SAMJ Vol 106, No 12 (2016) by HMPG

DECEMBER 2016

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GUEST EDITORIAL Women, gender-based violence and HIV CME Child abuse IN PRACTICE Male circumcision â&#x20AC;&#x201C; policy and law CASE REPORT Psychosis in neurosyphilis RESEARCH Gender-based violence risk among men in rural KwaZulu-Natal Safeguarding child and maternal health in South Africa

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DECEMBER 2016

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FROM THE CEO 4

Strengthening publishing capacity to support academic medicine in South Africa H Kikaya

FROM THE EDITOR 5 5

Reviewers – the backbone of academic publishing B Farham

Thank you from HMPG and the Editor B Farham

HMPG

The dual burden of gender-based violence and HIV in adolescent girls and young women in South Africa Q Abdool Karim, C Baxter

EDITOR’S CHOICE CORRESPONDENCE

EDITORS EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon) JP de V van Niekerk, MD, FRCR ASSOCIATE EDITORS Q Abdool Karim, A Dhai, N Khumalo, R C Pattinson, A Rothberg, A A Stulting, J Surka, B Taylor, M Blockman, J M Pettifor

GUEST EDITORIAL 8

EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB

Willingness of tobacco smokers to contribute financially towards cessation resources K Rao, A L Slogrove, M L Cooke, M F Cotton

IZINDABA

CEO AND PUBLISHER Hannah Kikaya | Email: hannahk@hmpg.co.za MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan Paula van der Bijl PRODUCTION MANAGER Emma Jane Couzens

HMPG in 2016 B Farham

DTP AND DESIGN Clinton Griffin Travis Arendse

30 days in medicine B Farham

CHIEF OPERATING OFFICER Diane Smith | Tel. 012 481 2069 Email: dianes@hmpg.co.za

OBITUARY Maurice Aaron Kibel

SALES MANAGER (CAPE TOWN) Azad Yusuf

CME 21

GUEST EDITORIAL Tackling child abuse and neglect in South Africa K Joyner ARTICLES Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study S Mathews, L J Martin

Maternal mental health and the first 1 000 days R E Turner, S Honikman

Using a child rights approach to strengthen prevention of violence against children L Lake, L Jamieson

IN PRACTICE 35

MEDICINE AND THE LAW Addressing legal and policy barriers to male circumcision for adolescent boys in South Africa A E Strode, J D Toohey, C M Slack

COCHRANE CORNER South African Guidelines Excellence (SAGE): Adopt, adapt, or contextualise? J M Dizon, K Grimmer, Q Louw, T Kredo, T Young, S Machingaidze

ISSUES IN PUBLIC HEALTH The universities of Stellenbosch/Cape Town low-carbohydrate diet review: Mistake or mischief? Z Harcombe, T Noakes

ISSUES IN MEDICINE Research competency and specialist registration: Quo vadis? C P Szabo, S Ramlall

CASE REPORTS Revisiting an old foe: The face of psychosis in neurosyphilis Y Moolla, J Abdul

December 2016, Print edition

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A case of convergence spasms – do not be caught off-guard L Smit

Diabetic cachectic neuropathy: An uncommon neurological complication of diabetes A Iyagba, A Onwuchekwa

Atypical chest pain: Needles in a haystack J M Jansen van Vuuren, S Pillay, K Ramchandre

RESEARCH 53

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries* M F Chersich, S Luchters, D Blaauw, F Scorgie, E Kern, A van den Heever, H Rees, E Peach, S Kharadi, S Fonn

Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal, South Africa* N Mngoma, S Fergus, A Jeeves, R Jolly

Prevalence and correlates of violence among South African high school learners in uMgungundlovu District municipality, KwaZulu-Natal, South Africa* N Khuzwayo, M Taylor, C Connolly

Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa* A Gokhul, P M Jeena, A Gray

Risk factors for unsuccessful lumbar puncture in children* C Procter, H Buys, H Carrara, J Thomas

Evaluating point-of-care testing for glycosylated haemoglobin in public sector primary care facilities in the Western Cape, South Africa* R Mash, A Ugoagwu, C Vos, M Rensburg, R Erasmus

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa* N Folb, M O Bachmann, E D Bateman, K Steyn, N S Levitt, V Timmerman, C Lombard, T A Gaziano, L R Fairall

Awareness, perceived risk and practices related to cervical cancer and Pap smear screening: A cross-sectional study among HIV-positive women attending an urban HIV clinic in Johannesburg, South Africa* I Mokhele, D Evans, K Schnippel, A Swarts, J S Smith, C Firnhaber

Mutations of mtDNA polymerase-γ and hyperlactataemia in the HIV-infected Zulu population of South Africa* D B A Ojwach, C Aldous, P Kocheleff, B Sartorius

Screening for calreticulin mutations in a cohort of patients suspected of having a myeloproliferative neoplasm* A de Kock, C Booysen

The mass miniature chest radiography programme in Cape Town, South Africa, 1948 - 1994: The impact of active tuberculosis case finding* S M Hermans, J R Andrews, L-G Bekker, R Wood

ONLINE CONTENTS LISTED IN Index Medicus (Medline) Excerpta Medica (EMBASE) Biological Abstracts (BIOSIS) Science Citation Index (SciSearch) Current Contents/Clinical Medicine SAMJ SUBSCRIPTION RATES Local subscriptions ZAR1 368.00 p.a. Foreign subscriptions ZAR3 108.00 p.a. Single copies ZAR114.00 local, ZAR259.00 foreign Members of the South African Medical Association receive the SAMJ only on request, as part of their membership benefit. Subscriptions: Tel. 012 481 2071 Email: members@samedical.org The SAMJ is published monthly by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA. HEAD OFFICE Health and Medical Publishing Group (Pty) Ltd Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 Tel. 012 481 2069 Email: dianes@hmpg.co.za EDITORIAL OFFICE Suite 11, Lonsdale Building, Lonsdale Way, Pinelands, 7405 Tel. 021 532 1281 | Cell. 072 635 9825 Email: publishing@hmpg.co.za Please submit all letters and articles for publication online at http://www.editorialmanager.com/samj © Copyright: Health and Medical Publishing Group (Pty) Ltd, a subsidiary of the South African Medical Association Use of editorial material is subject to the Creative Commons Attribution – Non-commercial Works Licence. http://creativecommons.org/licenses/by-nc/3.0 Printed by TANDYM PRINT

*Full article available online only.

CAREERS & CLASSIFIEDS

DECEMBER 2016

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CPD QUESTIONS

GUEST EDITORIAL Women, gender-based violence and HIV

Background photo: Recently circumcised Xhosa boys | Brent Stirton/Getty Images

CME Child abuse IN PRACTICE Male circumcision – policy and law CASE REPORT

Hexagon photos: Maternal mental health | DGL images; Gender abuse | otnaydur; Pulmonary tuberculosis | stockdevil

December 2016, Print edition

Psychosis in neurosyphilis RESEARCH Gender-based violence risk among men in rural KwaZulu-Natal Safeguarding child and maternal health in South Africa

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

FROM THE CEO

Strengthening publishing capacity to support academic medicine in South Africa That the results of medical and health research must be disseminated is one of the fundamental principles of biomedical ethics. Enshrined in the World Medical Association’s 1964 Declaration of Helsinki,[1] the requirement for publication of findings, whether positive or negative, aims to ensure that the risk accepted by participants in research studies is balanced by the benefit of knowing their data helped to advance scientific knowledge. But what happens if there are no journals interested in publishing the work? What if editors judge it as uninteresting? Or reviewers point out similar work has been published elsewhere? It may be deemed too ‘specialist’ for a general journal. Or too context specific to make the grade on the international stage. For all South African (SA) researchers who have written papers that found no home, these scenarios should strike a resounding chord. Pressure to write more and more has been mounting since subsidies based on numbers of papers published in accredited journals were introduced by the Department of Higher Education and Training in 2004. The incentive worked almost immediately: a 50 - 60% increase in papers published between 2004 and 2008, compared with a decade earlier.[2] Additional financial incentives for universities to encourage all doctors-in-training to do at least some research (MMed) have further swollen the submissions pool. But capacity in academic publishing, and particularly in peer review, has not increased at nearly the same rate. The result is a mismatch between the number of authors seeking publication in high-quality journals and the capacity of journals to respond. Although a 2006 analysis of SA’s academic publishing industry concluded that the country had an ‘extraordinarily high’ number of scholarly journals compared with the number of publishing scholars, the prominence of SA journals in internationally recognised indexes was found to be low, and quality among non-indexed journals was a problem.[3] The report, published by the South African Academy of Sciences, further identified a ‘significantly ageing cohort of actively publishing scientists in the SA science system’, meaning that younger authors are not getting the support they need to establish their publishing careers, and are not joining their senior colleagues in the ranks of journal editorial boards or reviewer networks. This context led us at HMPG to reflect on the role of journals in SA’s scientific development, and what we should be doing to help. Our conclusion was that we can – and should – be far more systematic and strategic in our work to ensure that we actively recruit wider networks of reviewers and academic editors, contribute to sharing knowledge about publishing processes, and support early- to mid-career professionals to become involved in peer review on a routine basis. To this end, we have established two clear goals for our publishing activities: (i) to support the advancement of academic medicine in

SA by promoting the publication and dissemination of all health and medical research that meets quality standards; and (ii) to contribute to the strengthening of SA’s research culture by anchoring our peer review and editorial processes within the academic communities we intend to support. In order to implement the necessary changes to our internal process and external relationships, we have refocused our work around the priorities of researchers: fast turnaround times for peer review, publication as soon as possible after acceptance, wide distribution of published content through international online platforms (PubMed, Sabinet, Scopus, SciELO, DOAJ, among others), and provision of more extensive administrative support to authors, reviewers and academic editors. Coupled with these changes, we have made the decision to be far more inclusive in our editorial policy – with the support of an expanded team of associate editors drawn from academia and with expertise spanning the spectrum of health and medical research. We have revised our guidelines to authors to reflect the fact that we are actively seeking submissions from researchers in all health and medical disciplines and have launched a new highend online submission system to make the process of submission as smooth as possible. All these changes are aimed at ensuring that the SAMJ becomes the first-choice journal for publication of health and medical research with relevance to the SA context, and fulfils its aim to act as a platform for the exchange of crucial new knowledge among the country’s academic medical communities. We acknowledge that one journal cannot be ‘all things to all people’ but hope that by setting out a clear intention to respond to the needs of researchers in SA, and help address the capacity gaps in academic publishing, we will forge the strong relationships we need to make sure we stay on the right track. Hannah Kikaya CEO and publisher Health and Medical Publishing Group, South Africa 1. World Medical Association. Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects. Helsinki: WMA, 1964. http://www.wma.net/en/30publications/10policies/ b3/ (accessed 16 November 2016). 2. Woodiwiss AJ. Publication subsidies: Challenges and dilemmas facing South African researchers. Cardiovasc J Afr 2012;23(8):421-427. 3. Gevers W, Hammes M, Mati X, et al. Report on a strategic approach to research publishing in South Africa. Pretoria: Academy of Sciences of South Africa, 2006. http://www.assaf.org.za/files/2011/02/2466ASSAF-Strategic-approach-to-research-publishing-2.pdf (accessed 16 November 2016).

S Afr Med J 2016;106(12):1148. DOI:10.7196/SAMJ.2016.v106i12.12202

December 2016, Print edition

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

FROM THE EDITOR

Reviewers – the backbone of academic publishing As we end 2016 – which has effectively been my first year as de facto editor of the SAMJ – I have a bit of time to reflect. It has been a steep learning curve – going from working with a highly respected academic who made most of the decisions, to taking over – with all the slings and arrows that come with this! On a run recently I chatted briefly to my old teacher and friend, Raymond Abratt, who said that he was warned, as editor of a journal, that he wouldn’t have many friends left! As a professional editor, rather than an academic, I may have been somewhat immune to this, and I have certainly enjoyed my expanded role. However, what has not always been easy is trying to find reviewers for all the papers submitted to us. In this issue we thank all those who have reviewed for us during the course of 2016, and it looks like a long list. However, there are times when it proves almost impossible to find reviewers for some articles, which leaves us in a very difficult position. We offer a service to researchers in South African medicine – publishing the papers that report their research. To comply with the highest of international standards, we need all these papers, with very few exceptions, to be reviewed. Reviewers are the backbone of academic publishing. Without you, we cannot publish. I know that academics in medical disciplines in South Africa are under increasing pressure. The demands of medical practice,

teaching, research and, increasingly, politics are enormous, so requests to review papers mean yet another burden on your time. But I would make the plea, as we end this very difficult academic year, to please find the time. If we have more reviewers, there will be fewer requests to those who routinely review for us. In turn, we are making an effort to ensure that the papers we do send for review comply with our author guidelines – not always easy, and probably the topic of another editorial comment in the new year! I will finish 2016 with much thanks and appreciation to all who have supported my team and me during the past year, and also end with a plea to everyone to try, whenever possible, to respond positively to our requests for review when they land in your inbox. Bridget Farham Editor ugqirha@iafrica.com S Afr Med J 2016;106(12):1149. DOI:10.7196/SAMJ.2016.v106i12.12186

Thank you from HMPG and the Editor The SAMJ reviewers

The Health and Medical Publishing Group and the editor of SAMJ would like to take this opportunity to thank all those individuals who participated in the peer review process during 2016. We are grateful for the expertise, insight and thoughtful critiques shared with our authors through the review process, and without which maintaining the high standard of our journal would be impossible. We apologise if we have inadvertently excluded any individual reviewer, and to those reviewers who were recruited after this issue went to press. Nathlee Abbai, Medical Research Council Yasmin Adams, Chris Hani Baragwanath Academic Hospital/ University of the Witwatersrand Oladele Adeniyi, Walter Sisulu University Nermien Adly, Ain Shams University Nazeer Alli, University of the Witwatersrand/National Health Laboratory Service Kofi Amegah, University of Oulu Márcio Araújo, International Integration of the Lusophone AfroBrazillian (Unilab) Affirul Ariffin, Universiti Sains Islam, Malaysia Joash Auka, Kenya Medical Training College Daynia Ballot, University of the Witwatersrand Eric Balti, Brussels Free University Colleen Bamford, National Health Laboratory Service Marc Blockman, University of Cape Town Dirk Blom, University of Cape Town Liza Bornman, University of Johannesburg Ismail Cassimjee, University of the Witwatersrand

Alain Chichom-Mefire, University of Buea Antoinette Cilliers, University of the Witwatersrand Damian Clarke, University of KwaZulu-Natal Francesca Conradie, University of the Witwatersrand Ian Cook, University of Limpopo Peter Cooper, University of KwaZulu-Natal Graeme Copley, Private Christina Cutter, University of Michigan Francois de Villiers, University of Limpopo Eric Decloedt, Stellenbosch University Wim Delva, Stellenbosch University Daan den Hollander, University of KwaZulu-Natal Robin Dyers, Western Cape Government Robert Dunn, University of Cape Town Jennifer Edge, Private Fahmida Essop, National Health Laboratory Service June Fabian, University of the Witwatersrand Richard Feinman, State University of New York Karen Fieggen, University of Cape Town Mirta Garcia-Jardon, Walter Sisulu University Heike Geduld, University of Cape Town Jennifer Geel, University of the Witwatersrand Lara Goldstein, University of the Witwatersrand Rajeshree Govender, University of KwaZulu-Natal Jonathan Peter, University of Cape Town Robin Green, University of Pretoria Leslie Greenberg, University of Cape Town Bronwyn Harris, University of the Witwatersrand Karen Hofman, University of the Witwatersrand Leigh Johnson, University of Cape Town

December 2016, Print edition

FROM THE EDITOR

Portia Jordan, Nelson Mandela Metropolitan University John Joska, University of Cape Town Ben Jugmohan, University of the Witwatersrand Kerry Kalweit, University of Pretoria/Youth with Diabetes Munira Khan, University of KwaZulu-Natal David Kloeck, University of the Witwatersrand Amanda Krause, National Health Laboratory Service Tamara Kredo, Medical Research Council Warren Lowman, University of the Witwatersrand Fikile Mabena, University of the Witwatersrand Shabir Madhi, University of the Witwatersrand Johnny Mahlangu, University of the Witwatersrand Andre Marais, University of Pretoria Bob Mash, Stellenbosch University Richard Matzopoulos, Medical Research Council Neil McKerrow, KwaZulu-Natal Department of Health David McQuoid-Mason, University of KwaZulu-Natal Graeme Meintjes, University of Cape Town Marc Mendelson, University of Cape Town David Moore, University of Johannesburg Shan Naidoo, University of the Witwatersrand Marie-Louise Newell, University of Southampton Bongani Nkambule, University of KwaZulu-Natal Mary Norval, University of Edinburgh Ntobeko Ntusi, University of Cape Town Marta Nunes, University of the Witwatersrand Jessica Opie, University of Cape Town Nicky Padayachee, Private Nesri Padayatchi, University of KwaZulu-Natal Andy Parrish, Walter Sisulu University/Cecilia Makiwane Hospital Charles Parry, Medical Research Council Robert Pattinson, University of Pretoria Amy Peden, James Cook University/Royal Life Saving Society Nazia Peer, Health Systems Trust Remco Peters, Anova Health Institute/University of Pretoria Gregory Petro, University of Cape Town Travis Pollock, University of Cape Town Janet Poole, University of the Witwatersrand Jaishree Raman, National Institute for Communicable Diseases Gary Reubenson, University of the Witwatersrand Heinz Rode, University of Cape Town Vanessa Roman, University of the Witwatersrand Haroon Saloojee, University of the Witwatersrand Marthinus Schoon, Free State Department of Health Alison September, University of Cape Town Maylene Shung-King, University of Cape Town Werner Sinclair, Private Elvira Singh, National Health Laboratory Service Simpiwe Sobuwa, Durban University of Technology Priya Soma-Pillay, University of Pretoria Richard Spence, University of Cape Town Willem Stassen, University of Johannesburg Chantal Stewart, University of Cape Town David Stone, University of the Free State Allan Taylor, University of Cape Town Bettina Taylor, Medscheme Health Policy Unit Lloyd Tooke, University of Cape Town Aneesa Vanker, University of Cape Town Sheeba Varughese, University of the Witwatersrand Sandro Vento, Nazarbayev University Cathy Visser, University of Pretoria Tim Walker, University of Rwanda/Butare University Teaching Hospital

Imtiaz Wani, Sher-I-Kashmir Institute of Medical Sciences Catherine Ward, University of Cape Town Sean Wasserman, University of Cape Town David Watkins, University of Washington Nicola Wearne, University of Cape Town Anthony Westwood, University of Cape Town Margaret Williams, Nelson Mandela Metropolitan University Jo Wilmshurst, University of Cape Town

The CME guest editors and authors

As editor of CME and SAMJ, I would like to thank the guest editors and authors for their truly excellent contributions to CME during 2016. January, February, March 2016: Cardiovascular medicine in primary healthcare in sub-Saharan Africa (parts 1, 2 and 3) Guest editors: Ntobeko Ntusi and Gboyega Ogunbanjo Authors: Ntobeko Ntusi, Gboyega Ogunbanjo, Sarah Krause, Karen Sliwa, Cecilia B I Coccia, Gregori H Palkowski, Beverley Schweitzer, Phetho Mangena, Sadick Saban, Kefilwe Hlabyago, Brian Rayner, Blanche J Cupido, Ferande Peters, Jens Hitzeroth, Nazlea Beckett, Patrick Ntuli, Charles G Kyriakakis, Bongani M Mayosi, Elma de Vries, Abdul Isaacs, Anton F Doubell, Shaheen Pandie, Derek Hellenberg, Farrel Hellig, Mpiko Ntsekhe, Ashley Chin, Brian Vezi, Mosedi Namane, Hellmuth Weich, Rob Scott-Millar April, May 2016: Acute viral bronchiolitis in South Africa: Diagnosis and current management (parts 1 and 2) Guest editors: Robin Green, Heather Zar and Shabir Madhi Authors: Debbie A White, Heather J Zar, Shabir A Madhi, Prakash Jeena, Brenda Morrow, Refiloe Masekela, Samuel Risenga, Robin Green, Humphrey Lewis, Charles Feldman, Debbie A White June, July 2016: Adolescent health (parts 1 and 2) Guest editor: Quarraisha Abdool Karim Authors: Saeeda Paruk, Enver Karim, Neo K Morojele, Leane Ramsoomar, Hoosen Coovadia, Yashna Jugnundan, Arthi Ramkissoon, Nasheeta Peer, Yasmeen N Ganie August, September 2016: Functional neurosurgery (parts 1 and 2) Guest editor: J M Nico Enslin Authors: J M Nico Enslin, A Graham Fieggen, Sally J Rothemeyer October 2016: Intimate partner violence Guest editor: Kate Joyner Authors: Chivaugn Gordon, Claudia Lopes, Nataly Woollett, Abigail M Hatcher November 2016: Sexual violence Guest editor: Kate Joyner Authors: Nataly Woollett, Kirsten Thomson, Marianne Tiemensma, Arjan B van As December 2016: Child abuse Guest editor: Kate Joyner Authors: Lori Lake, Lucy Jamieson, Shanaaz Mathews, Lorna J Martin, Roseanne Turner, Simone Honikman Bridget Farham Editor ugqirha@iafrica.com

December 2016, Print edition

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

GUEST EDITORIAL

The dual burden of gender-based violence and HIV in adolescent girls and young women in South Africa The 16 Days of Activism is an international awareness-raising campaign that promotes no violence against women and children. Each year the campaign runs between 25 November and 10 December and overlaps with World AIDS Day on 1 December. Adopted by South Africa (SA) in 1998, the campaign aims to raise awareness among South Africans about the negative impact of violence against women and children on all members of the community. This campaign is particularly relevant in the SA context, as young women aged 15 - 24 years, who have the least power in society, bear an enormous burden of both intimate partner violence (IPV) and HIV. Violence against women takes many forms – physical, sexual, economic, and psychological – with IPV being a particularly significant public health problem. Although population-based surveys show that prevalence of IPV among ever-married or partnered women aged 15 - 49 years has declined between 2000 and 2014 in some countries, the global prevalence of recent IPV remains unacceptably high. Globally, about 1 in every 3 women has ever experienced physical and/or sexual violence inflicted by an intimate partner.[1] Interestingly, the prevalence of IPV among young women aged 15 - 19 years is similar (29%) to the average lifetime prevalence of IPV, suggesting that violence commonly starts early in women’s relationships.[1] A study undertaken by the South African Medical Research Council shows that about 1 in every 4 women aged 18 - 49 years in SA has experienced IPV.[2] A recent community-based study in SA among 3 515 children aged 10 - 17 years revealed that 31.2% of adolescent girls had ever experienced physical abuse in their lifetimes, with 8.4% reporting sexual abuse or rape.[3] Despite being a fundamental violation of women’s human rights, gender-based violence (GBV) is often rooted in socially accepted gender inequality and discrimination and is therefore condoned. [4,5] The power imbalances between men and women, at both societal and individual relationship levels, are often established during adolescence. [6] Unfortunately, feelings of shame, stigma and discrimination, whether real or perceived, keep women from reporting experiences of violence, and all too often survivors of violence are not effectively supported by health and public services.[7] Women who have experienced physical or sexual violence by their partners have increased rates of adverse health outcomes, including unwanted pregnancies and adverse maternal and newborn health outcomes, as well as other short- and long-term physical, psychological and social impacts.[1,8,9] Teenage pregnancies, an outcome of sexual abuse in some instances, result in curtailment of secondary schooling, leading to vicious cycles of poverty and dependency.[10] In some regions, experiences of IPV have been shown to be an important determinant of women’s HIV risk.[11-13] A systematic review that included 28 studies involving 331 468 individuals from 16 countries showed that IPV was associated with a 1.2-fold increased risk of HIV infection among women.[14] In SA, women with violent or controlling male partners were 1.5 times more likely to acquire HIV compared with women who had not experienced partner violence.[11,15] GBV is regarded as a major problem in SA communities, and is seen to be exacerbated by unemployment, poverty and alcohol abuse.[16] Although SA has made significant progress in transforming AIDS from an inevitably fatal condition to one that is chronic and manageable through the use of antiretrovirals, young women continue to experience high rates of new HIV infections. In SA, the

prevalence of HIV among adolescent girls and young women is up to six times higher than that of their male peers.[17] One of the reasons for this age-sex disparity in HIV infection rates is that young girls often partner with men 5 or more years older and who are more likely to be living with HIV.[18-21] Multiple complex pathways connect IPV with HIV. Gender inequality, the threat of IPV and male controlling behaviour can increase a young woman’s vulnerability to HIV[11,14,22] by limiting her ability to successfully negotiate consistent condom use with her male partner(s), insist on mutual monogamy or refuse unwanted sex, thus constraining her ability to control her own HIV risk. Studies have shown that women who have been subjected to GBV often adopt risky behaviors such as alcohol abuse, which in turn can lead to more unprotected sex and an increased risk of acquiring HIV.[23-25] The fear of IPV can also discourage women from getting tested for HIV,[26] discourage disclosure of their HIV-positive status[27] and serve as a barrier to treatment uptake and adherence,[27,28] and may disrupt HIV prevention services[29] and result in poorer HIV outcomes.[28,30] The relationship between IPV and HIV is also bidirectional. Some women are at increased risk of IPV following disclosure of their HIV-positive status[27,31-35] or following screening during pregnancy.[31,35,36] With the implementation of Option B+ in antenatal services, where antiretroviral treatment is initiated on HIV-positive status confirmation in pregnant women, adherence rates decline after delivery, particularly in women who have not disclosed their HIV status to their partner, thereby enhancing their risk of progressing to AIDS and dying.[37] Numerous interventions aimed at addressing IPV and sexual violence among adolescents have been assessed. A review of the evidence to support these interventions shows that schoolbased programmes that address dating violence, communitybased interventions to promote gender-equitable attitudes, and interventions aimed at adolescents who have been maltreated and at their parents to be the most promising.[38] An example of a successful intervention is the cluster-randomised study in Uganda known as the SASA!, which showed that harmful gender norms can be changed through a community mobilisation intervention. After 4 years there was a 58% reduction in physical IPV in the intervention communities and a significant decrease in the social acceptance of IPV among men and women.[39,40] Education of adolescent girls and young women is regarded as a fundamental intervention to prevent GBV.[5,41] Keeping girls in school has also been shown to have other beneficial health outcomes, including lower rates of HIV infection, delayed childbearing, lower infant and maternal mortality rates, and improvement of other development outcomes.[10,42] Novel social protection interventions that provide cash transfers/incentives have been shown in some settings to improve school attendance, decrease risky sexual behaviour and activity and improve income and social opportunities for women.[43] Given that IPV and HIV are so intimately intertwined, efforts to eliminate GBV/IPV have the potential also to improve sexual and reproductive health outcomes and HIV prevention among adolescent girls. Primary healthcare/antenatal care clinics provide the opportunity to assess GBV among clients and offer post-exposure prophylaxis for those who have experienced GBV, as well as preexposure prophylaxis for young girls and women who experience IPV. These clinics could also serve as an opportunity to establish whether pregnancies are planned or unplanned and to quantify what

December 2016, Print edition

GUEST EDITORIAL

Did you know?

• SA bears 18% of the global burden of HIV infection and yet is home to <1% of the world’s population.[4] • Four out of the five districts in SA that have an HIV prevalence of >40% among pregnant women are in KwaZulu-Natal Province. The remaining seven districts in KwaZulu-Natal have HIV prevalence rates ranging between 33.7% and 40.0% among pregnant women, compared with the overall prevalence of 30% in SA.[46] • Young women between the ages of 15 and 24 years have up to six times more HIV infection than their male peers, and are experiencing the highest death rates.[17] • Men and women who have experienced GBV are more likely to have behaviours that increase their risk of acquiring HIV infection. • Compared with an HIV-negative women, a woman who discloses her HIV-positive status to a partner of unknown HIV status is more likely to experience physical and emotional abuse.

proportion of pregnancies result from GBV/IPV v. unprotected sex with a partner. Changing the face of these two epidemics will require substantial rethinking and conceptualisation at a structural level on constructions of masculinity and femininity and the value placed on women and their rights. The World Health Organization and UNAIDS have developed programming tools to address violence against women in the context of the HIV epidemic.[44,45] The coercive arm of the law also offers some hope and protection to vulnerable women experiencing both epidemics, but it is social mobilisation and solidarity that will enable true transformation and the real possibility for all women to reach their full potential in a safe and healthy manner. Quarraisha Abdool Karim Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban; School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; and Mailman School of Public Health, Columbia University, New York, USA quarraisha.abdoolkarim@caprisa.org Cheryl Baxter Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban; and School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1. World Health Organization. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-partner Sexual Violence. Geneva: World Health Organization, 2013. http://www.who.int/iris/bitstream/10665/85239/1/9789241564625_eng. pdf (accessed 26 September 2016). 2. Jewkes R, Penn-Kekana L, Levin J, Ratsaka M, Schrieber M. Prevalence of emotional, physical and sexual abuse of women in three South African provinces. S Afr Med J 2001;91(5):421-428. 3. Meinck F, Cluver LD, Boyes ME, Loening-Voysey H. Physical, emotional and sexual adolescent abuse victimisation in South Africa: prevalence, incidence, perpetrators and locations. J Epidemiol Comm Health 2016;70(9):910-916. http://dx.doi.org/10.1136/jech-2015-205860 4. Joint United Nations Programme on HIV/AIDS (UNAIDS). Global AIDS Update – 2016. Geneva: UNAIDS, 2016. http://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016 (accessed 2 November 2016).

5. Garcia-Moreno C, Zimmerman C, Morris-Gehring A, et al. Addressing violence against women: A call to action. Lancet 2015;385(9978):1685-1695. http://dx.doi.org/10.1016/S0140-6736(14)61830-4 6. Abdool Karim Q. Heterosexual transmission of HIV – the importance of a gendered perspective in HIV prevention. In: Abdool Karim SS, Abdool Karim Q, eds. HIV/AIDS in South Africa. Cape Town: Cambridge University Press, 2005:243-261. 7. World Health Organization. Global Plan of Action to Strengthen the Role of the Health System Within a National Multisectoral Response to Address Interpersonal Violence, in Particular Against Women and Girls, and Against Children, Building on Existing Relevant WHO Work. Geneva: WHO, 2016. http://www.who.int/topics/violence/UNFPA-GAP2-violence.pdf (accessed 2 November 2016). 8. World Health Organization. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-partner Sexual Violence. Geneva: WHO, 2013. http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf (accessed 22 September 2016). 9. Dellar R, Waxman A, Abdool Karim Q. Understanding and responding to HIV risk in young South African women: Clinical perspectives. S Afr Med J 2015;105(11):952. http://dx.doi.org/10.7196/ SAMJ.2015.v105i11.10099 10. De Neve JW, Fink G, Subramanian SV, Moyo S, Bor J. Length of secondary schooling and risk of HIV infection in Botswana: Evidence from a natural experiment. Lancet Glob Health 2015;3(8):e470-e477. http://dx.doi.org/10.1016/S2214-109X(15)00087-X 11. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. Lancet 2010;376(9734):4148. http://dx.doi.org/10.1016/S0140-6736(10)60548-X 12. Van der Straten A, King R, Grinstead O, Serufilira A, Allen S. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995;9(8):935-944. 13. Maman S, Mbwambo JK, Hogan NM, et al. HIV-positive women report more lifetime partner violence: Findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health 2002;92(8):1331-1337. http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.92.8.1331 (accessed 7 November 2016). 14. Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. Intimate partner violence and HIV infection among women: A systematic review and meta-analysis. J Int AIDS Soc 2014;17:18845. http:// dx.doi.org/10.7448/IAS.17.1.18845 15. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004;363(9419):1415-1421. http://dx.doi.org/10.1016/S0140-6736(04)16098-4 16. Strebel A, Crawford M, Shefer T, et al. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. SAHARA J 2006;3(3):516-528. http://dx.doi.org/10.1080/17290376.2006.9724879 17. Joint United Nations Programme on HIV/AIDS (UNAIDS). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013. Geneva: UNAIDS, 2013. http://www.unaids.org/en/media/unaids/ contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf (accessed 25 September 2016). 18. Gregson S, Nyamukapa CA, Garnett GP, et al. Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. Lancet 2002;359(9321):1896-1903. http://dx.doi. org/10.1016/S0140-6736(02)08780-9 19. Kelly RJ, Gray RH, Sewankambo NK, et al. Age differences in sexual partners and risk of HIV1 infection in rural Uganda. J Acquir Immune Defic Syndr 2003;32(4):446-451. http://dx.doi. org/10.1097/00126334-200304010-00016 20. MacPhail C, Williams BG, Campbell C. Relative risk of HIV infection among young men and women in a South African township. Int J STD AIDS 2002;13(5):331-342. http://dx.doi. org/10.1258/0956462021925162 21. Pettifor AE, Rees HV, Kleinschmidt I, et al. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey. AIDS 2005;19(14):1525-1534. http://dx.doi.org/10.1097/01.aids.0000183129.16830.06 22. Durevall D, Lindskog A. Intimate partner violence and HIV in ten sub-Saharan African countries: What do the demographic and health surveys tell us? Lancet Glob Health 2015;3(1):e34-e43. http:// dx.doi.org/10.1016/S2214-109X(14)70343-2 23. Pitpitan EV, Kalichman SC, Eaton LA, Sikkema KJ, Watt MH, Skinner D. Gender-based violence and HIV sexual risk behavior: Alcohol use and mental health problems as mediators among women in drinking venues, Cape Town. Soc Sci Med 2012;75(8):1417-1425. http://dx.doi.org/10.1016/j. socscimed.2012.06.020 24. Joint United Nations Programme on HIV/AIDS (UNAIDS). Together We Will End AIDS. Geneva: UNAIDS, 2012. http://www.unaids.org/en/resources/campaigns/togetherwewillendaids/ (accessed 14 October 2016). 25. Gupta GR, Weiss E, Whelan D. Male-female inequalities result in submission to high-risk sex in many societies. Special report: women and HIV. AIDS Analysis Africa 1995;5(4):8-9. 26. Adams JL, Hansen NB, Fox AM, et al. Correlates of HIV testing among abused women in South Africa. Violence Against Women 2011;17(8):1014-1023. http://dx.doi.org/10.1177/1077801211414166 27. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: Implications for prevention of mother-to-child transmission programmes. Bull World Health Organ 2004;82(4):299-307. http://www.who.int/ bulletin/volumes/82/4/299.pdf?ua=1 (accessed 7 November 2016). 28. Hatcher AM, Smout EM, Turan JM, Christofides N, Stockl H. Intimate partner violence and engagement in HIV care and treatment among women: A systematic review and meta-analysis. AIDS 2015;29(16):2183-2194. http://dx.doi.org/10.1097/QAD.0000000000000842 29. Roberts ST, Haberer J, Celum C, et al. Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: A prospective cohort study. J Acquir Immune Defic Syndr 2016;73(3):313-322. http://dx.doi.org/10.1097/QAI.0000000000001093 30. Schafer KR, Brant J, Gupta S, et al. Intimate partner violence: A predictor of worse HIV outcomes and engagement in care. AIDS Patient Care STDs 2012;26(6):356-365. http://dx.doi.org/10.1089/ apc.2011.0409 31. Hatcher AM, Woollett N, Pallitto CC, et al. Bidirectional links between HIV and intimate partner violence in pregnancy: Implications for prevention of mother-to-child transmission. J Int AIDS Soc 2014;17:19233. http://dx.doi.org/10.7448/IAS.17.1.19233 32. Mulrenan C, Colombini M, Howard N, Kikuvi J, Mayhew SH, Integra I. Exploring risk of experiencing intimate partner violence after HIV infection: A qualitative study among women with HIV attending postnatal services in Swaziland. BMJ Open 2015;5(5):e006907. http://dx.doi.org/10.1136/ bmjopen-2014-006907 33. Olowookere SA, Fawole OI, Adekanle DA, Adeleke NA, Abioye-Kuteyi EA. Patterns and correlates of intimate partner violence to women living with HIV/AIDS in Osogbo, Southwest Nigeria. Violence Against Women 2015;21(11):1330-1340. http://dx.doi.org/10.1177/1077801215594889 34. Shamu S, Zarowsky C, Shefer T, Temmerman M, Abrahams N. Intimate partner violence after disclosure of HIV test results among pregnant women in Harare, Zimbabwe. PLoS One 2014;9(10):e109447. http://dx.doi.org/10.1371/journal.pone.0109447 35. Ezechi OC, Gab-Okafor C, Onwujekwe DI, Adu RA, Amadi E, Herbertson E. Intimate partner violence and correlates in pregnant HIV positive Nigerians. Arch Gynecol Obstet 2009;280(5):745752. http://dx.doi.org/10.1007/s00404-009-0956-9

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GUEST EDITORIAL

36. Hatcher AM, Stockl H, Christofides N, et al. Mechanisms linking intimate partner violence and prevention of mother-to-child transmission of HIV: A qualitative study in South Africa. Soc Sci Med 2016;168:130-139. http://dx.doi.org/10.1016/j.socscimed.2016.09.013 37. Phillips T, Thebus E, Bekker LG, McIntyre J, Abrams EJ, Myer L. Disengagement of HIV-positive pregnant and postpartum women from antiretroviral therapy services: A cohort study. J Int AIDS Soc 2014;17:19242. http://dx.doi.org/10.7448/IAS.17.1.19242 38. Lundgren R, Amin A. Addressing intimate partner violence and sexual violence among adolescents: Emerging evidence of effectiveness. J Adolesc Health 2015;56(1 Suppl):S42-S50. http://dx.doi. org/10.1016/j.jadohealth.2014.08.012 39. Abramsky T, Devries K, Kiss L, et al. Findings from the SASA! Study: A cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med 2014;12:122. http://dx.doi. org/10.1186/s12916-014-0122-5 40. Abramsky T, Devries KM, Michau L, et al. The impact of SASA!, a community mobilisation intervention, on womenâ&#x20AC;&#x2122;s experiences of intimate partner violence: Secondary findings from a cluster randomised trial in Kampala, Uganda. J Epidemiol Community Health 2016;70(8):818-825. http://dx.doi.org/10.1136/jech-2015-206665 41. Heise LL, Kotsadam A. Cross-national and multilevel correlates of partner violence: An analysis of data from population-based surveys. Lancet Glob Health 2015;3(6):e332-e340. http://dx.doi. org/10.1016/S2214-109X(15)00013-3

42. UNICEF. Goal: Promote gender equality and empower women. UNICEF-Millennium Development Goals. http://www.unicef.org/mdg/index_genderequality.htm (accessed 28 September 2016). 43. Taaffe J, Cheikh N, Wilson D. The use of cash transfers for HIV prevention â&#x20AC;&#x201C; are we there yet? Afr J AIDS Res 2016;15(1):17-25. http://dx.doi.org/10.2989/16085906.2015.1135296 44. World Health Organization, United Nations Joint Programme on HIV/AIDS. 16 Ideas For Addressing Violence Against Women in the Context of the HIV Epidemic: A Programming Tool. Geneva: WHO, 2013. http://apps.who.int/iris/bitstream/10665/95156/1/9789241506533_eng.pdf (accessed 26 September 2016). 45. World Health Organization, United Nations Office on Drugs and Crime (UNODC). Strengthening the Medico-legal Response to Sexual Violence. Geneva: WHO, 2015. http://www.who.int/ reproductivehealth/publications/violence/medico-legal-response/en/ (accessed 26 September 2016). 46. National Department of Health, South Africa. The 2013 National Antenatal Sentinel HIV Prevalence Survey South Africa. Pretoria: National Department of Health, 2015. https://www.health-e.org.za/wpcontent/uploads/2016/03/Dept-Health-HIV-High-Res-7102015.pdf (accessed 2 November 2016).

S Afr Med J 2016;106(12):1151-1153. DOI:10.7196/SAMJ.2016.v106i12.12126

December 2016, Print edition

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REFERENCES: 1. Russell RG, et al. Mechanisms of action of bisphosphonates: similarities and differences and their potential influence on clinical efficacy. Osteoporos Int (2008) 19:733-759. 2. Nancollas GH, et al. Novel insights into actions of bisphosphonates on bone: Differences in interactions with hydroxyapatite. Elsevier Inc. Bone 38 (2006) 617–627. 3. Iwamoto J. Monthly Risedronate for the Treatment of Postmenopausal Osteo¬porosis. Pharmaceutica Analytica Acta 5:285. 2014. 4. Roux C, et al. Efficacy of risedronate on clinical vertebral fractures within six months. Current Medical Research and Opinion® VOL. 20, NO. 4, 2004, 433–439. 5.Harrington JT, et al. Risedronate Rapidly Reduces the Risk for Nonvertebral Fractures in Women with Postmenopausal Osteoporosis. Calcif Tissue Int (2004) 74:129–135. 6. McClung Mr, et al. Efficacy and safety of risedronate 150-mg once a month in the treatment of postmenopausal osteoporosis: 2-year data. Osteoporos Int (2013) 24:293–299. 7. Mellström DD, et al. Seven Years of Treatment with Risedronate in Women with Postmenopausal Osteoporosis. Calcif Tissue Int (2004) 75:462–468. 8. Silverman SL, et al. Effectiveness of bisphosphonates on nonvertebral and hip fractures in the first year of therapy: The risedronate and alendronate (REAL) cohort study. Osteoporos Int (2007) 18:25–34. 9. Actonel 5mg Film Coated Tablets. Summary of Product Characteristics Updated 21-Nov-2014. 10. Taggart H, et al. Upper Gastrointestinal Tract Safety of Risedronate: A Pooled Analysis of 9 Clinical Trials. Mayo Clin Proc. 2002;77:262-270. 11. SEP (excl. VAT) as per DOH approval 15 November 2016. For full prescribing information refer to the package inserts approved by the Medicines Control Council. S3 Actonel Once-A-Month. Each film coated tablet contains risedronate sodium equivalent to risedronic acid 150.0 mg. Reg. No. 43/3.2/0131. Applicant: Watson Pharma No1 (Pty) Ltd 1st Floor, Block C, Sandton Close 1, Cnr 5th Street and Norwich Close, Sandton, 2196. Marketed by Cipla Medpro (Pty) Ltd Reg. No. 1995/004182/07. Building 9, Parc du Cap, Mispel Street, Bellville, 7530, RSA. Website: www.cipla.co.za Customer Care: 080 222 6662

EDITOR’S CHOICE

CME: Tackling child abuse in South Africa (SA)

Child abuse, also termed ‘maltreatment’, is disturbingly common in SA. It presents an outrageous scourge that calls for greater attention, skills, resources and political support. As health professionals, we need to know how to deal with it better. ‘Maltreatment is one of the biggest paediatric public health challenges, yet any research activity is dwarfed by work on more established childhood ills.’[1] This knowledge/practice gap is compounded by another deficit, namely the need for more effective national collaboration between the Department of Social Development (DSD) and the Department of Health on integrated systems for data and service provision. Regarding allegations of child maltreatment, the Children’s Act No. 38 of 2005[2] requires the DSD to record the child’s name, perpetrator’s name and type(s) of abuse committed against the child in the National Child Protection Register. Despite the fact that digital online open access to an up-to-date national list of paedophiles is standard practice in the developed world, in SA this has not yet been developed. Furthermore, widespread resistance to the use of this specific term/identifier has resulted in the DSD referring more generically to ‘perpetrators’ instead. Significantly, the Child Protection Register relies on the submission of Form 22, for the initial report of alleged maltreatment, followed by Form 23. The latter must be completed by a registered social worker or specified professional and confirms that maltreatment is verified/ proven. Note that health professionals are legally obliged to complete and submit Form 22 whenever abuse is suspected. However, hospital cases via dental or medical/surgical units are not always reported, revealing a major shortcoming in our national professional standards. This edition of CME aims to enhance health professionals’ skills and knowledge so that they are better equipped to bring perpetrators to book and to care effectively for traumatised children and their families.

The dual burden of gender-based violence (GBV) and HIV in adolescent girls and young women in SA

The 16 Days of Activism is an international awareness-raising campaign that promotes no violence against women and children. Each year the campaign runs between 25 November and 10 December and overlaps with World AIDS Day on 1 December. Adopted by SA in 1998, the campaign aims to raise awareness among South Africans about the negative impact of violence against women and children on all members of the community. This campaign is particularly relevant in the SA context, as young women aged 15 - 24 years, who have the least power in society, bear an enormous burden of both intimate partner violence (IPV) and HIV.[3] Violence against women takes many forms – physical, sexual, economic, and psychological – with IPV being a particularly significant public health problem. Although population-based surveys show that the prevalence of IPV among ever-married or partnered women aged 15 - 49 years declined between 2000 and 2014 in some countries, the global prevalence of recent IPV remains unacceptably high. Globally, about 1 in every 3 women has ever experienced physical and/or sexual violence inflicted by an intimate partner. Interestingly, the prevalence of IPV among young women aged 15 - 19 years is similar (29%) to the average lifetime prevalence of IPV, suggesting that violence commonly starts early in women’s relationships. A study undertaken by the South African Medical Research Council shows that about 1 in every 4 women aged 18 49 years in SA has experienced IPV. A recent community-based study in SA among 3 515 children aged 10 - 17 years revealed that 31.2% of adolescent girls had ever experienced physical abuse in their lifetimes, with 8.4% reporting sexual abuse or rape.

Multiple complex pathways connect IPV with HIV. Gender inequality, the threat of IPV and male controlling behaviour can increase a young woman’s vulnerability to HIV by limiting her ability to successfully negotiate consistent condom use with her male partner(s), insist on mutual monogamy or refuse unwanted sex, thus constraining her ability to control her own HIV risk. Changing the face of these two epidemics will require substantial rethinking and conceptualisation at a structural level on constructions of masculinity and femininity and the value placed on women and their rights. The World Health Organization and UNAIDS have developed programming tools to address violence against women in the context of the HIV epidemic. The coercive arm of the law also offers some hope and protection to vulnerable women experiencing both epidemics, but it is social mobilisation and solidarity that will enable true transformation and the real possibility for all women to reach their full potential in a safe and healthy manner.

GBV: Psychosocial risk and protective factors among men in rural KwaZuluNatal

Rates of GBV in SA are among the highest in the world. In societies where social ideals of masculinity encourage male dominance and control over women, gender power imbalances contribute to male perpetration and women’s vulnerability. The drivers that cause men to perpetrate GBV and those that lead to HIV overlap and interact in multiple and complex ways. Multiple risk and protective factors for GBV perpetration by males operate interdependently at a number of levels; at the individual level, these include chronic anxiety and depression, which have been shown to lead to risky sexual behaviours. This study concentrated on psychosocial risk factors as well as protective factors reported by a cohort of men in rural KwaZulu-Natal.[4] The participants were relatively young (mean age 22 years); over half were schoolgoers, and 91.3% had never married. Over 43% of the sample reported clinical levels of anxiety and depressive symptoms on the Brief Symptom Inventory. Rates of GBV perpetration were 60.9%, 23.6% and 10.0% for psychological abuse, non-sexual physical violence and sexual violence, respectively. GBV perpetration was associated with higher depression, higher anxiety, lower self-esteem and lower social support. The study concluded that interventions to address GBV need to take modifiable individual-level factors into account.

Child Support Grant (CSG) before birth: Safeguarding maternal and child health in SA

Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. SA offers a post-delivery CSG, which could encompass support during pregnancy, informed by lessons learnt from similar grants. Chersich et al.[5] review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. Thirtytwo programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational

December 2016, Print edition

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EDITOR’S CHOICE

barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes, and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-tomeasure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

The low-carbohydrate (CHO) diet wars: Critique of a meta-analysis

A 2014 meta-analysis from the universities of Stellenbosch and Cape Town reported that diets with a lower CHO content are no more effective for producing weight loss than are high-CHO diets, so-called isoenergetic ‘balanced’ diets. Zoe Harcombe and Tim Noakes[6] have re-examined the article and found numerous errors, many material in nature. Studies were included that failed the authors’ own inclusion criteria; invalid and subjective meta-analysis sub-grouping was used; and data extraction was repeatedly inaccurate. All but one error favoured the balanced diet. The article was widely publicised, highly impactful and inaccurate. The findings of the Naude et al.[7] meta-analysis were widely reported in the SA media as disproof of the overall value of the low-CHO, high-fat (LCHF) diet. Indeed, some reports misused this messaging to warn about the ‘dangerous’ nature of low-CHO diets. The objective of this re-examination was to test whether or not the findings of the Naude et al. article were robust, and this study suggested that they were not. The re-examination additionally

showed that, notwithstanding two features of the study, which by design or by chance disadvantaged low-CHO diets, had the Naude et al. meta-analysis been properly performed, it would have concluded that the lower-CHO diet produced greater weight loss than the balanced diet. This would have radically altered the nature of the message heard across SA after its publication and might have influenced the eagerness of SA medical authorities to put the LCHF/ Banting diet on public ‘trial’. A reasonable question to ask is: how could the published metaanalysis have included so many errors and have come to the incorrect conclusion despite peer review? Another reasonable question to ask is: what is the chance that essentially all these errors favoured the so-called balanced diet and disadvantaged the lower-CHO diet, especially when many of the authors of this article are on public record as being vigorously opposed to lower- or low-CHO diets and to those who promote such eating plans? BF 1. Mikton C, Releva M, Makoae M, et al. The assessment of the readiness of five countries to implement child maltreatment prevention programs on a large scale. Child Abuse Negl 2013;37(12):1237-1251. http://dx.doi.org/10.1016/j.chiabu.2013.07.009 2. South Africa. Children’s Act No. 38 of 2005:ss111-ss128. 3. Abdool Karim Q, Baxter C. The dual burden of gender-based violence and HIV in adolescent girls and young women in South Africa. S Afr Med J 2016;106(12):1151-1153. http://dx.doi.org/10.7196/ SAMJ.2016.v106i12.12126 4. Mngoma N, Fergus S, Jeeves A, Jolly R. Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal, South Africa. S Afr Med J 2016;106(12):1211-1215. http://dx.doi.org/10.7196/SAMJ.2016.v106i12.11233 5. Chersich MF, Luchters S, Blaauw D, et al. Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries. S Afr Med J 2016;106(12):1192-1210. http://dx.doi.org/10.7196/ SAMJ.2016.v106i12.12011 6. Harcombe Z, Noakes T. The universities of Stellenbosch/Cape Town low-carbohydrate diet review: Mistake or mischief? S Afr Med J 2016;106(12):1179-1182. http://dx.doi.org/10.7196/SAMJ.2016. v106i12.12072 7. Naude CE, Schoonees A, Senekal M, Young T, Garner P, Volmink J. Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: A systematic review and metaanalysis. PLoS One 2014;9(7):e100652. http://dx.doi.org/10.1371/journal.pone.0100652

Erratum The future cost of cancer in South Africa: An interdisciplinary cost management strategy

In the guest editorial entitled ‘The future cost of cancer in South Africa: An interdisciplinary cost management strategy’, which appeared in the October 2016 SAMJ (106(10):949-950), author V Sharma’s affiliation should have read: ‘Head, Department of Radiation Oncology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa’. The online version of the article (http://dx.doi.org/10.7196/SAMJ.2016.v106i10.11375) was corrected on 25 November 2016. S Afr Med J 2016;106(12):1270. http://dx.doi.org/10.7196/SAMJ.2016.v106i12.12182

December 2016, Print edition

DIE SUID AFRIKAANSE VERENIGIGING VAN ANESTSIOLOË THE SOUTH AFRICAN SOCIETY OF ANAESTHESIOLOGISTS

ANAESTHESIOLOGY UPDATE MEETING Hosted by SASA, Western Cape Branch

INVITATION

Lagoon Beach Hotel, Cape Town Saturday, 6 May 2017 OVERVIEW Doctors: For speaker topics please see the programme on www.sasawesterncape.co.za Nurses: For speaker topics please see the programme on www.sasawesterncape.co.za COST SASA Members: Early Registration: R250.00 • Late Registration: R350.00 Non-SASA Members: Early Registration: R1 000.00 • Late Registration: R1 200.00 Nurses: Early Registration: R450.00 • Late Registration: R500.00 CPD The Update Meeting will be accredited REGISTRATION Early registration closes 22 April 2017 To register please visit our website: www.sasawesterncape.co.za Date: Venue:

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CORRESPONDENCE

Willingness of tobacco smokers to contribute financially towards cessation resources

To the Editor: Exposure to tobacco smoke accounts for approximately 9% (95% confidence interval 8.1 - 10.2) of all South African (SA) deaths.[1] Seventeen percent of SA adults are self-reported active smokers and an alarming 32% of pregnant women were found to be active smokers on urine cotinine testing.[2,3] Despite the publication in 2013 of the South African Tobacco Smoking Cessation Clinical Practice Guideline,[4] tobacco smoking cessation programmes in the public health sector remain scarce. We conducted a cross-sectional survey in 2010 of 100 adult smokers at Tygerberg Academic Hospital in Cape Town to determine the rate of nicotine dependence using the Fagerström questionnaire and alcohol codependence using the CAGE questionnaire.[5,6] We also assessed willingness to contribute financially to smoking cessation resources. The Human Research Ethics Committee of Stellenbosch University approved the study (N10/05/179). The majority of subjects were identified by smoking behaviour outside entrance number 2, the entrance to Tygerberg Children’s Table 1. Demographic, tobacco and alcohol dependence characteristics (N=100) Demographic Age (years), median (IQR)

34 (27 - 43)

Female, n (%)

57 (57)

Education, n (%) < Grade 8

21 (21)

Grade 8 - 12

66 (66)

Any tertiary education

13 (13)

Hospital. The median age of participants was 34 years (interquartile range 27 - 43 years). Two-thirds were parents or caregivers accompanying child patients to the hospital (Table 1). Despite 54% having reported smoking fewer than 10 cigarettes per day, two-thirds had medium to high nicotine dependence and 22% had alcohol codependence (Table 1). Ninety-three percent understood that smoking was dangerous both to themselves and to others. Sixtyfour percent had been advised by a healthcare worker to quit and 72% had unsuccessfully attempted to quit at least once. Eighty-one percent (52/64) of those advised to quit and 67% (24/36) not advised had made at least one attempt to do so. Sixty-eight percent of smokers were willing to pay the equivalent of their current cigarette expenditure for cessation resources. Those willing to pay tended to have a higher rate of attempting cessation compared with those not willing to pay (82% v. 72%, p=0.09). The majority spent from less than ZAR10 to ZAR25 per day on tobacco products and only 9% spent more than ZAR25 per day. The mean annual expenditure on tobacco products was ZAR6 000 per smoker. The high rate of medium to high nicotine dependence and the frequent unsuccessful attempts to quit in this sample indicate the need for both professional counselling and pharmacotherapy to assist smoking cessation in this population. These smokers were financially invested in the process and willing to contribute financially to cessation resources, an unexplored opportunity for smokers and the public health sector to share the financial responsibility of smoking cessation programmes in SA. Acknowledgement. We gratefully acknowledge the late Prof. Chris Bollinger’s advice on this study.

Karthik Rao

Johns Hopkins University School of Medicine, Baltimore, MD, USA

58 (58)

Amy L Slogrove

Number of people in house, median (IQR)

5 (3 - 6)

M Louise Cooke

Number of smokers in house, median (IQR)

2 (1 - 3)

Employed Home environment

Number of children (<13 years) in house, median (IQR)

Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa Department of Paediatrics, University of Cape Town, South Africa

1.5 (0.5 - 2)

Tobacco dependence by Fagerström score, n (%) High

17 (17)

Medium

49 (49)

Low

34 (34)

Alcohol use, n (%) Drinks alcohol

43 (43)

Others in house drink alcohol

43 (43)

Alcohol dependent (by CAGE questionnaire)

22 (22)

Mark F Cotton

Division of Paediatric Infectious Diseases and Family Clinical Research Unit (FAM-CRU), Stellenbosch University, Cape Town, South Africa mcot@sun.ac.za 1. Institute for Health Metrics and Evaluation. Deaths and DALYs due to smoking and second hand smoke exposure: South Africa. Global Burden of Disease (GBD) Results Tool 2015. http://ghdx. healthdata.org/gbd-results-tool?params=querytool-permalink/1ad6db1837cded023f571b1374a600b1 (accessed 9 October 2016). 2. Reddy P, Zuma K, Shisana O, Kim J, Sewpaul R. Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey. S Afr Med J 2015;105(8):648-655. http://dx.doi.org/10.7196/SAMJnew.7932 3. Vanker A, Barnett W, Brittain K, et al. Antenatal and early life tobacco smoke exposure in an African birth cohort study. Int J Tuberc Lung Dis 2016;20(6):729-737. http://dx.doi.org/10.5588/ijtld.15.0697 4. Van Zyl-Smit RN, Allwood B, Stickells D, et al. South African tobacco smoking cessation clinical practice guideline. S Afr Med J 2013;103(11):869-876. http://dx.doi.org/10.7196/SAMJ.7484 5. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86(9):1119-1127. 6. Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA 1984;252(14):1905-1907.

S Afr Med J 2016;106(12):1154. DOI:10.7196/SAMJ.2016.v106i12.12106

December 2016, Print edition

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IZINDABA

HMPG in 2016 The year 2016 has seen some major changes to the Health and Medical Publishing Group (HMPG) in general, and to the SAMJ in particular. From a practical perspective, one of the biggest changes has been to our online submission system for journals, which has moved from the open-source OJS (open journal system) to Editorial Manager/ Production Manager, an international system used by large international publishers including The Lancet and Elsevier. Over the past 6 months or so, the editorial team, led by managing editors Ingrid Nye and Claudia Naidu, has invested a huge amount of time and effort in the development of guidelines, support materials and helpdesk structures to ensure that they will be able to guide users through the transition from the old OJS sites to the new system. Another significant change is that the SAMJ is now an online journal. The indexed issue is online only. The print edition is a ‘highlights’ package that is distributed to members of the South

African Medical Association and is shorter than the actual journal issue. This allows us a much wider readership, and also allows us to publish more per issue without the cost constraints associated with print. In addition to this, we are in the process of building a corporate website that will include a payment mechanism for SAMF sales, a newsletter programme, and professional and classified advertising functionality. This will also become the online publishing platform for all our journals.

Editorial efficiency improvements

The investments made in strengthening the pre-publication and peer review processes within HMPG have already resulted in demonstrable improvements in the service we provide for authors. In 2015, articles were taking an average of over 6 months to be published, with some taking more than a year. However, the editorial team is

Table 1. Comparison of editorial processing times for the three main article types, 2015 - 2016 Submission to publication (average months) Correspondence In Practice Research Range (the difference between the minimum and maximum number of months) Correspondence In Practice Research

2015

2016

% improvement

4.7 6.1 7.1

3.3 4.2 6.2

30.1 30.3 12.8

12 12 14

2 7 7

83 42 50

now both faster at making decisions and more consistent, meaning that the majority of authors who submit to HMPG can now expect their articles to be published within 4 months (Table 1). We have also eliminated the backlog of accepted articles that were waiting to be published. Some of these articles had been waiting for more than a year before being allocated space in the journal. These improvements have generated a very positive response from our authors and reviewers. A new editorial team structure is in the process of being introduced, with a board of Associate Editors being recruited for the main specialties covered by the SAMJ. I am now the substantive editor of the SAMJ, in charge of the in-house editorial team that functions as the secretariat and operational support to the team of academic Associate Editors, which will be chaired by an Editor-in-Chief. HMPG recently moved into new offices in Pinelands to accommodate the expanded staff, which includes two design and layout staff, an expanded sales team and an additional junior copy editor. The whole HMPG team is excited about these new developments, which put us in a better position to respond to the needs of authors, reviewers and readers. We are looking forward to 2017 and to attracting the best research across the country in all medical disciplines. Bridget Farham Editor ugqirha@iafrica.com S Afr Med J 2016;106(12):1155. DOI:10.7196/ SAMJ.2016.v106i12.12187

30 days in medicine The J-curve: Blood pressure and cardiovascular disease

Treatment, not screening, cause of reduction in breast cancer deaths

Vidal-Petiot E, Ford I, Greenlaw N, et al. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: An international cohort study. Lancet 2016;388(10056):2142-2152. http://dx.doi.org/10.1016/S0140-6736(16)31326-5

Welch HG, Prorok PC, O’Malley AJ, Kramer BS. Breast cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med 2016;375:1438-1447. http://dx.doi.org/10.1056/NEJMoa1600249

An analysis of data from 22 672 patients with stable coronary artery disease who were treated for the condition showed that reducing blood pressure to too low a level had poor outcomes. In patients with hypertension and coronary artery disease from routine clinical practice, systolic blood pressure of <120 mmHg and diastolic blood pressure of <70 mmHg were both associated with adverse cardiovascular outcomes, including mortality. This supports the idea of a J-curve in optimal blood pressure, since very low diastolic blood pressure leads to poor myocardial perfusion, causing problems.

A recent study in the New England Journal of Medicine shows that improved systemic therapy and not early detection of tumours was the cause of the fall in breast cancer deaths seen after the introduction of widespread mammography in the USA. Assuming that the underlying pattern of breast cancer progression was stable, the researchers calculated that only 30 of the additional 162 small tumours per 100 000 women that were diagnosed on screening would have progressed to become large. This implied that the remaining 132 cases of cancer per 100 000 women were ‘overdiagnosed’ by screening and would never have led to clinical symptoms.

December 2016, Print edition

IZINDABA

Maternal and newborn mortality directly affected by quality of care at health facilities

Global efforts to increase the number of births at healthcare facilities will only reduce maternal or newborn mortality if the quality of care in these facilities is sufficient, according to Margaret Kruk and colleagues. They analysed nationally representative health system surveys with data for volume of deliveries and quality of delivery care from Kenya, Namibia, Rwanda, Tanzania and Uganda. They used an index of 12 indicators of structure and processes of care, including infrastructure and use of evidence-based routine and emergency care interventions, completing national surveys between April 2006 and May 2010. They found that >40% of facility deliveries in these five African countries occurred in primary care facilities, which scored poorly on basic measures of maternal care quality. Facilities with caesarean section capacity, particularly those that managed >500 births per year, had higher scores for maternal care quality. The authors recommend systematic assessment of maternal care quality in low- and middle-income countries to accelerate reduction of maternal and newborn deaths. Kruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RMK, Langer A. Quality of basic maternal care functions in health facilities of five African countries: An analysis of national health system surveys. Lancet Glob Health 2016;4(11):e845-e855. http://dx.doi.org/10.1016/S2214-109X(16)30180-2

Can we reach the 2025 WHO global tuberculosis targets?

Post-2015, the End TB Strategy proposes targets of a 50% reduction in tuberculosis (TB) incidence and a 75% reduction in TB-related mortality by 2025. Using 11 independently developed mathematical models of TB transmission, the authors of this article projected the epidemiological impact of currently available TB interventions for prevention, diagnosis and treatment in China, India and South Africa (SA). Country-specific intervention scenarios were provided by representatives from national TB programmes and the advocacy community. Aggressive scale-up of any single intervention, which includes symptom screening, active case finding and prevention therapy, could not achieve the targets in any country. However, the models projected that, in the SA national TB programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based symptom screening and improved TB care could achieve a 55% reduction in incidence and a 72% reduction in mortality compared with 2015 levels. For India and particularly for China, full scale-up of all interventions in TB programme performance fell short of the 2015 targets, despite preventing a cumulative 3.4 million cases. Houben RMG, Menzies NA, Sumner T, et al. Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: A combined analysis of 11 mathematical models. Lancet Glob Health 2016;4(11):e806-e815. http://dx.doi.org/10.1016/S2214-109X(16)30199-1

No more cranberry juice for urinary tract infections

Cranberry juice is commonly thought of as a natural way of treating urinary tract infections, but a recent study published in Journal of the American Medical Association suggests that it is little better than placebo. The authors tested the effect of two oral cranberry capsules daily on the presence of bacteriuria plus pyuria among

185 women aged >65 years with or without bacteriuria plus pyuria living in nursing homes using a double-blind, randomised, placebocontrolled efficacy trial over 1 year. The two oral cranberry capsules each contained 36 mg of the active ingredient proanthocyanidin, equivalent to 72 mL of cranberry juice. They found no significant difference in the presence of bacteriuria plus pyuria and placebo during the year of administration. Juthani-Mehta M, van Ness PH, Bianco L. Effect of cranberry capsules on bacteriuria plus pyuria among older women in nursing homes: A randomized clinical trial. JAMA 2016;316(18):1879-1887. http://dx.doi. org/10.1001/jama.2016.16141

Little difference in outcome between treated and monitored prostate cancer

A study comparing active monitoring, radical prostatectomy and external beam radiotherapy for treatment of clinically localised prostate cancer found no significant difference between treatments, and 10-year prostate cancer-specific mortality was generally low. Between 1999 and 2009, a total of 82 429 men aged 50 - 69 years received a prostate-specific antigen test; 2 664 received a diagnosis of localised prostate cancer, and 1 643 agreed to undergo randomisation to active monitoring (545 men), surgery (553) or radiotherapy (545). There were 17 prostate cancer-specific deaths overall – 8 in the active monitoring group, 5 in the surgery group and 4 in the radiotherapy group. Higher rates of disease progression were seen in the active monitoring group than in the surgery or the radiotherapy groups. Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016;375(15):1415-1424. http://dx.doi.org/10.1056/ NEJMoa1606220

Industry-funded studies find no link between sugary drinks and diabetes and obesity

Research studies funded by the sugary drinks industry are significantly less likely than those without such ties to find links between sugary drink consumption and diabetes and obesity, according to a literature review published recently in Annals of Internal Medicine. The introduction of initiatives such as taxes to limit consumption of sugary drinks in order to reduce levels of diabetes and obesity has resulted in the industry disputing any evidence of causation. However, a systematic review investigating whether studies that found no link between sugary drinks and diabetes or obesity were more likely to be funded by industry than studies that found a link, found that all (100%) of the 26 studies that found no association had funding ties to industry. On the other hand, only one of the 34 studies that found an association between diabetes and obesity and drinking sugary beverages was supported by industry (2.9%). This would appear to be another example of industry manipulating science to advance their business interests. Schillinger D, Tran J, Mangurian C, Kearns C. Do sugar-sweetened beverages cause obesity and diabetes? Industry and the manufacture of scientific controversy. Ann Intern Med 2016. http://dx.doi.org/10.7326/ L16-0534 (published online 1 November 2016).

Bridget Farham Editor ugqirha@iafrica.com

December 2016, Print edition

IZINDABA

OBITUARY Maurice Aaron Kibel (14 November 1929 - 9 October 2016)

Emeritus Professor Maurice Aaron Kibel passed away peacefully on 9 October after a short period of declining health. He was an icon and a pioneer in paediatrics and child health in southern Africa. A medical graduate of the University of the Witwatersrand, he undertook paediatrics training in Edinburgh before moving to practise in Zimbabwe, where his clinical skills, teaching, innovation and experience gained globally were given full rein in a distinctly African setting. After a distinguished career as a paediatrician in Bulawayo for more than 20 years and then professor at the Boston Children’s Floating

Hospital in the USA, he established the Child Health Unit as the first Stella and Paul Lowenstein Professor of Child Health in the Department of Paediatrics and Child Health at the University of Cape Town in 1979. Since the 1980s, Maurice was associated with the South African Tuberculosis Vaccine Initiative and was instrumental in the establishment of the clinical trial site in Worcester – now the largest in the world – where he mentored many clinicians. He was actively involved in a number of clinical trials, in particular the first trial that compared percutaneous v. intradermal BCG vaccine, one of the largest conducted to date at the site. Maurice was the author of more than 120 peer-reviewed publications on wide-ranging topics in paediatrics, as well as architect and lead editor of the now-classic textbook Child Health for All, contributor to Fofar’s Textbook of Paediatrics, and co-author with David Bass of the popular First Aid for Babies and Children. For several years Maurice served as the official University Orator, and he will also be remembered as an excellent singer who had a remarkable talent for writing lyrics to well-known tunes and then performing the songs at many academic events and conferences across the world. His witty ditties have been immortalised in a book treasured by many colleagues, and some were published in 2010 as General Tso’s Chicken and the Seven Deadly Sins: A Collection of Rhyme and Reason, described as ‘a celebration of a lifetime of words, music and medicine, written with good humour and an empathetic pen’.

December 2016, Print edition

Prof. Heather Zar speaks of Maurice as an extraordinary man – a great paediatrician, a visionary and leader in child health, a brilliant teacher and clinician, and an inspirational and deeply humble human being who continued to contribute to the health of the most disadvantaged children and their families long after his retirement. His legacy lives on in the many child health academics and practitioners who were touched and inspired by him, and in his family: his wife, Leonora, his children, Owen, Shelley and David, and his grandchildren. Marian Jacobs Emeritus Professor, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa marian.jacobs@uct.ac.za Heather Zar Professor and Head, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and Medical Research Council Unit on Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town, South Africa David Beatty Emeritus Professor, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa Gregory Hussey Director: Vaccines for Africa Initiative, University of Cape Town, South Africa

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CME

GUEST EDITORIAL

Tackling child abuse and neglect in South Africa Child abuse is disturbingly common in South Africa (SA). As such, it presents an outrageous scourge that calls for greater attention, skills, resources and political support. Also termed ‘maltreatment’, health professionals need to know how to deal with it better. ‘Maltreatment is one of the biggest paediatric public health challenges, yet any research activity is dwarfed by work on more established childhood ills.’[1] This knowledge/practice gap is compounded by another deficit, namely the need for more effective national collaboration between the departments of Social Development (DSD) and Health regarding integrated systems for data and service provision. Regarding allegations of child maltreatment, the Children’s Act No. 38 of 2005[2] requires the DSD to record the child’s name, perpetrator’s name and type(s) of abuse committed against the child in the National Child Protection Register. Despite the fact that digital online open access to an up-todate national list of paedophiles is standard practice in the developed world, in SA this is not yet in place. Furthermore, widespread resistance to the use of this specific term/identifier has resulted in the DSD referring more generically to ‘perpetrators’ instead. Significantly, the Child Protection Register relies upon the submission of Form 22 for the initial report of alleged maltreatment, followed by Form 23. The latter must be completed by a registered social worker or specified professional and confirms that maltreatment is verified/ proven. Note that health professionals are legally obliged to complete and submit Form 22 whenever abuse is suspected. However, hospital cases via dental or medical/surgical units are not always reported, revealing a major shortcoming in our national professional standards. This is particularly concerning, as Mathews and Martin’s[3] analysis of fatal child abuse and associated injury patterns reveals that the greatest burden of fatal child abuse and neglect was found among the under-1-year-old group. Abandonment at birth was most common, followed by blunt force injuries and strangulation/asphyxiation deaths. Their article presents the findings from 707 cases analysed by child death review teams at two SA pilot sites during 2014. It also describes necessary components for the efficient functioning of these teams and reflects on their feasibility within the SA setting to strengthen identification of child abuse deaths and to influence practice. In conclusion, they emphasise the importance of prioritising prevention efforts to break the cycle of child maltreatment, especially at home. Linking directly with this concern, Turner and Honikman[4] provide insightful guidance regarding the assessment of, and care for, maternal mental health within the first 1 000 days. Approaching the mother/caregiver and infant/child as a dyad, their evidence-based directives for identification and treatment of common mental disord-

ers are firmly grounded within the realities of the SA context. This is further enhanced by their deep understanding of the necessity of good-quality perinatal mental healthcare. Their valuable contribution provides clear information and other tools for practice. The issue of child rights and national efforts to strengthen prevention and responses to violence against children is taken up by Lake and Jamieson.[5] They provide an expert outline of patterns of violence towards children, risks, effects and protective factors before moving to a detailed discussion of key implications for healthcare practice. Specific and practical, they include key referral resources and clear guidance about what could and should be prioritised, including future advocacy initiatives. Importantly, and in line with qualitative findings the world over, violated patients most need a human being on the other side of the clinical encounter. Whether adult or child, female or male, patients miss the attending clinician’s acknowledgement that they have survived a horrific experience. They need reassurance that their traumatised reactions are a normal response to abnormal events. In conclusion, this edition of CME aims to further enhance health professionals’ skills and knowledge so as to be better equipped to bring perpetrators to book as well as to care more effectively for traumatised children and their families. Kate Joyner Division of Nursing, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa katejoyner.kj@gmail.com 1. Mikton C, Releva M, Makoae M, et al. The assessment of the readiness of five countries to implement child maltreatment prevention programs on a large scale. Child Abuse Neglect 2013;37(12):1237-1251. http://dx.doi.org/10.1016/j.chiabu.2013.07.009 2. South Africa. Children’s Act No. 38 of 2005:ss111-ss128. 3. Mathews S, Martin LJ. Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study. S Afr Med J 2016;106(12):1160-1163. http://dx.doi. org/10.7196/SAMJ.2016.v106i12.12130 4. Turner RE, Honikman S. Maternal mental health and the first 1 000 days. S Afr Med J 2016;106(12):11641167. http://dx.doi.org/10.7196/SAMJ.2016.v106i12.12129 5. Lake L, Jamieson L. Using a child rights approach to strengthen prevention of violence against children. S Afr Med J 2016;106(12):1168-1172. http://dx.doi.org/10.7196/SAMJ.2016.v106i12.12128

S Afr Med J 2016;106(12):1159. DOI:10.7196/SAMJ.2016.v106i12.12178

December 2016, Print edition

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CME

Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study S Mathews,1 MPH, PhD; L J Martin,2 MB BCh, Dip For Med (SA), MMed Path (Forens), FCFor Path (SA) 1 2

Children’s Institute, Faculty of Health Sciences, University of Cape Town, South Africa Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: S Mathews (shanaaz.mathews@uct.ac.za)

Fatal child abuse is the severest consequence of violence against children. Yet, little is known about this phenomenon, as routine data do not describe it. Child death review (CDR) teams have been established to systematically review deaths from birth to adolescence as a public health response to better identify child abuse deaths, to develop policy and to improve the child protection response. This article describes the incidence of fatal child abuse and injury patterns associated with such deaths. CDR teams reviewed all child fatalities from 1 January to 31 December 2014 at two pilot sites in South Africa (SA). Data were collected on demographics, causes and circumstances of the death, and family social context. We assessed the feasibility of CDR teams in the SA setting to strengthen the identification of child abuse deaths and influence practice. A total of 707 cases were reviewed. Over half (52.4%) of the deaths were due to natural causes. A third were caused by murder, with nearly half (44%) of all murders attributed to fatal child abuse. The burden of fatal child abuse and neglect was found among the <1-year age group. Abandonment at birth was most common, followed by blunt force injuries and strangulation/asphyxiation deaths. CDR teams are effective in better identifying deaths due to child abuse and neglect via a multidisciplinary approach and regular case reviews. S Afr Med J 2016;106(12):1160-1163. DOI:10.7196/SAMJ.2016.v106i12.12130

Violence against children is a pervasive problem in South Africa (SA). Yet, there is an absence of routine data sources to monitor the prevalence and incidence of child violence, in particular child abuse and neglect. Fatal child abuse is the most severe consequence and forms a proxy measure for the effectiveness of a country’s child protection system.[1] The SA child homicide study estimates a child homicide rate of 5.5/100 000 children <18 years of age[2] – more than double the global child homicide rate.[3] Furthermore, the relationship between child homicide and fatal child abuse was noted, with nearly half (44.6%) of child homicides related to child abuse and neglect. However, child abuse deaths were not always managed within a child protection framework and many of these deaths remain hidden.[4] Underestimating the burden of child maltreatment has been shown in multiple settings, with only a third of these deaths classified as homicide.[5] It is estimated that 13% of all injury deaths in children <15 years old are due to child abuse and neglect.[3] Studies from high-income settings have shown that fatal child abuse is poorly detected in vital statistics, by child protection services, and by the police, resulting in a huge underestimation of fatal child abuse.[5] The poor detection rates of child abuse deaths are primarily owing to difficulties in identifying such deaths, investigating and reporting of such deaths by police to child protection services, and a lack of standard definitions of child maltreatment.[6] Deaths caused by violence or severe physical abuse are more likely recognised as child abuse deaths,[7] while deaths related to neglect/omission of care – including abandonment or those resulting in drowning, poisoning and fire injury – are more likely to remain undetected.[7] Furthermore, deaths in infancy due to asphyxiation from smothering or overlaying (accidental smothering of the child by a larger person lying on them, e.g. in crowded beds) are easily misclassified as sudden infant death syndrome (SIDS), with 10% of SIDS deaths shown to be infanticide.[8]

Child death review (CDR) teams have been implemented in high-income countries to address the poor identification of child maltreatment deaths to develop policy and interventions to prevent such deaths.[9] CDR teams aim to review each child death using a public health framework to identify factors to prevent future child deaths. These CDR processes collate comprehensive data for each child death. Viewed as a sentinel event, each suggests potential modifiable factors to inform recommendations for improvement of the health and child protection system.[10] The efficacy of CDR teams is the result of its multidisciplinary nature, consisting of a forensic pathologist, investigating officer, child protection worker (social worker), prosecutor and paediatrician as the core team who meet regularly to share case-specific information on the circumstances surrounding each child death.[11] Over the last three decades, CDR processes have evolved in high-income countries, with variation across countries, but most have adopted a prospective rapid response approach for all unexpected child deaths to understand the clinical causes and contributing factors.[10] Based on gaps identified by the child homicide study and a review of international practices to manage child deaths, a CDR process was identified as best practice for strengthening responses.[12] This article draws on the SA CDR pilot study to explore its use in improved identification of child abuse- and neglect-related deaths and the implications for practice.

The child death review pilot study – testing a multi-agency model

A CDR pilot study was initiated in 2014 at Salt River Mortuary, Western Cape, and Phoenix Mortuary, KwaZulu-Natal, SA. CDR teams were established at both pilot sites and all child deaths from 1 January to 31 December 2014 were reviewed. The formation of

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these multi-agency teams was based on services available in the district and the responsibility of agencies to manage child health and child abuse. Development and co-ordination of the teams were key. This process was led by the Children’s Institute, University of Cape Town, which facilitated the process of identifying and meeting with relevant government agencies and non-governmental services operating in the two districts. This allowed for buy-in into the concept and identification of core team members from the relevant sectors to participate in the process. Participation by CDR team members was voluntary, but based on the agency mandate to focus on child health or protection. This pilot study was modelled on the international multiagency approach.[10] It aimed to facilitate a co-ordinated response between police, forensic pathology services, prosecution authorities, paediatricians and social services in the management of all child deaths. Two pilot sites were selected based on an interest from the forensic pathologists, the difference in size of the mortuaries and the diversity of the catchment districts. Forensic pathologists play the lead role in the review process, as they identify the cases presenting to the mortuary on a monthly basis and prepare the cause of death data and the known social circumstances information for the monthly CDR meetings. Confidentiality is key; therefore, all shared information is anonymised. Team members all signed a confidentiality agreement, as most cases are still undergoing legal investigation that should not be compromised through this process. Moreover, families are at the centre of the investigation and distressed by the death of their child. The CDR sample included all children admitted to the mortuaries in terms of the Regulations (No. R636) to the National Health Act 61 of 2003.[13] This definition of unnatural death includes all sudden and unexpected deaths. Although the CDR pilot study’s overarching goal tested the efficacy of CDR teams in the SA setting to identify gaps in health and social services to prevent future child deaths, a particular focus was to improve the identification of fatal child abuse cases. The multi-agency approach promoted a prospective rapid response investigation into suspected child abuse and neglect, as all roleplayers are involved in the case discussion to facilitate an appropriate medicolegal investigation. The review process adopted a social autopsy approach, where the social contributors to a child’s death are discussed alongside the medical cause of death.[14]

Overview of the CDR process steps

• Team discussion to clarify all case information: initially the forensic pathologist leads the discussion on the autopsy findings and cause of death. • Clarify the events that led to the death: forensic officer’s report, crime scene investigation report and police investigation report provide the team with a fuller picture to match the forensic examination with the child’s death circumstances. • Identify whether additional information is required: social contributors to the deaths are discussed alongside the medical cause to determine whether further investigation is required. • Establish whether the death was avoidable: this decision is taken once all the information is brought to the CDR meeting. • Identify potential preventable or remedial factors: the team decides on further action based on the outcome of the full discussion.

What have we learnt?

We reviewed 707 cases, with 52.4% of the deaths due to natural causes (Table 1). This was followed by accidental deaths (25.6%) and murder (15.5%). Deaths in the <1-year age group were mainly due to natural causes (81.7%), whereas accidents were highest (71.9%)

in the 5 - 9-year-old group. Murder and suicide were highest among 15 - 17-year-olds. Table 2 shows type of violence by demographic and murder characteristics. Overall, there were more male (64.8%) than female (33.1%) deaths. Over half (60.4%) of girls were killed in the context of child abuse compared with 33.3% of males. Neglect-related deaths were more common among males (60.1%) than females (39.4%). Non-abuse murders mainly occurred in males (91.8%). Most (60.4%) child abuse-related deaths occurred in the <1-year age group. Similarly, neglect-related deaths were most common in the <1-year age group (60.1%), followed by the 1 - 4-year age group (27.7%). Older boys in the 15 - 17-year age group were most likely (83.6%) to be victims of non-abuse-related murder. Overall, most children were killed in public spaces (47.2%) or the victim’s home (33.8%). Child abuse (40.4%) and neglect deaths (72.7%) were more likely to occur at home than non-abuse murder (74.2%) in public spaces. Gunshots (22.5%) and stab wounds (21.8%) were the most common causes of death in non-abuse murders. Abandonment at birth was the most common cause of abuse- and neglect-related deaths (37.5%), followed by blunt force injury (14.6%) and strangulation/ asphyxiation (14.6%) deaths. There were 8 cases of rape homicide of girl children; 1 each in the 1 - 4-year and 5 - 9-year age groups; and 3 each in the 10 - 14-year and 15 - 17-year age groups (data not presented). Lower-respiratory tract infection was most common (39.4%) in neglect-related deaths.

What are the implications for practice?

The CDR process reviews all cases of child deaths admitted to the Forensic Pathology Service (FPS). The regulations define unnatural death (requiring referral to the FPS) as any death due to physical or chemical influence, direct or indirect, or related complications; any death, including those which would normally be considered to be due to natural causes, which in the opinion of a medical practitioner, has been the result of an act of commission or omission, which may be criminal in nature; and where the death is sudden and unexpected, or unexplained, or where the cause of death is not apparent.[13] It is suspected that not all sudden, unexpected or unexplained deaths are referred to the FPS. This could account for the difference seen in our results between the two sites in terms of the numbers of ‘natural’ cases admitted (Salt River – 60.6%, Phoenix – 27.6%),[15] which were mainly in the younger age groups. Most cases admitted under the category of sudden, unexplained and unexpected are reclassified into natural cases on postmortem examination. The extent of the postmortem examination is at the discretion of the examining forensic practitioner following national guidelines, and may not include a full autopsy. However, in such cases, especially in the younger age groups, a concealed homicide or accidental overlaying may be missed by a clinician who completes a death notification form as a natural cause of death without referring the case to the FPS for further investigation. This has been highlighted previously, where infant deaths caused by asphyxiation from smothering or overlaying are potentially misclassified and remain undetected.[7,8] The importance of referrals of sudden unexpected death in infants (SUDI) and interconnections with possible omission of care or neglect by a caregiver were highlighted by the CDR pilot study. We referred 50 SUDI cases for further investigation and support to the Department of Social Services to investigate the social circumstances, in particular the care that children received before their death; 33 cases were confirmed as neglect. In one case an 8-month-old baby presented at the mortuary as a SUDI. At autopsy the cause of death was gastro-

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Table 1. Proportion of child deaths by age and manner of death Manner of death

<1 year (n=374), %

1 - 4 years (n=105), %

5 - 9 years (n=57), %

10 - 14 years (n=63), %

15 - 17 years (n=108), %

Total (N=707), %

Accidental Murder* Natural Suicide Undetermined

6.0 7.1 81.7 0.0 5.9

53.9 6.7 37.5 0.0 3.8

71.9 3.5 19.3 3.5 3.3

54.0 23.8 11.1 9.5 1.8

26.9 52.8 6.5 12.0 1.9

25.6 15.5 52.4 3.0 4.5

*Neglect-related deaths were not included as part of murder.

Table 2. Type of violence v. children by category Category

Child abuse-related murder (n=48)

Neglect-related deaths (n=33)

Non-abuse-related murder (n=61)

Total (N=142)

Gender (%) Male Female Unknown

33.3 60.4 6.3

60.1 39.4 0.0

91.8 8.2 0.0

64.8 33.1 2.1

Age (years), % <1 1-4 5-9 10 - 14 15 - 17

60.4 10.4 4.2 12.5 12.5

60.1 27.7 9.1 3.0 0.0

0.0 1.6 0.0 14.8 83.6

34.5 10.6 3.5 11.3 40.1

Scene of death (%) Home Other home Public space Hospital/clinic Place unknown

40.4 4.3 38.3 12.8 4.3

72.7 3.0 9.1 15.2 0.0

8.1 9.7 74.2 4.8 3.2

33.8 6.3 47.2 9.9 2.8

Cause of death (n) Blunt force Burns Abandonment/concealment Diarrhoeal disease Drowning Lower-respiratory tract infection Malnutrition Multiple injuries Poisoning Road traffic accident Septicaemia/infection Gunshot Stab Strangulation/asphyxiation Train accident Undetermined

14.6 2.1 37.5 0.0 4.2 0.0 0.0 10.4 4.2 0.0 0.0 4.2 8.3 14.6 0.0 0.0

0.0 6.1 0.0 9.1 3.0 39.4 6.1 0.0 0.0 6.1 9.1 0.0 0.0 0.0 3.0 18.2

6.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 49.2 44.3 0.0 0.0 0.0

7.8 2.1 12.7 2.1 2.1 9.6 1.4 3.5 1.4 1.4 2.1 22.5 21.8 4.93 0.7 4.2

enteritis and severe dehydration in a child with features of fetal alcohol syndrome, who was underweight for age. The CDR process revealed that the child had not been attended to at the local child health clinic for immunisation and no medical assistance was sought prior to his death, although he was ill for a few days. Based on these indicators of possible neglect, the case was referred to the child protection agency (CPA) for an investigation into the child’s home circumstances. This investigation revealed referral to the CPA for the mother’s alcohol abuse and questionable care of her children 6 years

previously. It was established that two other child deaths occurred during the CPA’s ‘care’. The two remaining children were removed from the mother by means of a children’s court enquiry. This case highlights the need to adopt a multi-agency approach to information gathering and response to prevent further deaths of children. Critically, the forensic pathologist reports suspected nonaccidental injury deaths to the police by completing Form 22, which serves as a reporting form to the Department of Social Development. The Children’s Act No. 38 of 2005 obliges medical practitioners to

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report suspected abuse (or a reasonable suspicion of abuse or neglect) by completing Form 22 when the child is admitted to a health facility and submitting it to the Department of Social Development or a designated child protection organisation.[16] The CDR team discussion facilitated a process that allowed team decisions to be made regarding suspected fatal abuse and neglect, thereby providing the clinician with a support system to deliberate difficult cases and relieve the burden of making such decisions alone. Another apparent difference in practice between the two sites highlighted by this study, and noted in a previous study,[17] is the performance of a full v. a partial v. no autopsy in infants. Salt River Mortuary admitted 322 infants, where 48.8% underwent a full or partial autopsy, whereas Phoenix Mortuary admitted 52 infants, 98% of whom underwent a full or partial autopsy. The volume of cases admitted, the availability of a good history, and the routine availability of a Lodox Xmplar-dr X-ray system (Lodox, SA) at the Salt River Mortuary may account for the difference in practice. This difference may raise concerns at the possible over- or underdiagnosing of deaths owing to lower-respiratory tract infection in infants, but the high proportion of deaths due to lower-respiratory tract infection is consistent with international reports.[17]

Discussion

The pattern of child abuse-related deaths in this study is similar to that reported by the national child homicide study.[2] Child abuseand neglect-related deaths were most common in the under-5 age group, but the CDR pilot study identified an increase in the number of neglect-related deaths.[2] The CDR process, through its detailed inquiry into the social contributors alongside the medical cause of death, allowed for more accurate identification of contributing circumstances. We have shown that the multi-agency approach to the review of child deaths facilitates a comprehensive process of enquiry by means of a review of biological and social factors and service delivery elements.[18] The cause of death (biological factor) on its own in a SUDI cannot provide the full picture of the circumstances leading to the death. The road-to-health chart, supporting health data and information about the social circumstances provide an enhanced understanding of the context in which children are dying in SA. The variance in referral patterns at the two sites regarding ‘natural’ cases is worrying, and awareness needs to be created with medical colleagues and communities of the definition of an unnatural death, specifically the sudden, unexpected and unexplained deaths that must be referred to the FPS for medicolegal investigation. This practice may extend beyond the two sites and be a provincial occurrence, as the referral of sudden, unexpected and unexplained deaths to all the facilities in the Western Cape in this age group is fairly consistent. A concern is the potential for child homicides, in particular neglect-related deaths, to remain undetected and result in further deaths. The pattern of child abuse-related deaths reveals the high rate of fatal child abuse, particularly among infants. The rate of infanticide in SA is estimated to be among the highest reported rates globally,

at 28.4/100 000 live births,[1] only surpassing a reported rate for Dar es Salaam, Tanzania.[19] Abandonment and injury deaths of infants were found to be common immediately after birth. This suggests a large number of unwanted pregnancies, which is surprising in a country where contraception is readily available and termination of pregnancy should be accessible during the first trimester. This points to the need for reproductive health services to integrate a mental health component (and vice versa) to identify at-risk mothers perinatally for the provision of support services and home-visiting programmes to reduce the risk of such deaths. The levels of child abuse- and neglect-related deaths found in this pilot study reflect the endemic nature of child maltreatment in SA, with fatal child abuse conceptualised as the extreme part of the continuum of violence against children.[1] The first national prevalence study on child abuse confirms excessive rates of child maltreatment, with one-third of children reporting experiences of sexual and/or physical abuse during childhood.[20] The insidious nature of violence against children highlights the need to prioritise prevention efforts to break the cycle of child maltreatment, particularly in the home. We have to initiate innovating approaches to prevention by exploring what is effective in similar settings to start shifting the pattern of violence against children. 1. Abrahams N, Mathews S, Martin LJ, Lombard C, Nannan N, Jewkes R. Gender differences in homicide of neonates, infants, and children under 5 y in South Africa: Results from the Cross-Sectional 2009 National Child Homicide Study. PLoS Med 2016;13(4):e1002003. http://dx.doi.org/10.1371/journal. pmed.100200321 2. Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C. The epidemiology of child homicides in South Africa. Bull World Health Organ 2013;91(8):562-568. http://dx.doi.org/10.2471/BLT.12.117036 3. Pinhiero P. World Report on Violence against Children. Geneva: United Nations, 2006. 4. Mathews S, Abrahams N, Jewkes R, Martin LJ. Underreporting child abuse deaths: Experiences from a national study on child homicide. S Afr Med J 2013;103(30:132-133. http://dx.doi.org/10.7196/SAMJ.6724 5. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;3;373(9657):68-81. http://dx.doi.org/10.1016/ S0140-6736(08)61706-7 6. Schnitzer PG, Covington TM, Wirtz SJ, Verhoek-Oftedahl W, Palusci VJ. Public health surveillance of fatal child maltreatment: Analysis of 3 state programs. Am J Public Health 2008;98(2):296-303. http:// dx.doi.org/10.2105/AJPH.2006.087783 7. Crume TL, DiGuiseppi C, Byers T, Sirotnak AP, Garrett CJ. Underascertainment of child maltreatment fatalities by death certificates, 1990 - 1998. Pediatrics 2002;110(2):e18. http://dx.doi.org/10.1542/peds.110.2.e18 8. Levene S, Bacon CJ. Sudden unexpected death and covert homicide in infancy. Arch Dis Child 2004;89:443-447. http://dx.doi.org/10.1136/adc.2003.036202 9. Shanley JR, Risch EC, Bonner BL. US Child Death Review Programs. Am J Prev Med 2010;39(6):522528. http://dx.doi.org/10.1016/j.amepre.2010.08.010 10. Fraser J, Sidebotham P, Frederick J, Covington T, Mitchell EA. Learning from child death review in the USA, England, Australia, and New Zealand. Lancet 2014;384(9946):894-903. http://dx.doi. org/10.1016/S0140-6736(13)61089-2 11. Christian CW, Sege RD. Child fatality review. Pediatrics 2010;126(3):592-596. http://dx.doi. org/10.1542/peds.2010-2006 12. Mathews S, Abrahams N, Martin LJ. Child Deaths Reviews in the Context of Child Abuse Fatalities – Learning from International Practice. Cape Town: Children’s Institute, University of Cape Town, 2013. 13. South Africa. National Health Act of 2003. Regulations: Rendering of forensic pathology services. Government Gazette No. 30075, 2007. (Published under Government Notice R636.) 14. Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: A comprehensive literature review to examine the concept and the development of the method. Popul Health Metr 2011;9:45. http://dx.doi.org/10.1186/1478-7954-9-45 15. Mathews S, Martin LJ, Coetzee D, et al. The South African child death review pilot: A multi-agency approach to strengthen healthcare and protection for children. S Afr Med J 2016;106(9):895-889. http:// dx.doi.org/10.7196/SAMJ.2016.v106i9.11234 16. South Africa. Children’s Act No. 38 of 2005. 17. Groenewald P, Bradshaw D, Neethling I, et al. Linking mortuary data improves vital statistics on cause of death of children under five years in the Western Cape Province of South Africa. Trop Med Int Health 2016;21(1):114-121. 18. Sidebotham P, Fraser J, Covington T, et al. Understanding why children die in high-income countries. Lancet 2014;384(9946):915-927. http://dx.doi.org/10.1111/tmi.12624 19. Outwater AH, Mgaya E, Campbell JC, Becker S, Kinabo L, Menick DM. Homicide of children in Dar es Salaam, Tanzania. East Afr J Public Health 2010;7(4):345-349. http://dx.doi.org/10.4314/eajph. v7i4.64758 20. Burton P, Ward C, Artz L, Leoschut L. The Optimus Study on Child Abuse, Violence and Neglect in South Africa. Cape Town: UBS Optimus Foundation, 2015.

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CME

Maternal mental health and the first 1 000 days R E Turner, MSc, Postgraduate Diploma in Montoring and Evaluation; S Honikman, MB ChB, MPhil Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: R E Turner (roseanne.turner@uct.ac.za)

Even though maternal mental health receives low priority in healthcare, it is a vital component for the developing fetus and the raising of healthy children who are able to contribute meaningfully to society. This article explores risk factors for common mental illnesses and treatment options available in under-resourced settings. S Afr Med J 2016;106(12):1164-1167. DOI:10.7196/SAMJ.2016.v106i12.12129

The first 1 000 days of a child’s life have been identified as a period of substantial vulnerability, which also carries the potential for lifelong health, prevention of disease and intellectual development. These 1 000 days, which start at conception and continue to the end of the child’s 2nd year, have become the target area for many public health interventions that focus on nutrition, early childhood development and maternal physical health and mental wellbeing. Common mental disorders (CMDs) include depression and the anxiety disorders. Some scholars and practitioners also include alcohol and substance use disorders in this group. The CMDs are distinguished from psychotic disorders, because in CMDs there is no loss of contact with reality, and there are no delusions or hallucinations. CMDs affect thoughts, feelings and behaviours over a period of time and have an associated effect on functioning in the home, relationships, community, work or school. Living with a CMD is debilitating for those who are affected. In South Africa (SA), where there is limited focus on mental health, an estimated 20 - 25% of those in need of help have access to adequate treatment and healthcare for their mental health needs.[1,2] This treatment gap between those in need and those who receive treatment relates to shortages of mental health workers, lack of public awareness about possibilities for improvement and recovery, and stigma and discrimination against people suffering from mental health problems. This prevents individuals from seeking help, even where services are available and accessible.[3] CMDs during the first 1 000 days of a child’s life are of particular concern because of the disabling effects on the mother’s ability to function, and the possible negative physical and developmental effects on the fetus and infant.[4]

Risk factors for poor maternal mental health

A previous history of mental illness is one of the strongest risk factors for CMDs during pregnancy.[5] In SA, where there is a large treatment gap, this risk is usually unknown. Other factors that increase the likelihood of women developing a CMD during and after pregnancy are social rather than biological, and these are exacerbated by poverty. Lack of social support, including emotional and financial support from partner, friends or community, intimate partner violence, an unintended or unwanted pregnancy, low levels of education, adolescent pregnancy, and alcohol and substance use comprise key risk factors.[6] Women living in poverty may encounter food

insecurity, which carries other risks for the developing fetus. These and other risk factors are highlighted below. Maternal mental disorders often result in lower uptake of available services by mothers. This is a result of several factors, including a compromised ability to plan effectively, together with low levels of energy and motivation and fear of discrimination. Decreased access to care, in turn, leads to adverse maternal and child outcomes, which further add to levels of stress and consequently increase mental health problems. Similar vicious cycles of escalation exist between many risk factors and mental health problems, as can be seen in Fig. 1.

Poverty

It is important for SA healthcare workers to be aware of the povertymental illness cycle documented in low- and middle-income countries.[1] There is an increased risk of mental illness for those living in poverty, and an increased likelihood that those suffering from a mental illness will drift into or remain in poverty. The driving forces for this cycle are complex and include factors such as additional stresses of unemployment, poor housing and food insecurity. Furthermore, women living in poverty are more likely to have low educational levels and thus are unlikely to be able to generate adequate income, if they do find work. Women with CMDs are also more likely to experience stigma and social isolation and are prone to develop physical conditions and symptoms. Therefore, in addition to being more likely to spend time away from work, thereby losing income-generating potential, it is more probable that they will spend time and money on healthcare.[2] Adverse maternal outcomes

Poverty HIV status Violence Lack of support

Maternal mental illness

Poor uptake of services

Migrancy Substance abuse

Teen pregnancy

Fig. 1. Risk factors for maternal mental health problems.

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Adverse child outcomes

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HIV status

Many women learn about their HIV status during pregnancy. A positive result can have a significant impact on a woman’s mental health. In SA, the prevalence of any diagnosable mental disorder among people living with HIV/AIDS is 43.7%, which is significantly higher than the rate of 30.3% in the general population.[7,8] Depression is associated with lowered adherence to antiretroviral medication and poor use of antenatal care and prevention of mother-to-child transmission (PMTCT) programmes.[9] Mental illness is a significant factor in AIDS-related mortality among women.[10] Local research has shown that HIV-positive women are more likely to experience abuse, and those who are abused, are more probable to contract HIV.[11]

Violence

SA has one of the highest rates of gender-based violence in the world. In addition, local research has shown that abuse and violence tend to increase during pregnancy, with the severity increasing as the pregnancy progresses. Abuse during pregnancy contributes to pregnancy complications and miscarriages.[11] The mental health sequelae of gender-based violence include substance misuse and CMDs, such as post-traumatic stress disorder, depression and suicidality. In addition to violence resulting in CMDs, those with mental health problems are also more vulnerable to experiencing domestic and gender-based violence.

Adolescents

Pregnant teenagers experience higher rates of depression than pregnant adults.[12] Teenage mothers with untreated depression have a far greater likelihood of having a second pregnancy within 2 years.[13] Mental disorders in teenagers are more likely to persist throughout adulthood. Maternal mortality data in SA show high rates of suicide in women <20 years of age and during their first pregnancy. Teenage mothers with a CMD are also less likely to complete their education, and more likely to engage in risky sexual behaviour. Teenage mothers are less likely to attend prenatal care, which increases the pregnancy risk in this age group. Also, there is a greater risk of pre-eclampsia and risks associated with a small bony pelvis.[14,15] Another factor that impacts on their children is that teens are likely to develop harsh parenting styles, which are associated with an increased risk for child mental health disorders.[16,17]

Refugees and migrants

CMDs are more prevalent in refugee women, who frequently experience extreme trauma, violence, rape and loss of loved ones when they flee from their countries. In cases of language differences, and a mistrust of others developed through the experience of war and oppression, refugee women may find it difficult to make friends and they have little support – all strong risk factors for developing CMDs.[18]

Mental ill-health in the perinatal period

crying for no apparent reason, and feeling impatient, unusually irritable, restless, anxious, overwhelmed, inadequate, lonely and sad. These symptoms last from a few hours to 2 weeks after delivery, and usually resolve with compassionate support. About one-fifth of women with baby blues go on to develop depression.

Depression

Depression or a major depressive episode is characterised by low mood, loss of interest and enjoyment, and reduced energy for at least 2 - 4 weeks. Common symptoms of depression also include: • extreme sadness, tearfulness • difficulty in concentrating, forgetfulness • disturbed appetite or sleep (too much or too little) • thoughts of worthlessness (low self-esteem) • feelings of guilt • helplessness, hopelessness • irritability • extreme tiredness • loss of sex drive • many physical symptoms, such as body aches and pains • ideas or attempts of self-harm or suicide.

Anxiety

Anxiety is characterised by an abnormal and great sense of uneasiness, worry or fear. The symptoms of anxiety are normal in the presence of a real threat. However, when someone suffers from these symptoms in response to ordinary events, and the symptoms interfere with daily tasks, then they may have an anxiety disorder. Symptoms of anxiety include emotional symptoms, such as: • nervousness • worry • panic • irritability • feelings of dread • tiredness • fear of being alone or with others • difficulty concentrating. Anxiety also results in physical symptoms, which include: • sleep disturbance • physical tension • sweating • increased pulse • muscle tightness • body aches or gastrointestinal problems (e.g. nausea, diarrhoea).

It is important to note that baby blues, which commonly occurs in the early postnatal phase, is not a mental health disorder. Postnatal psychosis, which occurs in 0.02% of births, is not a CMD, but a psychotic disorder.

A careful history may be required to distinguish the typical physical symptoms of pregnancy from those of anxiety. Furthermore, it is important to note that depression and anxiety often coexist and that there is substantial overlap of symptoms.

Baby blues

Postpartum psychosis

Baby blues is not a common mental disorder but rather a temporary psychological state occurring in 50 - 80% of mothers. It usually starts on the 3rd day after delivery and is linked to hormonal changes. It involves sudden mood swings (feeling very happy, then very sad),

In contrast to the conditions described above, postpartum psychosis is a psychotic disorder – a severe mental condition that results in abnormal thinking and perceptions. People with psychoses are out of touch with reality. Two of the main symptoms of psychosis

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are delusions and hallucinations. The management of psychosis depends on the type of disorder and is fortunately relatively rare. However, in the postnatal period, the development of psychotic symptoms may be more rapid than at other times and there are greater associated risks of harm. Therefore, referral to specialist mental healthcare is urgent in these cases. Postnatal psychosis occurs in 2:1 000 births, but women with a history of bipolar disorder are at a greatly increased risk.

Management of CMDs

Poor maternal mental health

Detection

Poor maternal mental health may have a profound and wide-reaching effect on mothers, pregnancy and children.

Effect on the neonate and pregnancy outcomes

Untreated maternal anxiety may cause hormonal alterations in the intrauterine environment that have persistent implications for the physical, cognitive and emotional development of the child. The following occur in pregnant women with common mental disorders: • a higher incidence of miscarriage • a higher risk of bleeding during pregnancy • higher rates of caesarean section delivery • higher rates of preterm delivery • prolonged labour • low-birth-weight babies (a primary cause of infant mortality and morbidity).

Effect on the child

Mothers with a CMD are more likely to have impaired bonding with their infants, which may result in breastfeeding problems. These mothers are more probable to discontinue breastfeeding early. The emotional and psychological development of the child may also be significantly impacted when the mother has mental health problems. Children have a higher risk of developing the following: • conduct problems • attention deficit hyperactivity disorder • anxiety symptoms • child antisocial personality traits. Research shows that later in life, children of depressed mothers are also more likely to be abused, to perform poorly at school and to develop mental illness. Fathers and others who provide maternal support play an important buffering role in reducing the effects of CMDs on children. It should, however, be remembered that fathers may develop paternal depression, which is also associated with adverse child outcomes.

Effect on mothers

With regard to the wellbeing of the mother, studies show that CMDs result in the following: • an increased likelihood of mothers ‘self-medicating’ with alcohol or drugs • reduced sleep and appetite • poor antenatal weight gain • increased probability of maternal mortality. Studies in developed countries have shown that suicide is a leading cause of maternal mortality, with higher rates of suicide in women <20 years old and in their first pregnancy. In addition, if left undiagnosed and untreated, mental illness can increase a woman’s risk of HIV infection, violence and abuse, economic insecurity, and subsequent unintended pregnancy.

Management of CMDs should be based on the following principles: • detection • empathic care • psycho-education • early treatment • holistic management • suicide risk assessment.

Ideally, every woman should be screened several times during pregnancy and in the first years postpartum, when she engages with health or social services. As this is not always possible, care should be taken to screen women at least once during and after pregnancy. A combination of risk factor screening and symptom screening is recommended. Attempts are being made to include screening questions into standardised stationery. There are several screening tools available for common mental problems. The most commonly used tools are: • The Whooley depression screen (two yes/no items plus an item on whether help is desired).[19] • The Edinburgh postnatal depression scale (EPDS) (10 multiplechoice items).[20] These tools have been validated for use in the SA setting. It is important to note that these screening tools are not diagnostic. Further assessment by a qualified practitioner may be required for a diagnosis.

Empathic care

Empathic care should form the basis for all communication with all women during the perinatal period. It includes creating a safe, caring space, active listening to understand her problems, and empowering the mother by assisting her to find her own solutions. Not every woman needs to be referred for specialist care. Many respond positively to empathic care provided by general health workers. Women may be offered practical strategies for reducing stress, which include mindfulness-based interventions, breathing exercises and guided imagery.

Psycho-education

Psycho-education involves informing the woman about her mental health status in non-technical and understandable terms, and includes the management options available. When appropriate, it is important that she understands that her feelings and responses to the difficult situation are part of an accepted range of emotional experiences. Where a women has a mental illness, it is helpful to emphasise that the illness is not her fault or a result of any personal weakness. Further, it should be stressed that recovery or improvement of symptoms and functioning is highly probable with appropriate management and follow-up.

Early treatment

Women with CMDs need to be treated as early as possible to reduce the consequences described above and the risk of suicide. Women with a history of CMDs may need to be treated prophylactically. The first line of treatment for mild to moderate CMDs would be use of one of the talking therapies. There are several types of evidence-based talking therapies that have shown benefit for people with CMDs, including women in the perinatal period. These include problemsolving therapy, cognitive behavioural therapy and interpersonal therapy. Research has demonstrated that lay health workers, well

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trained and supervised, may successfully provide these therapies. For women with moderate to severe CMDs or those who do not adequately respond to talking therapy, medication or more specialised care may be warranted. Antidepressants, especially selective serotonin re-uptake inhibitors (SSRIs), have been found to be generally safer than the possible risks to the fetus and breastfeeding infant of a mother with untreated CMDs.[21] Women who are stable on antidepressant medication when they become pregnant should continue on the medication as before, as switching types or discontinuing medication may cause serious relapse. Those who develop a CMD can safely be commenced on an antidepressant. Care should be taken when SSRIs are introduced, as these may initially increase the risk of suicide. There are limited data on the safety of tricyclic antidepressants on the fetus, as an overdose may be lethal. They lead to increased sedation compared with the SSRIs, but have the benefit of not causing agitation when started. Antidepressants treat both depression and anxiety. Sulpiride (Eglonyl), which is commonly used to improve breastfeeding in agitated and distressed mothers, should usually be avoided, as it increases the risk of suicide in some women and does not treat the underlying depression.

Holistic management

It is important that women be managed as holistically as possible. This includes management of underlying causes or factors that exacerbate CMDs. It may be critical to arrange careful referrals to social services, appropriate non-governmental organisations and community-based services. Food security and physical security need to be prioritised. Linking vulnerable women with supportive social networks may be extremely valuable. Follow-up and case management will support uptake of care and recovery. Although this work may be time consuming initially, it is a useful investment in the long-term physical and mental health outcomes for both mothers and their offspring. Further, birth companionship has been shown in several clinical trials to have a wide range of physical and mental health benefits.

Conclusion

Common mental disorders in the perinatal period affect 20 - 40% of women in SA. This may be due to the multiple risk factors facing

women in this country, especially those living in poverty and with violence. Ideally, all antenatal clinics should screen for CMD and provide integrated care to pregnant women. CMDs can be detected and effectively managed, thereby reducing a large range of possible adverse consequences for mothers, their children and their family. 1. Lund C, Breen A, Flisher AJ, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med 2010;71(3):517-28. http://dx.doi.org/10.1016/j. socscimed.2010.04.027 2. Lund C, de Silva M, Plagerson S, et al. Poverty and mental disorders: Breaking the cycle in lowincome and middle-income countries. Lancet 2011;378(9801):1502-1514. http://dx.doi.org/10.1016/ S0140-6736(11)60754-X 3. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet 2007;370(9590):878-889. http://dx.doi.org/10.1016/S0140-6736(07)61239-2 4. Stein A, Pearson RM, Rapa E, et al. Effects of perinatal mental disorders on the fetus and child. Lancet 2016;384(9956):1800-1819. http://dx.doi.org/10.1016/S0140-6736(14)61277-0 5. Fisher J, Cabral de Mello M, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bull World Health Organ 2012;90(2):139-149G. http://dx.doi.org/10.2471/BLT.11.091850 6. Van Heyningen T, Myer L, Onah M, Tomlinson M, Field S, Honikman S. Antenatal depression and adversity in urban South Africa. J Affect Dis 2016;203:121-129. http://dx.doi.org/10.1016/j. jad.2016.05.052 7. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR. The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J 2009;99(5):339-344. 8. Freeman M, Nkomo N, Kafaar Z, Kelly K. Mental disorder in people living with HIV/AIDS in South Africa. S Afr J Psychol 2008;38(3):489-500. http://dx.doi.org/10.1177/008124630803800304 9. Rochat TJ, Richter LM, Doll HA, Buthelezi NP, Tomkins A, Stein A. Depression among pregnant rural South African women undergoing HIV testing. JAMA 2006;295(12):1376-1378. http://dx.doi. org/10.1001/jama.295.12.1376 10. Cook JA, Grey D, Burke J, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health 2004;94(7):1133-1140. http://dx.doi.org/10.2105/ ajph.94.7.1133 11. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004;363(9419):1415-1421. http://dx.doi.org/10.1016/s0140-6736(04)16098-4 12. Barnet B, Joffe A, Duggan AK, Wilson MD, Repke JT. Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Arch Pediatr Adolesc Med 1996;150(1):64-69. http://dx.doi. org/10.1001/archpedi.1996.02170260068011 13. Barnet B, Liu J, deVoe M. Double jeopardy: Depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Arch Pediatr Adolesc Med 2008;162(3):246-252. http://dx.doi.org/10.1001/ archpediatrics.2007.60 14. Hodgkinson SC, Colantuoni E, Roberts D, et al. Depressive symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc Gynecol 2010;23(1):16-22. http://dx.doi.org/10.1016/j.jpag.2009.04.006 15. Block RW, Saltzman S, Block SA. Teenage pregnancy: A review. Adv Pediatr 1981;28:75-98. 16. Siegel RS, Brandon AR. Adolescents, preganancy and mental health. Pediatr Adolesc Gynecol 2014;27(3):138-150. http://dx.doi.org/10.1016/j.jpag.2013.09.008 17. Yookyong L. Early motherhood and harsh parenting: The role of human, social, and cultural capital. Child Abuse Neglect 2009;33(9):625-637. http://dx.doi.org/10.1016/j.chiabu.2009.02.007 18. Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: General approach in primary care. Can Med Assoc J 2011;183(12):E195-E165. http://dx.doi. org/10.1503/cmaj.090292 19. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are as good as many. J Gen Intern Med 1997;12(7):1525-1497. http://dx.doi.org/10.1046/ j.1525-1497.1997.00076.x 20. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh postnatal depression scale. Br J Psych 1987;150(6):782-786. http://dx.doi.org/10.1192/ bjp.150.6.782 21. Du Toit E, Thomas E, Koen L, et al. SSRI use in pregnancy: Evaluating the risks and benefits. S Afr J Psychiatry 2015;22(2):48-52. http://dx.doi.org/10.7196/SAJP587

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Using a child rights approach to strengthen prevention of violence against children L Lake, BA Hons; L Jamieson, BA Hons, MSocSci Children’s Institute, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: L Lake (lori.lake@uct.ac.za)

Violence against children is widespread in South Africa. Much of it remains hidden, and social services are thinly stretched. This article therefore focuses on children’s rights to protection and considers the implications for healthcare practice. Children’s rights can be considered both a ‘language of critique’ and a ‘language of possibility’ – encouraging us to evaluate current practice from a child-centred perspective and to re-imagine ways in which we deliver healthcare services. The article outlines the nature, extent and long-term effects of violence against children, introduces a framework for conceptualising violence prevention, and considers ways in which health professionals can better respond to cases of abuse and neglect, and prevent violence against children from taking place. S Afr Med J 2016;106(12):1168-1172. DOI:10.7196/SAMJ.2016.v106i12.12128

In March 2015, media attention focused on the rape and murder of two Cape Town teenagers – Franziska Blöchliger, who was attacked while running in the Tokai forest, and Sinoxolo Mafevuka, who was strangled to death in Khayelitsha. Their stories are brutal, tragic and shocking, but these are not isolated events. Violence against women and children is pervasive in South Africa (SA), cutting across class and race divides. Of the >62 000 sexual offences reported in 2013/14, one in every three victims was <18 years of age.[1] The abovementioned high-profile cases suggest that most instances of violence against children are committed by strangers. Yet, the findings of the 2009 child homicide study tell a different story: • Adolescent boys are five times more likely to be murdered than teenage girls, and most are killed by acquaintances in the context of interpersonal violence. • Nearly half (45%) of child homicides occurred in the context of child abuse and neglect: of these 36% were babies abandoned in the first week of life, and 74% were under 5 years of age. Most occurred in the home and the perpetrator (most often the mother) was known to the child.[2]

What kinds of violence do children experience in SA?

While homicide is the most extreme form of violence against children, community-based studies suggest that at least 55% of children have been physically abused by caregivers, teachers or relatives;[3] 35 - 45% have witnessed domestic violence;[4] and corporal punishment remains widespread, with nearly 58% of parents using physical punishment and 33% using a belt or stick.[5] A 2016 national prevalence study found that 1 in 3 children has been sexually abused.[6] Boys and girls are equally vulnerable, with girls more likely to experience forced and penetrative sex, and boys more likely to be exposed to sexual acts and pornographic material. Nearly a third were abused by a known adult. Only 33% sought assistance for their injuries – with boys least likely to tell anyone about sexual abuse.

Most violence against children remains hidden and unreported, and it mostly occurs in the home, where children are relatively powerless and dependent on adult support. Corporal punishment and intimate partner violence are widely tolerated, and in cases of sexual abuse, children are often groomed and/or threatened by the perpetrator. The family may blame the child and side with the perpetrator. Unsurprisingly, children often choose to remain silent, as they fear intimidation and not being taken seriously.[6]

How does this change across the life course?

Violence starts in the home where young children are most at risk of physical abuse, neglect and abandonment. At school, corporal punishment, bullying and sexual violence become more prevalent. Teenage boys are most at risk of interpersonal violence, while teenage girls are more likely to experience sexual and physical violence in the context of dating relationships;[7] >33% of teenage girls report forced sexual initiation.[8] Understanding how patterns of violence change across the life course enables the adoption of a proactive approach to violence prevention – intervening early before patterns of violence become entrenched (Fig. 1).

Male teenage violence 15 - ≥18 years

Dating violence 14 - ≥18 years Sexual abuse birth - ≥18 years Child abuse and neglect birth - 17 years Infanticide/ abandonment birth - 12 months

Fig. 1. Violence against children across the life course (from Mathews and Benvenuti,[7] with permission).

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What are the effects of violence on children?

The impact of violence extends beyond physical injury and has a cumulative and long-lasting effect on children’s cognitive and psychosocial development, including impaired attachment, failure to thrive, trauma, anxiety and depression, and aggressive, antisocial or self-destructive behaviour.[9] The cycle of violence is rooted in early childhood, where exposure to strong, frequent or long-lasting physical or emotional abuse, domestic violence, neglect, caregiver substance abuse, and mental illness results in ‘toxic stress’, causing neurological and psychological damage with longterm consequences for learning, behaviour, and physical and mental health.[10] Girls tend to internalise their experiences of violence, exhibiting signs of depression, anxiety and suicidality, while boys tend to externalise through risk-taking and aggressive behaviour. Exposure to violence increases the risk of re-victimisation or perpetration later in life: girls are at increased risk of sexual assault and intimate partner violence, while boys are more likely to become perpetrators.[11,12] The effects of violence extend into adulthood, where limited emotional control, substance abuse and violence may compromise relationships and parenting abilities.[12-14] It is therefore essential to intervene as early as possible to break the intergenerational cycle of violence.

How do we break the cycle of violence?

Efforts have traditionally focused on responding to incidents of violence, yet it is more effective – and less costly – to prevent children from getting hurt.[15,16] Prevention can occur before and after violence: • Primary prevention aims to prevent violence before it takes place (e.g. by building self-esteem and promoting positive forms of discipline). • Secondary prevention focuses on immediate responses to violence (e.g. ensuring the safety of the child and providing medical care). • Tertiary prevention includes short- and long-term interventions to reduce trauma and rehabilitate both child victims and offenders. In SA, the Children’s Act No. 38 of 2005[17] makes a similar, but different, distinction between prevention, early intervention, and child protection services, where: • Prevention focuses on strengthening the capacity of families to safeguard children’s wellbeing and best interests by promoting healthy non-violent relationships and assisting families to access essential services. • Early intervention offers targeted support to families at risk and includes therapeutic programmes, family preservation programmes and temporary safe care. • Child protection services investigate reports of child abuse and neglect, provide counselling and therapeutic services, and may place the child in temporary safe care. Yet, social work services in SA are under-resourced and overstretched, and budgets are focused on child protection rather than prevention and early intervention services.[18] A more proactive approach is needed, increasing investment in prevention services and exploring ways other sectors can strengthen and support children and families.

Identifying risk and protective factors

The causes of violence are complex and the chances of a child becoming either a victim or perpetrator are shaped by their personal history, close relationships, communities and broader society. The

Society

Community

Relationship

Individual

Fig. 2. The social-ecological model.

Centers for Disease Control and Prevention’s social-ecological model (Fig. 2) provides a useful framework, encouraging recognition of the complex interplay of risk and protective factors (Table 1) to inform prevention efforts.[19]

Adopting a rights-based approach

Children’s rights to protection are enshrined in the SA Constitution, African Charter on the Rights and Welfare of the Child, and United Nations (UN) Convention on the Rights of the Child. Section 12 of the Bill of Rights states that everyone has the right to be ‘free from all forms of violence’ and ‘not to be treated or punished in a cruel, inhuman or degrading way’, while Section 28 recognises ‘the right of every child to be protected from maltreatment, neglect, abuse or degradation’.[20] However, what does this mean in practice? The UN Committee on the Rights of the Child[21] issues general comments that provide guidance on how to interpret and give effect to children’s rights and evaluate progress. General Comment 13 focuses on the child’s right to freedom from violence and outlines key principles that should guide our approach to violence prevention. General Comment 13 highlights ways in which violence threatens children’s survival, health, development, and dignity. It also acknowledges how children’s access to social assistance, family and alternative care, education, healthcare and social services can be protective. Children’s rights are thus interdependent and indivisible. The General Comment calls for an holistic and co-ordinated approach to address multiple risk factors across a range of settings and to ‘overcome isolated, fragmented and reactive approaches to violence prevention’.[21] In particular, it calls for a paradigm shift in child care and protection that recognises children’s human dignity, individual personalities, distinct needs and interests. It recognises children’s agency and evolving capacities, and argues that ‘their empowerment and participation should be central to child caregiving and protection strategies and programmes’.[21] This is particularly pressing in the SA context, where children are often silenced and socialised to respect and obey adults without question, making them more vulnerable to abuse and exploitation, and reluctant to report abuse.

What are the implications for healthcare practice?

Health professionals have a vital role to play in violence prevention. Critical opportunities exist to support children and families across the life course, from early childhood to adolescence.

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Table 1. Common risk and protective factors* Risk factors

Protective factors

Individual

Alcohol and substance abuse Personal history of violence Mental illness

Strong attachment Healthy self-esteem Knowledge of protection against abuse

Relationship

Caregiver stress and depression Poor supervision of children Family conflict and domestic violence Substance abuse Inadequate support from friends/family

Family cohesion and support Sensitive, affectionate and positive parenting Healthy communication between caregiver and child Use of non-violent discipline

Community

Crime, gang and interpersonal violence Access to alcohol, drugs and weapons Poverty and unemployment Low community cohesion Limited support services

Strong community leadership Social support and cohesion Access to support services Positive activities for children and youth Responsive policing

Societal

Income inequality and social exclusion Social and cultural norms that justify violence Gender inequality Weak law enforcement

Strong legislative framework and political leadership Policies to regulate use of guns and alcohol Investment in prevention, early intervention and protection services Quality education and employment Media that promote positive role models, gender equality and alternatives to violence

*Adapted from Mathews and Benvenuti,[7] with permission.

Enable children’s participation

Children have a right to participate, and ensuring that they can express their views and are heard and taken seriously, assists with violence prevention. What can I do? • Make children feel welcome. • Build trust (by respecting children’s rights to privacy, confidentiality and physical integrity). • Provide information in a language and format that is child and youth friendly. • Encourage children to speak out and ask questions. • Listen carefully to their words and body language, and to what is said and left unspoken. • Take children seriously and recognise and respond to early warning signs. • Treat what they say with confidence, subject to statutory reporting obligations. • Ask, and receive permission, before touching. In other words, we need to build relationships of trust, facilitate open communication, take children seriously, and give them the confidence to speak out rather than enact blind obedience to adults in authority.[22]

Support caregivers of young children in the first 1 000 days

Early intervention can potentially break the cycle of violence. Sensitive and responsive caregiving has been found to prevent or reverse the damaging effects of toxic stress, helping children regulate their behaviour and emotions, and providing a solid foundation for future relationships and schooling. Furthermore, it is important to: reduce children’s exposure to abuse, conflict and violence; address

caregivers’ mental illness, including substance abuse; and alleviate extreme poverty.[23] The new National Integrated Policy on Early Childhood Development recognises the central role of caregivers and their need for support, especially in the first 1 000 days of life (from conception until the child’s 2nd birthday).[24] It also recognises how health services are often the primary if not the only point of contact with young children and families, and can serve as a critical gateway to other forms of support, such as social grants and social services. What can I do? Before the child is born: • Be supportive, not judgemental. • Screen for maternal mental health, substance abuse, domestic violence. Help women access support services. • Many pregnant women feel isolated and overwhelmed; therefore, encourage them to get the support they need from partners, friends and family.[25] After the child is born: • Take time to ask how mothers are doing, as their wellbeing is central to that of the child. • Observe mother-to-child interactions and promote warm responsive caregiving. • Look out for and respond to signs of maternal depression, domestic violence and harsh parenting. • Encourage the active involvement of fathers in maternal and child health and child care. • Support the call for a ban of corporal punishment. Enquire about positive discipline and share these techniques with your patients.[26] • Find out about social grants, child maintenance, training and income-generating programmes so that you know how to help families in need of financial support.

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Promote adolescent health and youth development

Adolescence is a period during which lifelong behaviour patterns are established. As a time of increased risk behaviour, it offers opportunities for support and intervention. Yet, adolescents complain of being treated with a lack of respect, privacy and confidentiality that compromises their access to healthcare services.[27,28] loveLife has spearheaded the development of adolescent- and youth-friendly clinics that aim to respond to these challenges. They have also extended their work beyond healthcare facilities, through their groundBREAKERs youth development programme that reaches out from their Y-centres to promote healthy lifestyles, while two tollfree helplines provide information, guidance and counselling in a safe and non-judgemental environment.[29] Moreover, it is important to work with parents as the UBS Optimus study found that parents’ knowledge of ‘who young people spend their time with, and how they spend their time and where they go’ can prevent child maltreatment, as do warm and supportive parentchild relationships.[6] What can I do? • Contact loveLife to find out how to develop a youth-friendly service. • Provide information about healthy relationships and local youth development programmes. • Encourage parents to remain involved and supportive. • Find out about programmes run by Sonke Gender Justice that work with boys and men to promote gender equality and prevent gender-based violence.

Identify other potentially vulnerable children

• Actively consider the wellbeing of children in contexts of domestic violence or substance abuse. Put systems in place to ensure their safety and protection. • Recognise that children with disabilities are particularly vulnerable to neglect and physical and sexual abuse in the home, community and institutional settings. Promote inclusion, address stigma and provide respite care and support for caregivers.[30] • Put plans in place to safeguard children when their primary caregiver is hospitalised, and ensure that your facility has a child protection policy to ensure the safety of child patients and provide clear guidelines for the reporting of child abuse.[6]

Respond to abuse and neglect

The Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007) makes reporting sexual offences mandatory for anyone who has ‘knowledge’ of a sexual offence committed against a child. This includes consensual sexual activities between a child <16 years of age and anyone >16 years old, where their age gap is >2 years (in 2015, the definitions of consensual sexual activities in the Sexual Offences Act were amended, which changed the nature of the offences of statutory rape and statutory sexual assault).[31] Particular care should be taken when reporting children for consensual sexual activities, as it may violate their rights and best interest.[32] Any child younger than 12 is considered too young to consent to sex, therefore any sexual act with a young child constitutes rape (if there is penetration) or sexual assault. In addition, the Children’s Act[17] obliges certain professionals to report if they ‘conclude on reasonable grounds’ that a child has been abused in a manner causing physical injury; sexually abused; or deliberately neglected; where their conclusion is based on the balance of probabilities following observation of signs and indicators. The reason for mandatory reporting is based on the assumption that children are relatively vulnerable and powerless in society and

less able to protect themselves. Persons such as health professionals, teachers, psychologists and social workers carry a higher duty of care owing to their professional ethical responsibilities and heightened positions of authority and credibility in society. If you report in good faith, but it turns out that the signs you observed were not the result of abuse, you cannot be prosecuted or sued in a civil court. However, if you do not report, you can be held accountable and face suspension by the Health Professions Council of SA, or be fined or imprisoned.[33] Both laws aim to protect the affected child and others from harm. However, the Children’s Act aims to link children and families with support services, while the objective of the Sexual Offences Act is to prosecute perpetrators. [17,32] What must you do? • Make sure you are familiar with the signs of physical, emotional and sexual abuse and neglect as outlined in Regulation 35 of the Children’s Act.[17] • Learn how to manage disclosure. (Remain calm, listen, empathise and affirm. Reassure the child that they are not to blame: ‘I believe you. It’s not your fault.’ Support and safeguard the child and minimise secondary trauma.) • Know how to report abuse and neglect and to complete Form 22 to initiate a social work investigation.[34] • Make sure abused children are prioritised and receive immediate medical attention, including mental healthcare, to minimise secondary trauma.[6] • Recognise that disclosure and reporting cause significant distress for the child and family and can disrupt the home environment. Therefore, follow up to ensure children have received counselling and therapeutic support.

Strengthen safety nets and care pathways

Given the complex interplay of risk and protective factors, it is vital to engage with a range of service providers to strengthen safety nets and care pathways. The Thuthuzela Care Centres (TCCs) provide one model of best practice, bringing together specialised health professionals, police investigators, prosecutors and social workers to provide an integrated service for sexual and intimate partner violence. Located in public hospitals, the TCCs aim to reduce secondary trauma and improve conviction rates by providing counselling, medical care, and more efficient and sensitive police investigations. What can I do? • Build a directory of local services. Find out about the child protection organisations in your district.[35] Get to know them personally to facilitate referrals and follow-up. • Make information about confidential helplines and local support services available in wards and waiting areas so that children, youth and caregivers are able access these services independently. • Think beyond child protection. Build a broader network of organisations that promotes the health, safety and wellbeing of children, families and communities – from parenting programmes, moms and tots groups and early childhood development centres to sports and cultural programmes that promote the health, safety and wellbeing of children, families and communities (Table 2).

Conclusion

Healthcare providers are ideally placed to protect children from violence, and have both a legal and moral obligation to respond to cases of abuse and neglect, and to prevent violence against children from taking place. A child rights approach foregrounds the benefits

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CME

Table 2. Potential partners and support services • • • • • • • • •

Black Sash (www.blacksash.org.za) provides free paralegal advice and help with social grants through their helpline: 072 66 33 739 Childline (www.childlinesa.org.za) offers online counselling and training and runs a child-friendly crisis line: 08000 55555 Disabled Children’s Action Group (www.dicag.co.za) works with parents and children with disabilities loveLife (www.lovelife.org.za) runs youth-friendly clinics, and has youth development programmes and a toll-free helpline: 0800 121 900 National Association of Child and Youth Care Workers (www.naccw.org.za) provides training for child and youth care workers, and includes the Isibindi programme to support vulnerable children and youth in low-resourced settings Parent Centre (www.theparentcentre.org.za) runs home visiting and teen parenting programmes, and provides counselling, training and support Shukumisa (www.shukumisa.org.za) is an alliance of civil society organisations providing shelter, counselling and legal advice to victims of gender-based violence Sonke Gender Justice (www.genderjustice.org.za) works with men and boys to prevent violence, promote gender equality and actively involve fathers in children’s lives Thuthuzela Care Centres (www.justice.gov.za/vg/TCCs-list.pdf) offer an integrated one-stop service for survivors of sexual violence and abuse

of child participation and intersectoral collaboration in promoting safe and healthy homes, communities and relationships. In addition, it requires health professionals to view children with fresh eyes, to listen and take them seriously, and to speak out against violence in all its forms. Acknowledgements. This article draws on the findings of the South African Child Gauge 2014[7] and focuses on preventing violence against children and the implications for healthcare practice. It also draws on lessons learned from engaging with health and social service professionals and identifying opportunities for systems strengthening through the Children’s Institute’s courses on child rights and child law.

1. South African Police Service. Police Crime Statistics. Pretoria: SAPS, 2014. 2. Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C. The epidemiology of child homicides in South Africa. Bull World Health Organ 2013;91(8):562-568. http://dx.doi.org.10.2471/BLT.12.117036 3. Meinck F, Cluver LD, Boyes ME, Loenig-Voysey H. Physical, emotional and sexual abuse of children in South Africa: Prevalence, incidence, perpetrators and locations of child abuse victimisation in a large community sample. J Epidemiol Community Health 2016;70(9):910-916. http://dx.doi.org.10.1136/ jech-2015-205860 4. Nagia-Luddy F, Mathews S. Service Responses to the Co-victimisation of Mother and Child: Missed Opportunities in the Prevention of Domestic Violence. Technical Report. Cape Town: Resources Aimed at the Prevention of Child Abuse and Neglect and Medical Research Council, 2011. 5. Dawes A, Kafaar Z, Richter L, Kropiwnicki Z. Survey examines South Africa’s attitude towards corporal punishment. HSRC Institutional Repository 2005;1(2):2-4. 6. Artz L, Burton P, Ward CL, et al. Optimus Study South Africa: Technical Report. Sexual Victimisation of Children in South Africa. Final Report of the Optimus Foundation Study: South Africa. Zurich: UBS Optimus Foundation, 2016. 7. Mathews S, Benvenuti P. Violence against children in South Africa: Developing a prevention agenda. In: Mathews S, Jamieson L, Lake L, Smith C, eds. South African Child Gauge 2014. Cape Town: Children’s Institute, University of Cape Town, 2014. 8. Mahlangu P, Gevers A, de Lannoy A. Adolescents: Preventing interpersonal and gender-based violence. In: Mathews S, Jamieson L, Lake L, Smith C, eds. South African Child Gauge 2014. Cape Town: Children’s Institute, University of Cape Town, 2014. 9. Pinheiro PS. World Report on Violence Against Children. Geneva: United Nations, 2006:63-66. 10. Center on the Developing Child. The impact of early adversity on child development. 2007. http:// www.developingchild.harvard.edu (accessed 14 October 2016). 11. Dunkle K, Jewkes R, Brown HC, et al. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol 2004;160(3):230-239. http://dx.doi.org/10.1093/aje/kwh194 12. Mathews S, Jewkes R, Abrahams N. ‘I had a hard life’: Exploring childhood adversity in the shaping of masculinities among men who killed an intimate partner in South Africa. Br J Criminol 2011;51(6):960-977. http://dx.doi.org/10.1093/bjc/azr051

13. Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prev Med 1998;14:245-258. 14. Gershoff E. Spanking and child development: We know enough now to stop hitting our children. Child Develop Perspect 2013;7(3):133-137. http://dx.doi.org/10.1111/cdep.12038 15. Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Neglect 2012;36(2):156-165. http://dx.doi. org/10.1016/j.chiabu.2011.10.006 16. Doyle O, Harmon CP, Heckman JJ, Tremblay RE. Investing in early human development: Timing and economic efficiency. Economics Human Biol 2009;7:1-6. http://dx.doi.org/10.1016/j.ehb.2009.01.002 17. South Africa. Children’s Act No. 38 of 2005. 18. Jamieson L, Wakefield L, Briede M. Towards effective child protection: Ensuring adequate financial and human resources. In: Mathews S, Jamieson L, Lake L, Smith C, eds. South African Child Gauge 2014. Cape Town: Children’s Institute, University of Cape Town, 2014. 19. Centers for Disease Control and Prevention. The Social-Ecological Model: A Framework for Prevention. 2016. http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html (accessed 16 October 2016). 20. Constitution of the Republic of South Africa, 1996. Pretoria: Government Printer, 1996. 21. United Nations Committee on the Rights of the Child. General Comment No. 13: The right of the child to freedom from all forms of violence. Geneva: UN, 2011. 22. Kruger J, Coetzee M. Children’s relationships with professionals. In: Jamieson L, Bray R, Viviers A, Lake L, Pendlebury S, Smith C, eds. South African Child Gauge 2010/2011. Cape Town: Children’s Institute, University of Cape Town, 2011. 23. Tomlinson M. Caring for the caregiver: A framework for support. In: Mathews S, Jamieson L, Lake L, Smith C, eds. South African Child Gauge 2014. Cape Town: Children’s Institute, University of Cape Town, 2014. 24. Republic of South Africa. National Integrated Early Childhood Development Policy. Pretoria: Government Printer, 2015. 25. Field S, Honikman S, Woods D. Bettercare – maternal mental health. A guide for health and social workers. Perinatal Mental Health Project. http://pmhp.za.org/ (accessed 27 October 2016). 26. Save the Children’s Resource Centre. Alternatives to corporal punishment. http://resourcecentre. savethechildren.se/keyword/positive-discipline (accessed 27 October 2016). 27. World Health Organization. Health for the world’s adolescents – a second chance in the second decade. 2015. http://apps.who.int/adolescent/second-decade/section6/page3/quality-&-coverage.html (accessed 16 October 2016). 28. Geary RS, Gomez-Olive FX, Kahn K, Tollman S, Norris SA. Barriers to and facilitators of the provision of a youth-friendly health services programme in rural South Africa. BMC Health Serv Res 2014;14:259. http://dx.doi.org/10.1186/1472-6963-14-259 29. loveLife. www.lovelife.org.za (accessed 27 October 2016). 30. Groce NE. Violence against disabled children: UN Secretary General’s Report on Violence against Children Thematic Group on Violence against Disabled Children. Findings and Recommendations. New York: UNICEF, 2005. 31. Bhamjee S, Essack Z, Strode A. Amendments to the Sexual Offences Act dealing with consensual underage sex: Implications for doctors and researchers. S Afr Med J 2016;106(3):256-259. http:// dx.doi.org.10.7196/SAMJ.2016.v106i3.9877 32. McQuoid-Mason D. Mandatory reporting of sexual abuse under the Sexual Offences Act and the ‘best interests of the child’. S Afr J Bioethics Law 2011;4(2):74-78. 33. Hendricks ML. Mandatory reporting of child abuse in South Africa: Legislation explored. S Afr Med J 2014;104(8):550-552. http://dx.doi.org/10.7196/samj.8110 34. Jamieson L, Lake L. A Guide to the Children’s Act for Health Professionals. 5th ed. Cape Town: Children’s Institute, University of Cape Town, 2013. 35. Department of Social Development. Children Services Directory. http://csd.dsd.gov.za/ (accessed 27 October 2016).

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MEDICINE AND THE LAW

Addressing legal and policy barriers to male circumcision for adolescent boys in South Africa A E Strode,1,2 LLM, PhD; J D Toohey,2 LLB; C M Slack,2 MA Clin Psyc, PhD School of Law, University of KwaZulu-Natal and member of the HIV/AIDS Vaccines Ethics Group, School of Applied Human Sciences, College of Humanities, University of KwaZulu-Natal, Pietermaritzburg, South Africa 2 HIV/AIDS Vaccines Ethics Group, School of Applied Human Sciences, College of Humanities, University of KwaZulu-Natal, Pietermaritzburg, South Africa 1

Corresponding author: A Strode (strodeA@ukzn.ac.za)

With millions of adolescents becoming infected with HIV globally, it is essential that barriers to much-needed interventions are reduced for at-risk adolescents. In this article we review the legal and policy framework in South Africa for adolescent access to male circumcision. We are of the view that the framework does confer protection for adolescent boys while enabling access to male circumcision; however, we identify ambiguities and tensions that exist between the Children’s Act, regulations and national guidelines. We recommend reform to further enable access by this vulnerable group to this prevention modality. S Afr Med J 2016;106(12):1173-1176. DOI:10.7196/SAMJ.2016.v106i12.12106

There are many valid religious, cultural and public-health benefits to male circumcision. In South Africa (SA), it is often practised for religious reasons (generally performed shortly after the birth of a baby boy) or as part of cultural initiation practices (adolescent boys). Recently, there has been increased attention to male circumcision for another purpose, that of reducing the risk of HIV infection.[1,2] Clinical trials have demonstrated that male circumcision is an effective strategy to reduce the risk of HIV transmission from HIVpositive women to uninfected men.[1,2] Male circumcision is a key component of SA’s national strategic plan.[3] Many parents or legal guardians may elect to have boys in their care circumcised, and older boys themselves may wish to be circumcised; however, some human rights concerns have been raised regarding the practice. Firstly, how can children be protected from possible adverse consequences, such as botched cultural circumcisions?[4] Secondly, how can the bodily integrity and autonomy rights of young boys be promoted, given that their parents or legal guardians may make the decision on their behalf in many instances? Thirdly, how can the involvement of older children in such decisions be facilitated where this is appropriate?[5] Male circumcision of boys under 18 years is regulated by the Children’s Act (No. 58 of 2005) – hereafter referred to as the Act.[6] The procedures that should be followed to implement these provisions are detailed in the General Regulations Regarding Children of 2010 (hereafter referred to as the Regulations).[7] This creates a protective, normative framework for when and how circumcisions may take place involving boys under 18.[6] The legislative framework is to be read with the National Department of Health (NDoH)’s national guidelines, which address medical male circumcision performed under local anaesthetic.[8] A critical question is whether and to what extent this legal and policy framework facilitates medical male circumcisions of adolescent boys. This article describes the legal and policy framework, and critically reviews the approach it takes. It concludes with recommendations for law and policy reform to ensure better access to this valuable HIV-prevention tool for this at-risk group.

Legal and policy framework for medical male circumcision of boys under 18

The Act deals expressly with male circumcision of boys under 18 by providing when and how it may take place.[6] There are several protections for all male children, as well as some additional restrictions for boys under 16 who have less legal capacity.[6] The Act’s approach is guided by two broad principles: (i) that ‘every child has the right not to be subjected to social, cultural and religious practices that are detrimental to his/her well-being’[6] (this includes the right, in certain circumstances, to choose not to be circumcised);[6] and (ii) that a child, depending on his/her age, maturity and stage of development, has the right to participate in any matter concerning him/her.[6]

Circumcision of boys over 16 but under 18 years of age

Reason The Act allows 16- and 17-year-old boys to be circumcised for any reason provided several requirements are met. Consent The Act requires that a 16- or 17-year-old boy must have consented (in the prescribed manner) to his own circumcision.[6] The boy has the right to refuse to be circumcised.[6] This clearly indicates that the drafters of the Act intended boys of 16 and over to be able to consent independently to a circumcision, regardless of the method used. For circumcision for cultural reasons, this consent should be documented using a form supplied in the Regulations.[9] If the circumcision is being done for another reason, there is no official form that must be used to record the consent. We hold this to mean that, generally, there is no requirement in the Act for parental involvement in the circumcision of boys aged 16 and 17.[10,11] However, if the circumcision is being done for social-cultural reasons, or for medical reasons and is being performed under local anaesthetic, then the Regulations and the national guidelines,

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respectively, introduce parental involvement. More specifically, where circumcision is being done for social or cultural reasons, Form 2 of the Regulations provides that the parent or legal guardian should sign the circumcision consent form to confirm that they have ‘assisted’ the child in making the decision, and that the boy is over 16 and has capacity to understand the risks and benefits of the procedure. More specifically, where circumcision is being done for medical reasons and is being performed under local anaesthetic, the NDoH guidelines do not clearly state that over-16s can provide self-consent (without parental involvement),[8] and the rationale given in the guidelines about the consent approach seems anchored in consent for treatment or, alternatively, consent for surgery at various places in the document, which is confusing for those trying to apply the guidelines. Counselling The Act requires that 16- or 17-year-old boys must have been given ‘proper’ counselling.[6] The Regulations provide that if the circumcision is for social or cultural reasons, then the counselling should be provided by a parent, legal guardian or a person providing social services.[7] Prescribed manner The Act requires that 16- or 17-year-olds must be circumcised in the manner prescribed.[6] The Regulations only set out norms for procedures to be followed for social or cultural circumcision,[7] namely that it must be performed in accordance with the accepted cultural practices of that boy.[7] Furthermore, it must be done by a medical practitioner or person with knowledge of the social or cultural practice, who is properly trained to conduct such circumcisions.[7] The national guidelines also detail the procedures and equipment that should be used for a medical circumcision.[8] For a social or cultural circumcision, the person performing the procedure must use the prescribed equipment, including sterilisation and universal infection control procedures.[7] Table 1 outlines the existing norms. If we apply these norms to the issue of 16- and 17-year-old boys wishing to access medical male circumcision for HIV prevention, there is no potential ‘reason’ barrier because any reason for circumcision is acceptable. However, there is potential conflict about the consent process because the Act has a self-consent approach that allows 16- and 17-year-old boys to consent independently, whereas the national guidelines for medical circumcision involving local anaesthetic appear to introduce parental involvement in the decisions of 16- and 17-year-olds. We argue that the Act should prevail over the policy. Boys must receive counselling before the circumcision. The Act requires ‘proper’ counselling but no detail is provided on who

should provide this service or its content. Nevertheless, there is some practical guidance in the national guidelines on the purpose and the issues that should be raised during counselling.[8] These include helping clients to identify their HIV risk, exploring the benefits of knowing one’s HIV status and ensuring they know circumcision may not provide full protection against HIV acquisition;[8] therefore, persons involved in offering male circumcision for HIV prevention should include these topics in counselling.

The circumcision of boys under 16 years

Reason The Act prohibits male circumcision of boys under 16 unless it can be shown that the circumcision will be performed for ‘religious’ purposes or ‘medical’ reasons.[6] The Act does not expressly refer to, or define, cultural circumcisions[12] (even though the former provisions are all under the sub-heading of ‘social, cultural and religious practices’). This omission implies that boys should only be circumcised for a cultural reason when they reach the age of 16.[13] The circumcision of boys under 16 for ‘religious purposes’ Reason The Act does not define the term ‘religious purposes’, yet it provides that such circumcisions be carried out in accordance with the practices of that religion.[6] The Regulations state further that such a circumcision must be part of the doctrines of that religion.[7] Neither the Act nor the Regulations define the term ‘religious doctrine’ but dictionary definitions are available.[12] Consent The Regulations (in 6(3)) provide further that religious circumcision with under-16s must be undertaken with the consent of both parents or guardians, and documented on Form 3 of the Regulations. Other In addition, such circumcisions must be performed by a medical practitioner or a person from that religion, who has been trained to perform such circumcisions, and carried out using the prescribed equipment, sterilisation and universal infection-control procedures.[7] The circumcision of boys under 16 for ‘medical reasons’ Reason The Act does not define the term ‘medical reasons’ but it is assumed that the rationale is to address either an immediate health condition such as a urinary tract infection,[8] or a condition the child may be at risk for in the future, such as HIV infection, other sexually transmitted infections, genital cancers and balanitis.[1,8]

Table 1. Existing norms for male circumcision of 16- and 17-year-old boys Reason Any reason Social or cultural practice

Medical

Consent to be provided by Boy himself (age 16 - 17) (CA[6]); and documented on Form 2 (Regulations[9]) Boy himself (age 16 - 17) (CA[6]); ‘assisted’ by parent or guardian and documented on Form 2 (Regulations[9]) Boy himself (age 16 - 17) (CA[6]); parent or legal guardian if regarded as surgery (NDoH guidelines[8])

Procedure performed by Not prescribed (Regulations[7]) Trained practitioner (Regulations[7])

Medical practitioner Detail (NDoH guidelines[8]) (NDoH guidelines[8])

CA = Children’s Act.

Requirements for the procedure Not prescribed (Regulations[7]) Prescribed equipment (Regulations[7])

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Consent The Act does not specifically state who should provide consent for circumcisions of boys under 16 when they are done for medical reasons.[13] The Regulations also do not give any further details on this issue, or provide any accompanying form to be completed to document the consent process. This creates some ambiguity. However, we submit that useful guidance is implied in the Act, which provides that over-16s provide independent consent, therefore implying that under-16s need proxy consent.[14] Furthermore, the medical procedure used could provide some direction on the consent norms. If circumcision is considered an invasive surgical procedure performed under local anaesthetic, i.e. an ‘operation’ (as in fact it is defined by the national guidelines[8]), then the norms in the Act would be that the ‘assistance’ of a parent or legal guardian is required in addition to the consent of persons from the age of 12.[6,13] Other ‘Medical’ circumcisions must be done on the recommendation of a medical practitioner.[6] The Regulations do not detail how such medical circumcisions should be done, but this is detailed in the NDoH guidelines.[8] Table 2 summarises the norms for circumcision of boys under 16. If we apply these norms to the issue of under-16-year-old boys wishing to access medical male circumcision for HIV prevention, it is important to recognise that adolescents should ideally have access to HIV-prevention tools before sexual debut, which makes younger adolescents a key subsample for accessing circumcision. We argue that HIV prevention is a valid medical reason for a circumcision. Other commentators have also asserted that the term ‘medical reasons’ is broad enough to include HIV prevention.[15] In contrast, McQuoid-Mason[16] has argued that a circumcision has to be for a current medical reason and not a possible future one. We recommend following Vawda and Maqutu’s[15] approach because, given the severity of the HIV epidemic and the HIV risk adolescents face, taking steps to minimise such risk is a critical health issue.[13] If circumcision is to be offered to boys under 16 as part of HIVprevention strategies, then the health reason for the circumcision should be documented, i.e. to lower their current or future risk of HIV infection. A parent or guardian should give permission for medical circumcisions for boys under 16, as implied by the Act. National guidelines could be consulted for the form to be used. National guidelines should be consulted for how to implement the procedure.

Conclusions

There is a protective framework for male circumcision of adolescent boys. There are more restrictions on ‘religious’ and ‘cultural’

circumcisions for boy children than on ‘medical’ circumcisions, perhaps because the former are done at birth when child participation principles cannot be applied, and the latter because of the adverse consequences observed each year.[4] However, tensions and ambiguities remain in this protective framework. Roll-out of medical male circumcision may be even further facilitated if these were addressed. We recommend some reforms to strengthen the framework to facilitate access by at-risk adolescents in SA to this one component of a comprehensive portfolio of HIV-prevention options.

Regarding consent

HIV-prevention providers trying to ensure access for boys aged 16 and 17 may experience confusion about whether to seek consent from the adolescent alone, or to seek involvement from a parent as well. This is because the Act implies self-consent and the national guidelines imply parental involvement. Adopting a parental consent approach may deter some 16- and 17-year-olds from seeking this prevention service. The national guidelines should be revised to be much clearer about the consent approach, and should mirror the consent approach implied in the Children’s Act (i.e. self-consent at 16, parental consent for under-16s). Also, HIV-prevention providers trying to ensure access for boys aged 12 - 15 may be uncertain of the consent procedures. For under-16s, the Act or Regulations should spell out which adults are required to consent for health-related circumcisions, and include a form designed to document this.

Regarding reasons

All HIV-prevention providers may breathe more easily if it were understood that HIV prevention is a legitimate health reason for male circumcision.[13] Also, we recommend that the Regulations should specify the minimum standards that should be followed in the procedure so as to ensure that medical circumcisions are treated equally to those done for religious or cultural reasons.[13] The Regulations should also include a form specifically designed to document consent to circumcision for a health reason. Lastly, we recommend that the national guidelines[8] should provide that HIV prevention is a valid medical reason for circumcision of boys under 16.[13] With 2.1 million adolescents infected with HIV globally,[17] and adolescents showing some of the highest incidence rates in the world,[18] it is essential that any barriers hindering access to prevention modalities be addressed – including possible legal/policy barriers. In SA, we hope that amendments to the legal and policy framework could further expand access by this much-affected group to a muchneeded intervention in the form of male circumcision.

Table 2. Existing norms for male circumcision of boys under 16 years of age Reason Religious purposes as it is part of the religious doctrines of that religion (CA[6])

Consent to be provided by Both parents/guardians documented on Form 3 (Regulations[7])

Medical reasons (CA[6])

A parent/ guardian (implied by CA[6]) ‘With the assistance of a parent/guardian and with the consent of a boy child himself if over 12 (alternatively with the consent of the parent/ guardian if under 12) (applying norms of the CA for ‘operations’) Circumcision is prohibited (CA[6])

Any other reason (CA[6])

Procedure performed by Medical practitioner or trained person from that religion (Regulations[7]) Specified (NDoH guidelines[8])

Requirements for the procedure Using prescribed equipment (Regulations[7])

Specified (NDoH guidelines[8])

Procedure is prohibited Procedure is prohibited

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Acknowledgements. This article was made possible by funding from award number 1RO1 A1094586 from the National Institutes of Health (NIH) entitled CHAMPS (Choices for Adolescent Methods of Prevention in South Africa). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. It does not necessarily represent the views of any council or committee with which the authors are affiliated. Many thanks also to Mr Amin Matola for assistance with referencing and formatting. 1. Auvert B, Taljaard D, Lagarde E, et al. Correction: Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2006;3(5):e226. 2. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS 2000;14(15):2361-2370. 3. National Department of Health, South Africa. National Strategic Plan on HIV, STIs and TB 2012 - 2016. Pretoria: NDoH. http://www.gov.za/documents/national-strategic-plan-hiv-stis-and-tb-2012-2016 (accessed 29 February 2016). 4. Child Rights International Network (CRIN). South Africa: Clamping down on botched circumcisions, 2007. https://www.crin.org/en/library/news-archive/south-africa-clamping-downbotched-circumcisions (accessed 21 December 2015). 5. Svoboda JS. Circumcision of male infants as a human rights violation. J Med Ethics 2013;39(7):469474. http://dx.doi.org/10.1136/medethics-2012-101229 6. South Africa. Children’s Act No. 38 of 2005. Government Gazette No. 28944, 2005. http://www.plusto. com/uploads/5780/docs/Childrens-Act.pdf (accessed 29 February 2016). 7. South Africa. Children’s Act No. 38 of 2005. Regulations: General Regulations Regarding Children. Pretoria: Government Gazette No. 33076, Notice No. 261, 2010.

8. National Department of Health, South Africa. South African National Guidelines for Medical Male Circumcision under Local Anaesthesia (2010). Pretoria: NDoH, 2010. 9. South Africa. Children’s Act No. 38 of 2005. Regulations: General Regulations Regarding Children. Form 2. Pretoria: Government Gazette No. 33076, Notice No. 261, 2010. 10. Strode A, Slack C, Essack Z. Child consent in South African law: Implications for researchers, service providers and policy-makers. S Afr Med J 2010;100(4):247-249. 11. Strode A, Slack C, Essack Z. Child consent in South African law: Implications for researchers, service providers and policy-makers (Letter to the Editor). S Afr Med J 2011;101(9):604-606. 12. The Free Dictionary - Medical Dictionary. http://medical-dictionary.thefreedictionary.com/ medical+treatment (accessed 21 December 2015). 13. University of Washington. Department of Global Health. AIDS Law Brief Background Paper: Age of Consent to Voluntary Male Medical Circumcision in South Africa. June 2015. Seattle: University of Washington, 2015. 14. Strode A, Slack C. Child research in South Africa: How do the new regulations help? S Afr Med J 2015;105(11):899-900. http://dx.doi.org/10.7196/SAMJ.2015.V105I11.9838 15. Vawda YA, Maqutu LN. Neonatal circumcision – violation of children’s rights or public health necessity? S Afr J Bioethics Law 2011;4(1):36-41. 16. McQuoid-Mason DJ. Is the mass circumcision drive in KwaZulu-Natal involving neonates and children less than 16 years of age legal? What should doctors do? S Afr Med J 2013;103(5):283-284. http://dx.doi.org/10.7196/SAMJ.6701 17. World Health Organization. Maternal, newborn, child and adolescent health: Adolescent development. Geneva: WHO, 2016. http://www.who.int/maternal_child_adolescent/topics/adolescence/dev/en (accessed 29 February 2016). 18. Bekker L-G, Gill K, Wallace M. Pre-exposure prophylaxis for South African adolescents: What evidence? S Afr Med J 2015;105(11):907-911. http://dx.doi.org/10.7196/SAMJ.2015.v105i11.10222

Accepted 19 October 2016.

COCHRANE CORNER This open-access article is distributed under CC-BY-NC 4.0.

South African Guidelines Excellence (SAGE): Adopt, adapt, or contextualise?

J M Dizon,1,2 PhD, MSPT, BSPT; K Grimmer,3,4 PhD, MMedSc, LMusA, BPt, Cert Health Economics; Q Louw,4 PhD, MASP, BSc (Physio); T Kredo,5 MMed (Clin Pharm), MB ChB, Dip HIV Man; T Young,1,5 PhD, MMed, FCPHM, MB ChB; S Machingaidze,5,6 MPH, BSc Hons, BSc Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Center for Health Research and Movement Science, University of Santo Tomas, Manila, Philippines 3 International Centre for Allied Health Evidence, City East Campus, University of South Australia, Adelaide, Australia 4 Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa 5 Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa 6 European and Developing Countries Clinical Trial Partnership, Cape Town, South Africa 1 2

Corresponding author: J M Dizon (dizonj@sun.ac.za)

Clinical practice guideline (CPG) activities must be planned carefully for efficient use of available resources and evidence-based implementation. De novo development of CPGs may sometimes ‘recreate the wheel’ and delay implementation. Three innovative alternatives to de novo CPG development (adopt, contextualise or adapt) are outlined, which have greater potential than de novo development to best use the limited available resources, personnel and time in settings such as South Africa. S Afr Med J 2016;106(12):1177-1178. DOI:10.7196/SAMJ.2016.v106i12.11374

Clinical practice guidelines (CPGs) assist policymakers, managers, clinicians and patients to make evidence-informed healthcare decisions.[1] Most CPGs have been developed by reputable internationally recognised groups with established methods, and experienced multidisciplinary teams (methodologists and content experts).[2-5] They are generally based in higher-income countries and focus on their healthcare priorities and systems.[6] As more low- and middle-income countries (LMICs) use CPGs to improve healthcare practices, policymakers, managers and clinicians can draw on existing CPGs. However, these may be of questionable relevance to local settings (nature of practice, resources available, etc.) and local health priorities (country-specific priorities such as HIV or

TB in Africa). Consequently, CPG groups in these countries may opt to develop de novo locally relevant CPGs, rather than considering how they could efficiently ‘localise’ existing CPGs. Developing de novo guidelines is expensive and time-consuming and requires CPG knowledge, skills and expertise, which are limited in LMICs, including South Africa (SA).[7] The need for evidenceinformed and cost-efficient healthcare is urgent, and CPGs produced for local needs in these countries may have compromised quality and credibility and fail to meet international reporting standards for CPGs.[8] We have previously examined critical components of good-quality CPGs,[9] the potential of dedicated projects such as South African Guidelines Excellence (SAGE) to better understand the development,

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implementation and use of CPGs in SA primary care settings,[10] and the construction and management of effective, efficient and outcome-focused CPG teams.[11] An alternative approach to CPG development is proposed that involves adopting, contextualising or adapting existing CPGs to suit local purposes. We outline four steps for determining the need for developing de novo CPGs, or identifying an alternative (Fig. 1).

Step 1. Establish the CPG condition, target patient group and endusers

Identify the condition, and the characteristics of patients for whom guidance is needed and who will use the CPG.

Step 2. Identify existing CPGs

Search reputable guideline sources for relevant CPGs. Several guideline sites allow free access to full CPGs developed for a range of conditions. Useful CPG resources can be accessed at http://www.mrc.ac.za/ cochrane/SAGEResources.pdf

Step 3. Screen the CPGs and decide whether de novo development is necessary

Check whether the CPG was published within the past 5 years and is of good quality using standardised tools[12-13] such as AGREE II[14] or the iCAHE tool.[15] (a) If a CPG is outdated or of poor quality, an update is recommended using formal de novo methods.[1,16] (b) If a CPG is current and of good quality, it is justifiable to use it and decide whether to adopt, contextualise or adapt the recommendations.

Step 4. Consider whether to adopt, adapt or contextualise Step 4.1 Adopt

Decide to adopt if the CPG has recommendations that are relevant and applicable to local needs and settings. CPG adoption is a method where CPGs produced elsewhere are used as is, and directly implemented into practice.[17] Step 1

Step 2

Establish CPG condition, target patient group and end-users

Identify existing CPGs

Countries with the same patient types, health systems and resources should be able to adopt and implement such CPG recommendations.

Step 4.2 Contextualise

Decide to contextualise if the CPG has recommendations relevant to local needs; however, consideration of local context issues is required prior to implementation. CPG contextualisation is a method where recommendations from CPGs produced elsewhere can be adopted; however, additional information is required to address local contexts. [17-18] Current good-quality CPGs for many conditions, such as chronic pain, should be applicable to patients in most settings. The challenge is to contextualise (localise the evidence to fit local contexts),[19] e.g. highquality CPGs for chronic pain commonly recommend that patients should participate in individualised exercise programmes to improve function,[18-20] which is relevant to chronic pain patients internationally. However, this may be difficult to implement in many SA communities, as trained exercise instructors, exercise equipment or safe exercise spaces may not be available. To implement this CPG recommendation, contextualisation is therefore required (find a secure community space, and use mats, towels, and kitchen items for weights), and regular group/community exercise programmes may be implemented as alternative strategies.

Step 4.3 Adapt

Decide to adapt if CPG recommendations are unachievable in local circumstances, and new evidence must be added to make them relevant to local conditions and therefore implementable. CPG adaptation is a method where recommendations are taken from CPGs produced elsewhere but amended to include local research evidence and expert group consensus.[15] In adapting, a process of layering the evidence underpinning recommendations from existing CPGs with additional local evidence is used. For example, if drug A, which is recommended in high-quality CPGs for patients with acute stroke, is not available in a country (not registered, too expensive, cannot be safely stored, etc.) and Step 3 Screen the CPGs and decide if de novo development is necessary

Step 4 Consider whether to: 4.1 adopt 4.2 adapt 4.3 contextualise

Fig. 1. Steps in determining the need for CPG de novo development and other CPG approaches.

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instead drug B is locally available, affordable, with locally tested evidence and with equivalent benefits to drug A, the CPG recommendation could be adapted to suggest that drug B could be used. Acknowledgements. We acknowledge Dawn Ernstzen, Division of Physiotherapy, Stellenbosch University, for her contextualisation work for chronic pain management in SA used in the example in this article. We also thank Michelle Galloway for her support in finalising the submission on behalf of the author team. Funding. The authors were funded, partially or in full, by the SAGE project, a 3-year (2014 2017) Flagship Grant from the South African Medical Research Council. The Flagship Grant programme was not involved in the conceptualisation or conduct of this study. 1. Schünemann HJ, Wiercioch W, Etxeandia I, et al. Guidelines 2.0: Systematic development of a comprehensive checklist for a successful guideline enterprise. Can Med Assoc J 2014;186(3):E123-E142. http://dx.doi.org/10.1503/cmaj.131237 2. National Institute for Health and Care Excellence. http://www. nice.org.uk/ (accessed 26 April 2016). 3. Scottish Intercollegiate Guidelines Network. http://www.sign. ac.uk/ (accessed 26 April 2016). 4. National Health and Medical Research Council. http://www. nhmrc.gov.au/ (accessed 26 April 2016). 5. World Health Organization. http://www.who.int/publications/ guidelines/en/ (accessed 26 April 2016). 6. Birbeck G, Wiysonge C, Mills E, Frenk J, Xiao-Nong Z, Jha P. Global health: The importance of evidence-based medicine. BMC Med 2013;11:223. http://dx.doi.org/10.1186/1741-7015-11-223 7. Kredo T, Gerritsen A, van Heerden J, et al. Clinical practice guidelines within the Southern African development community: A descriptive study of the quality of guideline development and concordance with best evidence for five priority diseases. Health Res Pol Syst 2012;10(1):1-13. http:// dx.doi.org/10.1186/1478-4505-10-1 8. Machingaidze S, Zani B, Abrams A, et al. Quality and Reporting Standards of South African Primary Care Clinical Practice Guidelines. J Clin Epidemiol 2016 (in press). 9. Machingaidze S, Kredo T, Young T, Louw Q, Grimmer K. South African Guidelines Excellence (SAGE): Clinical practice guidelines – quality and credibility. S Afr Med J 2015;105(9):743745. http://dx.doi.org/10.7196/SAMJnew.7697 10. Kredo T, Machingaidze S, Louw Q, Young T, Grimmer K. South African Guidelines Excellence (SAGE): What’s in a name? S Afr Med J 2016;106(1):18-20. http://dx.doi.org/10.7196/SAMJ.2016. v106i1.10286 11. Grimmer K. Louw Q, Kredo T, Young T, Machingaidze S, Dizon JMR. South African Guidelines Excellence (SAGE): Efficient, effective and unbiased clinical practice guideline teams. S Afr Med J 2016;106(5):440-441. http://dx.doi.org/10.7196/ SAMJ.2016.v106i5.10770 12. Grimmer K, Machingaidze S, Dizon JMR, Kredo T, Louw Q, Young T. South African clinical practice guidelines quality measured with complex and rapid appraisal instruments. BMC Res Notes 2016;9:244. http://dx.doi.org/10.1186/s13104-016-2053-z 13. Siering U, Eikermann M, Hausner E, et al. Appraisal tools for clinical practice guidelines: A systematic review. PLoS One 2013;8:e82915. http://dx.doi.org/10.1371/journal.pone.0082915 14. AGREE Organization. http://www.agreetrust.org/agree-ii/ (accessed 26 April 2016). 15. Grimmer K, Dizon J, Milanese S. Efficient clinical evaluation of guideline quality: Development and testing of a new tool. BMC Res Notes 2014;14(63):1-10. http://dx.doi.org/10.1186/1471-2288-14-63 16. Gambito E, Gonzalez-Suarez CB, Grimmer K, et al. Updating contextualized clinical practice guidelines on stroke rehabilitation and low back pain management using a novel assessment framework that standardizes decisions. BMC Res Notes 2015;8(643):1-12. http://dx.doi.org/10.1186/s13104-015-1588-8 17. Dizon JMR, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC Res Notes 2016:9:442. http://dx.doi. org/10.1186/s13104-016-2244-7 18. Gonzalez-Suarez C, Grimmer-Somers K, Dizon JM, et al. Contextualising Western guidelines for stroke and low back pain to a developing country (Philippines): An innovative approach to putting evidence into practice efficiently. J Healthc Leadersh 2012;4:141-146. http://dx.doi.org/10.2147/JHL.S35370 19. Eisenberg JM. Globalize the evidence, localize the decision: Evidence-based medicine and international diversity. Health Aff 2002;21(3):166-168. http://dx.doi.org/10.1377/hlthaff.21.3.166 20. Hooten WM, Timming R, Belgrade M, et al. Institute for Clinical Systems Improvement: Assessment and Management of Chronic Pain. Updated November 2013. https://www.icsi. org/_asset/bw798b/ChronicPain.pdf (accessed 26 April 2016).

Accepted 24 August 2016.

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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ISSUES IN PUBLIC HEALTH

The universities of Stellenbosch/Cape Town lowcarbohydrate diet review: Mistake or mischief? Z Harcombe,1 PhD; T Noakes,2 OMS, MB ChB, MD, DSc, PhD (hc) 1 2

Public Health Nutrition, Cardiff, UK Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: T Noakes (noakes@iafrica.com)

A 2014 meta-analysis from the universities of Stellenbosch and Cape Town reported that diets with a lower-carbohydrate (CHO) content are no more effective for producing weight loss than are high-CHO diets, so-called isoenergetic ‘balanced’ diets. We have re-examined the article and found numerous errors, many material in nature. Studies were included that failed the authors’ own inclusion criteria; invalid and subjective meta-analysis sub-grouping was used; and data extraction was repeatedly inaccurate. All but one error favoured the balanced diet. The article was widely publicised, highly impactful and inaccurate. This begs the question: mistake or mischief? S Afr Med J 2016;106(12):1179-1182. DOI:10.7196/SAMJ.2016.v106i12.12072

In July 2014, the South African (SA) media reported that, by proving that low-carbohydrate (CHO) diets were not better than ‘balanced’ eating,[1] a recently published article[2] from the universities of Stellenbosch and Cape Town had effectively ‘debunked the Banting diet’.[3] Other reports echoed this sentiment. The Cape Times personalised the message: ‘Noakes’s low-carb diet not healthier’, while quoting the chief executive of the Heart and Stroke Foundation of SA: ‘Based on the current evidence we cannot recommend a low carbohydrate diet to the public.’[4] The claim that a low-CHO diet was no better than balanced eating does not ‘debunk’ the low-CHO diet. These reports could as easily have stated that eating a balanced diet is no better for producing weight loss than eating a low-CHO diet is. This media positioning is interesting and particularly important in the current context that low-CHO diets have been placed on trial in SA.[5] More objective reporting of Naude et al.’s[2] systematic review should have made two important points: First, the study could not provide any information about Banting or low-CHO diets because it failed to study either. The average carbohydrate intake for the 14 studies included in the systematic review[6] was 35% (fat 35%; protein 30%).[7-20] This is substantially different from the 5% CHO (<50 g/day), moderate protein, and high fat, which is the dietary composition of the low-CHO diet promoted for the therapeutic management of obesity and type 2 diabetes mellitus.[21-23] Second, the objective of Naude et al.’s[2] article was ‘To compare the effects of low (sic) CHO and isoenergetic balanced weight loss diets in overweight and obese adults’. As a key effect of the lowCHO diet is to reduce hunger by increasing satiety despite a reduced energy intake,[24] the caloric intake of subjects on the control diet in isoenergetic trials must be voluntarily restricted to match this effect. This effectively negates the advantage provided by the uniquely satiating effect of genuinely low-CHO diets. Both of these points served to disadvantage the lower-CHO diets included by Naude et al.[2] in their systematic review. Regarding the first point, the introduction to the Naude et al.[2] article confirmed the authors’ understanding of what constitutes a low-CHO diet: ‘Some weight loss diets widely promoted through

the media … recommend a regime greatly restricting carbohydrates (CHO).’ The introduction continued: ‘To achieve the very low CHO intake, these diets prescribe restriction of most vegetables and fruit … .’ Confirming their understanding of what constitutes a lowCHO diet, the authors proceeded to find against these diets without actually studying them. Only 1 of the 19 trials they initially reviewed was sufficiently low in CHO to qualify as a trial of the (therapeutic) low-CHO diet.[13] The other 18 trials reviewed were lower in CHO content than current public health dietary guidelines, but they were not low-CHO diets. There is a substantial difference between lower(than dietary guidelines) and therapeutically low-CHO diets. The therapeutic low-CHO diet is prescribed specifically to lower the daily CHO intake to <50 g/day, which is the level at which optimal benefits of this dietary intervention occur.[22] In view of the pivotal importance of this article to the conduct of the ‘trial’ against low-CHO diets in SA, we considered it important to submit the article to a rigorous re-analysis. In the course of our investigation we uncovered a multitude of errors that materially altered the conclusions promoted by the article. In the context of the current debate on low-CHO diets in SA, it is important that the erroneous messages conveyed to the SA public as a result of the inaccuracies in that study[2] should be rectified expeditiously.

A re-examination of the Naude et al.[2] article The main conclusion

The main conclusion presented in the abstract of the Naude et al.[2] article was: ‘In non-diabetic participants, our analysis showed little or no difference in mean weight loss in the two groups at 3 - 6 months.’ This conclusion was based on a study of 14 trials that were deemed moderate-quality evidence.[7-20]

The studies selected

The inclusion criteria set for the selection of these 14 studies by Naude et al.[2] were: randomised controlled trials (RCTs); published in English; >10 participants randomised in each group; diet was the only intervention; control and intervention diets were isocaloric (isoenergetic); complete macronutrient profile of intervention diet

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was available; control diet was deemed balanced (defined as 45 - 65%, 25 - 35% and 10 - 20% of total energy from CHO, fat and protein, respectively); and the follow-up period was ≥12 weeks. We started with the assumption that the 14 studies had been chosen in good faith. It transpired that the following four studies should not have been included: • Luscombe et al.,[16] as it was a duplication of Farnsworth et al.’s[15] article. • Keogh et al.[17] and Sacks et al.,[14] as they failed the inclusion criteria set by Naude et al.[2] that fat should provide 25 - 35% of the energy in a balanced diet. Instead, fat provided only 20% of the target calories in the control diets in both those studies. • De Luis et al.,[9] as the data are not conducive to meta-analysis. The two De Luis et al.[8,9] studies are visibly incongruent in Fig. 3 of the Naude et al.[6] article (Supplemental material 1: Table 4*). Fig. 3 reported weight data from the end of the trial (but without data on weight at the start of the trial), when weight loss during the trial was the target outcome. The error of including these data is inexplicable. The study of De Luis et al.[9] cannot be used in meta-analysis, as the study did not report standard deviation (SD) data for the weight losses in the diet and control groups. However, the data of De Luis et al.[8] can be used in meta-analysis. We extracted the weight loss and SD data from De Luis et al.,[8] as Naude et al.[2] should have done for consistency with their other methods of data extraction (Supplemental material 1: Table 6*).

The meta-analysis sub-grouping

Naude et al.[6] split the 14 studies into so-called ‘high fat variants’ and ‘high protein variants’. Neither achieved a significant result. However, this split was not justified. Sub-grouping may be undertaken in meta-analysis when two different interventions are being compared, e.g. the comparison of the effects of two different drugs v. no drug control. The sub-grouping of studies into those deemed ‘high fat’ or ‘high protein’ was not justified, as Naude et al.’s[2] original objective was not to compare high-fat or high-protein diets with balanced diets. Their objective was ostensibly to study the effects of ‘low’-CHO diets by comparing lower-CHO diets v. balanced diets. Furthermore, the classification of diets as either high fat or high protein by Naude et al.[2] was entirely subjective. To clarify, the studies of Frisch et al.[10] and Klemsdal et al.[11] complicated calculations of the average macronutrient compositions of all the diets, as these authors reported only the ranges of macronutrient intakes. Frisch et al.[10] reported CHO/fat/protein percentage proportions as <40/>35/25 and >55/<30/15 for the diet and control groups, respectively. Klemsdal et al.[11] reported CHO/fat/protein percentage proportions as 30 - 35/35 - 40/25 - 30 and 55 - 60/<30/15 for diet and control groups, respectively. We used CHO/fat/protein in percentage proportions of 40/35/25 and 55/30/15 for the diet and control groups, respectively, in the study by Frisch et al.,[10] and 33/38/28 (mid-points rounded up) and 55/30/15 for the respective groups in the study of Klemsdal et al.,[11] to calculate average macronutrient intakes for the 14 studies included in the Naude et al.[2] meta-analysis as 35/35/30 for the diet groups and 56/27/17 for the control groups. Protein intake in the diet groups of their so-called low-CHO high-protein (LCHP) and low-CHO highfat (LCHF) studies averaged 31.5 - 32.5% and 28.4%, respectively, probably a biologically insignificant difference. (The variation in the protein proportion for the LCHP group results from macronutrient proportions differing in the abstract and narrative of two studies[15-16] (Supplemental material 1: Table 2*)). In the studies by Lim et al.[13] and Aude et al.[7] there were higher percentage protein intakes than in four of the six studies placed in their high-protein group.[15,16,18,19] Additionally, if the four studies were excluded that should have been

excluded,[9,14,16,17] the protein differential narrows even further to 31.3% and 29.3% for so-called LCHP and LCHF, respectively. The sub-grouping was therefore not necessary, not justified and not robust.

Errors in data extraction

The primary claim emanating from the Naude et al.[2] article was that there was little or no difference in mean weight loss between a lower-CHO diet and a so-called balanced diet. This was the only part of the article that we re-examined. We found tens of errors in this re-examination. These are fully detailed in the Supplemental material 1: Tables 1 - 6.* The material errors that we detected are summarised as follows: • The findings in the studies by Frisch et al.,[10] Layman et al.,[19] Lim et al.[13] and Wycherley et al.[20] all favoured the lower-CHO intervention. For all of these studies, Naude et al.[2] reported the number of completers in the study at a time later than that at which the weight loss data they included had been recorded. This resulted in lower weighting being assigned to these studies in meta-analysis, as these studies would appear to include fewer participants than was the case. This would have disadvantaged the overall pooled effect for lower-CHO diets. • The study of Wycherley et al.[20] included weight loss data for 52 weeks of the trial. Naude et al.[2] reported that they had used those data, but they did not. Instead, they used data from 12 weeks of the study. Use of the 52-week data would have favoured the lower-CHO intervention. • Krauss et al.[12] illustrated the macronutrient compositions of four different diets. Three diets differed in macronutrient composition, but not in saturated fatty acids (SFAs) and were marked as planned (a priori) comparisons. The CHO content of these three were 54%, 39% and 26%, respectively. The fourth diet also contained 26% CHO, but was reported as high in SFA and marked as intended to be compared with the 26% CHO/low-SFA diet alone. Naude et al.[2] compared the 26% high-SFA diet with the balanced low-SFA diet, which unnecessarily introduced a second variable and was to the disadvantage of the direct comparison between the lower-CHO and the balanced diet. • The studies by Farnsworth et al.[15] and Luscombe et al.[16] were a duplication of the same study. Both studies favoured the control balanced dietary intervention. Furthermore, the weight loss in the control diet intervention was reported by Naude et al.[2] as 7.95 kg, rather than the 7.9 kg actually reported by Farnsworth et al.[15] • The use of end-value data for body weight, not weight loss, in the De Luis et al.[8,9] studies was absurd and favoured the control balanced dietary intervention. • The weight loss data for the study by Krauss et al.[12] as reported by Naude et al.[2] recorded equal weight losses for the diet and control groups. Those specific data could not be found in the original publication. Instead, the actual data reported by Krauss et al.[12] slightly favoured the lower-CHO diet intervention. • The study by Sacks et al.[14] should not have been included, as it did not meet Naude et al.’s[2] criteria for inclusion. Having been included, the data for weight loss appear to have been reported the wrong way round so that the slightly higher weight loss occurring in the lower-CHO diet was incorrectly assigned to the control diet. • The study by Keogh et al.[17] similarly failed Naude et al.’s[2] inclusion criteria, but the data for weight loss in that study slightly favoured the lower-CHO diet intervention. However, the data for the number of completers were taken at the end of the study, whereas the data for weight loss were from an earlier part of the trial. This mitigated some of any advantage afforded to the lower-CHO diet intervention. All errors made, except for part of the last one listed,[17] favoured the control group.

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Study limitations

A number of the studies were not designed to evaluate weight loss as their primary objective. The study of De Luis et al.[9] was designed to study two different hypocaloric diets on the secretion of glucagon-like peptide 1. Another study by De Luis et al.[8] evaluated weight loss and blood adipocytokine concentrations in obese subjects with a genetic variant. Keogh et al.[17] studied flow-mediated dilatation, adhesion molecules and adiponectin after weight loss. The primary aim of the Klemsdal et al.[11] study was to evaluate the impact of low glycaemic load v. low-fat diets in people with and without the metabolic syndrome. Krauss et al.[12] sought to study the effects of reduced CHO intake and weight loss on atherogenic dyslipidaemia. Lasker et al.[18] studied the metabolic effects of two different weight loss diets on dyslipidaemia and post-prandial insulin responses to a meal. A number of the studies lacked generalisability to whole populations. Wycherley et al.[20] and Krauss et al.[12] studied males only. Farnsworth et al.[15] and Luscombe et al.[16] (noting that these are duplicate studies) studied men and women with insulin resistance and hyperinsulinaemia. De Luis et al.[8] included only obese subjects with the rs9939609 genetic variant. A number of the authors did not consider their interventions to be low-CHO diets. Lasker et al.[18] and Layman et al.[19] described their interventions as moderate-protein diets. The diet in Lasker et al.’s[18] study was additionally reported as ‘moderate carbohydrate’, whereas Farnsworth et al.[15] and Luscombe et al.[16] (duplicate studies) considered their interventions to be high-protein diets. The studies by De Luis et al.[8,9] were described as hypocaloric. Frisch et al.[10] reported that their study contrasted the effects of CHO-reducedintake and fat-reduced-intake diets. Wycherley et al.[20] considered their study to be a 52-week comparison of either high-protein or high-CHO diets. In addition, the four studies[25-28] reviewed by Naude et al.[2] to compare lower-CHO diets with balanced diets in overweight and obese adults with type 2 diabetes were of concern. We ask ourselves how interventions recommending a 40% CHO intake to participants who cannot metabolise carbohydrate effectively because they have diabetes mellitus type 2 were granted ethical approval.

A revised meta-analysis

Notwithstanding that the Naude et al.[2] article: (i) did not review genuinely low-CHO diets; and (ii) introduced an isocaloric inclusion criterion, which negated the natural advantage of low-CHO diets, to be robust in our re-examination we re-conducted the meta-analysis without the errors made by Naude et al.[2] The meta-analysis was repeated for the 10 studies that could be included in this analysis according to the authors’ own selection criteria (Supplemental material 2: Meta-analysis, Fig. 1*). Heterogeneity was evaluated using the Q-value, I² and T² calculations. Analyses were performed using Comprehensive Meta-Analysis version 2 (Biostat, USA). The overall pooled effect was calculated using random effects meta-analysis. The standard difference in means was significant at −0.272 (95% confidence interval −0.506, −0.039). In conclusion, when meta-analysis was performed on the 10 studies that qualified for inclusion in the study of Naude et al.[2] using their own criteria, the data confirmed that the lower-CHO diet produced significantly greater weight loss than did the balanced diet.

Discussion

The findings of the Naude et al.[2] meta-analysis were widely reported in the SA media as disproof of the overall value of the LCHF diet.

Indeed, some reports misused this messaging to warn about the ‘dangerous’ nature of low-CHO diets. The objective of our re-examination was to test whether or not the findings of the Naude et al.[2] article were robust. We have demonstrated that they were not. The main limitation of our article is that we re-examined only one part of Naude et al.’s[2] article. We found their analysis of the weight loss data to have many errors and those errors to have made a material difference to the conclusions. Given the number of errors we detected in that single section of the article, it is inconceivable that the remainder of the article is robust. Therefore, without the need to examine all sections of the article, we have shown that in its published form, it is not robust and cannot be relied on. We additionally showed that, notwithstanding two features of the study, which by design or by chance disadvantaged low-CHO diets, had the Naude et al.[2] meta-analysis been properly performed, it would have concluded that the lower-CHO diet produced greater weight loss than the balanced diet. This would have radically altered the nature of the message heard across SA after its publication and might have influenced the eagerness of SA medical authorities to put the LCHF/Banting diet on public ‘trial’. A reasonable question to ask is: how could the published metaanalysis have included so many errors and have come to the incorrect conclusion despite peer review? Another reasonable question to ask is: what is the chance that essentially all these errors favoured the so-called balanced diet and disadvantaged the lower-CHO diet, especially when many of the authors of this article are on public record as being vigorously opposed to lower- or low-CHO diets and to those who promote such eating plans? *Supplemental material. Supplemental material 1: Tables 1 - 6, and Supplemental material 2: Meta-analysis, are available from the corresponding author on request. Declarations of interest. ZH receives income from writing and from two small self-employment businesses: The Harcombe Diet Co. and Columbus Publishing. TN is the author of the books Lore of Running and Waterlogged and co-author of The Real Meal Revolution, Raising Superheroes and Challenging Beliefs. All royalties from the sales of The Real Meal Revolution and Raising Superheroes and related activities are donated to the Noakes Foundation, of which he is the chairman and which funds research on insulin resistance, diabetes and nutrition as directed by its Board of Directors. Money from the sale of other books is donated to the Tim and Marilyn Noakes Sports Science Research Trust, which funds the salary of a senior researcher at the University of Cape Town, South Africa. The research focuses on the study of skeletal muscle in African mammals, with some overlap to the study of type 2 diabetes in carnivorous mammals and of the effects of (scavenged) sugar consumption on freeliving (wild) baboons. 1. Houliston T. Low-carb diets not better than balanced eating! Womens Health, 10 July 2014. 2. Naude CE, Schoonees A, Senekal M, Young T, Garner P, Volmink J. Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: A systematic review and metaanalysis. PLoS ONE 2014;9(7):e100652. http://dx.doi.org/10.1371/journal.pone.0100652 3. Stassen W. New research could debunk banting diet. South African Health News Service, 10 July 2014. 4. Stassen W. Noakes’s low-carb diet not healthier. Cape Times, 10 July 2014. 5. Ismail A. Tim Noakes to face inquiry over ‘Banting’ tweet. Health24, 20 October 2015. 6. Naude CE, Schoonees A, Senekal M, Young T, Garner P, Volmink J. Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: A systematic review and metaanalysis. PLoS ONE 2014;9(7):18 (Fig. 3)e100652. http://dx.doi.org/10.1371/journal.pone.0100652 7. Aude YW, Agatston AS, Lopez-Jimenez F, et al. The national cholesterol education program diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat: A randomized trial. Arch Intern Med 2004;164(19):2141-2146. http://dx.doi.org/10.1001/archinte.164.19.2141 8. De Luis DA, Aller R, Izaola O, et al. Evaluation of weight loss and adipocytokines levels after two hypocaloric diets with different macronutrient distribution in obese subjects with rs9939609 gene variant. Diabetes Metab Res Rev 2012;28(8):663-668. http://dx.doi.org/10.1002/dmrr.2323

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9. De Luis DA, Sagrado MG, Conde R, Aller R, Izaola O. The effects of two different hypocaloric diets on glucagon-like peptide 1 in obese adults, relation with insulin response after weight loss. J Diabetes Complications 2009;23(4):239-243. http://dx.doi.org/10.1016/j.jdiacomp.2007.12.006 10. Frisch S, Zittermann A, Berthold HK, et al. A randomized controlled trial on the efficacy of carbohydrate-reduced or fat-reduced diets in patients attending a telemedically guided weight loss program. Cardiovasc Diabetol 2009;8:36. http://dx.doi.org/10.1186/1475-2840-8-36 11. Klemsdal TO, Holme I, Nerland H, Pedersen TR, Tonstad S. Effects of a low glycemic load diet versus a low-fat diet in subjects with and without the metabolic syndrome. Nutr Metab Cardiovasc Dis 2010;20(3):195-201. http://dx.doi.org/10.1016/j.numecd.2009.03.010 12. Krauss RM, Blanche PJ, Rawlings RS, Fernstrom HS, Williams PT. Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia. Am J Clin Nutr 2006;83(5):1025-1031; quiz 205. 13. Lim SS, Noakes M, Keogh JB, Clifton PM. Long-term effects of a low carbohydrate, low fat or high unsaturated fat diet compared to a no-intervention control. Nutr Metab Cardiovasc Dis 2010;20(8):599607. http://dx.doi.org/10.1016/j.numecd.2009.05.003 14. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360(9):859-873. http://dx.doi.org/10.1056/NEJMoa0804748 15. Farnsworth E, Luscombe ND, Noakes M, Wittert G, Argyiou E, Clifton PM. Effect of a high-protein, energy-restricted diet on body composition, glycemic control, and lipid concentrations in overweight and obese hyperinsulinemic men and women. Am J Clin Nutr 2003;78(1):31-39. 16. Luscombe ND, Clifton PM, Noakes M, Farnsworth E, Wittert G. Effect of a high-protein, energyrestricted diet on weight loss and energy expenditure after weight stabilization in hyperinsulinemic subjects. Int J Obes Relat Metab Disord 2003;27(5):582-590. http://dx.doi.org/10.1038/sj.ijo.0802270 17. Keogh JB, Brinkworth GD, Clifton PM. Effects of weight loss on a low-carbohydrate diet on flowmediated dilatation, adhesion molecules and adiponectin. Br J Nutr 2007;98(4):852-859. http://dx.doi. org/10.1017/s0007114507747815 18. Lasker DAW, Evans EM, Layman DK. Moderate carbohydrate, moderate protein weight loss diet reduces cardiovascular disease risk compared to high carbohydrate, low protein diet in obese adults: A randomized clinical trial. Nutr Metab 2008;5:30. http://dx.doi.org/10.1186/1743-7075-5-30 19. Layman DK, Evans EM, Erickson D, et al. A moderate-protein diet produces sustained weight loss and long-term changes in body composition and blood lipids in obese adults. J Nutr 2009;139(3):514-521. http://dx.doi.org/10.3945/jn.108.099440

20. Wycherley TP, Brinkworth GD, Clifton PM, Noakes M. Comparison of the effects of 52 weeks weight loss with either a high-protein or high-carbohydrate diet on body composition and cardiometabolic risk factors in overweight and obese males. Nutr Diabetes 2012;2:e40. http://dx.doi.org/10.1038/nutd.2012.11 21. Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Exp Clin Cardiol 2004;9(3):200-205. 22. Feinman RD, Pogozelski WK, Astrup A, et al. Dietary carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Nutrition 2014. http://dx.doi.org/10.1016/j. nut.2014.06.011 23. Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: A review of the therapeutic uses of verylow-carbohydrate (ketogenic) diets. Eur J Clin Nutr 2013;67(8):789-796. http://dx.doi.org/10.1038/ ejcn.2013.116 24. Yudkin J, Carey M. The treatment of obesity by the ‘highfat’ diet. The inevitability of calories. Lancet 1960;2(7157):939-941. 25. Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with type 2 diabetes: One-year follow-up of a randomised trial. Diabetologia 2004;47(10):1677-1686. http:// dx.doi.org/10.1007/s00125-004-1511-7 26. Krebs JD, Elley CR, Parry-Strong A, et al. The Diabetes Excess Weight Loss (DEWL) trial: A randomised controlled trial of high-protein versus high-carbohydrate diets over 2 years in type 2 diabetes. Diabetologia 2012;55(4):905-914. http://dx.doi.org/10.1007/s00125-012-2461-0 27. Larsen RN, Mann NJ, Maclean E, Shaw JE. The effect of high-protein, low-carbohydrate diets in the treatment of type 2 diabetes: A 12 month randomised controlled trial. Diabetologia 2011;54(4):731740. http://dx.doi.org/10.1007/s00125-010-2027-y 28. Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-protein, high-monounsaturated fat weight loss diet on glycemic control and lipid levels in type 2 diabetes. Diabetes Care 2002;25(3):425-430.

Accepted 29 September 2016.

ISSUES IN MEDICINE This open-access article is distributed under CC-BY-NC 4.0.

Research competency and specialist registration: Quo vadis?

C P Szabo,1 MB BCh, MMed, FCPsych, PhD, MSc Med (Bioethics and Health Law); S Ramlall,2 MB ChB, FCPsych, PhD 1 2

Department of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Department of Psychiatry, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: C P Szabo (christopher.szabo@wits.ac.za) Prof. Szabo and Dr Ramlall are both current members of the Council of the College of Psychiatrists, Colleges of Medicine of South Africa, with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary. Both have been involved in revision to the College’s regulations and contributing to the blueprinting process, and are actively involved in postgraduate training at their respective institutions. The article reflects their collective and personal understanding of the issue. The requirement of ‘research completion’ as necessary for specialist registration with the Health Professions Council of South Africa (HPCSA) has recently been subject to legal action, with a court order potentially shifting requirements beyond those envisaged by the HPCSA. The research requirement is congruent with National Department of Health strategy in this regard, i.e. the strengthening of research as a stated priority. While the expectation of research competency is not in itself contentious, the capacity of institutions and the ability of registrars to facilitate and complete, respectively, have brought the issue into focus. Specifically, the apparent discrepancy between a court order and a regulation needs to be resolved to ensure that specialist registration is not unduly hampered, while ensuring that a potentially important contributor to a national priority is not prejudiced. S Afr Med J 2016;109(12):1183-1185. DOI:10.7196/SAMJ.2016.v106i12.11217

The Standards Generating Body (SGB) Subcommittee of the Medical and Dental Professions Board (MDPB) reported in November 2010 on the low compliance with the exit outcomes related to registrar requirements to undertake and complete a relevant research study. In an attempt to align the qualification of specialists and subspecialists with the Higher Education Qualification Framework (HEQF) of South Africa (SA), the new requirements for registration of specialists

in SA would include the completion of a research study with a minimum of 60 credits in terms of the National Qualifications Framework.[1] The date of implementation, together with other changes, was 1 January 2011.[1] The inculcation and promotion of a culture of research has clinical and academic merit, as well as implications for providing a local evidence base for the policies of both the National and Provincial Departments of Health.[2] However,

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implementation of completed research, supervised by the Head of Department, as a mandatory requirement for specialist registration has highlighted the distinct roles and responsibilities of the various stakeholders involved in the registrar-to-specialist process.

Registrar training

Specialist training has evolved. This is both a desirable and necessary development. How educators have understood what works best in terms of teaching and assessment, and how clinicians have understood what constitutes core content for specialist knowledge and core competencies for specialist practice, have contributed to the status quo. The SGB, noting the lack of uniformity of specialist training programmes with respect to syllabuses and assessments – including the assessment of research knowledge and skills – defined new requirements for specialist registration.[1] With respect to the research requirement, it is required that this would be assessed at individual university level as opposed to the single exit examination which fell under the jurisdiction of the Colleges of Medicine of SA (CMSA). It may be argued that, in the overall pursuit of objectivity and alignment of medical training requirements with other higher education training programmes, processes have become more technical and, at times, overwhelming for both educators and trainees in specialist training platforms. Legally, the impetus has been as much about fair as it has been about defensible. The exponentially increasing content in all fields of medicine demands a rational approach to prioritising what specialist trainees need to know. Within the CMSA, individual Colleges have been required to undertake ‘blueprinting’ of individual syllabuses with explicitly stated and concisely defined training requirements, core knowledge and requisite competencies which, in turn, would inform examination content and methods. Academic imperatives and the increasing frequency of legal challenges to examination results highlighted the need for assessment methods to be revised to meet pedagogical standards of validity and reliability as well as withstand legal scrutiny. Into this changing scenario and evolution from medical education to medical pedagogy was added the need for specialists to demonstrate competence in research.[1] It would seem that the amended Health Professionals Council of SA (HPCSA) regulation will facilitate the National Department of Health goal of increasing relevant research[2] (recommendations from the National Health Research Summit[2] were incorporated into the Department of Health Strategic Plan 2014/15 - 2018/19).

Research requirements in the College of Psychiatrists

There has been an ongoing process of revision of regulations to align syllabus content with the aforementioned developments. The inclusion of research within the regulations as a requirement for entry to the Part II examination of the Fellow of the College of Psychiatrists (FCPsych) aligned the College with the HPCSA requirement for proof of research competence as a requisite for specialist registration. In this respect Psychiatry was not alone, with other Colleges, e.g. Obstetrics and Gynaecology, within the CMSA having likewise included a research component. However, while competence in research is a requirement for entry to the Part II final and exit examination (administered by the CMSA) and a requirement for registration as a specialist (by the HPCSA), it is ultimately the various universities that manage the acquisition of the research competency. To this end, the successfully examined research report is the third part that follows the successful completion of the Parts I and II examinations leading to the awarding of the MMed degree at university level. The

Part II examination conducted by the CMSA is the only specialist exit examination recognised by the HPCSA, while the Part I can be university administered (as a component of the MMed degree) or CMSA administered. In either case, all registrars are required to be registered at their respective universities for the MMed degree when commencing their registrar training. This complex tripartite system upholds the pillars of academia for specialist training while the trainees are all full-time employees of the fourth stakeholder on the registrar training platform, the Department of Health. The local shortage of medical doctors in a setting of significant financial constraints in the public health sector highlights the need to not only train more doctors but to ensure a smooth and efficient ‘pipeline’ that will serve the best interests of both academic institutions and health service delivery. The registrar training period has remained fixed at 4 years in general while the medical knowledge base grows continually; academic standards demand concise curricula and comprehensive formative and summative assessments. The implementation of the mandatory completion of the research component as a prerequisite for specialist registration raises questions about the adequacy of the current training period to meet the rigorous training requirements, as well as the respective roles and responsibilities of the four key stakeholders who serve as gatekeepers. The noble intentions underlying the mandate – academic, clinical and research – must be weighed against matters of pragmatism and practicalities. Legal challenge to the HPCSA requirement initiated by registrars in KwaZulu-Natal[3] warrant closer scrutiny of the status quo and, for illustrative purposes, the College of Psychiatrists will be used as an example (the legal challenge will be discussed in further detail later in the article).

Roles and regulations

CMSA/College of Psychiatrists, universities

The content of the College of Psychiatrists’ regulations related to research provides a clear description of what is expected.[4] Specifically, it is stated that there should be research experience as evidenced by, at minimum, a first draft of the research report approved by a Head of Department and supervisor. The requirement was implemented in response to the decision of the HPCSA’s Subcommittee for Postgraduate Education and Training – communicated in November 2010 – whereby completed research would become a requirement for specialist registration for all registrars commencing training in 2011, i.e. qualifying in 2015. The initial College content in this regard was open to interpretation insofar as stating that adequate progress should have been made as determined by the Head of Department. This allowed for variation between institutions whereby one institution might be satisfied with protocol completion whereas others might require completed data collection, a research report submitted for examination or a successfully examined research thesis/mini-dissertation. Such variation in requirements was subsequently not deemed acceptable, given that the College became the national exit examining body with the possibility of a university-obtained MMed no longer being suitable for specialist registration, i.e. only a Fellowship was acceptable. However, given the need for research competence, a university output became a College requirement for entry to examination and an HPCSA requirement for specialist registration. It should be stated that completed research that ultimately contributes towards awarded Master’s degrees does translate into much-needed revenue for universities. The College of Psychiatrists’ wording of this requirement was thereafter revised, noting that ‘the first draft must comprise data

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collection and analysis, i.e. a results section, with preliminary content related to the introduction/methods/discussion and conclusion sections’.[4] Such a first draft would technically constitute ‘completed’ research, albeit not examined towards a higher degree. However, it could be anticipated that such content would be examinable – subject to minor amendments and ensuring that content conforms to the required university academic standards and style requirements. The expectation would thus be that the content conferring eligibility need not have been examined or even submitted as a research report towards the MMed degree but would, at minimum, be work in progress towards examination of and awarding of the Master’s degree.

Health Professions Council of South Africa

The HPCSA notes the following in relation to research: ‘Completion of a research component will be a requirement for registration as a specialist in South Africa. The research study, which will be assessed at university level, may be used as a credit for Part III of the MMed degree’.[1] Interpretation of ‘may be used as a credit for Part III of the MMed degree’ suggests that ‘completion of a research component’ does not include research that has either been submitted or successfully examined. The content of the Form 57 MED for submission to the HPCSA as part of the specialist registration process states the following: ‘We the undersigned certify that the candidate has submitted a research component that complies with the HPCSA requirements and this has been signed off by the research supervisor(s). This research component has not contributed towards obtaining any other degree, including, but not limited to another MMed or MPhil degree’. This can be completed/signed in good faith by the respective Head of Department, Head of School and Dean of an individual Faculty, where a registrar has complied with the College’s research requirement for entry to the Part II, as it could indeed be seen as congruent with the HPCSA requirement. However, the issue is how Deans of different institutions, who are required to sign off on the Form 57, will interpret what constitutes ‘completed research’. In correspondence with the medical deans (personal communication to Prof. Hift dated 13 October 2015, but with intext reference to a November 2015 meeting of the Subcommittee for Postgraduate Education and Training (Medical)), the HPCSA refers to completion of research being a requirement for specialist registration but does not at any point refer to a completed MMed.

Role players

From the preceding content there are three official role players, each with specific functions and linked to the other as follows: • University – facilitates research process providing supervision/ assessment, with higher degree (MMed) throughput the ultimate aim; • College – specific research requirement for entry to Fellowship Part II/minimum content stated; • HPCSA – research requirement for specialist registration/minimum content stated/facilitated by university and College (through requirement for entry to Part II exam).

Challenges: Clinical, academic and courtroom

The College and HPCSA do not make allowance for universities being unequally resourced to meet the research requirement. A recent study relating to registrar perceptions of the research component noted some specific concerns, such as availability of time, appropriate supervision and necessary skills.[5] While the regulation requiring research

completion was in place from 2011, it was challenged legally only in 2015 when HPCSA specialist registration was denied to those who had failed to meet the research requirement.[3] The challenge was upheld, with the judge ruling that the complainants should be registered as specialists, having successfully completed their specialist examinations, but be given a further 2 years to complete the research component. To this end they were to be registered as specialists for the 2-year period but would be removed from the specialist register should they not successfully complete the research component, i.e. obtain the MMed within the 2-year grace period. In reading the court order, it is clearly stated that the requirement for specialist registration is a completed MMed as opposed to merely ‘undertaking/completing research’. This goes beyond what the HPCSA requirement stipulates. It should be noted that Johannesburg-based doctors had attempted to have the same ruling applied to them but the HPCSA declined to do so.[3] The legal challenge gives rise to several questions and concerns: • Would the HPCSA be required to amend, through the appropriate committee (Postgraduate Education and Training), its requirements for specialist registration? • Is the court now making a determination on specialist registration requirements, i.e. placing itself above an institution tasked with such a function (given that the institution is served by state/ university-employed academics who determine curricula, as well as teach and examine accordingly)? • Would the HPCSA challenge the court ruling in light of potentially being obliged to amend its requirement? • Should registrar training be extended to a 6-year period, accepting that a 4-year period is standard but seemingly inadequate to meet all the training and registration requirements? The last issue would then place an onus on provincial health authorities to review registrar contracts, with obvious and considerable financial implications. At a National Department of Health level, what would the implications be for numbers of specialists entering practice and how would that relate to planning for service provision? Clearly, the judgement raises many questions – certainly not the least of which is whether the judgement is appropriate or helpful. What the judgement does highlight, without specifically noting such, is that any requirement must be defensible and for successful implementation be unequivocally communicated, as well as, in this instance, be cognisant of the need for all training sites to be able to comply.

Conclusion and recommendations

Investing in the research capacity and calibre of medical professionals and thereby, hopefully, promoting an ongoing culture of research, is a noble endeavour which can only enrich healthcare. The call for greater financial investment in health research within the public sector, to 2% of the national health budget, should be factored into the current issue.[6] Due regard and recognition should be given to the unique role of registrars as registered university students who work in full-time jobs (including overtime) as part of their clinical training, and are required to successfully deliver a Master’s-level research project. Achieving this within a defined 4-year training period while honouring the dictates of the employer (clinical training body), the university (academic body), the CMSA (assessment/examining body) and the HPCSA (registering body) is a balancing act. It may be time to open a dialogue that reviews and clarifies the status quo, given adversarial developments that may prejudice the training environment and, ultimately, healthcare.

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1. Health Professionals Council of South Africa. Subcommittee for Postgraduate Education and Training. New requirements for the registration of specialists in South Africa. 18 November 2010. http:// www.hpcsa.co.za/uploads/editor/UserFiles/downloads/medical_dental/PETM%20-%20New%20 Requirements%20for%20the%20Registration%20of%20Specialists%20in%20South%20Africa18Nov2009ii-Edited.pdf (accessed 21 June 2016). 2. Mayosi BM, Mekwa NJ, Blackburn J, et al. National Health Research Summit Report: Strengthening research for health, development and innovation in South Africa. Pretoria: Department of Health, April 2012. http://www.nhrc.org.za 3. Padayachee K. ‘Specialist’ doctors in fight with council. The Mercury. 3 May 2016. 4. College of Psychiatrists. Documents attached to the Fellowship of the College of Psychiatrists of South Africa. https://www.cmsa.co.za/view_exam.aspx?examid=41 (accessed 21 June 2016).

5. Patel N, Naidoo P, Smith M, Loveland J, Govender T, Klopper J. South African surgical registrar perceptions of the research project component of training: Hope for the future? S Afr Med J 2016;106(2):169-171. http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10310 6. Paruk F, Blackburn JM, Friedman IB, Mayosi BM. National expenditure on health research in South Africa: What is the benchmark? S Afr Med J 2014;104(7):468-474. http://dx.doi.org/10.7196/ SAMJ.6578

Accepted 20 September 2016.

CASE REPORT This open-access article is distributed under CC-BY-NC 4.0.

Revisiting an old foe: The face of psychosis in neurosyphilis

Y Moolla, MB ChB, FCP (SA), MMed, Dip HIV Man (SA); J Abdul, MB ChB Department of Internal Medicine, Addington Hospital, Durban, South Africa Corresponding author: Y Moolla (moollayusuf@hotmail.com)

A delusional, agitated middle-aged man presented to hospital with a tenacious psychotic episode. Upon appropriate therapy for neurosyphilis, dramatic resolution of this brief episode ensued, prompting a literature review of psychosis associated with neurosyphilis. S Afr Med J 2016;106(12):1186-1187. DOI:10.7196/SAMJ.2016.v106i12.11446

Syphilis, a sexually transmitted disease caused by Treponema pallidum, continues to be a considerable health burden worldwide. It affects over 30 million people, the majority of whom are from Africa and South-East Asia.[1] This disease, which is also known as the ‘great imitator’, has three stages. Primary syphilis occurring at the site of inoculation may present as a painless macule which often later ulcerates. The secondary stage usually occurs 4 - 8 weeks later and may manifest with a generalised rash involving the palms and soles of the feet. Accompanying systemic vasculitis can cause a wide variety of syndromes, which include hepatitis, iritis, nephritis and neurological abnormalities. Left untreated, approximately 30% of affected individuals will go on to develop tertiary syphilis. The cardinal manifestations of this late form of syphilis are cardiovascular, gummatous and neurosyphilis.[2] Neurosyphilis has a wide array of clinical manifestations; the different pathological subtypes are shown in Table 1. Classic presentations of neurosyphilis are now becoming less common, as recent literature describes cases where psychiatric or neurocognitive symptoms are the solitary signs of the disease.[3] Except in the context of HIV infection, the diagnosis of neurosyphilis is generally considered unusual. Neurosyphilis may develop at any time in the course of T. pallidum infection, and while classic late syphilis manifested 5 - 25 years later in the pre-penicillin era, early meningovascular syphilis may develop within months to years following infection.[4] A paucity of available data remains regarding the prevalence of neurosyphilis among psychiatric patients in South Africa (SA). A recent study demonstrated that the prevalence of syphilis was 11.7% among psychiatric patients at a state psychiatric hospital.[5]

Table 1. Stages of neurosyphilis Stage

Symptoms

Asymptomatic

None

Symptomatic Early Late

Case report

Meningeal Meningovascular Gummatous Cerebral Spinal compression Parenchymatous General paresis Tabes dorsalis Optic atrophy

A 52-year-old man was escorted to our regional hospital by local police. The history provided during this involuntary consultation was that of aggression towards his family. The patient’s family had noticed a change in his personality, together with blunted emotional responses over the past few weeks. No history of chronic medical disease or of substance abuse was found. Our patient reported feeling well and repeatedly said that he could communicate with God. On clinical examination, there were no signs of trauma or alcoholism. He was not wasted, and signs of nutritional deficiency were absent. Stigmata of endocrine diseases were absent and normal systemic examination findings were evident. The central nervous system examination was normal; in particular no signs of meningitis

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Table 2. Results of investigations Syphilis screen Lumbar puncture

RPR + (titre >32) Polymorphs: 0; lymphocytes: 56; red blood cells: 0 Protein 0.92 g/L; glucose 3.3 mmol/L (serum 5.1) VDRL + (titre 128); TPHA + herpes simplex virus; PCR: negative (CSF)

TPHA = Treponema pallidum haemagglutination; PCR = polymerase chain reaction.

or cranial nerve neuropathies were present, pupil reflexes were normal and he had a normal gait. At first consultation we were unable to perform a mini-mental test and despite the use of typical antipsychotic therapy, the delusional state together with mild aggression had persisted. Biochemical and haematological markers were normal; in addition the C-reactive protein was low, thyroid function test normal and urine drug screen clear. Further investigations revealed a normal brain computed tomography (CT) scan, and a non-reactive HIV test. A lumbar puncture was then performed which prompted the performance of a rapid plasmin reagent (RPR). The results are listed in Table 2. Our patient was diagnosed with neurosyphilis and was started on penicillin G 24 million units per day intravenously, and he continued to receive a high dose of haloperidol. A repeat lumbar puncture performed on day 14 demonstrated a greater than fourfold decrease in cerebrospinal (CSF) Venereal Disease Research Laboratory (VDRL) titre, normalisation of lymphocyte count and CSF protein. Complete resolution of psychosis had occurred, and our patient was discharged.

Discussion

This case highlights how syphilis lives up to its name ‘the great imitator’ and, as illustrated, psychosis may be the sole sign of the disease. Psychosis is often associated with syphilis. Danielsen et al.[6] analysed 92 patients with neurosyphilis and 17% had presented with psychiatric symptoms, while Timmermans and Carr[7] described 51% of 161 patients having had neuropsychiatric manifestations. It has been cited that the most common presenting feature was personality change; however, memory impairment, hostility, confusion, hallucination and delusions may also occur in neurosyphilis.[8] These presenting signs should prompt a screening RPR. Furthermore, a study by Lin et al.[3] found that psychiatric manifestations were the primary symptoms of neurosyphilis in 52% of 169 patients. Numerous case reports further add to the minefield of neuropsychiatric manifestations associated with this disease, psychotic symptoms with hypomania, depression with psychotic features and somatic preoccupation, dementia with psychotic features, and treatment-resistant psychosis, to name a few.[9-12] Our case adds to these and parallels this change of face of modern neurosyphilis, but more importantly demonstrates that rapid clinical improvement and reversibility of the neuropsychiatric burden following antibiotic therapy is attainable. This phenomenon has been previously documented in patients with comparable presentations and further highlights the importance of a prompt diagnosis together with appropriate timely therapy.[13,14] While neither guideline nor consensus exists on the neurotropic agents of choice, Sanchez and Zisselman[15] in a case series support the utilisation of psychotropic medication in combination with antibiotic therapy. Haloperidol, atypical agent risperidone and quetiapine appeared to have provided clinical benefit. Anti-epileptic therapy also appeared to assist in mood stabilisation. Using the lowest effective dose is supported, together with periodic attempts to reduce or withdraw therapy.[15]

The atypical forms of neurosyphilis now seen may be attributed to the widespread use of beta-lactamase antibiotics and HIV co-infection.[16] Being in the midst of the HIV epidemic, clinicians in Africa should take heed of the re-emergence of this disease and have a heightened clinical suspicion. The prevalence of neurosyphilis among patients with HIV infection may be as high as 23.5%. HIV co-infection with syphilis is a symbiotic one, as syphilis infection is able to facilitate HIV transmission, while HIV allows for unusual and aggressive manifestations, which includes early neurological involvement.[17] Diagnosis may prove to be challenging, with higher rates of serological negative tests and increased false-negative non-treponemal tests secondary to the prozone effect while syphilis persistence following therapy is an added concern.[18]

Conclusion

While HIV has altered both the prevalence and presentation of neurosyphilis, the importance of routine non-treponemal testing as a screening tool for syphilis is vital in a psychotic patient regardless of HIV status. We emphasised its use together with further invasive investigations such as a lumbar puncture with CSF-VDRL testing in cases where the suspicion of neurosyphilis is heightened. Direct admission to a psychiatric unit should be avoided, as this may cause undue delay in the diagnosis and result in unnecessary investigations together with misuse of resources. Unlike the leopard phenotype which ceases to change, this chameleon of a disease continues to pose a challenge to both physician and psychiatrist. 1. World Health Organization. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections – 2008-2012. http://www.who.int/reproductivehealth/publications/rtis/stisestimates/en/ 2. French P. Syphilis. BMJ 2007;334:143-137. http://dx.doi.org/10.1136/bmj.39085.518148.BE 3. Lin L, Zhang H, Huang S, et al. Psychiatric manifestations as primary symptom of neurosyphilis among HIV-negative patients. J Neuropsychiatry Clin Neurosci 2014;26(3):233-240. http://dx.doi. org/10.1176/appi.neuropsych.13030064 4. Marra CM. Neurosyphilis. Continuum (Minneap Minn) 2015;21(6):1714-1728. http://dx.doi.org/10.1212/ con.0000000000000250 5. Henning MP, Krüger C, Fletcher L. Syphilis sero-positivity in recently admitted and long-term psychiatric inpatients: Screening, prevalence and diagnostic profile. S Afr J Psychiatr 2012;18(4):171-175. http://dx.doi.org/10.7196/SAJP.358 6. Danielsen AG, Weismann K, Jorgensen BB, Heidenheim M, Fugleholm AM. Incidence, clinical presentation, and treatment of neurosyphilis in Denmark, 1980-1997. Acta Derm Venereol 2004;84(6):459-462. http://dx.doi.org/10.1080/00015550410017308 7. Timmermans M, Carr J. Neurosyphilis in the modern era. J Neurol Neurosurg Psychiatry 2004;75(12):1727-1730. http://dx.doi.org/10.1136/jnnp.2004.031922 8. Roberts MC, Emsley RA. Psychiatric manifestations of neurosyphilis. S Afr Med J 1992;82(5):335-337. 9. Mahendran R. Clozapine in the treatment of hypomania with neurosyphilis. J Clin Psychiatry 2001;62(6):477-478. 10. Mirsal H, Kalyoncu A, Pektas Ö, Beyazyürek M: Neurosyphilis presenting as psychiatric symptoms: An unusual case report. Acta Neuropsychiatr 2007;19(4):251-253. http://dx.doi.org/10.1111/j.16015215.2007.00209.x 11. Hutto B. Syphilis in clinical psychiatry. Psychosomatics 2001;42(6):453-460. http://dx.doi.org/10.1176/ appi.psy.42.6.453 12. Van Eijsden P, Veldink JH, Linn FH, Scheltens P, Biessels GJ. Progressive dementia and mesiotemporal atrophy on brain MRI: Neurosyphilis mimicking pre-senile Alzheimer’s disease. Eur J Neurol 2008;15:e14–e15. http://dx.doi.org/10.1111/j.1468-1331.2007.02018.x 13. Mannekote ST, Singh VK. A case of neurosyphilis presenting with treatment-resistant psychotic symptoms and progressive cognitive dysfunction. German J Psychiatry 2008;11:153-155 14. Crozatti LL, Brito MH, Lopes BNA, Campos FPF. Atypical behavioral and psychiatric symptoms: Neurosyphilis should always be considered. Autopsy Case Rep 2015;5(3):43-47. http://dx.doi.org/10.4322/acr.2015.021 15. Sanchez FM, Zisselman MH. Treatment of psychiatric symptoms associated with neurosyphilis. Psychosomatics 2007;48(5):440-445. http://dx.doi.org/10.1176/appi.psy.48.5.440 16. Barry GH, Miriam B. Evolution of the serine β-lactamases: Past, present and future. Drug Resist Updat 2004;7(2):111-123. http://dx.doi.org/10.1016/j.drup.2004.02.003 17. Lynn WA, Lightman S. Syphilis and HIV: A dangerous combination. Lancet Infect Dis 2004;4(7):456-466. http://dx.doi.org/10.1016/S1473-3099(04)01061-8 18. Haslett P, Laverty M. The prozone phenomenon in syphilis associated with HIV infection. Arch Intern Med 1994;154(14):1643-1644. http://dx.doi.org/10.1001/archinte.1994.00420140115016

Accepted 30 August 2016.

December 2016, Print edition

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

IN PRACTICE

CASE REPORT

A case of convergence spasms â&#x20AC;&#x201C; do not be caught off-guard L Smit, MB ChB, MMed (Neurol) Department of Neurology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: L Smit (smitl@ufs.ac.za)

A hypertensive patient presented with complaints of headache and fluctuating double vision and deterioration in vision from 2010. She displayed symptoms associated with convergence spasms, which could be confused with sixth cranial nerve palsies. A few pointers are given to prevent clinicians from being caught off-guard when encountering this clinical condition. S Afr Med J 2016;106(12):1188-1189. DOI:10.7196/SAMJ.2016.v106i12.11417

Case report

A 42-year-old woman presented in 2014 with gradual onset of frontotemporal headaches associated with nausea and vomiting since 2010, following the birth of her youngest child. She also had complaints of double vision and deterioration of vision since 2010. The diplopia worsened on near fixation of objects. Occasional episodes of dizziness occurred after taking antihypertensive medication. She was known to have hypertension, treated with four agents, and had evidence of grade 4 hypertensive retinopathy. She had attempted suicide previously with antihypertensive medication. On examination she was alert, responsive, orientated to time and place, with no signs of raised intracranial pressure and meningeal irritation. No vomiting occurred in the ward. Pupils were equal and reactive to light. Visual acuity in both eyes was 20/40 on the Rosenbaum pocket vision screener. As demonstrated in Fig. 1, the patient had dysconjugate gaze in the primary position with the eyes adducted (turned toward the nose bridge). Fluctuating esotropia was present. When the object for fixation was held closer than 30 cm to examine the eye movements, the patient developed convergence and miosis was noted to occur synergistically. When eye movements were tested separately, they were normal with full range of pursuit movements and saccades. Bilateral contraction of the orbicularis oculi muscles was also noted. No other cranial nerve abnormalities or long tract signs were observed. The diagnosis of convergence spasm (spasm of the near reflex) was made.

Fig. 1. Patient showing dysconjugate gaze in the primary position with the eyes adducted.

The results of routine blood tests were normal. Urea and electrolytes, liver function, vitamin B12, full blood count and erythrocyte sedimentation rate were normal, and tests for Treponema pallidum and HIV were negative. A computed tomography (CT) scan of the brain was performed, which was essentially normal and did not disclose intra- or extra-axial spaceoccupying lesions. Asymmetry of the lateral ventricles was noted but was considered insignificant. During her stay in the ward, an incident occurred when her husband came to visit her. He was verbally and physically abusive towards her. She refused support from the social worker. When it was explained to her that her eye movements were stress-related, she accepted it as the cause of her problems. She was reassured that the movements should clear up as soon as the stress was reduced. On follow-up every morning in the ward, the convergence spasms became less noticeable. She was discharged with normal eye movements after a 2-week stay in hospital. This patient had presented in 2014 to physicians who were less experienced in neuro-ophthalmology. She had been wrongly diagnosed as suffering from bilateral sixth cranial nerve palsies as a result of raised intracranial pressure.

Discussion

Spasm of the near reflex is a disorder characterised by intermittent episodes of convergence, miosis and accommodation. It may mimic bilateral and sometimes unilateral nervus abducens paresis.[1] The patient complains of double vision or blurred vision. Prominent miosis on convergence is the clue in differentiating convergence spasm from true organic causes of convergence phenomena.[2] Spasm of the near reflex as described above may rarely occur in patients with organic disorders, but is more commonly psychogenic.[3,4] Spasm of the near reflex is one cause for esotropia. Organic disorders causing esotropia include conditions such as abducens palsy, tonic convergence spasm (part of dorsal midbrain syndrome), pons lesions in multiple sclerosis,[5] myasthenia gravis and Wernickeâ&#x20AC;&#x2122;s encephalopathy.[1] Patients with functional spasm of the near reflex have associated somatic complaints and behavioural abnormalities. Blepharoclonus (frequent blinking), poor co-operation in other motor tasks and tunnel vision may occur. The patient has a full range of eye movement with pursuit of own hand and with one eye covered. Normal optokinetic nystagmus is observed.[1]

December 2016, Print edition

IN PRACTICE

A few pointers that may be of value when examining a patient with convergence spasms include the following: • Should eye signs be confusing or fluctuating, it is useful to cover one eye and examine eye movements independently. • The fixation point should not be closer than 50 cm to the face of the patient when examining eye movements. • Check for miosis on convergence when unexplained ‘sixth cranial nerve’ palsies occur. Presence of such indicates a physiologically normal near response. • Look for contraction of the orbicularis oculi muscle if convergence spasm is suspected, in which case associated contraction of this muscle of the face during eye movement examination usually also occurs. • This condition in isolation seldom needs special investigations.

• Psychological support is usually indicated and may assist in spontaneous remission of the convergence spasms. 1. Lavin PJM. Neuro-ophthalmology: Ocular motor system. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley’s Neurology in Clinical Practice. Vol. 1. Principles of Diagnosis and Management. 6th ed. Philadelphia: Elsevier Saunders, 2012:87-633. 2. Anagnostou E, Katsika P, Kemanetzoglou E, Vassilopoulou S, Spengos K. The abduction deficit of functional convergence spasm. J Neurol Sci 2016;363:27-28. http://dx.doi.org/10.1016/j.jns.2016.02.027 3. Fekete R, Baizabal-Carvallo JF, Ha AD, Davidson A, Jankovic J. Convergence spasm in conversion disorders: Prevalence in psychogenic and other movement disorders compared with controls. J Neurol Neurosurg Psychiatry 2012;83(2):202-204. http://dx.doi.org/10.1136/jnnp-2011-300733 4. Ghosh A, Padhy SK, Gupta G, Goyal MK. Functional convergence spasm. Indian J Psychol Med 2014;36(3):332-334. 5. Anliaçik S, Uca AU, Kozak HH, Akpinar Z. A very rare paroxysmal symptom in multiple sclerosis: Convergence spasm. Am J Emerg Med 2016;34(1):117.e5-117.e6. http://dx.doi.org/10.1016/j. ajem.2015.05.025

Accepted 22 August 2016.

CASE REPORT This open-access article is distributed under CC-BY-NC 4.0.

Diabetic cachectic neuropathy: An uncommon neurological complication of diabetes

A Iyagba, MBBS, FWACP, FMCP; A Onwuchekwa, MBBS, FMCP Neurology Unit, Medicine Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria Corresponding author: A Iyagba (amiyagba@gmail.com)

A 40-year-old woman with diabetes of 12 years’ duration, with poor drug compliance, presented with a 4-month history of rapid progressive weight loss, burning sensations in the feet, abdominal swelling, and constipation with occasional episodes of epigastric pain. On examination, she was chronically ill-looking with a body mass index of 17.1 kg/m2, grossly distended abdomen (initially mistaken for gravid abdomen). Blood pressure measurements in the supine and standing positions were 200/130 mmHg and 180/100 mmHg, respectively. Neurological examination revealed stocking-pattern loss of pain, temperature, and light touch modalities. Vibration sensation was impaired up to the malleoli bilaterally, with impairment of joint position sense of both big toes. Random blood sugar level was 16.4 mmol/L; glycosylated haemoglobin was 13.2% with a haematocrit of 33.0%. Renal indices, uric acid, liver function tests and fasting lipid profile were all within normal limits. An abdominal ultrasound scan showed distended bowel loops. The vibration perception threshold average using biothesiometry was 27.3 mV. S Afr Med J 2016;106(12):1190-1191. DOI:10.7196/SAMJ.2016.v106i12.11198

Diabetic patients can be affected by a wide variety of neurological complications which may involve the peripheral or autonomic nervous system, or both. These complications significantly impair the quality of life of patients, with impact on morbidity and mortality outcomes. Diabetic cachectic neuropathy, also called diabetic neuropathic cachexia, is a very rare neurological complication of diabetes.[1] It was first described by Ellenberg[2] in 1934. It is associated with poor diabetic control that presents with profound unintentional weight loss associated with an acute symmetrical painful peripheral neuropathy without weakness.[3] Pain is characteristically burning in nature, with predominant lower-limb involvement and allodynia. The disorder affects both type 1 and type 2 diabetics and occurs irrespective of the duration of diabetes. Depression and, in males, impotence appear to be common, although other autonomic features can be present. Although a few case reports exist in the literature describing this condition, to the best of our knowledge, there has been no such report from our practice environment. This article serves to describe

a very rare neurological complication of diabetes that highlights our diagnostic and management experience.

Case report

A 40-year-old woman with diabetes of 12 years’ duration, with poor drug compliance and clinic follow-up, presented to us at the accident and emergency department of the University of Port Harcourt Teaching Hospital with a 4-month history of rapid progressive weight loss, burning sensations in the feet, abdominal swelling, and constipation with occasional episodes of epigastric pain. These were associated with generalised body weakness, tiredness, and postural dizziness with occasional episodes of falling. She also admitted to florid, itching, offensive vaginal discharge. In addition, she had frothy urine, intermittent episodes of retrosternal chest pain, palpitations, and symptoms of hyperglycaemia. Her obstetric history was significant: two previous stillbirths and one second-trimester intrauterine fetal death. She had a strong family history of diabetes. She had been amenorrhoeic for about 5 months.

December 2016, Print edition

IN PRACTICE

On examination, she was chronically ill-looking with a body mass index of 17.1 kg/m2, grossly distended abdomen (initially mistaken for gravid abdomen). She had a tachycardia of 128 bpm; blood pressure measurements in the supine and standing positions were 200/130 mmHg and 180/100 mmHg, respectively. Her apex beat was not displaced but she had a third heart sound with gallop rhythm. There were reduced breath sounds in both lung bases. Neurological examination revealed stocking-pattern loss of pain, temperature and light touch modalities. Vibration sensation was impaired up to the malleoli bilaterally, with impairment of joint position sense of both big toes. Her random blood sugar level was 16.4 mmol/L; glycosylated haemoglobin was 13.2% with a haematocrit of 33.0%. Renal indices, uric acid, liver function tests and fasting lipid profile were all within normal limits. Her urine was pale yellow and turbid. Urine microscopy showed 2 - 3 pus cells/high power field with yeast and epithelial cells. Urine culture yielded scanty growth of Staphylococcus aureus (sensitive to cefuroxime, ceftriazone and perfloxacin) and moderate growth of Candida albicans. An abdominal ultrasound scan showed distended bowel loops. Her liver, spleen and kidneys were not enlarged. There was no ascites. Pregnancy test was negative. Electrocardiogram showed tachycardia, left atrial enlargement and left ventricular hypertrophy. Chest radiography showed cardiomegaly and unfolded aorta in keeping with hypertensive cardiovascular changes. A biothesiometer was used to determine her vibration perception threshold. This was obtained by taking the average of three readings (R) obtained by placing the probe at the right toe (R1), left toe (R2) and again at the right toe (R3). The values obtained were 27 mV, 28 mV and 27 mV, respectively. The vibration perception threshold average was 27.3 mV. Management consisted of optimising glycaemic control with regular insulin and blood pressure control with antihypertensive agents (lisinopril and amlodipine, both 10 mg daily). She also received atorvastatin 10 mg daily, clopidogrel 75 mg daily and nystatin vaginal pessaries nocte (6 doses). Medication was initially carbamazepine controlled-release formulation 200 mg twice daily for her neuropathic pain. This had little effect and was discontinued. She, however, obtained rapid relief and amelioration of her neuropathic lower-limb pain with the introduction of pregabalin at 75 mg twice daily.

Discussion

Our patient had complications involving both her peripheral and autonomic nervous system. Our initial consideration, because of her distended abdomen, was that of a diabetic patient presenting with distal symmetrical peripheral neuropathy in pregnancy. However, abdominal distension was just one of the many features of autonomic neuropathy that she manifested. The others were constipation, tiredness and postural dizziness. Distended loops of bowel on abdominal ultrasonography are in keeping with autonomic neuropathy of the gastrointestinal tract. The marked postural drop in blood pressure (20/30 mmHg) is a feature of cardiovascular autonomic neuropathy. The presence of autonomic symptoms is poorly prognostic in these patients. The response of her neuropathic pain to pregabalin was dramatic. Pregabalin has been recommended as the first-line agent for the treatment of diabetic peripheral neuropathic pain in most guidelines.[4,5] The San Antonio Consensus Criteria[6] are commonly used to define diabetic neuropathy for research purposes, and recommend at least one measurement in five different categories for the diagnosis of diabetic neuropathy. For clinical neuropathy, the guidelines require symptoms and signs, or one of these with abnormal testing, or autonomic testing. Subclinical neuropathy is identified by abnormal testing only. Biothesiometry is an easy and objectively quantifiable means of diagnosing neuropathy in diabetic patients. A vibration perception threshold average of ≥25 mV is diagnostic of neuropathy. We were unable to perform nerve conduction studies, considered the gold standard for neuropathy diagnosis, because of lack of availability. 1. Knopp M, Rajabally YA. Common and less common peripheral nerve disorders associated with diabetes. Curr Diab Rev 2012;8(3):229-236. http://dx.doi.org/10.2174/157339912800564034 2. Ellenberg M. Diabetic neuropathic cachexia. Diabetes 1974;23:418-423. http://dx.doi.org/10.2337/diab.23.5.418 3. Knopp M, Srikantha M, Rajabally YA. Insulin neuritis and diabetic cachectic neuropathy: A review. Curr Diabetes Rev 2013;9(3):267-274. http://dx.doi.org/10.2174/1573399811309030007 4. Attala N, Cruccua G, Barona R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol 2010;17(9):1113-1123. http://dx.doi.org/10.1111/j.14681331.2010.02999.x 5. Moulin DE, Clark AJ, Gilron I, et al. Pharmacological management of chronic neuropathic pain: Consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage 2012;12(1):13-21. http://dx.doi.org/10.1155/2007/730785 6. American Diabetes Association-American Academy of Neurology: Report and recommendations of the San Antonio Conference on Diabetic Neuropathy (Consensus Statement). Diabetes Care 1988;11(7):592-597. http://dx.doi.org/10.2337/diacare.11.7.592

Accepted 28 June 2016.

December 2016, Print edition

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

IN PRACTICE

CASE REPORT

Atypical chest pain: Needles in a haystack J M Jansen van Vuuren,1 MB BCh; S Pillay,2 MB ChB, FCP (SA), MMed; K Ramchandre,2 MB ChB, FCP (SA) 1 2

Medical Intern, Pietermaritzburg Hospital Complex, South Africa Department of Internal Medicine, Edendale Hospital, Pietermaritzburg, South Africa

Corresponding author: J M Jansen van Vuuren (juanjvanvuuren@gmail.com)

A 20-year-old man presented with a 6-month history of intermittent chest pain. Initial imaging demonstrated approximately 15 sewing needles lodged in his myocardium, predominantly in the left ventricle. The patient has been referred to cardiothoracic surgery for further management. His progress will be monitored closely. S Afr Med J 2016;106(11):1090-1091. DOI:10.7196/SAMJ.2016.v106i11.11057

Case report

A 20-year-old previously healthy man, with no known comorbidities, presented to the triage desk at Edendale Hospital, Pietermaritzburg, South Africa (SA). He complained of a 6-month history of relapsing and remitting, spontaneous-onset chest pain lasting up to 3 days, after which he would experience no symptoms for several weeks at a time. The character of the pain was described as sharp, localised to his left subcostal margin and associated with pain in the tip of the left shoulder and left-hand paraesthesiae (without a specific dermatomal pattern). At about the time of the onset of these symptoms, the patient had experienced a brief psychotic disorder, reporting 2 weeks of visual and auditory hallucinations, grandiose delusions and disorganised speech and behaviour, which had interfered with his everyday life. This was his first and only such episode. Sober habits were reported. The patient had visited his local traditional healer, and reported receiving herbal remedies but no form of surgical intervention. Examination of the patient revealed vital signs that were within normal limits. He was in no form of distress and appeared comfortable, walking without assistance. General examination revealed no abnormalities except for four minute scars, measuring approximately 1 mm in length, which could be seen on his anterior chest, 2.5 cm superior and 1 cm left lateral to the xiphisternum. A prominent pulsation could be seen parasternally within the 5th intercostal space on the left, which was easily palpable. No added heart sounds or murmurs were audible. Thorough clinical examination revealed no further abnormalities. Chest radiographs (posteroanterior and lateral views, Fig. 1, A and B) showed approximately 15 radio-opaque foreign bodies lodged in the mediastinum, localised within what appeared to be the myocardium. Closer inspection of the radiographs showed these to be needles of the type used for sewing. An electrocardiogram showed a minor interference pattern but no ischaemic changes, and the results of blood tests were all within normal limits. An echocardiogram confirmed the presence of foreign bodies in the myocardium (Fig. 2). There was no evidence of valvular defects or pericardial abnormalities, but the needles could be seen moving freely within the myocardium with each contraction. Ultrasound Doppler imaging showed some blood flow into a small space created by one of the needles, indicating possible communication with the ventricular cavity.

Fig. 1. Posteroanterior (A) and lateral (B) chest radiographs. Note radioopaque foreign bodies (arrows).

Fig. 2. Echocardiogram. Note echogenic, linear foreign bodies (arrow).

A computed tomography scan with contrast enhancement was performed (Fig. 3). Although there was evidence of interference, the scan showed the presence and position of the foreign bodies.

December 2016, Print edition

IN PRACTICE

Fig. 3. Computed tomography scan, sagittal section (A) and 3D reconstruction (B).

The patient denied any knowledge of how, or perhaps even why, the needles were lodged within his heart. Although many hypotheses remain, no single theory can completely explain this phenomenon.

Discussion

The finding of a sewing needle (or multiple needles, in some instances) in the media-

stinum appears to be relatively uncommon compared with other foreign bodies, with approximately 160 such cases reported by the late 1980s.[1] Hermoni et al.[2] published a case report in which a 24-year-old man presented to an emergency department with acute-onset, sharp chest pain. Chest radiographs revealed 12 sewing needles, some of which were visi-

December 2016, Print edition

ble within the cardiac silhouette. He required urgent surgery and was discharged within 15 days of hospitalisation. Reported cases in the SA context are limited. One case reported by Sobnach et al.[3] involved an SA patient, with the striking difference being the mechanism of injury, which involved ingestion of the sewing needles with subsequent migration, as opposed to the transthoracic route in our patient. Their patient made a full recovery after a median sternotomy to remove the needles.[3] Ours was a unique case that will require a complex approach to management, but was easily diagnosed by simple chest radiography. The case is a good example of the importance of being vigilant when encountering abnormal presentations of common complaints. A follow-up report will be compiled and submitted for publication after our patient has been fully evaluated and managed by the cardiothoracic surgeons. 1. Actis Dato GM, Arslanian A, di Marzio P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: Report of fourteen cases and review of the literature. J Thorac Cardiovasc Surg 2003;126(2):408-414. http://dx.doi. org/10.1016/S0022-5223(03)00399-4 2. Hermoni Y, Engel PJ, Gallant TE. Sequelae of injury to the heart caused by multiple needles. J Am Coll Cardiol 1986;8(5):12261231. http://dx.doi.org/:10.1016/S0735-1097(86)80405-3 3. Sobnach S, Castillo F, Blanco Vinent R, Kahn D, Bhyat A. Penetrating cardiac injury following sewing needle ingestion. Heart Lung Circ 2011;20(7):479-481. http://dx.doi.org/10.1016/j.hlc.2011.01.006

Accepted 30 May 2015.

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

RESEARCH

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries M F Chersich,1,2 MB BCh, PhD; S Luchters,3,4,5 MB BCh, MSc (Public Health), PhD; D Blaauw,1 MB BCh, FCPHM (SA); F Scorgie,2 MA, PhD; E Kern,1 BA Hons, Dip Information Science; A van den Heever,6 MA (Economics); H Rees,2 MB BChir, MA, MRCGP; E Peach,3 BMBS, MPH, MSES; S Kharadi,7 BSc Hons; S Fonn,8 MB BCh, PhD Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Burnet Institute, Melbourne, Australia 4 Department of Epidemiology and Preventive Medicine, Medicine, Nursing and Health Sciences, Monash University, Australia 5 International Centre for Reproductive Health, Department of Urogynaecology, Faculty of Medicine and Health Sciences, Ghent University, Belgium 6 Wits School of Governance, Faculty of Commerce, Law and Management, University of the Witwatersrand, Johannesburg, South Africa 7 Independent consultant, Toronto, Canada 8 Gender and Health Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 1 2

Corresponding author: M Chersich (mchersich@wrhi.ac.za) Background. Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. Objectives. To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. Methods. Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. Results. Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. Conclusions. Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health. S Afr Med J 2016;106(12):1192-1210. DOI:10.7196/SAMJ.2016.v106i12.12011

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.12011

December 2016, Print edition

RESEARCH

Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal, South Africa N Mngoma,1,2 PhD; S Fergus,1 PhD; A Jeeves,3 PhD; R Jolly,1,4 PhD School of Kinesiology and Health Studies, Faculty of Arts and Science, Queen’s University, Kingston, Ontario, Canada School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada 3 Independent researcher, formerly Department of History, Faculty of Arts and Science, Queen’s University, Kingston, Ontario, Canada 4 Departments of Comparative Literature and English and Bioethics Program, Faculty of the Liberal Arts, Pennsylvania State University, USA 1 2

Corresponding author: N Mngoma (mngoman@yahoo.com) Background. Rates of gender-based violence (GBV) in South Africa (SA) are among the highest in the world. In societies where social ideals of masculinity encourage male dominance and control over women, gender power imbalances contribute to male perpetration and women’s vulnerability. The drivers that cause men to perpetrate GBV and those that lead to HIV overlap and interact in multiple and complex ways. Multiple risk and protective factors for GBV perpetration by males operate interdependently at a number of levels; at the individual level, these include chronic anxiety and depression, which have been shown to lead to risky sexual behaviours. Objectives. (i) To examine psychosocial risk factors (symptoms of anxiety and depression) as well as protective factors (social support and self-esteem) as self-reported by a cohort of males in rural KwaZulu-Natal (KZN) Province, SA; and (ii) to determine whether there are differences in anxiety, depression, social support and self-esteem between perpetrators and non-perpetrators. Methods. A cross-sectional study using quasi-probability cluster sampling of 13 of 28 wards in Harry Gwala District, KZN. Participants were then randomly chosen from each ward proportionate to size. Results. The participants were relatively young (median age 22 years); over half were schoolgoers, and 91.3% had never married. Over 43% of the sample reported clinical levels of anxiety and depressive symptoms on the Brief Symptom Inventory. Rates of GBV perpetration were 60.9%, 23.6% and 10.0% for psychological abuse, non-sexual physical violence and sexual violence, respectively. GBV perpetration was associated with higher depression, higher anxiety, lower self-esteem and lower social support. Conclusions. Interventions to address GBV need to take modifiable individual-level factors into account. S Afr Med J 2016;106(12):1211-1215. DOI:10.7196/SAMJ.2016.v106i12.11383

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.11383

Prevalence and correlates of violence among South African high school learners in uMgungundlovu District municipality, KwaZulu-Natal, South Africa N Khuzwayo, MA; M Taylor, PhD; C Connolly, MPH Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: N Khuzwayo (khuzwayone@ukzn.ac.za) Background. Young people grow up in homes and communities where many are exposed daily to crime and antisocial behaviours. Objective. To investigate the prevalence of violence and the demographic factors associated with such violence among South African (SA) high school learners in the uMgungundlovu District, KwaZulu-Natal, SA.

December 2016, Print edition

RESEARCH

Methods. In a cross-sectional study, we used stratified random sampling to select 16 schools in uMgungundlovu District. All Grade 10 high school learners (N=1 741) completed a self-administered questionnaire (Centers for Disease Control Youth Risk Behavior Survey). Data analysis was carried out using STATA 13 statistical software (Statacorp, USA). Results. Of the participants in this study, 420 (23.9%) had been bullied, 379 (21.7%) had missed school because of feeling unsafe, 468 (15.4%) had been involved in physical fights and 41 (2.4%) had carried weapons to school. There was a significant association between being in a physical fight and missing school (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.9 - 3.3; p<0.001). There were higher odds of male learners carrying weapons than female learners (OR 5.9, 95% CI 2.0 - 15.0). Among learners living in rented rooms, the OR of feeling unsafe was 2.7 (95% CI 0.8 - 3.0), in an informal settlement the OR was 0.8 (95% CI 0.3 - 2.0) and in reconstruction and development programme houses it was 2.7 (95% CI 1.0 - 5.0), compared with learners residing in Zulu homesteads. Conclusions. Violence among learners attending high schools in uMgungundlovu District is a major problem and has consequences for both their academic and social lives. Urgent interventions are required to reduce the rates of violence among high school learners. S Afr Med J 2016;106(12):1216-1221. DOI:10.7196/SAMJ.2016.v106i12.10969

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10969

Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa A Gokhul,1 MB ChB, DCH, FCPaed; P M Jeena,1 MB ChB, FCPaed, FCP Pulmonol; A Gray,2 BPharm, MSc (Pharm), FPS, FFIP Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 2 Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1

Corresponding author: A Gokhul (ashmikagokhul@yahoo.com) Background. Iatrogenic medication errors due to calculation errors are an under-reported concern in children. Objective. To determine the incidence and source of iatrogenic medication errors in a paediatric intensive care unit (PICU). Methods. A prospective study was conducted in the PICU at Inkosi Albert Luthuli Hospital, Durban, South Africa, over a 3-month period in 2014. Medication-related calculation skills of medical practitioners and nurses were assessed through the voluntary anonymous completion of a questionnaire. Medication errors were recorded either spontaneously or by review of all electronic records of admissions. Errors were classified as delays in the decision to prescribe, prescribing mistakes, dispensing errors and administration issues. Results. Of 25 staff members sampled, only 6 (24.0%) were able to complete all medication calculations accurately, while 44.0% (n=11) were unable to answer three or more questions correctly. Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases. Of the errors, 73.8% were detected on chart review and 26.2% by spontaneous reporting. Overall, 89.2% of errors occurred during prescribing, with 10.0% having a â&#x2030;Ľ10-fold increase or decrease in dosage calculations. Only 2.7% of medication errors were reported as resulting in adverse events. Conclusion. Therapeutic skills of healthcare professionals working in the PICU need to be improved to decrease iatrogenic medication errors. S Afr Med J 2016;106(12):1222-1229. DOI:10.7196/SAMJ.2016.v106i12.10940

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10940

December 2016, Print edition

RESEARCH

Risk factors for unsuccessful lumbar puncture in children C Procter,1,2 MBBS, FCPaed (SA); H Buys,1,2 MB ChB, FCPaed (SA); H Carrara,3 MPH; J Thomas,1,4 MB ChB, FFA Red Cross War Memorial Childrenâ&#x20AC;&#x2122;s Hospital, Cape Town, South Africa Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa 3 School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 4 Department of Anaesthesia, Faculty of Health Sciences, University of Cape Town, South Africa 1 2

Corresponding author: C Procter (clairemprocter@gmail.com) Background. This descriptive study provides the first information on an association between the use of sedation and a reduction in the prevalence of unsuccessful lumbar puncture (LP) in African children of all races. Objective. Our hypothesis was that children who do not receive any procedural sedation are more likely to have unsuccessful LPs. Methods. A cross-sectional observational study examined LPs performed from February to April 2013, including details of the procedure, sedation or analgesia used, and techniques. The setting was the Medical Emergency Unit at Red Cross War Memorial Childrenâ&#x20AC;&#x2122;s Hospital, Cape Town, South Africa, and the participants all children aged 0 - 13 years who had an LP in the unit during the time period. Results. Of 350 children, 62.9% were <12 months of age, the median age being 4.8 months (interquartile range 1.5 - 21.7). The prevalence of unsuccessful (traumatic or dry) LP was 32.3% (113/350). Sedation was used in 107 children (30.6%) and was associated with a reduction in the likelihood of unsuccessful LP (p=0.002; risk ratio (RR) 0.5 (95% confidence interval (CI) 0.34 - 0.78)) except in those <3 months of age, where sedation did not significantly reduce the likelihood (p=0.56; RR 1.20 (95% CI 0.66 - 2.18)). Conclusions. Unsuccessful LP was common. Sedation was not routinely used, but the results suggest that it may be associated with a reduction in the rate of unsuccessful LP. Unsuccessful LP may lead to diagnostic uncertainty, prolonged hospitalisation and unnecessary antibiotic use. Whether a procedural sedation protocol would reduce the rate of unsuccessful LP requires further study. S Afr Med J 2016;106(12):1230-1235. DOI:10.7196/SAMJ.2016.v106i12.10703

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10703

Evaluating point-of-care testing for glycosylated haemoglobin in public sector primary care facilities in the Western Cape, South Africa R Mash,1 MB ChB, FCFP, FRCGP, PhD; A Ugoagwu,1 MB ChB, MMed; C Vos,1 MB ChB, MMed; M Rensburg,2 MB ChB, MMed; R Erasmus,2 MBBS, FMCPath (Nig), DABCC, DHSM, FCPath (SA) 1 2

Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Division of Chemical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Corresponding author: R Mash (rm@sun.ac.za) Background. Diabetes mellitus contributes significantly to the burden of disease in South Africa (SA). Monitoring of glycaemic control with glycosylated haemoglobin (HbA1c) is recommended, even though current laboratory-based testing does not support immediate clinical decision-making. Objective. To evaluate the costs and consequences for quality of care by introducing point-of-care (POC) testing for HbA1c for patients with type 2 diabetes at community health centres in Cape Town, SA. Methods. A quasi-experimental study was conducted at two control and two intervention sites in the same sub-district. The DCA Vantage Analyzer (Siemens, Germany) for POC testing was introduced at the intervention sites for 12 months. Patients were randomly selected from the diabetes register at the intervention (n=300) and control (n=300) sites, respectively, and data were collected from patient records at baseline and 12 months. Focus group interviews were performed at the intervention sites. Technical quality and cost implications were evaluated.

December 2016, Print edition

RESEARCH

Results. POC testing was feasible, easy to integrate into the organisation of care, resulted in more immediate feedback to patients (p<0.001) and patients appeared more satisfied. POC testing did not improve test coverage, treatment intensification, counselling or glycaemic control. There was an incremental cost of ZAR2 110 per 100 tests. Compliance with quality control was poor, although control tests showed good reliability. Conclusion. This study does not support the introduction of POC testing for HbA1c in public sector primary care practice in the current context. POC testing should be evaluated further in combination with interventions to overcome clinical inertia and strengthen primary healthcare. S Afr Med J 2016;106(12):1236-1240. DOI:10.7196/SAMJ.2016.v106i12.10728

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10728

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa N Folb,1,2,3 MB ChB, MRCGP (UK); M O Bachmann,4 MB ChB, PhD, FFPH (UK); E D Bateman,1,2,3 MB ChB, MD, FRCP (UK); K Steyn,2,3 MSc, NED, MD; N S Levitt,2,3 MB ChB, MD, FCP (SA); V Timmerman,1 PhD; C Lombard,5 MSc, PhD; T A Gaziano,3,6 MD, MSc; L R Fairall,1,2,3 MB ChB, PhD University of Cape Town Lung Institute, Groote Schuur Hospital, Cape Town, South Africa Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 4 Department of Population Health and Primary Care, Norwich Medical School, Faculty of Medicine and Health, University of East Anglia, UK 5 Biostatistics Unit, South African Medical Research Council, Cape Town, and School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 6 Division of Cardiovascular Medicine, Brigham & Women’s Hospital, Boston, Mass., USA 1 2

Corresponding author: N Folb (naomi.folb@uct.ac.za) Background. Low socioeconomic status is associated with the risk of hypertension. There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). Objective. To investigate associations between patients’ socioeconomic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. Methods. We enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for antihypertension medications were recorded at baseline and follow-up. Logistic regression models assessed associations between patients’ socioeconomic status, characteristics of primary healthcare facilities, and control and treatment of blood pressure. Results. Blood pressure was uncontrolled in 60% (1 917/3 220) of patients at baseline, which was less likely in patients with a higher level of education (p=0.001) and in English compared with Afrikaans respondents (p=0.033). Treatment was intensified in 48% (892/1 872) of patients with uncontrolled blood pressure at baseline, which was more likely in patients with higher blood pressure at baseline (p<0.001), concurrent diabetes (p=0.013), more education (p=0.020), and those who attended clinics offering off-site drug supply (p=0.009), with a doctor every day (p=0.004), or with more nurses (p<0.001). Conclusion. Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics. S Afr Med J 2016;106(12):1241-1246. DOI:10.7196/SAMJ.2016.v106i12.12005

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.12005

December 2016, Print edition

RESEARCH

Awareness, perceived risk and practices related to cervical cancer and Pap smear screening: A crosssectional study among HIV-positive women attending an urban HIV clinic in Johannesburg, South Africa I Mokhele,1 BSc, MSc; D Evans,2 DBiomed; K Schnippel,1,3 MPA; A Swarts,3 MSc; J S Smith,4 BA, MPH, PhD; C Firnhaber,1,3 MD, MS, DTM&H Right to Care, Johannesburg, South Africa Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 4 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA 1 2

Corresponding author: I Mokhele (idah.mokhele@gmail.com) Background. Cervical cancer is a major cause of cancer-related deaths, especially in the context of the HIV epidemic. Objective. To examine awareness, perceived risk and practices related to cervical cancer screening among HIV-positive women. Methods. Interviewer-administered structured questionnaires were administered to HIV-positive women (aged ≥18 years) enrolled in a cervical cancer screening study at the Themba Lethu Clinic, Johannesburg, South Africa, from November 2009 to December 2011. Modified Poisson regression with robust standard errors was used to identify factors at enrolment associated with awareness, perceived risk and adequate practice related to cervical screening. Adjusted relative risks (aRRs) with 95% confidence intervals (CIs) are presented. Results. Of the 1 202 women enrolled, 71.3% and 18.2% were aware of the Pap smear and HPV, respectively. Of the 1 192 participants with data evaluated, 76.5% were worried and 23.5% were not worried about cervical cancer; 28.6% of the women had adequate screening practice. Older age (40 - 49 years or ≥50 years v. 18 - 29 years) (aRR 1.63, 95% CI 1.12 - 2.37; aRR 2.22, 95% CI 1.44 - 3.41), higher education (tertiary v. less than grade 10) (aRR 1.39, 95% CI 1.00 - 1.93), initiation on combination antiretroviral therapy (aRR 1.36, 95% CI 1.00 - 1.85) and awareness of Pap smear screening (aRR 16.18, 95% CI 7.69 - 34.01) were associated with adequate screening practice. Conclusions. High levels of Pap smear awareness and low levels of Pap smear screening uptake were observed. However, Pap smear awareness was associated with adequate screening practice. More research into effective health education programmes to address these gaps is needed. S Afr Med J 2016;106(12):1247-1253. DOI:10.7196/SAMJ.2016.v106i12.11224

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.11224

Mutations of mtDNA polymerase-γ and hyperlactataemia in the HIV-infected Zulu population of South Africa D B A Ojwach,1,2 BSc Hons, MMedSci; C Aldous,2 PhD; P Kocheleff,3 MB ChB; B Sartorius,4 BSc, BSc Hons, MSc, EPIET, PhD Discipline of Genetics and Microbiology, School of Life Sciences, College of Agriculture, Engineering and Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa 2 Discipline of Clinical Genetics, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Health Systems Trust, Pietermaritzburg, South Africa 4 Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1

Corresponding author: D B A Ojwach (dtyachieng@hotmail.com)

December 2016, Print edition

RESEARCH

Background. Mitochondrial toxicity, particularly symptomatic hyperlactataemia or lactic acidosis (SHL/LA), has been attributed to the use of nucleoside reverse transcriptase inhibitors (NRTIs), possibly because of their capacity to impede human mitochondrial DNA polymerase-γ (POLG), which is responsible for the replication of mitochondrial DNA. Objective. To determine whether known monogenic POLG1 polymorphisms could be linked with the unexpectedly high incidence of SHL/ LA observed in HIV-infected Zulu-speaking patients exposed to the NRTIs stavudine or zidovudine in their antiretroviral therapy. Methods. One hundred and sixteen patients from Edendale Hospital, Pietermaritzburg, South Africa, participated in the study between March and August 2014. Fifty-nine symptomatic cases were compared with 57 non-symptomatic controls on stavudine for ≥24 months. Among the symptomatic patients, 13 had SHL with measured lactate between 3.0 and 4.99 mmol/L, and 46 had LA with a lactate level ≥5 mmol/L. Genomic DNA from 113 samples was used for subsequent allelic discrimination polymerase chain reaction screening for the R964C and E1143G single-nucleotide polymorphisms of POLG1. Sequencing was performed for 40/113 randomly selected samples for confirmation of the genotyping results. Results. Neither of the two known POLG1 mutations was observed. The cases presented with SHL/LA between 4 and 18 months on stavudine. Females (70.4%) were significantly (p<0.001) more likely to be cases (adjusted odds ratio 24.24, 95% CI 5.14 - 114.25) compared with males. Conclusion. This study has shown that our sample of the Zulu-speaking population does not exhibit a genetic predisposition to SHL/LA associated with known monogenic POLG1 mutations, indicating another possible predisposing factor for increased risk of SHL/LA. S Afr Med J 2016;106(12):1254-1259. DOI:10.7196/SAMJ.2016.v106i12.10818

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10818

Screening for calreticulin mutations in a cohort of patients suspected of having a myeloproliferative neoplasm A de Kock, PhD; C Booysen, BMedSc Hons Haematology Department, Tissue Typing Laboratory, Universitas Academic Hospital, Bloemfontein, South Africa Corresponding author: A de Kock (dekocka@ufs.ac.za) Background. The discovery of calreticulin (CALR) has shown it to be the second most frequent mutation after the Janus Kinase 2 (JAK2) mutation in myeloproliferative neoplasms (MPNs). Its structure indicates various functions, of which two are to ensure calcium homeostasis and proper folding of other target proteins. Over 36 types of CALR mutations have been identified, all causing a recurrent frameshift in the C-terminal domain affecting CALR’s localisation and calcium-binding function. Objective. To screen a cohort of 89 patients suspected of having an MPN for the CALR mutations. Methods. Capillary and gel electrophoresis were used in conjunction as confirmatory tests to screen the cohort of patients. Results. Of three samples containing a type 1 CALR mutation, two were heterozygous and one homozygous for a 52-base pair deletion in CALR. Conclusions. Most studies report CALR mutations to be present only in patients with primary myelofibrosis or essential thrombocythaemia, with mutual exclusivity to JAK2 mutations. The findings of this study indicate that JAK2 and CALR mutations are no longer considered mutually exclusive. Similarly, patients with a polycythaemia vera phenotype could also carry a CALR mutation. S Afr Med J 2016;106(12):1260-1262. DOI:10.7196/SAMJ.2016.v106i12.10769

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10769

December 2016, Print edition

RESEARCH

The mass miniature chest radiography programme in Cape Town, South Africa, 1948 - 1994: The impact of active tuberculosis case finding S M Hermans,1,2,3 MD, MSc, PhD; J R Andrews,4 MD, SM; L-G Bekker,1,5 FCP (SA), PhD; R Wood,1,5,6 FCP (SA), DSc (Med) Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Netherlands 3 Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda 4 Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Calif., USA 5 Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 6 Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK 1 2

Corresponding author: S M Hermans (sabine.hermans@hiv-research.org.za) Background. Tuberculosis (TB) control programmes rely mainly on passive detection of symptomatic individuals. The resurgence of TB has rekindled interest in active case finding. Cape Town (South Africa) had a mass miniature radiography (MMR) screening programme from 1948 to 1994. Objective. To evaluate screening coverage, yield and secular trends in TB notifications during the MMR programme. Methods. We performed an ecological analysis of the MMR programme and TB notification data from the City of Cape Town Medical Officer of Health reports for 1948 - 1994. Results. Between 1948 and 1962, MMR screening increased to 12% of the population per annum with yields of 14 cases per 1 000 X-rays performed, accounting for >20% of total annual TB notifications. Concurrent with increasing coverage (1948 - 1965), TB case notification decreased in the most heavily TB-burdened non-European population from 844/100 000 population to 415/100 000. After 1966, coverage declined and TB notifications that initially remained stable (1967 - 1978) subsequently increased to 525/100 000. MMR yields remained low in the European population but declined rapidly in the non-European population after 1966, coincidental with forced removals from District 6. An inverse relationship between screening coverage and TB notification rates was observed in the non-European adult population. Similar secular trends occurred in infants and young children who were not part of the MMR screening programme. Conclusion. MMR of a high-burdened population may have significantly contributed to TB control and was temporally associated with decreased transmission to infants and children. These historical findings emphasise the importance of re-exploring targeted active case finding strategies as part of population TB control. S Afr Med J 2016;106(12):1263-1269. DOI:10.7196/SAMJ.2016.v106i12.10744

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i12.10744

December 2016, Print edition

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The CPD programme for SAMJ is administered by Medical Practice Consulting. CPD questionnaires must be completed online at www.mpconsulting.co.za.

True (A) or false (B): SAMJ Safeguarding maternal and child health in South Africa (SA) by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries 1. Only 14% of pregnant women in the poorest quartile are employed, either in the informal or the formal sector. 2. Eligibility (for the SA Child Support Grant) is based on a means test, and currently there are over 10 million beneficiaries. Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal (KZN), SA 3. Rates of gender-based violence (GBV) in SA are among the lowest in the world. 4. Up to 77% of women in Limpopo Province have experienced some form of GBV during their lifetime. Prevalence and correlates of violence among SA high-school learners in KZN 5. In this survey, one in five learners (22%) had experienced some form of violence while at school. 6. Violence among young people is associated with depression, unwanted teenage pregnancy and HIV. Evaluating point-of-care testing for glycosylated haemoglobin (HbA1c) in public sector primary care facilities in the Western Cape, SA 7. The estimated prevalence of diabetes mellitus in SA is 6.5% among adults aged 20 - 79 years. 8. Small but sustained reductions in HbA1c can lead to a significant reduction in the risk of complications.

CME Developing an understanding of fatal child abuse and neglect: Lessons from the SA child death review pilot study 11. Sudden, unexpected and unexplained deaths are natural deaths. 12. All unnatural deaths must be referred to the Forensic Pathology Service. 13. Overlaying in infants is a natural death in SA. 14. A child abuse death must be reported using a Form 22 to the Department of Social Development. Maternal mental health and the first 1 000 days 15. Women are relatively protected from domestic violence during pregnancy. 16. The potential risks of antidepressant treatment for the fetus far exceed the risks for the fetus of untreated maternal anxiety during pregnancy. 17. Mothers with common mental health problems need to be managed by mental health specialists. Using a child rights approach to strengthen prevention of violence against children 18. Girls are more likely than boys to experience sexual abuse. 19. Exposure to â&#x20AC;&#x2DC;toxic stressâ&#x20AC;&#x2122; in early childhood can drive an intergenerational cycle of violence. 20. Child abuse can only be reported on a J88 form.

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, SA 9. Low socioeconomic status was associated with the risk of hypertension. 10. Uncontrolled blood pressure was less likely in patients with a higher level of education.

Readers please note: articles may appear in summary/abstract form in the print edition of the Journal, with the full article available online at www.samj.org.za

A maximum of 3 CEUs will be awarded per correctly completed test.

INSTRUCTIONS 1. Read the journal. All the answers will be found there, in print or online. 2. Go to www.mpconsulting.co.za to answer the questions. Accreditation number: MDB015/038/01/2016

December 2016, Print edition

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GUEST EDITORIAL Women, gender-based violence and HIV CME Child abuse IN PRACTICE Male circumcision – policy and law CASE REPORT Psychosis in neurosyphilis RESEARCH

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Gender-based violence risk among men in rural KwaZulu-Natal Safeguarding child and maternal health in South Africa

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