South African Medical Journal (SAMJ)
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The science of obesity
No full textKEY MESSAGES
• Obesity arises from a complex interplay of genetic, biological, behavioural, psychosocial and environmental factors.• Obesity has a strong genetic component, with twin studies indicating a 50 - 80% concordance in body mass index (BMI) and regional fat distribution. A Swedish study on identical twins raised apart found no correlation between BMI and their adoptive families but a strong correlation with their biological twin, despite being raised in separate households.• The regulation of appetite, body weight and energy balance is highly complex, governed by a network of hormonal signals from the gut, adipose tissue and other organs, as well as neural signals that shape eating behaviours. Many of these signalling pathways are disrupted in people living with obesity.• Since body weight is homeostatically regulated, weight loss triggers physiological adaptations that promote weight regain. These include a decrease in energy expenditure, and hormonal changes that enhance appetite while reducing satiety.• Adipose tissue influences the central regulation of energy homeostasis, and excess adiposity can become dysfunctional, with production of proinflammatory cytokines and associated metabolic health complications.• Individual variations in body composition, fat distribution and function result in a highly variable threshold at which excess adiposity begins to negatively affect health.• Emerging research in obesity science has widened to include brown fat, the gut microbiome, immune system regulation, and the intricate mechanisms that regulate body weight.• Obesity can be classified as primary, secondary and genetic obesity.• In the current management of primary obesity, prevention (the path in) and treatment (the path out) need to be distinctly separated.• Effective primary obesity treatment requires an integrated approach that addresses the non-modifiable cause (increased appetite) together with modifiable contributors (poor diet quality, increased stress, poor sleep, reduced physical activity and increased sedentary behaviour). Behavioural modification and psychological support provide additional benefit.• Effective treatment in genetic and secondary obesity requires treatment of the underlying causes along with modification of the contributors
Metabolic and bariatric surgery: Selection and preoperative work-up
No full textRECOMMENDATIONS
1. We suggest that a comprehensive medical and nutritional evaluation be completed and nutrient deficiencies corrected in candidates for MBS (Level 4, Grade D).
2. We suggest screening for and treatment of obstructive sleep apnoea in people seeking MBS (Level 4, Grade D).
3. Preoperative smoking cessation can minimise postoperative complications (Level 2a, Grade B)
Rising trends in sodium nitrite suicides: A case series from Cape Town, South Africa
Get PDFSodium nitrite (NaNO2) ingestion results in methaemoglobinaemia, which can cause hypoxia, metabolic acidosis and death. Sodium nitrite is an inorganic salt, easily accessible and widely used as a colourant, food preservative and corrosion inhibitor. Although previously rarely seen in medicolegal practice, sodium nitrite poisoning cases are increasing globally. This case series examines three fatalities investigated at the Observatory Forensic Pathology Institute (formerly Salt River Mortuary) in Cape Town, Western Cape Province, South Africa, between 2020 and 2023. The three cases involve sodium nitrite, with labelled containers found at the death scene. Postmortem findings included chocolate-brown discolouration of the blood, blue-grey discolouration of the nail beds and distinctive skin lividity. Toxicological analyses included ethanol, common drugs of abuse, methaemoglobin and sodium nitrite determined in various matrices. This report highlights the importance of thorough death scene investigations and challenges in ancillary testing, and contributes to the literature on sodium nitrite-related suicides. The accessibility and rapid lethality of the chemical underscore the need for greater awareness among medical professionals and policy-makers regarding its misuse
The Use of venous thromboembolism prophylaxis in relatioN to patiEnt risk profilINg (TUNE IN) Wave 3 study
Get PDFBackground. Thromboprophylaxis significantly reduces the risk of venous thromboembolism (VTE) in hospitalised medical and surgical patients. Nonetheless, the implementation of thromboprophylaxis in South Africa (SA) and worldwide is low.Objective. The TUNE-IN (The Use of venous thromboembolism prophylaxis in relatioN to patiEnt risk profilINg) Wave 3 study is an extension of TUNE-IN Wave 1 and 2. This prospective, cross-sectional study assessed the use of VTE thromboprophylaxis in hospitalised medical, surgical and orthopaedic patients.
Methods. Over a 9-month period, 451 consenting patients >18 years of age hospitalised at Charlotte Maxeke Johannesburg Academic Hospital in Gauteng, SA, were systematically included. Patients were assessed and risk stratified according to the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding risk and Caprini risk assessment tools. Data on the use of VTE thromboprophylaxis, agent and dose were collected from the hospital records.
Results. The study identified 180 (40%) medical, 198 (44%) surgical and 73 (16%) orthopaedic participants. VTE thromboprophylaxis was administered in 263 (58%) study participants. In accordance with the American College of Chest Physicians guidelines on VTE prevention, adequate thromboprophylaxis was administered in 233 (52%). The most common thromboprophylaxis agent was low molecular weight heparin. Subsequently, the Caprini risk assessment tool identified 337 participants (75%) with a VTE risk score >2, whereas the IMPROVE risk assessment tool identified 22 participants (5%) with a high bleeding risk score (≥7). In accordance with the risk assessment tools, recommended thromboprophylaxis was administered in 68% of medical, 59% of surgical and 79% of orthopaedic high-risk participants (p<0.012). The proportion of medical and surgical participants at high VTE risk was similar to that in the Wave 1 and/or 2 studies; however, the rates of VTE thromboprophylaxis in the present study were lower (p=0.097 for medical and p<0.001 for surgical participants).
Conclusion. This study shows a significant gap between evidence-based thromboprophylaxis recommendations and clinical practice in a large sample of hospitalised medical, surgical and orthopaedic participants. It is recommended that an institutional VTE risk assessment tool be implemented to standardise risk evaluation and improve the administration of appropriate thromboprophylaxis for hospitalised patients
Section on heritable human genome editing withdrawn from the National Health Research Ethics Council Guidelines
Get PDFA roadmap for kidney health for South Africa in the context of universal health coverage
Get PDFChronic kidney disease (CKD) in South Africa (SA) is a growing public health crisis, driven by the intersecting burdens of HIV, tuberculosis, hypertension, diabetes and obesity. In Black African populations, high-risk apolipoprotein L1 (APOL1) variants add a genetic predisposition to non-diabetic kidney diseases, compounding risk. Global recognition of CKD has recently advanced, marked by the 2025 World Health Organization (WHO) non-communicable disease resolution, which urges the integration of kidney care into national health strategies. This resolution emphasises prevention, early detection and treatment, while strengthening primary healthcare and addressing social determinants of health, particularly in low-income countries. However, in SA, domestic capacity has not kept pace. Public-sector dialysis slots have remained static since 1994, while the private sector has expanded rapidly, deepening inequities by province and income. In the public sector, dialysis is rationed to patients eligible for transplantation, yet transplant access is limited by organ shortages, logistical barriers and variable provincial resources. Expanding deceased donation and implementing kidney paired donation (KPD) programmes are essential to increase transplant opportunities, particularly for incompatible donor- recipient pairs, and to improve equity in access. Children and adolescents face additional barriers, including limited age-specific pathways and the absence of structured transition to adult care. Workforce shortages, inadequate regulatory oversight, inconsistent procurement processes and incomplete registry reporting undermine service quality, limit expansion and perpetuate inequities in access. Without urgent reform, CKD will continue to drive preventable morbidity, premature mortality and escalating costs. Scaling equitable dialysis and transplantation services, integrating KPD and investing in prevention, workforce and infrastructure are critical to reversing current trends and fulfilling the WHO’s call for action
Comment on ‘Paediatric nephroblastoma at a South African tertiary hospital: A 21-year retrospective analysis’
Get PDFResponse to ‘An open letter: In solidarity with all children suffering in wars; to all who hold or share a concern for the wellbeing of children’
Get PDFThe utility of a smartphone electronic referral application in facilitating telemedicine in pulmonology
No full textBackground. A streamlined referral system for respiratory diseases is essential, and telemedicine offers a viable solution, particularly within the public healthcare sector. There is a paucity of data on the utility of the Vula medical referral application in pulmonology, a field that lends itself to telemedicine.
Objectives. To perform a 1-year retrospective observational study to assess the Vula medical referral application utility in a tertiary referral centre in Cape Town, South Africa (SA).
Methods. This retrospective study was conducted at a large tertiary-level hospital located in Cape Town, SA. All adult patients referred to the Division of Pulmonology at the institution from January to December 2023 via the Vula virtual referral platform were included. During the study period, all physicians who contacted the pulmonology outpatient department (OPD) or the pulmonologist-on-call were requested to use the Vula virtual referral platform. Emergency referrals (e.g. life-threatening haemoptysis) were discussed in person, but details were still uploaded to Vula. Results were extracted from archived data.
Results. During the study period, a total of 2 073 adult patients were referred through Vula. Of these, 1 699 referrals (82%) resulted in a working diagnosis or respiratory syndrome requiring further evaluation, identified by either the referring physician or the pulmonologist. The most common reasons for referral were suspected malignancy (n=767, 45%) and post-tuberculosis lung disease (n=170, 10%). Nearly half (868, 42%) of the referrals required only medical advice on further management, or assistance with medical image interpretation. A further 538 patients (26%) were scheduled for diagnostic or therapeutic procedures without an outpatient review. Only 537 patients (26%) were ultimately given an appointment date for further evaluation in the pulmonology OPD.
Conclusion. Telemedicine in the form a smartphone electronic referral application significantly improved access to and efficiency of pulmonology services in a resource-constrained environment. Approximately 75% of referrals required either guidance with further medical management, assistance with thoracic imaging interpretation, or diagnostic or therapeutic procedures, significantly reducing the outpatient load.