Cross-sectional study of acral melanoma awareness in a group of South African final phase medical students.

BACKGROUND: Acral melanoma refers to melanoma arising on the palms, soles and nail unit, which are sun-protected areas and ultraviolet exposure is not a risk factor. Acral melanoma is associated with a poorer prognosis than other melanoma subtypes most likely due to the high rates of delayed diagnosis. Acral melanoma affects all skin types equally. There is a misconception that people with more pigmented skin types (Fitzpatrick 4-6) do not develop melanoma, due to the protective effect of melanin. OBJECTIVES: The aim of the study was to determine acral melanoma knowledge and awareness of a group of South African, final phase medical students. METHODS: This was a quantitative and cross-sectional study. A questionnaire consisting of 20 clinical images of skin lesions requiring a diagnosis and management plan was distributed. Responses to six images of melanomas were analysed. Further questions to measure acral melanoma knowledge and related issues were included in the study. A biostatistician appropriately managed statistical analysis. RESULTS: Hundred and one final phase medical students' answers were gathered and analysed. Only 7.9% of the participants diagnosed all six melanomas correctly; 61.4% correctly diagnosed ≥50% of the melanomas. While 77.2% of the participants identified all non-acral cutaneous melanoma correctly, only 8.9% identified all acral melanomas. However, of all participants making the correct diagnosis, >90% selected the appropriate management plan (urgent referral). LIMITATIONS: This study examined a small sample of trainee healthcare workers. The results cannot be assumed to apply to all South African healthcare workers. Responses given in a questionnaire may not reflect actual behaviour. The dermatology division in question has made acral melanoma a research priority, thus acral melanoma knowledge in this group may in fact be better than in other institutions. CONCLUSION: The present study demonstrates that groups of imminent doctors have low rates of recognition of melanoma, particularly acral melanoma. This is consistent with high levels of primary misdiagnosis of acral melanoma reported in the literature. Fortunately, these participants managed the melanomas they diagnosed appropriately in >90% of cases. This confirms that the deficit in the participant group is awareness and knowledge. Those aware of the disease immediately acknowledged the need for urgent referral.

Patterns of leprosy at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, and review of current clinical practice.

BACKGROUND: The World Health Organization announced a strategy to eliminate childhood leprosy infections, visible deformities and discriminatory legislation against leprosy patients by 2020. However, challenges in achieving a leprosy-free world and preventing neurological sequelae still exist. HIV infection is a challenge in South Africa (SA). HIV-leprosy co-infection may result in an increase in the frequency of leprosy reactions without affecting the spectrum of leprosy. From 1921 to 1997, the prevalence of leprosy remained <1 patient per 10 000 population. Current SA literature has very scanty information regarding leprosy infections. OBJECTIVES: To describe the trend of new leprosy patients at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, from 1999 to 2015, including demographics, clinical spectrum and treatment outcomes. METHODS: A retrospective review of patients' clinical records was undertaken. Data on demographics, clinical spectrum including the leprosy classification, reactions, neurological involvement, association with HIV infection and treatment outcomes were extracted. Data analysis was performed using descriptive and inferential statistics and a time series analysis. RESULTS: An upward trend from 1999 to 2001 was followed by a decline in the number of new patients. Eighty patients were registered over a period of 17 years, with a male-to-female ratio of 3:1. Thirty-six patients were immigrants, and 5 were children aged <15 years. Multibacillary leprosy was the most common type (n=71 patients). Thirty-six patients had the lepromatous leprosy subtype, 22 were borderline lepromatous, 13 were borderline tuberculoid, 6 were borderline borderline, and 3 had tuberculoid leprosy. Thirty-one patients presented with reactions, type 1 in 9 patients and type 2 in 21 patients, with both types in 1 patient. Grade 2 neurological deformities were diagnosed in 37 patients, of whom 2 were children. Eight patients were found to have HIV-leprosy co-infection. Of 52 patients who completed treatment, 26 were cured and 26 were lost to follow-up. Twenty-one patients defaulted from treatment, while 3 patients relapsed. CONCLUSIONS: This study highlights the current status of leprosy in a low-endemic centre with declining numbers of new patients. Multibacillary forms with grade 2 disabilities (G2Ds) are common. The constant emergence of leprosy in our population highlights shortfalls in our control campaigns. Furthermore, a high rate of G2Ds necessitates scrutiny of education directed at early patient detection and follow-up strategies.

Epidemiology of lobomycosis-like disease in bottlenose dolphins Tursiops spp. from South America and southern Africa.

We report on the epidemiology of lobomycosis-like disease (LLD), a cutaneous disorder evoking lobomycosis, in 658 common bottlenose dolphins Tursiops truncatus from South America and 94 Indo-Pacific bottlenose dolphins T. aduncus from southern Africa. Photographs and stranding records of 387 inshore residents, 60 inshore non-residents and 305 specimens of undetermined origin (inshore and offshore) were examined for the presence of LLD lesions from 2004 to 2015. Seventeen residents, 3 non-residents and 1 inshore dolphin of unknown residence status were positive. LLD lesions appeared as single or multiple, light grey to whitish nodules and plaques that may ulcerate and increase in size over time. Among resident dolphins, prevalence varied significantly among 4 communities, being low in Posorja (2.35%, n = 85), Ecuador, and high in Salinas, Ecuador (16.7%, n = 18), and Laguna, Brazil (14.3%, n = 42). LLD prevalence increased in 36 T. truncatus from Laguna from 5.6% in 2007-2009 to 13.9% in 2013-2014, albeit not significantly. The disease has persisted for years in dolphins from Mayotte, Laguna, Salinas, the Sanquianga National Park and Bahía Málaga (Colombia) but vanished from the Tramandaí Estuary and the Mampituba River (Brazil). The geographical range of LLD has expanded in Brazil, South Africa and Ecuador, in areas that have been regularly surveyed for 10 to 35 yr. Two of the 21 LLD-affected dolphins were found dead with extensive lesions in southern Brazil, and 2 others disappeared, and presumably died, in Ecuador. These observations stress the need for targeted epidemiological, histological and molecular studies of LLD in dolphins, especially in the Southern Hemisphere.

Avoiding misperceptions: classifying rehabilitation projects using letters rather than numbers.

A classification system proposed earlier of the many different known rehabilitation approaches and activities used a quantitative scoring system, thus giving the impression that projects with a higher score were better, more correct or more important than projects with a lower score. We therefore propose an alternative classification based on letters, so that a given combination of letters characterizes a particular type of project. The letters are derived from four dimensions: desired outcome of the intervention, participation of the clients in the rehabilitation process, the target group served and the services offered. Some examples are presented. The classification serves to analyse rehabilitation projects, to define policy and as a starting point for evaluation.

Leprosy in Mpumalanga Province, South Africa--eliminated or hidden?

In South Africa, leprosy has been a notifiable condition since 1921. Although the WHO elimination target of less than one case per 10,000 population has been achieved at country level, the distribution of leprosy in the country is distinctly heterogeneous, with a prominent 'leprosy belt' of greater prevalence stretching across Mpumalanga Province into northern Kwa-Zulu Natal. The highest prevalence in this 'belt' has historically been in Ermelo District. Recent trends of few newly detected leprosy patients in this district raised concerns that health system changes may have resulted in failure to detect leprosy cases. Thus a large-scale community awareness campaign was conducted followed by an intensively advertised screening programme of 3-month duration at schools and central gathering points in villages and farms from 1 June to 31 August 2000. One thousand one hundred and seventy-seven people presented for clinical screening at designated points, while 790 scholars were screened at schools and an additional 1433 people were screened at their homes by the field team. Forty-four people with skin or nervous system lesions compatible with leprosy were referred for specialized assessment and biopsy where indicated. Four new leprosy patients were diagnosed, including an elderly lady with pronounced disability. Two of these patients had prior contact with the health service due to dermatological manifestations of leprosy without diagnosis being made. All patients provided a history of close prolonged contact with known leprosy patients. Ongoing intense tracing and follow-up of close contacts of proven leprosy cases may be a more efficient method of detecting leprosy cases in areas with relatively stable populations that have accomplished 'leprosy elimination', than resource intensive community surveys.

Bophuthatswana's contribution towards the elimination of leprosy as a public health problem in southern Africa by the year 2000.

Before independence in December 1977, the control of leprosy in Bophuthatswana was conducted by specialized centres such as Mjanyana, Mkambati, Westfort, etc in the Republic of South Africa. As a result of this 'verticalization', very few cases of leprosy were diagnosed and treated in the general and/or community hospitals. Professional awareness of the disease in these institutions decreased and stigmatization of its sufferers by the community increased. In 1989, the first leprosy control programme based on the multidrug therapy as recommended by the World Health Organization was jointly launched by the Leprosy Mission of Southern Africa and the Bophuthatswana Department of Health and Social Services. The initial leprosy database for the programme was provided by the review of the medical records at Westfort Hospital (the only leprosy referral centre in the region) from 1973 to 1988 (15 years). This article reviews the epidemiologic course of leprosy in Bophuthatswana as it has evolved over the last 15 years, prior to the launching of the programme in 1989, and assesses the impact of the newly introduced control measures on the intended elimination of leprosy as a public health problem in the region by the year 2000.

A study of autoantibodies in chronic mycobacterial infections.

Infections can cause autoantibody production. The purpose of this study was to determine the prevalence of autoantibodies in patients with chronic mycobacterial infections. Sera from 41 leprosy patients and from 49 untreated and 73 treated tuberculosis (TB) patients were tested for the presence of rheumatoid factor, antinuclear factor, and several other autoantibodies. The rheumatoid factor, measured by the Rheuma Tec RF latex test, was positive in 2.4% of the leprosy patients and 2.7% of the treated TB patients but absent in the untreated TB group. The titers ranged from 40 to 160 international units. Positivity was dependent upon the technique utilized, and existed in 21% of untreated TB group and 4% of the treated TB patients when using the Rheuma-Wellcotest technique. The antinuclear antibody was positive in 7.3% of the leprosy group, 6.1% of the untreated TB group, and 15% of the treated TB patients (p = 0.0125). Antinuclear antibody positivity correlated with the duration of treatment of the TB patients (p = 0.025). The antinuclear antibody titers were low and gave no specific pattern on staining. No patient had antibodies against native deoxyribonucleic acid, ribonuclear protein, Ro (SS-A) or La (SS-B) antigens. Due to their low prevalence and frequency in these chronic infections, these autoantibodies should not lead to confusion in distinguishing these conditions from the connective tissue diseases.