Milner, J

Pinkney-Atkinson, V

Rayner, B L

Seedat, Y K

Veriava, Y

South African Medical Journal (SAMJ)

March 2007, Vol. 97, No. 3  SAMJBRIEWE1524. South African society still has archaic and paternalistic patterns. The legal system appears to be failing the victims of sexual abuse. Adults must take responsibility for not using children and adolescents to satisfy their own needs. 5. Sexual crimes are endemic in South Africa and it is not uncommon for women to have experienced multiple rapes before they reach adulthood. Have we become so desensitised that even in the legal proceedings sexual abuse is accepted as the norm?We urge government to finalise the New Sexual Offences Bill. It redefines rape to include male victims and penetration of body orifices with non-sexual organs. It also sets the age of consent for all forms of sexual activity at 16 years for boys and girls. Children under the age of 12 are confirmed to be incapable of consenting to sex, but the Bill includes a qualified decriminalisation of sexual experimentation where this occurs between children aged 12 - 15 years, provided that the difference in age is not more than 2 years.It is widely acknowledged that a ‘cycle of abuse’ exists. A main factor in becoming a child sexual perpetrator is having been sexually abused as a child. Therefore the apparent increase in number of sexual assaults on children is of even greater concern, as this is likely to drive a cycle of ever-increasing abuse.Nicolette Booysen, Carla Brown, Nicolette Collison, Ralph Diedericks, Funeka Ginger, Sean Hatherill, Shehaam Hendricks, Noluthando Loleka, Licia Karp, Andre Pieters, Lynette Slabbert, Sebastian van AsChild Abuse TeamRed Cross Children’s HospitalCape Townabvanas@ich.uct.ac.za1. Van As AB, Whithers M, Millar AWJ, Rode H. Child rape – patterns of injury, management and outcome. S Afr Med J 2001; 91: 1035-1038.The South African Hypertension Guideline 2006 is evidence-based and not cost-effective – a rebuttalTo the Editor: Gaziano1 criticises the South African Hypertension (SAH) Guideline 20062 for being evidence-based but not cost-effective. He argues that global cardiovascular (CVS) risk assessment is important in making informative cost-effective treatment decisions. He gives examples that cost of treatment may range from US$20 000 per life-year saved to US$2 000 000, depending on the underlying global CVS risk. He argues that the SAH Guideline is too imprecise to assess CVS risk, and that patients at high risk may be denied treatment and patients at low risk may be treated inappropriately. For example, Gaziano argues that a patient with blood pressure (BP) below 140/90 mmHg may have an absolute risk between 1% and 25%, which is too large to make effective decisions. Additionally, a significant amount of information can be lost by creating a change from one risk category to the next by the presence of 1 - 2 major risk factors, many of which are dichoctomised. It is very unfortunate that the SAMJ did not give the SAH Guideline Committee the opportunity to respond to Gaziano’s criticism in the same issue of the journal. The Committee gave considerable thought to both cost-effective and evidence-based guidelines. There was complete agreement that a CVS risk-assessment strategy should be adopted to optimise resources to patients at higher risk. However, there was considerable debate with regard to whether the Committee should adopt the global CVS risk assessment or an absolute risk assessment. It was decided to base our policy on the absolute risk table of the ESH/ESC guidelines,3 mainly for practical reasons of implementation in the primary care setting. Gaziano himself states that ‘Guidelines must focus on the absolute or global clinical risk instead of the individual risk factors approaches in order to achieve an overall cost-effective reduction of disease.’1Gaziano is indeed correct that the actual absolute risks are not stated in the Guideline, and this is an omission. Low, medium, high and very high risk give an absolute risk of CVS event in the next 10 years of < 15%, 15 - 20%, 20 - 30% and > 30% based on Framingham data, and absolute risk of CVS death of < 4%, 4 - 5%, 5 - 8%, and > 8% based on the SCORE charts respectively.3 Gaziano suggests that a 45-year-old male with no risk factors has a 2% chance of developing a CVS event in the next 10 years and will ultimately require therapy according to the SAH Guideline, whereas a 55-year-old smoker with a low-density lipoprotein/high-density lipoprotein (LDL/HDL) cholesterol ratio of 6, and BP 139/84 mmHg, would not be treated according to the Guideline because he is at low risk, whereas his actual risk is 25% in the next 10 years. Let us examine these examples more carefully.The first patient is clearly at low CVS risk, and there is agreement between Gaziano and the SAH risk table. The SAH Guideline recommends that the patient undergo lifestyle changes for the next 6 - 12 months and then requires drug treatment if the BP level remains above 140/90 mmHg. Gaziano is at issue with this policy as it is not cost-effective. It is purely speculative whether this patient will indeed require drug treatment. Most clinicians recognise that this patient is most likely to have white-coat hypertension because of the lack of risk factors and target organ damage. Repeated monitoring, which results in habituation to BP measurement, or self- or ambulatory BP monitoring, may reveal a quite normal BP profile in time. Additionally, lifestyle changes may also be helpful. Furthermore, if BP is still not controlled after 12 months, this patient is likely to be treated with a low-dose thiazide plus angiotensin-converting enzyme (ACE) inhibitor. The current cost in the state sector is R3.33 per month. Based on the risk table published by Gaziano,1 the number needed to treat for 10 years to prevent 1 event is 33 and the direct drug Pg 146-156.indd   152 2/16/07   2:23:35 PMMarch 2007, Vol. 97, No. 3  SAMJBRIEWE154costs to the state sector will be R1 368. According to the Gaziano risk chart the patient must remain untreated for 10 years even if his BP remains persistently elevated at levels just below 180/110 mmHg, and this approach takes no cognisance of the patient’s high lifetime risk for a CVS event. With regard to the second case, Gaziano states that according to the SAH Guideline the patient will not be treated as he is at low risk. This is simply not true. The Guideline explicitly states that this patient must undergo lifestyle changes (cessation of smoking, dietary change and exercise), which will dramatically lower his risk. More importantly, however, Gaziano exploits a weakness in any risk table by creating an artificial patient with major risk factors just below the dichotomised thresholds. If we merely change the patient’s age to 55 years and 1 month, he has 3 major risk factors and therefore is at high CVS risk. This type of anomaly can be just as easily exploited in the risk chart creat-ed by Gaziano because of dichotomisation of age. For instance, a 54-year-old man with a total cholesterol 6.9 mmol/l and BP 179/109 mmHg with no other risk factors, and a 53-year-old diabetic with total cholesterol 4.9 mmol/l and BP 169/109 mmHg, have the same CVS risk as a 35-year-old male with BP 130/80 mmHg and total cholesterol 4.1 mmol/l, namely less than 20%, and both patients require no drug treatment.  How-ever, it must be explicitly stated that these arguments are not directed at belittling the global risk chart created by Gaziano, but the use of his chart in the South African context needs to be debated. It must always be emphasised that every guideline or risk chart (table) has its potential weaknesses or anomalies that can be exploited by creating imaginary patients. These risk charts are guidelines only and must be used in conjunction with good clinical judgement, assessment of target organ damage and recognition of associated conditions.  Finally, we would like to state categorically that the SAH Guideline in no way intends to diminish the need for lifestyle intervention as implied by Gaziano. It is quite clear from the whole tone of the guideline that lifestyle intervention is critically important and is the first step in the treatment algorithm regardless of CVS risk. B L RaynerY K Seedat J Milne V Pinkney-AtkinsonY VeriavaSouth African Hypertension Guideline Committeerayner@curie.uct.ac.za1. Gaziano TA. The South African Hypertension Guideline 2006 is evidence-based but not cost-effective. S Afr Med J 2006; 96: 1170-1173. 2. Joint National Hypertension Guideline Working Group 2006. South African Hypertension Guideline 2006. S Afr Med J 2006; 96 (4, Part 2): 337-362.3. Guidelines Committee.  2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension.  J Hypertens 2003; 21: 1011-1053.Salmonella typhi central nervous system infectionTo the Editor:  This report aims to document Salmonella typhi as a cause of central nervous system infection.Typhoid fever is caused by the facultative intracellular organisms S. enterica serotype Typhi (S. typhi) and S. paratyphi.1 Infection is mainly associated with ingestion of contaminated water and food.1 One to five per cent of people become chronic carriers despite antibiotic treatment,1 while co-infection with Schistosoma spp. may contribute to this condition.2 With an incubation period ranging from 5 to 21 days,1 characteristic symptoms may include headache, fever, gastrointestinal disturbances, relative bradycardia, splenomegaly and leucopenia.1 Extra-intestinal infectious complications involving various systems may occur.1  A 47-year-old man presented with generalised weakness and paralysis, including a spell of general seizures.  Clinical examination revealed a Glasgow Coma Scale of 5/15, rigidity, increased tone, papilloedema and neck stiffness.  Lateralising signs were present. A cerebrospinal fluid (CSF) sample was collected and processed.  CSF microscopic analysis revealed 35 polymorphonuclear cells/μl, 7 lymphocytes/μl and 188 erythrocytes/μl. Gram-negative bacteria were observed on Gram stain, while capsular antigen detection was negative. Serum C-reactive protein level was 194.5 mg/l and full blood count revealed a leukocyte count of 6.20 x 109 cells/l. Computed tomography (CT) revealed communicating hydrocephalus.  Non-lactose fermenting colonies were observed on MacConkey agar within 24 hours (Oxoid, England). Biochemical identification (API 20E, Biomerieux SA, Marcy-l’Etoile, France) revealed S. typhi.  Trace amounts of hydrogen sulphide, positive Vi antigen agglutination (Wellcolex, Remmel) and the general biochemical inert nature, confirmed the identification.3 The isolate tested sensitive to all antibiotics analysed (enterobacteriaceae panel, Clinical Laboratory Standards Institute).4-6 Intravenous cefotaxime (2 g q4h) was commenced at admission.  However, the patient died 2 days later. Central nervous system (CNS) infection with S. typhi occurs in 3 - 35% of patients. A wide range of CNS manifestations include encephalopathy, meningitis, transient parkinsonism, motor neuron disorders, ataxia, cerebral abscesses, cerebral oedema, seizures, and Guillain-Barré syndrome.1 Patients present with fever, headache, vomiting, seizures, altered state of consciousness, papilloedema and focal neurological deficits.1 Neuro-imaging may be helpful when a lumbar puncture is contraindicated.1 In this case microbiological examination of the CSF established the diagnosis of S. typhi infection.  Parenteral ceftriaxone for 14 - 28 days is the Pg 146-156.indd   154 2/16/07   2:23:35 PMMarch 2007, Vol. 97, No. 3  SAMJBRIEWE156recommended therapy.1 Corticosteroids are recommended as adjunctive therapy for children with S. typhi meningitis, although this is still controversial in adults.1 A review from 1884 to 1984 documented eight cases of focal intracranial lesions caused by S. typhi.1,7 Bacteraemia  with S. typhi may involve multiple systems; however serious extra-intestinal infectious complications are relatively uncommon.Linda MeyerMarthie M EhlersMike G DoveDepartment of Medical MicrobiologyUniversity of Pretorialmeyer@medic.up.ac.zaGerhard F WeldhagenMolecular Biology Laboratory Drs Du Buisson, Bruinette and Kramer IncAMPATH National Laboratory Services, andUniversity of Pretoria1. Huang DB, Du Pont H. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis 2005; 5: 341-348.2. Coon DR. Schistosomiasis: overview of the history, biology, clinicopathology and laboratory diagnosis. Clin Microbiol Newslett 2005; 27: 163-168.3. Winn W, Allen S, Janda W, et al. eds. Koneman`s Color Atlas and Textbook of Diagnostic Microbiology. 6th ed. Baltimore: Lippincott Williams & Wilkins, 2006: chapt. 6.4. Clinical Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; sixteenth informational supplement. M100-S16. Wayne, Penn.: Clinical and Laboratory Standards Institute, 2006.5. Bradford PA. Extended β-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev 2001; 14: 933-951.6. Livermore DM, Winstanley TG, Shannon KP. Interpretive reading: recognizing the unusual and inferring resistance mechanisms from resistance phenotypes. J Antimicrob Chemother 2001; 48: 87-102.7. Gokul BN, Chandramukhi A, Ravikumar R, Khanna N. Salmonella infections of the central nervous system. NIMHANS Journal 1988; 6: 115-119.SAMA URGES DOCTORS TO IMPROVE SKILLS FOR EFFECTIVE MANAGEMENT OF TUBERCULOSISThe growing incidence of extreme drug-resistant tuberculosis in South Africa highlights the urgent need for more doctors to diagnose, prevent, detect and manage TB effectively. Currently South Africa ranks seventh in reported TB cases in the world, and is among the 22 high-burden countries targeted as part of the World Health Organization’s Stop TB initiative. In 2002, the incidence rate in South Africa was just under 300/100 000 population.The South African Medical Association (SAMA) recognises the threat that TB poses to the South African population. SAMA, in conjunction with the Foundation for Professional Development (FPD), has embarked on a project that offers doctors countrywide the opportunity to enrol for a course in the management of tuberculosis. The training course is specifically targeted at doctors in the private sector with a view to complementing the efforts and activities around TB in the public health sector. ‘We must pool our skills and resources to deal with the burden of TB and the effect the disease has on the quality of life and the productivity of our population. SAMA encourages every doctor to enrol for this course,’ said Dr Aquina Thulare, Secretary-General of SAMA. A considerable international grant from PEPFAR has made it possible for the FPD to offer this training programme at only R228 per person. Without sponsorship, this course would have cost approximately R2 200. The course is aimed at providing doctors with the appropriate skills to:• Diagnose, prevent, detect and manage TB• Treat tuberculosis•  Prevent long-term complications with the reduction of premature morbidity and mortality• Promote education and self-care• Control associated disorders• Promote therapy compliance• Improve quality of life and productivity• Reduce the economic burden on the individual, family and community.The training course, which comprises self-study modules and a 2-day interactive workshop, will be accredited according to the CPD guidelines of the Health Professions Council of South Africa published in November 2006. The first workshop is scheduled for March 10 and 11 in Midrand. For more information and registration, contact Pepe Mchiza or Zandi Pule on 012 481-2089/2101 or enquire at pepem@foundation.co.za / zandip@foundation.co.za  Dates and venues of workshops for the Management of TuberculosisVenue DateMidrand March 10 and 11Cape Town March 17 and 18Kimberley April 14 and 15Port Elizabeth April 21 and 22Durban May 5 and 6Polokwane May 19 and 20Nelspruit May 26 and 27Bloemfontein June 2 and 3Klerksdorp June 9 and 10Pg 146-156.indd   156 2/16/07   2:23:36 PM

The South African Hypertension Guideline 2006 is evidence-based and not cost-effective - a rebuttal

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The South African Hypertension Guideline 2006 is evidence-based and not cost-effective - a rebuttal

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