against the abuse of Biblical texts to support the ideology of apartheid. Trained at the Seminary in Stellenbosch, Deist turned out to be a noted scholar who combined his urge for honest critical study with a pietism expressed in a flood of academic and popular publications ― which were not always consistent with his own statement that The Word of God could not be connected to Scripture with an is-equal-to symbol. Vorster, who received his education at the University of Pretoria, became equally well known as a scholar and gained international recognition for his application of semantics in the study of the Gospels. He also applied his knowledge of languages in what came to be known as The New Quest for the historical Jesus who, as a Jew and a Galilean, distinguished himself during a brief period as a teacher and eschatological prophet. In the study of the contributions of these three outstanding men to our understanding of the Bible, another major aspect of the Bible as problematic text is addressed: The emphasis the authors and redactors of the Scriptures placed on the roles of men, fathers and sons, patently to the exclusion of women, mothers and daughters. As a result many of the so-called Church Fathers found in the Bible sufficient material to look down upon women ― the verdict expressed in Revelations 14:3-4 being one of numerous texts pointing to women as objects of derision in glaring contradiction to the contents of Genesis 1:26-31.Biblical and Ancient StudiesD. Phil. (Biblical Studies

Genetic testing approaches for hereditary breast cancer: Perspectives from a private diagnostic laboratory

Breast cancer is highly prevalent in South Africa, and up to 10% of breast cancer cases may be hereditary. The landscape of genetic testing options for hereditary breast cancer (HBC) has changed significantly over the past decade, and healthcare providers are faced with multiple options when referring breast cancer patients for genetic testing. We have performed a retrospective study of 3 years’ worth of breast cancer genetic testing referrals to our laboratory. While Afrikaner and Ashkenazi Jewish founder screens may be appropriate as first-line tests in a limited subset of patients, we have shown that in the majority of cases it is more effective to adopt a multigene panel approach. While variants in the BRCA1 and BRCA2 genes still account for a significant proportion of cases, close to 40% of pathogenic variants were found in genes other than BRCA1 or BRCA2. There are many factors that healthcare providers should consider when requesting genetic testing for breast cancer patients and families, including family history, ancestral background, cost, medical aid scheme reimbursement and scope of testing. We summarise our findings and provide advantages and disadvantages of each approach, with the aim of assisting clinicians and genetic counsellors to make appropriate testing decisions

Exploring critical failure modes in the rail environment and the consequential costs of unplanned maintenance

CITATION: Conradie, P. D. F. & Treurnicht, N. F. 2012. Exploring critical failure modes in the rail environment and the consequential costs of unplanned maintenance. In CIE42 Proceedings, 15-18 July 2012, Cape Town, South Africa.This study explores in-service failure modes for rolling stock in the rail environment, identifies the most critical failures and explores the consequential cost of these failure modes. Rolling stock is maintained according to maintenance plans with a major goal being the prevention of in-service failures, but due to the nature of the equipment not all failures can be prevented. In-service failures normally result in train delays or the cancellations of trains not only disrupting commuter services but also causing financial losses. The typical failures of rolling stock are analysed using data from the facility maintenance management system. The critical failure modes are identified and classified according to cause, severity, consequence and frequency parameters. A decision model is employed to classify the criticality of the failure modes. The most prominent critical failure modes are analysed to determine root causes, to conclude the investigation. Areas are identified where the focus of future investigation and planned maintenance will have the most significant impact.Post prin

A call to action: Addressing the reproductive health needs of women with drug-resistant tuberculosis

Although there is substantial risk to maternal and neonatal health in the situation of pregnancy during treatment for rifampicin-resistant tuberculosis (RR-TB), there is little evidence to guide clinicians as to how to manage this complexity. Of the 49 680 patients initiated on RR-TB treatment from 2009 to 2014 in South Africa, 47% were women and 80% of them were in their reproductive years (15 - 44). There is an urgent need for increased evidence of the safety of RR-TB treatment during pregnancy, increased access to contraception during RR-TB treatment, and inclusion of reproductive health in research on the prevention and treatment of TB