BACKGROUND South Africa (SA) has a long history of goldmining that has resulted in locally high levels of environmental contamination from uranium and its decay products (radium-226 and radon-222) from the mine tailings. Populations living around mine tailings of the Witwatersrand goldfields may be exposed through various pathways, raising concern about potential health risks associated with haematological malignancies (HMs), for which evidence is inconclusive. OBJECTIVES We designed a prospective case-series study of HMs at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, the major public hospital in the area, to describe demographic and clinical characteristics, lifetime residential history and potential environmental uranium exposure pathways. METHODS All patients, male and female, aged ≥18 years and newly diagnosed with any form of leukaemia, lymphoma or myeloma at the CHBAH Haematology Unit in 2014 and 2015 were considered for inclusion in the study. Information on uranium exposure pathways and lifetime residential history was recorded from interviewer-administered questionnaires. These characteristics were described overall and according to subtypes of HM. RESULTS Of 556 patients with HMs diagnosed in 2014 and 2015 at CHBAH, 189 patients aged 18 - 90 years were interviewed, mainly with non-Hodgkin's lymphoma (NHL) (37.6%), leukaemia (32.8%) and Hodgkin's lymphoma (HL) (13.8%). HIV status was positive for 39.2% of the patients, mostly with NHL and HL. Potential environmental uranium exposure pathways were identified. Working on goldmines was reported by 12 patients (6.3%). Consumption of soil (geophagia) was a habit of 51 patients (27.0%), particularly during pregnancy. Drinking water was mainly piped water (76.6% in childhood and 97.9% in adulthood). Animal products and vegetables were most frequently obtained from stores (82.0% and 68.7%, respectively, in childhood and 96.3% and 83.6% in adulthood). Patients were referred to CHBAH by government clinic doctors (44.4%), referral hospitals (24.3%) and private doctors (20.1%). Most participants had been born and lived in Gauteng Province and Soweto (94.7% and 58.2%, respectively), and reported two lifetime places of residence on average and living at their current residence for ≥20 years (49.2%). CONCLUSIONS We identified potential environmental uranium exposure pathways (occupational, lifestyle related and domestic) among patients with HMs that could have resulted in increased uranium exposure. HIV is common among patients with HMs. Together with the results from a previous retrospective case series of HMs at CHBAH (2004 - 2013), our findings suggest that further research on environmental uranium exposure in mining areas and HM risk in residents is warranted.

BACKGROUND:Sepsis is a leading cause of morbidity and mortality after surgery. Most studies regarding sepsis do not differentiate between patients who have had recent surgery and those without. Few data exist regarding the risk factors for poor outcomes in pediatric postsurgical sepsis. Our hypothesis is pediatric postsurgical, and medical patients with severe sepsis have unique risk factors for mortality.METHODS:Data were extracted from a secondary analysis of an international point prevalence study of pediatric severe sepsis. Sites included 128 pediatric intensive care units from 26 countries. Pediatric patients with severe sepsis were categorized into those who had recent surgery (postsurgical sepsis) versus those that did not (medical sepsis) before sepsis onset. Multivariable logistic regression models were used to determine risk factors for mortality.RESULTS:A total of 556 patients were included: 138 with postsurgical and 418 with medical sepsis. In postsurgical sepsis, older age, admission from the hospital ward, multiple organ dysfunction syndrome at sepsis recognition, and cardiovascular and respiratory comorbidities were independent risk factors for death. In medical sepsis, resource-limited region, hospital-acquired infection, multiple organ dysfunction syndrome at sepsis recognition, higher Pediatric Index of Mortality-3 score, and malignancy were independent risk factors for death.CONCLUSIONS:Pediatric patients with postsurgical sepsis had different risk factors for mortality compared with medical sepsis. This included a higher mortality risk in postsurgical patients presenting to the intensive care unit from the hospital ward. These data suggest an opportunity to develop and test early warning systems specific to pediatric sepsis in the postsurgical population.

Background. South Africa (SA)'s high levels of environmental contamination of mine tailings from uranium and its decay products, coupled with remarkably short distances between mine tailings and residential areas, raise concern about whether there is an association between environmental uranium exposure and risk of cancer, including haematological malignancies. Objectives. We reviewed information on cases from the central hospital offering cancer diagnostics and treatment in a major mining area of SA to describe their basic clinical and demographic characteristics, as part of assessing whether a cancer epidemiological study in this area would be feasible. Methods. Basic clinical, demographic and residential information on patients with haematological malignancy diagnosed between 2004 and 2013 was collected retrospectively from the patient files at Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg. Results. In total, 1 880 patients aged 18 - 94 years were identified. Referral from distant provinces was not uncommon, but >80% lived within 50 km of the hospital. Non-Hodgkin's lymphoma accounted for 44% of the haematological malignancies, followed by leukaemia with 26%. HIV status was known for 93% of the patients, of whom 47% were HIV-positive. Conclusions. Caution is required when interpreting spatial distributions of patients, given inaccuracies in residential addresses and referral patterns to the hospital, and with HIV and other infections probable important confounders. Our study therefore shows that active case recruitment is required for accurate assessment of residential information. However, some findings on spatial distributions in the study warrant the continuation of efforts to develop a study protocol to investigate the possible link between uranium exposure in mining areas and haematological malignancies in residents. Disproportionately high incidence rates of haematological malignancies observed in specific districts would be relevant for further investigation.

South Africa has a long history of uranium (U) production from gold mining and milling that has resulted in locally high-levels of environmental contamination from uranium and its decay products (radium 226 and radon 222). Due to short distances from mining tailings to residential areas, populations living around gold mine tailings of the Witwatersrand goldfields may be exposed to uranium and its decay products from the tailings through multiple pathways, including ingestion of contaminated water and food grown in contaminated areas, direct consumption of soil (geophagia) and inhalation of dust, raising concern about potential health risks associated with environmental U-exposure, and in particular regarding haematological malignancies (HM). We designed a case-series study of HM from Chris Hani Baragwanath Academic Hospital (CHBAH), South Africa, to assess the feasibility of an analytical study on the association between U-exposure and HM risk in this setting. First, patient and cancer characteristics and spatial distribution were retrospectively reviewed from patient files of the HM cases diagnosed between 2004 and 2013 at CHBAH. Spatial relations between residential addresses of patients and location of mine tailings and other U-sources were analysed using a specifically designed GIS-supported virtual geographical environment. Then, we assessed the feasibility of collecting additional information, from patients newly diagnosed with a HM at CHBAH (in 2014–2015), on potential environmental U-exposure pathways and referral patterns from interviewer-administered questionnaires. Among the 1880 cases aged 18–94 years and retrospectively identified from CHBAH's patient files, 44% were diagnosed with Non-Hodgkin lymphoma (NHL), 26% with leukemia and 17% with myeloma. Referral from distant provinces was not uncommon but more than 90% of patients lived within 50 km of the hospital. Human immunodeficiency virus (HIV) status was known for 94%, of which 44% were HIV-positive. No clear and consistent spatial relations between patient's residences and mine tailings deposits could be established. A total of 196 haematological cancer cases aged 18–90 were prospectively diagnosed between 2014 and 2015 at CHBAH, with NHL (35%), leukemia (34%) and myeloma (16%). HIV status was available for all patients, 41% being HIV-positive. Working in gold mines was reported by 12 cases (6%), all men. Soil consumption was a habit for 53 cases (27%), mostly women, and came from backyards and road vendors. Soil consumption occurred more frequently during adulthood and pregnancy. Drinking water came from piped water; untreated water from nearby rivers was not drunk. Animal products and vegetables came from stores and backyards. At the time of interview, 95% of cases were living in Gauteng Province, in Soweto (58%). Half of the cases were living at their current residence for 20 years or more. Cases were referred to CHBAH by governmental clinic doctors (44%), referral hospitals (25%) and private doctors (20%). Most cases lived less than one hour from CHBAH (77%). This case-series analysis showed the capacity of CHBAH to recruit HM patients and allowed the description of the HM burden of the area. Caution is required when interpreting the spatial distributions of patients; our results may not reflect population-incidence rates due to referral patterns to the hospital and inaccuracies in residential addresses retrospectively collected from clinical records. This needs to be considered when analyzing spatial relations related to various exposure pathways. The questionnaire administered to the prospective cases allowed collecting information on U-related exposure, although results generally showed low exposure prevalence in our study population. As infections, such as HIV, may be a risk factor for some HM, collecting clinical data on infections and subtypes of HM needs to be considered in the investigation of HM risk.

Background. Pneumocystis jiroveci pneumonia is still a common cause of severe disease in HIV-infected infants <5 months of age. Despite attention to the prevention of mother-to-child transmission programme in South Africa (SA), HIV testing remains incomplete and infants are still at risk. The management of Pneumocystis pneumonia requires ventilation strategies and combination antibiotics.Methods. A prospective but open intervention was performed on all HIV-exposed patients admitted with severe pneumonia to the paediatric intensive care unit (PICU) at Steve Biko Academic Hospital, SA, during a 3-year period from January 2009 to December 2011. All patients were treated with ampicillin, amikacin, co-trimoxazole, prednisone and intravenous gancilovir. Highly active antiretroviral therapy (HAART) was initiated in the PICU as soon as tuberculosis was excluded and HIV status confirmed with an HIV viral load (VL). Routine blood and tracheal specimens were cultured for bacteria and tested by direct fluorescent antigen testing for P. jiroveci. Cytomegalovirus (CMV) VL was tested. All infants were ventilated in a standard fashion and none were oscillated.Results. A total of 87 patients were admitted during the 3-year period. Of these, 29 patients were excluded from the study because they were HIV-unexposed. Ten patients died during the 3-year period. In a multivariate analysis of the presence or absence of P. jiroveci, HIV VL, CD4 count, timing of HAART initiation and CMV VL, no single factor was documented to influence mortality.Conclusion. Mortality from Pneumocystis pneumonia continues to decrease in this PICU. No single factor is responsible and yet all therapeutic strategies contribute to survival. A national policy and guideline is urgently required.

Why an article on prevention of atopic dermatitis and education of patients and their families? Well one might consider these two topics the two extremes of management of patients at risk from, or with, the condition. A physician might be called to intervene when families with risk factors for atopy consult at a very early stage (possibly even in pregnancy), and then again when a child has the disease expression. Without education in the management plan, all therapies for skin care are doomed to fail. Therefore, both these steps might be considered educational principles - education to avoid the condition if possible, and education to prevent flares of the condition. We are firm believers that the management of atopic and chronic conditions is centered on patient education.

The Journal, Current Allergy and Clinical Immunology, is now in its 27th edition. At the helm Professor Matt Haus, together with Professor Eugene Weinberg, have completely overhauled the format and feel of this, the most important mouthpiece, of the Allergy Society of South Africa.

Martin Davis, Paediatrician, Linksfield Clinic, Johannesburg Di Hawarden, Department of Medicine, Groote Schuur Hospital Cathy van Rooyen, Ampath Laboratory, Pretoria Eftyxia Vardas, Lancet Laboratories, Johannesburg Carla Els, Paediatric Pulmonologist, Linksfield Clinic, Johannesburg Charles Feldman, Professor, Department of Internal Medicine, University of the Witwatersrand Michael Levin, Professor, Department of Paediatrics and Adolescent Health, University of Cape Town Marinda McDonald, General Practitioner, Sandton Stefaan Bouwer, Member of Executive Committee, South African Society of Otorhinolaryngology, Head & Neck Surgery G Peter Tunguy-Desmarais, ENT Surgeon, Umhlanga Rocks Alan McCulloch, ENT Surgeon, Mediclinic Sandton Humphrey Lewis, Paediatrician, Private Practice, Unitas Hospital, Pretoria Ian Hunt, Physician, Private Practice, Sandton Lionel Wolff, ENT Surgeon, Private Practice, Durban Fred Mokgoadi, Paediatrician, Private Practice, Limpopo Martin Gill, ENT Surgeon, Private Practice, Fourways Life Hospital Farouk Jooma, Paediatrician, Private Practice, Pietermaritzburg Ahmed Manjra, Paediatrician, Durban Teshni Moodley, Paediatrician, Private Practice, Johannesburg Prakash Jeena, Professor, Department of Paediatrics and Child Health, University of KwaZulu-Natal Gustav J Joyce, ENT Surgeon, Private Practice, Pretoria East Hospital Riaaz Seedat, Professor, Department Otorhinolaryngology, University of Free State Paul Potter, Professor, Department of Medicine, University of Cape Town Adele Pentz, Department of Paediatrics and Child Health, University of Pretoria

Educating patients with atopic dermatitis is an essential and necessary part of therapy and particularly important when young children are involved. Quality of life is seriously impaired if patients or their carers do not understand the chronic and relapsing nature of the disease and how it can be treated.

Welcome to the first edition of the new look Journal for 2014. For the passionate doctor: A NEW year... A NEW challenge... A NEW opportunity!

The management of fever in children is a subject that garners many different opinions and interventions. Various approaches seem to be acceptable, from the physician who never uses antipyretic medication, to the use of multiple combination therapies. Following the recent publication of guidelines for the management of acute fever in children, there is now a standard against which fever in children should be managed. These guidelines aim to standardise the process of examining pyrexial children, elicit a reasonable history and then investigate the likely illnesses, so as to justify appropriate therapy.

BACKGROUND:Colonisation of the airway by Pseudomonas spp. in cystic fibrosis has been reported to be an important determinant of decline in pulmonary function.OBJECTIVE:To assess pulmonary function decline and the presence of bacterial colonisation in patients with cystic fibrosis (CF) attending a CF clinic in a developing country.METHODS:A retrospective audit of patients attending the CF clinic at Steve Biko Academic Hospital, Pretoria, South Africa, was performed. The data included spirometric indices and organisms routinely cultured from airway secretions (Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA)).RESULTS:There were 29 study subjects. Analysis of variance for ranks (after determining that baseline pulmonary function, age, gender and period of follow-up were not contributing to pulmonary function decline) revealed a median decline in forced expiratory volume in 1 second, forced vital capacity and forced expiratory flow over 25 - 75% expiration of 12%, 6% and 3%, respectively, for individuals colonised by PA. There was no pulmonary function decline in individuals not colonised by PA, or in individuals colonised by SA.CONCLUSION:Pulmonary function decline in this South African centre is significantly influenced by chronic pseudomonal infection. Other influences on this phenomenon should be explored.

There have been a number of advances in the diagnosis and management of allergic diseases that are relevant to South African (SA) circumstances. These are all published or about to be published in new guidelines that provide practical advice to guide SA doctors who treat patients with these conditions. The guidelines include those for atopic dermatitis, allergic rhinitis and food allergy. This article reflects the most pertinent aspects of the guidelines. It also provides a short summary of a new allergy diagnostic test available in SA, the multiplexmicroarray chip, known as the immuno-solid-phase allergen chip (ISAC) test. It provides component-resolved allergy testing for special circumstances and complex allergic problems and is certainly not required as a screening allergy test. Finally, this article gives an update on allergen immunotherapy - some patients with allergic conditions may benefit from immunotherapy. In SA, some forms of immunotherapy for allergic rhinitis and mild asthma may currently include sublingual immunotherapy.

The practice of Allergology has reached great heights in the last 2 years. South Africa has progressed from having Diplomates in Allergology to the recognition of sub-specialist Allergologists in Paediatrics, Internal Medicine and Family Practice. This is a new era for those of us interested in bringing the science of Allergology to our patients and already there is a sense that Allergology has joined other subspecialities in our country, to advance this aspect of science and medicine. However, the number of subspecialists in Allergology will remain small for many years and in the mean time, we will need our Allergy Diplomates, and other interested clinicians, to uphold the practice of Allergology in their own practices. This article is intended to provide a useful philosophical guide to what would make the general allergy clinic better able to meet the needs of patients. In this article we provide some ideas firstly for the ideal Children's Chest and Allergy Clinic. We believe that allergic children and their parents want three things. They want an answer (a diagnosis), then they want a treatment (a therapeutic strategy) and lastly they want a therapeutic strategy that works or leads to a solution (improved quality of life). This article will suggest ways to achieve this in your own clinic.

Welcome to the first edition of the new look Journal for 2014. For the passionate doctor: A NEW year... A NEW challenge... A NEW opportunity!

The concept of a 'united airway' became popular to link allergic rhinitis and asthma in many individuals who had symptoms of both upper and lower airway disease. Because of the common epithelium that runs all the way down the airway it is not surprising that in many individuals allergens trigger inflammation in both sites. However, the mere fact that some individuals have both symptoms of rhinitis and lower airway pathology does not mean the condition has an atopic basis. Since the airway has a limited number of ways of expressing symptoms, namely runny, sneezy, itchy and blocked nose, as well as cough or wheeze, these symptoms may also be produced in individuals who have quite a long list of other disease states. Although these are less common, healthcare workers will have to consider at some time that symptoms may be from primary ciliary dyskinesia, immune deficiency (primary or secondary), cystic fibrosis, Samter's triad or even recurrent viral airway infections. This article explores these conditions, suggesting their pathophysiology and symptom base. A clear message, to think of one of these conditions if symptoms do not have an allergy base and do not respond to first-line therapy, is expressed.

To the Editor: Medical communication is often so formal, and one can't help thinking that sometimes a more light-hearted approach would be nice. We recently attended an advanced paediatric life support course in Pretoria (may we suggest that all doctors treating children should think of doing this course?), and on one of the days our group was in a silly mood. Attempting to describe perfusion in a child who isn't shocked but also doesn't have perfect perfusion, we came up with the term 'good-ish'. It felt so right, and everybody could identify with what we meant - '-ish': something that falls outside a medical tick-box; 'normal-ish': something's not quite right but one won't put one's medical head on the block; 'ok-ish': better, but who knows what will happen?

A two-month-old HIV-infected infant was ventilated for very severe Pneumocystis jiroveci pneumonia. After successful extubation, he was started on antiretroviral therapy. He developed a proven cytomegalovirus infection, localising as pneumonia. This required repeated ventilation. He was extubated after six weeks and completed 32 days of ganciclovir.