Editorial
73 2011 Volume 16 No 2 JEMDSA
Editorial
This edition of JEMDSA again contains something for everyone. Klisiewicz and Huddle review the management of type 2 diabetes. Although directed at our general practitioner colleagues, the paper addresses most aspects of importance in the practical management of this pandemic disease, eloquently combining own experience and knowledge with international and local SEMDSA guidelines. Ross and Levitt have produced a seminal paper on the aetiology, diagnosis and management of patients with Addison’s disease, based on insights gained from a large local cohort. Of particular concern is the significant atherogenic profile among South African patients and the fact that many patients may be dying from undiagnosed disease. Another pandemic, HIV and its treatment are prone to metabolic complications like lipodystrophy/metabolic syndrome, lactic acidosis, myopathy, neuropathy and nephropathy, which are thought to develop as a result of mitochondrial dysfunction. Van der Watt provides an extensive review of the basic biology of mitochondrial dysfunction in HIV infection. Other papers in this issue address the very unusual case of a parathyroid carcinoma presenting with a brown tumour, as well as a case of ectopic ACTH syndrome secondary to a neuroendocrine carcinoma of the anal canal; this patient also had a poorly defined lung lesion, but the authors provide a strong argument based, in part, on the local lymphatic spread, for a primary anal tumour. The abovementioned papers are indeed fascinating and have undoubtedly contributed to the value of this edition of our journal.
Also included in this issue of JEMDSA is an original research paper by Srinivas and colleagues, which inves- tigates the effects of a service-learning-based health- promotion elective among predominantly school learners, in influencing the knowledge and understanding of diabetes and its prevention. The paper concludes that this elective was indeed successful in raising awareness and increasing knowledge about diabetes. The authors are to be commended on this study. This does, however, address an issue of concern: the current dearth of local, original research papers in endocrinology and metabolism presented for publication in our journal. The conundrum is all too familiar and poses a challenge that every local scientific journal faces: if the science is good, an attempt is made to get it published, not in a local journal, but in a reputable international journal. It is, therefore, incumbent upon the editors and supporters of JEMDSA to develop niche areas where colleagues would want to publish their work; not work that is inferior and has been rejected elsewhere, but good science, that we can feel proud of. One example is the research projects of registrars and young researchers, work that is still in progress and has not been completed: pilot studies and preliminary reports that will be
subjected to fair but rigorous peer review, and will benefit all parties concerned. An open invitation is, therefore, directed at all registrars and young researchers: submit your original research papers for publication in JEMDSA.
Finally, an ethical issue, and one of significant clinical importance. In a letter to the editor, a private practitioner well-versed in osteology and drug trials, Dr Jan de Weerd from Pretoria, questions the ethical acceptability of placebo–controlled trials in osteoporosis and hip fracture.
This is, of course, a contentious topic, deserving of thorough discussion and debate, and not a mere editorial comment.
Suffice to note here that the National Osteoporosis Foundation of South Africa (NOFSA) has, for some time, expressed concern about the matter. In fact, more than a decade ago the subject was extensively discussed by the NOFSA Council and concern was expressed that, given the difficulties involved in assessing the response to therapy and the timely identification of those at risk of fracture, subjects who had already sustained a major osteoporotic fracture (e.g. hip, spine), should not be enrolled in blinded, placebo trials.1 In the Endocrine Unit at Tygerberg Academic Hospital and Stellenbosch University Faculty of Health Sciences, we have, over the course of the past decade, enrolled a significant number of patients in osteoporosis trials. These have, however, always included patients with a diagnosis of osteoporosis based on bone mass (BMD) measurements (so-called T- and Z-scores), and never on the basis of a fragility fracture. I accept that this view is not shared by all.
When contacted at the time, international regulatory bodies like the International Osteoporosis Foundation (IOF) and the American ASBMR had no policy, nor comment to make on the matter. It is, however, rewarding that more and more multinational studies on osteoporosis are doing exactly what Dr De Weerd is suggesting, namely, respecting the principle of clinical equipoise,2 and, unless genuine uncertainty within the expert medical community exists about the preferred treatment, refraining from blinded placebo-controlled trials, instead comparing the efficacy and safety of the new experimental drug with that of existing therapy. I accept that this is a complex issue, especially when trials are conducted in a resource-restricted country such as ours, but I fully support Dr De Weerd’s contention on this issue. I look forward to hearing your views on the subject.
Stephen Hough Editor: JEMDSA
References
1. Hough FS. The placebo arm of drug trials in patients with osteoporosis – is it ethically justifiable? (Editorial). JEMDSA. 2001; 6(2):52.
2. Freedman B. Equipoise and the ethics of clinical research. New Engl J Med.
1987;317(3):141-145.
