South African hypertension practice guideline 2014.

OUTCOMES: Extensive data from many randomised, controlled trials have shown the benefit of treating hypertension (HTN). The target blood pressure (BP) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg, with minimal or no drug side effects. Lower targets are no longer recommended. The reduction of BP in the elderly should be achieved gradually over one month. Co-existent cardiovascular (CV) risk factors should also be controlled. BENEFITS: Reduction in risk of stroke, cardiac failure, chronic kidney disease and coronary artery disease. RECOMMENDATIONS: Correct BP measurement procedure is described. Evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. Lifestyle modification and patient education are cornerstones of management. The major indications, precautions and contra-indications are listed for each antihypertensive drug recommended. Drug therapy for the patient with uncomplicated HTN is either mono- or combination therapy with a low-dose diuretic, calcium channel blocker (CCB) and an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB). Combination therapy should be considered ab initio if the BP is ≥ 160/100 mmHg. In black patients, either a diuretic and/or a CCB is recommended initially because the response rate is better compared to an ACEI. In resistant hypertension, add an alpha-blocker, spironolactone, vasodilator or ß-blocker. VALIDITY: The guideline was developed by the Southern African Hypertension Society 2014©.

Validation of a Rapid Tuberculosis PCR Assay for Detection of MDR-TB Patients in Gauteng; South Africa

Nucleic acid amplification tests offer shorter turnaround times for diagnosis of tuberculosis (TB) and drug resistance of isolates compared to conventional culture methods. The rapid molecular-based multidrug-resistant (MDR)-TB assay; GenoTyper MTBDRplus (Hain Lifescience) was evaluated in Gauteng; South Africa; as a pilot investigation to assess its performance for detection of MDR-TB in patients who were at high risk of drug-resistant TB. A total of 945 sputum specimens sequentially received within a period of six weeks from seven hospitals were assessed by MTBDRplus and compared to liquid culture drug susceptibility tests (DST) using the MGIT 960 system (BD Diagnostic Systems) as the `gold standard'. Of the 945 specimens processed; 731 had interpretable results from both tests and therefore were included in the analysis. The overall sensitivities of the MTBDRplus in detecting individual resistance to rifampicin (RMP) and isoniazid (INH); as well as MDR were 95.0; 93.4and 100; respectively. The specificities were 99.7for RMP; and 100for INH and MDR. The Genotyper MTBDRplus assay showed excellent concordance with the conventional `gold standard' MGIT DST; and it detected all the MDR-TB cases analysed

Hospital management of voluntary total fasting among political prisoners.

In 1989 20 political detainees, held without trial for up to 32 months, were admitted, on hunger strike, to the Johannesburg Hospital, South Africa. Most were held under the regulations of the State of Emergency (since revoked) and 5 were held incommunicado under section 29 of the Internal Security Act (still in force). Guidelines for ethical management were based on the Declaration of Tokyo, which included the understanding that such detentions constituted mental torture. Conditions of detention in hospital were complicated by police interference in medical and nursing care, and by the chaining of some prisoners to their beds. Doctors are in a unique position to protest against inhuman treatment of prisoners, and should use this authority.

Hypertension as a cause of end-stage renal failure in South Africa.

We reviewed the data of 3,632 patients with end-stage renal failure entered into the South African Dialysis and Transplantation Registry over a six-year period. The male to female ratio was 1.4:1. Of these patients, 48.8% were white, 26.2% black, 17.6% coloured and 7.4% Asian. Essential hypertension was the cause of end-stage renal failure in 15.9% of patients. Malignant hypertension was the diagnosis in 57% of the essential hypertensives. Hypertension was responsible for 34.6% of end-stage renal failure in blacks, 20.9% in coloureds, 4.3% in whites and 13.8% in Asians. In the age group 30-39 years, 37.4% of patients with malignant hypertension commenced dialysis, while 28.4% and 28.8% of benign hypertensives commenced dialysis in the 30-39 and 40-49 age groups, respectively. The survival at 36 and 72 months was the same whether hypertension was the cause of end-stage renal failure or not, and whether the hypertension was malignant or benign. Cardiac causes were responsible for most of the deaths. The percentage of deaths from cardiac causes was similar in patients with renal failure from essential hypertension and other causes (33.2% and 29.3% respectively). Hypertension is the commonest cause of end-stage renal failure in black South Africans and the most common preventable cause of end-stage kidney disease in the country.

Malignant hypertension and its renal complications in black South Africans.

Malignant hypertension is an important cause of morbidity and mortality among urban black South Africans. Hypertension accounts for 15.9% of all patients and for 34.6% of blacks receiving treatment for end-stage renal failure. Malignant hypertension is more commonly diagnosed than benign hypertension and two-thirds of patients present in the age group 30 - 49 years. Together they are the most common preventable cause of end-stage renal failure in this country. Acute partially reversible renal failure occurs in 20% of patients with malignant hypertension who require dialysis. This is an important subgroup, who may be recognised by their younger age, female preponderance and fulminant presentation. Short-term peritoneal dialysis and effective control of blood pressure will result in satisfactory return of renal function. However, only adequate country-wide control of hypertension will prevent these costly renal complications.

Dermatomyositis in pregnancy. A case report.

Few cases of dermatomyositis affecting pregnancy have been reported. In this case the fetal outcome was good, but postpartum, pregnancy-induced hypertension was associated with acute exacerbation of the disease and led to maternal death. Both the fetal and maternal outcome differed from those in previously reported cases.

Plasma vitamin E levels in a chronically hemolyzing group of dialysis patients.

Plasma vitamin E levels and the ascorbate cyanide test were assessed in 15 chronic hemodialysis (HD) patients (group A) exposed to persistently elevated chloramine levels in the dialysis water. The vitamin E levels in these patients, who had evidence of oxidant induced hemolytic anemia, were compared to 15 chronic HD patients exposed to low chloramine levels (group B) and 17 controls (group C). Vitamin E levels were found to be significantly lower in group A than in either groups B or C (p less than 0.001). Within group A, levels were lower in those patients who had a positive ascorbate cyanide test (p less than 0.05). Upon removal of chloramines from the dialysis water, vitamin E levels in group A were no longer significantly different from those found in groups B or C.