Role of pharmacists in the provision of palliative care services and support in South Africa.

OBJECTIVES: South Africa (SA) has high demand but inequitable access to palliative care (PC). Realising this need and the growing recognition of pharmacists' in PC globally, a study was undertaken regarding the role of pharmacists in the provision of PC services and support in SA. METHOD: A descriptive cross-sectional quantitative study was conducted among 540 community and hospital pharmacists. A self-administered, closed-ended questionnaire covering knowledge, attitude, current role, future role and barriers to PC was used. Data was coded and analysed using SPSS® Version 24.0. P-values < 0.05 were considered statistically significant. KEY FINDINGS: Response rate was 48.7% (n = 263). Pharmacists (72.2%) were already playing a role in PC, however, only 20.5% reported frequent involvement in PC. Services provided included medicine supply (88.2%), side-effect/symptom management (82.1%), information sharing (60.8%), bereavement counselling (60.8%), treatment/care needs (57.4%) and spiritual support (52.1%). More pharmacists (96.6%) wanted to play a role in PC, beyond medicine supply to include PC team member (91.6%), medicine reviews (91.3%), referrals (80.2%) and patient visits (50.6%). Pharmacists had a good knowledge (71.4%) and a positive attitude (61.5%) towards PC despite many health system barriers such as lack of training (91.3%), inadequate clinical experience (90.5%) and insufficient resources (77.2%). CONCLUSIONS: Pharmacists with their high level of knowledge, positive attitude and broad scope of practice are well-placed to play a role in PC. Further strengthening and integration of their roles into the continuum of care, will encourage the involvement of more pharmacists, enhancing availability, access and resources for PC.

High laboratory cost predicted per tuberculosis case diagnosed with increased case finding without a triage strategy.

SETTING: Cape Town, South Africa. OBJECTIVE: To model the effects of increased case finding and triage strategies on laboratory costs per tuberculosis (TB) case diagnosed. METHODS: We used a validated operational model and published laboratory cost data. We modelled the effect of varying the proportion with TB among presumptive cases and Xpert cartridge price reductions on cost per TB case and per additional TB case diagnosed in the Xpert-based vs. smear/culture-based algorithms. RESULTS: In our current scenario (18.3% with TB among presumptive cases), the proportion of cases diagnosed increased by 8.7% (16.7% vs. 15.0%), and the cost per case diagnosed increased by 142% (US$121 vs. US$50). The cost per additional case diagnosed was US$986. This would increase to US$1619 if the proportion with TB among presumptive cases was 10.6%. At 25.9-30.8% of TB prevalence among presumptive cases and a 50% reduction in Xpert cartridge price, the cost per TB case diagnosed would range from US$50 to US$59 (comparable to the US$48.77 found in routine practice with smear/culture). CONCLUSION: The operational model illustrates the effect of increased case finding on laboratory costs per TB case diagnosed. Unless triage strategies are identified, the approach will not be sustainable, even if Xpert cartridge prices are reduced.

HIV/AIDS-associated Kaposi's sarcoma of the gastrointestinal tract: A pictorial spectrum.

We briefly report two cases of HIV/AIDS-associated Kaposi's sarcoma affecting the gastrointestinal tract. Both patients were seen at Edenvale General Hospital, Johannesburg, South Africa.

HIV, vascular surgery and cardiovascular outcomes: a South African cohort study.

Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. When compared with HIV-negative patients, the HIV-positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0-5 [0-2]) vs 0 (0-2 [0-0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p = 0.78); three-day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.

Establishing a health promotion and development foundation in South Africa.

South Africa has a 'quadruple burden of disease'. One way to reduce this burden, and address the social determinants of health and social inequity, could be through health promotion interventions driven by an independent Health Promotion and Development Foundation (HPDF). This could provide a framework to integrate health promotion and social development into all government and civil society programmes. On priority issues, the HPDF would mobilise resources, allocate funding, develop capacity, and monitor and evaluate health promotion and development work. Emphasis would be on reducing the effects of poverty, inequity and unequal development on disease rates and wellbeing. The HPDF could also decrease the burden on the proposed National Health Insurance (NHI) system. We reflect on such foundations in other countries, and propose a structure for South Africa's HPDF and a dedicated funding stream to support its activities. In particular, an additional 2% levy on alcohol and tobacco products is proposed to be utilised to fund the HPDF.

What is the best pre-operative risk stratification tool for major adverse cardiac events following elective vascular surgery? A prospective observational cohort study evaluating pre-operative myocardial ischaemia monitoring and biomarker analysis.

Although brain natriuretic peptide has been shown to be superior to the revised cardiac risk index for risk stratification of vascular surgical patients, it remains unknown whether it is superior to alternative dynamic risk predictors, such as other pre-operative biomarkers (C-reactive protein and troponins) or myocardial ischaemia monitoring. The aim of this prospective observational study was to determine the relative clinical utility of these risk predictors for the prediction of postoperative cardiac events in elective vascular surgical patients. Only pre-operative troponin elevation (OR 56.8, 95% CI 6.5-496.0, p < 0.001) and brain natriuretic peptide above the optimal discriminatory point (OR 6.0, 95% CI 2.7-12.9, p < 0.001) were independently associated with cardiac events. Both brain natriuretic peptide and troponin risk stratification significantly improved overall net reclassification (74.6% (95% CI 51.6%-97.5%) and 38.5% (95% CI 22.4-54.6%, respectively)); however, troponin stratification decreased the correct classification of patients with cardiac complications (-59%, p < 0.001). Pre-operative brain natriuretic peptide evaluation was the only clinically useful predictor of postoperative cardiac complications.

The role of brain natriuretic peptide in prognostication and reclassification of risk in patients undergoing vascular surgery.

The aim of this study was to determine whether measurement of pre-operative brain natriuretic peptide can significantly improve risk stratification of vascular surgical patients. The study endpoint was postoperative raised troponins. Net reclassification improvement was determined for risk categories based on the Revised Cardiac Risk Index. Two reclassifications were conducted based on either the optimal discriminatory point or brain natriuretic peptide tertiles. Two hundred and sixty-seven patients were studied of whom 36 (13.5%) had raised postoperative troponin. The Revised Cardiac Risk Index score and the pre-operative brain natriuretic peptide were independent predictors of postoperative troponin elevation (p = 0.02 and p = 0.001, respectively). Reclassification based on the optimal discriminatory point significantly improved risk stratification (net reclassification improvement 38.3% (95% CI 9.3-67.3%), p = 0.01 for the entire cohort and 70.3% (95% CI 27.1-113.6%), p = 0.002 for intermediate risk patients). The brain natriuretic peptide tertiles only improved stratification of intermediate risk patients (net reclassification improvement 50.0% (95% CI 16.7-83.3%), p = 0.01). We have shown that measurement of pre-operative brain natriuretic peptide is relevant in the context of risk assessment in this cohort of patients.

Pyogenic abscess complicating a resolving cerebral haematoma secondary to a cavernous haemangioma: computed tomography and magnetic resonance imaging findings.

A case is discussed of a brain abscess complicating an intracerebral haemorrhage occurring in a cavernous haemangioma. A young child presented with focal seizures as a result of a large intracerebral haemorrhage, occurring in a cavernous haemangioma. The only clue to the underlying vascular malformation was the presence of an associated developmental venous anomaly. The case was complicated by the development of a brain abscess at the site of the intracranial haematoma. The CT and MRI findings are discussed.

Lymphoepithelioma-like carcinoma of the breast with associated sclerosing lymphocytic lobulitis.

The purpose of this article is to highlight an unusual form of breast carcinoma and discuss its differential diagnosis. A 50-year-old woman underwent wide local excision of a breast lump. Microscopic examination revealed features of a lymphoepithelioma-like carcinoma. Individual tumor cells were present within an abundant lymphoid stroma. Immunohistochemistry revealed the epithelial nature of the cells and excluded a diagnosis of lymphoma. In addition, surrounding nontumorous breast tissue displayed the histologic features of sclerosing lymphocytic lobulitis or lymphocytic mastopathy. This is the second report of a lymphoepithelioma-like carcinoma of the breast, but to the best of our knowledge, it is the first description of coexistent sclerosing lymphocytic lobulitis.

Bowel preparation for colonoscopy: a randomized prospective trail comparing sodium phosphate and polyethylene glycol in a predominantly elderly population.

Many patients find polyethylene glycol-based preparations (PEG) difficult to take because of the large volume of fluid they are required to consume. One hundred and sixteen predominantly elderly patients were randomized to receive either sodium phosphate (n = 61) or PEG (n = 55) bowel preparations before colonoscopy. Patients with a history of symptomatic ischaemic heart disease or cerebrovascular disease in the preceding 6 months, severe liver disease or heart failure, or serum creatinine above 200 micrograms/L were excluded from the study. Each patient filled in a questionnaire about the bowel preparation prior to the procedure. The colonoscopists, who were not aware which preparation had been used, were asked to complete a questionnaire about the quality of the bowel preparation after the procedure. The patients found the sodium phosphate preparation slightly more tolerable than PEG. Side effects were slightly more common with sodium phosphate. Neither difference was statistically significant. However, 91% of patients who had previously had PEG found sodium phosphate easier to take. Approximately 25% of patients in each group experienced at least one episode of incontinence. The colonoscopists found no difference in the overall quality of the bowel preparation. The amount of fluid in the colon was greater in patients prepared with PEG. As expected, patients taking sodium phosphate developed hyperphosphataemia (mean phosphate level before colonoscopy 1.56 mmol/L, normal 0.8 -1.3). They also had a lower mean serum potassium level (3.8 mmol/L) than the PEG group (4.2 mmol/L). However, there were no clinically significant consequences. Sodium phosphate was a safe and effective bowel preparation for colonoscopy in this carefully selected group of patients. It was preferred by patients who had previously had PEG. Many elderly patients were found to develop faecal incontinence, irrespective of the type of bowel preparation used.

Still's disease in an adult. A case report.

A Black woman presented with pyrexia of unknown origin. Exhaustive investigations to rule out infection, a malignant tumour or a connective tissue disease were performed. The diagnosis of adult Still's disease was made a year after presentation.

Penicillamine-induced myasthenia gravis in a patient with rheumatoid arthritis. A case report.

This article reports some observations made in a woman who developed myasthenia gravis after treatment with D-penicillamine. Withdrawal of the drug was not followed by spontaneous remission of the myasthenic syndrome.

Cystinosis with Fanconi's syndrome. A case report.

A 19-year-old girl suffering from the nephropathic form of cystinosis presented with the full clinical and biochemical picture of Fanconi's syndrome. Polyuria, polydipsia and photophobia associated with severe growth retardation and rickets were the main clinical features. The essential biochemical abnormalities consisted of hypophosphataemia, hypokalaemia and hypo-uricaemia together with a systemic acidosis and a reduced creatinine clearance rate. There was generalized amino-aciduria, glycosuria and bicarbonaturia. In addition, the fractional excretion of potassium, phosphate and uric acid was significantly increased. Slit-lamp examination of the cornea and histological examination of the conjuctiva, liver, bone marrow and kidney demonstrated cystine crystals.

Fanconi's syndrome in an adult. A case history.

A case of the Fanconi syndrome in an adult presenting with life-threatening hypokalaemia is described. Amino-aciduria, glycosuria, high phosphate and uric acid clearances with reduced plasma levels of these two substances, reduced urinary concentrating power and abnormal urinary potassium loss with a systemic acidosis, were the essential biochemical abnormalities. Osteomalacia was shown by a radiological bone survey.