SA RespiratoryJournalVol20Issue2 PDF

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SA Smoking
Cessation Guidelines
Obstructive sleep apnoea
ISSN 2304-0017
VOLUME 20 NO 2
June 2014
WITH
Gentle-Haler
Taking the air out of inflated prices
REFERENCE:
1. Department of Health website: http://www.doh.gov.za - accessed 29/07/2013.
Cipla Medpro (Pty) Ltd. Reg. No. 1995/004182/07, Parc du Cap, Building 9, Mispel Street, Bellville, 7530, RSA.
Tel (021) 943 4200, Fax (021) 914 4699. E-mail: medicalpa@ciplamedpro.co.za Website: www.cipla.co.za
R107,79
R144,87
R194,89
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DSSURYHGE\WKH0HGLFLQHV5HJXODWRU\$XWKRULW\$OODGYHUVHHYHQWVVKRXOGEHUHSRUWHGE\FDOOLQJWKH$VSHQ0HGLFDO+RWOLQHQXPEHURUGLUHFWO\WR*OD[R6PLWK.OLQHRQ)2$
Aspen GSK Division

Bayer Healthcare
Boehringer Ingelheim
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South African
RESPIRATORY
JOURNAL
Editor-in-Chief:
Deputy Editor:
Editorial
Sleep disordered breathing an African Problem!
- Greg Symons, Richard Raine
30
Original Paper:
Obstructive Sleep Apnoea Risk in Patients attending Medical
Outpatient Clinics in University of Benin Teaching Hospital,
Benin City, Nigeria
- Adesuwa Queeen Aigbokhaode; Alphonsus Rikevwe Isara
32
Case report:
Right-sided pulmonary vein atresia with a bronchopulmonary
sequestration
- Riaz Khan; Charl Verwey; Harshad Bhagwandas Ranchod;
Tracy Westgarth-Taylor
36
Silica-associated systemic sclerosis (Erasmus syndrome) revisited

- Shaun Maasdorp
38
Prof K Dheda
Prof C Koegelenberg
Section editor:
Breath-taking news: Prof E Irusen
Editorial board:
Prof G Ainslie, Prof E Bateman, Prof K Dheda,
Prof R Green, Prof E Irusen, Prof M Jeebhay,
Prof P Jeena, Dr C Koegelenberg,
Prof U Lalloo, Prof A Linegar, Prof R Masekela,
Dr K Nyamande, Dr J OBrien, Dr R Raine,
Prof G Richards, Dr R van Zyl Smit,
Prof M Wong, Prof H Zar
International Editorial Board Members:
Prof Adithya Cattamanchi - USA
Prof Fan Chung - UK
Prof GB Migliori - Italy
Prof Surendra Sharma - India
Prof Wing Wai Yew - China
President SA Thoracic Society:

Dr Sabs Abdool-Gaffar
Editorial
The electronic cigarettes debate
- Brian Allwood, Richard van Zyl-Smit
40
Guideline:
The South African tobacco smoking cessation clinical
practice guideline
Address for Correspondence:

PO Box 13725
Mowbray
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Telephone:
Fax:
Email:
AIRWAVES CONGRESS:
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Abstracts Contents
Abstracts
54
57
58
Whos Who in SATS
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NAEP News
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Diary of Congresses and CME events
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Product News
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Instructions to Authors
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The South African Respiratory Journal

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29
Editorial
Sleep disordered breathing an African Problem!
Dr Greg Symons1, Dr Richard Raine1
1
Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town
The paper by Isara in this issue is a timely reminder that

sleep-disordered breathing may be a major problem in the
developing, as well as the developed, world but this has not
been well documented.
Obstructive sleep apnoea (OSA) is a common condition.
Whilst no data exists for South Africa, estimates from the
United States of America suggest that 9% of women and
24% of men, aged between 30 and 60 years, have sleep
GLVRUGHUHG EUHDWKLQJ DSQRHDK\SRSQRHD LQGH[ $+,
hour). Approximately 2% of women and 4% of men meet
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5).1 There is evidence that OSA is more prevalent and severe
in blacks.2 Concerningly, even in a well-resourced society, a
study using the Wisconsin sleep cohort showed that 82% of
men and 93% of women with moderate or severe OSA had
not had the diagnosis made.3
South Africa has a population of approximately 53 000
000, about 43% aged > 30 years.4 The number of individuals
over the age of 30 years with OSA in South Africa can be
estimated to be in excess of 675 000. A very small number of
these have been investigated or treated for OSA.
OSA is associated with major comorbidities, these are
dominated by cardiovascular disease sudden cardiac death,
myocardial infarction, heart failure, arrhythmias, stroke
and severe hypertension.5-83RRUTXDOLW\RIOLIHGLIFXOW\LQ
FRQFHQWUDWLRQORVVRIHPSOR\PHQWDQGURDGWUDIFDFFLGHQWV
(RTA) are important social consequences of OSA. RTA
in particular have been shown to be associated with OSA,
and individuals with OSA involved in an RTA have a more
complicated course.9
Treatment of OSA, usually with continuous positive
airways pressure devices, has been shown to improve quality
of life and functioning, to improve control of hypertension,
to improve cardiac function, to decrease arrhythmias
SDUWLFXODUO\DWULDOEULOODWLRQDQGWRGHFUHDVHPRUWDOLW\5,10-12
It is important for clinicians in all spheres of medicine to
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diagnosed with resistant hypertension, cardiac arrhythmias
HJ DWULDO EULOODWLRQ DQG WKRVH ZLWK D KLVWRU\ RI H[FHVVLYH
snoring, gasping, witnessed apnoeas and poor quality sleep
with excessive daytime somnolence should be referred to a
centre capable of performing polysomnography. There is an
urgent need for much greater capacity for investigating and
treating this common disorder.
3. Young T, Evans L, Finn L, Palta M. Estimation of the clinically

diagnosed proportion of sleep apnea syndrome in middle-aged
men and women. Sleep 1997;20:705-6
4. Statistics South Africa. Mid-year population estimates. 14 May
2013.
5. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing
and mortality: eighteen-year follow-up of the Wisconsin sleep
cohort. Sleep 2008;31:1071-8.
6. Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW,
Grunstein RR. Sleep apnea as an independent risk factor
for all-cause mortality: the Busselton Health Study. Sleep
2008;31:1079-85.
7. Gami AS, Olson EJ, Shen WK, et al. Obstructive sleep apnea
and the risk of sudden cardiac death: a longitudinal study of
10,701 adults. J Am Coll Cardiol 2013;62:610-6.
8. Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal
arrhythmias with sleep-disordered breathing: The Sleep Heart
Health Study. Am J Respir Crit Care Med 2006;173:910-6.
9. Irwin ED, Reicks P, Beal A, Byrnes M, Matticks C, Beilman
G. A prospective study of the role of sleep related disordered
breathing as a risk factor for motor vehicle crashes and the
development of systemic complications in non-commercial
drivers. World J Emerg Surg 2014;9:2.
10. Pepin JL, Tamisier R, Barone-Rochette G, Launois SH, Levy P,
Baguet JP. Comparison of continuous positive airway pressure
and valsartan in hypertensive patients with sleep apnea. Am J
Respir Crit Care Med 2010;182:954-60.
11. Craig SE, Kohler M, Nicoll D, et al. Continuous positive airway
pressure improves sleepiness but not calculated vascular risk in
patients with minimally symptomatic obstructive sleep apnoea:
the MOSAIC randomised controlled trial. Thorax 2012;67:10906.
12. Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang X.
Meta-analysis of obstructive sleep apnea as predictor of atrial
EULOODWLRQUHFXUUHQFHDIWHUFDWKHWHUDEODWLRQThe Am J Cardiol
2011;108:47-51.
References
1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The
occurrence of sleep-disordered breathing among middle-aged
adults. N Eng J Med 1993;328:1230-5
2ODUDQ\H2$NLQERER\H20LWFKHOO-(2JHGHJEH*-HDQ
Louis G. Obstructive sleep apnea and cardiovascular disease
in blacks: a call to action from the Association of Black
Cardiologists. Am Heart J 2013;165:468-76.
30
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Obstructive Sleep Apnoea Risk in Patients

attending Medical Outpatient Clinics in
University of Benin Teaching Hospital, Benin
City, Nigeria
Adesuwa Queeen Aigbokhaode MPH; Alphonsus Rikevwe Isara FMCPH
University of Benin, Benin City, Edo, Nigeria
Abstract
Background:
The prevalence of Obstructive Sleep Apnoea (OSA) risk
and its attendant sequelae among patients with chronic
diseases in Nigeria appears to be increasing.
Aims:
This study assessed the prevalence of OSA risk in
patients attending medical outpatient clinics (MOPCs) in
the University of Benin Teaching Hospital, Benin City,
Nigeria.
Materials and Methods:
This descriptive cross-sectional study was conducted
among patients attending medical outpatient clinics at the
University of Benin Teaching Hospital, Benin City, Nigeria.
The Berlin and Epworth Sleepiness Scale questionnaires
were the tools used for data collection. Statistical analysis
was done using SPSS version 16 statistical software.
Results:
A total of 102 medical outpatients with a mean age of 55.1
13.6 years were interviewed. There were 55 females
(53.9%) and 47 males (46.1%). The majority (87.3%) were
hypertensive while 46.0% and 27.5% were overweight and
obese respectively. The prevalence of OSA risk among the
respondents who were positive according to the Berlin
questionnaire was 67 (65.7%). There was a statistically
VLJQLFDQW DVVRFLDWLRQ EHWZHHQ DJH JURXS LQ \HDUV 3
0.01), body mass index (P < 0.001), blood pressure (P <
0.001), Epworth Sleepiness Scale score (P < 0.001) and
Berlin risk of OSA.
Conclusion:
The prevalence of OSA risk in patients attending the
MOPCs in UBTH was high. There is a need for medical
practitioners to increase their level of suspicion of OSA
risk among medical patients. Also, there should be health
education of all patients accessing the MOPCs on risk
factors for OSA.
Key Words:
Obstructive Sleep Apnoea Risk, Medical Outpatients,
Hypertension, UBTH
Introduction
Obstructive Sleep Apnoea (OSA), also referred to as
Obstructive Sleep Apnoea-Hypopnoea (OSAH), is a sleep
GLVRUGHU WKDW LQYROYHV FHVVDWLRQ RU VLJQLFDQW GHFUHDVH LQ
32
DLURZ LQ WKH SUHVHQFH RI EUHDWKLQJ HIIRUW1 It is the most

common type of sleep disordered breathing characterized by
recurrent episodes of upper airway collapse during sleep.1
These episodes are associated with recurrent oxyhaemoglobin
desaturations and arousals from sleep. Apnoea may occur
hundreds of times at night, one to two times per minute in
patients with severe OSA, and is often accompanied by wide
swings in heart rate, a decrease in oxygen saturation and brief
arousals in electroencephalography (EEG).2
The cardinal symptoms of OSA include snoring,
VOHHSLQHVV DQG VLJQLFDQWRWKHU UHSRUWV RI VOHHS DSQRHD
HSLVRGHV 7KH ULVN IDFWRUV IRU 26$ DUH RYHUZHLJKWREHVLW\
male, having a relative who has OSA, people above 65
years, black race, Hispanics and smoking.3 Other risk factors
include certain physical attributes such as having a thick
neck, deviated septum, receding chin and enlarged tonsils
or adenoids (the most common cause of sleep apnoea in
children).3 The airways may be blocked or narrowed during
sleep simply because the throat muscles tend to relax more
than normal. Allergies or other medical conditions that cause
nasal congestion and blockage can also contribute to OSA.3
Sleep disorders are on the rise globally. The prevalence of
OSA in the United States is currently estimated to be between
5% and 10%.4 It is estimated that only 10% of the population
has been adequately screened for appropriate diagnosis.5
This estimate is based on the prevalence of risk factors for
OSA in the population. The prevalence of snoring among
adults varies in different part of the world from 5 to 44%.6,7
In a report from Abuja, Nigeria, the overall prevalence of
snoring in adults was 31% while the prevalence of Clinically
Suspected Obstructive Sleep Apnoeas (CSOSA) was 1%
(1.9% in males, 0.5% in females).6 Obstructive Sleep Apnoea
Syndrome (OSAS) may be a more common medical problem
among Nigerians than ever imagined.
OSAS is very important because of its association with, and
the potential to cause, many of the most debilitating medical
conditions, including hypertension, cardiovascular disease,
coronary artery disease, type 2 diabetes mellitus, depression,
and sleepiness-related accidents.8,9 This association between
OSA and chronic medical conditions could be due to risk
factors such as age, obesity, alcohol consumption and tobacco
smoking.2,8-11 Hypertension and OSA has been described
among many populations,10,11 with more hypertensive
patients experiencing adverse cardiovascular sequelae. These
sequelae include stroke, myocardial infarction, congestive
heart failure, excessive day time sleepiness, sleep-related
accidents and death.8,12,13
The complications of hypertension, including congestive
KHDUWIDLOXUHKDYHEHHQIRXQGWREHVLJQLFDQWO\DVVRFLDWHG
with excessive daytime sleepiness and OSA risk resulting in
poor quality of life in these patients.8,12,13 OSA and its risk also
KDYHVLJQLFDQWQHJDWLYHLPSDFWRQWKHDOUHDG\FRPSURPLVHG
quality of life in patients with congestive heart failure as well
as individuals with other medical conditions.13
OSA remains undiagnosed in many individuals especially
among medical patients.5-8 OSAS is a common medical
FRQGLWLRQZLWKVLJQLFDQWDGYHUVHPHGLFDODQGSXEOLFKHDOWK
consequences.14,15 The estimation of the prevalence of OSA
risk among medical outpatients will not only help in the better
management and reduction of the complications of OSA, but
will also help in improving their quality of life. This study was
designed to assess the prevalence of OSA risk among patients
attending the medical outpatient clinics in the University of
Benin Teaching Hospital, Benin City, Nigeria.
weighing scales were used to measure the heights and

weights respectively. When measuring their height, the
respondents were asked to stand erect with their feet together,
heels, buttocks, shoulders and occiput touching the meter rule
behind with their eyes looking straight ahead. The body mass
index (BMI) of the patients was calculated using the standard
formula. This was then used to classify the patients as follows:
underweight, BMI less than 18.5, normal weight, BMI 18.5
24.9, over weight, BMI 25 29.9 and obese, BMI 30 and
above.20 The blood pressure (BP) of the patients was measured
using a mercury sphygmomanometer (Accoson, Essex, UK).
It was taken with the cuff covering about three-quarters of the
left arm and over the brachial artery with the respondent in a
sitting position. The BP of each respondent was taken before
and after the interview over an interval of 15 - 20 minutes and
the average BP was used for each respondent. This was done
to minimize the effect of anxiety.
Materials and methods

Statistical analysis
The study was approved by the University of Benin Teaching
Hospital Ethics and Research Committee. Permission was
sought from the consultants in charge of the various medical
out-patient clinics. Written informed consent was obtained
from each respondent before conducting interviews. The
FRQGHQWLDOLW\DQGSULYDF\RIWKHUHVSRQGHQWVZDVUHVSHFWHG
during the interviews. Health education of the respondents
on OSA was carried out at the end of each day after data
collection.
The University of Benin Teaching Hospital (UBTH)
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situated in Benin City (the capital of Edo State) in the
South-South geo-political zone of Nigeria. The medical
outpatient clinics are held daily from Mondays to Fridays
with the patients registered under various consultants in
the Department of Internal medicine. The Department of
Internal Medicine has eight medical outpatient clinics which
are Respiratory, Endocrinology, Nephrology, Neurology,
Clinical Pharmacology, Gastroenterology, Dermatology and
Cardiology clinics with an estimated average attendance of
4,000 patients weekly.
The study population was made up of adult patients who
attended the medical out-patient clinics in UBTH from January
to March 2013. The minimum sample size required for this
study, calculated using the appropriate formula for sample
size determination in a descriptive study and a prevalence of
4.7%16 was 69. After adjusting for 10% non-response, the
minimum sample size came to 76. A systematic sampling
method was used in the selection of patients from the clinic
registers. On each day, the lists (sampling frame) of all the
patients attending the clinics was obtained from the clerical
RIFHUVDQGWKHVDPSOLQJLQWHUYDOZDVGHWHUPLQHGEDVHGRQ
the total number of patients on the list and estimated study
sample size. The starting point in the sampling frame was
a randomly selected from the numbers within the sampling
interval and respondents were recruited proportionately until
the required sample size was obtained.
The Berlin questionnaire17 and the Epworth Sleepiness
6FDOHYDOLGDWHGIRU26$ULVNSUROH18,19 were used to collect
data from the patients. Two trained research assistants who
were Community Health Extension Workers (CHEW) from
the Department of Community Health, UBTH assisted in data
collection.
A standardized stadiometer and bathroom (Hana)
The questionnaires were screened for completeness by the

researchers, coded and entered into the Statistical Package
IRU 6FLHQWLF 6ROXWLRQV 6366 YHUVLRQ VRIWZDUH
Categorical data were presented as proportions while
continuous variables were expressed as mean standard
deviation. Chi Square statistical test of association was used
to test the association between OSA risk and hypertension,
age, body mass index, sex and Epworth sleepiness scale
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The three sections of the Berlin questionnaire were used
in classifying respondents into high and low risk for OSA.
The 8-question Epworth Sleepiness Scale questionnaire was
used in scoring respondents daytime sleepiness on a scale
of increasing probability from 0 to 3 for the eight different
situations that most people engage in during their daily lives.
This gives a highest possible score of 24. A score of 0 9 was
considered to be normal while a score of 10 24 indicates
that the patient was likely to be at risk of a sleep disorder like
OSA.
Results
A total of 102 adult medical outpatients were interviewed.
Table 1 showed the socio-demographic characteristics of the
respondents. They comprised 55 (53.9%) females and 47
(46.1%) males. The mean age of the respondents was 55.1
13.6 years with 29 (28.4%) of them in the age group > 65 years,
followed by 45 54 years age group with 27 (26.5%). A high
proportion 47 (46.0%) of the respondents were overweight
and the prevalence of obesity among the respondents was
28 (27.5%). A little above one quarter 26 (25.5%) of the
respondents had normal weight. The study also found out that
89 (87.3%) of the respondents were hypertensive.
Table 2 shows the prevalence of OSA risk among the
respondents who answered positive to the Berlin questionnaire
was 67 (65.7%). A cross-tabulation of the Berlin risk of
OSA by age group in years, sex, BMI, BP and Epworth
Sleepiness Scale score of respondents is shown in Table 3.
7KHUHZDVDVWDWLVWLFDOO\VLJQLFDQWDVVRFLDWLRQEHWZHHQDJH
JURXS3 %0,3%33(SZRUWK
sleepiness scale score (P < 0.001) and Berlin risk of OSA.
The proportion of respondents with OSA risk increased with
increase age, increasing BMI, high BP and positive Epworth
33
Table 1:
Socio-demographic characteristics of respondents
Variables
Frequency
(N=102)
Percent
Table 3:
Berlin Risk of Obstructive Sleep Apnoea and Age group, Sex, Body
Mass Index, Blood Pressure, Epworth Sleepiness Scale Score
Variables
Berlin Risk of
Obstructive
Sleep Apnoea
Age group in years

20 34
8.8
35 44
12
11.8
45 54
27
26.5
55 64
25
24.5
> 65
29
28.4
Mean age of respondents
6' \HDUV
Sex
Male
47
46.1
Female
55
53.9
Body mass index

Under weight
1.0
Normal weight
26
25.5
Overweight
47
46.0
Obese
28
27.5
High blood pressure

Yes
89
87.3
No
13
12.7
Table 2:
Prevalence of Obstructive Sleep Apnoea risk among respondents using
the Berlin Questionnaire
Berlin Risk of Obstructive Sleep
Apnoea
Frequency
Percent
Positive
67
65.7
Negative
35
34.3
Total
102
100.0
Sleepiness Scale score. However, there was no statistically

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Discussion
There were more females in this study who were positive for
OSA risk. This is in contrast to other studies in which more
males were found to have OSA risk.7,21,22 This could be due
to the fact that more females were overweight, obese and
hypertensive, and this may have predisposed them to snoring
and tiredness. Also, females generally have better healthseeking behaviour than their male counterparts. In addition,
older postmenopausal women are more at risk of OSA.23
More than one quarter of the respondents were aged more
than 65 years. The age of 65 years and above has been found
to be a risk factor for OSA.9,22 This could be due to the fact
that older age is associated with muscular and neurological
loss of muscle tone, and the upper airway is not spared.
The resultant effect of this is narrowing of the airway and
obstructed breathing. The combination of OSA and other
medical and social problems usually associated with old
age will further increase the burden of caring for old people
ZLWKLQWKHFRQQHVRIVFDUFHUHVRXUFHV
The prevalence of OSA risk was high among the patients
(65.7%). This could be attributed to the fact that many of the
UHVSRQGHQWV ZHUH RYHUZHLJKW DQG REHVH 7KLV QGLQJ ZDV
34
No Berlin Risk
of Obstructive
Sleep Apnoea
X2
P value
Age Groups (years)

20 34
2 (22.2)
7 (77.8)
35 44
10 (83.3)
2 (16.7)
45 54
21 (77.8
6 (22.2)
55 64
18 (72.0)
7 (28.0)
> 65
16 (55.2)
13 (44.8)
12.8
0.01*
0.614
0.43
17.5
<0.001*
12.0
<0.001*
33.3
<0.001*
Sex
Male
29 (61.7)
18 (38.3)
Female
38 (69.1)
17 (30.9)
Body Mass Index

Under weight
0 (0.0)
1 (100.0)
Normal weight
10 (38.5)
16 (61.5)
Overweight
32 (68.1)
15 (31.9)
Obese
25 (89.3)
3 (10.7)
High Blood Pressure

Yes
64 (71.9)
25 (28.1)
No
3 (23.1)
10 (76.9)
Epworth Sleepiness Scale scores

Negative
21 (39.6)
32 (60.4)
Positive
46 (93.9)
3 (6.1)
6WDWLVWLFDOO\VLJQLFDQW
consistent with a study in Abuja, Nigeria, and in the United

States in which overweight and obese patients were more at
risk of OSA.9,21,22 This could be due to the rising prevalence of
obesity and other non-communicable diseases in Nigeria and
in other developing countries. The increase in consumption
of fast food and the lack of regular physical exercise have
contributed to the rising proportion of overweight and obese
people in Nigeria.
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majority of the respondents had high BP and this may have
contributed to the high prevalence of OSA risk. Apart from
hypertension, OSA risk has been found to be associated
with other chronic medical conditions like diabetes mellitus,
congestive cardiac failure and depression.9,13,21
A higher proportion of the respondents with positive
Epworth Sleepiness Scores had risk for OSA and this was
similar to other studies carried out in Nigeria7 and the United
States.21,22 This could be due to the fact that sleepiness and
tiredness are cardinal symptoms in OSA. This not only
leads to poor quality of sleep, excessive daytime tiredness,
cardiovascular conditions such as stroke, heart attack, heart
failure, cardiac rhythm disturbances especially intermittent
DWULDO EULOODWLRQ EXW DOVR WR ORZ ZRUN SHUIRUPDQFH SRRU
interpersonal relationships and, ultimately poor quality of life
and productivity.
The association between OSA risk and age, BP and BMI
RIWKHSDWLHQWVZDVIRXQGWREHVWDWLVWLFDOO\VLJQLFDQW7KLV
was probably due to the high proportion of older patients
who were overweight, obese and hypertensive in this study.
7KLVQGLQJLVFRQVLVWHQWZLWKWKRVHRIRWKHUVWXGLHVGRQHLQ
Nigeria and India in which older age group (40 years and
above), overweight, obesity and high BP were associated

with OSA.7,10,12,13 OSA often goes undiagnosed among
medical outpatients in many health facilities because medical
practitioners usually cannot detect the condition during
routine hospital visits. This is compounded by the fact that no
blood test can help in making the diagnosis of this condition.
Polysomnography remains the gold standard for diagnosing
OSA. However, in the absence of polysomnography
especially in resource limited settings like Nigeria, the Berlin
and Epworth sleepiness scale questionnaires are veritable
tools in identifying patients who are at risk of OSA.
Conclusion
The prevalence of OSA risk in patients attending MOPCs in
UBTH was high. The factors associated with this included
increasing age, high BP, overweight and obesity. There
is need for medical practitioners to increase their level of
suspicion of OSA risk among medical patients in the course
of their duty. Also, the hospital should institute a health
education programme for all adult patients accessing the
MOPCs. This should be targeted at lifestyle medication such
as regular exercise and appropriate diet, which will reduce the
incidence of overweight and obesity among medical patients
as they may be unaware of these as risk factors for OSA. This
will not only reduce the attendant problems of OSA but will
lead to improvement in the quality of life and reduction in
untimely deaths among medical patients.
References
1. Guilleminault C, Tilkian A, Dement WC. The sleep Apnea
syndromes. Annu Rev Med. 1976; 27: 465-484.
2. Hiestand D, Britz P, Goldman M, Philips B. Prevalence of
Symptoms and Risk of Sleep Apnea in the U S Population.
Chest. 2006; 130 (3): 780 786
3. Smith, M, Robinson L and Segal R. Sleep Apnea, Symptoms,
Causes, Cures and Treatment Options. 2012. www.Helpguide.
RUJ$FFHVVHG
4. Young T, Evans L, Finn L, Palta M. Estimation of the clinically
diagnosed proportion of sleep Apnea syndrome in middle-aged
men and women. Sleep. 1997; 20 (9):705-706.
5. Olson LG, King MT, Hensley MJ. A community study of snoring
and sleep-disordered breathing. Prevalence. Am J Respir Crit
Care Med. 1995; 152 (2):711-716.
6. Young T, Peppard, PE, Gottlieb DJ. Epidemiology of obstructive
sleep Apnea: a population health perspective. Am J Respir Crit
Care Med. 2002; 165, 1217-1239
7. Adewole OO, Hakeem A, Fola A, Anteyi E, Ajuwon Z, Erhabor
G. Obstructive sleep apnoea among adults in Nigeria. J Natl
Med Assoc. 2009, 101 (7):720-725
8. Downey R, Obstructive Sleep Apnea. Medscape Education and

7UDLQLQJZZZPHGVFDSHRUJ$VVHVVHG
9. Botros N, Concato J, Mohsenin V, Selim B, Doctor K, Yaggi HK.
Obstructive Sleep Apnea as a risk factor for Type II Diabetes.
Am J Med. 2009; 122 (12): 1122-1127.
10. Akintunde AA, Okunola OO, Oluyombo R, Oladosu OY,
Opadijo GO. Snoring and obstructive sleep apnoea syndrome
among hypertensive Nigerians: prevalence and clinical
correlates. The Pan African Medical Journal. 2012;11:75
11. American Academy of Sleep Medicine. International
&ODVVLFDWLRQ RI 6OHHS 'LVRUGHUV ,Q 'LDJQRVWLF DQG &RGLQJ
Manual. Second Edition. Westchester, Ill: American Academy
of Sleep Medicine; 2005.
12. Campana L, Eckert DJ, Patel SR, Malhotra A. Pathophysiology
and genetics of obstructive sleep apnoea. Indian J Med Res.
2010; 131, 176-187
13. Patidar AB, Andrews GR, Seth S. Prevalence of Obstructive
Sleep Apnea, associated risk factors, and quality of life among
India congestive heart failure patients: a cross sectional survey.
J Cardiovasc Nurs. 2011; 26(6): 452-459
14. Mooe T, Franklin KA, Holmstrom K, Rabben T, Wiklund U.
Sleep-disordered breathing and coronary artery disease: longterm prognosis. Am J Respir Crit Care Med. 2001; 164:1910
1913.
15. Shamsuzzaman AS, Gersh BJ, Somers VK. Obstructive sleep
apnea: implications for cardiac and vascular disease. JAMA 290:
2003; 19061914.
16. Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, VelaBueno A, et al. Prevalence of sleep disordered breathing: effect
of gender. Am J Respir Crit Care Med. 2001; 163: 608 13.
17. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using
the Berlin Questionnaire to identify patients at risk for the
sleep apnea syndrome. Ann Intern Med.1999; 131:485- 491.
18. Johns MW. A new method for measuring daytime sleepiness:
the Epworth sleepiness scale. Sleep. 1991; 14 (6): 540545.
-RKQV 0: 6HQVLWLYLW\ DQG VSHFLFLW\ RI WKH PXOWLSOH VOHHS
latency test (MSLT), the maintenance of wakefulness test and
the Epworth Sleepiness Scale: failure of the MSLT as a gold
standard. J Sleep Res. 2000; 9 (1): 511.
20. World Health Organization. Obesity: preventing and managing
the global epidemic. WHO, Geneva. June 3 5, 1997.
21. Hiestand DM, Britz P, Goldman M, Phillips B. Prevalence
of Symptoms and Risk of Sleep Apnea in the United States
Population. Chest. 2006; 130(3): 780-786.
22. Demede M, Pandey A, Zizi F, Bachmann R, Donat M,
McFarlane SI, Jean-Louis G, and Ogedegbe G. Resistant
Hypertension and Obstructive Sleep Apnea in the Primary-Care
Setting. International Journal of Hypertension. 2011 (2011) 5
23. Young T. Menopause, hormone replacement therapy, and sleepdisordered breathing: are we ready for the heat. Am J Respir Crit
Care Med 2001; 163: 597-598.
35
Right-sided pulmonary vein atresia with a

bronchopulmonary sequestration
Riaz Khan MBChB, FCPaed (SA); Charl Verwey MBChB, FCPaed (SA); Harshad Bhagwandas
Ranchod MBBCh (Wits), DCH (SA), FCPaed (SA); Tracy Westgarth-Taylor MBChB FC Rad (diag)
Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
Abstract
Unilateral pulmonary vein atresia is a rare condition, which
results in ipsilateral pulmonary hypoplasia and a small
ipsilateral pulmonary artery. We report a case of an infant
who presented with haemoptysis and who was found to
have a unilateral right-sided pulmonary vein atresia, a
hypoplastic right pulmonary artery, a right sided hypoplastic
lung and a bronchopulmonary sequestration.
Case Report
A seven month old girl was referred from a regional hospital
to Chris Hani Baragwanath Academic Hospital in Soweto,
South Africa. Her presenting complaint at the regional
hospital was that of a cough, fast breathing and haemoptysis
for 3 days. She was diagnosed with a pneumonia based on
her chest radiograph and given a course of antibiotics. Her
repeat radiograph two weeks later showed no radiological
improvement. The non-resolving pneumonia was the reason
for her referral.
She was a term baby with a normal birth history and was
HIV exposed but with a negative six week HIV PCR.
On examination she was underweight (z-score: -2.6) and
stunted (z-score: -2-8), but on the median for weight-forOHQJWK 6KH KDG D UHVSLUDWRU\ UDWH RI PLQ ZLWK QR VXE
or intercostal recessions. Her oxygen saturation was 99% in
room air. She was not pale and had no clubbing. Her trachea
was situated centrally. There was dullness to percussion and
bronchial breathing in the right upper and middle zones with
QRUPDOEUHDWKVRXQGVWKURXJKRXWWKHUHVWRIKHUOXQJHOGV
On cardiovascular examination there were no signs of a
cardiac lesion or of pulmonary hypertension.
Anteroposterior chest radiograph revealed a small right
OXQJ ZLWK D ODUJH RSDFLFDWLRQ LQ WKH ULJKW XSSHU ]RQH DQG
ipsilateral mediastinal shift. There was compensatory
K\SHULQDWLRQ RI WKH OHIW OXQJ ZLWK LQFUHDVHG YDVFXODU
markings (JXUH). The differential diagnosis based on the
chest radiograph included a congenital thoracic malformation,
a congenital vascular anomaly or a congenital small lung.
)XOO EORRG FRXQW DQG FORWWLQJ SUROH ZHUH QRUPDO
Bronchoscopy showed extensive mucosal hyperaemia
through-out the visualized airways of the right lung. A
ventilation scan was not possible to do due to the patients age.
Perfusion scan showed no uptake of tracer in the right lung.
Echocardiography showed a hypoplastic right pulmonary
artery and absent right pulmonary veins. Pulmonary pressures
were not markedly raised with a TR gradient of 31 mmHg.
$ &7 DQJLRJUDP RI WKH FKHVW FRQUPHG WKH DEVHQW ULJKW
pulmonary veins (JXUH ), a small right sided pulmonary
artery (JXUH ), a hypoplastic right lung and a right lower
36
Figure 1 (above)
Anteroposterior chest radiograph demonstrates a small volume
ULJKW OXQJ ZLWK PHGLDVWLQDO VKLIW WR WKH ULJKW DQG DQ RSDFLFDWLRQ
LQWKHULJKWXSSHU]RQH7KHUHLVFRPSHQVDWRU\K\SHULQDWLRQDQG
increased vascular markings of the left lung.
Left pulmonary
veins
Absent right
pulmonary veins
Figure 2 (above)
Contrast-enhanced CT (axial image) demonstrates a hypoplastic
right pulmonary artery
lobe bronchopulmonary sequestration which received its

arterial supply from a branch of the abdominal aorta (JXUH)
Diagnosis of a unilateral right sided pulmonary vein atresia
with resultant pulmonary hypoplasia and a hypoplastic
right pulmonary artery was made. There is also a rightsided congenital thoracic malformation in keeping with an
intralobar bronchopulmonary sequestration.
Hypoplastic right
pulmonary artery
Left pulmonary
artery
Figure 3 (left)
Contrast-enhanced
CT scan (axial image)
demonstrates a smooth
left atrial wall at
expected location of
right pulmonary veins.
Figure 4 (right)
Contrast-enhanced
CT scan (sagittal
image) demonstrates
a right lower lobe
bronchopulmonary
sequestration with
arterial supply from a
branch of the abdominal
aorta.
Discussion
Bronchopulmonary sequestrations are part of the spectrum of
congenital thoracic malformations (CTM) seen in childhood.
It is the second most common CTM seen after congenital
pulmonary airway malformation1 with an incidence ranging
from 0.5-6.4% of all congenital pulmonary malformations.2
Bronchopulmonary sequestration refers to non-functional
disorganized pulmonary tissue that does not communicate
with the tracheobronchial tree. They usually have a systemic
arterial supply from the aorta or one of its branches. They
can be divided into intralobar and extralobar types. The
intralobar type is found within normal lung parenchyma and
the extralobar type is completely separate from any normal
lung parenchyma. Bronchopulmonary sequestrations can act
as a nidus for recurrent chest infections. Management usually
involves resection of the sequestration.3
Pulmonary vein atresia is a rare condition in which the
pulmonary veins fail to be incorporated into the left atrium.
The veins draining the lung are obstructed by medial
K\SHUWURSK\ DQG LQWLPDO EURVLV4 likely due to a disruption
during embryogenesis.5 The ipsilateral pulmonary artery is
small, likely because of preferential pulmonary artery blood
RZWRWKHFRQWUDODWHUDOVLGHZLWKUHVXOWDQWLPSDLUHGJURZWK
of the affected pulmonary artery.6 7KH GHFUHDVHG RZ RI
blood to the lung leads to failure of the development of the
alveolar bed and resultant pulmonary hypoplasia. Venous
drainage from the affected lung can occur via the bronchial
venous system and the azygous vein into the systemic venous
system.7
The most frequent presenting complaints include recurrent
chest infections in the affected lung, exercise intolerance and
haemoptysis.4, 7, 8 These symptoms usually start in infancy or
early childhood.8
$ 94 VFDQ VKRZV GHFUHDVHG RU DEVHQW RZ RI EORRG
to the affected lung and is useful in demonstrating the
GHDG VSDFH YHQWLODWLRQ WKDW RFFXUV &7 DQJLRJUDP QGLQJV
include a small lung with ipsilateral mediastinal shift, a small
ipsilateral pulmonary artery and absence of the pulmonary
vein connection to the left atrium.6
The mucosal hyperaemia as seen on bronchoscopy is
likely due to venous engorgement secondary to pulmonary
vein obstruction. The haemoptysis was also likely caused by
the rupture of these dilated engorged veins.
$ GHQLWLYH GLDJQRVLV RI LVRODWHG XQLODWHUDO SXOPRQDU\
Bronchopulmonary
sequestration
vein atresia usually requires cardiac catheterization with

SXOPRQDU\DQJLRJUDSK\ZKLFKVKRZVVORZRZRIFRQWUDVW
into the affected lung and failure to demonstrate the pulmonary
veins on the affected side. Severe pulmonary hypertension is
also often demonstrated.
Most children with pulmonary vein atresia die from
pulmonary hypertension. The mortality rate approaches
50% in untreated patients9 and most children die by one
year.10 6XSSRUWLYH&RQVHUYDWLYH WUHDWPHQW FDQ EH DWWHPSWHG
for asymptomatic patients but a pneumonectomy should be
considered if the patient has severe pulmonary hypertension,
recurrent pulmonary infections in the affected lung or
dyspnoea due to ventilation perfusion mismatch.4,7,8
In our patient cardiac catheterization was planned as
the next step in the work-up. A decision regarding further
management and the possible need for a pneumonectomy
would then have been made based on all the available
information. Unfortunately the patient was lost to follow-up
and many attempts to contact the family were unsuccessful.
References
1. Davenport M, Warne SA, Cacciaguerra S, Patel S, Greenough A,
Nicolaides K. Current outcome of antenally diagnosed cystic lung
disease. J Pediatr Surg. 2004;39(SXE
2. Savic B, Birtel FJ, Tholen W, Funke HD, Knoche R. Lung
sequestration: report of seven cases and review of 540 published cases.
Thorax.1979;34(SXE
3. Stanton M, Davenport M. Management of congenital lung lesions. Early
Hum Dev. 2006;82(SXE
4. Pourmoghadam KK, Moore JW, Khan M, Geary EM, Madan N,
Wolfson BJ, et al. Congenital unilateral pulmonary venous atresia:
GHQLWLYH GLDJQRVLV DQG WUHDWPHQW Pediatr Cardiol. 2003;24(1):73-9.
(SXE
5. Edwards JE. Congenital stenosis of pulmonary veins. Pathologic
and developmental considerations. Lab Invest 1960;9:46-66. Epub

6. Dixit R, Kumar J, Chowdhury V, Rajeshwari K, Sethi GR. Case report:
Isolated unilateral pulmonary vein atresia diagnosed on 128-slice
multidetector CT. Indian J Radiol Imaging. 2011;21(4):253-6. Epub

7. Cullen S, Deasy PF, Tempany E, Duff DF. Isolated pulmonary vein
atresia. Br Heart J. 1990;63(SXE
8. Argueta-Morales IR, Garg R, DeCampli WM. Diagnosis and
management of congenital right pulmonary venous atresia. Cardiol
Young. 2009;19(SXE
9. Cabrera A, Vazquez C, Lekuona I. Isolated atresia of the left pulmonary
veins. Int J Cardiol. 1985;7(SXE
10. Mata JM, Caceres J, Lucaya J, Garcia-Conesa JA. CT of congenital
malformations of the lung. Radiographics. 1990;10(4):651-74. Epub

37
Silica-associated systemic sclerosis (Erasmus

syndrome) revisited
Shaun Maasdorp
University of the Free State, Bloemfontein, South Africa
A 46 year old male presented with complaints of progressive
dyspnoea and chronic non-productive coughing for a one
month period. At presentation he had grade 2 dyspnoea
DFFRUGLQJ WR WKH PRGLHG 0HGLFDO 5HVHDUFK &RXQFLO
(mMRC) dyspnoea scale and he became easily fatigued during
H[WUDQHRXVSK\VLFDODFWLYLW\+LVSDVWKLVWRU\ZDVVLJQLFDQW
for having received treatment for pulmonary tuberculosis
the previous year, but he denied having any constitutional
symptoms at the current evaluation. Furthermore, the patient
had a history of working underground in gold mines for 10
years and had a 1.5 pack year smoking history, although he
stopped smoking 17 years ago.
On clinical examination, the patient was not visibly
GLVWUHVVHGZKLOHDWUHVW+HKDGFOXEELQJRIKLVQJHUVDQGWKH
VNLQRIKLVQJHUVKDQGVIRUHDUPVDQGIDFHZDVWKLFNHQHG
and tethered to the subdermal structures. On examination
of the respiratory system his trachea was central and he had
normal vesicular breath sounds bilaterally. Pulse oximetry
revealed an oxygen saturation of 94% while he was breathing
URRP DLU 7KH SDWLHQWV EORRG SUHVVXUH ZDV PP+J
SXOVH UDWH EHDWVPLQ DQG KLV FDUGLRYDVFXODU H[DPLQDWLRQ
was normal. The rest of the systemic examination was also
normal.
His chest x-ray revealed diffuse reticulo-nodular
opacities bilaterally. High resolution computed tomography
RI WKH FKHVW FRQUPHG VPDOO QRGXOHV PDLQO\ LQ WKH XSSHU
OXQJ ]RQHV DV ZHOO DV HJJVKHOO FDOFLFDWLRQ RI WKH KLODU
lymph nodes (JXUH ) in keeping with a diagnosis of
VLOLFRVLV $ SHFXOLDU QGLQJ KRZHYHU ZDV WKH SUHVHQFH RI
GLIIXVHJURXQGJODVVRSDFLFDWLRQLQERWKORZHUOXQJ]RQHV
(JXUH $QRWKHU LQWHUHVWLQJ QGLQJ RQ &7FKHVW ZDV DQ
DEQRUPDOO\GLODWHGGLVWDORHVRSKDJXV7KHQGLQJRIDGLODWHG
oesophagus prompted oesophageal manometry testing which
demonstrated oesophageal dysmotility. On spirometry the
FVC was 2.05 L (48% of predicted), FEV1 1.38 L (40% of
predicted) and FEV1)9& UDWLR ZLWK QR UHYHUVLELOLW\
post-bronchodilator inhalation. Diffusion capacity of the lung
to carbon monoxide measured by means of the single breath
technique was 37% of predicted. During a 6-minute walk
test, the patient became severely dyspnoeic and desaturated
markedly from 91% to 83%. The test was abandoned after
he covered a distance of 80 meters. ANA was positive with
a titre of 1:80 and anti-Scl 70 antibodies was also positive
ZLWKDWLWUHRI!8PO6SXWXPDVZHOODVEURQFKRVFRSLF
alveolar lavage for microscopy and culture, tuberculosis
and PCP were negative. A lung biopsy was requested and
KLVWRORJLFDO HYDOXDWLRQ WKHUHRI UHYHDOHG LQWHUVWLWLDO EURVLV
ZLWK DUHDV RI EUREODVWLF IRFL DV ZHOO DV KRQH\FRPELQJ LQ
some areas (figure 3), in keeping with usual interstitial
pneumonia.
Final diagnosis:
Silica-associated systemic sclerosis (Erasmus syndrome)
38
Figure 1 (above)
Figure 2 (above)
Figure 3 (above)
Discussion:
In 1957, Erasmus published a report of an increased
incidence of diffuse systemic sclerosis among South African
gold miners on the Witwatersrand.1 Subsequent case studies
conducted among South African gold miners from diverse
HWKQLF EDFNJURXQGV FRQUPHG WKH DVVRFLDWLRQ RI V\VWHPLF
sclerosis and high-level silica dust exposure.2,3 A recent metaanalysis of 16 published studies found a relative risk of 3.20
(95% CI 1.89-5.43) for developing systemic sclerosis in silica
exposed workers.4
The pathogenesis of systemic sclerosis is still not clearly
GHQHG EXW VLOLFD SDUWLFOHV LQJHVWHG E\ PDFURSKDJHV FDQ
seemingly cause enhanced antigen stimulation of T and
B lymphocytes that lead to increased antibody, including
auto-antibody production, immune complex formation and
VWLPXODWLRQRIEUREODVWVUHVXOWLQJLQFROODJHQGHSRVLWLRQLQ
the blood vessels, skin and internal organs.5
The diagnosis of systemic sclerosis is usually made
clinically when skin thickening is associated with visceral
organ involvement. Pulmonary manifestations of systemic
VFOHURVLVLQFOXGHLQWHUVWLWLDOOXQJGLVHDVHHLWKHUQRQVSHFLF
interstitial pneumonia or usual interstitial pneumonia, and
pulmonary vascular disease presenting as pulmonary arterial
hypertension with minimal parenchymal involvement.
The prognosis for patients with pulmonary manifestations
of systemic sclerosis is poor. Cyclophosphamide is often used
in the treatment of patients with systemic sclerosis-associated
interstitial lung disease despite limited evidence of clinically
VLJQLFDQWLPSURYHPHQWLQ)9&DQG'/&26
Our patient had a short history of dyspnoea and no features
RIHQGVWDJHOXQJEURVLVRQWKH+5&7FKHVW$GHFLVLRQZDV
therefore made to treat the patient with cyclophosphamide and

low-dose systemic corticosteroid therapy for 6 months, where
after cyclophosphamide was substituted for azathioprine for
a further 18 months. The patient responded well to treatment
and on last follow up, he reported to have dyspnoea only on
severe exertion. He could cover a distance of 480 m during
a 6 minute walk test while maintaining normal oxygen
saturation. His FVC was 3.60 L (83% of predicted), FEV1
2.35 L (67% of predicted), FEV1)9&UDWLRDQG'/&2
54%.
7KLV FDVH GHPRQVWUDWHV WKH SRWHQWLDO EHQHW RI
immunosuppressive therapy in selected patients with silicaassociated systemic sclerosis and interstitial lung disease.
References
1. Erasmus LD. Scleroderma in gold-miners on the Witwatersrand
with particular reference to pulmonary manifestations. S Afr J
Lab Clin Med 1957; 3: 209-231
2. Sluis-Cremer GK, Hessel PA, Nizdo EH, Churchill AR, Zeiss
EA. Silica, silicosis, and progressive systemic sclerosis. B J Ind
Med 1985; 42: 838-843
3. Cowie RL. Silica-dust-exposed mine workers with scleroderma
(systemic sclerosis). Chest 1987; 92: 260-262
4. McCormic ZD, Khuder SS, Aryal BK, Ames AL, Khuder SA. Int
Arch Occup Environ Health 2010; 83: 763-769
5. Parks CG, Conrad K, Cooper GS. Occupational exposure to
crystalline silica and autoimmune disease. Environ Health
Perspect 1999; 107(suppl 5): 793-802
6. Poormoghim H, Lakeh MM, Mohammadipour M, Sodagari
F, Toofaninjed N. Cyclophosphamide for scleroderma lung
disease: a systematic review and meta-analysis. Rheumatol Int
2012; 32: 2431-2444
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6KRXOG\RXUHTXLUHDQ\DVVLVWDQFHZLWKDUWLFOHVXEPLVVLRQSOHDVHFRQWDFWWKHRIFHRIWKH
South African Respiratory Journal email: sarj@iafrica.com or telephone: 021-650 3050
39
Editorial
The electronic cigarettes debate
Reprinted with permission:
S Afr Med J 2013; 103(11): 832-833.
Electronic cigarettes (e-cigarettes) are relatively new in South Africa and their popularity is increasing. Their appearance
coincides with intensifying attempts by government and society to reduce tobacco smoking through stricter limitation on its
sale, advertising and use. Debate has been triggered on their use regarding the potential risks of increasing nicotine addiction
DQGHQFRXUDJLQJSHRSOHWRVWDUWVPRNLQJRUZKHWKHUHFLJDUHWWHVPLJKWVHUYHUDWKHUDVDQHIFLHQWPHDQVRIWUHDWLQJDGGLFWLRQ
thus assisting smokers to quit.
Opinions among doctors regarding e-cigarettes vary, some seeing potential for good, others condemning them outright.
Several professional medical societies have taken the stand that, whatever their potential as a smoking-cessation method, they
cannot be encouraged since they are produced and promoted by the tobacco industry. Also, that research supported by the
manufacturers of e-cigarettes may not be presented at their meetings or in their medical journals.
:HSUHVHQWWKHIROORZLQJDUJXPHQWVIRUWKHSRWHQWLDOEHQHWDQGKDUPVRIHFLJDUHWWHVEDVHGRQWKHFXUUHQWO\DYDLODEOH
evidence.
(OHFWURQLFFLJDUHWWHV7KHSRWHQWLDOEHQHWVRXWZHLJKWKHULVNV
Cigarettes kill over 6 million people each year almost
twice that from HIV and tuberculosis combined1 Smoking
LV VWURQJO\ DVVRFLDWHG ZLWK WKH YH OHDGLQJ FDXVHV RI
global mortality, namely ischaemic heart disease, stroke,
chronic obstructive pulmonary disease, lower respiratory
tract infection and lung cancer.2 It is estimated that without
tobacco, one-third of all cancer deaths would be avoided.3 Yet,
despite this overwhelming evidence of harm not to mention
QDQFLDOEXUGHQWKHPDMRULW\RIVPRNHUVDUHXQDEOHWRTXLW
The cigarettes combination of chemical and psychological
addiction overwhelms common sense; in smoking-cessation
trials, where only highly motivated patients are enrolled,
sustained quit rates rarely exceed 25%.4 We need more strings
to our bow, if we hope to win this battle. Could e-cigarettes
play a role in smoking cessation? The argument in favour
of physicians supporting the use and sale of e-cigarettes is
simple: they are safer than cigarettes, they are effective in
reducing tobacco risk and, potentially, they are the best
method of assisting smokers to quit.
Although many South African doctors are not familiar
with e-cigarettes, they already boast 2.5 million users in
the US alone and have been on the market for almost 10
years. E-cigarettes are battery-powered devices, similar in
appearance to conventional cigarettes that vaporise nicotine
for inhalation. There is great public interest in this product.
Google search volumes for e-cigarettes have exceeded those
for both nicotine replacement therapy (NRT) (e.g. gum) and
varenicline for the last 2 years5
Many smokers have embraced e-cigarettes as an
acceptable alternative. Users feel that they are a healthier,
cheaper substitute for tobacco and purchase them primarily
to help quit smoking or avoid relapse (77% of 3 587 internet
responders).67KHHPHUJLQJGDWDRQHIFDF\DUHHQFRXUDJLQJ
e-cigarettes may reduce health risks of smokers. One key
randomised clinical trial, performed in smokers who were
not motivated to quit, showed sustained quit rates similar to
those in motivated populations using trial interventions (e.g.
40
varenicline). Without any form of counselling or incentive,

quit rates at 1-year were 8.7%, with a further 10.3% having
>50% reduction in smoking. Moreover, 73% of those who
gave up smoking at 1 year had quit the use of e-cigarettes
as well.7 Perhaps even more impressive is a second smaller
study using e-cigarettes in schizophrenic patients who had
no intention of quitting. In this highly addicted group, 64%
of study participants achieved either abstinence (14% of
subjects) or a sustained 50% reduction in cigarette smoking
(in 50% of subjects), at 1 year.8
Naturally, the question of safety arises. The main
FRPSRQHQWV RI WKH UHOO XLG DUH QLFRWLQH WKH YDSRULVLQJ
propellant (propylene glycol or vegetable glycerin) and
FKHPLFDOVXVHGDVDYRXUDQWV7KH\GRQRWSURGXFHVPRNH
but a vapour that is inhaled, and the common adverse effects of
e-cigarettes (cough, mouth irritation and headache) are mild
and appear to decrease over time.7 The nicotine component
of e-cigarettes is thought to be safe as it has not been shown
to cause cancer, cardiovascular disease or lung damage [9]
neither has it been shown to be cytotoxic to stem cells.10 An
additional advantage is that e-cigarettes are not associated
with side-stream smoking they have not been shown to
affect bystanders, which could potentially reduce the 600 000
annual deaths associated with passive smoking.1,11 A further
advantage of their use is that switching is not associated with
WKHZHLJKWJDLQVHHQLQVPRNHUVZKRTXLW%XWWKHUHDOEHQHW
for those who convert is the sparing of exposure to the over
8 000 chemicals (including carcinogens) found in cigarette
smoke. It is highly unlikely that e-cigarettes are as toxic to
human tissues as conventional cigarettes. In support of this,
e-cigarettes do not result in the acute rise in white blood cells or
carbon monoxide levels seen with conventional cigarettes.7,11
The reduction in exposure to innumerable carcinogens, with
the long-term reduction in risk of numerous cancers, is likely
WRSURYHWKHHFLJDUHWWHVJUHDWHVWEHQHW
E-cigarettes are used as NRT to overcome the unpleasant
cravings of nicotine withdrawal. Although not as effective as
FLJDUHWWHVWKH\ DUH PRUH HIFLHQWWKDQ RWKHU IRUPV RI 157

in their ability to deliver nicotine.12 Thus they alleviate the
desire to smoke, and most users surveyed report being able to
cut back successfully on tobacco and believe that e-cigarettes
helped them to achieve smoking cessation.12,13 Uniquely,
e-cigarettes address the psychological and social aspects
of smoking that bind many people to the habit by allowing
potential quitters to participate in the ritual of smoking.7
7KHDYRXULQJRIHFLJDUHWWHVLQFOXGLQJWREDFFREODFNEHUU\
YDQLOOD DQG HYHQ UHGEXOO DYRXU SURYLGHV DQ H[FLWLQJ
socially acceptable alternative to cigarettes.
It is estimated that smoking cessation before the age of 45
years adds, on average, 9 years to a persons life.14 In light of
this, if e-cigarettes improve quit rates, surely they should be
considered, if not embraced. They remain the only currently
available therapy that simultaneously addresses both the
physical and psychological components of tobacco addiction
assisting smokers to both quit and cut down, with the added
EHQHWRIDYRLGLQJSDVVLYHVPRNLQJE\RWKHUV
E-cigarettes are safe and effective and, based on the
DYDLODEOH HYLGHQFH WKH SRWHQWLDO EHQHWV PXVW RXWZHLJK
their risks, especially when compared with the alternative:
smoking.
5.

7.
8.
9.
10.
B Allwood
Division of Pulmonology and Lung Institute,
University of Cape Town and Groote Schuur Hospital, Cape
Town, South Africa
:RUOG +HDOWK 2UJDQL]DWLRQ 7REDFFR KWWSZZZZKRLQW
PHGLDFHQWUHIDFWVKHHWVIVHQDFFHVVHG-XO\
2. Lozano R, Naghavi M, Foreman K, et al. Global and regional
mortality from 235 causes of death for 20 age groups in 1990
and 2010: A systematic analysis for the Global Burden of
Disease Study 2010. Lancet 2012;380>KWWS
G[GRLRUJ6@
3. Centers for Disease Control. Fact Sheet: Health Effects of
&LJDUHWWH6PRNLQJKWWSZZZFGFJRYWREDFFRGDWDBVWDWLVWLFV
IDFWBVKHHWVKHDOWKBHIIHFWVHIIHFWVBFLJBVPRNLQJLQGH[KWP
(accessed 13 September 2013).
4. Fiore MC, Jaen RC, Baker T, Bailey WC, Benowitz NL, Curry
11.
12.
13.
14.
SJ. Treating Tobacco Use and Dependence: 2008 Update.

Rockville, MD: US Department of Health and Human Services,
2008.
Ayers JW, Ribisl KM, Brownstein JS. Tracking the rise in
popularity of electronic nicotine delivery systems (electronic
cigarettes) using search query surveillance. Am J Prev Med
2011; 40(4): 448-453.
>KWWSG[GRLRUJMDPHSUH@
(WWHU-)%XOOHQ&(OHFWURQLFFLJDUHWWHXVHUVSUROHXWLOL]DWLRQ
VDWLVIDFWLRQ DQG SHUFHLYHG HIFDF\ Addiction 2011; 106(11):
2017-2028.
>KWWSG[GRLRUJM[@
Caponnetto P, Campagna D, Cibella F, et al (I&LHQF\ DQG
Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes
substitute: A prospective 12-month randomized control design
study. PLoS ONE 2013;8H>KWWSG[GRLRUJ
journal.pone.0066317]
Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R.
Impact of an electronic cigarette on smoking reduction and
cessation in schizophrenic smokers: A prospective 12-month
pilot study. Int J Environ Res Public Health 2013;10(2):446>KWWSG[GRLRUJLMHUSK@
Mendelsohn C. Optimising nicotine replacement therapy in
clinical practice. Aust Fam Physician 2013;42(5):305-309.
Bahl V, Lin S, Xu N, Davis B, Wang Y, Talbot P. Comparison
RIHOHFWURQLFFLJDUHWWHUHOOXLGF\WRWR[LFLW\XVLQJHPEU\RQLF
and adult models. Reprod Toxicol 2012;34>KWWS
G[GRLRUJMUHSURWR[@
Flouris AD, Poulianiti KP, Chorti MS, et al. Acute effects of
electronic and tobacco cigarette smoking on complete blood
count. Food Chem Toxicol 2012;50 >KWWS
G[GRLRUJMIFW@
Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen
M. Effect of an electronic nicotine delivery device (e cigarette)
on desire to smoke and withdrawal, user preferences and
nicotine delivery: Randomised cross-over trial. Tob Control
2010;19>KWWSG[GRLRUJWF@
Odum LE, Dell KAO, Schepers JS. Electronic cigarettes: Do they
have a role in smoking cessation? J Pharm Pract 2012;25(6):13>KWWSG[GRLRUJ@
Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century
KD]DUGV RI VPRNLQJ DQG EHQHWV RI FHVVDWLRQ LQ WKH 8QLWHG
States. N Engl J Med 2013;368(4):341-350.
>KWWSG[GRLRUJ1(-0VD@
(OHFWURQLFFLJDUHWWHV7KHSRWHQWLDOULVNVRXWZHLJKWKHEHQHWV
Should the legislation on the sale and promotion of electronic
cigarettes (e-cigarettes) be similar to that for tobacco smoking,
RU DUH WKH\ GLIIHUHQW" ,V WKHUH SRWHQWLDO PHGLFDO EHQHW LQ
their availability and use? I shall argue that they should be
regulated, based on the overwhelming potential for their harm
to society, and particularly to those that they are intended
to help. Firstly, the evidence for their being an effective
method for smoking cessation is unconvincing. Secondly,
they are a means for maintaining nicotine addiction and
dependence. Thirdly, they may even encourage more habitual
use of nicotine, which, in time, might encourage a switch to
cigarette smoking. Other concerns are that their safety has
not been proven in large studies of long-term use, their effect
during pregnancy is unknown, and that many e-cigarettes are
owned, produced and aggressively promoted by the tobacco
industry. The tobacco industry has a track record of scant
concern for the fact that they are promoting the single most
important preventable cause of malignancy worldwide, apart
from their other effects. Thus, I will argue that this new vice
should be subjected to the same, if not more rigid, scrutiny
applied to tobacco and habit-forming drugs before it is
released freely to the unsuspecting population.
$UJXDEO\ WKH RQO\ VRXQG MXVWLFDWLRQ IRU SK\VLFLDQV WR
support the introduction of e-cigarettes would be if they proved
an effective means of helping addicted tobacco smokers quit.
However, even if they prove effective in this, it would have
to be shown that they did not do harm by convincing new
clients that smoking can be safe! Or, as intended by some
of the manufacturers, acting as gateway devices to cigarette
smoking.
7KHUVWSULRULW\LQKHDOWKFDUHLVVDIHW\VDIHW\IRUWKHXVHU
and for the bystander. Primary concerns relate to the lack of
41
regulation in manufacturing processes in some parts of the

world.1 There are several hundred brands of e-cigarettes and
certain studies have documented e-cigarettes contaminated
with diethylene glycol, nitrosamines, acetaldehyde and
acetone.1 Although, it is likely that more reputable brands
have stricter manufacturing controls and thus contain only
what is written on the package insert, these too may not be
safe. There are data showing acutely increased pulmonary
resistance after smoking and there is a complete lack of longterm safety data.2 Furthermore, nicotine itself is not entirely
safe: it is toxic at high doses, increases insulin resistance,
is immunosuppressive and directly stimulates pulmonary
mucus secretion.3,4 Tobacco smoking was considered to be
safe and fashionable in the early 1900s, until Richard Dolls
revolutionary work in the 1950s showed otherwise.5 Over 50
million tobacco-related deaths are estimated to have occurred
in the past 10 years despite us knowing full well the harms of
tobacco smoke.6
:KDW RI HIFDF\" 6RPH FRQYLQFLQJ GDWD H[LVW WKDW
smokers of e-cigarettes smoke fewer tobacco cigarettes.7
7KHUHDUHVFDQWGDWDKRZHYHURQWKHLUHIFDF\DVDEULGJH
to stop smoking.8 To date, the results presented are from
small poorly-designed studies with inadequate blinding and
FRQWUROSODFHER DUPV DQG KDYH VKRZQ QR FOHDU HYLGHQFH
that e-cigarettes assist individuals in stopping smoking. The
two largest studies, both from the same centre, evaluated 27
subjects completing a 6-month study (no control arm) and
LQD\HDUVWXG\XQEOLQGHG7KXVWRGDWHHIFDF\DQG
safety are based on trial data from a few hundred patients
alone.7,8
E-cigarettes are not necessarily cheaper alternatives to
tobacco. If their use does not result in complete smoking
cessation (tobacco and e-cigarettes) they may merely
SHUSHWXDWH WKH QDQFLDO EXUGHQ RI VPRNLQJ ,I PDUNHWHG DV
fashionable and progressive, like the hookah pipe (hubblybubbly), they may additionally yield a new generation
of e-smokers, chemically addicted to nicotine. Nicotine,
although not known to be a bridge to narcotic or other drug
usage, potentially opens the door to chemical tolerance,
and long-term users may seek increasingly higher nicotine
concentrations, ultimately resorting to tobacco. E-cigarettes
are advocated as a healthier alternative, but the obvious
long-term addiction to nicotine remains unaddressed.
E-cigarettes have not been shown to be safe or effective
in smoking cessation. They contain nicotine, which is toxic
and addictive, and tobacco companies are selling them.
How can they be good? The e-cigarette industry needs to be
tightly regulated, and independent assessment of the harms
needs to be made, or we risk replacing one evil for another.
E-cigarettes may be less dangerous than tobacco, but given
that tobacco kills 50% of its users, what would not be safer?
>KWWSG[GRLRUJFKHVW@
3. Benowitz NL. Clinical pharmacology of nicotine: Implications for
understanding, preventing, and treating tobacco addiction. Clin
Pharmacol Ther 2008;83 >KWWSG[GRLRUJ
clpt.2008.3]
4. Sopori ML, Kozak W, Savage SM, Geng Y, Kluger MJ. NicotineLQGXFHGPRGXODWLRQRI7FHOOIXQFWLRQ,PSOLFDWLRQVIRULQDPPDWLRQ
and infection. Adv Exp Med Biol 1998;437:279-289.
5. Doll R. Smoking and lung cancer. Proc R Soc Med 1957;50(7):503504.
6. Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. 3 ed.
Atlanta: American Cancer Society, 2009.
7. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo
C. Effect of an electronic nicotine delivery device (e-cigarette) on
smoking reduction and cessation: A prospective 6-month pilot study.
BMC Public Health 2011;11 >KWWSG[GRLRUJ
2458-11-786
8. Caponnetto P, Campagna D, Cibella F, et al.(I&LHQF\DQG6DIHW\RI
an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute:
A prospective 12-month randomized control design study. PLoS
ONE 2013; 8(6):e66317.
>KWWSG[GRLRUJMRXUQDOSRQH@
R N van Zyl-Smit
Division of Pulmonology and Lung Institute,
University of Cape Town, South Africa
1. Riker CA, Lee K, Darville A, Hahn EJ. E-cigarettes: Promise or
peril? Nurs Clin North Am 2012;47 >KWWSG[GRL
RUJMFQXU@
2. Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou
V, Connolly GN, Behrakis PK. Short-term pulmonary effects of
XVLQJDQHOHFWURQLFFLJDUHWWH,PSDFWRQUHVSLUDWRU\RZUHVLVWDQFH
impedance, and exhaled nitric oxide. Chest 2012;141(6):1400-1406.
42

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43
Guideline
South African tobacco smoking cessation
clinical practice guideline
R N van Zyl-Smit,1,2,3 MB ChB, MRCP (UK), FCP (SA), Dip HIV Man (SA), MMed, Cert Pulm (SA), PhD;
B Allwood,1,2 MB BCh, DCH (SA), DA (SA), FCP (SA), MPH, Cert Pulm (SA);
D Stickells,4 MB ChB, FCP (SA);
G Symons,2 MB ChB, FCP (SA), Cert Pulm (SA);
S Abdool-Gaffar,5 MB ChB, FCP (SA), FCCP;
K Murphy,3 PhD; U Lalloo,6 MB ChB, FCCP, FRCP (UK);
A Vanker,7 MB ChB, FCPaed, MMed, Cert Pulm Paed;
K Dheda,1,2 MB BCh, FCP (SA), FCCP, PhD, FRCP (UK);
G A Richards,8 MB BCh, PhD, FCP (SA), FRCP
1
University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, South Africa; 2Division of
Pulmonology, Department of Medicine, University of Cape Town, South Africa; 3Chronic Disease Initiative for Africa, University
of Cape Town, South Africa; Pulmonologist, Private Practice, Port Elizabeth, South Africa; 5Pulmonologist, Private Practice,
Durban, South Africa; 6Department of Pulmonology and Critical Care, School of Clinical Medicine, Nelson R Mandela College
of Medicine, University of KwaZulu-Natal, Durban, South Africa; 7Department of Paediatrics and Child Health, Red Cross
War Memorial Childrens Hospital, University of Cape Town, South Africa; 8Departments of Critical Care and Pulmonology,
Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
This guideline has been complied on behalf of the South African Thoracic Society to provide practising clinicians with a resource
from which to base individual cessation interventions for patients within the South African environment.
Corresponding author: R N van Zyl-Smit (richard.vanzyl-smit@uct.ac.za)
Reprinted with permission:
S Afr Med J 2013; 103'2,6$0-
7REDFFRVPRNLQJLHFLJDUHWWHVUROOHGWREDFFRSLSHVHWFLVDVVRFLDWHGZLWKVLJQLFDQWKHDOWKULVNVUHGXFHGOLIHH[SHFWDQF\

and negative personal and societal economic impact. Smokers have an increased risk of cancer (i.e. lung, throat, bladder),
chronic obstructive pulmonary disease (COPD), tuberculosis and cardiovascular disease (i.e. stroke, heart attack). Smoking
affects unborn babies, children and others exposed to second hand smoke. Stopping or quitting is not easy. Nicotine is highly
addictive and smoking is frequently associated with social activities (e.g. drinking, eating) or psychological factors (e.g. work
SUHVVXUHFRQFHUQVDERXWERG\ZHLJKWDQ[LHW\RUGHSUHVVHGPRRG7KHEHQHWVRITXLWWLQJKRZHYHUDUHDOPRVWLPPHGLDWH
with a rapid lowering of blood pressure and heart rate, improved taste and smell, and a longer-term reduction in risk of cancer,
heart attack and COPD. Successful quitting requires attention to both the factors surrounding why an individual smokes (e.g.
stress, depression, habit, etc.) and the symptoms associated with nicotine withdrawal. Many smokers are not ready or willing
WRTXLWDQGUHTXLUHIUHTXHQWPRWLYDWLRQDOLQSXWRXWOLQLQJWKHEHQHWVWKDWZRXOGDFFUXH,QDGGLWLRQWRDQHYDOXDWLRQRIQLFRWLQH
GHSHQGHQFHFRH[LVWHQWPHGLFDORUSV\FKLDWULFFRQGLWLRQVDQGEDUULHUVWRTXLWWLQJVKRXOGEHLGHQWLHG$WDLORUHGDSSURDFK
encompassing psychological and social support, in addition to appropriate medication to reduce nicotine withdrawal, is likely
to provide the best chance of success. Relapse is not uncommon and reasons for failure should be addressed in a positive
manner and further attempts initiated when the individual is ready.
Key steps in smoking cessation include:
LLGHQWLI\LQJDOOVPRNHUVDOHUWLQJWKHPWRWKHKDUPVRIVPRNLQJDQGEHQHWVRITXLWWLQJ
(ii) assessing readiness to initiate an attempt to quit;
(iii) assessing the physical and psychological dependence to nicotine and smoking;
LYGHWHUPLQLQJWKHEHVWFRPELQDWLRQRIFRXQVHOOLQJVXSSRUWDQGSKDUPDFRORJLFDOWKHUDS\
(v) setting a quit date and provide suitable resources and support;
YLIUHTXHQWIROORZXSDVRIWHQDVSRVVLEOHYLDWH[WWHOHSKRQHRULQSHUVRQ
(vii) monitoring for side-effects, relapse and on-going cessation; and
(viii) if relapse occurs, providing the necessary support and encourage a further attempt when appropriate.
S Afr Med J 2013; 103'2,6$0-
44
Guideline
1. Tobacco smoking in South Africa
There are an estimated 1.3 billion smokers worldwide
and over 5 million deaths per year attributable to tobacco
smoking.1 Even though smoking rates are declining, there are
an estimated 7 million smokers in South Africa (SA).2 Tobacco
smoking is undoubtedly the primary risk factor for chronic
obstructive pulmonary disease (COPD), which is estimated
to be the third highest cause of death globally by 2030. SA
has a particularly high prevalence of smoking (20%).3,4 SA
also has one of the highest burdens of tuberculosis (TB) and
HIV, which are both risk factors for COPD and exacerbate
the effects of smoking.5,6 Tobacco smoking increases the
risk for TB, cancer, pneumonia, ischaemic heart disease and
stroke, which are all leading causes of death globally.1 The
mortality among current smokers in SA is nearly double that
of non- or ex-smokers.7,8 Up to a third of all male deaths in SA
adults over the age of 35 years have recently been attributed
to tobacco use.7,9 Passive smoking also increases the risk
of cardiovascular disease in adults and respiratory disease,
particularly among children. The cost of smoking-related
disease to the SA economy is estimated to be R1.2 billion.10
7KHEHQHWVRIVWRSSLQJVPRNLQJDUHDOPRVWLPPHGLDWHZLWK
a lowering of blood pressure within minutes, and longer-term
EHQHWVVXFKDVLPSURYHGOXQJIXQFWLRQDQGUHGXFHGULVNIRU
lung cancer, stroke and heart disease. Smoking cessation is a
critical component of the effective management of COPD.11
Savings of disposable income, achieved by quitting smoking,
would also be available for basic necessities, particularly for
those living in poverty.
Many smokers have no desire to quit and will require
repeated engagement by health practitioners to affect
behaviour change. Interviewing techniques have changed
IURP WKH PRUH WUDGLWLRQDO DSSURDFK W\SLHG E\ VFROGLQJ RU
lecturing, to one that involves support, encouragement and the
provision of information.12 For those who wish to stop there
are many options available such as cold turkey, cognitive
behavioural therapy, acupuncture, hypnosis, internet and
cellular phone-based support programmes, and medication.
This guideline assesses published evidence and reviews
LQWHUQDWLRQDOJXLGHOLQHVDSSO\LQJWKHPWRWKHVSHFLFQHHGV
and circumstances in SA in developing a clinical practice
guideline for SA clinicians.
Published international guidelines from the US Centers
for Disease Control, the American College of Chest
Physicians (ACCP), the UK National Institute for Clinical
Excellence (NICE) and the Cochrane Collaboration Database
of Systematic Reviews for all topics relating to tobacco
smoking were reviewed. In addition, PubMed was searched
IRU QHZHU VWXGLHV RQ VSHFLF WRSLFV VXFK DV HFLJDUHWWHV
smoking in pregnancy, and smoking in persons infected with
HIV or TB. Smoking in this guideline refers to all forms of
smoking tobacco products such as cigarettes, cigars and rolled
tobacco. Smoking cessation also referred to as quitting, is
the process of stopping smoking. Where available, evidence
grading is provided with the grading source.
2. Tobacco smoking cessation strategies

Smoking cessation can be broadly divided into two phases:
LWKHLGHQWLFDWLRQRIVPRNHUVDQGDVVLVWLQJWKHPWRTXLW
and (ii) initiating and sustaining the quit attempt (Fig. 1). The
strength of evidence for each intervention varies. For each
stage and intervention, key points and strength of supporting

data are presented and expert opinion was relied on where
data was lacking.
2.1 Identifying smokers and initiating quit attempts
7KH VWUDWHJ\ RI LGHQWLI\LQJ VPRNHUV GXULQJ URXWLQH
consultations with healthcare practitioners increases quit
attempts (Grade A13).
%ULHI VPRNLQJ FHVVDWLRQ LQWHUYHQWLRQV VKRXOG EH
implemented, regardless of the availability of, and access
to, specialised services (Grade A13).
If you dont think about it, you wont do it. Using stickers,
tags or reminders in folders for the nurses or doctors increases
the likelihood of discussions with patients around smoking,
counselling and referral for cessation advice. The inclusion
RIVPRNLQJDVRQHRIWKHYLWDOVLJQVLGHQWLHVRUPRUHRI
smokers attending primary care facilities.14
2.2 Clinical interventions to initiate and sustain smoking
cessation
5HSHDWHGHQFRXUDJHPHQWDQGDVVLVWDQFHSURYLGHGE\PRUH
WKDQRQHSK\VLFLDQKHDOWKFDUHZRUNHUWKURXJKDUDQJHRI
supportive options, increase the likelihood of abstinence
(Grade A13).
,QWHUYHQWLRQVDVEULHIDVPLQFDQVLJQLFDQWO\LQFUHDVHTXLW
rates, but intensive interventions are more effective (more
comprehensive treatments being those that occur over multiple
YLVLWVIRUDORQJHUSHULRGRIWLPHDQGRUDUHSURYLGHGE\PRUH
than one clinician).14 The goal should be for every tobacco
user to be LGHQWLHG and offered at least a brief intervention
at every clinical consultation. A commonly recommended
approach is the 5As model, which is an effective, structured
approach to providing brief interventions (3 - 10 min) in the
primary care setting. The 5 steps are:
(i) asking about smoking;
LLDOHUWLQJWKHSDWLHQWWRWKHEHQHWVRITXLWWLQJ
(iii)assessing readiness to make a quit attempt;
(iv) assisting those willing to quit; and
(v) arranging for follow-up contact and referral to further
resources, such as quitlines.
Problem solving, skills training and psychosocial support
during treatment are all effective elements of counselling.
They can be used as part of brief interventions, but also form
the foundation of more intensive interventions.14
2.3 Motivational interviewing approach
Many patients lack the motivation to quit or express a lack of
readiness to quit. This may be because they lack information,
KDYH FRQFHUQV DERXW TXLWWLQJ IDFH VLJQLFDQW VRFLDO
HQYLURQPHQWDOEDUULHUVRUODFNFRQGHQFHLQWKHLUDELOLW\WR
TXLW 6XFK SDWLHQWV PD\ EHQHW IURP FRXQVHOOLQJ PHWKRGV
derived from motivational interviewing (MI).12
In this approach, the clinician encourages the smoker to
H[SORUHWKHLUIHHOLQJVRIDPELYDOHQFHDERXWVPRNLQJTXLWWLQJ
by discussing, for example, the pros and cons of smoking from
their perspective, and by exploring how personally important
FHVVDWLRQPD\EHDQGKRZFRQGHQWWKH\IHHODERXWLW,QWKLV
process, the provider supports and strengthens any intentions
45
Guideline
6PRNHUVZKRDUHKLJKO\QLFRWLQHGHSHQGHQWKDYHVRFLDO
stressors and psychiatric comorbidities, are less likely to
be successful.
to change, which come from the patients themselves. The

idea is to elicit self-motivational statements, rather than tell
the patient what they should do and how they should do it. MI
posits that a good collaborative relationship, in which a client
LVYLHZHGDVWKHH[SHUWRQKLVKHURZQOLIHVHUYHVWRPLQLPLVH
resistance to change and thereby enhances motivation.15
7KLV YDULHV VLJQLFDQWO\ IURP WKH WUDGLWLRQDO DGYLFHJLYLQJ
approach, which casts the provider in a dominant, directing
role and the patient merely as a passive recipient of their
expert knowledge. Meta-analyses have shown that MI can
VLJQLFDQWO\ LPSURYH VPRNLQJ FHVVDWLRQ UDWHV RYHU EULHI
advice.16
3. Pharmacological intervention
(drug treatment to aid smoking cessation)
Several pharmacological strategies are available to assist in
smoking cessation predominantly to address acute nicotine
ZLWKGUDZDO 7KHVH PD\ EH VLPSO\ FODVVLHG DV QLFRWLQH
replacement therapies (NRTs) or drugs that reduce addiction.
Although both classes of drug are an aid to smoking cessation,
they have little or no effect on the underlying addiction and
do not address the psychosocial factors that cause a person to
smoke. Most studies of pharmacological interventions have
EHHQFRQGXFWHGLQVXEMHFWVZKRVPRNH!FLJDUHWWHVGD\DQG
IUHTXHQWO\!FLJDUHWWHVGD\7KHUHLVOLWWOHHYLGHQFHWRJXLGH
the use of pharmacological therapy in subjects who smoke
RQO\FLJDUHWWHVGD\RULQWKRVHZLWKYHU\ORZQLFRWLQH
dependence. Table 1 outlines the comparative performance
of the various drugs available to assist in smoking cessation.
2.4 The individual who is not ready to quit

(QFRXUDJHWKHLQGLYLGXDOWRWKLQNDERXWTXLWWLQJLGHQWLI\
the reasons for smoking and the barriers to quitting and
provide an opportunity for follow-up.
For individuals who are not ready or willing to quit, on-going
encouragement and offers of support are necessary. The
practitioner can provide information about the risks of
VPRNLQJ DQG WKH EHQHWV RI TXLWWLQJ DQG HQFRXUDJH WKH
patient to return for further discussions if and when they are
ready to quit. Assisting the patient to identify the perceived
EHQHWV WKDW WKH\ JDLQ IURP VPRNLQJ LH VWUHVV UHGXFWLRQ
weight control), their perceived barriers to quitting (i.e.
VRFLDO SUHVVXUH ZLWKGUDZDO V\PSWRPV DQG WKH EHQHWV RI
quitting (i.e. health improvement, cost savings) can lay the
foundation to behavioural change at a later date and enhance
the possibility of a quit attempt.
3.1 NRT
157LVHIIHFWLYHDQGVKRXOGEHHQFRXUDJHG*UDGH$13).
$FRQWUROOHUSDWFKDQGUHOLHYHUJXPVSUD\DSSURDFKLV
the most effective way to use NRT (Grade A13).
NRT has been the mainstay for addressing nicotine
withdrawal. It is particularly effective when employing dual
NRT one as a controller and one as a reliever (odds ratio
25FRQGHQFHLQWHUYDO&,IRUVXFFHVV
and abstinence rates 36.5% (95% CI 28.6 - 45.3) at the end of
therapy).14 This approach, which is advocated by the ACCP,
is more effective than using a single form of NRT (relative
risk (RR) 1.34; 95% CI 1.18 - 1.51).17 Titration of the NRT
(via patch strength) to the level of symptom severity based
on the Fagerstrm scale (Table 2), or of cotinine level is
recommended to ensure that adequate control of withdrawal
symptoms is achieved. If breakthrough symptoms occur the
reliever NRT should be used (gum, spray, etc.) The use of
2.5 Assisting the motivated patient to quit

&RXQVHOOLQJSOXVPHGLFDWLRQWRWUHDWQLFRWLQHZLWKGUDZDO
is more effective than either intervention alone (Grade
A13).
0XOWLSOHRSWLRQVDUHDYDLODEOHDQGFDQEHWDLORUHGWRVXLW
the individual patient and circumstance.
6PRNHUV ZKR DUH PRWLYDWHG KDYH VXSSRUWLYH QHWZRUNV
and are ready to change, have higher success rates.
Table 1.
Comparisons of abstinence rates achieved with different pharmacological interventions to support smoking cessation*
Medication
Arm, n
OR (95%CI)
80
Nicotine gum
15
1.5 (1.2 - 1.7)
19 (16.5 - 21.9)
Nicotine patch
32
1.9 (1.7 - 2.2)
23.4 (21.3 - 25.8)
Nicotine spray
2.3 (1.7 - 3)
26.7 (21.5 - 32.7)
Bupropion SR
26
2 (1.8 - 2.2)
24.2 (22.2 - 26.4)
Nortriptyline
1.8 (1.3 - 2.6)
22.5 (16.8 - 29.4)
Clonidine
2.1 (1.2 - 3.7)
25 (15.7 - 37.3)
3.1 (2.5 - 3.8)
33.2 (28.9 - 37.8)
Placebo
Estimated abstinence rate (95%CI)

13.8
NRT
$QWLGHSUHVVDQWVFHQWUDOO\DFWLQJDJHQWV
Nicotine receptor agonist

9DUHQLFOLQHPJGD\
25 RGGVUDWLR&, FRQGHQFHLQWHUYDO157 QLFRWLQHUHSODFHPHQWWKHUDS\65 VORZUHOHDVH

*
Data from Fiore et al13 comparisons are with placebo treatment.
46
Guideline
Give motivational pamphlet

and encourage follow-up
Ask
1. Do you smoke?
2. Do you know the risks?
3. Have you thought of quitting?
Alert
'R\RXNQRZWKHEHQHWVRITXLWWLQJ"
2. Do you know that we can help you?
Assess
1. Are you ready to quit?
$VVLVW$UUDQJH
No
Yes
Maybe
Arrange for cessation
intervention
Quitlines and useful websites

National Council Against Smoking quitline:
011 720 3145
CANSA Call Centre: 0800 22 66 22
website:KWWSZZZHNLFNEXWWRUJ]D
Patient resources:
KWWSZZZLFKDQJHKHDOWKFR]D
6SHFLFQLFRWLQHGHSHQGHQFHUHYLHZ
Motivated
Low Dependence
Could manage with

FRXQVHOOLQJVXSSRUWDORQHRU
NRT
Support group
7H[WLQWHUQHWVPDUWSKRQH
based support
)DJHUVWU|P&2OHYHOV
Current smoking and history of quit attempts
6RFLDOVWUHVVRUVKRXVHKROGVPRNHUV
Have you
already
attempted
to quit
smoking?
How many
times do
you smoke
per day?
How soon after

Level of
waking in the
dependence
morning do you
VPRNH\RXUUVW
cigarette?
Yes
>30
> 5min
Very high
Yes
20-30
5-30 min
High
Yes
10-20
30-60 min
Medium
No
<10
> 60 min
Low
Motivated
High Dependence
Probably will need added

pharmacological support
$VVHVVPHGLFDOSV\FKLDWULF
history
Evaluate capacity to purchase
medicine
Review availability of
medication
Set quit date

Arrange appropriate support and medication if
needed
Follow up
Assess withdrawal symptoms and drug sideeffects
Evaluate mood and psychosocial stressors
Identify potential for relapse
Medication options
Nicotine replacement therapy
SDWFKJXPVSUD\
Varenicline
Bupropion
)LJ6PRNLQJFHVVDWLRQDSSURDFKLQFOLQLFDOSUDFWLFH$OOVPRNHUVVKRXOGEHLGHQWLHGDQGWKHLUUHDGLQHVVWRTXLWHYDOXDWHG,IUHVLVWDQFHWR
quitting exists, information and suitable follow-up should be provided (top). If an individual is ready to make a quit attempt, evaluation of
nicotine dependence, co-morbid disease and psychosocial factors should guide the clinician in the choice of effective interventions (bottom).
&2 FDUERQPRQR[LGH157 QLFRWLQHUHSODFHPHQWWKHUDS\
47
Guideline
Table. 2.
Fagerstrm test for nicotine dependence85
Question
Score
+RZVRRQDIWHU\RXZDNHXSGR\RXVPRNH\RXUUVWFLJDUHWWH"
Within 5 min
6 - 30 min
31 - 60 min
After 60 min
'R\RXQGLWGLIFXOWWRUHIUDLQIURPVPRNLQJLQSODFHVZKHUH
it is forbidden?
Yes
No
3. Which cigarette would you hate most to give up?

7KHUVWLQWKHPRUQLQJ
Any other
3.3 Nicotine receptors agonists
4. How many cigarettes per day do you smoke?

11 - 20
21 - 30

'R\RXVPRNHPRUHIUHTXHQWO\GXULQJWKHUVWKRXUVDIWHUZDNLQJ
than during the rest of the day?
Yes
No
6. Do you smoke even if you are so ill that you are in bed most of
the day?
Yes
No
0
TOTAL SCORE
Interpretation of total score86

0-3
Mild dependence
4-6
Moderate dependence
7 - 10
Severe dependence
Additionally, bupropion appears to reduce long-term relapse

and the weight gain associated with quitting.21 Its most
frequent side-effects are insomnia, dry mouth and nausea.20
Bupropion may also reduce the seizure threshold and a seizure
ULVNRIKDVEHHQUHSRUWHG22 There is no evidence that
selective serotonin re-uptake inhibitors (SSRIs) are effective
for smoking cessation.20
Nortriptyline (not registered in SA) is generally considered
a second-line therapy for those who have failed NRT and
EXSURSLRQYDUHQLFOLQH23 Nortriptyline is a metabolite of
amitriptyline, which is available in SA. There are, however,
no published data on smoking cessation using amitriptyline.
Given the increased associated risk of suicide in smokers,24,25
the serious complications of amitriptyline overdose and its
XQNQRZQHIFDF\DVDVPRNLQJFHVVDWLRQDLGWKHGUXJFDQQRW
be recommended for smoking cessation until further data are
available.
nicotine spray may be preferred to gum in some individuals.18

Combinations of NRT with bupropion are more effective than
NRT alone (OR 2.57; 95% CI 1.05 - 6.32),19 but based on
the theory of their mechanism of action, there should be no
value in using both NRT and varenicline together. Despite
WKLVWKHUHDUHDQHFGRWDOUHSRUWVRIDGGLWLRQDOEHQHWDQGWKLV
has recently been tested in the VARNIC study, the results of
which are expected during 2014. Note: at the time of writing
these practice guidelines, nicotine patches were not available
in SA.
9DUHQLFOLQH LV DQ HIIHFWLYH VPRNLQJ FHVVDWLRQ WKHUDS\

(Grade A13).
$OWKRXJK QRW FRQUPHG LQ ODUJH VWXGLHV DQG PHWD
analyses, there is concern about incidents of suicide or
suicidal behaviour.
,WLVVWURQJO\DGYLVHGWKDWDOOSDWLHQWVZKRDUHSUHVFULEHG
these drugs are closely monitored for behavioural change
DQGRUQHXURSV\FKLDWULFV\PSWRPV
Two nicotine receptor partial agonists have been marketed:
varenicline (Champix registered in SA) and cytisine (Tabex
not registered in SA). By acting as partial agonists, they
stimulate dopamine release and reduce nicotine withdrawal
symptoms.26-28 In controlled trials and meta-analyses,
varenicline has been shown to be the most effective single
drug for smoking cessation (RR 3.1; 95% CI 2.5 - 3.8)29,30
whereas cytisine, although effective, appears to result in only
a modest increase in quit rates.29,31 The most common sideeffects reported with varenicline include abnormal dreams,
nausea and headache.32,33 While smokers as a group are at
higher risk of suicide than non-smokers,24,25 there are concerns
about the neuropsychiatric side-effects of varenicline. While
the US Food and Drug Administration (FDA) mandated
a black box warning in 2008, meta-analyses have not
FRQUPHGWKLVULVN29,34 Recent studies have also reported that
varenicline appears to be safe in patients with schizophrenia35
and in patients with cardiac disease.29,36-38 Nevertheless, it
should be used with caution and under supervision. Champix
is a schedule 5 drug in SA and patients should be monitored
regularly with particular attention to changes in their
emotional state, unusual behaviour and suicidal ideation.
3.2 Antidepressants
3.4 Electronic cigarettes
%XSURSLRQ LV DQ HIIHFWLYH GUXJ IRU VPRNLQJ FHVVDWLRQ
particularly in combination with NRT (Grade A13).
1RUWULSW\OLQHLVDPRGHUDWHO\HIIHFWLYHGUXJIRUVPRNLQJ
cessation (Grade A13).
7KH XVH RI EXSURSLRQ RU QRUWULSW\OLQH PXVW EH XQGHU
medical supervision due to potential side-effects and
interactions.
Bupropion (Zyban) used at doses of 150 mg twice daily for
7 - 12 weeks is effective (RR 1.69; 95% CI 1.53 - 1.85).20
48
7KHUHLVQRHYLGHQFHWKDWHOHFWURQLFFLJDUHWWHVHFLJDUHWWHV
are effective aids to smoking cessation, although they
may reduce the number of cigarettes smoked.
E-cigarettes are battery-powered devices, similar in
appearance to conventional cigarettes that vaporise nicotine.
A large variety of products are on offer. They are available
LQGLIIHUHQWDYRXUVDQGPD\EHXVHGLQDQDWWHPSWWRUHGXFH
the symptoms of nicotine withdrawal while allowing the
Guideline
smoker to participate in the ritual of smoking. E-cigarettes
are available over the counter and there is currently little
legislative control on their use, availability and marketing.
Recently however, both the FDA and the South African
Medicines Control Council have begun to consider regulation
of these products.39
The role of e-cigarettes in smoking cessation algorithms
remains unclear. As they are likely to be less hazardous than
tobacco smoking,40 they may, in future, have a role in smoking
cessation, either to reduce nicotine intake or as a bridge to
smoking cessation. In a small pilot study, they appeared to
decrease cigarette consumption,41 and they may be especially
useful in reducing consumption in chronic psychiatric
(schizophrenic) patients.42 Side-effects include mouth and
throat irritation, dry cough, nausea and headache, although
these appear to decrease over time. Concerns have been
raised about the long-term safety of e-cigarettes, particularly
ZLWK UHJDUG WR WKH DYRXULQJ XVHG43 Additionally, although
e-cigarettes do not produce classic smoke, they have been
found to produce short-term adverse physiological effects on
the airways.44
&XUUHQWO\ JLYHQ WKH ODFN RI GDWD RQ HIFDF\ DQG OLPLWHG
long-term safety data, they are not recommended as part of
smoking-cessation strategies.
3.5 Nicotine vaccine
7KH WKHRU\ EHKLQG QLFRWLQH YDFFLQHV LV WKDW WKH\ LQGXFH
antibodies that bind to nicotine, reducing its availability
to central receptors.
1LFRWLQH YDFFLQHV DUH VWLOO LQ GHYHORSPHQW DQG WKHLU
HIFDF\KDVQRWEHHQFRQUPHG45
3.6 Complementary medicine
Several forms of complementary medical approaches are in
common use and are widely advertised as aids to smoking
cessation.
These include hypnotherapy, acupuncture, acupressure and
electro-stimulation. However, none of these methods are
VXSSRUWHG E\ FRQYLQFLQJ HIFDF\ GDWD ZKHQ VXEMHFWHG WR
review using Cochrane Library methods. Although positive
results have been reported in individual studies, there is a
lack of data from large, randomised, controlled studies. When
SHUIRUPHGE\H[SHULHQFHGDQGTXDOLHGLQGLYLGXDOVWKH\DUH
OLNHO\WREHVDIHDQGPD\EHQHWVRPH+RZHYHUWKH\DUHQRW
recommended as effective strategies.
3.6.1 Hypnotherapy
7KHUH LV QR HYLGHQFH WR VXSSRUW K\SQRWKHUDS\ DV DQ
effective aid to smoking cessation.
Hypnotherapy is a widely promoted aid to smoking cessation
and multiple approaches, techniques and success rates have
been reported. Two recently published meta-analyses, in
which different study selection criteria were employed,
FRQFOXGHGWKDWK\SQRWKHUDS\ZDVQRWHIIHFWLYHDVLQVXIFLHQW
quality data existed comparing hypnotherapy with other
methods for smoking cessation. Estimates in the two separate
meta-analyses for success of hypnotherapy in achieving
smoking cessation were: OR 4.55 (95% CI 0.98 - 21.01)46
and RR 1.49 (95% CI 0.86 - 2.5).47
3.6.2 Acupuncture
7KHUHLVQRFRQVLVWHQWHYLGHQFHWKDWHLWKHUDFXSXQFWXUH
or acupressure are effective in smoking cessation.48
Several studies and meta-analyses have evaluated the
effects of acupuncture on smoking cessation in a controlled,
randomised manner.48-50 Differing methods used in these
studies (e.g. the nature of control procedures and the selection
RIFRQWUROJURXSVGRQRWSURYLGHVXIFLHQWFRQVLVWHQF\IRU
a bias-free analysis. The most recent and comprehensive
Cochrane review concluded that acupuncture is less effective
than NRT (RR 1.05; 95% CI 0.82 - 1.35).48
6PRNLQJFHVVDWLRQLQVSHFLFVLWXDWLRQV
4.1 Pregnancy
6PRNLQJSRVHVVLJQLFDQWULVNVWRPRWKHUDQGIHWXV
%ULHI FRXQVHOOLQJ E\ D KHDOWKFDUH SURYLGHU DV SDUW RI
routine antenatal care is effective and well received by
pregnant women.
7KHUH LV DV \HW LQVXIFLHQW KLJKTXDOLW\ HYLGHQFH WR
determine whether the use of pharmacotherapy (i.e. NRT,
bupropion or varenicline) is effective and safe during
pregnancy.
The risks to mother and child from smoking during pregnancy,
and in the post-natal period are well established. Maternal
smoking is associated with obstetric risks (miscarriage and
premature rupture of membranes, placental abruption, intrauterine growth retardation and stillbirth).51 Maternal exposure
to second-hand smoke in pregnancy can also increase the
risk of low-birthweight children.52 Although quitting early
LQ SUHJQDQF\ ZLOO SURGXFH WKH JUHDWHVW EHQHWV VWRSSLQJ
DW DQ\ VWDJH GXULQJ SUHJQDQF\ \LHOGV EHQHWV WR WKH IHWXV
and mother, and the child in the postnatal period.53 Passive
smoking increases the risk for asthma, middle ear and
recurrent chest infections in children.54 Counselling should be
RIIHUHGDWWKHUVWDQWHQDWDOYLVLWDQGLISRVVLEOHVPRNHUVLQ
WKHKRXVHKROGRUZRUNSODFHVKRXOGEHLGHQWLHG$VPRNLQJ
cessation intervention involving brief counselling by lay
counsellors, supported by midwives and by educational
PDWHULDOVVSHFLFDOO\WDLORUHGWRSUHJQDQF\ZDVVKRZQWREH
effective in increasing cotinine-validated quit rates among
disadvantaged women attending public sector antenatal care
clinics in SA.55 On the basis of the substantial evidence of
EHQHWIURP157LQWKHJHQHUDOSRSXODWLRQDQGWKHOLPLWHG
evidence available among pregnant women,53,56,57 some
guidelines recommend the use of NRT in pregnancy under
medical supervision, but only when behavioural therapy
has failed and in heavily dependent smokers who remain
motivated to quit.58
4.2 Adolescents/paediatrics
7UHDWPHQW VWUDWHJLHV UHO\LQJ RQ EHKDYLRXUDO FKDQJH DUH
effective.
1R VPRNLQJ FHVVDWLRQ PHGLFDWLRQ LV OLFHQVHG IRU XVH LQ
children aged less than 18 years.
3DHGLDWULFLDQV DQG KHDOWKFDUH ZRUNHUV SURYLGLQJ FDUH WR
children must address smoking by parents and advise on
smoking-cessation strategies.
49
Guideline
Tobacco smoking in adolescents frequently leads to long-term
nicotine addiction and the consequent adverse health-effects.
In SA in 2008, 21% of learners (grade 8 - 10) were found
to be current smokers, with 6.8% having initiated smoking
before the age of 10 years.59 The smoking of hookah pipes
(hubbly-bubbly) should be addressed among adolescents
who frequently believe it to be tobacco-free and, hence, safe.
Preventing adolescents from starting to smoke is vital to
reduce the numbers of adults who smoke.
Nearly half of adolescent smokers in SA attempt to quit
each year but factors such as stress, depression, peer pressure
and weight gain impact on their success.59-62 Behavioural
change can be encouraged by focussing on the health
EHQHWVDQGLPSURYHGVFKRRODQGVSRUWSHUIRUPDQFHDQGE\
recognising the effects of cultural differences and the social
pressures that exist with regard to smoking.60-62 A variety of
methods (ranging from one-on-one sessions to group therapy,
telephonic helplines and web-based programmes) have been
tried and, if tailored to individual needs, may double success
UDWHV7KHUHDUHLQVXIFLHQWVWXGLHVFRPSDULQJWKHVHPRGHOVLQ
order to recommend one particular strategy in adolescents.13,63
It is imperative to speak to the adolescent alone (without
WKH FDUHJLYHU SUHVHQW DQG WR PDLQWDLQ FRQGHQWLDOLW\ ZKHQ
encouraging behavioural change.
SA data show that adolescents who have been exposed
to smokers are more likely to smoke than those who have
not (74.5% v. 44%, respectively).59 Counselling of parents on
the harmful effects of smoking and on interventions to aid
quitting may reduce secondary smoke exposure in children.13
Parental smoking cessation is also associated with higher quit
rates among adolescents.62,64
No smoking-cessation medications are FDA-approved
in children or adolescents (under 18 years). The UK NICE
guidelines, however, support the use of NRT if required,
along with behavioural interventions in teenagers over 12
years of age.58 If a decision is made to use NRT in a teenager,
it should be used in conjunction with behavioural therapy and
should be individualised. Although safety studies have been
conducted with bupropion and varenicline in adolescents,
both are only approved for adults in SA.33
4.3 Tuberculosis
6PRNHUVKDYHDSSUR[LPDWHO\GRXEOHWKHULVNRIGHYHORSLQJ
TB and of dying from TB than non-smokers.
6PRNLQJFHVVDWLRQIRUSHRSOHZLWKDFWLYH7%LVDIHDVLEOH
and effective intervention.
There is substantial epidemiological evidence that smokers
have a higher risk of developing TB (both latent and active)
and dying from TB.65-67 In SA, with the added risk of HIV,
the importance of smoking cessation to reduce the risk of TB,
HIV-related diseases and COPD is unquestionable.6,68 There
are some data to show that integrating smoking cessation
efforts (support plus NRT) with TB treatment is feasible,69
improves quit rates (77% v. 8.7%, respectively) and
completion of TB treatment (97.5% v. 84.8%, respectively).70
It is unclear, however, whether stopping smoking during
TB therapy will reduce the excess mortality associated with
smoking and TB,71QRUDUHWKHUHDQ\HIFDF\GDWDDYDLODEOH
on whether using bupropion or varenicline with concomitant
DQWL7%WKHUDS\PD\EHRIEHQHW6PRNLQJFHVVDWLRQVKRXOG
however, be encouraged in all TB patients and appropriate
50
support provided.
4.4 HIV/antiretroviral therapy
6PRNLQJ FHVVDWLRQ LV DQ LPSRUWDQW DQG HIIHFWLYH
intervention in individuals living with HIV.
'UXJGUXJLQWHUDFWLRQVPD\RFFXUZLWKEXSURSLRQ
The risks of smoking in HIV-infected individuals are
well described and include inter alia pneumonia, TB and
lung cancer.72 There are several small trials on smoking
cessation in the context of HIV that have concluded that it
is an important and effective intervention.72-74 Smoking and
nicotine are known to induce hepatic enzymes,75,76 but not
those metabolising common antiretrovirals (ARVs). Enzyme
LQKLELWLRQLQGXFWLRQ E\ $59V VXFK DV ORSLQDYLUULWRQDYLU
may increase or reduce serum concentrations of bupropion and
should be used with caution.74 Varenicline is not metabolised
by the liver, thus drug-drug interactions should not occur, but
common side-effects such as nausea may interfere with ARV
compliance.73
4.5 Mental illness
6PRNLQJLVFRPPRQLQLQGLYLGXDOVZLWKPHQWDOLOOQHVV
$GHTXDWH PDQDJHPHQW RI WKH XQGHUO\LQJ SV\FKLDWULF
illness is key to successful smoking cessation.
Anxiety disorders, depression, and schizophrenia are strongly
associated with tobacco smoking.35,77,78 There is evidence to
suggest that psychiatric disorders may lead to self-medication
with nicotine and that smoking may predispose individuals
to mental illness.78,79 Smoking cessation is important even in
those with complex psychiatric disorders. Where necessary,
consultation with an experienced psychiatrist may be
EHQHFLDOLQFKRRVLQJWKHEHVWRSWLRQVIRUPDQDJHPHQWRIWKH
mental illness and drugs for smoking cessation if required.
A recent Cochrane review concluded that bupropion and
varenicline appear to be safe and effective in schizophrenia,
EXW157DQGSV\FKRORJLFDOLQWHUYHQWLRQVVKRZQREHQHW35
In patients with current depression, management of the
GHSUHVVLRQVKRXOGEHDGGUHVVHGUVWDVWKHUHLVOLPLWHGVXFFHVV
of smoking cessation interventions (even bupropion).77
4.6 In-hospital cessation
,QKRVSLWDO FHVVDWLRQ FRXQVHOOLQJ ZLWK SRVWGLVFKDUJH
follow-up is an effective intervention to assist in smoking
cessation.
7KH DGGLWLRQ RI 157 VXEVWDQWLDOO\ LPSURYHV TXLW UDWHV
EXWLQVXIFLHQWGDWDH[LVWDVWRWKHDGGLWLRQDOEHQHWVRI
bupropion or varenicline.
As smoking is banned in most public places and particularly
in hospitals, acute admissions in which smoking cessation is
imposed are convenient opportunities to promote smoking
cessation. Many trials have demonstrated that appropriate
in-hospital counselling and post-discharge follow-up
are effective.80 The additional use of NRT appears to be
highly effective (54% increase in cessation rates).80 There
DUH LQVXIFLHQW GDWD FRQFHUQLQJ WKH XVH RI EXSURSLRQ RU
varenicline during hospitalisation. Acute pre-operative
cessation has mixed reports of long-term success, although
Guideline
lower complication rates (in relation to wound healing and
lung function) occur in those who quit at least 6 - 8 weeks
prior to surgery.81-84
5. Relapse
Relapse is common; frequently, because the underlying
psychosocial factors or nicotine addiction have not been
adequately addressed. Relapses can be viewed as an
opportunity to learn how to approach a subsequent quit
attempt, rather than as outright failure. Many attempts may
be required before long-term success is achieved. If relapse
does occur, appropriate support should be provided and the
reasons for relapse reviewed before another quit attempt.
6. Implementation and further research

Smoking cessation at the primary level will require adequate
training of staff to provide the necessary counselling to
motivate patients to attempt to quit. Lay counsellors providing
HIV adherence support could be trained to offer smoking
cessation counselling and support. The prescription of
medication to support quit attempts may need to be restricted
WR FOLQLFLDQVFOLQLFV ZKR DUH DEOH WR IXOO\ DVVHVV QLFRWLQH
dependence and monitor side-effects of the medication.
5HVHDUFK LQWR WKH RSWLPDO XVH RI PHGLFDWLRQV LQ +,97%
patients as well as the possible use of amitriptyline is needed.
7. Summary and recommendations

Nicotine addiction and psychosocial stressors make smoking
FHVVDWLRQGLIFXOWHYHQLQWKRVHZKRDUHPRWLYDWHGWRTXLW
Motivating those with no apparent interest in quitting nor
FRQGHQFHWRTXLWUHTXLUHVVXSSRUWDQGHQFRXUDJHPHQWIURP
healthcare practitioners at every contact and should involve
the entire health team. Although time is limited in clinical
practice, brief motivational counselling with appropriate
referral of the individual who is motivated to quit, is effective.
These practice guidelines serve as an aid to the clinician in
deciding on the best strategies to use for smoking cessation.
Even the best programmes internationally have only modest
success rates, with frequent relapses if the underlying reasons
predisposing to smoking or the barriers to cessation have not
been addressed. Informing the smoker about the immediate
DQGORQJWHUPEHQHWVRITXLWWLQJDQWLFLSDWLQJWKHGLIFXOWLHV
that could be expected and problem solving with the patient,
as well as prescribing appropriate medication where needed,
all increase the possibility of success. If such interventions
are widely applied to a large proportion of smokers, they have
the potential to achieve important reductions in disease and
associated excess healthcare costs.
Acknowledgements
The South African Thoracic Society guideline committee is
grateful to Professors Eric Bateman and Dan Stein for their
input and review of this guideline.
&RQLFWVRILQWHUHVW
None of the authors have any relationship with the tobacco
industry. No funding was received from any source to prepare
these guidelines. RVZS, DS and GR have received honoraria
IURP3]HU*6.'6*5*5'6DQG6$*KDYHEHHQRQ
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References
1. World Health Organization. WHO Report on the Global Tobacco
Epidemic, 2008. The MPOWERPackage. Geneva: WHO, 2008.
KWWSZZZZKRLQWWREDFFRPSRZHUPSRZHUBUHSRUWBIXOOB
pdf (accessed 1 October 2013).
2. van Walbeek C. Recent trends in smoking prevalence in South
Africa some evidence from AMPS data. S Afr Med J 2002; 92(6):
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3. BuistAS, McBurnieMA, VollmerWM, et al. International variation
in the prevalence of COPD (the BOLD Study): A population-based
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RUJ6@
4. World Health Organization. The World Health Report 2002
Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002.
KWWSZZZZKRLQWZKUHQDFFHVVHG2FWREHU
5. Crothers K, Butt AA, Gibert CL, et al. Increased COPD among
HIV-positive compared to HIV-negative veterans. Chest 2006;
130(5): 1326-1333.
>KWWSG[GRLRUJFKHVW@
6. vanZyl-Smit RN, Pai M, Yew WW, et al. Global lung health: The
colliding epidemics of tuberculosis, tobacco smoking, HIV and
COPD. Eur Respir J 2010; 35(1):27-33.
>KWWSG[GRLRUJ@
7. Sitas F, Egger S, Bradshaw D, et al. Differences among the coloured,
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RUJ6@
(Non-US government research support)
8. Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century
KD]DUGVRIVPRNLQJDQGEHQHWVRIFHVVDWLRQLQWKH8QLWHG6WDWHVN
Engl J Med 2013; 368(4): 341-350.
>KWWSG[GRLRUJ1(-0VD@
(Non-US government and US National Institutes of Health (NIH)
extramural research support)
9. Groenewald P, Vos T, Norman R, et al. Estimating the burden of
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2007; 97(8): 674-681.
7REDFFR $WODV 2QOLQH KWWSZZZWREDFFRDWODVRUJ DFFHVVHG
October 2013).
11. Warnier MJ, van Riet EE, Rutten FH, et al. Smoking cessation
strategies in patients with COPD. Eur Respir J 2013; 41(3):727>KWWSG[GRLRUJ@
12. Rollnick S, Butler CC, Kinnersley P, et al. Motivational interviewing.
BMJ 2010;340F>KWWSG[GRLRUJEPMF@
13. Fiore MC, Jaen CR, Baker TB. Treating Tobacco Use and
Dependence: 2008 Update. Rockville: US Department of Health
and Human Services, Public Health Service, 2008.
14. Fiore MC. Treating tobacco use and dependence: 2008 update
U.S. Public Health Service Clinical Practice Guideline executive
summary. Respir Care 2008;53(9):1217-1222.
15. Lundahl B, Burke BL. The effectiveness and applicability of
motivational interviewing: A practice-friendly review of four metaanalyses. J Clin Psychol 2009;65(11):1232-12345.
>KWWSG[GRLRUJMFOS@
16. Lai DT, Cahill K, Qin Y, et al. Motivational interviewing for smoking
cessation. Cochrane Database Syst Rev&'>KWWS
G[GRLRUJ&'SXE@
0HWDDQDO\VLV
review)
17. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy
for smoking cessation. Cochrane Database Syst Rev 2012; 11:
&' >KWWSG[GRLRUJ&'SXE@
(Non-US government research support)
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(Randomised controlled trial (RCT); non-US government research
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51
Guideline
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insert South Africa. 2010.
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1 October 2013).
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reprotox.2012.08.001 (Non-US government research support)
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pulmonary effects of using an electronic cigarette: Impact on
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Chest 2012; 141 >KWWSG[GRLRUJ
chest.11-2443] (Non-US government research support)
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(Meta-analysis review)
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cessation aids: A meta-analysis of randomized controlled trials.
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cessation. Cochrane Database Syst Rev 2010(10): CD001008.
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analysis review)
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exposure and perinatal outcomes: A systematic review and metaanalyses. Acta Obstet Gynecol Scand 2010; 89>KWWS
G[GRLRUJ@ 0HWDDQDO\VLV QRQ86
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reduction during pregnancy on the birth weight of term infants. Am J
Guideline
Epidemiol 2001; 154(8): 694-701. (Clinical RCT; PHS government
research support)
54. Cook DG, Strachan DP. Health effects of passive smoking 10:
Summary of effects of parental smoking on the respiratory health of
children and implications for research. Thorax 1999;54(4):357-366.
(Review)
55. Everett-Murphy K, Steyn K, Mathews C, et al. The effectiveness
of adapted, best practice guidelines for smoking cessation
counseling with disadvantaged, pregnant smokers attending
public sector antenatal clinics in Cape Town, South Africa. Acta
Obstet Gynecol Scand 2010; 89 >KWWSG[GRL
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:LQGVRU 5 2QFNHQ & +HQQLQJHOG - et al. Behavioral and
pharmacological treatment methods for pregnant smokers: Issues
for clinical practice. J Am Med Womens Assoc 2000;55(5):304-310.
(PHS government research support)
57. Swamy GK, Roelands JJ, Peterson BL, et al. Predictors of adverse
events among pregnant smokers exposed in a nicotine replacement
therapy trial. Am J Obstet Gynecol 2009; 201(4): 354.e1-354.
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Pharmacies, Local Authorities and Workplaces, Particularly for
Manual Working Groups, Pregnant Women and Hard to Reach
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2008. Cape Town: South African Medical Research Council, 2010.
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60. Panday S, Reddy SP, Bergstrom E. A qualitative study on the
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among adolescents in the Southern Cape-Karoo region, South
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62. Brook JS, Morojele NK, Brook DW, et al. Predictors of cigarette
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cessation discourage adolescent smoking? Prev Med 1999; 28(3):
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research support)
65. Bates MN, Khalakdina A, Pai M, et al. Risk of tuberculosis from
exposure to tobacco smoke: A systematic review and meta-analysis.
Arch Intern Med 2007;167(4):335-342.
66. Slama K, Chiang CY, Enarson DA, et al. Tobacco and tuberculosis:
A qualitative systematic review and meta-analysis. Int J Tuberc
Lung Dis 2007; 11(10): 1049-1061.
67. Lin HH, Ezzati M, Murray M. Tobacco smoke, indoor air pollution
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smoking cessation intervention in Directly Observed Therapy ShortCourse tuberculosis treatment clinics in Rio de Janeiro, Brazil. Rev
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70. Awaisu A, Nik Mohamed MH, Mohamad Noordin N, et al. The

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of tuberculosis and tobacco smoke? Mycobacterial Diseases 2012;
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72. Lifson AR, Lando HA. Smoking and HIV: Prevalence, health risks,
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73. Ferketich AK, Diaz P, Browning KK, et al. Safety of varenicline
among smokers enrolled in the lung HIV study. Nicotine Tob Res
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in the HIV-infected population. Proc Am Thorac Soc 2011; 8(3):
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in adolescence on early adult anxiety symptoms and the relationship
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of varenicline clinical trial data. Nicotine Tob Res 2012;14(12):1467 >KWWS >KWWSG[GRLRUJQWUQWV@ &OLQLFDO SKDVH
II RCT; non-US government research support)
53
Airwaves Congress
International Faculty
Peter Barnes
DM, DSc, FRCP, FCCP, FMedSci, FRS
Peter Barnes is Margaret-Turner Warwick Professor of Medicine at the National Heart
and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary
Consultant Physician at Royal Brompton Hospital, London.
3URI3HWHU%DUQHVTXDOLHGDW&DPEULGJHDQG2[IRUG8QLYHUVLWLHVUVWFODVVKRQRXUV
and was appointed to his present post in 1987. He has published over 1000 peer-review
papers on asthma, COPD and related topics (h-index 140) and has written or edited
over 50 books. He is the 7th most highly cited researcher in the world, has been the most
highly cited clinical scientist in Europe and the most highly cited respiratory researcher
in the world over the last 20 years.
+HZDVHOHFWHGD)HOORZRIWKH5R\DO6RFLHW\LQWKHUVWUHVSLUDWRU\UHVHDUFKHU
IRURYHU\HDUV+HLVFXUUHQWO\DPHPEHURIWKH6FLHQWLF&RPPLWWHHRIJOREDOJXLGHOLQHVRQDVWKPD*,1$DQG&23'
(GOLD). He also serves on the Editorial Board of over 30 journals and is currently an Associate Editor of American Journal
of Respiratory and Critical Care Medicine, Chest, Journal of COPD and respiratory Editor of PLoS Medicine. He has given
several prestigious lectures, including the Amberson Lecture at the American Thoracic Society, the Sadoul Lecture at the
European Respiratory Society and the Croonian Lecture at the Royal College of Physicians, London. He has been received
honorary MD degrees from the Universities of Ferrara (Italy), Athens (Greece), Tampere (Finland) and Leuven (Belgium).
He is a NIHR Senior Investigator and was elected a Master Fellow of the American College of Chest Physicians and a member
of Academia Europaea in 2012. He is currently President of the European Respiratory Society.
He co-founded an Imperial spin-out company RespiVert, which was acquired by Johnson & Johnson and has developed novel
inhaled treatments for COPD and severe asthma.
Andy Bush
Professor of Paediatric Respirology, National Heart and Lung Institute London
Professor and Head of Paediatrics, Imperial College, London
Co-Editor of Cystic Fibrosis in the 21st Century
Joint Editor in Chief of Thorax
John Odell
Professor John Odell is a graduate of the University of Cape Town and trained locally in
Durban under the guidance of Professor Ben Le Roux and Andrew Logan. He returned
to Cape Town in 1986 and was appointed the Chris Barnard Professor of Cardiothoracic
Surgery. While in Cape Town he was a Founder Member of the Organ Donor Foundation
and later became chairman of this organization. In 1993 he was recruited to The Mayo
Clinic spending three years (winters) in Rochester, Minnesota before moving to warmer
Mayo Clinic Florida, where he was head of the Division of Cardiothoracic Surgery and
Surgical Director of Lung Transplantation, a program which he started. He retired as
Emeritus Professor of Surgery in April 2014 but continues to do lung transplantation call.
His interests are all aspects of cardiothoracic surgery, but particularly management of
pleuropulmonary suppuration, the history of thoracic surgery and lung transplantation.
He has published widely, has been a guest reviewer for many journals, has served on
editorial boards and is currently Deputy Editor of the Annals of Thoracic Surgery.
54
Airwaves Congress
Daniel Peckham
Honarary Clinical Associate Professor, University of Leeds
Clinical Lead for Respiratory Medicine and Cystic Fibrosis, St. Jamess University
Hospitals, Leeds.
Member of the British Thoracic Society Education Steering Group developing
e-learning.
Michael Perlis PhD

Associate Professor of Psychiatry
Director of the Upenn Behavioural Sleep Medicine Program
University of Pennsylvania
Dr. Perlis is internationally known for his work in the area of Behavioural Sleep
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senior author of a published CBT-I treatment manual and a larger text summarizing
all BSM treatments.
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behaviour effects of sedative hypnotics and placebos, the development of alternative
treatment approaches for insomnia, and sleep in depression. His work has been, and
continues to be, funded by the National Institutes of Health and he has published more
than 100 articles and chapters on the sleep research related topics.
In addition to his academic endeavours, he serves on the editorial boards of Sleep, the Journal of Sleep Research, the journal
of Behavioural Sleep Medicine, and Sleep Medicine Research. Dr. Perlis has also served as a member, or chair, of several
committees and task forces of the Sleep Research Society and the American Academy of Sleep Medicine and he was a
IRXQGLQJPHPEHURIWKH6RFLHW\RI%HKDYLRXUDO6OHHS0HGLFLQHDQGVHUYHGDVWKHVRFLHW\VUVWSUHVLGHQW
Colin Shapiro
Professor of Psychiatry and Ophthalmology at the University of Toronto
Director of the Sleep & Alertness Clinic & Sleep Research Laboratory, Toronto
Western Hospital
Director of the Youthdale Child & Adolescent Sleep Clinic, Toronto
3URI6KDSLURKDVEHHQLQYROYHGLQVOHHSUHVHDUFKIRURYHUWZHQW\YH\HDUV+HWUDLQHG
in medicine in South Africa subsequently doing his PhD in sleep physiology at the
University of Edinburgh.
He came to Canada approximately eighteen years ago as a full Professor in the
Department of Psychiatry. He is Director of the Neuropsychiatry Program at the
Toronto Western Hospital and Director of the Sleep and Alertness Clinic.
55
Airwaves Congress
Peter Sly
Professor Peter Sly is a paediatric respiratory physician with extensive research
experience in respiratory physiology, developmental immunology and childrens
environmental health.
Professor Slys research aims to understand the mechanisms underlying chronic
childhood lung diseases in order to improve clinical management and to delay or
prevent their onset, with consequent reductions in adult lung diseases.
Harm Tiddens
Prof Tiddens PhD is an Associate Professor in the Department of Paediatric
Respiratory Medicine at the Sophia Childrens Hospital in Rotterdam. He has held
his current position since 1994. He is also the Chairman of the Cystic Fibrosis team
at the Erasmus Medical Centre, where he has initiated many programs including fund
raising, patient newsletter, a CF-database and a website.
3URI 7LGGHQV DOVR KDV D VSHFLDO LQWHUHVW LQ 3DHGLDWULF 5DGLRORJ\ D HOG LQ ZKLFK
he has published widely. He holds a position as an honorary member of the
Radiology Department at the Erasmus Medical Centre. He was a visiting professor
at the University of Washington, School of Medicine Childrens hospital CF
Therapeutics Development Network Coordination Centre from 2006 till 2011.
Prof Tiddens is widely published with over 100 peer-reviewed international
publications, 33 chapters in books and has given presentations and lectures in over 200 meetings all over the world. He is
also an editorial board member of the Journal of Aerosol Medicine and Paediatric Pulmonology and regularly a reviewer in
numerous publications including the American Journal of Respiratory and Critical Care Medicine, European Respiratory
journal and Chest among others. He is also an active member of a number of respiratory societies. He is the current chairperson
of the ERS Task Force on CT scanning in CF and the current chair of the clinical review committee of the ECFS-Clinical trials
network. Prof Tiddens is married to Rosaria Tiddens-Macri and they have three children.
Adrian Williams
Professor Williams is a Diplomat of the American Board of Sleep Medicine, a
founding member of The British Sleep Foundation, the Sleep Medicine Section of
the Royal Society of Medicine, and the RLS. UK Group and was recently awarded
WKHUVW&KDLULQ6OHHS0HGLFLQHDW.LQJV&ROOHJH/RQGRQ
Professor Williams graduated from University College Hospital, London and
after a lectureship at The Cardiothoracic Institute, Brompton Hospital in 1975
took up an appointment at Harvard, Boston where his interest in sleep began with
the investigation of Sudden Infant Death Syndrome (S.I.D.S.) and publication of
DGHQLWLYHVWXG\LPSOLFDWLQJREVWUXFWLYHVOHHSDSQRHD26$DVDFDXVHRIWKLV
syndrome. An invitation to University of California (UCLA) in 1977 to take up
a post as Chest Physician allowed this early interest in OSA in infants to extend
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oximetry as a natural diagnostic tool. In 1985 Professor Williams became tenured
Professor of Medicine at UCLA and co-director of the UCLA Sleep Laboratory. As Sleep Medicine gelled as a speciality,
3URIHVVRU:LOOLDPVZDVRQHRIWKHUVWWRWDNHWKH%RDUGH[DPVLQWREHFRPHDQDFFUHGLWHGSRO\VRPQRJUDSKHUDQG
later member of the American Academy of Sleep Medicine. In 1994 he returned to London where he established the Sleep
Disorders Centre at St. Thomas Hospital.
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more than 60 other published papers including chapters and books. His main interests now lie in sleep-related diaphragm
dysfunction, the recognition and diagnosis of periodic limb movement disorder and the genetics of parasomnias.
56
Congress ABSTRACTS
Abstracts Contents
Abstract Title
First author
Society
Page
Acute lower respiratory tract infections in African Children
Abbott, Salome
SATS Paed Pulm
58
Assessment of previous TB status in adults using questionnaires, chest Allwood, Brian

x-rays and CT scans
SATS Adult
58
0HFKDQLVP RI $LURZ 2EVWUXFWLRQ LQ WXEHUFXORVLVDVVRFLDWHG Allwood, Brian

Obstructive Pulmonary Disease (TOPD)
SATS Adult
59
The effect of short term use of Stilnox MR on poor sleep, daily pain Benjamin, Daniela
and depression in arthritis patients
SASSM
60
$FFXUDF\DQGLPSDFWRI;SHUW07%5,)RQWUDFKHDODVSLUDWHVIRUWKH Calligaro, Greg

diagnosis of TB in SA intensive Care Units
SATS Adult
60
An overview of the circadian and shift work-related research in the Davy, Jonathan
Department of Human Kinetics and Ergonomics at Rhodes University
SASSM
61
The burden of lower respiratory tract infections in HIV-uninfected de Campos, Katya

and HIV-infected children hospitalized at Tshwane District Hospital,
Pretoria
SATS Paed Pulm
61
Circadian and Sleep effects on memory and regulatory CD4 T Cells
SASSM
62
Formoterol and indacaterol but not salbutamol effectively suppress the Feldman, Charles
reactivity of human neutrophils in vitro.
SATS Adult
62
10 Neutrophil targeted, cysteinyl leukotriene receptor-1-independent, Feldman, Charles

DQWLLQDPPDWRU\DFWLYLWLHVRIPRQWHOXNDVWSUDQOXNDVWDQG]DUOXNDVW
SATS Adult
63
11
Duxbury, Vania
Prevalence and molecular characterisation of dominant bacteria Goolam Mahomed, SACFA

LVRODWHGIURPSDWLHQWVDWWHQGLQJDF\VWLFEURVLVFOLQLFLQ3UHWRULD
Tanweer
63
12 Infant lung function and exhaled nitric oxide in healthy South African Gray, Diane M
infants
SATS Paed Pulm
64
13 Disrupted sleep is a possible mechanism for impaired cognition in Henry, Michelle

Addisons Disease patients
SASSM
65
14 Disrupted REM sleep predicts poor declarative Memory Performance Lipinska, Malgorzata SASSM
in Post-Traumatic Stress Disorder
65
15 The effect of lifestyle interventions on obstructive sleep apnoea and Lowe, Alex SW
the metabolic syndrome: a systematic review
SASSM
66
16 Older Age as a mediating Factor in the role that sleep spindles play in McCreesh, Siobhan
declarative Memory Consolidation
SASSM
66
17 Rare Pulmonary Malignancies in children: A case series
Naidoo, Krubin
SATS Paed Pulm
67
18 Case report: primary epithelioid angiosarcoma of the pericardium
Nqwata, Lamla
SATS Adult
67
19 Blue light and sleep: An examination of the interactions
Pearce, Matthew
SASSM
68
20 Sleep disruption is associated with pain and increased CD4 counts in Redman, Kirsten
HIV positive patient
SASSM
68
21 Sleep in treated HIV positive patients
SASSM
69
22 High risk sleep apnoea on the Berlin Questionnaire is associated with Scheuermaier,
hypertension in south Africans of Black Ancestry
Karine
SASSM
69
23 Chronically-elevated night-time cortisol and sleep-dependent memory Timol, Ridwana

consolidation in adult asthmatics
SASSM
70
24 The relationship between PTSD, hypervigilance and disordered sleep
SASSM
70
SATS Adult
71
Redman, Kirsten
van Wyk. Mariza
25 The effect of pleural drainage on pulmonary function testing in patients Wilken, Elisma
with tuberculous pleural effusions: a pilot study
26 Lung function measures in unsedated 1 year South African Infants
27 Usefulness of
QGLQJV
Willemse, Lauren
))'* 3(7&7 VFDQV LQ VDUFRLGRVLV SUHOLPLQDU\ Wong, Michelle
18
SATS Paed Pulm
71
SATS Adult
72
57
Congress ABSTRACTS
1. ACUTE LOWER RESPIRATORY TRACT INFECTIONS
IN AFRICAN CHILDREN
Abbott S1, Annamalay A2, Bizzintino J2, Khoo S2, Le Souf
P2, Green RJ1
1
Department of Paediatrics and Child Health, University of

Pretoria
2
School of Paediatrics and Child Health, University of
Western Australia
Rationale
Acute lower respiratory tract infections (ALRI) are the
leading cause of childhood mortality worldwide. Human
rhinovirus (HRV) is the most common cause. The aetiology
of ALRI in Africa is not well understood.
Objectives
This project aims to describe the i) role of bronchiolitis and
pneumonia in ALRI; ii) symptoms associated with ALRI and
iii) viral aetiology of ALRI including HRV.
Methods
Nasopharyngeal aspirates were collected from children under
2 years admitted to hospital with an ALRI. Healthy controls
were included. A diagnosis of pneumonia or bronchiolitis was
made by the doctor. Information on symptoms was collected.
A diagnosis of HIV was made using ELISA (and PCR if under
PRQWKV5HVSLUDWRU\YLUXVHVZHUHLGHQWLHGXVLQJ3&5
Results
106 cases and 54 controls (median ages, 5.6 and 8.0 months
respectively) were recruited. Of the 106 cases, 58 (54.7%)
had pneumonia and 48 (45.3%) bronchiolitis. Of the 15
(14.2%) HIV infected ALRI cases, more had pneumonia than
bronchiolitis (93.3% vs. 6.7%, p<0.05). Wheeze was more
common among bronchiolitis than pneumonia cases (56.2%
YVS
+59ZDVWKHPRVWFRPPRQYLUXVLGHQWLHGDQGZDVHTXDOO\
prevalent between cases and controls (49% vs. 40%%,
S +,9LQIHFWHGDQGXQLQIHFWHGFDVHVYV
S DQG EURQFKLROLWLV DQG SQHXPRQLD FDVHV YV
S
Conclusion
Pneumonia is more common than bronchiolitis in HIV. HRV
is common in sick and healthy children and the role as a
pathogen is unclear.
2. ASSESSMENT OF PREVIOUS TUBERCULOSIS STATUS

IN ADULTS USING QUESTIONNAIRES, CHEST X-RAYS
AND CT SCANS
Brian Allwood1, Jonathan Goldin2, Qonita Said-Hartley1,
Richard van ZylSmit1, Greg Calligaro1, Aliasgar Esmail1,
Nulda Beyers3, Eric D Bateman1
1
Division of Pulmonology, Department of Medicine,

University of Cape Town & UCT Lung Institute,
2
David Geffen School of Medicine, University of California,
Los Angeles
3
Desmond Tutu Centre for TB Research, Department of
Paediatrics and ChildHealth, Stellenbosch University
Introduction:
Determining with certainty whether an individual has
previously had pulmonary TB (PPTB) is important for
clinicians and in research. A record of bacteriologicallyFRQUPHG 37% LV RIWHQ QRW DYDLODEOH DQG 337% VWDWXV LV
EDVHGRQWKHSDWLHQWKLVWRU\DQGRUFKHVW;UD\:HFRPSDUHG
history, chest X-rays and CT scans to develop a method to
HVWDEOLVKZLWKJUHDWHVWFRQGHQFHWKHDEVHQFHRI337%
Subjects and Methods:
The study population comprised adults aged 40 years and
older diagnosed with obstructive lung disease in a large
community-based prevalence survey in Cape Town, South
Africa, performed using the BOLD (Burden of Obstructive
Lung Disease) methodology. PPTB status was assessed with
two administered questionnaires, standard chest X-rays and
high resolution CT scans of the chest reported by experienced
readers.
Results:
One hundred and four subjects completed the assessments.
Agreement between the two questionnaires was excellent
(kappa value 0.96), an episode of PPTB being reported in 41
of 107 (38.3%) of subjects using the BOLD questionnaire,
and in 39 of 104 (36.4%) with the PTbQ (Previous TB
4XHVWLRQQDLUH &KHVW ;UD\ UHSRUWV LGHQWLHG HYLGHQFH RI
PPTB in 45 of 104 of subjects (43.3%) and between-reader
agreement was good (Kappa value 0.73). There was moderate
FRQFRUGDQFH EHWZHHQ QGLQJV RI TXHVWLRQQDLUHV DQG FKHVW
X-rays (80.8%; kappa value 0.60). Changes compatible with
337%ZHUHLGHQWLHGRQFKHVW&7VFDQVLQRIVXEMHFWV
(71 of 104) and between-reader agreement was moderate
(Kappa value 0.43).
Using the combination of PTbQ and CT scan assessment as a
FRPSRVLWHGHQLWLRQTXHVWLRQQDLUHVDORQHKDGDVHQVLWLYLW\RI
53.4% for PPTB and a 32.7% false negative rate. Expert chest
;UD\UHDGDORQHKDGDVHQVLWLYLW\RIDQGDVSHFLFLW\
of 90.3% for PPTB.
Interpretation:
Both clinical history and chest X-ray markedly underestimate
the prevalence of PPTB in patients with COPD. The
combination of a structured questionnaire and a CT scan is
more reliable for situations in which PPTB needs to be ruled
RXWZLWKUHODWLYHO\JUHDWHUFRQGHQFH
Figure 1: HRV prevalence
58
Congress ABSTRACTS
3. MECHANISM OF AIRFLOW OBSTRUCTION IN
TUBERCULOSIS-ASSOCIATED
OBSTRUCTIVE PULMONARY DISEASE (TOPD)
Brian Allwood1, Rencia Gillespie1, Maya Galperin
Aizenberg2, Mary Bateman1, Helena Olckers1, Luis
Taborda-Barata3, Greg Calligaro1, Qonita Said-Hartley1,
Richard van Zyl-Smit1, Christopher B Cooper4, Eva
van Rikxoort5, Jonathan Goldin4, Nulda Beyers6, Eric D
Bateman1
1

University of Cape Town & UCT Lung Institute; 2University
of Pennsylvania; 3CICS Health Sciences Research Centre,
University of Beira Interior, Portugal; David Geffen School
of Medicine, University of California, Los Angeles; 5Radboud
University Medical Center, Nijmegen; 6Desmond Tutu Centre
for TB Research, Department of Paediatrics and Child
Health, Stellenbosch University
lower IC (95% CI: -33.9 to -10.5; P<0.001) than NPTB

VXEMHFWV0XOWLYDULDWHDQDO\VLVFRQUPHGWKDW'37%VXEMHFWV
had 6.5% higher gas-trapping score (95% CI: 1.34 to 11.60;
3 DQGKLJKHUEURVLVVFRUH&,WR
3 DQG KLJKHU HPSK\VHPD VFRUHV
&,3 WKDQVXEMHFWVZLWK137%
Conclusion
This structure-function evaluation of persons with TOPD, ie:
FKURQLF$)2DQGHYLGHQFHRISUHYLRXVKHDOHG37%FRQUPV
that patients with the latter risk factor should be considered
a distinct clinical phenotype of COPD, characterized by
ORZHU'/&2EXWPRUHJDVWUDSSLQJFRQUPHGE\ERWKOXQJ
physiology and CT scans.
Introduction
Epidemiological studies in populations with a high burden of
pulmonary tuberculosis (PTB) suggest an association between
37% DQG WKH GHYHORSPHQW RI FKURQLF DLURZ REVWUXFWLRQ
(AFO). The mechanisms responsible for AFO likely include
airway narrowing (from bronchiolitis, bronchiectasis or
SHUVLVWHQW ORZJUDGH LQDPPDWLRQ DVVRFLDWHG ZLWK KHDOHG
PTB) and reduced lung elastic recoil from coexistent
emphysema. These possibilities give rise to different opinions
on whether Tuberculosis-associated Obstructive Pulmonary
Disease (TOPD) should be viewed as a separate phenotype
ZLWKLQWKHEURDGGHQLWLRQRI&KURQLF2EVWUXFWLYH3XOPRQDU\
Disease (COPD). We performed dynamic quantitative CT
lung imaging and measured lung physiology in patients
with healed PTB and AFO to examine relationships between
structural abnormalities and physiological function.
Methods
The study population comprised subjects with chronic AFO
LGHQWLHGGXULQJDSRSXODWLRQEDVHG&23'SUHYDOHQFHVXUYH\
performed in two low-middle income suburbs of Cape Town,
South Africa in 2005 using Burden Obstructive Lung Disease
(BOLD) methodology. Beginning 2010, attempts were made
to trace all subjects and invite them to participate in this
follow-up study. Detailed questionnaires, lung physiology
(including spirometry, plethysmography and CO diffusion
capacity) as well as standardized low-dose quantitative chest
CT scans were performed to assess bronchial anatomy and
the presence of emphysema (HU<-950), gas trapping (HU<DQGEURVLV+8!
Results
One hundred and seven of 196 eligible subjects (54.6%)
diagnosed with AFO in the 2006 survey were enrolled. Lung
physiology was assessed in 103 and CT scans suitable for
TXDQWLWDWLYHDQDO\VLVLQVXEMHFWV$)2GHQHGDV)(91
)9& ZDV FRQUPHG LQ RQO\ VXEMHFWV
Based on history and CT scans, subjects were categorized
DV 1R SUHYLRXV 7% 137% Q 3UREDEOH
SUHYLRXV 7% 337% Q RU 'HQLWH 3UHYLRXV
7%'37%Q 6XEMHFWVZLWK'37%KDG
ORZHU '/&2 &, WR 3 DQG
59
Congress ABSTRACTS
4. THE EFFECT OF SHORT TERM USE OF STILNOX
MR ON POOR SLEEP, DAILY PAIN AND DEPRESSION IN
5. ACCURACY AND IMPACT OF XPERT MTB/RIF ON

TRACHEAL ASPIRATES FOR THE DIAGNOSIS
ARTHRITIS PATIENTS
OF TUBERCULOSIS IN
SOUTH AFRICAN INTENSIVE
CARE UNITS
Daniela Benjamin
Department of Physiology, University of the Witwatersrand,
Johannesburg, South Africa
Calligaro G1, Khalfey H1, Theron G1, Peter J1, Raine R1,
Miller M2, Piercy J2, Joubert I2 and Dheda K1
1
Introduction:
The bi-directional relationship between sleep and pain causes
patients with chronic daily pain, such as in Rheumatoid and
Osteoarthritis, to experience insomnia, fragmented sleep and
increased number of night-time awakenings. This poor sleep
results in an increased sensitivity to pain during the day. The
aim of the study was to assess the effect of Stilnox MR on
insomnia and chronic pain.
Methods:
11 patients from Chris Hani Baragwanath Hospital with
insomnia and daily pain spent 4 weeks in this double
blinded, placebo controlled study. Week 1-baseline, week
2 Intervention 1, week 3-washout and week 4-intervention
2. Patients who received Stilnox MR during intervention 1,
received a placebo during intervention 2 and vice versa. Data
collected included actigraphy, McGill Pain Questionnaire,
PSQI, BDI, physical activity questionnaire and daily sleep
and pain diaries containing VAS scales for sleep and pain.
Results:
1R VLJQLFDQW FKDQJHV ZHUH IRXQG LQ WKH SDLQ RU SK\VLFDO
activity levels in any of the patients. Sleep quality was
LPSURYHG E\ 6WLOQR[ 05 S 364, ZDV GHFUHDVHG
LQWKHQDOZHHNRIWKHVWXG\FRPSDUHGWREDVHOLQHYV
S DQG%',ZDVORZHULQZHHNWKDQEDVHOLQH
YV S %', ZDV DOVR ORZHU LQ ZHHN
compared to week 2 (7.7 vs. 12.8, p<0.05). However the
changes in PSQI and BDI were a result of the order of the
weeks, with patients interacting with the researcher and were
not due to either Stilnox MR or placebo. Anecdotal reports
include feeling more energised and capable of living life.
Conclusion:
This study has shown that human interaction is an important
component of treatment. Giving arthritis patients Stilnox MR
will not decrease their pain levels but will allow them to feel
better in terms of daily functioning.
Lung Infection and Immunity Unit, Division of Pulmonology

and UCT Lung Institute, Department of Medicine, University
of Cape Town and Groote Schuur Hospital, Cape Town, South
Africa. 2Division of Critical Care, Department of Medicine,
University of Cape Town and Groote Schuur Hospital, Cape
Town, South Africa.
3XOPRQDU\WXEHUFXORVLV7%LVDFRPPRQQGLQJLQSDWLHQWV
admitted to the intensive care unit (ICU) for both respiratory
and non-respiratory reasons in a high-burden setting. The
diagnostic accuracy of Xpert on tracheal aspirates (TA) is
unknown.
Aim:
To evaluate the performance of Xpert on TA and to determine
ULVN IDFWRUV IRU7%VSHFLF ,&8 PRUWDOLW\ LQ D KLJKEXUGHQ
setting.
Methods:
Consecutive patients admitted to one of 8 ICUs in Cape Town
with suspected TB were prospectively randomized to either
conventional diagnostics (smear and culture) or Xpert.
Results:
In 242 patients, the overall sensitivity of Xpert was
VLJQLFDQWO\ KLJKHU WKDQ VPHDU YHUVXV
S DQG ZDV VLJQLFDQWO\ ORZHU LQ +,9LQIHFWHG
versus uninfected patients (50% versus 100%, p<0.001).
Xpert detected an additional 9 cases of TB among patients
whose cultures that were either negative or contaminated.
In the XpertDUPFXOWXUHSRVLWLYHFDVHVRI7%ZHUH
FRUUHFWO\ VWDUWHG RQ WUHDWPHQW FRPSDUHG WR RQO\ LQ
the conventional arm. Three patients in the conventional
arm were started empirically on TB treatment versus none
in the Xpert arm. Median time to treatment initiation in the
Xpert arm was 0.25 days versus 0.59 in the conventional
DUP S 7KHUH ZDV QR GLIIHUHQFH LQ GXUDWLRQ RI ,&8
RU KRVSLWDO VWD\ DQG RYHUDOO RU 7%VSHFLF DQG GD\
mortality between the two arms. On multivariable analysis,
the presence of medical comorbities but not HIV infection
alone was associated with mortality.
Conclusions:
Xpert detected TB cases more accurately than smear
microscopy, and reduced the rate of empirical treatment.
60
Congress ABSTRACTS
6. AN OVERVIEW OF THE CIRCADIAN AND SHIFT
WORK-RELATED RESEARCH IN THE DEPARTMENT OF
HUMAN KINETICS AND ERGONOMICS AT RHODES
UNIVERSITY
7. THE BURDEN OF LOWER RESPIRATORY TRACT

INFECTIONS IN HIV-UNINFECTED AND
HIV-INFECTED CHILDREN HOSPITALIZED AT
TSHWANE DISTRICT HOSPITAL, PRETORIA
Jonathan Davy
RK de Campos, DD Granga, R Masekela
Department of Human Kinetics and Ergonomics, Rhodes

University, Grahamstown, South Africa

Pretoria, Pretoria, South Africa
The practise of shift work is associated with disruptions to

the circadian rhythm and the natural sleep-wake cycle, most
notably during night work. The consequent sleep loss reduces
alertness and performance, increases safety risks and, in
the long term, is associated with various health concerns.
In attempts to manage these challenges, a variety of shift
work countermeasures such as bright light, stimulant use,
different shift system designs and strategic napping have
been researched and applied. Since 2009, the Department of
Human Kinetics and Ergonomics at Rhodes University has
conducted research into different napping, activity-related and
shift system design countermeasures during simulated night
shift work settings. This has included exploring the effects
RIDH[LEOHRQHKRXUQDSRSSRUWXQLW\DQGWKHLQFOXVLRQRI
an extended protected sleep period. Other countermeasures
included a short, hourly exercise break and a novel shift system
design by which shift workers were gradually transitioned
into a night shift. This research was laboratory-based with
the above mentioned countermeasures being compared to
a standard night shift arrangement. Psychophysiological,
cognitive and perceptual measures were applied to determine
the impact of these conditions. Although the ecological
validity of these tests and the laboratory conditions limit the
applicability of these countermeasures in real-world settings,
the research highlights some positive effects that could be
employed in situ. Thus the purpose of this paper will be to
KLJKOLJKW WKH NH\ QGLQJV RI WKLV UHVHDUFK DQG GLVFXVV LWV
UHOHYDQFHWRWKHHOGRIVKLIWZRUNFRXQWHUPHDVXUHUHVHDUFK
Introduction
5HVSLUDWRU\ GLVHDVHV DUH FRPPRQ DQG FDUU\ D VLJQLFDQW
morbidity and mortality in children.
Objectives
The aim of the study was to evaluate the prevalence and
outcome of lower respiratory tract infections (LRTIs) in
HIV-infected and -uninfected of children at a primary level
hospital.
Methods
A descriptive cross-sectional study of children age 6-18 years
was conducted at Tshwane District Hospital. Recruitment
included HIV-positive children who were on HAART
for at least 6 months. Laboratory investigations collected
included an assessment of HIV-status with CD4 + T cell
counts and HIV viral load. In HIV-negative group, children
were enrolled from the TDH paediatric ward if they were
admitted for pneumonia. Data collected in both groups
included demographic data, immunization status, zinc
supplementation, history of previous lower respiratory tract
infections, environmental exposures and therapy given.
Results
15 HIV-negative and 50 children HIV-positive were enrolled.
In the HIV negative group, the children were younger (mean
age 15.5 11.0) versus (mean age 105 51.5) p<0.005;
with no difference in gender distribution in both groups.
The average number of hospitalization days was 4 days in
the HIV-negative group with only one admission in the HIVpositive group. The majority of HIV-positive children with
LRTI were treated as outpatients with Amoxycillin. Only
41% of children had pneumococcal vaccination and 7% were
exposed to biomass fuels.
Conclusion
Amoxicillin still is the drug of choice for uncomplicated
pneumonia for both groups. The levels of zinc supplementation
and pneumococcal vaccination were low, although this
seemed not to impact outcomes.
61
Congress ABSTRACTS
8. CIRCADIAN AND SLEEP EFFECTS ON MEMORY AND
REGULATORY CD4+ T CELLS
9. FORMOTEROL AND INDACATEROL BUT NOT

SALBUTAMOL EFFECTIVELY SUPPRESS THE REACTIVITY
OF HUMAN NEUTROPHILS IN VITRO
Vania Duxbury1, Kirsten Redman1, Daniela Benjamin1,

Patti Kay3, Melinda Suchard2, Karine Scheuermaier1
C. Feldman1, A.J. Theron2, H.C. Steel2, C Durandt2, G.R.

Tintinger2, R. Anderson2
Physiology, Faculty of Health Sciences, University of the

Witwatersrand
2
Molecular Medicine and Haematology, University of the
Witwatersrand and National Health Laboratory Service
3
Department of surgery, Faculty of Health Sciences,
University of the Witwatersrand
Introduction
0HFKDQLVPVIRUWKHLQXHQFHRIVOHHSRUFLUFDGLDQYDULDWLRQV
on the immune system are poorly understood. Sleep
reportedly improves antibody responses after vaccination.
9DFFLQDWLRQV KDYH EHHQ VKRZQ WR KDYH GLIIHUHQW HIFDFLHV
when administered at different times of the day. Many
autoimmune diseases such as rheumatoid arthritis show
F\FOLFDO XFWXDWLRQV LQ V\PSWRP VHYHULW\ ZLWK WLPH RI GD\
Sleep deprived lupus prone rats exhibit an earlier onset of
disease than rats that are not sleep deprived. This study
determined circadian rhythms and sleep effects in humans in
memory and regulatory CD4+ T cells.
Methods
We recruited six healthy males between the ages of 18-30. The
participants took part in a 60 hour protocol that consisted of
a baseline 8-hour sleep, a 40-hour constant routine followed
by an 8-hour recovery sleep. During the constant routine food
intake, posture, exposure to light and overall level of activity
were kept constant. This was done to ensure that there would
be no masking effect of endogenous signals on the rhythms of
the memory and regulatory CD4 T cells. T cell subsets were
DQDO\VHGXVLQJPXOWLFRORXURZF\WRPHWU\
Division of Pulmonology, Faculty of Health Sciences,

University of the Witwatersrand,
2
Department of Immunology, Faculty of Health Sciences
University of Pretoria
The clinical relevance of the well-described in vitro antiLQDPPDWRU\ SURSHUWLHV RI EHWDDJRQLVWV %2A) remains
FRQWHQWLRXV:HFRPSDUHGWKHDQWLLQDPPDWRU\DFWLYLW\RI
a short-, long-and ultralong-acting, commonly used, B2A,
namely salbutamol, formoterol and indacaterol in vitro.
Neutrophils were activated with either fMLP or PAF in the
absence or presence of the B2A, followed by measurement
of neutrophil oxygen consumption, generation of reactive
oxidants, and leukotriene B4, release of elastase, expression
of B2-integrin, CR3, using a combination of techniques.
These were correlated with alterations in concentrations of
cAMP, and cytosolic calcium. Formoterol and indacaterol at
FRQFHQWUDWLRQV RI Q0 FDXVHG VLJQLFDQW GRVHUHODWHG
LQKLELWLRQ RI SURLQDPPDWRU\ DFWLYLWLHV WHVWHG 6DOEXWDPRO
was much less active. Suppression of neutrophil reactivity
was accompanied by elevations in intracellular cAMP and
accelerated clearance of calcium from the cytosol of activated
neutrophils. B2A vary with regard to their ability to their
suppressive effects on activated neutrophil activity.
Results
$EVROXWHO\PSKRF\WHFRXQWVGLVSOD\HGDVLJQLFDQWFLUFDGLDQ
UK\WKP DQG GHFUHDVHG VLJQLFDQWO\ GXULQJ UHFRYHU\ VOHHS
compared to baseline sleep. Memory CD4 T cells displayed
D VLJQLFDQW FLUFDGLDQ UK\WKP ZLWK PD[LPXP IUHTXHQF\
during the day and minimum frequency 4 hours after bedtime
(P<0.001). Absolute counts of regulatory CD4 T cells showed
a trend of maximal count during the night and minimum
FRXQWVKRUWO\DIWHUZDNHS
Conclusion
Our results show that memory CD4 T cells are under circadian
regulation and that lymphocytes display not only a circadian
rhythm, but are also affected by the sleep wake cycle.
Regulatory CD4 T cells showed a trend towards circadian
rhythms, which would need to be further explored.
These results give preliminary data on which to base
further studies of sleep disturbances and their interactions
with clinical diseases. Such scenarios include patients with
autoimmune diseases, shift workers, patients with sleep
apnoea and patients with mood disorders.
62
Congress ABSTRACTS
10. NEUTROPHIL TARGETED, CYSTEINYL
LEUKOTRIENE RECEPTOR-1-INDEPENDENT, ANTIINFLAMMATORY ACTIVITIES OF MONTELUKAST,
11. PREVALENCE AND MOLECULAR

CHARACTERISATION OF DOMINANT BACTERIA
ISOLATED FROM PATIENTS ATTENDING A CYSTIC
PRANLUKAST AND ZAFIRLUKAST
FIBROSIS CLINIC IN
PRETORIA
C. Feldman1, H.C. Steel2, G.R. Tintinger2, C.M. Gravett2,

R. Anderson2, A.J. Theron2
Goolam Mahomed T1, Kock MM1,2, Masekela R3, Hoosien

E2 and Ehlers MM1,2
Division of Pulmonology, Faculty of Health Sciences,

University of the Witwatersrand,
2
Department of Immunology, Faculty of Health Sciences
University of Pretoria
Montelukast, the most commonly used cysteinyl leukotriene

receptor-1-(cysLTR1) antagonist, suppresses human
neutrophil activation by a secondary mechanism apparently
UHODWHG WR QRQVSHFLF SKRVSKRGLHVWHUDVH 3'( LQKLELWRU\
activity (Anderson R et al. Br J Pharmacol 2009;156:105115). The objective of the current study was to compare the
effects of montelukast on neutrophil activation with those of
SUDQOXNDVWDQG]DUOXNDVWRYHUDFRQFHQWUDWLRQUDQJHRI
0,VRODWHGKXPDQEORRGQHXWURSKLOVZHUHSUHWUHDWHGZLWK
the test agents followed by activation with either of the potent
FKHPRDWWUDFWDQWV I0/3 0 RU SODWHOHWDFWLYDWLQJ IDFWRU
Q0 DQG PHDVXUHPHQW RI WKH SURGXFWLRQUHOHDVH RI WKH
LQDPPDWRU\PHGLDWRUVVXSHUR[LGHHODVWDVHDQGOHXNRWULHQH
B4, as well as alterations in concentrations of cytosolic
Ca2+ ,Q DGGLWLRQ WKH HIIHFWV RI WKH WHVW DJHQWV 0
on cyclic AMP and cyclic GMP PDE activities in cytosolic
extracts of neutrophils were measured using a radioassay
procedure. All 3 test agents caused dose-related, essentially
equipotent inhibition, of the generation of superoxide and
/7%DQGUHOHDVHRIHODVWDVHDWWDLQLQJVWDWLVWLFDOVLJQLFDQFH
DW 0 7KHVH HIIHFWV ZHUH SDUDOOHOHG E\ VLJQLFDQW
reductions in both cytosolic Ca2+ and the activities of cAMP
and cGMP PDEs, consistent with a mechanistic relationship
between these events. Suppression of neutrophil reactivity is
apparently a common property of montelukast, pranlukast and
]DUOXNDVWSUREDEO\GXHWRQRQVSHFLF3'(DFWLYLW\ZKLFK
PD\ XQGHUSLQ WKH EURDGHQLQJ VSHFWUXP RI LQDPPDWRU\
conditions seemingly responsive to these agents.
Background:
Cystic Fibrosis (CF) is an autosomal recessive disease
that affects the lungs, predisposing patients to infections
with bacteria such as: Burkholderia cepacia complex,
Pseudomonas aeruginosa and Staphylococcus aureus.
Department of Medical Microbiology, University of Pretoria

National Health Laboratory Services (Tshwane Academic
Division)
3
Department of Paediatrics , University of Pretoria
2
Introduction:
In South Africa limited data is available on bacteria associated
with CF patients.
Methodology:
A total of 73 specimens were collected from patients attending
a CF clinic in Pretoria. Selective media were used to isolate
B. cepacia complex, P. aeruginosa and S. aureus, followed
E\ 0$/',WRI LGHQWLFDWLRQ 0XOWLSOH[ 3&5 DVVD\V ZHUH
performed for methicillin resistance (mec$ JHQH ELROP
formation (icaAB gene), Panton Valentine leukocidin toxin
(luk6)39 JHQHV TXDWHUQDU\ DPPRQLXP FRPSRXQG
resistance (qac genes) and insertion sequence (IS256)
detection in the isolates.
Results:
$ WRWDO RI EDFWHULD ZHUH LGHQWLHG 7KH PDMRULW\ >
@ZHUH*UDPSRVLWLYHDQGZHUH*UDP
negative. No B. cepacia FRPSOH[ LVRODWHV ZHUH LGHQWLHG
Pseudomonas aeruginosa were the dominant Gram negative
EDFWHULD>@DQGZHUHSRVLWLYHIRUWKH
qac genes. Staphylococcus aureus were the dominant Gram
SRVLWLYHEDFWHULD>@RIZKLFKZHUH
methicillin-resistant S. aureus (MRSA). The MRSA isolates
VKRZHG D SUHYDOHQFH RI IRU WKH icaAB gene,
IRU WKH 39/ WR[LQ JHQHV IRU WKH
qacJHQHVDQGIRUIS256.
Conclusion:
Both MRSA and P. aeruginosa are important clinical
pathogens and the high prevalence of these bacteria as well
as the various virulence genes detected is worrisome in this
susceptible population.
63
Congress ABSTRACTS
12. INFANT LUNG FUNCTION AND EXHALED NITRIC
OXIDE IN HEALTHY SOUTH AFRICAN INFANTS
Diane M Gray1, Emilee Smith2, Lauren Willemse1, Ane
Visagie1, Dorottya Czvek3,4, Peter D Sly4, Zoltn Hantos3,4
Graham L Hall5, Heather J Zar1
1
Department of Paediatrics and Child Health, Red Cross

War Memorial Childrens Hospital, University of Cape
Town, South Africa, 2Center for Infectious Disease Research
Institute, Department of Public Health, University of Cape
Town, South Africa 3Department of Medical Physics and
Informatics, University Of Szeged, Hungary Queensland
Childrens Medical Research Institute, University of
Queensland, Australia 5Telethon Institute for Child Health
Research, Centre for Child Health Research, University of
Western Australia, Perth, Australia
smoking were predictors of FRC but not LCI. Age,WAZ and

sex were predictors of TV and tPTEFWE. Age, birth weight
and caesarean section were predictors of eNO. Sex and size
were predictors of FOT R and C. The reference equations
GHYHORSHG WWHG EHWWHU WKDQ WKRVH SXEOLVKHG IRU (XURSHDQ
infants.
Conclusion:
This study provides reference data for unsedated infant lung
function testing in 6-10 week African infants living in a low
income setting and highlights the importance of developing
UHIHUHQFH HTXDWLRQV WKDW DUH VSHFLF IRU WKH SRSXODWLRQ
studied.
Background:
To accurately assess the impact of early life factors on lung
function and to distinguish between health and disease in a
population, appropriate reference data is essential. Currently
no normative lung function data exist for healthy African
infants.
Aim:
To describe normal lung function in healthy 6 week infants
living in a peri-urban area of South Africa.
Methods:
Healthy 6-10 week infants were enrolled from the Drakenstein
birth cohort study in Paarl, Western Cape. Infants were
excluded if they were born preterm (<37 weeks gestation)
or had a previous respiratory tract infection. All testing was
completed during quiet natural sleep.
Results:
Of the 364 infants tested, acceptable measures were obtained
in 356 (98%) of tidal breathing (TBFVL), 352 (97%) exhaled
nitric oxide (eNO), 345 (95%) multiple breath washout
0%: DQG IRUFHG RVFLOODWLRQ WHFKQLTXH
(FOT) tests.
7DEOH1RUPDWLYHGDWDDQGLQWUDVXEMHFWFRHIFLHQWRIYDULDWLRQ&9IRU
lung function measures
Median (25-75%)
CV med (25-75%)
MBW n=345
Functional residual capacity 75.1 (66.1 86.6)
(FRC) mL
5.4 (3.3 7.8)
Lung clearance index (LCI)
4.0 (2.4 5.8)
7.16 (6.91 7.46)
TBFVL n=356
Tidal Volume (TV) mL
34.52 (30.78 39.0) 7.7 (6.3 9.9)
tPTEFWE %
39.9 (31.6 46.7)
20.1 (16.8 25.2)
9.0 (5.0 - 13.7)
4.3 (3.4 6.5)
45.6 (38.1 57.2)
4.9 (3.0 8.0)
0.87 (0.68 1.15)
11.0 (6.1 17.9)
eNO n=352
Exhaled NO ppb
FOT n=293
Resistance (R) hPa.s.L-1
-1
Compliance (C) mL.hPa
tPTEFWEWLPHWRSHDNWLGDOH[SLUDWRU\RZRYHUWRWDOH[SLUDWRU\WLPH
Age, weight-for-age z score (WAZ), birth length and maternal

64
Congress ABSTRACTS
13. DISRUPTED SLEEP IS A POSSIBLE MECHANISM FOR
IMPAIRED COGNITION IN ADDISONS DISEASE PATIENTS
M Henry, KGF Thomas, IL Ross, P Wolf
Department of Psychology, University of Cape Town, Cape
Town, South Africa
The standard replacement therapy for Addisons disease
(AD) does not restore a normal circadian rhythm. In addition,
SDWLHQWVIUHTXHQWO\UHSRUWSRRUTXDOLW\RIOLIH4R/PHPRU\
DWWHQWLRQ GLIFXOWLHV DQG VOHHS GLVWXUEDQFHV 7KH SULPDU\
aim of this study was to a) investigate the relationship
between sleep, QoL, and cognition, b) determine whether
SUHYLRXVO\ UHSRUWHG VOHHS DQG FRJQLWLYH GHFLWV LQ $' DUH
FRQUPHGE\REMHFWLYHPHDVXUHVDQGFLQYHVWLJDWHZKHWKHU
VOHHSLVDSODXVLEOHPHFKDQLVPXQGHUO\LQJWKHVHGHFLWV
AD patients and 60 matched healthy controls participated in
a survey assessing QoL, sleep, and cognition. Thereafter, we
administered the Brief Test of Adult Cognition by Telephone
to 40 AD patients and healthy controls. The instrument
provides objective assessment of memory, attention, and
various domains of executive functioning. Finally we
conducted a sleep study using Polysomnography and
neuropsychological assessments to assess whether altered
circadian rhythms impact sleep architecture, and subsequent
memory functioning. A latent variable model on the survey
data revealed that in AD patients, poor QoL and cognition
are driven by poor sleep quality. Analyses of the telephonic
FRJQLWLYHDVVHVVPHQWFRQUPHGWKDW$'SDWLHQWVSHUIRUPHG
VLJQLFDQWO\PRUHSRRUO\WKDQFRQWUROVRQO\RQWKHHSLVRGLF
PHPRU\VXEWHVWWKHUHE\FRQUPLQJSUHYLRXVO\VHOIUHSRUWHG
FRJQLWLYH GHFLWV 5HVXOWV RI WKH VOHHS VWXG\ DUH \HW WR EH
analysed. If QoL and cognition are to be improved in AD
patients, patient sleep disturbances need to be targeted by
treatment, since disrupted sleep may be a neurobiological
PHFKDQLVPXQGHUO\LQJWKHVHGHFLWV
14. DISRUPTED REM SLEEP PREDICTS POOR

DECLARATIVE MEMORY PERFORMANCE IN
POSTTRAUMATIC STRESS DISORDER
Malgorzata Lipinska, Ridwana Timol, Debra Kaminer,
and Kevin G. F. Thomas
Town, South Africa
Successful memory consolidation during sleep depends
on healthy slow-wave and rapid eye movement (REM)
sleep, and on successful transition across sleep stages. In
posttraumatic stress disorder (PTSD), sleep is disrupted
and memory is impaired, but relations between these two
variables in the psychiatric condition remain unexplored. We
examined whether disrupted sleep, and consequent disrupted
memory consolidation, is a mechanism underlying declarative
PHPRU\GHFLWVLQ376':HUHFUXLWHGWKUHHPDWFKHGJURXSV
of participants: PTSD (n 7UDXPDH[SRVHGQRQ376'
(n DQG +HDOWK\ &RQWURO n 7KH\ FRPSOHWHG
memory tasks before and after 8 hours of sleep. We measured
sleep variables using sleep-adapted electroencephalography
(EEG).
376'GLDJQRVHG SDUWLFLSDQWV H[SHULHQFHG VLJQLFDQWO\ OHVV
VOHHSHIFLHQF\DQG5(0VOHHSSHUFHQWDJHDQGH[SHULHQFHG
more awakenings and wake percentage in the second
half of the night, than did participants in the other two
groups. After sleep, PTSD-diagnosed participants retained
VLJQLFDQWO\OHVVLQIRUPDWLRQRQDGHFODUDWLYHPHPRU\WDVN
than controls. REM percentage, wake percentage, and sleep
HIFLHQF\ FRUUHODWHG ZLWK UHWHQWLRQ RI LQIRUPDWLRQ RYHU
the night. Furthermore, lower REM percentage predicted
poorer retention in PTSD-diagnosed individuals. Our results
suggest that declarative memory consolidation is disrupted
during sleep in PTSD. These data are consistent with theories
VXJJHVWLQJ WKDW VOHHS EHQHWV PHPRU\ FRQVROLGDWLRQ YLD
predictable neurobiological mechanisms, and that REM
disruption is more than a symptom of PTSD.
65
Congress ABSTRACTS
15. THE EFFECT OF LIFESTYLE INTERVENTIONS ON
OBSTRUCTIVE SLEEP APNOEA AND THE METABOLIC
SYNDROME: A SYSTEMATIC REVIEW
16. OLDER AGE AS A MEDIATING FACTOR IN THE

ROLE THAT SLEEP SPINDLES PLAY IN DECLARATIVE
MEMORY CONSOLIDATION
Alex S.W. Lowe, Irshaad O. Ebrahim, Adrian J. Williams
Siobhan McCreesh
The London Sleep Centre, London, England

Town, South Africa
Obstructive sleep apnoea (OSA) and the metabolic syndrome

are frequently found together and obesity may be fundamental
WR GHYHORSPHQW RI ERWK FRQGLWLRQV 0RGLFDWLRQV WR
lifestyle, such as diet and exercise, can reduce weight and
VKRXOG WKHUHIRUH EH EHQHFLDO WR WKHLU PDQDJHPHQW 7KH
aim of our article was to review the recent literature that
has investigated the impact of lifestyle interventions on
OSA severity and components of the metabolic syndrome
in order to help identify which patients could gain the most
EHQHW:H SHUIRUPHG D V\VWHPDWLF UHYLHZ RI WKH OLWHUDWXUH
for relevant human studies using PubMed, Medline, and
EMBASE from 8th February 2004 to 7th February 2014. Our
VHDUFKLGHQWLHGVWXGLHV7KHUHZDVDZLGHUDQJHLQVWXG\
designs, often with limited information on the prevalence
of the metabolic syndrome. The majority of interventions
focused on OSA severity and weight loss with fewer studies
that assessed other components of the metabolic syndrome.
OSA severity and weight were most consistently improved
and patients with more severe OSA improved their AHI to a
greater extent. Assessment of glucose intolerance and blood
pressure were improved in some studies but we found mixed
UHVXOWVIRUWKHOLSLGSUROHDQGLWZDVXQFOHDUZKLFKJURXSV
RI SDWLHQWV EHQHWHG PRVW /LIHVW\OH LQWHUYHQWLRQV PD\ EH
useful in reducing the severity of both OSA and particular
components of the metabolic syndrome and should therefore
complement other treatments. Further larger trials with more
homogenous patient populations and longer follow-up are
required to further assess the effects of lifestyle interventions.
66
Previous research shows that sleep spindles play an essential

role in the consolidation of declarative and non-declarative
memory. Sleep spindles, characteristic of NREM sleep,
are purported to drive memory consolidation through
a synchronization of hippocampal ripple activity in the
hippocampal-to-neocortical dialogue. However, this process
is not well understood in the ageing population. During the
DJHLQJ SURFHVV VOHHS DUFKLWHFWXUH XQGHUJRHV VLJQLFDQW
changes, while there is a simultaneous decline in declarative
PHPRU\6SHFLFDOO\VOHHSVSLQGOHVVKRZDW\SLFDOUHGXFWLRQ
in amplitude, duration and density. The aim of this research
is to investigate sleep spindle characteristics and declarative
memory performance in older adults. The primary objective
of this study is to establish the relationship between changes
in sleep spindle characteristics after exposure to a declarative
memory task. Participants encoded 90 word-pairs, which
UDQJHIURPHDV\WRGLIFXOWHQFRGLQJ8VLQJDZLWKLQGHVLJQ
study, with 20 older female adults (55-65) and 20 younger
female adults (1830), data is obtained for a baseline and
experimental night of polysomnographic recording.
Congress ABSTRACTS
17. RARE PULMONARY MALIGNANCIES IN
CHILDREN: A CASE SERIES
18. CASE REPORT: PRIMARY EPITHELIOID

ANGIOSARCOMA OF THE PERICARDIUM
Krubin Naidoo
L Nqwata1, NI Vorajee2, ML Wong1
Charlotte Maxeke Johannesburg Academic Hospital and

University of the Witwatersrand
Malignant primary lung neoplasms in children are extremely

rare and therefore present unique challenges in their
management. Using two cases of pulmonary and pleuropulmonary blastoma, we illustrate the importance of a
multidisciplinary management strategy involving both local
and international expertise, in addressing these patients.
Division of Pulmonology, Chris Hani Baragwanath

Academic Hospital and the University of the Witwatersrand
2
Pathology Division, National Institute for Occupational
Health, National Health Laboratory Service
Angiosarcoma, although rare, is the most common primary
malignant tumour of the heart. It is characteristically highly
aggressive with early metastasis and poor prognosis. We
report a case of epithelioid angiosarcoma arising from
the pericardium in a 51 year old female. She presented
with cough, dyspnoea and a painful swelling of her left
upper limb. The remainder of the clinical examination was
unremarkable. Chest X-ray, computed tomography (CT) of
chest and echocardiogram revealed a cystic mass measuring
9.4 x 8.7 x 9.6 cm extending from above the aortic arch to
the left diaphragm and was inseparable from the pericardium.
Small bilateral pulmonary nodules were also visible on CT
scan. The patient underwent an exploratory left thoracotomy.
Due to the vascular nature of the tumour and invasion of
surrounding structures, only partial resection of the tumour
was possible. Histology showed a malignant neoplasm
comprising large spindle and epithelioid cells with abundant
clear to eosinophilic cytoplasm. Immunohistochemical
staining was positive for CD31, FLI-1 and EMA, consistent
with poorly differentiated epithelioid angiosarcoma. Two
months later, radiological investigations revealed large
pulmonary metastases and a lytic lesion of the left humerus
with an associated cortical fracture. She had also developed a
hard mass in the left labium majus. She died 6 weeks later of
progressive disease.
67
Congress ABSTRACTS
19. BLUE LIGHT AND SLEEP: AN EXAMINATION OF
THE INTERACTIONS
20. SLEEP DISRUPTION IS ASSOCIATED WITH PAIN AND

INCREASED CD4 COUNTS IN HIV POSITIVE PATIENTS
Matthew Pearce
Kirsten Redman

Town, South Africa
University of the Witwatersrand, School of Physiology
/LJKWLVDSRZHUIXO]HLWJHEHUEXWRIWHQWKHGHJUHHRIVSHFLFLW\
in its effects is underestimated. This research focuses on
whether removal of blue light from the polychromatic
spectrum reduces awakening effects in participants exposed
shortly before sleeping. Blue light is the portion of the light
spectrum that has the greatest awakening effect (Munch, et
al., 2005). Previous research has shown that blue-infused light
suppresses melatonin, and increases alertness in participants
during their waking hours (Pandi-Perumal, et al., 2006), but
other research has shown that some anticipated effects of blue
light do not occur. This shows the need for an elaboration
as to which exact mechanisms associated with general lightH[SRVXUHDURXVDO DUH VSHFLFDOO\ H[DJJHUDWHG ZLWK EOXH
OLJKW6SHFLFDOO\WKLVVWXG\ZLOOEHXVLQJERWKSK\VLRORJLFDO
measures through polysomnogram and melatonin analysis,
as well as qualitative measures of sleep and sleep inertia on
participants recruited from UCT undergraduates.
Introduction:
5.6 million people in South Africa are HIV positive and 1.5
million are currently treated with Highly Active Antiretroviral
Therapy (HAART). In the US, several studies have described
sleep disruption in treated HIV positive patients. This study
aims to assess whether or not sleep disturbances exist in a
South African cohort of HIV positive individuals, and to
investigate potential correlates to these sleep disturbances.
Methods:
VWXG\ SDUWLFLSDQWV DYHUDJH DJH 6' IHPDOHV
ZHUH UHFUXLWHG IURP WKH DGXOW +,9 FOLQLF DW
the Chris Hani Baragwanath Academic Hospital in Soweto,
Johannesburg.
We used validated questionnaires to measure sleep quality
(PSQI), daytime sleepiness (ESS), depression (BDI)
and the presence of pain (from the Wisconsin Brief Pain
Questionnaire). We also collected CD4 counts, viral load and
treatment information.
Results:
We found that there was indeed poor sleep present in the
cohort (PSQI>5 in 70% of study participants), and that this
poor sleep was correlated with an increased overall depression
score (BDI>17) (p<0.0001), the current presence of pain
(p<0.003), as well as an increased CD4 count (p<0.0001). In
multivariate analysis, we found an interaction between CD4
count and the presence of pain whereby the effect of increased
CD4 counts on sleep disruption was more pronounced in
WKRVHZLWKRXWSDLQS
Conclusion
There was a high prevalence of sleep disruption in this treated
HIV population, which matches that found in other treated
HIV cohorts in the USA. As expected, the presence of pain
was a predictor of increased sleep disruption. However, more
surprisingly, higher CD4 counts also predicted increased
sleep disruption. A follow up study aims to tease apart the
temporal relationship between immune reconstitution, sleep
quality and pain in treated HIV positive patients.
68
Congress ABSTRACTS
21. SLEEP IN TREATED HIV POSITIVE PATIENTS
22. HIGH RISK SLEEP APNEA ON THE BERLIN
Kirsten Redman
QUESTIONNAIRE IS ASSOCIATED WITH HYPERTENSION

IN SOUTH AFRICANS OF BLACK ANCESTRY
University of the Witwatersrand, School of Physiology
K. Scheuermaier1, R. Naran1,2, A. Woodiwiss2, G. Norton2
Introduction:
South Africa has 5.6 million HIV positive people, the highest
in the world and as a result, we have the largest antiretroviral
campaign in the world - Highly Active Antiretroviral Therapy
(HAART). On treatment, we have found that CD4 counts go up,
and viral loads are kept at undetectable levels. But at what cost
to the person?
The side effects of long-term usage of the HAART include
weight gain, dyslipidemia, lipodystrophy, diabetes and
metabolic syndrome. Other reports have shown that long-term
usage of HAART has been shown to increase development of
HIV peripheral neuropathy, and that there is a general increase
in pain sensitivity in treated HIV positive people.
Another factor that has come up over recent years is sleep
disruption, which is now shown to be present across most HIV
cohorts in the United States and in parts of Europe and India.
Each aforementioned problem could exacerbate sleep problems,
but conversely, poor sleep has been shown to increase metabolic
disturbances, enhance pain sensitivity and increases the incidence
of depression.
This study aims to assess whether or not sleep disturbances exist
in a South African cohort of treated HIV positive individuals,
and to examine correlation with a range of variables
Methods:
152 study participants were recruited from the adult HIV clinic
at the Chris Hani Baragwanath Academic Hospital in Soweto,
Johannesburg.
The study used questionnaires to measure sleep quality using
the Pittsburgh Sleep Quality Index, daytime sleepiness using
the Epworth Sleepiness Scale, the Horne-Ostberg MorningnessEveningness Questionnaire, depression as per Becks Depression
,QYHQWRU\ DQG WKH SUHVHQFH RI SDLQ XVLQJ D PRGLHG YHUVLRQ
of the Wisconsin Brief Pain Questionnaire. We also asked for
information about their disease status (CD4 counts) and comorbidities that may be present at the time of the questionnaire.
Results:
We found that there was indeed poor sleep present in the cohort,
(PSQI>5 in 70%; p<0,0001), and that this poor sleep was
correlated with an increased overall depression score (BDI>17),
the current presence of pain (p<0,003), as well as an increased
CD4 count (p<0,0001). There was an interaction between poor
sleep, CD4 count and the presence of pain whereby the effect
of pain on sleep disruption was lower with higher CD4 counts
S
We also found that subjects who reconstituted their immune
systems quicker, and those who reconstituted from very low
CD4 levels, were also more likely to have poor sleep quality.
Conclusion
There was a high prevalence of sleep disruption in this treated
HIV population, which matches that found in other treated
HIV cohorts in the USA. As expected, the presence of pain
was a predictor of increased sleep disruption. However, more
surprisingly, higher CD4 counts also predicted increased sleep
disruption. A follow up study is currently underway looking
at the development of sleep disturbances, pain, and immune
reconstitution in patients who have not started ARVs up until
two years on treatment. This aims to tease apart the temporal
relationship between immune reconstitution, sleep and pain in
treated HIV positive patients.
Brain Function Research Group - School of Physiology,

Cardiovascular Pathophysiology and Genomics Research
Unit - School of Physiology, University of the Witwatersrand,
Johannesburg, South Africa
Studies have shown an association between sleep apnoea

DQG K\SHUWHQVLRQ 7UHDWLQJ VOHHS DSQRHD EHQHWV UHVLVWDQW
hypertensives. Forty percent of people of Black Ancestry in
South Africa are hypertensive however there is currently no
DFFHVVWRVOHHSDSQRHDGHWHFWLRQWUHDWPHQWLQWKHKHDOWKFDUH
public sector. This cross-sectional study investigated the
association between sleep apnoea and hypertension in a
population of South Africans of Black Ancestry.
SDUWLFLSDQWVIHPDOHDYHUDJHDJH6' RI
South African Black Ancestry were recruited from random
households in Soweto, South Africa. We collected blood
pressure, waist circumference, body mass index (BMI) and
Berlin Questionnaire scores. We compared hypertensives
(controlled treated, resistant treated and untreated
K\SHUWHQVLYHV DQG QRQ K\SHUWHQVLYHV Q :H DOVR
examined the unadjusted and adjusted odds of high risk sleep
apnea in those two groups.
103 study participants were hypertensive. Their age
DYHUDJH6' YV%0,DYHUDJH6' YV
266 kg.m-2 DQG ZDLVW FLUFXPIHUHQFH DYHUDJH6'
YV FP ZHUH VLJQLFDQWO\ KLJKHU FRPSDUHG WR WKH
non hypertensives (all p< 0.0001). Fifty-six percent of
K\SHUWHQVLYHVYVRIWKHQRQK\SHUWHQVLYHVZHUHFODVVLHG
as high risk sleep apnea (p< 0.0001). When adjusting for
BMI, age and waist circumference, hypertensives had higher
RGGVWREHFODVVLHGLQWKHKLJKULVNVOHHSDSQHDJURXS:DOG
25 >&,@ >@
In this South African population of Black ancestry,
hypertension was positively associated with scoring high
risk sleep apnoea on the Berlin Questionnaire. These results
VXJJHVWWKDWRIIHULQJVOHHSDSQRHDGHWHFWLRQWUHDWPHQWLQWKH
KHDOWKFDUH SXEOLF VHFWRU PD\ EH XVHIXO LQ WKH SUHYHQWLRQ
treatment of hypertension in South Africa.
69
Congress ABSTRACTS
23. CHRONICALLY-ELEVATED NIGHT-TIME CORTISOL
AND SLEEP-DEPENDENT MEMORY CONSOLIDATION IN
24. THE RELATIONSHIP BETWEEN PTSD,

HYPERVIGILANCE AND DISORDERED SLEEP
ADULT ASTHMATICS
Mariza van Wyk

Ridwana Timol
Town, South Africa
Objectives: Episodic memory consolidation is thought to
EH PRVW HIFLHQW GXULQJ WKH UVW KDOI RI VOHHS SURSRUWLRQDO
to the richness of slow wave sleep (SWS) contained during
that period. Furthermore, awakening studies reveal that early
dreams contain more autobiographical elements than later
dreams, indirectly supporting the role of early sleep in the
processing of episodic memories. The nadir of the hormone
FRUWLVROGXULQJHDUO\VOHHSLVRQHRIWKHPHFKDQLVPVLGHQWLHG
in the literature as supporting both a healthy sleep architecture
and memory consolidation processes during sleep. The aim
of this study was to investigate the impact of chronicallyelevated cortisol on sleep architecture and subsequently
sleep-dependent mentation, in a population known to suffer
from abnormal cortisol patterns such as asthmatics.
Methods: 3DUWLFLSDQWV1 DJHGEHWZHHQWR0
6' \HDUVZHUHUHFUXLWHGWRRQHRIYHJURXSV
L0LOG$VWKPDQ LL0RGHUDWHWR6HYHUH$VWKPDQ
LLL8QWUHDWHG$VWKPDQ LY(F]HPD&RQWUROQ
DQGY+HDOWK\&RQWUROQ 6OHHSZDVUHFRUGHG
polysomnographically. Memory performance (declarative,
procedural, and working memory) was assessed before and
after sleep. Salivary cortisol and dream reports were collected
GXULQJWKHUVW5(0SHULRGVDQGDIWHUVSRQWDQHRXVPRUQLQJ
DZDNHQLQJ$GUHDPZDVGHQHGDVDQ\H[SHULHQFHWKDWFRXOG
be remembered and described. Dream reports were digitally
recorded and a Likert-scale questionnaire was used to rate
a number of subjective qualitative elements for each dream.
Results: Cortisol: $VWKPDWLFV VKRZHG VLJQLFDQWO\ KLJKHU
cortisol levels than the healthy control group during the night.
Sleep organization: Relative to healthy controls, asthmatics
GLVSOD\HGVLJQLFDQWVXSSUHVVLRQRI5(0VOHHSDQGDOWHUHG
distribution of SWS. Furthermore, untreated asthmatics
experienced greater proportions of stage 1 and stage 2 sleep.
Memory: There were no notable differences in memory
performance between asthmatics and healthy controls.
Dreaming:$VWKPDWLFSDUWLFLSDQWVH[SHULHQFHGDVLJQLFDQWO\
greater number of white or content-poor dreams. Analyses
UHYHDOHGVLJQLFDQWLQYHUVHUHODWLRQVKLSVEHWZHHQLFRUWLVRO
level and episodic memory performance after sleep, (ii)
cortisol level and the presence of episodic content in dreams.
Complex relationships were observed between REM sleep
and the memory content of dreams, while none were observed
between SWS and measures of dream content. Performance
on episodic memory tasks were positively correlated with
episodic memory content of dreams.

Town, South Africa
Disordered sleep in PTSD constitutes a major component
of the presenting symptomatology. However, the literature
on PTSD and sleep is characterized by discrepancies across
studies, especially regarding the selective use of objective
or subjective measures. As a result, disordered sleep and its
underlying mechanism have been ambiguously characterized
in PTSD. Our research focused on the link between PTSD
and disordered sleep, using both objective and subjective
PHDVXUHV RI VOHHS TXDOLW\ 6SHFLFDOO\ ZH LQYHVWLJDWHG
hypervigilance (one of the three symptom clusters in the
PTSD diagnosis) as an underlying mechanism of this link.
We also investigated whether hypervigilance affects dream
content in individuals with PTSD. We recruited 4 groups
of participants: 9 individuals with PTSD with prominent
hypervigilance symptoms (HYP+); 10 individuals with
PTSD without prominent hypervigilance symptoms (HYP); 14 individuals with depression (DEP), and 16 healthy
controls (CON). (The DEP group controlled for the frequent
comorbidity of depression in PTSD). Participants spent 1
night in our sleep laboratory undergoing polysomnographic
recordings. We measured sleep latency, awakenings, time
VSHQWDZDNHDIWHUVOHHSRQVHWVOHHSHIFLHQF\5(05(0
latency and SWS%. We also obtained self-reports of general
quality of sleep and two reports of most recent dreams.
Results were analyzed using one-way ANOVA for all
measures of sleep quality, as well as for the dream content
scores. Data from objective measures of sleep quality did
QRW VWDWLVWLFDOO\ FRQUP RXU K\SRWKHVLV ZKHUHDV GDWD IURP
VXEMHFWLYH PHDVXUHV RI VOHHS TXDOLW\ \LHOGHG VLJQLFDQW
results. Data from the dream content scores approached
VLJQLFDQFH
Conclusion: Chronically-elevated cortisol during sleep is

associated with changes in sleep organization and the memory
content of dreams. Abnormal cortisol patterns in asthma may
interfere with the cognitive and restorative functions of sleep,
with implications yet to be explored.
70
Congress ABSTRACTS
25. THE EFFECT OF PLEURAL DRAINAGE ON
26. LUNG FUNCTION MEASURES IN UNSEDATED 1

YEAR SOUTH AFRICAN INFANTS
PULMONARY FUNCTION TESTING IN PATIENTS WITH
TUBERCULOUS PLEURAL EFFUSIONS: A PILOT STUDY
Elisma Wilken1,Hannah Fengels1, Elvis M Irusen1, Enas

Batubara1, Johannes W Bruwer1, Francois Swart1, David
Maree1,Coenraad FN Koegelenberg1
1

Stellenbosch University & Tygerberg Academic Hospital,
Cape Town, South-Africa
Background:
Tuberculosis remains a common cause of pleural exudates
LQ PDQ\ SDUWV RI WKH JOREH 3OHXUDO EURVLV ZLWK UHVWULFWLRQ
is a well-known complication of tuberculous pleuritis, and
may be seen in up to 50% of cases. Current evidence suggests
WKDWSOHXUDOGUDLQDJHRIIHUVOLWWOHEHQHWRYHUDQGDERYHDQWL
tuberculous treatment in improving pulmonary function
testing.
Methods:
We enrolled 20 patients with proven tuberculous pleural
effusions (average age 32.7 years, 10 male, 12 HIV positive),
and performed therapeutic pleural drainage in 10 randomly
selected cases. Pulmonary function testing, chest radiography
and transthoracic ultrasound were performed on all patients
prior to treatment, at 7-10 days and at 3 months.
Results:
Complete therapeutic drainage was achieved in only 4 of the
SDWHQWV UDQGRPLVHG WR XQGHUJR GUDLQDJH 1R VLJQLFDQW
LPPHGLDWHEHQHWZDVDFKLHYHGLQWKHSDWLHQWVDVVLJQHG
to intervention. However, the intervention group was showed
VLJQLFDQW FKDQJHV FRPSDUHG WR WKH QRQLQWHUYHQWLRQ LQ
several functional parameters at three months: change in
IRUFHGYLWDOFDSDFLW\)9&/YV/SFKDQJH
LQ IRUFHG H[SLUDWRU\ YROXPH LQ VHFRQG )(91 1,08L vs.
/S FKDQJHLQWRWDOOXQJFDSDFLW\7/&/
YV / S DQG FKDQJH LQ WKH GLIIXVLRQ FDSDFLW\
IRU FDUERQ GLR[LGH '/CO YV S 7KH
LQWHUYHQWLRQ JURXS GLG QRW VLJQLFDQWO\ LPSURYH PLQXWH
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months compared to control group.
Conclusion:
Therapeutic drainage may offer additional medium term
IXQFWLRQDOEHQHWVWRSDWLHQWVZLWKSOHXUDOWXEHUFXORVLV/DUJHU
VFDOHSURVSHFWLYHVWXGLHVDUHQHHGHGWRGHQHWKHUROHRIWKLV
intervention in reducing long-term restrictive ventilatory
impairment and the need for surgical decortication.
Keywords:
3OHXUDO LQDPPDWLRQ IXQFWLRQDO LPSURYHPHQW SOHXUDO
thickening, effusion management
Lauren Willemse1, Diane Gray1, Ane Visagie1, GL Hall2,

HJ Zar1
1

Cape Town, South Africa 2Telethon Institute for Child Health
Research, University of Western Australia, Subiaco, Perth,
Australia
Introduction:
Low lung function in early life is a risk factor for acute and
chronic respiratory disease in later life. Measuring infant lung
IXQFWLRQ,/)KDVEHHQOLPLWHGE\WKHGLIFXOW\LQREWDLQLQJ
quality measures in unsedated infants. Moreover, chloral
hydrate, currently standard of care for sedated testing, is less
available due to discontinuation of drug manufacture.
Aim:
To assess the feasibility of unsedated ILF measures in healthy
1 year South African infants
Methodology:
Infants enrolled in the Drakenstein Child Lung Health Study
were tested at 1 year (1113 months), during natural quiet
sleep. Lung function measures included: tidal breathing
(TBFVL), exhaled nitric oxide (eNO) and multiple breath
washout (MBW).
Results:
Of the 219 infants tested, acceptable unsedated tests were
REWDLQHGLQRI7%)9/H12
DQG0%:WHVWV5HDVRQVIRUIDLOHGWHVWZHUH
LQVXIFLHQW TXLHW VOHHS WHFKQLFDO HUURUV DQG
failure to meet acceptable quality criteria (2%). Mean (SD)
testing time was 36 (17) min and total visit time 176 (73) min.
Table 1: Lung function outcomes in unsedated 1 year infants
Median (IQR)
CV Med (IQR)
Tidal Volume mL
93.2 (87 -101.5)
7.9 (6.2-9.7)
Respiratory Rate
n.min -1
27.6 (25 -30.4)
6.4 (5.5-8)
tPTEF/tE %
28.3 (22-35.7)
24.7 (20.8-28.8)
eNO (ppb)
8.5 (2.8-14.4)
9.3 (5-15.7)
NO output mcL.s
12.4 (10.2-15.2)
4.8 (1.7-8)
Functional residual
volume mL
0.2 (0.17-0.22)
4.6 (3.4-6.4)
Lung clearance index
6.7 (6.3-7)
4 (2.5-6)
&9 LQWUDVXEMHFW FRHIFLHQW RI YDULDWLRQ WPTEFWE:Time to peak tidal

expiratory fow over total expiratory time
Conclusion:
ILF testing can be successfully undertaken in unsedated
infants at 1 year. Success relies on skilled staff, dedicated
WHVWLQJVSDFHDGHTXDWHIXQGLQJIRUHTXLSPHQWDQGVXIFLHQW
time.
71
Congress ABSTRACTS
27. USEFULNESS OF 18F-FDG PET/CT SCANS IN
SARCOIDOSIS: PRELIMINARY FINDINGS
ML Wong1, L Louw2, MDTW Vangu2
1
Division of Pulmonology, Chris Hani Baragwanath Academic

Hospital and the University of the Witwatersrand 2Division of
Nuclear Medicine and Molecular Imaging, Charlotte Maxeke
Johannesburg Academic Hospital, Department of Radiation
Sciences, University of the Witwatersrand
Background
Integrated 18))'* 3(7&7 VFDQV DUH D XVHIXO IXQFWLRQDO
imaging modality used mainly for staging and follow-up
of patients with malignancies. Its role in the cost-effective
evaluation and management of patients with sarcoidosis is
still to be determined. This is a preliminary report of our
experience of patients enrolled from Chris Hani Baragwanath
Academic Hospital (CHBAH).
Methods
Selected patients attending the Respiratory Clinic at CHBAH
were subjected to 18))'*3(7&7VFDQVLIVDUFRLGRVLV
(a) was suspected but the diagnosis remained uncertain
despite conventional investigations or because the clinical
presentation was unusual, or
EGLVHDVHDFWLYLW\XWLOL]LQJFRQYHQWLRQDOWHVWVZDVGLIFXOW
WRGHWHUPLQHLQSUHYLRXVO\FRQUPHGFDVHV
Results
Nine patients were enrolled over a 14 month period (February
2013 to March 2014): 7 females and 2 males. The age range
was 30 -58 years. Eight patients were Black and one was
Asian.
Five patients were suspected to have sarcoidosis. 18F-FDG
3(7&7VFDQVZHUHXVHIXOLQVXSSRUWLQJWKHGLDJQRVLVLQ
but remained uncertain in 2.
Four patients previously diagnosed with sarcoidosis (followup 2.8 14.0 years), of whom 3 had been histologically
FRQUPHG XQGHUZHQW 18))'* 3(7&7 VFDQV WR HYDOXDWH
disease activity. All demonstrated evidence of active disease.
The extent of disease was greater than had been suspected.
Based on results of the scan, treatment for sarcoidosis was reinitiated in 1 patient and escalated in the remaining 3.
Conclusion
In this limited study, 18))'* 3(7&7 VFDQV DSSHDU WR EH
helpful in clinical decision-making, both in supporting or
excluding a diagnosis of sarcoidosis, and in assessing disease
activity in established cases. A larger study is needed to
VXSSRUWRXUSUHOLPLQDU\QGLQJV
72
Whos Who in SATS

Agneta Geldenhuys
$JQHWD*HOGHQKX\VLVD&DUGLRWKRUDFLF6XUJHRQZKRTXDOLHGLQDWWKH8QLYHUVLW\RI
Cape Town, Groote Schuur Hospital.
She currently practices both cardiac and thoracic surgery as a full time consultant at
Universitas Hospital, Bloemfontein and leads the clinical section of thoracic surgery. She
LV UHVSRQVLEOH IRU SRVW JUDGXDWH WUDLQLQJ LQ WKLV HOG ZKHUH VKH LV DSSRLQWHG DV DIOLDWHG
lecturer of the University of the Free State.
+HUVSHFLFLQWHUHVWVLQFOXGHDQWLIDLOXUHVXUJHU\LQERWKFDUGLDFDQGSXOPRQDU\HOGVDV
well as demographic studies in valve repair surgery.
Dr Christiaan Johannes Jordaan

MBChB, MMed, Cert Critical care
Head of Thoracic surgery and senior lecturer, Cardiothoracic surgery and Critical care.
School of Medicine, University of the Free State, Bloemfontein, SA.
Johan Jordaan is the head of Thoracic surgery at the department of Cardiothoracic surgery
at the School of Medicine, University of the Free State, Bloemfontein. He is also a senior
lecturer at the department of Critical care and the Central University of Technology.
Johan earned his MBChB from the University of the Free State in 1997, and subsequently his
MMed in Cardiothoracic surgery in 2005. He then went on to do a fellowship in Critical Care
in 2009 and is enrolled for a PhD in cardiothoracic surgery. He has been trained in ECMO
VXSSRUWDWWKH*OHQHOGKRVSLWDO/HLFHVWHU8QLWHG.LQJGRP
He is a member of the South African Thoracic society, South African Heart Association and
the Critical Care Society of South Africa.
+LVUHVHDUFKHOGVLQFOXGH
HIV and the impact the disease has on thoracic surgical outcomes, the development of novel
heart valves and the in vivo and in vitro testing of heart valves. He has given several lectures at national and international
VFLHQWLFPHHWLQJV
He is an avid mountaineer and has summited some of the worlds highest mountains and he is an Ultra distance athlete.
Alexia Kappos
University of the Free State: Paediatric Pulmonology.
, KHDG WKH SDHGLDWULF SXOPRQRORJ\ GLYLVLRQ LQ %ORHPIRQWHLQ ZKLFK LV WKH UVW WLPH VXFK D
division has become available to serve the paediatric population of the Free State. My clinical
duties involve daily referrals and consultations from in-patients and also from around the
province and Lesotho. I also have the capacity to admit up to 5 pulmonology patients to the
WHUWLDU\8QLYHUVLWDV+RVSLWDO2QFHDZHHN,KDYHDH[LEOHEURQFKRVFRS\WKHDWUHOLVWDQGDOVR
a Paediatric Pulmonology Out Patient clinic which sees on average 7 patients per week. Once a
month this clinic is converted into a Cystic Fibrosis clinic seeing patients with CF from 1 month
to 16 years of age. Non clinical duties involve medical student training as well as intern and
paediatric registrar training on appropriate paediatric respiratory topics.
73
Asthma limits the full potential of millions

of South Africans
you can
control your
The NAEP is striving to improve the health and well being of people living with
asthma and is here to help you with:
U Dissemination and Interpretation of accredited Asthma Treatment Guidelines
U Free asthma information
U Accredited education programmes for health professionals
Become a professional member today.

Encourage your patients to become members.
Tel: 0861 ASTHMA (278462) U Fax: 086 655 0809 U E-mail: naepr@netactive.co.za
www.asthma.co.za
74
Diary of Congresses and CME events
/D/'
KE&ZE
Zd

Dear Colleagues
In 1964 physicians, scientists, industry representatives and public health officials from around the
world gathered in New York City to consolidate and share their rapidly growing understanding and
knowledge about the links between asbestos and disease. It brought together pioneers and giants
like Wagner, Churg and Selikoff, and was a rare meeting of minds - a confluence of purpose which
has not been equalled in the asbestos research field since - and its importance could not be
overstated.1
October 2014 will mark 50 years since that landmark conference which spotlit the asbestos issue as
a massive public health concern. Dr Selikoff stated in his opening address that

d

Their conference ended on 21 October 1964, and we will be welcoming you to Cape Town and South
Africa for our mesothelioma conference exactly 50 years later on 21 October 2014, where we too
will be looking to have another confluence of minds, bringing together diverse fields and disciplines
in our common quest for cure. It is sobering to note that someone exposed to asbestos in 1964 may
yet be incubating mesothelioma.
Yours Sincerely,
Dr. Jim teWaterNaude and Professor Tony Linegar
*Please visit our website at www.imig2014.org
B. Case in Asbestos and its diseases. Craighead & Gibbs (eds). OUP 2008
75
The COPD Assessment Test

(CAT)
The CAT has been designed to measure the impact of COPD* on a patients health by enabling them to describe their symptoms
more accurately. This will improve communication with their doctor and give a better understanding of the diseases true
impact, allowing treatment to be better targeted and the patients care to be optimised.1,2
&23'OLPLWVDLURZLQWKHOXQJVFDXVLQJEUHDWKLQJGLIFXOWLHVWKDWDIIHFWSDWLHQWVKHDOWKTXDOLW\RIOLIHDQGXOWLPDWHO\VXUYLYDO
Over 210 million people worldwide have the condition3 and it causes around 250 deaths every hour, more than lung and breast
cancer combined.4,5 +RZHYHU SDUWO\ GXH WR GLIFXOWLHV LQ GHVFULELQJ DQG DVVHVVLQJ LWV IXOO LPSDFW LW FDQ EH VXERSWLPDOO\
managed, causing patients to suffer increased symptoms, risk of hospitalisation and disability.6,7
7KHLWHPVWKDWIRUPWKH&$7ZKLFKLVGHVLJQHGIRUSDWLHQWVWRFRPSOHWHWKHPVHOYHVZHUHLGHQWLHGIROORZLQJPDQ\LQWHUYLHZV
ZLWKSDWLHQWVFRXSOHGZLWKULJRURXVVFLHQWLFPHWKRGRORJ\$ZLGHUDQJHRILQWHUQDWLRQDOH[SHUWVLQ&23'SDWLHQWJURXSVDQG
professional societies also played a key role in its development.1,2
The CAT, which was funded by GlaxoSmithKline (GSK), is freely available for use at:
www.CATestonline.org.
References
1. Jones P, et al'HYHORSPHQWDQGUVWYDOLGDWLRQRIWKH&23'$VVHVVPHQW7HVW&$7$EVWUDFW$FFHSWHGIRUSUHVHQWDWLRQDW(56
2. Jones P, et al'HYHORSPHQWDQGUVWYDOLGDWLRQRIWKH&23'$VVHVVPHQW7HVWEur Respir J 2009: 34:648-54.
7KH :RUOG +HDOWK 2UJDQL]DWLRQ 0HGLD &HQWUH &KURQLF REVWUXFWLYH SXOPRQDU\ GLVHDVH &23' /DVW DFFHVVHG $XJXVW KWWSZZZZKRLQW
PHGLDFHQWUHIDFWVKHHWVIVHQ
4. The World Health Organization. The World Health Report 2002. Reducing risks, promoting healthy life. MDI.WHR.202.A.
5. Ferlay J, et al. GLOBOCAN 2002. Cancer Incidence, Mortality and Prevalence Worldwide. IARC CancerBase No.5, Version 2.0. IARCPress, Lyon, 2004.
&RQIURQWLQJ&23'LQ$PHULFD([HFXWLYH6XPPDU\KWWSZZZDDUFRUJUHVRXUFHVFRQIURQWLQJBFRSGH[HVXPSGIODVWDFFHVVHG
7. Wilkinson T et al. Am J Respir Crit Care Med 2004;169;12981303
Launch of Onbrez Breezhaler 150 +g

Novartis South Africa is pleased to announce the launch of Onbrez Breezhaler 150 +g (dry powder inhalation capsules)
effective from 1 March 2013.
Product MCC
Registration
Number
NAPPI Code
Product Description
Schedule
SEP excl VAT
UTI Product
Code
Barcode

717402001
Onbrez Breezhaler
150+g Indacaterol
maleate equivalent to
indacaterol 150+g
S3
R 228.00
102003
6005534002814
For any queries please contact the Novartis Customer Support Line on 0861 929 929.
76
Bayer HealthCare Pharmaceuticals is excited to announce the launch of XARELTO 15 and XARELTO 20, in South Africa. Each
XARELTO 15 tablet contains 15 mg rivaroxaban and XARELTO 20 tablet contains 20 mg rivaroxaban.
XARELTO 15 and XARELTO 20 Indications:
3UHYHQWLRQRIVWURNHDQGV\VWHPLFHPEROLVPLQSDWLHQWVZLWKQRQYDOYXODUDWULDOEULOODWLRQ63$)
7UHDWPHQWRIGHHSYHLQWKURPERVLV'97DQGIRUWKHSUHYHQWLRQRIUHFXUUHQWGHHSYHLQWKURPERVLV'97DQGSXOPRQDU\HPEROLVP
(PE).
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XARELTO 15 and XARELTO 20 Dosage:
3UHYHQWLRQRIVWURNHDQGV\VWHPLFHPEROLVPLQSDWLHQWVZLWKQRQYDOYXODUDWULDOEULOODWLRQ63$)20 mg once a day.
For patients with CrCl of 30 50 ml/min, 15 mg once a day is recommended.
7UHDWPHQWRIGHHSYHLQWKURPERVLV'97DQGSXOPRQDU\HPEROLVP3(DQGIRUWKHSUHYHQWLRQRIUHFXUUHQW'97DQG3(15 mg twice
DGD\IRUWKHUVWGD\VIROORZHGE\PJRQFHDGD\
There is no need for routine coagulation monitoring, frequent dose adjustments or dietary restrictions with XARELTO 15 and XARELTO
20.
Product name
Pack EAN code
NAPPI
UTI
SEP Excl
SEP Incl
sizes
CODE
PHARMA
VAT
VAT
XARELTO 15
42s
6006118001148
719859001
100767
R908.53
R1035.72
XARELTO 20
28s
6006118001186
719860001
100768
R605.68
R690.48
Should you require a local package

insert or more information, please
do not hesitate to contact us.
Anel
Berning,
Thrombosis
Marketing Manager, Tel: 011 921
5021, Cell: 072 606 2006,
Email: anel.berning@bayer.com
Lionel
Dobell,
Thrombosis
Product Manager, Tel: 011 921
5048, Cell: 083 6916988,
Email: lionel.dobell@bayer.com
77
Instructions to Authors
Author Guidelines
7KH6RXWK$IULFDQ5HVSLUDWRU\-RXUQDOLVWKHRIFLDOMRXUQDO
of the South African Thoracic Society. The journal accepts
submissions relating to both clinical and basic research in the
3XOPRQRORJ\ DQG 7KRUDFLF 6XUJHU\ HOGV DV ZHOO DV VWDWH
of-the-art reviews on any topic related to the scope of the
journal. It is important that authors comply with the format
VSHFLHGLQWKHVHJXLGHOLQHVDVIDLOXUHWRGRVRZLOOUHVXOWLQ
delayed publication.
Submission of Papers
The South African Respiratory Journal only accepts online
submission of papers. Papers should be submitted through the
South African Thoracic Society website where there is a link
for the South African Respiratory Journal. Authors may then
submit their papers after registration with Editorial Manager.
The relevant links are provided on the SATS website (www.
pulmonology.co.za).
As part of the submission process it will be necessary
to provide a cover letter which should be used to explain
why your manuscript should be published in the journal, to
elaborate on any issues and to declare any potential competing
interests. You will be also asked to provide the contact details
(including email addresses) of potential peer reviewers
IRU \RXU PDQXVFULSW7KHVH VKRXOG EH H[SHUWV LQ WKHLU HOG
who will be able to provide an objective assessment of the
manuscript. Any suggested peer reviewers should not have
published with any of the authors of the manuscript within the
SDVWYH\HDUVVKRXOGQRWEHFXUUHQWFROODERUDWRUVDQGVKRXOG
not be members of the same research institution. Suggested
reviewers will be considered alongside potential reviewers
UHFRPPHQGHGE\WKH(GLWRULQ&KLHIDQGRU(GLWRULDO%RDUG
members.
Types of manuscripts that will be accepted include:
Original articles should not exceed 3 500 words although this
may be reviewed on a case by case basis. References should
preferably be limited to no more than 40. See document
layout below for further details.
Brief reports: This should have an abstract of a maximum
of 150 words, the total word content of the paper (excluding
abstract and references) should be 1500 words, with a
maximum of 15 references. The abstract should be structured
in sub-headings as outlined above. This should contain a
PD[LPXPRIWDEOHDQGJXUHLHDPD[LPXPRILQVHUWV
RUJXUHVRUWDEOHV
Case reports: A 50 word unstructured abstract is required.
,QWURGXFWLRQ 0HWKRGV5HVXOWV VHFWLRQ IROORZHG E\ D
discussion section. It should not exceed 800 words and
should contain only 1 illustration or table, and a maximum of
5 references. The key learning points should be provided in a
table with bullet points - maximum 100 words.
Research letter: This should contain a 50 word unstructured
78
DEVWUDFWDQGPD\EHGLYLGHGLQWRDQ,QWURGXFWLRQ0HWKRGV
Results and a very brief Discussion section. The research
letter should not exceed 800 words, and a maximum of 7
UHIHUHQFHV2QHLQVHUWWDEOHRUJXUHLVDOORZHG
Editorials may be solicited by the Editor though contributors
are invited to submit editorials, or opinion pieces for
consideration by the Journal. These should normally not
exceed 1500 words.
Reviews: Contributors are encouraged to write to the Editor
about possible papers to be considered for review, and where
appropriate a review outline will be submitted to experts in the
HOGIRUFRQVLGHUDWLRQEHIRUHDIXOOUHYLHZLVFRPPLVVLRQHG
It is expected that an author or authors have substantial
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about. Reviews should be a maximum of 3500 words unless
an alternative word limit has been arranged with the Chief
Editor. Contributors are encouraged to include tables and
JXUHVLQWKHLUUHYLHZVWRNHHSWRWKHPD[LPXPZRUGFRXQW
Contributors are encouraged to submit pulmonary puzzles
which should not exceed a maximum of 800 words.
The Journal welcomes comments and opinions about the
published work, even if they are controversial and differ from
the views of the author or the Journal.
Authorship:
Manuscripts must be submitted by one of the authors of the
manuscript, and should not be submitted by anyone on their
behalf. The submitting author takes responsibility for the
article during submission and peer review. All named authors
PXVWFRQVHQWWRSXEOLFDWLRQDQGFRQUPDWLRQRIWKLVFRQVHQW
should be noted in the cover letter.
Ethical approval:
SARJ publishes work subscribing to the highest ethical
standards. Any work involving human or animal subjects must
be approved by the relevant institutional ethics committee. A
statement to the effect that the work has been approved by the
relevant ethical committee must be provided in the methods
section of the paper. Authors should provide evidence of
Research Ethics Committee approval of the research where
relevant. Authors must accept ethical responsibility for the
work submitted to the journal and must agree to address
ethical queries raised by the reviewers or the editor, should
these arise.
Protection of Patients Rights to Privacy:
Identifying information should not be published in written
descriptions, photographs, and pedigrees unless the
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(or parent or guardian) gives informed written consent for
publication.
Manuscript preparation:
Manuscripts must be provided in UK English.
There is a limit on the length of articles submitted and
authors are encouraged to be concise. There is no restriction

RQWKHQXPEHURIJXUHVRUWDEOHVWKDWFDQEHLQFOXGHGZLWK
each article online, however, authors should keep these to a
minimum as appropriate. It is important to note that the South
African Respiratory Journal will not comprehensively edit
submitted manuscripts for style or language and reviewers
may advise rejection of a manuscript if it is compromised by
grammatical errors.
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authors must be provided in the manuscript and in the online
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thereafter used consistently.
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Litres is denoted with a lowercase l e.g. ml for millilitres).
General formatting
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the main manuscript document:
Microsoft Word
Rich text format (RTF)
Portable document format (PDF)

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at line breaks and do not format the text in multiple
columns).
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to rearrange lines.
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title.
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Illustrations and tables

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compression):
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PDF
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Illustrations and graphs prepared in Microsoft PowerPoint
or Excel are not acceptable.
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republication obtained from the copyright holder for all tables
or illustrations previously published elsewhere.
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must be numbered in Arabic numerals (1,2,3...) and referred
to in the text (e.g. Table 1). Figures must be numbered in
Arabic numerals and referred to in the text e.g. (Fig. 1).
Figure legends should be listed at the end of the article.
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quality: 300 dpi or more is preferable (a minimum of 250
dpi is required and images must not be resized to increase
resolution. Unformatted and uncompressed images must
not be embedded in the manuscript and must be attached as
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Document layout:
Manuscripts submitted should include the following:
Title page
Abstract
Keywords
Introduction
Methods
Results
Discussion and Conclusions
List of abbreviations used
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Authors contributions
Acknowledgements
References
Title page
The title page should provide the title of the article, list the
full names, institutional addresses and email addresses for all
authors and indicate the corresponding author
The title should include the study design and abbreviations
should be avoided.
Abstract:
Please provide a structured abstract. This should not exceed
250 words and should be broken down into the following
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Results, and Conclusion. Please make sure that the conclusions
in the abstract are backed up by the data presented in the
abstract results section. Abbreviations should be avoided
as far as possible and no references should be cited in the
abstract.
Keywords
Please provide three to ten keywords representing the main
content of the article.
Introduction
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or idea being tested, and in general should not exceed a
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Methods
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words depending on the type of article. It should include
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materials involved, a description of interventions and
comparisons and the type of analysis used. Information about
ethical approval and consent should also be detailed here.
Results
This may be broken into subsections with short headings.
Discussion and Conclusions
This should state clearly the main conclusions of the research
and give a clear explanation of their importance and relevance.
79
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