BACKGROUND: Phentermine is an internationally recognised amphetamine derivative with significant appetite-suppressing properties. The drug is indicated for the short-term management of obesity, as the long-term (LT) use of phentermine may potentially be associated with severe cardiovascular side-effects, abuse and dependence. The LT use hereinafter describes periods exceeding 12 consecutive weeks. This use may also be associated with potential drug-drug interactions (PDDIs), which may result in adverse drug reactions (ADRs). The literature reports that phentermine is often prescribed LT and for several other off-label indications, increasing the risk for individuals to experience adverse drug events (ADEs) and drug-drug interactions (DDIs). There are, to our knowledge, no South African (SA) studies investigating the prevalence of co-prescribing LT phentermine with drugs that may potentially cause DDIs OBJECTIVE: To determine the prevalence of mild, moderate and severe DDIs with phentermine use when the duration of therapy in private healthcare exceeded 12 consecutive weeks METHODS: A cross-sectional drug utilisation review (DUR) was done by using data obtained from a SA pharmacy benefit management (PBM) company's database. Retrospective data of medicine claims for phentermine, from 1 January 2015 to 31 December 2019, were extracted for analysis. The number of days phentermine was supplied was used to identify the study population, in other words, those patients who received the drug LT. A drug interaction checker (Drugs.com) was used to identify potential mild, moderate and severe DDIs when using phentermine and co-prescribed drugs concurrently RESULTS: A total of 889 patients received phentermine LT. The top 20 drugs identified as being frequently co-prescribed in this study population demonstrated no mild PDDI, 15 (75%) moderate PDDIs and 5 (25%) severe PDDIs. The most common co-prescribed drug in the moderate group was dextromethorphan (n=282, 31.72%) and the least co-prescribed was formoterol (n=52, 5.85%). Among the drug group 'severe PDDIs', tramadol (n=416, 46.79%) was most frequently prescribed, whereas phenylpropanolamine (n=69, 7.76%) was the least prescribed to patients in this group CONCLUSION: There are patients who receive LT phentermine therapy despite the potential severe consequences that may result. These patients may receive concomitant therapy with phentermine and other pharmaceutical constituents, which may potentially cause DDIs, more specifically, moderate and severe DDIs. As such, these patients are not only confronted with the consequences of DDIs but are also at risk to experience ADRs as the residual effect of PDDIs

To achieve informed integrated water resource management and sustainability, an understanding of the quantity of water available for use within a spatial and temporal context is needed. This study was consequently focused on the estimation of water levels with the use of geospatial techniques. The availability of water data is a significant challenge, especially for smaller dams used by farmers. The lack of consistent water data in turn poses a problem by limiting the estimation of the overall water availability in water strategy models. This challenge is attributed to the cost of modeling all available water resources and the lack of complete records of all available water resources, as some small dams are not officially registered. This paper provides a simple protocol that can be implemented to reliably derive water levels for dams that are yet to be registered or accounted for, using the Katrivier Dam as a case study. Three main datasets were used which enabled the calculation of water levels - a 12.5 m digital elevation model, Sentinel-2 optical images, and water data from the Department of Water and Sanitation (DWS), as in-situ data. The resulting water level values were derived using a proposed model that includes two correction factors, k and s. The results obtained showed that the estimated water levels from the model proposed in this paper are analogous with those observed by the DWS. Therefore, the proposed method can serve as an additional cost-effective method in water accounting procedures as it requires less expensive equipment than alternatives such as bathymetric methods.

Procedural laws play an important role in legal practice through their use in the enforcement of the substantive rights of members of the public. Civil procedure, criminal procedure, and the law of evidence are the building blocks whereby matters are presented in court. Legal representatives, representing members of the public, should therefore be skilled and professionally trained in procedural laws. Due to their importance, students should not only have a thorough and foundational theoretical knowledge of procedural laws, but also the necessary practical skills in applying their knowledge to practical scenarios, which should be instilled as part of the teaching of procedural modules. The inherent methodological content of conventional teaching methodologies applied when teaching procedural law modules, i.e., the Socratic and case dialogue methodologies, however, prove to be inadequate in transferring the required skills and practical training. Several constituent parties in the legal profession, including academics, legal practitioners, and presiding officers, have remarked that law students, upon graduation, lack the necessary skills, ingenuity, and practical knowledge to make a good start in legal practice. It furthermore appears that university law faculties are generally not willing to train law students for practice. There is also the necessity for the development of identified essential skills required of competent legal practitioners. The continuous development of these skills in the teaching and practical application of procedural laws afford students the ability to advance future client representation professionally and confidently. Cultural, social and human elements should form part of the teaching and learning of procedural law modules, which will create an important awareness among students that, when working with clients in legal practice, they are attending to the rights and interests of human beings who may be of different races and cultures. This will further develop students' identities and values as professionals which include not only being responsible to individual clients, but also contributing services to the community. In developing the required identified skills, students will not only be able to apply technical legal procedures, but also learn how to assist clients more cost-effectively. By employing the Clinical Legal Education methodology in tandem with conventional lecture methodologies, students are introduced to the practical application of procedural laws, honing both their practical and intellectual skills. Application suggestions include tutorial sessions, mock trials, and reflective assignments. This article evaluates the efficacy of the current teaching methodologies applied in teaching procedural laws toward imparting students with the required practical skills. It recommends the development of procedural law modules by introducing applied practical skills to enable students to enter legal practice after graduation as more rounded and skilled future legal practitioners.

Herbal medicines made from the bark of the Cinchona tree, and later quinine, have been widely used for centuries to treat medical conditions such as tropical malaria. More recently, chloroquine (CQ) and its synthetic derivatives have been used as antimalarials and to treat systemic lupus erythematosus, rheumatoid arthritis, and in the past 14 months or so, COVID-19 pneumonia. Anecdotal evidence and the erratic covering through social media of its potential efficacy in the treatment of COVID-19 pneumonia have resulted in the widespread off-label use of CQ in South Africa and worldwide. This study aimed to show that access to CQ as a chronic medication for rheumatic and musculoskeletal diseases was limited during the COVID-19 pandemic, and that this resulted in an increased incidence of flares in these patients, affecting their morbidity and potentially leading to mortality.

BACKGROUND. The hyperinflammation seen as part of a dysregulated immune response to SARS-CoV-2 in its most severe form leads to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Corticosteroid therapy targets this hyperinflammation, otherwise known as a cytokine storm. It is the only therapeutic agent to date with a mortality benefit, with clear guidelines from national and international health authorities guiding its use. OBJECTIVES. To compare severity-of-illness indices, survival, length of intensive care unit (ICU) stay and potential ICU complications in patients treated with different corticosteroid regimens (high-dose hydrocortisone, high-dose methylprednisolone and lower-dose dexamethasone). METHODS. In this single-centre descriptive retrospective observational study of a cohort of patients with severe COVID-19 admitted to a COVID-dedicated ICU, we compared patients treated with the three different corticosteroid regimens. RESULTS. In 242 cases we could not demonstrate any statistically or clinically significant difference in the outcome of patients with critical COVID-19 treated with high-dose intravenous hydrocortisone (n=88) or methylprednisolone (n=46) compared with a relatively lower dose of dexamethasone (n=108). The survival rates were 38.6%, 39.1% and 33.3%, respectively (p=0.68). Patients treated with methylprednisolone tended to have a shorter length of ICU stay (median (interquartile range) 6 (4 - 10), 4 (2 - 8) and 5 (2 - 8) days; p=0.015) and fewer episodes of nosocomial sepsis (47.7%, 32.6% and 48.1%; p=0.01). CONCLUSIONS. Hydrocortisone or methylprednisolone can be given as an alternative to dexamethasone in the management of critical COVID-19, and this is a feasible alternative, especially in resource-constrained settings.

BACKGROUND: The hyperinflammation seen as part of a dysregulated immune response to SARS-CoV-2 in its most severe form leads to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Corticosteroid therapy targets this hyperinflammation, otherwise known as a cytokine storm. It is the only therapeutic agent to date with a mortality benefit, with clear guidelines from national and international health authorities guiding its useOBJECTIVES: To compare severity-of-illness indices, survival, length of intensive care unit (ICU) stay and potential ICU complications in patients treated with different corticosteroid regimens (high-dose hydrocortisone, high-dose methylprednisolone and lower-dose dexamethasoneMETHODS: In this single-centre descriptive retrospective observational study of a cohort of patients with severe COVID-19 admitted to a COVID-dedicated ICU, we compared patients treated with the three different corticosteroid regimensRESULTS: In 242 cases we could not demonstrate any statistically or clinically significant difference in the outcome of patients with critical COVID-19 treated with high-dose intravenous hydrocortisone (n=88) or methylprednisolone (n=46) compared with a relatively lower dose of dexamethasone (n=108). The survival rates were 38.6%, 39.1% and 33.3%, respectively (p=0.68). Patients treated with methylprednisolone tended to have a shorter length of ICU stay (median (interquartile range) 6 (4 - 10), 4 (2 - 8) and 5 (2 - 8) days; p=0.015) and fewer episodes of nosocomial sepsis (47.7%, 32.6% and 48.1%; p=0.01CONCLUSIONS: Hydrocortisone or methylprednisolone can be given as an alternative to dexamethasone in the management of critical COVID-19, and this is a feasible alternative, especially in resource-constrained settings

BACKGROUND: The hyperinflammation seen as part of a dysregulated immune response to SARS-CoV-2 in its most severe form leads to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Corticosteroid therapy targets this hyperinflammation, otherwise known as a cytokine storm. It is the only therapeutic agent to date with a mortality benefit, with clear guidelines from national and international health authorities guiding its use.OBJECTIVES: To compare severity-of-illness indices, survival, length of intensive care unit (ICU) stay and potential ICU complications in patients treated with different corticosteroid regimens (high-dose hydrocortisone, high-dose methylprednisolone and lower-dose dexamethasone).METHODS: In this single-centre descriptive retrospective observational study of a cohort of patients with severe COVID-19 admitted to a COVID-dedicated ICU, we compared patients treated with the three different corticosteroid regimens.RESULTS: In 242 cases we could not demonstrate any statistically or clinically significant difference in the outcome of patients with critical COVID-19 treated with high-dose intravenous hydrocortisone (n=88) or methylprednisolone (n=46) compared with a relatively lower dose of dexamethasone (n=108). The survival rates were 38.6%, 39.1% and 33.3%, respectively (p=0.68). Patients treated with methylprednisolone tended to have a shorter length of ICU stay (median (interquartile range) 6 (4 - 10), 4 (2 - 8) and 5 (2 - 8) days; p=0.015) and fewer episodes of nosocomial sepsis (47.7%, 32.6% and 48.1%; p=0.01).CONCLUSIONS: Hydrocortisone or methylprednisolone can be given as an alternative to dexamethasone in the management of critical COVID-19, and this is a feasible alternative, especially in resource-constrained settings.

BACKGROUND: Pneumococcal carriage studies provide a baseline for measuring the impact of pneumococcal conjugate vaccines (PCVs). The advent of conjugate vaccines has led to reductions in vaccine serotypes (VTs) in pneumococcal carriage. However, increasing non-vaccine serotypes (NVTs) remain a significant concern, necessitating continued surveillance of serotypes in the 13-valent PCV vaccine (PCV13) era.OBJECTIVES: To investigate pneumococcal carriage, serotype distribution and risk factors for pneumococcal colonisation among children presenting for routine immunisation at two clinics in Gauteng Province, South Africa (SA), 10 years after PCV introduction into the SA Expanded Programme on Immunisation (EPI-SA).METHODS: Nasopharyngeal swabs were collected from 322 healthy children aged between 6 weeks and 5 years at two clinic centres in 2014 and 2016. Demographic data, risk factors for colonisation and vaccination details were recorded. The pneumococcal isolates were serotyped and tested for antimicrobial susceptibility.RESULTS: Pneumococci were isolated from 138/316 healthy children (43.7%) presenting for routine immunisation at two clinics. The median age was 8.3 months and the age range 1.4 months - 5 years. Carriage varied across the age groups: 6-14 weeks 35.5%, 9 months 27.5%, 18 months 21.7%, and 5 years 15.2%. Risk factors significantly associated with pneumococcal colonisation included young age (9 -18 months (odds ratio OR 3.5; 95% confidence interval (CI) 1.9 - 5.9), type of dwelling (single room (OR 8.1; 95% CI 1.3 - 52.3) or informal dwelling (OR 2.4; 95% CI 1.2 - 4.5)) and Haemophilus influenzae carriage (OR 5.6; 95% CI 0.6 - 2.5). Of the 26 serotypes detected, 19F (10/121; 8.3%) was the most frequent. The most frequent NVTs were 23B (16/121; 13.2%), 15B/C (14/121; 11.6%) and 35B (11/121; 8.2%). Children aged 9 months carried the highest proportion of NVTs (33/101; 32.7%). Penicillin non-susceptibility was observed in 20 NVT isolates (20/36; 55.6%) and 2 VT isolates (2/36; 5.6%).CONCLUSIONS: The pneumococcal carriage prevalence described in our study varied across the age groups and was lower compared with other African studies that looked at pneumococcal carriage post PCV. The study gave insight into the common NVTs encountered at two immunisation clinics in Gauteng. Given that pneumococcal carriage precedes disease, common colonisers such as 15B/C and 35B may be sufficiently prevalent in carriage for expansion to result in significant disease replacement.

BACKGROUND: The surgical management of scapula body, neck and glenoid fractures remains a challenge. This study focuses on templating an available anatomical pre-contoured plating system using three-dimensional (3D)-printed scapulae to assess the ability of these plates to address the aforementioned fractures and to determine consensus on classifying scapula body, neck and glenoid fractures. METHODS: We used a cohort of 22 3D-printed scapulae prototypes and an available anatomical pre-contoured plating system to determine anatomical congruency and fit. Nine investigators templated the scapulae using four pre-contoured plates, and the investigators classified the 22 scapulae using the Ideberg and AO/OTA classification system. RESULTS: Eleven out of 22 fractures were found to be fixable using the plates under study. The long lateral plate addressed 83% of fractures involving the lateral border, while the glenoid plate was unable to adequately address any glenoid fractures. We observed good to excellent (p < 0.001) interobserver reliability for three of the four plates. The interobserver reliability was moderate (ICC = 0.74) for the AO/OTA classification and good (ICC = 0.88) for the Ideberg classification. CONCLUSION: We believe that the anatomical pre-contoured plating system does not address all the fracture patterns encountered in clinical practice and further development in plate design is required. There is good to moderate interobserver reliability using the Ideberg fracture classification for intra-articular fractures and the AO/OTA classification for extra-articular fractures involving the body. Level of evidence: Level 3

BACKGROUND. Although women are informed about the dangers of drinking and smoking during pregnancy when they book for antenatal care, it is uncertain whether this advice is accepted, or whether attempts are made to apply it in subsequent pregnancies.OBJECTIVES. To assess how pregnant women respond to the advice to refrain from smoking and drinking during pregnancy in subsequent pregnancies.METHODS. Research staff were trained to obtain accurate prospective information on smoking and drinking during pregnancy in a prospective study, using well-standardised methods. Care was taken to inform participants about the dangers of smoking and drinking during pregnancy. They were also given pamphlets on these dangers in their own language and a list of telephone numbers where they could find help to quit should they need it. This information was repeated at subsequent study visits (ranging from 1 to 3, depending on the gestational age at which they enrolled). Gestational age was determined by early ultrasound. Z-scores of birthweight for gestational age were determined according to the INTERGROWTH-21st study. Pregnancy outcomes of women who enrolled twice (n=888) or three times (n=77) in the Safe Passage Study were compared with those of women in the first enrolment (n=889).RESULTS. The proportion of drinkers did not change significantly (p=0.058) from the first to the second and third enrolments (63.8%, 59.0% and 54.6%, respectively). A similar trend was found for smokers (73.3%, 72.2% and 68.4%, respectively). Cannabis use was reported by 15.1%, 9.7% and 12.0% (p<0.005) of women, respectively, and use of methamphetamine by 10.1%, 6.6% and 12.7% (p<0.005). There was an increase in the rate of preterm births from 15.5% to 17.5% and 24.7%, respectively, but the increase was not significant. Although mean birthweight was lower in the third enrolment compared with the second, the difference was not significant. The z-score of birthweight for gestational age was significantly lower in the second enrolment compared with the first.CONCLUSIONS. Detailed information on the adverse effects of smoking and drinking during pregnancy was not effective in the population studied. Other methods to reduce or stop these toxic exposures should therefore be investigated. A short inter-pregnancy interval, as demonstrated by three enrolments in 7.5 years, is associated with preterm labour and fetal growth restriction, and is probably indicative of the role played by confounders such as poor socioeconomic conditions and drug exposure during pregnancy.

BACKGROUND. Globally, mothers have identified employment as one of the leading barriers to exclusive and continued breastfeeding. The workplace and employment setting has been highlighted as one component of an enabling environment for breastfeeding. Objectives. To assess breastfeeding support practices in designated workplaces in the Breede Valley sub-district, Western Cape, South Africa. METHODS. A quantitative, cross-sectional design study was used. An online survey was conducted amongst human resource managers and/or company managers to determine breastfeeding support practices in designated workplaces. RESULTS. Fourteen participants completed the online survey. Breastfeeding support practices in designated workplaces were limited and inadequate, with few supportive breastfeeding practices. Onsite or nearby crèche facilities (n=2; 14.3%), breastfeeding counsellors (n=1; 7.1%), promotion of the benefits of breastfeeding to employees (n=2; 14.3%) and provision of private space for expressing (n=2; 14.3%) were not common practices. Workplace breastfeeding policies (n=4; 28.6%) were not common practice, and were mostly found in the public sector. Forty-three percent of workplaces (n=6; 42.9%) did not provide time for expressing at work. CONCLUSION. There is an urgent need to create advocacy regarding the benefits of breastfeeding support in the workplace for employers, employees and society as well as the breastfeeding rights of women in the workplace. The legislated breastfeeding break times need to be monitored to ensure better compliance in workplaces.

BACKGROUND. Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis.OBJECTIVES. To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups.METHODS. This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity.RESULTS. Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18 cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. Secondary outcomes. Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this.CONCLUSIONS. Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.

The first difficult contraceptive implant removals clinic in sub-Saharan Africa was started 2 years ago at New Somerset Hospital in Cape Town, South Africa, and has seen two cases of implant migration. We report these cases here. The first was a case of fascial migration and the second one of migration via the cephalic vein, both to a site just anterior to the glenohumeral joint. Both implants were removed without complications. Even with correct insertion technique, migrations can occur. Healthcare providers need to know how to manage difficult removals, and how to access and refer to difficult removals services when necessary. These services must therefore be available in all settings where implants are offered, to ensure access to rights-based family planning services for all women in southern Africa.

BACKGROUND: Mobile phone-linked spirometry technology has been designed specifically for evaluating lung function at primary care level. The Air-Smart Spirometer is the first mobile spirometer accepted in Europe for the screening of patients with chronic respiratory diseases OBJECTIVES: To prospectively assess the accuracy of the device in measuring forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) in a South African population, and to investigate the ability of the device to detect obstructive ventilatory impairment METHODS: A total of 200 participants were randomly assigned to perform spirometry with either the mobile spirometer connected to a smartphone or the desktop spirometer first, followed by the other. The FEV1/FVC ratio as well as the absolute FEV1 and FVC measurements were compared, using each participant as their own control. A Pearson correlation and Bland-Altman analysis were performed to measure the agreement between the two devices. We defined obstructive ventilatory impairment as FEV1/FVC <0.7 measured by desktop spirometry in order to calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the Air-Smart Spirometer RESULTS: There was a strong correlation between the absolute FEV1 and FVC values and FEV1/FVC ratio measured with the mobile AirSmart Spirometer and more conventional pulmonary function testing, with r=0.951, r=0.955 and r=0.898, respectively. The Air-Smart Spirometer had a sensitivity of 97.6%, specificity of 74.4%, PPV of 73.0% and NPV of 97.8% for obstructive ventilatory impairment CONCLUSIONS: The mobile Air-Smart Spirometer compared well with conventional spirometry, making it an attractive and potentially affordable tool for screening purposes in a primary care setting. Moreover, it had a high sensitivity and NPV for obstructive ventilatory impairment

Vaardigheidsopleiding, wat onderhoudsvoering insluit, is aanvullend tot 'n kliniek se oogmerk van sosiale geregtigheid, aangesien dit studente bemagtig om uitspraak uit te stel, om vanoor 'n verskeidenheid te kommunikeer en oplossings te soek. Onderhoudsvoeringvaardighede is 'n basis van kliniese regsopleiding, 'n leermetode in 'n lewende-kliënt kliniek. Aangesien studente oor die algemeen sonder kliniese toesig onderhoude voer, is hul opleiding in die verband noodsaaklik. In die bespreking van onderhoudsvoeringopleiding, val die klem op die voorbereiding van studente, wat die taking van vooropgestelde idees en aannames insluit, asook beradingsvaardighede. 'n Verskeidenheid van ondervragings-tegnieke word bespreek en daar word aangedui dat onderrigliteratuur die veronderstelling ondersteun dat die manier waarop vrae gestapel word belangriker mag wees vir die bevordering van begrip as die kognitiewe vlak van die vraag. Periodieke opsommings help die studente om 'n beter begrip van die sake te vorm. 'n Bondeling van optredes wat binne konteks geïnterpreteer moet word, is nie-verbale aanduidings, gedrag wat obstuksies tussen die studente en hul kliënte mag vorm, spieëlgedrag en prosedie. Regsanalise en strategieë met potensiële oplossings waarvoor studente verantwoordelikheid moet aanvaar, aangesien hulle handelinge andere mag beïnvloed, word bespreek. Die doelstellings van kliniese regsopleiding, soos van toepassing op onderhoudsvoering, word aangedui.