van Niekerk, G D

English

South African Medical Journal (SAMJ)

July 2004, Vol. 94, No. 7  SAMJbetter in the breast-fed arm, significantly so in the first 6months. The cardinal point to remember is that thesesimilarities in outcome, and the nutritional benefit of breast-feeding, occurred after 24 months (median duration of breast-feeding 17 months), when the HIV infection rate in the breast-feeding arm was a whopping 37% compared with 21% in theformula arm. Accordingly breast-feeding over this prolongedperiod remained effective for these outcomes despite the veryhigh HIV infection rate; the obvious answer is to reduce HIVtransmission through breast-feeding while retaining itsadvantages! Six months provides adequate benefits of breast-feeding, and the transmission risk of HIV is at worst about 5%(the latter is from a meta-analysis of nine African trialsinvolving 4 085 children).4 If our group’s hypothesis is correctthis figure may be even lower with exclusive breast-feeding.What is critical to the thrust of this letter is that in theNairobi trial all women ‘had access to potable water, extensivehealth education regarding safe preparation of formula, areliable supply of formula, and access to medical care for theirinfants’. So breast-feeding stood up to comparison withformula in a developing country setting, which is as good as itcan get for minimising the disadvantages of formula.There are other examples of breast-feeding in urbanenvironments. In Durban and Harare (an extremely large trial)studies are detecting substantial benefits in children of HIV-infected mothers who breast-feed in preference to formula-feeding.We have to promote solutions that are not abstracted fromthis continent’s priorities and that respect the durability andstrength of African traditions; breast-feeding is more than justabout infant feeding, it affirms a wider public good.H CoovadiaUniversity of NatalDurban1. Hilderbrand K, Goemaere E, Coetzee D, The prevention of mother-to-child HIV transmissionprogramme and infant feeding practices. S Afr Med J 2003; 93: 779-781.2. Vlahov D, Galea S. Urban health: a new discipline. Lancet 2003; 362: 1091-1092.3. Mbori-Ngacha D, Nduati R, John G, et al. Morbidity and mortality in breastfed and formula-fed infants of HIV-1-infected women. JAMA 2001; 286: 2413-2420.4. The Breastfeeding and HIV International Transmission Study (BHITS). Late postnataltransmission of HIV-1 in breastfed children: an individual patient data analysis. Abstract noMoPeF3881. XIII International AIDS Conference, Barcelona, July 2002.Auto-antibody testing inobstetric patientsTo the Editor: We read with interest the article by Afman et al.1on the relationship of auto-antibodies and obstetric outcome ina tertiary high-risk obstetric unit. In our view the lack of anassociation between antinuclear antibodies (ANAs) andadverse pregnancy outcome may be due to a fundamentalerror in interpretation of the ANA results. The authors havegrouped the 33 true ANA-positive patients with the 13 patientswho had only an anti-cytoplasmic pattern on indirectimmunofluorescence (IIF) testing. The latter staining pattern isa ‘by-product’ of the IIF test using HEp-2 cells, and in thisstudy is likely to be due to anti-parietal and anti-smoothmuscle antibodies that were presumably confirmed on tissuesubstrate (method not given in paper). By definition, antibodiesdirected at cytoplasmic components cannot be considered to beANAs. Hence, the comparison should have been between the33 true ANA- positive patients and relevant control patients. Asecondary issue is that negative IIF does not rule out thepresence of anti-Ro antibodies even when HEp-2 cells are usedas substrate. Anti-Ro antibodies are highly associated with therare event of neonatal lupus and need to be sought by othermethods if there is any suspicion of this condition.Secondly, it would have been helpful to know the totalnumber of patients in the two groups who were HIV-positive,and the frequencies of the respective auto-antibodies. We alsonote the finding that anticardiolipin (ACL) antibodies weremore frequent in women with severe pre-eclampsia. In aprevious study based on our own experience in a routineantenatal clinic, ACL antibodies were poorly predictive for pre-eclampsia,2 so the test may be more useful where there is ahigher pretest risk of an associated event. Finally, we feel thetitle of the paper is not an accurate reflection of the study. ACLantibodies are not directed against nuclear antigens. ‘Auto-antibody testing in obstetric patients’ might be a more accuratetitle and a better reflection of the nature of the study.Mohammed TiklyChris Hani Baragwanath Hospital andUniversity of the WitwatersrandJohannesburgNeil McHugh Royal National Hospital for Rheumatic DiseasesBathUK1. Afman IE, Cronjé HS, Joubert G, Badenhorst PN, Schoon MG.  Antinuclear antibody testingin obstetric patients. S Afr Med J 2003; 93: 932-9372. Stuart RA, Kornman LH, McHugh NJ. A prospective study of pregnancy outcome in womenscreened at a routine antenatal clinic for anticardiolipin antibodies. Br J Obstet Gynaecol 1993;100: 599-600.Pressure chamber explosion —Southern African Underwaterand Hyperbaric MedicalAssociation statementTo the Editor: Members of the Southern African Underwaterand  Hyperbaric Medical Association (SAUHMA), a specialinterest group of  the South African Medical Association, wereshocked to learn of the death of the Eloff brothers when achamber they apparently built and used  exploded, killing498them both.  A third member of the family was injured, andthere was extensive damage to property.In brief, hyperbaric oxygen (HBO) therapy uses oxygenunder pressure in a chamber in a well-controlled manner as aprimary or adjunctive treatment for a number of  recognisedmedical and surgical conditions.SAUHMA’s executive and its members have received anumber of calls from concerned patients currently undergoingHBO therapy at recognised and certified treatment facilities.Patients and relatives are naturally concerned about their ownsafety after the terrible event.Any avoidable accident that involves loss of life, injury, ordamage to property is indeed a tragic occurrence.  Worldwide accidents involving pressure vessels are rare.While the facts of this case are not yet understood, or in facteven known, SAUHMA is able to provide the assurance that,provided the basic rules pertaining to hyperbaric equipmentare adhered to, hyperbaric medicine is and will remain a safeand well-controlled form of treatment.  The authorities in South Africa have provided us withmodern and relevant legislation and standards that govern andguide the use of any potentially lethal or dangerous gascontainers.The Occupational Health and Safety Act (Act No. 85 of 1993)and the Vessels under Pressure Regulations incorporatedtherein contain a clear blueprint of the duties and  respon-sibilities of all the parties, viz. the users, manufacturers andsuppliers.  Once can read up on the matter using the linkhttp://www.labourwise.co.za/laws/Safety.PressureVessels.htm#Design which  is offered free of charge.  In addition, we havean SABS Code of  Practice (SANS 0377-1) for Pressure  Vesselsfor Human Occupancy, and since 1999 we have had theSAUHMA Risk Assessment Guide which provides guidancefor  medical practitioners, operational staff and anyone taskedwith the responsibility of ensuring that a facility is safe. Allthese documents are clear, appropriate and cover all the aspectsof concern, and all of them have been compiled by people witha wealth of practical experience.Safety is, of course, only partly ensured by a chamber beingbuilt in compliance with rules and regulations; it is essentialthat those operating and maintaining the equipment aretrained,  experienced and competent to do so.  This is all welldescribed within our legislation.We do not lack for clear or relevant guidance in our country.Based on over 80 years of relevant experience from around theworld, nowhere has any compliant facility ever seen the effectsJuly 2004, Vol. 94, No. 7  SAMJthat this horrific accident have brought home to us.  What wedo need to realise though, is that we have to understand therisks involved and therefore perform our duties in such a wayas to minimise, remove or at least contain these risks if we areto be truly safe.  Safety is vitally important and understandingis the key. We earnestly appeal to all people contemplating the use ofHBO to ensure three things before entering any chamber:  (i)ensure that HBO is, in fact, medically indicated and advisablefor the particular illness or condition; (ii) ensure that thechamber is tested, licensed and approved by the Department ofLabour and that such approval is up to date; and (iii) ensurethat the chamber personnel and operators are fully trained andregistered in medical HBO administration.SAUHMA is always very willing to offer expert advice andhelp to anyone who might need assistance with regard to HBOand its medically approved indications Simply contact usthrough Divers Alert Network (DAN) at (011) 254-1991/2.SAUHMA also has in its members a wealth of expertise and wewould gladly assist the authorities with their investigation ofthe incident.G D van NiekerkPresident, SAUHMAP Bag X197Halfway House1685Psychopathology and coping inrecently diagnosed HIV/AIDSpatients — the role of genderTo the Editor: Olley et al.1 provide valuable insight into theburden of mental illness among patients with HIV/AIDS andmake useful recommendations. However, there is no evidenceto support the hypothesis that ‘women with HIV/AIDS mayface greater stigmatisation’. Stigma is a complex concept andconfounds the relationship between HIV and mental illness.Olley et al.1 offer no measure or indication of ‘high levels ofstigmatisation and stress faced by HIV/AIDS patients in SouthAfrica’. Berger et al.2 have recently validated an HIV stigmascale, which would have provided valuable information in thissample.The reliability of assessing sexual risk behaviour in a singleinterview using an adapted scale is questionable.  Genderdifferences in HIV infection in this sample and the generalpopulation indicate that it is women who are more at risk ofHIV infection. There is a larger body of evidence to support theclaim that women are more likely than men to ‘exchange sexfor drugs and money’.3 Social inequality and poverty are thefactors responsible for women’s vulnerability to HIV infection.4This contradicts the assertion that men ‘exchange sex for drugsand money’.1 Scales and other psychometric tests can improvequalitative research.  However Barbour5 warns that‘overzealous and uncritical use can be counterproductive’.5 Itsinappropriate use will threaten construct validity.  This, inaddition to the selection bias, may have contributed to theinability to detect gender differences in this sample.Dinesh SinghColumbia UniversityMailman School of Public HealthNew YorkUSA1. Olley BO, Gxamza F, Seedat S, et al. Psychopathology and coping in recently diagnosedHIV/AIDS patients — the role of gender. S Afr Med J 2003; 93: 928-931.2. Berger BE, Farrans CE, Lashley FR. Measuring stigma in people with HIV:  psychometricassessment of the HIV stigma scale. Res Nurs Health 2001; 24: 518-529.3. Selbourne C, Forge NG, Kung F, et al. Personal and psychosocial characteristics associatedwith psychiatric conditions among women with human immunodeficiency virus. WomensHealth Issues 2003; 13: 104-110.4. Farmer P.  Invisible women: class, gender and HIV.  Infections and Inequalities:  The ModernPlague. Berkley, Calif: University of California Press, 1999: 90-124.5. Barbour RS. Checklists for improving rigour in qualitative research: a case of the tailwagging the dog? BMJ 2001; 322: 1115-1117.Tariff relativityTo the Editor: It is most unusual to find in one journal, twowriters with whom I served on Federal Council. With DougieGurnell we put together the Tariff for GPs. René le Roex wasChairman of the CCCP, of which I was a member. Both wrotein the April issue of the SAMJ,1,2 and it is to René’s article that Irefer.2 He makes no mention of all the effort we put intomaintaining the relativity between the various disciplines,which had been established by several Commissions. I wrote tothe Commissioner of the Competition Commission and saidthat their policy would eliminate the above relativity andcreate chaos. This is precisely what has happened as eachgroup now negotiates its own tariff with the variousAdministrators and relativity has gone down the plughole.All those years of effort are being wasted in this new erawhere medicine has become a business, no longer a calling,and certainly no longer fun. It used to be a pleasure to take ona family and live with them, at least through their healthtroubles, visiting them in their homes, when necessary even atnight. All gone — now it appears to be survival with noconcern but for oneself.Maybe the bad old days weren’t so bad after all, despite theadvent of third party payers.I only hope our profession survives. Des SonnenfeldPO Box 75107Gardenview20471. Gurnell DR. Fee for service (Letter). S Afr Med J 2004; 94: 241-242.2. Le Roex RD. The development of medical tariffs in South Africa. S Afr Med J 2004; 94: 261-263.500

Pressure chamber explosion - Southern African Underwater and Hyperbaric Medical Association statement

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Pressure chamber explosion - Southern African Underwater and Hyperbaric Medical Association statement

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