SAMJ Vol 105, No 10 (2015) by HMPG

OCTOBER 2015

VOL. 105 NO. 10

South Africa’s fourth epidemic: The ugly face of trauma • Paediatric polytrauma – pedestrian-motor vehicle collisions 823 • Motor vehicle accidents (MVAs) and interpersonal violence (IPV) 827 • Road traffic crashes as the cause of major incidents 831 • Spinal cord injury due to MVAs and IPV 835 • Fatal community assault 848 Inappropriate use of emergency medical services in KZN 844 Emergency centres and TB transmission risks 862 CME: Case reports 874-878

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S2 ALLERWAY 5. Each film-coated tablet contains levocetirizine dihydrochloride 5 mg. Reg. No. 43/5.7.1/0815 Please refer to detailed package insert for full prescribing information. References: 1. Seema Rani, M.C. Gupta, Prem Verma, Dalbir Singh. A Comparative Study of Clinical Efficacy And Tolerability Of Second Generation (Cetirizine) and Third Generation (Levocetirizine) Antihistaminics in Seasonal Allergic Rhinitis. Available at: http://www.scopemed.org/?mno=30140. (Accessed 23/03/2015 2. Garg G, Thami GP. Comparative efficacy of cetirizine and levocetirizine in chronic idiopathic urticaria. The journal of dermatological treatment 2007; 18(1):23-4. 3. Kapp A, Demarteau N. Cost Effectiveness of Levocetirizine in Chronic Idiopathic Urticaria. Clin Drug Invest. 2006;26 (1):1-11. Accessed via Medscape 01/06/2014. Available at: http://www.medscape.com/viewarticle/521307 4. Passalacqua G ,Canonica GW. A review of the evidence from comparative studies of levocetirizine and desloratadine for the symptoms of allergic rhinitis. Erratum in.Clin Ther.2005 Oct:27(10):1669 ZA/05/2015/Allerway/001

OCTOBER 2015

VOL. 105 NO. 10

FROM THE EDITOR

SAMJ

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Data → information → knowledge → wisdom: When is South Africa going to get her act together? J Seggie

EDITOR-IN-CHIEF Janet Seggie, BSc (Hons), MD (Birm), FRCP (Lond)

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EDITOR’S CHOICE

DEPUTY EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB

CORRESPONDENCE 798

Zolpidem and restoration of consciousness – fact or fiction? A Venter

IZINDABA 799 801 802

Rendering a dangerous healthcare ocean safer Euthanasia in SA – sacrificing one to render many vulnerable? Man impaled on crowbar saved by hospital trauma team

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CLINICAL ALERT Non-typhoidal Salmonella infections in HIV-positive adults E L Subramoney

SAMJ FORUM

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HEALTHCARE DELIVERY Indications for the use of bronchial thermoplasty in severe asthma K Dheda, C F N Koegelenberg, A Esmail, E Irusen, M E Wechsler, R M Niven, K F Chung, E D Bateman RECOMMENDATIONS Recommendations for the use of endoscopic lung volume reduction in South Africa: Role in the treatment of emphysema* C F N Koegelenberg, J Theron, K Dheda, J W Bruwer, B W Allwood, M J Vorster, F von Groote-Bidlingmaier, D-J Slebos, P L Shah, F J F Herth

EDITORIAL 816

Geography should be taught at medical school S de Vries, H Geduld

RESEARCH 817

Impact of transthoracic echocardiography at district hospital level W F Bedeker, A S Lachman, M Borkum, D Hellenberg, C S Cupido

823

The wrong and wounding road: Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period N Naidoo, D J J Muckart

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Interpersonal violence as a major contributor towards the skewed burden of trauma in KwaZulu-Natal, South Africa* C Lewis, D Wood

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The epidemiology of major incidents in the Western Cape Province, South Africa* D J van Hoving, H J Lategan, L A Wallis, W P Smith

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Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury (GSH ASCI) Unit, Cape Town, South Africa, over the past 11 years* J Sothmann, J Stander, N Kruger, R Dunn

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Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa: More ambulances won’t help C Stein, L Wallis, O Adetunji

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The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa P R Newton, R Naidoo, P Brysiewicz

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October 2015, Vol. 105, No. 10

EDITORS EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon) JP de V van Niekerk, MD, FRCR ASSOCIATE EDITORS Q Abdool Karim, A Dhai, N Khumalo, R C Pattinson, A Rothberg, A A Stulting, J Surka, B Taylor, M Blockman HMPG CEO AND PUBLISHER Hannah Kikaya Email: hannah.kikaya@hmpg.co.za MANAGING EDITOR Ingrid Nye TECHNICAL EDITORS Emma Buchanan Paula van der Bijl NEWS EDITOR Chris Bateman | Email: chrisb@hmpg.co.za PRODUCTION MANAGER Emma Jane Couzens DTP & DESIGN Carl Sampson HEAD OF SALES AND MARKETING Diane Smith | Tel. 012 481 2069 Email: dianes@hmpg.co.za JOURNAL ADVERTISING Charles Duke Benru de Jager Reneé van der Ryst Ladine van Heerden ONLINE SUPPORT Gertrude Fani | Tel. 072 635 9825 Email: publishing@hmpg.co.za FINANCE Tshepiso Mokoena HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Adv. Y Lemmer, Prof. E L Mazwai, Dr M Mbokota, Mr G Steyn, Dr G Wolvaardt ISSN 0256-9574 SAMA website: www.samedical.org Journal website: www.samj.org.za

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A 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town, South Africa* C I Herbst, M Tiemensma, S A Wadee

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A review of primary and secondary burn services in the Western Cape, South Africa* H Rode, A D Rogers, A Numanoglu, L Wallis, R Allgaier, L Laflamme, M Hasselberg, L Blom, R Duvenage

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Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective* M Govender, C Aldous, L Ferndale, S R Thomson, D L Clarke

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Pulmonary tuberculosis in a South African regional emergency centre: Can infection control be improved to lower the risk of nosocomial transmission?* H Casey, A Smith, L Parker, M Dipper, T Gould

866

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Prevalence of breast tuberculosis: Retrospective analysis of 65 patients attending a tertiary hospital in Durban, South Africa* D P Ramaema, I Buccimazza, R J Hift Prenatal BoBsTM in the cytogenetic analysis of products of spontaneous miscarriage* S Mellali, K Haoud, L Gouas, M B Khaled, P Vago, S Moulessehoul

CONTINUING MEDICAL EDUCATION

CONTENTS LISTED IN Index Medicus (Medline). Excerpta Medica (EMBASE). Biological Abstracts (BIOSIS). Science Citation Index (SciSearch). Current Contents/Clinical Medicine SAMJ SUBSCRIPTION RATES Local subscriptions R1 248.00 p.a. Foreign subscriptions R2 832.00 p.a. Single copies R104.00 local, R236.00 foreign Members of the Association receive the SAMJ only on request, as part of their membership benefit. Subscriptions: Tel. 012-481-2071 E-mail: members@samedical.org The SAMJ is published monthly by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA. Suites 9 & 10, Lonsdale Building, Gardner Way, Pinelands, 7405 Tel. 072 635 9825 E-mail: publishing@hmpg.co.za

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EDITORIAL A variety of conditions B Farham

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CASE REPORTS Bacillary angiomatosis: A rare finding in the setting of antiretroviral drugs* M C Madua

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Basedow paraplegia: A possible misnomer* L Smith, T Kemp, C H van der Meyden, C-M Schutte

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Cryptococcal laryngitis: An uncommon presentation of a common pathogen* Y Atiya, S D Masege

Use of editorial material is subject to the Creative Commons Attribution – Noncommercial Works License. http://creativecommons.org/licenses/bync/3.0

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Efavirenz as a cause of ataxia in children* M P K Hauptfleisch, D P Moore, J L Rodda

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The real value of endobronchial ultrasound* M J Vorster, P T Schubert, C F N Koegelenberg

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False-negative HIV-1 polymerase chain reaction in a 15-month-old boy with HIV-1 subtype C infection* R Oladokun, S Korsman, N Ndabambi, N Hsiao, L Hans, C Williamson, M-R Abrahams, B Eley

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Delayed presentation and diagnosis of metastatic hepatocellular carcinoma in pregnancy* C N Mnyani, J C Hull, M B Mbakaza, A O A Krim, E Nicolaou

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Kounis syndrome* P M Ntuli, E Makambwa

Please submit all letters and articles for publication online at www.samj.org.za

Plagiarism is defined as the use of another’s work, words or ideas without attribution or permission, and representation of them as one’s own original work. Manuscripts containing plagiarism will not be considered for publication in the SAMJ. For more information on our plagiarism policy, please visit http://www.samj.org.za/ index.php/samj/about/editorialPolicies Printed by TANDYM PRINT

*Full article available online only.

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October 2015, Vol. 105, No. 10

FIRST PUBLISHED IN 1884

Data → information → knowledge → wisdom: When is South Africa going to get her act together? ‘For what can men do when so many have grown lawless? Who can enjoy the lovely land, who can enjoy seventy years, and the sun that pours down on the earth, when there is fear in the heart?’[1] As I completed this editorial, the government was considering amending the law to charge reckless drivers responsible for deaths on the road with murder, following recent news of the deaths of young girls travelling to a reed dance in open trucks! Of 36 killed in a bus crash. Of 16 killed when a minibus taxi failed to stop as a train approached, crashing through the barriers and onto the tracks. Of 12 killed as yet another minibus taxi rolled. For decades the SAMJ has been publishing articles highlighting this country’s unenviable record as one in which the chances of being killed or maimed in a motor vehicle crash (MVC), murdered or raped are extremely high – whether adult or child. Nearly 25 years ago, Muckart[2] referred to the ‘malignant epidemic’ (‘malignant anarchy’ might be more apt), calling for ‘stricter application of the legislation governing alcohol, driving and firearm control’ and stating that ‘a regionalised trauma care programme is desperately needed to contain this epidemic’. He and a young colleague write along similar lines in this issue, reporting the appalling life-changing injuries and deaths of children in MVCs, as passengers and as pedestrians.[2] A number of similarly themed articles[4-6] further highlight our continued culture of horrific trauma and interpersonal violence. With regard to the latter, there is the recent hacking to death of the principal of a school in Pietermaritzburg, with rumours that she was murdered because of her appointment, in the setting of the killing of teachers by people who are selling teaching jobs. Much is spoken these days of powerful computers and cloud computing, about ‘big’ data.[7] The articles in this SAMJ do not constitute ‘big’ data, but are no less compelling. Authors have trawled their respective data sets to garner information and to present the ‘information’ as ‘knowledge’ for us as individuals, as society and as provincial and national government(s). In the hands of the latter resides the ‘wisdom’ to act on the knowledge presented. In 2013, non-natural deaths (transport accidents, crime, fire or drowning, suicide and others) accounted for some 45 000 deaths in South Africa (SA); 60% of deaths in young males (aged 20 - 24) were ‘non-natural’, and the highest number of female deaths were of girls aged 5 - 9.[8] Transport deaths were highest in Limpopo Province. Assault in the Western Cape Province was the second most common cause of death (after infectious disease) – at a rate more than three times that recorded in Gauteng. Both assault and transport deaths peak in March, June and December – December being ‘particularly deadly for assaults’, according to statistician-general Lohahla.[9] In SA violence ‘is related to problems such as poverty, unemployment, poor housing, rapid urbanisation, gender inequalities, erosion of family life and social decay in a society in transition’.[10] In any society, poor people bear most of the brunt of violence, which is associated with ‘over-crowding, family disruption, weak social structures, high population concentrations, population transiency and social norms which encourage the use of violence to cope with difficulties’.[11] The poor bear most of the brunt of trauma in minibus taxi and bus accidents also … 40% of motor crashes, at least in the Western Cape, involve minibus taxis.[6] Add to the mix taxi violence and conflict between taxi associations that place the lives of drivers and commuters at risk, and other ongoing crimes: ‘theft of cables which reduces lighting on our streets, reducing visibility

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and endangering lives of drivers and pedestrians and causing traffic lights at intersections to malfunction or be out of order; theft of crash barriers and man-hole covers sold as scrap metal; fences stolen especially in rural areas & next to informal settlements, creating increased risks of animals entering and crossing roads; stones and other large obstructions placed on the roads with the intention of causing vehicles to crash and providing an opportunity to rob crash victims and stones thrown from cross-over bridges causing road crashes and leaving the victims defenceless to robbery. Then there are those who refuse to obey the rules of the roads: who are impaired and driving under the influence of drugs and alcohol; “Blue light gangs” who present themselves as police officials only to hijack and rob innocent road users; cash in transit robberies that not only endanger the lives of security guards but also all those who share the roads with these vehicles.’[12] According to the Road Accident Fund (RAF), which serves as the social security safety net for those who are maimed on SA’s roads, motor vehicle crashes cost ZAR306 billion per annum (ZAR4.6 million of which is paid to lawyers).[13] In 2014 the RAF paid over 7 000 funeral claims, more than half resulting from the 14 000 road fatalities that occur every year.[12] Thanks to Arrive Alive,[14] started in 2003 by Free State attorney Johan Jonck after losing his mother and a friend in separate car accidents, SA motorists can also contribute data on hazardous road conditions and on bad drivers, aimed at increasing awareness of road safety and reducing the number of deaths on the country’s roads. Janet Seggie

Editor janet.seggie@hmpg.co.za 1. Paton A. Cry The Beloved Country. 1949. Chapter 12, p. 67. 2. Muckart DJJ. Trauma – the malignant epidemic. S Afr Med J 1991;79(2):93-95. 3. Naidoo R, Muckart D. The wrong and wounding road: Paediatric polytrauma admitted to a level I trauma intensive care unit over a 5-year period. S Afr Med J 2015;105(10):823-826. [http://dx.doi. org/10.7196/SAMJnew.8090] 4. Herbst CI, Tiemensma M, Wadee SA. A 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town, South Africa. S Afr Med J 2015;105(10):848-852. [http:// dx.doi.org/10.7196/SAMJnew.8274] 5. Sothmann J, Stander J, Kruger N, Dunn R. Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury (GSH ASCI) Unit, Cape Town, South Africa, over the past 11 years. S Afr Med J 2015;105(10):835-839. [http://dx.doi.org/10.7196/SAMJnew.8072] 6. Van Hoving DJ, Lategan HJ, Wallis LA, Smith WP. The epidemiology of major incidents in the Western Cape Province, South Africa. S Afr Med J 2015;105(10):831-834. [http://dx.doi.org/10.7196/ SAMJnew.7766] 7. Wikipedia. Big data. https://en.wikipedia.org/wiki/Big_data (accessed 11 September 2015). 8. Statistics South Africa. Mortality and causes of death in South Africa, 2013: Findings from death notification. http://beta2.statssa.gov.za/publications/P03093/P030932013.pdf (accessed 11 September 2015). 9. South Africa.info. SA’s mortality rate at its lowest in over a decade. http://www.southafrica.info/about/ health/mortality-report-031214.htm#.VdcepCyqqko#ixzz3jSBTHfeg (accessed 11 September 2015). 10. Gilbert L. Urban violence and health – South Africa 1995. Soc Sci Med 1996;43(5):873-886. http:// www.researchgate.net/profile/Leah_Gilbert/publication/14336950_Urban_violence_and_health-South_Africa_1995/links/00b7d52089fa4a7ff7000000.pdf (accessed 11 September 2015). 11. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for preventing violence. Health Affairs 1993;12(4):7-29. http://content.healthaffairs.org/content/12/4/7.full.pdf (accessed 27 August 2015). 12. Arrive Alive. Crime as a threat to road safety in South Africa. https://www.arrivealive.co.za/Crime-asa-Threat-to-Road-Safety-in-South-Africa (accessed 27 August 2015). 13. South Africa.info. Road Accident Fund pays out a record R22bn. http://www.southafrica.info/news/ road-accident-fund-pays-out-record-R22bn.htm#.Vdcj6iyqqko#ixzz3jSH3noQ3 (accessed 27 August 2015). 14. South Africa.info. Arrive Alive: SA’s road safety website. http://www.southafrica.info/services/ arrivealive.htm#.VdcoDyyqqko#ixzz3jST0SKey (accessed 27 August 2015).

S Afr Med J 2015;105(10):795. DOI:10.7196/SAMJnew.8800

October 2015, Vol. 105, No. 10

EDITOR’S CHOICE

This month’s CME is once again made up of a series of case reports covering a variety of conditions, including entities such as the littleknown Kounis syndrome. The wonderful thing about case reports is that they can be about just about anything. While they are seldom peer reviewed and are certainly not regarded as research, they are very useful entities. Simple reporting is one of their functions – alerting clinicians to potential problems of well-known diseases that may not have surfaced in someone else’s experience. They can also be used to alert people to unexpected drug side-effects – ataxia in children taking efavirenz, for example. There is even a Journal of Medical Case Reports, which I find fascinating reading. If you have a broad interest in all things medical, this is for you. Case reports should highlight clinical concerns – such as the importance of taking a good history, the pitfalls of assumptions, and descriptions of rare or even novel clinical entities.

Bronchial thermoplasty and endoscopic lung volume reduction

A ‘Forum’ article by Dheda et al.[1] introduces practitioners to indications for the use of bronchial thermoplasty in severe asthma, while Koegelenberg et al.[2] provide recommendations for endoscopic lung volume reduction (ELVR) in emphysema.[2] It is recommended that all ELVR procedures should be performed in the context of a local and/or international registry. The Assembly on Interventional Pulmonology of the South African Thoracic Society is willing to assist potential centres wishing to establish an ELVR service in terms of training and accreditation.

South Africa (SA)’s burden of trauma and violence

This month’s SAMJ highlights SA’s frightful record of trauma (interpersonal violence, burns, motor vehicle crashes and pedestrian injury – particularly in children[3]). The evidence resides in several articles from those working in emergency centres and trauma/ surgical units[4,5] and in forensic pathology.[6] Naidoo and Muckart[3] show in ‘The wrong and wounding road: Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period’ that motor vehicle-related injuries, especially those involving pedestrians, dominate severe paediatric trauma (see Table 1 in the article), and stress that there is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality. Our little ones (aged up to 10 years) simply have no experience of road traffic, and SA drivers have no culture of caring for or slowing down for pedestrians. Motor vehicle collisions accounted for 88.4% of deaths. Of the 181 injured children, 112 (61.9%) had traumatic brain injury, of the 26 children who died, 23 (88.4%) had associated head trauma, and in 18 deaths (69.2%) severe traumatic brain injury was the primary cause. There is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality. Importantly, as the authors point out, their mortality statistics do not reflect the extent of the trauma problem, as their results exclude deaths at the scene and address only critically injured children admitted to a level 1 trauma intensive care unit. Of children with severe traumatic brain injury who survive, many are permanently disabled for life, and in the public sector have little access to adequate rehabilitation facilities. And for every severely injured child there are many more who have suffered less devastating injuries and are admitted to regional or district hospitals. The psychological, physical

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and economic burdens that are imposed on the individual, family and society are incalculable. For young passengers, the SA Law on Seatbelts in Regulation 213 of the National Road Traffic Act in force since 30 April 2015 stipulates that the driver of a motor vehicle operating on a public road shall ensure that a child seated on a seat of the motor vehicle uses an appropriate child restraint if it is available in the motor vehicle, or if no child restraint is available, wears a seatbelt if an unoccupied seat is fitted with one. Similarly, the driver of such a motor vehicle shall ensure that an infant travelling in the vehicle is seated on an appropriate child restraint. However, there is a big ‘but’: these provisions do not apply in the case of ‘a minibus or bus operating for reward’. A retrospective analysis of 777 major incidents registered in the Western Cape Major Incident database for the period 2008 - 2014 (Van Hoving et al.,[4] ‘The epidemiology of major incidents in the Western Cape Province, South Africa’) showed that road traffic crashes were the biggest contributor (in 94%).[4] Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district (long, boring road) had the highest incidence (11.97/10 000 population). Surely to no one’s surprise, minibus taxis were involved in 40% of crashes. A total of 8 732 patients were injured (median per incident 8.0), and ten incidents involved 50 or more victims! Most patients were adults (80%, n=6 986) and male (51%, n=4 455), and more than half of the patients sustained minor injuries (54.6%, n=4 605). The authors call for a national database that will provide a full perspective of the burden of major incidents. In ‘Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa’, Stein et al.[7] elegantly show that more ambulances won’t help. Modelling a number of scenarios showed that the target of 90% of responses within 15 minutes was not achieved despite a 150% increase in vehicles (see Fig. 1 in the article, reproduced below). Moreover, since each equipped and staffed ambulance costs some ZAR3.5 million, the total cost of a modest (14%) improvement in response time would be in the range of ZAR195 million. For decision-makers in SA emergency medical services systems, the key to improving response time performance in high-acuity cases is optimal vehicle utilisation and efficiency, rather than increasing numbers. A rethink of outdated decades-old models of response system design is required. Violence remains the leading cause of death in SA, accounting for more than one-third of all unnatural deaths, as a 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town[6] confirms. Community assaults, also known 18

Mean response time, min

CME: A variety of conditions

10 1

4 Scenario

Ambulances & PRVs Ambulances

Fig. 1. Mean response times for both models. (Error bars indicate 95% CIs.)

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EDITOR’S CHOICE

as bundu or kangaroo courts and sometimes mob killings or vigilante justice, are attributed to community members who, dissatisfied with the lack of adequate law enforcement, take the law into their own hands. These so-called acts of vigilantism were a significant topic during the Khayelitsha Commission of Inquiry held in 2014. Highlighted by Newton et al.[8] in a study of the appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal is the tendency on the part of the citizenry to pervert the emergency (ambulance) responses, sometimes for no other reason than to obtain transport to a local clinic, costing the country a fortune and prejudicing responses to those in real need of emergency care. All the above research papers offer important data for the health and transport (and justice) ministries, at national and provincial levels. The cost to the fiscus in terms of hospitalisation, rehabilitation, funeral services and loss of the family breadwinner can only be imagined!

Burn services in the Western Cape

A further major source of trauma continues to be burns, as Rode et al.[9] reveal in their review of primary and secondary burn services in the Western Cape. More than half of those affected are children, the incidence is highest in the winter months, and hot liquid scalds remain the most frequent cause. The majority of burn injuries are minor and are satisfactorily managed at primary level, patients being treated by nurse practitioners and discharged. However, there are considerable delays in the transfer of more severe cases, and pain control is insufficient. The four regional secondary hospitals in the province manage the majority of moderate to severe burns. Rode et al. point out that there is room for improvement in terms of treatment facilities and consumables at all levels. Ten strategies are offered that could, if implemented, lead to tangible improvements in management of burn patients at primary and secondary levels in the Western Cape and around the country. Regional hospitals are particularly restricted by outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a specialised burns unit when indicated.

Reducing the risk of nosocomial transmission of pulmonary tuberculosis (TB)

Given the high burden of TB in SA and absent or rudimentary infection control procedures in the humming emergency centre (EC)

units in which patients with TB are often first seen, EC staff and patients are at high risk of nosocomial infection. Asking whether infection control can be improved to lower the risk of nosocomial transmission, Casey et al.[10] surveyed the situation at George Regional Hospital, a 272-bed referral hospital that serves the Eden and Central Karoo districts of the Western Cape. They sought to establish the burden of pulmonary TB presenting to George Hospital via the EC and to audit current infection prevention and control practices regarding patients with pulmonary TB to determine whether these measures were inadequate and required design of new practices. They concluded that implementation of simple adjustments to assessment and management of patients with suspected TB in the EC significantly reduced the length of patient stay, with a consequent reduction in the risk to both staff and waiting patients. Further improvements are envisaged, e.g. creation of a sputum collection room and regular assessment of the ventilation system in the EC that would further decrease the risk of infection. The impact of these measures will be studied in the near future. JS 1. Dheda K, Koegelenberg CFN, Esmail A, et al. Indications for the use of bronchial thermoplasty in severe asthma. S Afr Med J 2015;105(10):808-809. [http://dx.doi.org/10.7196/SAMJnew.8208] 2. Koegelenberg CFN, Theron J, Dheda K et al. Recommendations for the use of endoscopic lung volume reduction in South Africa: Role in the treatment of emphysema. S Afr Med J 2015;105(10):810-815. [http://dx.doi.org/10.7196/SAMJnew.8147] 3. Naidoo R, Muckart D. The wrong and wounding road: Paediatric polytrauma admitted to a level I trauma intensive care unit over a 5-year period. S Afr Med J 2015;105(10):823-826. [http://dx.doi. org/10.7196/SAMJnew.8090] 4. Van Hoving DJ, Lategan HJ, Wallis LA, Smith WP. The epidemiology of major incidents in the Western Cape Province, South Africa. S Afr Med J 2015;105(10):831-834. [http://dx.doi.org/10.7196/ SAMJnew.7766] 5. Sothmann J, Stander J, Kruger N, Dunn R. Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury (GSH ASCI) Unit, Cape Town, South Africa, over the past 11 years. S Afr Med J 2015;105(10):835-839. [http://dx.doi.org/10.7196/SAMJnew.8072] 6. Herbst CI, Tiemensma M, Wadee SA. A 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town, South Africa. S Afr Med J 2015;105(10):848-852. [http:// dx.doi.org/10.7196/SAMJnew.8274] 7. Stein C, Wallis L, Adetunji O. Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa: More ambulances won’t help. S Afr Med J 2015;105(10):840-844. [http://dx.doi.org/10.7196/SAMJnew.8087] 8. Newton PR, Naidoo R, Brysiewicz P. The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa. S Afr Med J 2015;105(10):844-847. [http://dx.doi.org/10.7196/SAMJnew.8273] 9. Rode H, Rogers AD, Numanoglu A, et al. A review of primary and secondary burn services in the Western Cape, South Africa. S Afr Med J 2015;105(10):853-857. [http://dx.doi.org/10.7196/ SAMJnew.8187] 10. Casey H, Smith A, Parker L, et al. Pulmonary tuberculosis in a South African regional emergency centre: Can infection control be improved to lower the risk of nosocomial transmission? S Afr Med J 2015;105(10):862-865. [http://dx.doi.org/10.7196/SAMJnew.7813]

Keeping South Africa’s drivers on the straight and narrow. (Images: ArriveAlive.co.za)

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October 2015, Vol. 105, No. 10

CORRESPONDENCE

Zolpidem and restoration of consciousness – fact or fiction?

To the Editor: Recently the magical effect of zolpidem in bringing people in a vegetative state back to life was proclaimed in the general media. Since then physicians, including paediatricians, have been flooded by hopeful individuals seeking treatment for a wide variety of cerebral pathologies. Looking at three recent publications on this topic, all may not be as it was made out to be. Zolpidem is a short-acting non-benzodiazepine gamma-amino butyric acid agonist hypnotic approved for the treatment of insomnia. It has been shown to have a paradoxical effect in some patients with disorders of consciousness, leading to improvement of arousal and cognitive abilities. It has been suggested, and partly proven, that zolpidem disinhibits the globus pallidus interna, and in that way increases the thalamic excitatory role on the frontal lobes. After a cerebral insult, patients may stay in a prolonged period of unconsciousness. They usually evolve from a comatose state to a vegetative state (eyes open but only showing reflex behaviours) to a minimally conscious state (MCS). This state is characterised by inconsistent reproducible evidence of awareness. If these are present without command following, it is classified as MCS–, and with command following as MCS+. From a research perspective, emergence from an MCS is characterised by recovery of functional communication and/or functional object use.[3] Several case studies have shown that zolpidem effected impressive recoveries in patients with severe brain damage of various causes. However, this effect occurs in only 5 - 7% of patients. It is important to realise that there is not always significant functional recovery; patients may regain the ability to follow simple commands, recognise objects and regain some communication, but unfortunately the effect lasts for about 4 hours (the half-life is 2.4 hours) and is often followed by increased somnolence. The only placebo-controlled, double blind, single-dose crossover study was published last year.[1] A very complex research design, involving a cohort of 84 participants (>18 years of age) with traumatic and non-traumatic disorders of consciousness of at least 4 months’ duration, found that only 4.8% responded to zolpidem. In this study, all responders were male with a median age of 34 years. Responders could not be distinguished in advance from non-responders, although those

who did improve were more likely to have some signs of consciousness at baseline. The effect was usually apparent by the first hour after drug administration, but was already diminished or absent after one further hour. Side-effects were rated as mild and no intervention was required. Post-response somnolence was seen in several participants. While 10 mg was the dose used in this study, other studies have shown an increased effect with 20 mg. In one study a responder had been treated (on a three times a day dose) for more than 9 years without habituation.[2] The majority of persons who benefitted from zolpidem required other medications such as amantadine and lamotrigene to improve function. Conclusions: • There are no scientific data to support the use of zolpidem in children for restoration of consciousness. • There is a small chance (±5%) that patients in a vegetative state will respond favourably. • The effect of zolpidem is specific for patients in an MCS (probably MCS+) and has not been shown for all neurological conditions. • Even in those patients who respond, functioning may not be completely restored. • Lifelong treatment appears to be necessary, with multiple doses daily. There is no evidence whether it could be addictive or not. • In patients in a vegetative state or MCS, it may be worthwhile to consider one dose of 10 mg zolpidem to establish whether or not there is a response. André Venter

Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa, on behalf of the Paediatric Neurology and Development Association of South Africa (PANDA-SA) gnpdav@ufs.ac.za 1. Whyte J, Rosenbaum R, Katz D, et al. Zolpidem and resoration of consciousness. Am J Phys Med Rehabil 2014;93(2):101-113. [http://dx.doi.org/10.1097/PHM.0000000000000069] 2. Kaufman KR, Bagayogo IP, Kaufman IH, Das A. Zolpidem and anoxic encephalopathy: Prolonged treatment response. Ann Clin Psychiatry 2014;26(1):70-71. 3. Chatelle C, Thibault A, Gisseries O, et al. Changes in cerebral metabolism in patients with minimally conscious state responding to zolpidem. Front Hum Neurosci 2014;8:917. [http://dx.doi.org/10.3389/ fnhum.2014.00917]

S Afr Med J 2015;105(10):798. DOI:10.7196/SAMJnew.8334

This month in the SAMJ ... David Muckart,* of the Department of Surgery at the University of KwaZulu-Natal, is a surgical intensivist, trauma expert and single-malt connoisseur. His research interests are trauma intensive care and antimicrobial surveillance and stewardship. He enjoys running, cycling and the outdoors and is known for his dry Scottish sense of humour. Natasha Naidoo* is a senior surgical registrar in the same department. She is a true UKZN graduate, having also completed her undergraduate medical training at the Nelson Mandela School of Medicine. She has an interest in trauma and research, loves the sea like a true Durbanite, and spends hours just reading by the sea. * Naidoo R, Muckart D. The wrong and wounding road: Paediatric polytrauma admitted to a level I trauma intensive care unit over a 5-year period. S Afr Med J 2015;105(10):823-826. [http://dx.doi.org/10.7196/SAMJnew.8090]

Christopher Stein* is a senior lecturer in the Department of Emergency Medical Care at the University of Johannesburg. He holds a bachelor’s degree in emergency medical care and a PhD in emergency medicine, as well as an honours degree in computer science. He is President of the Emergency Care Society of South Africa and serves on the Board of the African Federation for Emergency Medicine. His research interests are in the area of prehospital emergency care, and focus mainly on problems related to emergency medical services systems and how to make them more efficient in delivering quality emergency care. * Stein C, Wallis L, Adetunji O. Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa: More ambulances won’t help. S Afr Med J 2015;105(10):840-844. [http://dx.doi.org/10.7196/SAMJnew.8273]

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IZINDABA

Rendering a dangerous healthcare ocean safer Take a tidal wave of patients, a trickle of specialists and a small shoal of medical students eager to palpate, probe and prick (at the very least), and mix them together in the public sector sea for several consecutive years. No CPD points for guessing the range of adverse events that can follow, and inevitably will. The reality is that these ongoing ratios cost provincial health authorities billions of rands in litigation payouts every year, never mind – in a best-case professional scenario – a debilitating knock to the confidence of overworked and undersupervised doctors and nurses. Yet one single, carefully considered crossdisciplinary intervention that trains pre- and postgraduate medical professionals correctly, without harming anyone or repeatedly invading the privacy of patients, is making a difference at Groote Schuur Hospital (GSH), and far wider afield. The University of Cape Town (UCT)’s publicly and privately funded simulation hub, spread across three spaces in the hospital, populated with high- and lowfidelity manikins and equipment, and staffed by several full- and part-time experts (both generalist and specialist), is an enviable hybrid teaching model. Dr Rachel Weiss, Director of the UCT Clinical Skills Centre and an expert in curriculum design and education, puts it succinctly: ‘Here you can give standardised teaching to everyone, without harming patients or imposing a major teaching burden on busy specialists.’ That’s not to say they don’t regularly call on specialists to teach and supervise certain procedures – that’s still a pragmatic, but now lower-impact, necessity.

An 11-year journey

Started in 2004, the Clinical Skills Centre has grown exponentially via progressive budgeting and tailored specialist equipment company funding. Today it has a simulation laboratory with traditional simulation equipment, a ‘patientless’ simulated ward, and a health and rehabilitation laboratory – all organised according to functions, not disciplines, in what Weiss describes as ‘an important ideological step towards integrated, multidisciplinary training’. She has helped source private sector funding

Anaesthesiologist Dr Andrie Alberts leads colleague Dr Ulla Plenge through a procedure.

for two young anaesthesiologists who have a passion for developing simulation-based education. Izindaba watched postgrad students acquire endoscopy skills, guiding instruments past life-like swollen airways, down ‘burnt’ throats and past tumours, not to mention doing a needle cricothyroidotomy (aka ‘crike’ or emergency airway procedure) – basically a range of airway problems that it might take years to encounter, let alone perfect, in a clinical patient setting.

Setting up and maintaining a simulation lab is an expensive but ultimately cost-effective exercise. An advanced life support ‘casualty’ manikin costs R140 000, while the price tag for a programmable, wireless ‘theatre’ manikin is close to R1 million – ‘we wouldn’t let third-years near him’, quips Weiss. The useful lifespan of a manikin is 5 years, while all machines need constant calibration. When it comes to undergraduate pro grammes, simulation is ‘scaffolded’ to build skills longitudinally. Take emergency medicine training for medical students: while first-year students do basic life support as taught to lay people, third-years progress to intermediate life support using a bagmask device and automated and manual

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defibrillators. Fourth-years are taught how to intubate a patient during resuscitation and to work with different kinds of drugs (e,g. cardiac resuscitation drugs) and advanced treatment algorithms, building skills towards difficult intubations and intravenous access (central and other forms of vascular access). By fifth year they’re pacing and ‘cardio verting’ patients with lethally slow and fast heart rates. ‘We also teach the so-called ‘soft skills’: how to work as a team around a bed, function as a team leader and communicate effectively in high-stress environments, so by sixth year they are able to run a full resuscitation scenario by themselves, taking responsibility for keeping somebody alive until more competence arrives.’

Costly but hugely effective

Setting up and maintaining a simulation lab is an expensive but ultimately cost-effective exercise. An advanced life-support ‘casualty’ manikin costs R140 000, while the price tag for a programmable, wireless ‘theatre’ manikin is close to R1 million – ‘we wouldn’t let third-years near him’, quips Weiss. The useful lifespan of a manikin is 5 years, while all machines need constant calibration. Weiss and her anaesthesiology colleagues, each of whom has a pet project that is either currently adding major value to the teaching programme or soon will be, via ‘cyber-reach’, believe in getting the basics right. ‘Patient safety is our first priority; for example, to inculcate a lifelong respect for infection control, second-year students start with hand-washing

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IZINDABA

UCT clinical simulation lab stalwarts Drs Ross Hofmeyr, Rowan Duys and Rachel Weiss.

(a talk from an infection control nurse whose favourite trick is to put students’ hands under a ‘glitter-bug’ light to show just how many bugs they’re carrying), while our third-years prepare sterile trolleys for blood cultures or learn how to create a sterile field while suturing.’ It is not only the patient who is at risk in a hospital; healthcare workers have a high risk of contracting tuberculosis (TB) from infected patients, or blood-borne diseases such as HIV and hepatitis during needlestick injuries. The centre fits and supplies every student with TB respirators in the wards and works with activist group TB PROOF to break the silence around occupational TB. A partnership with Becton Dickenson, manufacturers of safety needles, actively promotes sharps awareness and ensures that students receive intense, small-group, supervised practicals with a range of different safety devices. Simulation-based training provides opportunities to standardise care; instead of ‘see one, do one, teach one’ in the ward, students can (for example), insert intercostal drains on pork ribs or manikins repeatedly until they get it right. Here’s where the real diamonds on the training sea-bed lie; simulation means less risk to patients, students speedily improving hand-to-eye co-ordination skills, and more people taught in less time. ‘You can stop and correct errors and re-do things. We see them making a mistake and we stop that before it gets ingrained. It’s optimal and repeated practice. As a student you may never get a chance to do this stuff before your internship. Here you learn, so that one day when you end up in a deep rural hospital, people don’t die from preventable errors.’

Giving patients their humanity back

One of Weiss’s dreams is to start a ‘patientpartner’ programme, recruiting a small group of jobless people with manageable conditions (mild cardiac failure or hypertension) to

simulate situations and help teach medical students how to communicate by giving them feedback. Weiss says the more junior the doctor, ‘the more they tend to palpate the patient’s liver repeatedly to learn’ – not ideal for tertiary inpatients lying vulnerable in a ward. ‘We did a study in 2011 and found that patients are completely disempowered. They sometimes get students coming up to them five times a day to practise on them – and they still say yes!’ ‘We have a lot of patients here who cannot work because of their condition, so this would be job creation and they’d replace the patients in the actual wards. Our in-hospital patients are really ill – so it’s actually a human rights issue,’ she adds. Dr Rowan Duys, an anaesthetist and recent Fellow in Simulation and Education (partially funded by Dräger, which also donated ZAR10 million in medical equip ment to the centre), takes time off from leading a simulation to tell me that as far back as second year, he can remember wondering what the point was of learning to ‘look after the patient in front of you when the system around you is broken’.

Anaesthesiologist applies his life lessons

What stuck from Duys’s internship at George Mukhari Hospital, north of Pretoria, was ‘the amazing individual clinicians but a real lack of leadership and training’, while his community service at Hlabisa Hospital in northern KwaZulu-Natal helped hone his survival skills. Subsequent work in the NHS in the UK first exposed him to simulation training and taught him that minimum standards there were far better protected and that the UK ‘holes in the net’ for patient care were far smaller than locally. His more recent registrar time here left him painfully aware of the stark differences in

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skills levels between UK nurses and their local counterparts – and the differences in training methodology. ‘I developed a real passion for developing nursing education and skills levels and finding innovative ways to train people better,’ he says, explaining a journey that led him to approach Dräger to fund his current post from August this year. Nearly 5 years ago he began training a short course in anaesthesia to GSH (and other) nurses using the simulation lab for scenariobased training. In simulation he sees three major areas: technical skills, crew resource management (team interaction, leadership and communication skills), and systems testing and development – which can lead to a latent risk or adverse event being identified during simulation that one can report as a real-time human event, one of the more hidden lifesaving benefits.

‘Here you can give standardised teaching to everyone, without harming patients or imposing a major teaching burden on busy specialists.’

Mitigation in a dysfunctional system

Duys’s colleague Dr Ross Hofmeyr is the Storz Fellow in Airway and Thoracic Anaes thesia (predominantly funded by Storz, manufacturers of endoscopy equipment), and has tellingly similar motives. ‘If I’m a highly skilled anaesthetist working in a dysfunctional system, my patients will get poor care, no matter how good I am! You can try and tackle that from a management point of view or a political point of view, but I want to tackle it from a training and education angle,’ he asserts. As far as he knows, he and Duys are the only Cape metropole consultants (across disciplines) taking up either partor full-time educational roles. Hofmeyr says that while anaesthesia is generally very safe, it has a zero tolerance for adverse outcomes. ‘Nobody ever got better because of anaesthesia – everything we do places the patient at risk, yet there are low-frequency, high-risk events which we don’t see often, but they have dire consequences.’ It is here that simulation can avoid things like anaphylaxis, malignant hypothermia, major haemorrhage or difficult intubation. ‘You hardly ever get to practise these, but you’re supposed to be good at managing them,’ he adds. His ‘extra value add’ to the Clinical Skills Centre is developing a utilitarian e-learning platform for nurses by creating and tailoring modules on the internet, working with a Dutch university.

IZINDABA

Duys is developing a similar algorithm-based e-learning platform that can be adapted by any medical student to his or her skills and knowledge levels. Weiss is no slouch in this department either; drawing on expertise and resources from the Division of Cardiology, she’s collaborating with a senior registrar, Charl Viljoen, who wants to super-specialise in cardiology. With a small ZAR30 000 grant they’re using in-house programming skills and a bank of cardiology electrocardiograms (ECGs) to create an on-line learning plat

form to plug a major learning gap – the interpretation of ECGs. ‘We got complaints from people teaching sixth-years, saying that students don’t retain their third-year ECG interpretation theory.’ Online exercises now enable students from third to sixth year not only to interpret ECGs but to assess their own knowledge levels. She says that research studies both internationally and locally suggest that ‘most doctors, unless they are cardiologists, suck at ECGs’, and this bolstered her proposal and subsequent funding.

What is certain is that the impact of UCT’s world-class Clinical Skills Centre will increas ingly reverberate across the country and the continent as medical professionals emerge more proficient than ever before – with commensurate huge savings in lives and money. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(7):799-801. DOI:10.7196/SAMJnew.8758

Euthanasia in SA – sacrificing one to render many vulnerable? The ‘sacred’ value of auto nomy in euthanasia and assis ted suicide is not absolute, because people change their minds – while passing enabling laws ‘holds grave conse quences’ for both individuals and society. This was the view of Dr Tom Angier of the University of Cape Town (UCT)’s Department of Philosophy, who contended that the ‘sacred trilogy’ of values, compassion, dignity and autonomy in the euthanasia debate would be undermined by a euthanasia-practising regime. Angier was debating with his UCT colleague Prof. David Benatar of the Bioethics Centre in the Department of Philosophy on campus on 18 August on the potential implications of recent local legal developments on euthanasia and physicianassisted suicide (PAS). Benatar had asked Angier how existing South African (SA) law (rendering either means of death illegal) aided autonomy in a scenario where two people were in an appalling and unbearable physical condition and one wanted to ‘carry on’ while the other had ‘had enough’. ‘The law enables you to express your wish and precludes me; how is that aiding autonomy?’ he asked. Angier said there wasn’t enough time to give several frightening examples of cases in the Netherlands, Belgium and Switzerland, where the law conditionally favoured PAS and euthanasia. However, granting just one case on the grounds of mental suffering, for example (notoriously difficult to quantify), would be ‘one case too many’, not to mention the suffering and loss to family members ‘when a person says they can’t take it any more’, he countered. ‘This needs a communal

and sustaining response, not simply changing the law [in SA] and getting a quick fix,’ he added. He cited Holland’s 42 cases of euthanasia involving psychiatric illness (where therapies were no longer working) in 2013, and a 62-year-old civil servant who appealed against a tribunal that turned down his PAS application – only for him to find two supportive doctors who helped him to win his appeal. ‘We also have non-voluntary (but conditional) euthanasia practised on babies with spina bifida in Holland. Out of free will – everyone has access, no questions asked. This is not a paranoid fear, though it’s worthless to appeal to the law to block this kind of development because it’s the law itself that embodies the slippery slope and has failed to safeguard people [in Holland],’ he said.

‘Slippery slope’ concerns

Earlier Chris Fisher, of the Faculty of Law and Department of Philosophy at UCT, sketched the status of existing law and developments in SA v. several Benelux countries, Switzerland, the USA and Canada, where pro-euthanasia and PAS legislation or judgments exist. Giving input on the ‘slippery slope’ concerns of anti-euthanasia legislation protagonists during the debate, Fisher said there was empirical evidence of increased terminations of pregnancy, while neonatal euthanasia declined in Holland in the 5 years since the publication of the ‘Groningen Protocol’ (which helps identify situations in which neonatal euthanasia might be appropriate). A comprehensive study found that ‘neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a

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transformation of the healthcare system after antenatal screening policy became a part of antenatal care.’[1] The Netherlands was the first country in the world to legalise euthanasia in adults, and more recently neonatal euthanasia for severely defective newborn babies became legal under very narrowly defined circumstances.

A binding precedent

In SA, the Supreme Court’s granting of individual PAS status to a terminally ill Cape Town advocate, Robin Stransham-Ford, in April this year set a binding precedent for Gauteng Province and was ‘legally persuasive’ in other provinces. Judge H J Fabricius strongly recommended that existing law be developed to bring it into line with the Constitution, adding that other applicants with similar conditions could approach the courts for rulings. He stressed, however, that existing law pertained. The judge said that Stransham-Ford, who was suffering from terminal cancer with only weeks to live, was highly qualified, ‘of vast experience’ in the legal profession, and knew exactly what he required and why. The applicant was psychologically assessed and found to have no cognitive impairments: ‘in fact he impressed as being totally rational’. He had a good understanding and appreciation of the nature, cause and prognosis of his illness, plus the clinical, ethical and legal aspects of assisted suicide. Stransham-Ford, who died just hours before the ruling was made, argued in papers before the court that there was no logical distinction between withdrawing treatment to allow the natural process of death, and physician-assisted death, labelling this distinction ‘intellectually dishonest’. Judge Fabricius said that while there was

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‘much to be said’ for this view, he would ‘leave it to the philosophers’ and confine himself to the constitutional debate.

Intrinsic and attributed human dignity

Angier told a packed Groote Schuur Hospital lecture theatre audience that distinguishing between intrinsic human dignity (which was inviolable) and attributed dignity (which came ‘in degrees’) was critical to the debate. ‘As we get older we need help, become more dependent. We are fed, helped to go to the toilet; we suffer a loss of intrinsic dignity. What we can learn from this distinction is that the whole debate is dominated by attributed dignity. We all suffer this as we get older … for some that loss is a lifelong truth, particularly the disabled – that’s why the disabled are almost always against any liberalisation of the law on euthanasia,’ he argued. The idea that if you fell below a certain threshold of functioning you were living an undignified life, and that by giving people the right to kill themselves or be killed you were upholding their dignity, was ‘leading us seriously astray’. There were already documented changes in attitudes in the Netherlands since the law outlawing euthanasia there changed, he said, citing the case of a person whose partner was disabled being asked why he was being kept alive. ‘It’s perfectly consistent with one’s intrinsic dignity to let death take its natural course in the context of palliative care [PC]. What goes against this is [the idea] that if you’re upholding dignity, you must kill. That’s untrue and threatens all of us, especially the most vulnerable.’

Palliative care

Dr Liz Gwyther, convenor of programmes in palliative medicine at the School of Public Health and Family Medicine at UCT (and President of the World Palliative Care Association), said that PC affirmed life and regarded dying as a normal process. PC neither hastened nor postponed death, and euthanasia was anathema to it. She said the most compelling argument people had for wanting the choice to end their lives was ‘the fear and imaginings of how dreadful the experience of dying will be’. Instead of the choice being either unbearable pain or euthanasia, the ethical and compassionate response should be effective pain management which today could deal with over 90% of situations. ‘You can escalate the dose of morphine to titrate it against the patient’s pain. Constipation is the only lasting long-term side-effect.’ She said it was a little-known fact that Stransham-Ford had recently begun PC when the ground-breaking court ruling was made, rendering the facts upon which the ruling was based no longer true. PC enhanced a person’s autonomy and dignity through attitude, behaviour, compassion and dialogue while successfully managing their pain. One questioner juxtaposed Oregon, where just 0.3% of all deaths were a result of PAS since its Death with Dignity Act was passed in 1997, with SA, where just 4% of South Africans had access to PC, asking ‘are we not missing context here?’ (In Oregon, as Fisher explained, terminally ill, mentally competent adult residents with less than 6 months to live may request a script for life-ending medication under strictly monitored conditions.) Benatar agreed that context was ‘crucial’, but said the absence of euthanasia in SA had not

exercised anybody to provide more PC. Instead the prospect of this extreme option ‘may actually wake somebody up to the lack of care’, he emphasised. He proposed the introduction of a ‘sunset clause’ in local euthanasia legislation as among the safeguards against abuse. Angier wryly said that it was influential philosophers who were at ‘the forefront of the wrong side of this debate’, citing several overseas authors.

Racial and cultural variables

Asked to address the racial and cultural disparities in attitudes towards euthanasia, Benatar said there might be some cultural variables on mental illness (for example), but this was not a racial question. ‘We’re all sentient beings who suffer in this way,’ he added. Angier said most of the pressure for PAS and euthanasia came from the white, educated, middle-class sector. ‘They tend to be white, well-off and worried. There are some sociological grounds to think that those worries are not as prevalent in black communities where there are ten times stronger community bonds and strong spiritual resources,’ he said. The State intends to appeal to the Supreme Court of Appeal against the Stransham-Ford ruling, which may eventually be heard by the Constitutional Court. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(7):801-802. DOI:10.7196/SAMJnew.8760 1. Verhagen AAE. J Med Ethics 2013;39:293-295. [http://dx.doi. org/10.1136/medethics-2013-101402]

Man impaled on crowbar saved by hospital trauma team A cool-as-a-cucumber Carl ton v ille mine engineer walked out of hospital 19 days after being impaled from groin to upper back by a 2-metre, 2 cm-thick industrial crowbar, his survival and recovery due to his presence of mind, and world-class trauma surgery. The crowbar pierced three of his body cavities – his pelvis, abdomen and chest – missing his heart by 5 cm and destroying a kidney. Daniel de Wet slipped while helping with a production breakdown 3.5 km underground at the goldmine this July. He was using the

Mining engineer Daniel de Wet’s Lodox scan. Note the proximity of the crowbar to the heart.

sharpened metal crowbar, commonly known as a gwala, to stir up mud in an underground

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dam he and a fellow miner were washing out. He said he tried to stand up on a

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metre-high suction pipe, but slipped. To his utter disbelief, he saw that the gwala had penetrated between his legs, coming out just below his shoulder blade. ‘I was talking the whole time, trying to keep the other guys calm – because of the adrenaline rush I had absolutely no pain at first. There was (initially) only one guy with me, he became very scared and didn’t know what to do. I told him to calm down and call for help on the two-way radio.’ Within minutes, a rigger crew with a first-aid pack and stretcher arrived. ‘They didn’t know how to put me on the stretcher because of the way the gwala was sticking out of my back. I told the guys: ‘Calm down, let’s think what to do.’ Accustomed to keeping a cool head in dangerous situations because of being a member of the mine’s rescue team and trained to deal with emergencies, De Wet instructed the riggers to perch him on the stretcher in a sitting position – the only way he could be carried ‘safely’.

‘I was talking the whole time, trying to keep the other guys calm – because of the adrenaline rush I had absolutely no pain at first. There was (initially) only one guy with me, he became very scared and didn’t know what to do. I told him to calm down and call for help on the two-way radio.’

Calm, slow and steady does it

They carried him through knee-high muddy water for some 40 metres in order to reach a station area, where a cage lift was waiting to hoist them to the surface – no mean feat, as the bottom of the gwala stuck out below De Wet’s feet. ‘On 34-level sub-shaft, mine paramedics met me and gave me morphine for the pain. I remember nothing further, until I woke up two weeks later in Netcare Milpark Hospital,’ said De Wet. Fortunately he was in highly professional hands, both at the mine and in the hospital. Having been brought up to surface level in three different lifts at a pace that would ensure that he did not suffer adverse decompression effects (more commonly known in deep-water diving as ‘the bends’), he was manoeuvred into a waiting Netcare emergency helicopter, the crowbar tearing the upholstery to accommodate

its human ‘kebab’. Nearly four hours after the underground accident, the helicopter touched down at Netcare’s Milpark Hospital emergency department – one of only two level 1-accredited trauma units in South Africa (Netcare is the only private hospital group in South Africa to have obtained independent classification of its trauma unit, done by the Trauma Society of South Africa using the internationally recognised criteria). The hospital’s Trauma Director, Prof. Kenneth Boffard, said he had ‘no idea of what was coming [to him], except that it was an impalement’. He began assembling an appropriate operating team and readying the Lodox lowdose, full-body-scan X-ray machine to obtain a precise picture to enable them to plan their surgery. Asked about his initial reaction when confronted by the sight of a person with a metal pole stuck vertically through his body, an unflappable Boffard responded: ‘At first it was “good grief ”, but then I had to apply my mind to the technical problem in order to decide on the best course of treatment.’ De Wet was anaesthetised lying on his side. Boffard explained: ‘We needed to get him in a position that would enable us to operate, but with the gwala sticking through his back, it was rather awkward. Once he was under, we got some strong paramedics to pull out the gwala by about half a metre so that it was flush with his body. This allowed us to lie him on his back. Fortunately, the gwala had been pressing on the blood vessels and this pressure prevented too much blood loss.’ Two surgical teams scrubbed in, one concentrating on the abdomen and one on the chest area.

Staggered operations ensured survival

‘We operated twice on Mr De Wet. In order to safeguard the patient, given the traumatic nature of his injury, our first operation could not last any longer than 60 minutes. During this procedure we did massive damage control in order to stem the bleeding and to contain any form of contamination caused by his injury.’ ‘This is a technical exercise in that one has to know when to stop so that the patient can live to fight another day,’ explained Boffard. ‘During the next, more major procedure [36 hours later when the patient had fully stabilised], extensive repair work was undertaken. This methodology was crucial to full recovery.’ De Wet says that his wife was distraught when she heard of the accident, and one of his colleagues immediately drove her to the hospital. ‘At the hospital, Prof.

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Where the crowbar entered De Wet’s body.

De Wet before his first operation.

Boffard met my wife, and she described his manner as very calm and reassuring. He reassured her that if I arrived at the hospital alive, I would go home alive.’ Mrs De Wet waited anxiously as the two surgical teams, led by Boffard and Prof. Elias Degiannis, another renowned trauma surgeon at the hospital, worked to save her husband’s life. Once the gwala was pulled completely free of De Wet’s body, the doctors saw that the impalement had caused significant damage, destroying one kidney and damaging the small bowel and numerous blood vessels. After the initial surgery, Boffard came out of the theatre to speak to Mrs De Wet. ‘When Prof. Boffard came out with the gwala in his hand, my wife says she didn’t know how to thank him,’ De Wet says.

Going beyond the call of duty

The couple are immensely grateful for what De Wet described as ‘absolute caring – Prof. Boffard and his wife also gave my wife a lot of support’. The survivor’s team from the mine came to the hospital to offer support, telling the

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nurses they wanted to pray for him outside the intensive care unit (ICU). The sisters allowed them into the ICU for five minutes, however, and they prayed around their colleague. Says De Wet: ‘Even though I was unconscious, they told me later that the tears were rolling down my cheeks when they prayed.’ Once he regained consciousness, he had trouble sleeping and felt anxious. ‘One of the nurses was so kind to me, she would talk to me until I fell asleep. The hospital’s doctors and nurses went above and beyond the call of duty, not just treating my physical injuries but also showing great compassion for my state of mind and my wife’s emotional wellbeing.’ Although he had lost a kidney, he made rapid progress and was able to walk after being transferred to the highcare unit, being discharged only 19 days after his dramatic accident. Boffard said the 19-second-duration Lodox scan revealed

what a ‘miraculous’ escape De Wet had, it being ‘the longest impalement I’ve ever dealt with, never mind the survival’. He revealed an added factor that contributed to his patient’s recovery: De Wet is a seven-time Comrades Marathon athlete and was in superb physical shape. He has since returned to active duty at the mine and continues to serve on its rescue team. ‘Everyone thought I would resign from mine rescue, but I won’t. I have already attended to three fires underground since the accident,’ De Wet says. His employers have had the gwala chromed and mounted on a stone with a bible verse on it, and De Wet plans to donate it to Netcare Milpark Hospital. ‘What I have learnt from this whole experience is: “You must believe in miracles every day.”’ Boffard said that everything happened according to the textbook. ‘We were well prepared to deal with the incoming

patient, the mine recovery team were excellent, and Mr De Wet had the benefit of being treated at a world class, level-one trauma unit.’ No doubt the patient’s level-headedness was another strong contributing factor. Boffard, Emeritus Professor of Surgery at the University of the Witwatersrand and President Elect of the elite 60-member International Surgery Group, said that the most common impalements he and his local colleagues dealt with were ‘front-to-back’, usually caused by someone intending grievous bodily harm, burglars jumping out of buildings onto fences or poles (mostly vertical), and motorcyclists flung off their seats in accidents (normally confined to the chest cavity). Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(7):802-804. DOI:10.7196/SAMJnew.8603

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CLINICAL ALERT

Non -typhoidal Salmonella infections in HIV-positive adults E L Subramoney Evette Subramoney is a medical officer in the Department of Internal Medicine at Mahatma Gandhi Memorial Hospital, Durban, South Africa. Her areas of special interest include infectious diseases and emergency medicine. Corresponding author: E L Subramoney (evette.subramoney238@gmail.com)

Non-typhoidal salmonellae are important pathogens causing bacteraemia, especially in immunocompromised patients, but there are limited data explicitly describing the clinical characteristics and outcome in these individuals. Recurrent invasive salmonellosis has been recognised as an AIDS-defining condition in HIV-positive patients since the 1980s. Salmonella meningitis is an infrequent complication of Salmonella sepsis, accounting for 0.8 - 6% of all cases of bacterial meningitis, and is associated with a high mortality rate. S Afr Med J 2015;105(10):805-807. DOI:10.7196/SAMJnew.7802

Non-typhoidal salmonellae (NTS) are increasingly recognised as important pathogens causing bacteraemia, especially in immunocompromised patients.[1] However, there are limited data explicitly describing the clinical characteristics and outcome in this cohort of individuals.[2] Since the 1980s, recurrent invasive salmonellosis has been recognised as an AIDS-defining condition in HIV-positive patients.[3] Salmonella meningitis, a rare complication of Salmonella sepsis accounting for 0.8 - 6% of all cases of bacterial meningitis,[4] was first reported by Ghon in 1907 (cited by Ohaiseadha et al.[5]). While relatively infrequent in adults, even those who are HIV-infected, meningitis due to Salmonella species is associated with a high mortality rate.[1]

Case presentation

A 33-year-old woman had tested HIV-positive in 2011; her baseline CD4 count was unknown. She had received antiretroviral therapy (ART) since 2011 (initial regimen unknown, changed to a fixed-dose combination drug in August 2013). At that time her CD4 count was 67 cells/µL. She had had pulmonary tuberculosis in 2012 and had completed 6 months of antituberculosis treatment. At the time of her admission in July 2014, her CD4 count was 96 cells/µL and her HIV viral load was suppressed. She reported having had a generalised headache for 5 days, and had a longstanding history of visual impairment. Her vision had deteriorated acutely 2 days before admission. There was no associated vomiting, fever, photophobia, confusion or seizures. She had a recent history of constipation but no diarrhoea or abdominal discomfort. Clinically, the patient was chronically ill with generalised wasting. Recorded vital signs on admission were essentially normal apart from sinus tachycardia. She had pallor, clubbing and significant lymphadenopathy, but no oral candidiasis. Central nervous system assessment revealed that the patient was conscious, alert and fully orientated. She had terminal nuchal rigidity. She was blind and had no perception of light; fundal examination showed pallor of both optic discs, the left being more affected than the right. There were no gross motor or sensory deficits, but her gait was not assessed owing to her visual deficit. Findings on examination of the other systems were unremarkable.

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The working diagnosis was acute meningitis, and intravenous (IV) ceftriaxone 2 g 12-hourly was empirically commenced, pending results of a lumbar puncture (LP). Blood investigations were undertaken. An enhanced computed tomography (CT) scan of the brain showed no intracranial abnormality. As there were no contraindications, a diagnostic LP was performed. Blood cultures and stool microscopy studies were negative, as was syphilis serology. An ophthalmological assessment led to the conclusion that the blindness was due to bilateral disc atrophy secondary to meningitis. Cerebrospinal fluid (CSF) findings on admission and after 12 days of antibiotic treatment are shown in Table 1. The patient completed 2 weeks of IV ceftriaxone. In view of the CSF findings following ceftriaxone therapy, she was commenced on antituberculosis therapy with steroids.

The salmonellae

Salmonellae are Gram-negative, facultative anaerobic bacilli that can colonise a wide range of mammalian hosts. Two distinct species exist, S. enterica and S. bongori. Most of the isolates that are pathogenic in humans belong to S. enterica, comprising more than 2 600 different serovars differentiated by their antigenic presentation.[6] S. enterica are food-borne pathogens capable of causing both intestinal and extraintestinal infections in humans. The innate virulence of each serovar and host resistance are key determinants of clinical manifestations.[7] Human infections are classically divided into diseases caused by typhoidal salmonellae or NTS. The typhoidal serotypes (S. typhi and S. paratyphi) are restricted to human hosts and are highly invasive, but are rarely associated with immuno suppression. In contrast, NTS have a more severe and invasive presentation in immunocompromised adults.[1,7]

Burden of disease and epidemiology

The burden of NTS is significant, with an estimated 93.8 million cases and 155 000 deaths globally each year.[6] Despite global morbidity, mortality is primarily restricted to the developing world. In subSaharan Africa, invasive NTS is a major cause of bacteraemia in adults and children,[7] with an estimated annual incidence of 175 388/100 000 children aged 3 - 5 years and 1 800 - 9 000/100 000 HIV-infected adults.[7,8] Case fatality and relapse rates are high,[7]

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Table 1. CSF findings on admission and after 12 days of antibiotic treatment On admission Protein

2.99 g/L

Glucose

<0.3 mmol/L

Chloride

115 mmol/L

Polymorphonuclear cells

970/µL

Lymphocytes

0/µL

Erythrocytes

60/µL

Gram stain

Gram-negative bacilli

Culture

Salmonella spp.

Sensitivity

Most antibiotics, including ceftriaxone

Cryptococcal latex antigen test

Negative

Gene Xpert

Negative

Following 12 days of IV antibiotics Protein

4.11 g/L

Glucose

2.2 mmol/L

Chloride

106 mmol/L

Polymorphonuclear cells

6/µL

Lymphocytes

106/µL

Erythrocytes

510/µL (traumatic tap)

Gram stain

No bacteria

Culture

No growth

antibiotic resistance is an increasing problem,[9] and no vaccine is currently available.[6] Despite evidence that the initiation of ART in HIV-infected adults leads to a reduction in recurrent invasive NTS disease, there are no population data to demonstrate the impact of ART on the incidence of NTS disease.[7] The incidence of NTS is highest during and after the rainy season in tropical climates and during the warmer months in temperate climates.[8] Certain NTS serovars cause extraintestinal infections, the serotypes varying in different countries. The most common serotypes across Africa are S. typhimurium and S. entiritidis, although investigators at some sites report contributions from other serotypes such as S. isangi in South Africa, S. concord in Ethiopia and S. stanleyville and S. dublin in Mali.[8] Studies conducted in Malawi and Kenya have isolated a novel variant of S. typhimurium (ST 313), which has frequently been implicated in cases of invasive NTS in the sub-Saharan region.[9]

Pathogenesis

Salmonellae are typically acquired from the environment by oral ingestion of contaminated water or food, or through contact with a carrier. Following ingestion, the bacteria bypass gastric defences, multiply, and penetrate the intestinal mucosa. They survive within the macrophages of the reticuloendothelial system and disseminate via the systemic circulation, thereby causing infection.[10] Cellmediated immunity is vital for defence against intracellular bacteria such as salmonellae, and leucocytes, especially lymphocytes, are essential to host defence.[1] The ability of salmonellae to persist depends on a balance between immune responses that lead to the clearance of the pathogen and avoidance of damage to host tissues. [10] In their study evaluating the long-term relationship of Salmonella

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with its host, Ruby et al.[10] showed that the balance of T-helper cells subsets 1 and 2 (Th1/Th2) is crucial for the maintenance of bacterial persistence and survival of the host, as a strong Th1 response leads to clearance of the bacteria, while Th2 skewing leads to susceptibility and death of the host.[10] Three essential immunological defects can probably explain the invasive pathogenesis[8] and high rate of recurrence of NTS in HIVinfected adults.[7] The first involves the gastrointestinal mucosa, which is one of the earliest and most affected sites of CD4 T-cell depletion, especially of interleukin-17-producing T cells (Th17 cells), in HIV infection.[7,8] Th17 cells and their associated family of cytokines are essential for the integrity, repair and maintenance of the epithelial mucosal barrier and enable epithelial cell expression of antimicrobial peptides,[8] thereby playing a vital role in controlling local invasion by Salmonella. Moreover, Th17 cells have an important role in the stimulation of innate immune responses, by mediating neutrophil chemoattraction and function. Secondly, cytokine responses are crucial for control of intracellular Salmonella infection. However, in advanced HIV there is dysregulated cytokine production during intracellular infection, which appears to allow persistence and recurrence of invasive NTS.[1] Thirdly, the significance of antibodies is increasingly recognised, both for serum killing and intracellular oxidative killing of invasive Salmonella. Antibodies directed against Salmonella lipopolysaccharide are shown to impair serum killing by blocking or competing with coexisting effective bactericidal antibodies directed against outer membrane proteins of Salmonella.[7]

Clinical presentation

Clinical manifestations range from subclinical infection to severe life-threatening disease, viz. enteric (68%), Salmonella sepsis (8%), non-enteric focal infections (7%, including meningitis (0.8%)), and a chronic carrier state (15%).[5] NTS infections present primarily with a self-limiting enterocolitis, which often does not require antimicrobial therapy; invasive NTS infections manifest with high fever, hepatosplenomegaly and respira tory complications, with intestinal symptoms often being absent.[8] When Salmonella bacteria enter the systemic circulation, all tissues and organs are susceptible, leading to focal Salmonella infections, including meningitis.[4] It is postulated that high-grade bacteraemia is required for meningeal invasion, although in the case of NTS this bacteraemia may not be detected in up to 40% of cases.[3] Clinical manifestations of NTS meningitis appear to be typical for bacterial meningitis. The mortality rate associated with NTS focal infections is high, in the order of 30% in published series, particularly in the case of meningitis, when it approaches 50%.[3] Impairment of consciousness at presentation has been cited as a risk factor for mortality in such cases,[3] and of patients who do survive, 43% are left with permanent neurological deficits.[4] Ventriculitis, subdural empyema, hydrocephalus and rarely brain abscess are recognised acute neurological complications of Salmonella meningitis.[4] Chronically infected hosts are often asymptomatic and transmit disease to naive hosts via faecal shedding of bacteria, thereby serving as a critical reservoir for disease.[10] However, despite symptoms lasting only for a few days, adults may excrete Salmonella for an average of a month following infection, while children under the age of 5 years shed bacteria in their faeces for an average of 7 weeks.[11] Several studies have shown that treatment with antibiotics can prolong shedding of NTS bacteria,[11] although these findings are controversial.[6] Our patient had no history suggestive of a preceding bout of enterocolitis, yet she had clinical features in keeping with meningitis. It is likely that she had significant bacteraemia (on account of the organism being isolated from the CSF), but was one of the 40% of

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reported cases in whom this may not be detected. Stool microscopy studies were also negative, which eliminated her as a carrier.

Investigations

The diagnosis of NTS infection is based on isolation of the organism from freshly passed stool, or from blood or any other normally sterile body fluid. All salmonellae isolated in clinical laboratories should be sent to local public health departments for serotyping.[3] Once a working diagnosis of meningitis is made, an LP is the key investigation to confirm the clinical suspicion. It is vital to bear in mind the contraindications to such a procedure, especially in resource-limited settings where there may not be ready access to a CT scan facility. According to recently published guidelines for the management of acute meningitis,[12] isolated cranial nerve palsies are not a contraindication to LP, but there is need for vigilance when the patient has a concomitant depressed level of consciousness. The CSF is usually normal or reveals mild pleocytosis, elevated protein and a decreased glucose level.[3] The serotypes isolated from CSF are similar to those causing bacteraemia, and it is has therefore been postulated that no serotype has a particular predilection for the central nervous system.[13]

Treatment

Uncomplicated NTS gastroenteritis should be managed sympto matically, as the symptoms are usually self-limited and the duration of fever and diarrhoea is not significantly decreased by antibiotic therapy; however, antimicrobials may be considered in patients at increased risk of invasive NTS infections.[11] There are no studies indicating the best combined antimicrobial and ART regimen to treat acute infection and prevent relapse.[8] The Infectious Disease Society of America guidelines[8] for the manage ment of invasive NTS in HIV-infected adults recommend 2 - 6 weeks of fluoroquinolone therapy.[8] Feasey et al.[8] propose that rapid initiation of ART may prevent relapse. Moreover, zidovudine has been documented to show anti-Salmonella activity in vitro and appears to be clinically useful in the prevention of relapse of infection.[11] In Africa and most other developing regions, multidrug resistance is an escalating problem and is linked to poor disease outcome.[6] Currently the fluoroquinolones are the first-line agents for salmon ellosis, given their efficacy against intracellular Gram-negative bacteria,[7] with third-generation cephalosporins reserved as secondline agents. Azithromycin (a macrolide) has shown activity against both nalidixic acid-resistant and multidrug-resistant strains.[6] Treatment of Salmonella meningitis is very difficult, and has never been standardised; however, it is recommended that antimicrobial therapy be used for 4 weeks.[13] Prolonged therapy for Salmonella meningitis is indicated in view of slow response and the high probability of relapse (~64%).[4] Various alternative drugs have been used during recent decades, including chloramphenicol, ampicillin, co-trimoxazole, third-generation cephalosporins and fluoroquinolones, with the former three

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producing unsatisfactory results.[13] For meningitis or deep CNS involvement, high-dose ceftriaxone is the best choice for optimal penetration of the blood-brain barrier.[11] There are currently no data to suggest that combination therapy (e.g. a ﬂuoroquinolone with a third-generation cephalosporin) is more effective than either as a single agent.[11,13] Our patient’s treatment regimen unfortunately spanned a period of only 2 weeks, as the finding of sterile CSF following only 12 days of IV ceftriaxone led us to be satisfied with progress and therefore to conclude prematurely that she had been adequately treated. According to suggested guidelines, therapy should have been prolonged for a further 2 weeks. Of note, she had been on ART since 2011 and her HIV viral load was supressed, yet she still acquired an opportunistic NTS infection reflecting her immunosupression (and low CD4 count of only 96 cells/µL). Our decision to commence antituberculosis therapy was prompted by the last LP findings (high CSF protein, low CSF glucose, and a predominant lymphocytosis), her immunocompromised state and chronic tuberculous meningitis being the most likely explanation for her loss of vision. Disclaimer. The views expressed in this article are the author’s own and not an official position of Mahatma Gandhi Memorial Hospital. Acknowledgment. The author thanks Dr Susan Brown for proofreading the article. 1. Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008;56(6):413-422. [http://dx.doi.org/10.1016/j.jinf.2008.03.012] 2. Dhanoa A, Fatt QK. Non-typhoidal Salmonella bacteremia: Epidemiology, clinical characteristics and its association with severe immunosuppression. Ann Clin Microbiol Antimicrob 2009;8:15. [http:// dx.doi.org/10.1186/1476-0711-8-15] 3. Belloso WH, Romano M, Greco GS, et al. Recurrent meningitis and subarachnoid haemorrhage due to Salmonella in an HIV+ patient: Case report and mini-review of the literature. Open AIDS J 2011;5:6266. [http://dx.doi.org/10.1186/1476-0711-8-1510.2174/1874613601105010062] 4. Fuad Khalil AA, Salem A, Rafid A, et al. Salmonella meningitis in an adult with type B viral hepatitis and an incidental schwannoma. BMJ Case Rep 2009;2009:bcr11.2008.1209. [http://dx.doi.org/10.1136/ bcr.11.2008.1209] 5. Ohaiseadha CO, Dunne OM, Desmond F, et al. Salmonella meningitis and septicaemia in an nonimmunocompromised adult, associated with a cluster of Salmonella enteriitidis PT 14b, Ireland, November 2009. Euro Surveill 2010;15(7):pii=19489. http://www.eurosurveillance.org/ViewArticle. aspx?ArticleId=19489 (accessed 7 September 2015). 6. Gal-Mor O, Boyle EC, Grassi GA. Same species; different diseases: How and why typhoidal and non typhoidal Salmonella enterica serovars differ. Front Microbiol 2014;4(5):391. [http://dx.doi. org/10.3389/fmicb.2014.00391] 7. Gordon MA. Invasive non-typhoidal Salmonella disease – epidemiology, pathogenesis and diagnosis. Curr Opin Infect Dis 2011;24(5):484-489. [http://dx.doi.org/10.1097/QCO.0b013e32834a9980] 8. Feasey NA, Dougan G, Kingsley RA, et al. Invasive non-typhoidal Salmonella disease: An emerging and neglected tropical disease in Africa. Lancet 2012;379(9835):2489-2499. [http://dx.doi.org/10.1016/ S0140-6736(11)61752-2] 9. De Jong HK, Parry CM, van der Poll T, et al. Host-pathogen interaction in invasive salmonellosis. PLoS Pathog 2012;8(10):e1002933. [http://dx.doi.org/10.1371/journal.ppat.1002933] 10. Ruby T, McLaughlin L, Gopinath S, et al. Salmonella’s long-term relationship with its host. FEMS Microbiol Rev 2012;36(3):600-615. [http://dx.doi.org/10.1111/j.1574-6976.2012.00332.x] 11. Hohmann EL. Non typhoidal salmonellosis. Clin Infect Dis 2001;32(2):263-269. [http://dx.doi. org/10.1086/318457] 12. Boyles TH, Bamford CM, Bateman K. Guidelines for the management of acute meningitis in children and adults in South Africa. South Afr J Epidemiol Infect 2013;28(1):5-15. 13. Owusu-Ofori A, Scheld WM. Treatment of Salmonella meningitis: Two case reports and a review of the literature. Int J Infect Dis 2003;7(1):53-60. [http://dx.doi.org/10.1016/S1201-9712(03)90043-9]

Accepted 25 August 2015.

October 2015, Vol. 105, No. 10

Building a better society through Education and Capacity Development. Register now for one of our exciting CEU programmes!

METABOLIC SYNDROME

DIAGNOSTIC ULTRASOUND

CLINICAL MANAGEMENT OF THE METABOLIC SYNDROME

SHORT COURSE IN DIAGNOSTIC ULTRASOUND

Metabolic syndrome is a combination of the medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Some studies have shown the prevalence in SA to be estimated at 61% of South Africans who are overweight, obese or morbidly obese. This comprehensive programme shifts away from the limited and often a skewed term obesity to metabolic syndrome which is a better defined and more medically orientated than the often thought of cosmetic corpulence. This course is an interactive, activity based workshop. Medical knowledge changes daily and this course will serve to keep the participant updated as it includes numerous website links and cross references and as these sites evolve and grow with new information so does the content of the course. We believe that this course will serve to be entertaining, user friendly, informative and spark an interest and controversial debate around metabolic syndrome.

COURSE CONTENT This course covers the following modules: • Measurement modalities • Anatomical anomalies • Pathophysiological phenomena • Psycho-social associations • Aetiologies • Congenital • Acquired • Presentations of diseases • Co-morbidities , measurements and management • Specific medical management • Ethical and legal considerations • Controversies

In a report of a WHO scientific group on the future of new imaging technologies in developing countries it was stated that “the difficulties in making accurate diagnosis from ultrasound images are such that the purchase of ultrasound equipment, without making provision for the training of an operator, is contrary to good healthcare practice and is unlikely to be cost effective. Proper training and experience is required, preferably with facilitators who are highly skilled and who have practised ultrasound for many years.

COURSE CONTENT After completing this course participants will be able to: • Choose ultrasound equipment; • Identify the organs in the abdominal cavities, normal abdominal and gynaecological ultrasound anatomy; • Recognise abdominal structures in multiple planes; • Recognise the sectional ultrasound anatomy in the transverse and longitudinal planes; • Describe the patient preparation and position; • Interpret ultrasound findings in common abdominal gynaecological pathologies; • Document ultrasound; • Demonstrate ultrasound imaging; • Understand the criteria for quality and • Understand the capabilities and limitations of ultra-sound.

ACCREDITATION Accredited according to the HPCSA CPD Guidelines for Health Professionals -November 2006, for 30 CEUs on level 2. (Workshop: 10 CEUs, Assessment 20 CEUs)

ACCREDITATION

COURSE FEE, DATES AND VENUE

Accredited according to the HPCSA CPD Guidelines for Health Profes Professionals - November 2006, for 22 CEUs on level 2.

COURSE FEE, DATES AND VENUE

R 5150 (Inclusive of all VAT and taxes where applicable) This amount includes everything except travel and accommodation.

DATE

R 3 770 (Inclusive of all VAT and taxes where applicable) This amount includes everything except travel and accommodation.

DATE

VENUE

17 - 18 October 2015 14 - 15 November 2015

Cape Town Pretoria

REGISTRATION EVELYN MAHLANGU / ASANDA DAANTJIES Tel: (012) 816 9000 / 9105 Fax: 086 502 2071 Email: evelynm@foundation.co.za asandad@foundation.co.za Address: P.O. Box 75324 Lynnwood Ridge 0040 Website: www.foundation.co.za A member of SAIHCM

VENUE

24 - 25 October 2015 Cape Town 21 - 22 November 2015 Durban

REGISTRATION Phindile Mahlangu Tel: 012 816 9174 Fax: 086 567 0279 Email: staceys@foundation.co.za phindilem@foundation.co.za Address: P.O. Box 75324, Lynnwood Ridge, 0040 Website: www.foundation.co.za

Foundation for Professional Development (Pty) Ltd, Registration number 2000/002641/07 Registered with the Department of Education as a Private Institution of Higher Education under the higher education act, 1997. Registration number 2002/HE07/013

A member of the SAMA Group

FORUM

HEALTHCARE DELIVERY

Indications for the use of bronchial thermoplasty in severe asthma K Dheda, C F N Koegelenberg, A Esmail, E Irusen, M E Wechsler, R M Niven, K F Chung, E D Bateman Prof. Keertan Dheda is Head of the Lung Infection and Immunity Unit and the Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa. Prof. Coenie Koegelenberg is a consultant in Pulmonology and Critical Care at Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town. Dr Aliasgar Esmail is a consultant pulmonologist in the Lung Infection and Immunity Unit and the Division of Pulmonology, Department of Medicine and UCT Lung Institute, UCT and Groote Schuur Hospital. Prof. Elvis Irusen is Head of the Division of Pulmonology at Stellenbosch University and Tygerberg Academic Hospital. Prof. Michael Wechsler is Co-Director of the Asthma Institute, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA. Dr Rob M Niven is a consultant chest physician and Senior Lecturer in Respiratory Medicine at the University Hospital of South Manchester NHS Foundation Trust, University of Manchester, UK. Prof. Kian Fan Chung is the Head of Experimental Studies at the National Heart and Lung Institute, Imperial College London and National Institute for Health Research, and Consultant Chest Physician at the Royal Brompton & Harefield NHS Trust. Emeritus Prof. Eric Bateman is Director of the UCT Lung Institute and Honorary Consultant in the Division of Pulmonology, UCT and Groote Schuur Hospital. Corresponding author: K Dheda (keertan.dheda@uct.ac.za)

Approximately 5% of the ~3 million asthmatics in South Africa have severe asthma that is associated with substantial morbidity, cost, absenteeism, preventable mortality, and the requirement for costly chronic medication that may be associated with significant adverse events. There is an unmet need for alternative safer and more effective interventions for severe asthma. A recently introduced option, bronchial thermoplasty (BT), imparts radiofrequency-generated heat energy to the airways to cause regression of airway smooth muscle. The effectiveness of this technique has been confirmed in randomised control trials and is now endorsed by several international guidelines, including the Global Initiative for Asthma (GINA) guideline, the British Asthma Guideline, and the UK National Institute of Clinical Excellence (NICE) guideline. We recommend BT as a potential therapeutic intervention for severe uncontrolled asthma, provided that it is performed by an experienced pulmonologist at an accredited centre and done within the broader context of appropriate management of the disease by doctors experienced in treating difficult-to-control asthma. S Afr Med J 2015;105(10):808-809. DOI:10.7196/SAMJnew.8208

The burden of severe asthma and the unmet need

There are almost 3 million asthma sufferers in South Africa (SA), which ranks fourth highest in asthma mortality globally. In a subset of about 5% of asthma patients, the disease remains uncontrolled despite optimised therapy and good adherence. These individuals experience substantial morbidity, time off work or school, and increased mortality. Severe asthma consumes a disproportionate amount (up to 80%) of asthma-related healthcare resources. Oral corticosteroids, alternative oral agents and biological agents such as omalizumab, when appropriate, are often required to improve or maintain control.[1-3] These therapies are associated with substantial cost and adverse events, and efficacy remains suboptimal. Better tools are urgently needed. A procedure called bronchial thermoplasty (BT) has recently been validated in clinical trials and is now available in over 30 countries worldwide. We summarise key aspects of BT including the concept, the mechanism of action, the efficacy and safety of the procedure, and in what context it should be used in clinical practice. A more comprehensive outline of the procedure, indications and contraindications, adverse events, evidence for long-term efficacy and safety, recommendations about using BT in South Africa, and international guidelines and agencies that have endorsed the procedure was provided in a more detailed article in last month’s SAMJ.[4]

What is bronchial thermoplasty and how does it work?

Bronchial thermoplasty entails imparting radiofrequency-generated heat energy to medium-sized and large airways using a special

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catheter introduced through a bronchoscope (Fig. 1). The procedure takes approximately 45 minutes and is usually performed under conscious sedation with same-day discharge; general anaesthesia can be used in appropriate cases. Three treatment sessions 3 - 4 weeks apart are required. Animal and human studies have demonstrated that BT results in substantial regression of airway smooth muscle,[5,6] but other mechanisms may underpin the beneficial effects, including an impact on airway wall remodelling, immune modulation and neurogenic function.

Efficacy, safety and duration of benefit

The efficacy of BT has been confirmed in two feasibility studies[7,8] and three randomised controlled trials.[9-11] Collectively, these studies have shown that BT improves asthma control and asthma-related quality of life scores. However, most important in patients with severe asthma are reductions in exacerbations, asthma-related emergency room visits, and the need for oral corticosteroids. Two long-term prospective follow-up studies have shown that these benefits are sustained for up to 5 years.[12,13] Three long-term studies have shown that BT is safe and not associated with any long-term adverse events such as bronchiectasis or airway stenosis.[12-14] Short-term adverse effects of the procedure, which occur in 5 - 10% of cases, include precipitation of an exacerbation that may require short-term hospital admission. No pneumothorax, intensive care unit-related admissions, or fatalities have been reported so far among the over 4 000 patients who have undergone the procedure. On the basis of these data, the use of BT for severe asthma has been endorsed by several international guidelines including the 2014 British Thoracic Society/

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Scottish Intercollegiate Guidelines Network (SIGN) Asthma Guideline (British Guideline on the Management of Asthma), the 2014 UK National Institute of Clinical Excellence (NICE) and Global Initiative for Asthma (GINA) guidelines, and the 2014 European Respiratory Society/American Thoracic Society (ERS/ATS) Guidelines on the Definition, Evaluation, and Treatment of Severe Asthma.

When should BT be considered?

BT should be considered in difficult-to-treat asthma when the usual recommended measures described in treatment guidelines have been employed.[1-3] Treatment should have been assessed and optimised by a clinician experienced in managing severe asthma, and should include the following steps: (i) confirmation of the diagnosis of asthma; (ii) exclusion by relevant investigations of alternative diagnoses that can masquerade as asthma, such as chronic obstructive pulmonary disease, cardiac failure, bronchiectasis, vocal cord dysfunction, endo bronchial sarcoidosis and tuberculosis, obstructive airway lesions and inhaled foreign bodies, among others, as potential causes of or contributors to patients’ symptoms (BT is not indicated in bronchopulmonary aspergillosis); (iii) consideration and where possible correc tion of comorbid medical or psychosocial factors that contribute to the failure of asthma control (comorbid conditions include gastrooesophageal reflux disease, rhinosinusitis and drug allergies); (iv) an attempt at nonpharmacological measures such as removal, where possible, of contributing environmental and occupational allergens or factors that precipitate or worsen asthma; and (v) finally, and importantly, optimal pharmacological measures indicated for the treatment of severe asthma (described as steps 4, 5 and 6 in differ ent guidelines) must have been employed under supervision for at least 3 months, with careful checking and confirmation of good inhaler technique and adherence to the drugs. The treatments described on steps 4 and higher are maintenance treatment with at least medium to high doses of inhaled corticosteroid with one or more additional controller medications, which may include a long-acting beta-2agonist (LABA), a long-acting antimuscarinic (tiotropium has recently been approved in many countries for the treatment of severe asthma),[2] slow-release theophylline, and a leukotriene modifier (montelukast). Finally, patients may have received or be taking maintenance oral corticosteroids, or have received treatment with omalizumab.[3] Omalizumab is an injectable monoclonal antibody recently approved for use in SA for patients with severe allergic asthma. Disadvantages of maintenance oral

Fig. 1. Outline of the equipment, the BT procedure, and effects on airway smooth muscle. A: Alair radiofrequency controller; B: Alair BT catheter tip (basket electrode) with the 5 mm spacer markings guiding sequential activations; C: Handle grip controlling expansion of the catheter tip; D: Gel-type return electrode to complete the circuit; E: Foot pedal triggering delivery of the radio frequency-mediated thermal energy; F: BT procedure performed using a flexible fibreoptic bronchoscope; G: Catheter in the bronchus delivering controlled radiofrequency thermal energy; H: Histological sections of dog bronchial wall before (top) and 12 weeks after BT (bottom), showing reduction in airway smooth muscle and preserved integrity of the epithelium, mucous glands and subepithelial tissue;[6] I: Biopsies before and after BT in the lower lobes of two patients, showing reduction in airway smooth-muscle mass (the percentage of airway smooth-muscle surface area/total biopsy area) is shown numerically in the sub-figure. From www.btforasthma.com, reproduced with permission.

corticosteroids are their short- and long-term side-effects, while the use of omalizumab is limited by cost, lack of efficacy in a significant proportion of patients, and the necessity for indefinite use.

Conclusion

BT is indicated in patients with severe asthma who remain uncontrolled despite optimal work-up and medical therapy. BT should only be performed by an experienced pulmonologist at an accredited centre, preferably as part of a national or international registry or a prospective study, so that long-term safety and efficacy can be evaluated. Performed under these strict conditions and according to these recommendations, BT is a useful addition to the treatments available for this debilitating and life-threatening condition. 1. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014;43(2):343-373. [http://dx.doi. org/10.1183/09031936.00202013] 2. Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2015. http://www.ginasthma.org/ (accessed 29 July 2015). 3. SIGN. British Guideline on the Management of Asthma. British Thoracic Society, Scottish Intercollegiate Guidelines Network, 2014. http://www.sign.ac.uk/pdf/SIGN141.pdf (accessed 6 September 2015). 4. Dheda K, Koegelenberg CFN, Esmail A, et al. Recommendations for the use of bronchial thermoplasty in the management of

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severe asthma. S Afr Med J 2015;105(9):726-732. [http://dx.doi. org/10.7196/SAMJnew.8207] 5. Danek CJ, Lombard CM, Dungworth DL, et al. Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs. J Appl Physiol 2004;97(5):1946-1953. [http://dx.doi.org/10.1152/japplphysiol.01282.2003] 6. Pretolani M, Dombret MC, Thabut G, et al. Reduction of airway smooth muscle mass by bronchial thermoplasty in patients with severe asthma. Am J Respir Crit Care Med 2014;190(12):14521454. [http://dx.doi.org/10.1164/rccm.201407-1374LE] 7. Cox G, Miller JD, McWilliams A, Fitzgerald JM, Lam S. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med 2006;173(9):965969. [http://dx.doi.org/10.1164/rccm.200507-1162OC] 8. Miller JD, Cox G, Vincic L, Lombard CM, Loomas BE, Danek CJ. A prospective feasibility study of bronchial thermoplasty in the human airway. Chest 2005;127(6):1999-2006. [http://dx.doi. org/10.1378/chest.127.6.1999] 9. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: A multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med 2010;181(2):116-124. [http://dx.doi.org/10.1164/rccm.200903-0354OC] 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med 2007;356(13):13271337. [http://dx.doi.org/10.1056/NEJMoa064707] 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med 2007;176(12):1185-1191. [http://dx.doi. org/10.1016/j.anai.2013.05.002] 12. Pavord ID, Thomson NC, Niven RM, et al. Safety of bronchial thermoplasty in patients with severe refractory asthma. Ann Allergy Asthma Immunol 2013;111(5):402-407. [http://dx.doi. org/10.1016/j.anai.2013.05.002] 13. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: Long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol 2013;132(6):1295-302. [http:// dx.doi.org/10.1016/j.jaci.2013.08.009] 14. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med 2011;11:8. [http://dx.doi. org/10.1186/1471-2466-11-8]

Accepted 31 July 2017.

FORUM

RECOMMENDATIONS

Recommendations for the use of endoscopic lung volume reduction in South Africa: Role in the treatment of emphysema C F N Koegelenberg, J Theron, K Dheda, J W Bruwer, B W Allwood, M J Vorster, F von Groote-Bidlingmaier, D-J Slebos, P L Shah, F J F Herth Prof. Coenie Koegelenberg is a consultant in pulmonology and critical care at Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa, and the current chairman of Assembly on Interventional Pulmonology of the South African Thoracic Society. Dr Johan Theron is an interventional pulmonologist in private practice at Panorama Mediclinic, Cape Town, and an honorary lecturer at Stellenbosch University. Prof. Keertan Dheda is Head of the Lung Infection and Immunity Unit and the Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town and Groote Schuur Hospital, Cape Town. Dr Willie Bruwer is an interventional pulmonologist in private practice at Windhoek Mediclinic, Namibia. Dr Brian Allwood is a consultant in pulmonology and critical care, Dr Morné Vorster a senior registrar and Dr Florian von Groote-Bidlingmaier an honorary lecturer in the Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital. Dr Dirk-Jan Slebos is a consultant in interventional pulmonology in the Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, The Netherlands. Dr Pallav Shah is a consultant physician in respiratory medicine at Royal Brompton Hospital, London, UK. Prof. Dr. med. Felix Herth is the Director of Pulmonology and Critical Care Medicine, Thoraxklinik, University Hospital Heidelberg, Heidelberg, Germany. Corresponding author: C F N Koegelenberg (coeniefn@sun.ac.za)

Emphysema is a very common cause of morbidity and mortality in South Africa (SA). Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) is increasingly being used internationally for the treatment of advanced emphysema in a subset of patients with advanced disease, aiming to obtain the same functional advantages as surgical lung volume reduction while reducing risks and costs. In addition to endobronchial valves, ELVR using endobronchial coils is now available in SA. The high cost of these interventions underscores the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The Assembly on Interventional Pulmonology of the South African Thoracic Society appointed a committee comprising both local and international experts to extensively review all relevant evidence and provide advice on the use of ELVR in SA based on published evidence, expert opinion and local access to the various devices. S Afr Med J 2015;105(10):810-815. DOI:10.7196/SAMJnew.8147

Chronic obstructive pulmonary disease (COPD) is one of the most common causes of morbidity and mortality in South Africa (SA).[1-3] While smoking remains the most common risk factor for the development of COPD locally, long-term biomass fuel exposure, tuberculosis and HIV also contribute significantly to the disease burden.[4] In addition, poverty has been shown to be associated with an increased burden of COPD.[5] Pharmacotherapy and guidance on smoking cessation continue to form the backbone of management guidelines for COPD in SA.[1,6] In advanced emphysema, therapeutic options are limited. Surgical lung volume reduction is known to improve functional status and mortality, but only in the subgroup of patients with predominant upper-lobe emphysema and low exercise capacity, and at the cost of high morbidity.[7] Endoscopic lung volume reduction (ELVR) refers to bronchoscopically facilitating volume loss to improve pulmonary mechanics and compliance,[8,9] and is now increasingly being used internationally for the treatment of advanced emphysema. The aim of ELVR is to obtain the same functional advantages as surgical lung volume reduction, with reduced risks and costs. These techniques aim to achieve regional reductions in lung volume,[8] thereby decreasing dynamic hyperinflation, with resultant improvement in diaphragm and chest wall mechanics. In addition, endobronchial coils in particular re-tension the airway network and in so doing

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mechanically increase elastic recoil in the emphysematous lungs, tethering open airways and thereby preventing airway collapse.[10] There is a growing body of evidence that certain patients with advanced emphysema benefit from ELVR, provided that a systematic approach is followed and selection criteria are met. In addition to endobronchial valves, endobronchial coils for ELVR are now available in SA. The high cost of these interventions underscores the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The Assembly on Interventional Pulmonology of the South African Thoracic Society appointed a committee comprising both local and international experts to review the evidence and provide advice on the use of ELVR in SA based on published evidence, expert opinion and local access to the devices used for ELVR. The aim is to provide SA pulmonologists with an overview of the efficacy of the various techniques and evidence for their use, and to suggest an evidencebased approach for the appropriate local use of these devices.

1. Modalities and devices currently available in SA 1.1 U nidirectional endobronchial and intrabronchial valves

Unidirectional valves block entrance of air during inspiration, but permit exhalation of air and secretions, causing partial or complete

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lobar collapse. The valves are self-expanding devices that are implanted via a catheter introduced through the working channel of a flexible bronchoscope.[8] Currently, Zephyr endobronchial valves (Pulmonx Inc., USA) and IBV intrabronchial valves (Olympus Respiratory America, USA) are commercially available in SA. Zephyr valves (Fig. 1) are made of a nitinol (nickel titanium) mesh covered by silicone and contain a double silicone membrane that opens during expiration and closes during inspiration. They are available in two sizes, one for segmental (4.0 - 9.0 mm) and one for lobar bronchi (5.5 - 8.5 mm).[8] IBV valves (Fig. 2) are umbrella-shaped devices made of a nitinol mesh covered by a polyurethane membrane, and available in four different sizes (5, 6, 7 and 9 mm).

Fig. 1. Endobronchial (Zephyr) valves of varying diameters for lobar or segmental occlusion.

Fig. 2. Intrabronchial (IBV) valves of varying diameters.

Two major caveats for the use of valves and other bronchial blocking devices are the presence of either a homogeneous distribution of emphysema or significant collateral ventilation.[8] The degree of heterogeneity can be judged either by visual inspection of a high-resolution chest compu ted tomography (HRCT) scan or with specifically designed software. Heterogeneous emphysema is denoted by a >25% difference in emphysema score between ipsilateral upper and lower lobes, measured at a threshold of <−950 Hounsfield units.[11] In the absence of heterogeneous emphysema, bronchial blocking devices are unlikely to be successful.

Similarly, endobronchial blocking devi ces are unlikely to be beneficial in the presence of significant interlobar collateral ventilation. Such collateral ventilation prevents atelectasis and thereby subverts the deflating effect of the devices. The presence of incomplete fissures, seen on an HRCT scan, is considered a proxy for physiological interlobar collateral ventilation. Recent evidence suggests that if the fissures are <75% intact, further evaluation should not be performed as collateral ventilation is always present, whereas with >90% complete fissures, collateral ventilation is practically never present. The Chartis system is an endobronchial catheter system (Chartis Pulmonary Assessment System; Pulmonx Inc.) used to directly measure the percentage of interlobar collateral ventilation in patients with between 75% and 90% fissural integrity.[12] The system is made up of a balloon catheter that is connected to a console and inserted into an airway via a bronchoscope. Once inflated it occludes the bronchus, preventing direct outflow of inspired air. A near-constant rate of expiratory airflow during the assessment is observed in cases with collateral ventilation, whereas a steady reduction in flow is observed in the absence of collateral ventilation.[12] The current evidence for the use of endobronchial and intrabronchial valves is summarised in Table 1. Although nume rous observational and randomised trials showed statistical benefits in respect of practically all functional parameters, minimal clinically important differences (MICDs) were significantly more likely to be observed in patients with advanced heterogeneous emphysema and no collateral ventilation and in those in whom unilateral valve placement achieved complete lobar collapse.[13-19] The most common reported adverse events were pneumothoraces (5 - 10%), mild haemoptysis (2 - 6%) and exacerbations of underlying COPD (8 40%). The recently completed STELVIO trial provided the strongest evidence for use of valves in patients without collateral ventilation.[19] Dutch investigators random ised 68 patients with severe heterogeneous emphysema on HRCT with visual esti mation of complete or near-complete fissures to endobronchial Zephyr valve treatment (n=34) or standard medical care (n=34). The primary outcome measures were change in spirometric measures and 6-minute walking distance (6MWD) at 6 months. Clinical relevance was assessed

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relative to MICDs. At 6 months, the MICDs were attained in all parameters in the treated group compared with controls (p<0.001 for all endpoints).

1.2 Coils

Coils (RePneu; BTG Inc., USA) are nitinol devices (Fig. 3) designed to be straightened for deployment into a subsegmental airway, and thereafter to resume their preformed shape.[10] This conformational shape change after deployment results in parenchymal retraction with volume loss, while maintaining airway patency.[10] The device is currently available in three lengths (100, 125 and 150 mm) to accommodate different-sized airways. The coils are implanted via a flexible bronchoscope under general anaesthesia or conscious sedation and fluoroscopic guidance using a proprietary delivery system.

Fig. 3. Endobronchial (RePneu) coils of varying lengths.

Current evidence (Table 2) suggests that candidates with both heterogeneous and homogeneous emphysema can experience clinically significant benefit from ELVR using coils.[10,20-23] This benefit is obtained regardless of the presence of collateral ventilation, or complete lobar collapse post insertion, but requires that no more than 75% of the total lung parenchyma is destroyed by emphysema prior to inser tion.[11,22] Approximately 75 - 80% of patients will experience MICDs in lung function and quality of life, while mild haemoptysis of <5 mL (50 - 75%), exacerbations of COPD (5 - 12%), mild chest discomfort (15 - 50%) and infrequent pneumothoraces (3%) are the described adverse events.[11,22] A recent report on the 3-year follow-up data of 38 patients who underwent ELVR using coils suggested that the coil treatment was safe; no late pneumothoraces, coil migrations or unexpected adverse events occurred.[23] Although clinical benefit declined gradually over time, at 3 years after treatment approximately 50% of patients maintained improvements in 6MWD and subjective dyspnoea, as well as quality of life scores.

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Table 1. Summary of key clinical studies that evaluated the safety and efficacy of ELVR with valves Primary efficacy measures

Major outcomes

Major adverse events

Study details

Design

Snell et al.,[13] 2003 Number enrolled: 10

Case series: bilateral ELVR (feasibility study)

No major change in radiological findings, lung function or 6MWD; DLCO improved from mean (SD) 7.47 (2.0) to 8.26 (2.6) mL/min/ mmHg (p=0.04)

No major complications (at 30 days). Minor complications included exacerbation of COPD (n=3), asymptomatic pneumothorax (n=1) and pneumonia (n=1)

Showed that ELVR with valves was feasible and safe, but that further studies were needed to explore patient characteristics that determine symptomatic efficacy

Comments

Toma et al.,[14] 2003 Number enrolled: 8

Case series: unilateral ELVR (feasibility study)

Median FEV1 increased from 0.79 to 1.06 L (p=0.028) and median DLCO from 3.05 to 3.92 mL/min/ mmHg (p=0.017)

Pneumothorax (n=2)

Acceptable short-term safety

VENT (USA) trial (Sciurba et al.[15]), 2010 Number enrolled: 321

RCT (2:1): unilateral ELVR v. standard medical care

Changes in FEV1 and 6MWD at 6 months

FEV1 1.9% higher (p=0.007) and 6MWD 19.1 m more (p=0.02) in treated group; SGRQ decreased by 3.4 (p=0.04)

COPD exacerbation requiring hospitalisation (7.9% v. 1.1%) (p=0.03) and haemoptysis (6.1% v. 0% (p=0.01). Pneumonia in target lobe (4.2%)

Greater radiographic evidence of emphysema heterogeneity and fissure completeness was associated with an enhanced response to treatment

VENT (Europe) trial (Herth et al.[16]), 2012 Number enrolled: 60

RCT (2:1): unilateral ELVR v. standard medical care

Changes in FEV1, cycle ergometry and SGRQ at 6 months

Mean change in FEV1 7.0% v. 0.5% (p=0.067); cycle ergometry 2W v. 3W (p=0.04); SGRQ –5 v. 0.3 points (p=0.047)

Pneumothorax (n=5). No difference in COPD exacerbation rates

Superior clinical results with computed tomography suggestive of complete fissures and with successful lobar occlusion

Ninane et al.,[17] 2012 Number enrolled: 73

Sham-controlled study (1:1): bilateral ELVR without lobar collapse

≥4-point improvement in SGRQ

24% responders in treated group v. 0% in control group (p=0.002)

COPD exacerbation 13% v. 9% (p=0.595)

Not effective in majority; major finding was that complications are due to bronchoscopy itself rather than device

Eberhardt et al.,[18] 2012 Number enrolled: 22

RCT (1:1): bilateral (incomplete occlusion ) v. unilateral (for total occlusion) treatment

FEV1, 6MWD, SGRQ

FEV1 improved in unilaterally treated group but not in the other group (21.4% v. 0.03%) (p=0.002)

Respiratory failure (n=2), pneumothorax (n=1)

Unilateral valve placement with complete occlusion superior to bilateral partial occlusion

STELVIO trial (Klooster et al.[19]), 2015 Number randomised: 68

RCT (1:1): unilateral ELVR (collateral ventilation excluded) v. standard medical care

FEV1, FVC, RV and 6MWD at 6 months

FEV1 22.7%, FVC 442 mL, RV –831 mL, 6MWD 106 m and SGRQ –14.7 points superior in treated group (all p<0.001)

Pneumothorax 17.6%

Best evidence that ELVR with valves in the absence of collateral ventilation results in statistically and clinically significant improvements in pulmonary function, exercise capacity and quality of life

RCT = randomised controlled trial; NA = not applicable; FEV1 = forced expiratory volume in 1 second; 6MWD = 6-minute walking distance; SGRQ = St George’s respiratory questionnaire; W=watt; FVC = forced vital capacity; RV = residual volume; DLCO = carbon monoxide diffusing capacity; SD = standard deviation.

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Table 2. Summary of key clinical studies that evaluated the safety and efficacy of ELVR with coils Study details

Design

Efficacy measures

Outcome

Major adverse events

Comments

Herth et al.,[10] 2010 Number enrolled: 11

Case series (feasibility study)

COPD exacerbations (mild), no pneumothorax

ELVR with coils was deemed safe and feasible

Slebos et al,[20] 2012 Number enrolled: 16

Prospective cohort pilot study

SGRQ, FEV1, FVC, RV, 6MWD

SGRQ improved by 14.9 points (in 11 patients by >4 points), FEV1 by 14.9%, FVC by 13.4%, RV by 11.4% and 6MWT by 84.4 m (all p<0.005)

Pneumothorax (n=1), pneumonia (n=2), COPD exacerbation (n=6), chest pain (n=4), mild (<5 mL) haemoptysis (n=21)

First study to show signiﬁcant improvements in pulmonary function, exercise capacity, and quality of life

RESET trial (Shah et al.[21]), 2013 Number enrolled: 47

RCT (1:1): bilateral ELVR v. standard medical care

SGRQ

−8.63 (p=0.04)

COPD exacerbation (4%)

Evidence of improved quality of life

Deslee et al.,[11] 2014 Number enrolled: 60

Prospective multicentre cohort trial

SGRQ, pulmonary function testing, mMRC and 6MWD up to 12 months

ΔSGRQ −11.1 points, Δ6MWD +51.4 m, ΔFEV1 +0.11 L, and ΔRV −0.71 (all p<0.01)

COPD exacerbation (6.1%), pneumonia (5.2%), pneumothorax (3.5%), haemoptysis (0.9%)

Significant responses for both heterogeneous and homogeneous emphysema

Klooster et al.,[22] 2014 Number enrolled: 10

Prospective singlecentre cohort trial

Change in 6MWD at 6 months

6MWD improved from 289 to 350 m (p=0.005), FVC from 2.17 to 2.55 L (p=0.047), RV from 5.04 to 4.44 L (p=0.007) and SGRQ from 63 to 48 points (p=0.028)

Pneumothorax (n=1), slight (<5 mL) haemoptysis (n=5), chest discomfort (n=6), COPD exacerbation (n=5)

The benefit of LVR coil treatment is not limited to patients with heterogeneous emphysema

Hartman et al.,[23] 2015 Number enrolled: 38

Prospective singlecentre cohort trial

mMRC, pulmonary function testing and 6MWD at 5 years

Significant improvement in mMRC score remained, with 40% of the patients reaching the 6MWD MICD and 59% the SGRQ MICD

No device-related complications

Best long-term data on safety of coils

NA = not applicable; SGRQ = St George’s respiratory questionnaire; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; RV = residual volume; 6MWD = 6-minute walking distance; mMRC = modified Medical Research Council dyspnoea score; Δ = change.

2. Modalities not available in SA

2.3 Vapour

2.1 Bronchial spigots

Watanabe Spigots (Novatech, France) have been used successfully in the management of pulmonary fistula and persistent pneumothorax with continuous air leakage.[24] Despite many reports describing successful treatment of persistent air leaks using endobronchial Watanabe Spigots, evidence for their use in the context of ELVR for emphysema is lacking.

2.2 Sealants

The AeriSeal system (Aeris Therapeutics Biological, Pulmonx Inc.) uses synthetic polymeric foam to obtain atelectasis. A recent multi centre randomised controlled trial, terminated early for financial reasons, confirmed significantly improvements from baseline in lung function, dyspnoea and quality of life when compared with controls at 3 months, but the fact that 44% of treated patients experienced adverse events requiring hospitalisation (including two deaths) raised some safety concerns.[25]

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Bronchoscopic thermal vapour ablation (InterVapor; Uptake Medical, USA) uses high-temperature water vapour delivered into the target lung segments through a catheter with precise amount of energy, thereby inducing thermal damage resulting in permanent airway fibrosis.[8] Although one potential advantage of this technology is that it is not influenced by interlobar collateral ventilation, it has been shown to have a relatively modest effect on lung function.[26,27] Adverse events, particularly COPD exacerbations, are frequently observed.[28]

2.4 Airway bypass

The technique of airway bypass is based on the creation of extraanatomical passages between the hyperinflated lung parenchyma and larger airways.[8] Evidence suggests that although some shortterm benefit may be achieved in patients with severe hyperinflation, pulmonary function appears to return to baseline within 3 months.[29-31]

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3. Evaluation of candidates for potential lung volume reduction

The initial screening of potential candidates with stable disease should ideally be performed by pulmonologists, and should include an assessment of severity of dyspnoea, functional impairment, past thoracic surgery, comorbidities and smoking status. Routine special investigations should include an HRCT scan (to estimate heterogeneity, integrity of fissures and degree of tissue destruction, and to exclude occult malignancy), full pulmonary function testing (including measurements of forced expiratory volume in 1 second, forced vital capacity, residual volume (RV), RV/total lung capacity (TLC), TLC, carbon monoxide diffusing capacity and 6MWD), arterial blood gas measurement and echocardiography (to exclude pulmonary artery pressures >50 mmHg). The general indications for and contra indications to valves and coils are summar ised in Table 3. ELVR should not be offered to active smokers, patients with pulmonary hypertension, unstable cardiac patho logy, active respiratory infections, a very poor exercise tolerance or no clear evidence of hyperinflation, or to patients on any type of long-term antiplatelet or anticoagulant therapy that cannot be stopped 7 days before the procedure. Appropriate or borderline candidates should be referred to a centre with the capacity to evaluate and treat them and follow them up, including managing complications and removal of devices if required. These centres should individualise the interventions on the basis of disease phenotype (e.g. heterogeneous v. homogeneous disease), degree of tissue destruction, the presence of collateral ventilation and pulmonary impairment.

4. S uggested approach to ELVR in SA

There is currently no official guideline from any of the major thoracic societies and no head-to-head evidence comparing the various techniques and devices. The Assembly on Interventional Pulmonology of the SA Thoracic Society has therefore based the approach summarised in Fig. 4 on the available published evidence, availability of the devices in SA and international expert opinion. The degree of severity of emphysema, the degree of tissue destruction, heterogeneity of the disease and the presence of collateral ventilation are all important factors in the final selection process.[8] The algorithm presented in Fig. 4 should not be viewed as a rigid guideline, and the clinician should still

Table 3. General indications for and contraindications to ELVR with endobronchial and intrabronchial valves and coils in patients with stable emphysema Indications 40 - 75 years Heterogeneous emphysema and no collateral ventilation (valves)* Dyspnoea despite maximal medical therapy and pulmonary rehabilitation FEV1 15 - 45% Hyperinflation with TLC >100% and RV >150 - 175% PaCO2 <6.7 kPa (50 mmHg) PaO2 >6 kPa (45 mmHg) while breathing ambient air 6MWD ≥140 m (after rehabilitation) Contraindications Homogeneous emphysema (valves)* Collateral ventilation/non-intact fissures (valves)* >75% parenchymal destruction on HRCT (coils)† Current smoking (past 6 months) DLCO <20% (relative) Giant bullae (>1/3 of hemithorax) Alpha-1-antitrypsin deficiency Previous thoracotomy, pleurodesis or chest wall deformity Excessive sputum Severe pulmonary hypertension (>50 mmHg) Active infection Unstable cardiac conditions Significant pleural or interstitial changes on HRCT ny type of antiplatelet or anticoagulant therapy that cannot be stopped for 7 days prior to A procedure FEV1 = forced expiratory volume in 1 second; TLC = total lung capacity; RV = residual volume; PaCO2 = partial pressure of carbon dioxide; PaO2 = partial pressure of oxygen; 6MWD = 6-minute walking distance; DLCO = carbon monoxide diffusing capacity. *Specific for endobronchial and intrabronchial valves. † Specific for endobronchial coils.

use discretion, especially in those patients who may potentially benefit from either coils or valves. For example, patients with 25 - 75% tissue destruction and no collateral ventilation may also benefit from valves, although the reported response rates and improvements in functional status and pulmonary function tests seem to be greater with coils.[7-9,16,19] It is recommended that all ELVR procedures should be performed in the context of a local and/or international registry. The Assembly on Interventional Pulmonology of the SA Thoracic Society is willing to assist potential centres wanting to establish an ELVR service in terms of training and accreditation.

5. Conclusions

Appropriate candidates with marked hyper inflation and relatively preserved lung parenchyma are more likely to benefit from ELVR with bilateral coils, irrespective of the collateral ventilation and heterogeneity

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of the disease. In contrast, patients with heterogeneous disease and no collateral ventilation are more likely to benefit from unilateral ELVR with valves, aiming to achieve complete lobar collapse. A well-structured evidence-based approach to ELVR, including initial screening and subsequent referral to a specialised centre, is important to avoid inappropriate use of devices, which may be both wasteful and harmful. Author contributions. The article was written by CFNK and JT, and extensively reviewed by KD, JWB, BWA, MJV, FvG-B, D-JS, PLS and FJFH. Conflicts of interest. FJFH and D-JS have performed consultant work for PulmonRx, PneumRx, Uptake Medical and Aeris. The remaining authors have nothing to declare. 1. Abdool-Gaffar M, Ambaram A, Ainslie G, et al. Guideline for the management of chronic obstructive pulmonary disease – 2011 update. S Afr Med J 2011;101(1):63-73.

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Initial review of patient with stable emphysema (performed by pulmonologist) • 40 - 75 years old • Dyspnoea despite maximal medical therapy & pulmonary rehabilitation • FEV1 15 ‐ 45% • Hyperinflation (TLC >100% & RV >150 - 175%) • PaCO2 <6.7 kPa • PaO2 >6 kPa (ambient air) • 6MWD ≥140 m

General inclusion criteria

General exclusion criteria

• • • • • • • • •

Current smoking (last 6 months) DLco <20% Giant bullae (>1/3 of hemithorax) α1-antitrypsin deficiency Previous thoracotomy, pleurodesis or chest wall deformity Severe pulmonary hypertension (>50 mmHg) Active infection or unstable cardiac conditions Significant pleural or interstitial changes on HRCT Antiplatelet/anticoagulant therapy that cannot be stopped

Modality-specific review by specialist centre

LVR not an option

Parenchymal destruction on HRCT

≤75%

>75%

* Heterogeneous disease

Homogeneous disease

Collateral ventilation (HRCT reconstruction or Chartis) Negative Positive (with low baseline perfusion) (with low excercise capacity)

Coils

Valves

Consider LVRS

Fig. 4. Suggested approach to ELVR in SA. (*Patients with 25 - 75% of tissue destruction and no collateral circulation may also benefit from valves, although the reported response rates and improvements in functional status and pulmonary function test seem to favour ELVR with coils. LVR = lung volume reduction; LVRS = lung volume reduction surgery; FEV1 = forced expiratory volume in 1 second; TLC = total lung capacity; RV = residual volume; PaCO2 = partial pressure of carbon dioxide; PaO2 = partial pressure of oxygen; 6MWD = 6-minute walking distance; DLCO = carbon monoxide diffusing capacity.) 2. Koegelenberg CFN, Theron J, Bruwer JW, Allwood BW, Vorster MJ, Dheda K. Endoscopic lung volume reduction in severe emphysema. S Afr Med J 2015;105(9):1-3. [http://dx.doi.org/10.7196/ SAMJnew.8144] 3. Vorster M, Koegelenberg CFN. Lung volume reduction in chronic obstructive pulmonary disease. S Afr Med J 2015;105(9):791. [http://dx.doi.org/10.7196/SAMJnew.8427] 4. Allwood B, Myer L, Bateman E. A systematic review of the association between pulmonary tuberculosis and the development of chronic airflow obstruction in adults. Respiration 2013;86(1):76-85. [http:// dx.doi.org/10.1159/000350917] 5. Burney P, Jithoo A, Kato B, et al. Chronic obstructive pulmonary disease mortality and prevalence: The associations with smoking and poverty – a BOLD analysis. Thorax 2014;69(5):465-473. [http://dx.doi. org/10.1136/thoraxjnl-2013-204460] 6. Van Zyl-Smit R, Allwood B, Stickells D, et al. South African tobacco smoking cessation clinical practice guideline. S Afr Med J 2013;103(11):869-876. [http://dx.doi.org/10.7196/SAMJ.7484] 7. National Emphysema Treatment Trial Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348(21):2059-2073. [http:// dx.doi.org/10.1056/NEJMoa030287] 8. Gasparini S, Zuccatosta L, Bonifazi M, Bolliger CT. Bronchoscopic treatment of emphysema: State of the art. Respiration 2012;84(3):250-263. [http://dx.doi.org/10.1159/000341171] 9. Koegelenberg CFN, Slebos D-J, Shah PL, et al. Time for the global rollout of endoscopic lung volume reduction. Respiration 2015 (in press). 10. Herth FJF, Eberhard R, Gompelmann D, Slebos D-J, Ernst A. Bronchoscopic lung volume reduction with a dedicated coil: A clinical pilot study. Ther Adv Respir Dis 2010;4(4):225-231. [http://dx.doi. org/10.1177/1753465810368553] 11. Deslee G, Klooster K, Hetzel M, et al. Lung volume reduction coil treatment for patients with severe emphysema: A European multicentre trial. Thorax 2014;69(11):980-986. [http://dx.doi.org/10.1136/ thoraxjnl-2014-205221] 12. Schuhmann M, Raffy P, Yin Y, et al. CT predictors of response to endobronchial valve lung reduction treatment: Comparison with Chartis. Am J Respir Crit Care Med 2015;191(7):767-774. [http://dx.doi. org/10.1164/rccm.201407-1205OC] 13. Snell G, Holsworth L, Borrill Z, et al. The potential for bronchoscopic lung volume reduction using bronchial prostheses: A pilot study. Chest 2003;124(3):1073-1080. [http://dx.doi.org/10.1378/chest.124.3.1073] 14. Toma T, Hopkinson N, Hillier J, et al. Bronchoscopic volume reduction with valve implants in patients with severe emphysema. Lancet 2003;361(9361):931-933. [http://dx.doi.org/10.1016/S01406736(03)12762-6] 15. Sciurba FC, Ernst A, Herth FJF, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med 2010;363(13):1233-1244. [http://dx.doi.org/10.1056/NEJMoa0900928] 16. Herth FJF, Noppen M, Valipour A, et al. Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort. Eur Respir J 2012;39(6):1334-1342. [http://dx.doi. org/10.1183/09031936.00161611] 17. Ninane V, Geltner C, Bezzi M, et al. Multicentre European study for the treatment of advanced emphysema with bronchial valves. Eur Respir J 2012;39(6):1319-1325. [http://dx.doi. org/10.1183/09031936.00019711]

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18. Eberhardt R, Gompelmann D, Schuhmann M, et al. Complete unilateral vs partial bilateral endoscopic lung volume reduction in patients with bilateral lung emphysema. Chest 2012;142(4):900-908. [http:// dx.doi.org/10.1378/chest.11-2886] 19. Klooster K, ten Hacken N, Hartman J, Kerstjens H, van Rikxoort E, Slebos D. Endobronchial valve treatment versus standard medical care in patients with emphysema without interlobar collateral ventilation (the STELVIO-Trial). Am J Respir Crit Care Med 2015;191(9):A6312. 20. Slebos DJ, Klooster K, Ernst A, Herth FJF, Kerstjens HM. Bronchoscopic lung volume reduction coil treatment of patients with severe heterogeneous emphysema. Chest 2012;142(3):574-582. [http:// dx.doi.org/10.1378/chest.11-0730] 21. Shah PL, Zoumot Z, Singh S, et al. Endobronchial coils for the treatment of severe emphysema with hyperinflation (RESET): A randomised controlled trial. Lancet Respir Med 2013;1(3):233-240. [http:// dx.doi.org/10.1016/S2213-2600(13)70047-X] 22. Klooster K, ten Hacken NHT, Franz I, Kerstjens HA, van Rikxoort EM, Slebos D-J. Lung volume reduction coil treatment in chronic obstructive pulmonary disease patients with homogeneous emphysema: A prospective feasibility trial. Respiration 2014;88(2):116-125. [http://dx.doi.org/10.1159/000362522] 23. Hartman J, Klooster K, Gortzak K, ten Hacken N, Slebos D. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology 2015;20(2):319-326. [http://dx.doi.org/10.1111/resp.12435] 24. Watanabe Y, Matsuo K, Tamaoki A, Komoto R, Hiraki S. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchology Interv Pulmonol 2003;10(4):264-267. [http://dx.doi.org/10.1097/00128594200310000-00005] 25. Come C, Kramer M, Dransfield M, et al. A randomised trial of lung sealant versus medical therapy for advanced emphysema. Eur Respir J 2015;46(3):651-662. [http://dx.doi.org/10.1183/09031936.00205614] 26. Snell G, Hopkins P, Westall G, Holsworth L, Carle A, Williams T. A feasibility and safety study of bronchoscopic thermal vapor ablation: A novel emphysema therapy. Ann Thorac Surg 2009;88(6):19931998. [http://dx.doi.org/10.1016/j.athoracsur.2009.06.038] 27. Snell G, Herth F, Hopkins P, et al. Bronchoscopic thermal vapour ablation therapy in the management of heterogeneous emphysema. Eur Respir J 2012;39(6):1326-1333. [http://dx.doi. org/10.1183/09031936.00092411] 28. Bandyopadhyay S, Henne E, Gupta A, et al. Segmental approach to lung volume reduction therapy for emphysema patients. Respiration 2015;89(1):76-81. [http://dx.doi.org/10.1159/000369036] 29. Choong C, Macklem P, Pierce J, et al. Airway bypass improves the mechanical properties of explanted emphysematous lungs. Am J Respir Crit Care Med 2008;178(9):902-905. [http://dx.doi.org/10.1164/ rccm.200712-1832OC] 30. Cardoso P, Snell G, Hopkins P, et al. Clinical application of airway bypass with paclitaxel-eluting stents: Early results. J Thorac Cardiovasc Surg 2007;134(4):974-981. [http://dx.doi.org/10.1016/j.jtcvs.2007.05.040] 31. Shah P, Slebos D, Cardoso P, et al. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): Randomised, sham-controlled, multicentre trial. Lancet 2011;378(9795):9971005. [http://dx.doi.org/10.1016/S0140-6736(11)61050-7]

Accepted 1 July 2015.

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EDITORIAL

Geography should be taught at medical school Geography in the South African (SA) context is as singular a driver of health-seeking behaviour as the burden of disease. This is the dilemma facing the rural patient presented with the ‘choice’ of health facilities where access could mean long transit times, or as is often the case, an expensive commute.[1] Geography, and more specifically infrastructure (or the lack thereof in rural areas), has long been identified as affecting access to health services, and by extension, disease outcome.[1,2] Nowhere is this more acutely felt than in the field of emergency medicine, where notions such as definitive care and the ‘golden hour’ seem to form an integral part of the therapeutic discourse. While health system ‘engineers’ and decision-makers appear to be cognisant of this challenge, it seldom manifests into equitable, affordable, available, acceptable and accommodating access. This manifests itself in the steady proliferation of health systems solutions to non-healthcare problems. There remains a need for collaborative and committed engagement between health and other government sectors and stakeholders (e.g. transport, community safety, etc.) with the aim of jointly meeting these challenges in creative and innovative ways. In this issue of SAMJ, Newton et al.[3] explore the appropriateness of emergency medical service (EMS) responses in the eThekwini district of KwaZulu-Natal Province, SA, and suggest that current practices result ‘in the wastage of expensive and limited resources that could be better utilised elsewhere’. This is the challenge we face in SA emergency care: overburdened prehospital and in-hospital systems, and patients caught in the middle, shunted from one area to another. As Wallis[4] put it in an SAMJ editorial in 2011, ‘where you live determines your chance of timely, appropriate, high-quality trauma care’. For patients in under-resourced areas, being able to make the distinction between health problems appropriate for a primary care clinic v. appropriate for a hospital is often impossible, and when accessing a local clinic on foot or by public transport is difficult, calling an ambulance may be a reasonable option. According to the SA Constitution (section 27(3)), no one may be refused emergency medical care, and by implication, all citizens have the right to access emergency care.[5] The distinctions around what is emergency care, who should provide it and where it should be provided are often out of the realm of the average person. While we do not deny that there is a need for community education and advocacy regarding the use of healthcare resources, we need to create a responsible citizenry who understand and accept the challenges of providing a critical emergency service under conditions of austerity. This will not be easy to achieve, but concerted efforts are needed to create and sustain dialogue between the public and EMS role players, a dialogue aimed at fostering meaningful and effective partnerships within the community, in order to create responsible and accountable service users but also facilitating safe ‘spaces’ for practitioners to render emergency care without fear of hostility or abuse. These partnerships may include community basic first-responder education and the establishment of community response networks, both of which have proven effective in empowering communities and creating engagement with emergency services.[6,7] However, we cannot completely defer responsibility to the citizenry – the onus is on the health system and its agents at key points (EMS dispatcher, prehospital provider, clinic and hospital receiving staff) to ensure that resource-appropriate decisions are made and guided by local policies. This is where a functional EMS system able to make these critical decisions becomes key. This is a challenge for us in SA, where far

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too many services are still reliant on paper-based systems. The poor and often flawed adoption of technology coupled with the absence of industry benchmarks or best practice is compounded by inappropriately trained agents and supervision.[8] These deficiencies are evident in the failure to establish a single national emergency number and the failure to establish GIS (Geographic Information System) location of emergency incidents. Geographical modelling for the distribution and deployment of EMS resources has been proven to be a useful tool to reduce morbidity and mortality globally.[9,10] EMS communication centres have the potential to become health intelligence resource centres, able to generate powerful data and analysis on several aspects of the health service. If we are to fully harness the potential that exists within our emergency care system, we will need to invest in our human capital – creating skilled staff able to develop and interpret these data. The SA EMS industry is not short of talent, but must become more integrated with the overall healthcare system, participatory and collaborative in terms of planning and pathways. Our emergency services, both in and out of hospital, are over burdened. Creating equitable access to care for all, rural and urban, is an ongoing challenge and needs a number of components: an informed and engaged community, a skilled and empowered EMS communication system, and an integrated healthcare system with policies and protocols to guide patients to the most appropriate site to receive appropriate care. And in the midst of all the resource protection, we must remember that there is still a patient – a person – at the centre of it all. Shaheem de Vries Director, Western Cape Emergency Medical Services, Cape Town, South Africa Heike Geduld Western Cape Emergency Medical Services, Cape Town, South Africa, and Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town Corresponding author: H I Geduld (heike.geduld@uct.ac.za) 1. Harris B, Goudge J, Ataguba JE, et al. Inequalities in access to health care in South Africa. J Public Health Policy 2011;32(Suppl 1):S102-S123. [http://dx.doi.org/10.1057/jphp.2011.35] 2. McLaren Z, Ardington C, Leibbrandt M. Distance as a Barrier to Health Care Access in South Africa. A Southern Africa Labour and Development Research Unit Working Paper Number 97. Cape Town: SALDRU, University of Cape Town, 2013. 3. Newton PR, Naidoo R, Brysiewicz P. The appropriateness of emergency medical services (EMS) responses in the eThekwini district of KwaZulu-Natal, South Africa. S Afr Med J 2015;105(10):844847. [http://dx.doi.org/10.7196/SAMJnew.8273] 4. Wallis LA. Trauma care in South Africa – a call to arms. S Afr Med J 2011;101(3):171. 5. South Africa. The Constitution of the Republic of South Africa. 1996. www.justice.gov.za (accessed 3 September 2015). 6. Sun J, Wallis LA. The emergency first aid responder system model: Using community members to assist life-threatening emergencies in violent, developing areas of need. Emerg Med J 2012;29(8):673678. [http://dx.doi.org/10.1136/emermed-2011-200271] 7. Sun J, Shing R, Twomey M, Wallis LA. A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa. Injury 2014;45(1):31-38. [http://dx.doi.org/10.1016/j.injury.2012.08.015] 8. Mould-Millman N, de Vries S, Stein C, et al. Developing emergency medical dispatch systems in Africa – recommendations of the African Federation for Emergency Medicine/International Academies of Emergency Dispatch Working Group. African Journal of Emergency Medicine 2015;5(3):141-147. [http://dx.doi.org/10.1016/j.afjem.2015.06.005] 9. Vanderschuren M, McKune D. Emergency care facility access in rural areas within the golden hour: Western Cape case study. Int J Health Geogr 2015;14(1):5-13. [http://dx.doi.org/10.1186/1476072X-14-5] 10. Kobusingye OC, Hyder AA, Hicks ER, Mock C, Joshipura M. Emergency medical systems in low-and middle-income countries: Recommendations for action. Bull World Health Organ 2005;83(8):626631. [http://dx.doi.org/10.1590/S0042-96862005000800017]

S Afr Med J 2015;105(10):816. DOI:10.7196/SAMJ.9980

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Impact of transthoracic echocardiography at district hospital level W F Bedeker,1 MB ChB; A S Lachman,2 FCP (SA), FACC; M Borkum,3 MB ChB, FCP (SA); D Hellenberg,1 MB ChB, MFamMed, FCFP (SA); C S Cupido,2 MB ChB, FCP (SA) ivision of Family Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa D Victoria Hospital, Wynberg, Cape Town, South Africa 3 Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa 1 2

Corresponding author: W F Bedeker (wfbedeker@gmail.com)

Background. The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has not translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinical impact, limiting generalisability to resource-constrained settings. Objectives. To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa. Methods. A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a 5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation with the referring doctor’s diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as well as usefulness without a change in management. Results. The results show that 83.8% of the patients’ management was impacted on by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment after myocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor’s diagnosis, yet were still associated with a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients to determine referral to a tertiary facility. Conclusion. ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. This should alert policy makers against restriction of access to ECHO and promote training of personnel in its use. S Afr Med J 2015;105(10):817-822. DOI:10.7196/SAMJnew.8102

The use of and demand for echocardiography (ECHO) have shown a marked increase worldwide. [1] As a ‘special’ investigation it has the potential to pro vide accurate haemodynamic as well as anatomical information non-invasively at the bedside.[1-3] Developing countries are showing a steady rise in non-communi cable diseases (NCDs), with cardiovascular diseases proving the largest burden in South Africa (SA).[4,5] The dual burden of communicable diseases and NCDs is disproportionately affecting vulnerable lowerincome groups in urban settings.[4] Ironically, patients accessing hospitals with the least available specialist expertise have been shown to have the highest number of comorbidities.[6] Access to investigations such as ECHO, traditionally and often exclusively at the hands of specialist cardiologists, remains restricted and uneven in SA. Recent advances in the developed world include open-access echocardiography (OAE), which is requested and the results acted on by general practitioners, hand-held devices, and point-of-care studies by non-cardiologists.[2,7-9] Apart from their usefulness in screening patients, appropriate care can be implemented at an earlier stage and waiting times for, or referrals to, tertiary care can be reduced. The main limitation for the roll-out of ECHO to primary healthcare settings is the lack of training of personnel.[10] A few recent studies have reviewed the utility of ECHO in large, mainly tertiary centres in the developed world.[11-13] The use is driven mainly by appropriate-use criteria (AUC). These AUC identify common clinical scenarios in which ECHO can be applied and aim

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at improving health outcomes by means of the equitable allocation of resources in cardiovascular imaging.[14] There is a paucity of data regarding the impact of ECHO in sub-Saharan Africa. Various definitions of impact and the different concepts of a district or general hospital limit the generalisability to resource-constrained areas, where, paradoxically, the clinical impact of ECHO may be of more value than the traditionally accepted clinical indications.

Objectives

To assess the clinical impact of an ECHO service in a district hospital in SA. Further conclusions on the demand to access and need for training in echocardiography were possible.

Methods

A prospective, descriptive, cross-sectional study was conducted at Victoria Hospital, a district-level hospital in Cape Town, SA, serving a patient population (in 2014) of nearly 600 000, mainly of low and middle socioeconomic status. The study cohort consisted of patients referred to the once-weekly ECHO service during the 14-week period between September 2013 and January 2014. Recruitment of study participants was achieved on the day of the prebooked ECHO appointments. All in- and outpatient referrals were considered, regardless of age and comorbidities. Patients unable to give written consent were excluded. Only screening transthoracic echocardiography (TTE) was included. It was performed by a registered cardiologist, accredited to perform ECHO.

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EpiCalc (freeware, version 1.02, 2000) was used to calculate the sample size. It was assumed that 80% of management decisions would change following results of the ECHO. To achieve a confidence level of 95% with a precision of 5% (i.e. a margin of error of 10%), a sample size of 245 patients was required. Data were collected prospectively, as the ECHO was performed. A questionnaire concerning patient characteristics and medical history was completed by the participant with the help of a research assistant. The cardiologist who performed the ECHO completed a second questionnaire in order to establish the impact of the ECHO by assessing the indication for the investigation, new information obtained, correlation with the referring doctor’s diagnosis and the management plan thereafter. AUC were used to classify indications explicitly. The average waiting period was randomly calculated on four dates, reviewing the time until the next available appointment. The cardiologist used a Toshiba Nemio machine with an adult ECHO probe PST25AT (1.8 - 4.2 mHz). The patients were screened in the supine and left lateral positions. Examinations were viewed in real time and done in standard trans thoracic views, parasternal long and short axis with apical four-chamber views; subxyphoid views were included when indicated. M-mode, 2D and colour flow Doppler were utilised. The ejection fraction was measured using the Teicholz method. Regional wall motion was visually evaluated in the abovementioned views. Continuous Doppler was not available on the machine, but colour flow Doppler was used when necessary. M-mode recording was done and printed out when deemed necessary, but not stored. The ECHOs performed were for screening purposes only and were not standard transthoracic evaluations. Even though some patients had repeated TTE, most patients did not have a baseline standard study. Impact was classified according to adapted criteria (Table 1).[11-13]

Statistical analysis

Data were captured with Excel version 14.0.0 (Microsoft, USA, 2011) and analysis was performed on Stata 12.0 (Statacorp, USA, 2011). Where data were not normally distributed (e.g. age), a Kruskal-Wallis test was used. The Pearson’s χ2 test or Fisher’s exact test (if the expected frequency of a group was smaller than five) was used to calculate the statistical significance of the

different proportions. Statistical significance was accepted as p<0.05. Prevalence ratios were then calculated. Absent data were perceived as missing completely at random, as categorical data were collected as tick sheets.

Ethical considerations

This study was approved by the Health Science Research Ethics Committee of the University of Cape Town (HREC 382/2013). Each participant gave written consent to participate in the study, and a study number was allocated to each in order to ensure confidentiality.

Results

A total of 210 participants were recrui ted (Fig. 1). Approximately one-third

of the patients did not attend on their appointment date. The majority of the participants were referred by the Department of Medicine, either from the ward or via the Outpatient Department (Table 2). Self-reported and documented comorbi dities included 9 HIV-positive participants (4.3%), 5 with rheumatic heart disease (2.8%) and 4 with a previous mitral valve replacement (2.3%), all associated with impact. It was not documented whether these valve replacements were initially indicated for rheumatic heart disease. Of the participants, 131 (62.4%) had a history of smoking, one-third of these indicating a current smoking habit. Of those older than

Table 1. Clinical impact criteria Description

Impact level Active

Escalation

More rational drug therapy Confirmation of vegetation Cardioversion required Referred for further imaging (angiography or nuclear medicine study) Referred to tertiary cardiology services Other referrals: palliative care programme, disability grant assessment

De-escalation

Reassurance of normal study, omitting further testing or avoiding further referral

No change, but clinically useful

Contesting clinical suspicion/diagnostic value Repeat echo advised/monitoring purpose Cleared for theatre

No impact

Continue current management plan Confirming clinical suspicion with no change in management

Patients booked for TTE (n=312)

Unbooked patients (n=29)

Did not consent (n=14)

Consented (n=220)

Done by cardiologist (n=210)

Fig. 1. Recruitment of participants.

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Did not attend (n=107)

Not done by cardiologist (n=10)

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16 years, 34 (17.4%) were employed, while 29 (13.8%) were receiving disability grants and 63 (30.0%) were pensioners. An average number of 17 ECHOs were performed per clinic during the study period. The average waiting time until the next available appointment was 89 days.

Clinical utility and association with impact

We found that 83.8% of TTEs had an impact on the patient’s management. In total, 51.0% of ECHOs resulted in an escalation of management, and 19.0% in de-escalation, while 13.8% had an impact without a change of management.

Table 2. Characteristics of patients referred for TTE Total impact

No impact

Total 53 (50; 20.13)

Age (years), median (range or mean; SD)

52 (2 - 86)

60 (25 - 87)

Male, n (%)

90 (50.8)

18 (54.5)

108 (51.4)

Female, n (%)

87 (49.1)

15 (45.4)

102 (48.6)

Employed (>16 years old), n (%)

27 (16.7)

7 (21.2)

34 (17.4)

Pensioner, n (%)

49 (27.7)

14 (42.4)

63 (30.0)

Receiving DG, n (%)

24 (13.6)

5 (15.1)

29 (13.8)

Currently inpatient, n (%)

48 (27.1)

5 (15.1)

53 (25.2)

76 (42.9)

16 (48.5)

92 (43.8)

Referring facility, n (%) Medical ward ED

34 (19.2)

7 (21.2)

41 (19.5)

MOPD

32 (18.1)

9 (27.3)

41 (19.5)

POPD

12 (6.8)

12 (5.7)

CHC

12 (6.8)

12 (5.7)

5 (2.8)

5 (2.4)

Private sector

1 (0.6)

1 (0.5)

Other

4 (2.3)

1 (3.0)

5 (2.4)

Unknown source of referral

1 (0.6)

1 (0.9)

Comorbidities, n (%) Hypertension

91 (51.4)

28 (84.8)

119 (56.6)

Ischaemic heart disease

54 (30.5)

13 (39.4)

67 (31.9)

Hypercholesterolaemia

49 (27.7)

12 (36.4)

61 (29.5)

Diabetes mellitus

40 (22.6)

9 (27.3)

49 (23.3)

Cardiac failure

30 (18.2)

6 (18.2)

36 (17.1)

Atrial fibrillation

16 (9.0)

2 (6.1)

18 (8.6)

COPD

15 (8.5)

2 (6.5)

17 (8.1)

Known cardiomyopathy

13 (7.3)

3 (0.1)

16 (7.6)

Stroke

12 (6.8)

1 (3.0)

13 (6.2)

HIV

9 (5.1)

9 (4.3)

Thyroid disease

8 (4.5)

8 (3.8)

Obesity

4 (2.3)

2 (6.1)

6 (2.9)

Rheumatic heart disease

5 (2.8)

5 (2.4)

Mitral valve replacement

4 (2.3)

4 (1.9)

Habits, n (%) Ex-smoker

70 (39.5)

15 (45.4)

85 (40.5)

Current smoker

38 (21.5)

8 (24.2)

46 (21.9)

Alcohol

30 (16.9)

9 (27.3)

39 (18.6)

Drugs (ex or current)

16 (9.0)

1 (3.0)

17 (8.1)

176 (83.8)

34 (16.2)

210 (100.0)

Total, n (%)

SD = standard deviation; DG = disability grant; ED = emergency department; MOPD = medical outpatients department; POPD = paediatric outpatients department; CHC = community healthcare centre; DH = (neighbouring) district hospital; COPD = chronic obstructive pulmonary disease.

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Valvular lesions were the main indication for referral (Table 3). Only one patient’s indication was seen as inappropriate when compared with the AUC.[14] The major contribution of TTE was the information provided to aid the diagnosis of heart failure (29.0%) and ischaemic heart disease (23.8%) (Table 4). Of all participants, one-third had impaired left ventricular (LV) function. Three cases of apical thrombus were identified after myocardial infarction, which resulted in the initiation of anticoagulation therapy. The most common valvular lesions identified, in order of prevalence, are listed in Table 4. Of these, mitral stenosis, discerning aortic scleroses from stenosis, identifying non-pathological murmurs and aortic regurgitations were statistically significantly associated with clinical impact. In addition to the five participants known to have rheumatic heart disease prior to the TTE, three further cases were diagnosed, the total prevalence being 3.8% in our study cohort. Six participants were diagnosed with cor pulmonale and four with pulmonary hypertension; none of these was known to be suffering from chronic obstructive pulmonary disease. Despite the fact that 56.2% of all TTEs (n=118) confirmed the referring doctor’s diagnosis, these ECHOs were still significantly linked to impact (confidence interval 0.64 0.80). In 39.1% (n=82) the pre-referral diag nosis was contested and in 4.8% (n=10) it was unknown. Of the 34 TTEs that did not have an impact, 88.2% (n=30) correlated with the pre-referral diagnosis.

Spectrum of clinical impact

TTE was found to be most useful in the rational prescription of medication (n=80). Twenty-seven participants, one-fifth of those who had an escalation in manage ment, required referral to tertiary services (Fig. 2). Of these upstream referrals, 9 patients were referred for surgery: 5 were for valve replacements, 3 for the correction of atrial septal defects and 1 for surgery of an atrial myxoma. Three patients, with severe disease, required referral to the hospital’s social worker for a disability grant. De-escalation of care, with return to pri mary healthcare services, was recommended in 40 cases. Fifteen participants were offered reassurance for non-pathological murmurs and six participants for idiopathic chest pain, preventing further testing or referral to a higher level of care. The remainder benefited in that TTE ruled out cardiac sources of emboli, structural causes for

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Table 3. Indications and their association with clinical impact Total impact n (%)

No impact n (%)

Total n (%)

Prevalence ratio 95% CI

Evaluation of valvular function

66 (37.5)

7 (20.6)

73 (34.8)

1.01 - 1.26

Unknown cause of heart failure

47 (26.7)

7 (20.6)

54 (25.7)

0.93 - 1.19

Post-myocardial infarction (for regional wall motion abnormalities)

26 (14.8)

9 (26.5)

35 (16.7)

0.61 - 0.90

Suspected hypertensive heart disease

18 (10.2)

16 (47.1)

34 (16.2)

0.38 - 0.72

Rhythm abnormality on ECG

31 (17.6)

1 (2.9)

32 (15.2)

1.08 - 1.31

Cardiomegaly, found clinically and radiologically, not known with CCF

22 (12.5)

2 (5.9)

24 (11.4)

0.97 - 1.27

Known cardiomyopathy

13 (7.4)

3 (8.8)

16 (7.6)

0.79 - 0.89

Evaluation of chest pain of unknown cause

14 (7.9)

2 (5.9)

16 (7.6)

0.86 - 1.27

History suggestive of arrhythmia, e.g. palpitation, light-headedness, presyncope or syncope

14 (7.9)

14 (6.7)

0.78 - 0.88

Evaluation of cardiovascular source of embolus

9 (5.1)

1 (2.9)

10 (4.8)

0.87 - 1.34

Other

21 (11.9)

1 (2.9)

22 (10.5)

Total

176 (83.8)

34 (16.2)

210 (100.0)

ECG = electrocardiogram; CCF = congestive cardiac failure; Other = pulmonary hypertension, suspected infective endocarditis, new cardiomyopathy, evaluation of aortic disease, suspected pulmonary embolism.

Table 4. New information found on TTE Total impact n (%)

No impact n (%)

Total n (%)

Prevalence ratio 95% CI

Detection of LV systolic dysfunction

57 (32.4)

9 (26.5)

66 (31.4)

0.93 - 1.18

Cause of heart failure established

28 (15.9)

6 (17.6)

34 (16.2)

0.82 - 1.16

Cause of heart failure confirmed

24 (13.6)

3 (8.8)

27 (12.9)

0.92 - 1.24

Wall motion abnormality found

28 (15.9)

4 (11.8)

32 (15.2)

0.91 - 1.22

Wall motion abnormality ruled out

12 (6.8)

6 (17.6)

18 (8.6)

0.48 - 0.92

LV hypertrophy

29 (16.5)

14 (41.2)

43 (20.5)

0.54 - 0.82

Congenital heart disease

4 (2.3)

4 (1.9)

0.79 - 0.89

LV aneurysm

1 (0.6)

1 (0.5)

0.78 - 0.89

Mitral regurgitation

56 (26.7)

5 (15.1)

61 (29.0)

1.01 - 1.25

Tricuspid regurgitation

34 (16.2)

5 (15.1)

39 (18.6)

0.90 - 1.19

Aortic sclerosis discerned from aortic stenosis

21 (11.9)

9 (26.5)

30 (14.3)

0.55 - 0.88

Aortic stenosis

17 (8.1)

3 (9.1)

20 (9.5)

0.83 - 1.23

Functional murmur

15 (8.5)

15 (7.1)

0.77 - 0.88

Mitral stenosis

14 (6.7)

0.78 - 0.88

Aortic regurgitation

8 (3.8)

0.79 - 0.89

Total

176 (83.8)

34 (16.2)

210 (100.0)

Other, 6, 14%

Palliative care, 4, 9%

Valvular lesions

perceived arrhythmia (symptomatic or on electrocardiogram), pulmonary hyper tension and infective endocarditis. ECHOs performed on 29 participants resulted in no change in management, but

provided clinically useful information. Of these, two-thirds (n=16) were advised to have follow-up ECHOs (implying ongoing monitoring of their current condition). Eleven participants had ECHOs that

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Stress ECG, 6, 14%

CMO clinic, 6, 14%

Surgery, 9, 21%

Arrythymia clinic, 6, 14% Angiography, 6, 14%

Fig. 2. Upstream referrals (impact or upstream referral clinic, number of cases, percentage of escalated management) after ECHO. (CMO = cardiomyopathy; ECG = electrocardiogram.)

contested the referring doctor’s diagnosis and two were deemed fit for surgery as part of an anaesthetic work-up. Behavioural advice, for example direct advice on alcohol consumption, weight reduction and smoking cessation, was docu mented but not analysed. Three female patients with postpartum cardiomyopathy were advised against future pregnancies.

Discussion

We found that the majority (83.8%) of ECHOs had a positive impact on patients referred to a district hospital – a proportion much higher than that previously reported in developed country settings of 32 - 76%.[12,13] The diversity of patients’ ages, comorbidities and sources of referral revealed the broad value of this investigative modality.

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The value of a prospective study is that single ECHO assessment in a non-tertiary setting can immediately address a focused, clinical question or suspicion raised, and may have an immediate impact. Our definition of impact is different from previous larger impact studies, undertaken either in tertiary settings or in community hospitals with specialised cardiology services.[12,13] A few older studies done at district hospitals either reviewed the impact more than 30 years ago, using only M-mode ECHO, or focused on intensive care units.[3,15,16] The lack of generalisability to current district hospital practice seems obvious, especially in resource-constrained settings. We have established the role of ECHO in causing de-escalation in therapy and continuation of management at district hospital level. This potential for decreasing referral to tertiary specialists seems similar to other studies.[7,9,16] Previous studies have cautioned against undervaluing a study with normal findings.[8,11,17] This latter benefit was confirmed in 32.9% (n=69) of all the participants referred, without escalating management. Its use in screening prescreened patients is evident, with a particularly high impact level in all paediatric patients, mainly aiding in de-escalation of services relating to a murmur that had been auscultated prior to referral. This has been undervalued by previous studies.[12,15] Our study has shown that impact does not necessarily translate into a change in management – many patients without a change in clinical status require follow-up, which is seen as a valid indication in itself in early and late stages of cardiac disease.[14] The major change in management proved to be rational prescription of medication. The other main benefit was determining which patients required up-referral to tertiary services, e.g. for cardiac surgery. AUC are not used in SA. Nevertheless, only one participant’s indication could not be classified according to AUC, as the referral was for possible cardiac cause for seizures. This indicates the high level of appropriate use of ECHOs in our district hospital. The most common indication was suspected valve disease. Its significance could not be statistically linked to impact, perhaps owing to the small sample size achieved. New information gathered was nevertheless significant for mitral stenosis and aortic regurgitation, mirroring the finding of a previous audit of the beneficial value of ECHO in assessing diastolic (more than systolic) murmurs.[15] Three adult participants but no paediatric patients were newly diagnosed with rheumatic heart disease. A recent study in SA has shown the decrease in rheumatic heart disease in children in SA, which may be due to improved access to healthcare and an improved socioeconomic environment.[18] The use of ECHO as a screening tool for rheumatic heart disease has yet to be translated into impact on prognosis and effective secondary prophylaxis for subclinical disease. Results suggest that adults may benefit from screening more than children.[19] Of all indications for ECHO, assessment of regional wall motion abnormalities and suspected hypertensive heart disease were statistically significantly associated with impact. The value of ECHO in defining prognosis in these two conditions has been described previously.[20,21] One study found that the evaluation of wall motion abnormalities constitutes the most statistically significant, independent prognostic data provided by TTE.[20] Although screening of all hypertensive patients has been recommended, as left ventricular hypertrophy itself implies a worse prognosis,[22] others assert that ECHO confirmation would probably not intensify the treatment of the hypertension itself.[22,23] In our study, heart failure was the major indication for ECHO, as was the case in a systematic review of patients referred for OAE from primary care.[23] The role of TTE in providing new information in this context is nonetheless unsurpassed, by detecting LV dysfunction and either establishing or confirming the cause of

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failure.[17] This is of particular value in our setting, where heart failure is usually diagnosed and monitored by clinical means only. Despite two-thirds of the cohort having a smoking history, low numbers of cases of COPD and its complications were reported. Screening for and assessing cardiac complications, such as cor pulmonale and pulmonary hypertension, in patients with COPD can be useful, as both infer increased morbidity and mortality.[24] The diagnosis of a clinically unsuspected atrial myxoma in this small cohort was a finding that would otherwise have remained undetected. Discrepancies between the results of the TTEs and the assessment of the referring clinician prior to the test were confirmed, as per previous studies.[25,26] It appears that the positive impact of TTE is independent of the clinical accuracy of the referring doctor. On the other hand, a lack of impact was nonetheless associated with accurate pre-referral assessment. This may indicate that a thorough history and physical examination may lessen the need for a diagnostic test.[25] Thirty-nine percent of the ECHOs disproved the pre-referral diagnosis. In some of the participants who had had previous TTEs, repeat ECHO nevertheless had an important clinical impact. An earlier study found that the added diagnostic value of a repeat ECHO is significantly independent of whether the test had been performed previously.[25] Approximately one-fifth of patients were referred from the hospital’s emergency department; this may indicate the need for training in question-focused, point-of-care studies. A review of TTEs performed by non-cardiologists showed an active change in management in 16 - 37% of patients in an emergency setting.[9] Failure of referral of patients from primary healthcare facilities was found despite doctors being free to refer patients directly for TTEs; it is not clear whether the medical staff were unaware of the existence of the service. Notably, among the few patients in this study cohort who were referred from community healthcare settings, the ECHOs had an important impact. The waiting time for the next available appointment was six times as long as the recommended time period of 2 weeks advised by the National Institute for Care Excellence guidelines for patients with chronic heart failure and after myocardial infarction.[27] A Dutch study of OAE reports a waiting time of 5 weeks.[7] In developing countries, a lack of resources and scarce skills may be the reason for this long waiting time. The poor socioeconomic status of our participants, including pensioners and those receiving disability grants, suggests a reliance on public sector facilities. The poor attendance for TTE appointments shows the undervaluing of this restricted resource. Non-attendance is often due to lack of funds for transport. Having this service only at a distant tertiary centre may add to poor attendance.

Study limitations

Our study does have limitations. The participants were referred from the hospital ward or outpatient departments and had been prescreened after being admitted via the emergency department or referred from a primary healthcare facility. This may overvalue the impact owing to a lower incidence of negative findings. Patients with acute cardiac illness, such as heart failure or myocardial infarction, may be more likely to benefit from ECHO. The inclusion of hospitalised patients probably increased the likelihood of appropriate referrals by doctors.[11] The ECHOs were performed by an experienced cardiologist, with this specialist assessment in itself likely to have an impact on patient management, causing impact to be overestimated. The risk of possible bias exists, as the

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cardiologist was involved in the clinical decision-making process and management of participants. The study size was smaller than initially anticipated, mainly because of patients defaulting on their appointments. Following the participants’ completion of the questionnaires, all data were checked to correlate with the clinical information in their folders. This allowed for more accurate analysis of the patient characteristics and the echocardiograms as well as their indications. Fifteen patient folders were missing and were not checked retrospectively. The downstream risks of TTE, such as incorrect interpretation and residual anxiety despite a normal study, should not be disre garded.[1,14,28] It would be important to gain insight into whether clinical impact and changes in management eventually translate into improved health outcomes in primary healthcare. These effects could be assessed in a follow-up study. Other than its clinical impact, the cost implications of a restricted resource should be studied. The benefits of more accurate diagnosis, improving rational drug prescription and decreasing the burden on the tertiary healthcare system should be evaluated. A patient-centred approach can also evaluate patients’ own perception of impact on their illness.

Conclusion

Echocardiography had a positive impact on patient management in a district hospital setting. Limited access for patients may negatively impact on their management, as a valuable contribution of TTEs to overall management was found. A normal ECHO is important in offering reassurance to patients and diagnostic assistance to the referring doctor, and aiding in referral back to the primary level of care. In the overburdened public health sector, where continuity of care is frequently a problem, it may reduce time and costs. By providing an ECHO service in non-tertiary settings, patients can be screened and more appropriately referred to scarce upstream specialists and subspecialist departments. Training in interpretation and accreditation in the use of ECHO should be a priority for teaching and academic facilities, especially for personnel working in general, emergency and family medicine. The prospect of hand-held devices would definitely enhance access, but may compromise quality. Policy makers should be alerted to the added value offered by an ECHO assessment. The rapidly growing burden of NCDs should encourage investment in such service-based interventions to local communities.[4] District hospitals can establish protocols in the communities they serve, to assist with procurement and referrals from primary health care. Acknowledgements. H Carrara assisted with the statistical analysis. D Lunga collected data as research assistant. Funding. A research grant was obtained from the Department of Public Health and Family Medicine of the University of Cape Town.

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References 1. Feigenbaum H. Evolution of echocardiography. Circulation 1996;93(7):1321-1327. [http://dx.doi. org/10.1161/01.CIR.93.7.1321] 2. Chung J. Echocardiography in 2009: State of the art. J Invasive Cardiol 2009;21(7):346-351. 3. Brown AK, Anderson V. The use of cross-sectional echocardiography in a general hospital. J Postgrad Med 1980;56:221-228. 4. Mayosi BM, Flisher AJ, Lalloo UG, et al. The burden of non-communicable diseases in South Africa. Lancet 2009;374(9693):934-947. [http://dx.doi.org/10.1016/S0140-6736(09)61087-4] 5. Puoane TR, Tsolekile LP, Calbick S, et al. Chronic non-communicable diseases in South Africa: Progress and challenges. In: Padarath A, English R, eds. South African Health Review 2012/13. Durban: Health Systems Trust, 2013. http://www.hst.org.za/publications/south-african-healthreview-2012/13 (accessed 13 August 2013). 6. De Vries E, Raubenheimer P, Kies B, Burch VC. Acute hospitalisation needs of adults admitted to public facilities in the Cape Town Metro district. S Afr Med J 2011;101(10):760-764. 7. Van Gurp N, Boonman-De Winter LJM, Meijer Timmerman Thijssen DW, Stoffers HEJH. Benefits of an open access echocardiography service: A Dutch prospective cohort study. Neth Heart J 2013;21(9):399-405. [http://dx.doi.org/10.1007/s12471-013-0416-9] 8. Rao A, Henton D, Walsh J. Evolving trends in open access echocardiography – experience over eight years. http://www.priory.com/med/echo.pdf (accessed 13 August 2013). 9. Haji DL, Royse A, Royse CF. Review article: Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas 2013;25(1):4-12. [http://dx.doi.org/10.1111/1742-6723.12033] 10. Xiao HB, Sethi A. Community echocardiography. Clinical Focus Primary Care 2006;1(3):88-93. 11. Alqarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriate-use criteria for transthoracic and transoesophageal echocardiography. Int J Cardiovasc Imaging 2012;28(8):1951-1958. [http://dx.doi.org/10.1007/s10554-012-0008-6] 12. Matulevicius SA, Rohatgi A, Das SR, Price AL, de Luna A, Reimold SC. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med 2013;173(17):1600-1607. [http://dx.doi. org/10.1001/jamainternmed.2013.8972] 13. Ballo P, Bandini F, Capecchi I, et al. Application of 2011 American College of Cardiology Foundation/ American Society of Echocardiography Appropriateness Use Criteria in hospitalized patients referred for transthoracic echocardiography in a community setting. J Am Soc Echocardiogr 2012;25(6):589598. [http://dx.doi.org/10.1016/j.echo.2012.03.006] 14. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/ SCMR 2011 appropriate use criteria for echocardiography: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2011;57(9):1126-1166. Published online before print 19 November 2010. [http://dx.doi.org/10.1016/j.jacc.2010.11.002] 15. Pollick C. Echocardiography in a district general hospital. Postgrad Med J 1978;54(631):297-301. [http://dx.doi.org/10.1136/pgmj.54.631.297] 16. Orme RML, Oram MP, McKinstry CE. Impact of echocardiography on patient management in the intensive care unit: An audit of district general hospital practice. Br J Anaesth 2009;102(3):304-344. [http://dx.doi.org/10.1093/bja/aen378] 17. Chambers J, Fuat A, Liddiard S, et al. Community echocardiography for heart failure: A consensus statement from representatives of the British Society of Echocardiography, British Heart Failure Society, CHD collaborative and Primary Care Cardiovascular Society. Br J Cardiol 2004;11(5):399-402. 18. Cilliers AM. Rheumatic fever and rheumatic heart disease in Gauteng on the decline: Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. S Afr Med J 2014;104(9):632-634. [http://dx.doi.org/10.7196/SAMJ.8318] 19. Zühlke L, Mayosi BM. Echocardiographic screening for subclinical rheumatic heart disease remains a research tool pending studies of impact of prognosis. Curr Cardiol Rep 2013;15(3):343. [http://dx.doi. org/10.1007/s11886-012-0343-1] 20. Madsen BK, Egeblad H, Hojberg S, et al. Prognostic value of echocardiography compared to other clinical findings. Cardiology 1995;86(2):157-162. [http://dx.doi.org/10.1159/000176863] 21. Weissman NJ, Ristow B, Schiller NB. Role of echocardiography in acute myocardial infarction. http://www.uptodate. com/contents/role-of-echocardiography-in-acute-myocardial-infarction.htm (accessed 10 December 2013). 22. Amidon TM, Chou TM, Foster E, Kee LL. Role of echocardiography in primary care medicine: Controversies in hypertension, atrial fibrillation, stroke and endocarditis. West J Med 1996;164(3):269275. [http://dx.doi.org/10.1111/j.1540-8175.2000.tb01151] 23. Khunti K. Systematic review of open access echocardiography for primary care. Eur J Heart Fail 2004;6(1):79-83. [http://dx.doi.org/10.1016/j.ejheart.2003.10.002] 24. Gupta NK, Kamar Agrawal R, Srivastav AB, Ved ML. Echocardiographic evaluation of heart in chronic obstructive pulmonary disease and its co-relation with the severity of disease. Lung India 2011;28(2):105-109. [http://dx.doi.org/10.4103/0970-2113.80321] 25. Krumholz HM, Douglas PS, Goldman L, Waksmonski C. Clinical utility of transthoracic twodimensional and Doppler echocardiography. J Am Coll Cardiol 1994;24(1):125-131. [http://dx.doi. org/10.1016/0735-1097(94)90552-5] 26. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA 1997;278(21):717-722. [http://dx.doi.org/10.1001/ jama.1997.03550210037021] 27. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. http:// www.nice.org.uk/guidance/cg108/chapter/key-priorities-for-implementation (accessed 29 October 2014). 28. McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora’s box: The unpredictability of reassurance by a normal test. BMJ 1996;313(7053):329-332.

Accepted 25 June 2015.

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The wrong and wounding road: Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period N Naidoo, MB ChB; D J J Muckart, FRCS, MMSc Crit Care (SA) Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa Corresponding author: D J J Muckart (davidmuc@ialch.co.za)

Background. Injury in childhood is a major cause of potentially preventable morbidity and mortality. In order to implement effective preventive strategies, epidemiological data on mechanisms of injury and outcome are essential. Objectives. To assess the causation, severity of injury, morbidity and mortality of paediatric trauma admitted to a level 1 trauma intensive care unit (TICU). Methods. Children were defined as being <16 years of age. The study covered the 5-year period January 2008 - December 2012. Eligible patients were identified from a prospective database maintained in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Data extracted were referral source, mechanism of injury, age and gender distribution, injury severity score (ISS), anatomical distribution of injury and mortality. Results. A total of 181 patients admitted during the study period accounted for 15.9% of all admissions. There were 84 females (46.4%) and 97 males (53.6%), with a median age of 7 years (interquartile range (IQR) 4 - 10). Sources of admission were directly from the scene in 38 cases (21.0%), from a primary healthcare facility in 47 (26.0%), from a regional hospital in 56 (31.0%) and from a tertiary facility in 40 (22.0%). Mortality rates according to location of transfer were regional hospital 8 deaths (30.8%), tertiary facility 7 (26.9%), primary health clinic 7 (26.9%), and from the scene 4 (15.4%). Mechanisms of injury were pedestrian-motor vehicle collision (PMVC) in 105 cases (58.0%), motor vehicle passenger in 38 (21.0%), non-vehicular blunt trauma in 18 (10.0%), gunshot wounds (GSWs) in 12 (6.6%), stab wounds in 6 (3.3%), bull goring in 1 (0.5%) and bicycle accident 1 (0.5%). The median ISS for all admissions was 25 (IQR 16 - 38). ISSs were >25 in 98 patients (54.1%), 16 - 25 in 51 (28.2%), 9 - 15 in 9 (4.9%) and <9 in 13 (7.2%); 61.9% of patients had head injuries, 48.1% injuries to the extremities, 41.4% abdominal trauma, 40.3% thoracic trauma, 20.4% external soft-tissue trauma, 9.9% cervical injury and 9.4% facial trauma. There were 26 deaths (14.4%), of which PMVCs accounted for 16 (61.5%), motor vehicle passengers for 7 (26.9%), blunt trauma for 2 (7.7%) and GSWs for 1 (3.8%). The majority of deaths (92%) were of patients with an ISS >25. Of the 26 patients who died, 88.4% had a head injury, 46.2% an extremity injury, 38.5% an external injury, 34.6% abdominal or chest injuries, 19.2% neck injury and 11.5% facial injury. Conclusions. Motor vehicle-related injuries, especially PMVCs, dominate severe paediatric trauma and there is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality. S Afr Med J 2015;105(10):823-826. DOI:10.7196/SAMJnew.8090

Paediatric trauma is a major cause of potentially preventable disability and mortality in South Africa (SA).[1] In developing countries, infection and infestation account for the majority of deaths in the first 5 years of life,[2] and much effort has been put into reducing these causes. Death from trauma extends for another decade, but despite this childhood injury continues to receive scant attention[3] and prevention remains rudimentary. The extent of paediatric trauma in Africa as a whole is unknown and an appeal has been made to document the burden of this problem.[4] The limited information available suggests that motor vehicle collisions (MVCs), drowning and burns are the three commonest mechanisms causing severe injury.[3] Although falls account for the majority of childhood injuries,[5] MVCs are the major cause of severe morbidity and mortality. The majority involve pedestrians (PMVCs), and traumatic brain injury accounts for up to 80% of childhood trauma deaths.[6-9] In addition to the burden of motor vehicle-related injuries, studies from Nigeria and SA have shown that gunshot wounds (GSWs) in infants and children are a tragic emerging mechanism of injury. [8,10,11]

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Although the number of hospital admissions following GSWs in Cape Town decreased between 2000 and 2007, the vast majority of deaths occurred before treatment could be instituted and a steady increase in admissions was seen in the subsequent 3 years.[11] Africa has the dubious label of being the most dangerous place in the world for a child,[12] and prevention and political will to back up the necessary policies are the most cost-effective methods of reducing trauma-related deaths.[4] To that end, information documenting causation, morbidity and mortality are essential for planning, implementation and evaluation of preventive measures. We therefore undertook an analysis of a prospective database of paediatric admissions to a level 1 (tertiary) trauma intensive care unit (TICU) to determine the commonest causes of injury, severity of injury and outcome.

Patients and methods

The study was approved by the University of KwaZulu-Natal Bioethics Committee (BREC 286/14) and conducted in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, an academic

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Results

A total of 1 138 patients were admitted to the unit during the study period, of whom 181 (15.9%) were <16 years of age. The age and gender distribution, ISS and mechanism of injury are shown in Table 1 according to quintiles of age. There were 84 females (46.4%) and 97 males (53.6%), with no significant difference in gender distribution. The majority of admissions were a result of blunt trauma (89.5%), with MVCs, a combination of pedestrians and passengers, accounting for 79% of all injuries. PMVC dominance was maintained across all quintiles of age and for every year analysed (Fig. 1). Half of the pedestrian injuries arose in the middle quintile of 6 - 10 years of age. Penetrating trauma accounted for 10.5% of admissions, most commonly following GSWs. The majority of admissions (54.1%) were in the profound ISS category, and 149 patients (82.3%)

Table 1. Age, gender, ISS and mechanism of injury in 181 paediatric admissions according to age quintiles 0 - 5 years

6 - 10 years

11 - 15 years

Total

n (%)

65 (35.9)

80 (44.2)

36 (19.9)

181 (100.0)

Age (years), mean

Male, n (%)

42 (43.3)

37 (38.1)

18 (18.6)

97 (53.6)

Female, n (%)

23 (27.3)

43 (51.1)

18 (21.4)

84 (46.4)

Mild <9

7 (53)

5 (38.4)

1 (7.6)

13 (7.2)

Moderate 9 - 15

11 (57.9)

6 (31.6)

2 (10.5)

19 (10.5)

Severe 16 - 25

15 (29.4)

26 (50.9)

10 (19.6)

51 (28.2)

Profound >25

32 (32.6)

43 (43.9)

23 (23.5)

98 (54.1)

Pedestrian MVC

34 (32.4)

54 (51.4)

17 (16.2)

105 (58.0)

Passenger MVC

9 (23.7)

15 (39.5)

14 (36.8)

38 (21.0)

Falls

1 (50.0)

2 (1.1)

Blunt

6 (37.5)

8 (50.0)

2 (12.5)

16 (8.8)

GSWs

8 (66.7)

1 (8.3)

3 (25.0)

12 (6.6)

Stab wounds

5 (83.3)

1 (16.7)

6 (3.3)

Goring

1 (100.0)

1 (0.5)

Cyclist

1 (100.0)

1 (0.5)

Patients

ISS, n (%)

Mechanism of injury, n (%)

45 40 35 30 Patients, n

tertiary hospital in Durban, SA. The TICU is an integral part of the trauma unit, which also houses resuscitation rooms equipped to the standard of the intensive care unit (ICU) and two dedicated trauma theatres. Subspecialists in critical care and trauma surgery, whose training includes the management of paediatric trauma, staff the trauma unit and TICU. There is no distinct referral pattern, and the unit accepts patients directly from the scene and from any health facility throughout KwaZulu-Natal Province (KZN). Burn injuries and drownings were excluded, as the former are managed in a separate burns unit and the latter in the medical ICU. All patients <16 years of age admitted to the TICU during the 5-year period January 2008 - December 2012 were identified from the unit database, which is collated by senior trauma staff on a daily basis and is independent of the hospital’s electronic records system. Information extracted included referral source, age, gender and mechanism of injury (defined as MVC (pedestrian or passenger), nonvehicular blunt trauma in the form of falls and assault, GSWs, stab wounds, and other mechanisms). The injury severity score (ISS),[13] anatomical distribution of injuries and mortality during the hospital stay were computed. Quintile age divisions into 0 - 5, 6 - 10 and 11 - 15 years were analysed. Categorical data were analysed using the χ2 or Fisher’s exact test and continuous data by either Student’s t-test or analysis of variance if there were more than two groups for comparison. A p-value of <0.05 was considered significant. Privacy and confidentiality was maintained and no patient was identified by name.

Other Stab

Gunshot

Blunt

Passenger Pedestrian

10 5 0

2008

2009

2010

2011

2012

Year Fig. 1. Mechanisms of injury v. number of patients per year of admission (falls incorporated into blunt mechanism of injury).

had an ISS of >16. An average of 2.3 anatomical body regions were injured per child, with a total of 419 injuries. The anatomical distribution according to the six ISS body regions is shown in Fig. 2. Admission sources were regional hospital 56 cases (31.0%), primary healthcare facility 47 (26.0%), tertiary facility 40 (22.0%), and from the scene 38 (21.0%). Mortality rates relative to mechanism, severity of injury and admission source are

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shown in Table 2. Ninety-two percent of deaths were in the profound injury severity category, which had a 24.5% mortality rate (p<0.001). One child in the mild injury group died having developed acute kidney injury following blunt assault with widespread soft-tissue trauma, for which the ISS can only score one point. The remaining death was of a 7-year-old with moderate traumatic brain injury and a fractured femur, but who was HIV-positive

RESEARCH

Discussion

80 72% 70 60 48%

Percent

41%

40%

30 20%

10 0

Head and neck

Extremity

Abdomen

Thorax

External

Face

Body region

Fig. 2. Frequency (%) of body regions injured according to ISS categories (total percentage exceeds 100% as some children sustained multiple system injuries).

Table 2. Mortality rates according to ISS, admission source and mechanism of injury Total

Survived, n

Died, n (%)

Total, n (%)

155

26 (14.4)

181 (100.0)

ISS Mild <9

1 (7.6)

13 (7.2)

Moderate 9 - 15

1 (5.3)

19 (10.5)

Severe 16 - 25

51 (28.2)

Profound >25

24 (24.5)

98 (54.1)

Scene

4 (10.5)

38 (21.0)

Primary healthcare facility

7 (14.9)

47 (26.0)

Regional hospital

8 (14.3)

56 (31.0)

Tertiary hospital

7 (17.5)

40 (22.0)

PMVC

16 (15.2)

105 (58.0)

Passenger MVC

7 (18.4)

38 (21.0)

Admission source

Mechanism of injury

Falls

2 (1.1)

Blunt

2 (12.5)

16 (8.8)

GSW

1 (9.1)

12 (6.6)

Stab

6 (3.3)

Goring

1 (0.5)

Cyclist

1 (0.5)

on highly active antiretroviral therapy and severely malnourished on admission. There was no significant association of outcome with source of admission, although the mortality rate for direct admissions from the scene was on average 30% lower than that for interhospital transfers. MVCs accounted for 88.4% of deaths. Mortality rates did not differ significantly according to mechanism

of injury, although PMVCs had the highest mortality rate per mechanism of injury. Of the 181 injured children, 112 (61.9%) had traumatic brain injury, of the 26 who died 23 (88.4%) had associated head trauma, and in 18 deaths (69.2%) severe traumatic brain injury was the primary cause. The commonest anatomical combination of injuries according to the ISS distribution was head, extremity and external.

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On 19 and 20 November 2009, a Global Ministerial Conference on road safety was held in Moscow, which culminated in a declaration inviting the United Nations General Assembly to declare a decade of action for road safety. The General Assembly recognised (Resolution 64/255) that the number of road traffic deaths is unacceptably high, with an estimated 1.24 million lives lost in 2010, a trend which if ignored would result in 1.9 million deaths every year to 2020. Furthermore, it was noted that only 7% of the world’s population is covered by adequate laws that address behavioural risk factors including the non-use of helmets, safety belts and child restraints, driving under the influence of alcohol and drugs, inappropriate and excessive speed, and inappropriate use of cell phones while driving. Concern was also expressed that worldwide, half of all road traffic deaths involve pedestrians, motorcyclists and cyclists, and that in some developing countries there is inadequate infrastructure and a lack of policies to protect vulnerable road users. On 11 May 2011 the United Nations launched its programme ‘Decade of Action for Road Safety 2011 - 2020’. Almost half that decade has passed, and our results reflect that motor vehicle-related collisions in SA continue unabated to destroy the lives of children and their families. SA ranks among the top ten countries with the highest road traffic fatality rate per 100 000 of the population, and is the second highest in Africa.[14] One of the Millennium Development Goals identified in 2006 was a 50% reduction in road traffic fatalities by 2015, using 2007 as the benchmark year. Unfortunately there has been little if any improvement. Between March 2010 and March 2011 there was actually an increase in fatalities of 15%.[15] On average, there were 1 150 motor vehicle-related fatalities per month, equivalent to almost 38 per day. Paediatric pedestrian fatalities accounted for almost 25% of all pedestrian-related deaths, exceeded only by male pedestrian deaths in the 25 - 45-year age group. A similar distribution is found among passenger fatalities, with the most vulnerable paediatric age group being the second quintile of life. Unlike most of the other provinces in SA, where passengers accounted for the majority of deaths, in KZN the highest number of deaths occurred in pedestrians. Overall KZN was the worst-performing province, with a continuous increase in the quarterly number of road fatalities exceeding the set quarterly targets for the province. Although we found no statistically significant differences in mortality in relation to referral source, the proportion of deaths among patients

RESEARCH

admitted directly from the scene was on average 30% lower than among those referred from other facilities. Time to definitive care is an important determinant of outcome. The difference between time to admission to the trauma unit from the scene compared with interhospital transfer is 6 hours,[16] owing to a lack of adequately skilled prehospital personnel. Trauma contributes to 60% of the prehospital workload in KZN. Regardless of injury severity, the majority of patients are transported to district hospitals, which have limited imaging and surgical facilities.[17] If outcome is to be improved, delays in transfer to an appropriate level of care must be minimised, multiple transfers between health facilities discouraged, and standard referral patterns abandoned.[17] Importantly, our mortality statistics do not reflect the extent of the trauma problem, as our results exclude deaths at the scene and address only critically injured children admitted to a level 1 TICU. For every severely injured child there are many more who have suffered less devastating injuries and are admitted to regional or district hospitals. A 10-year analysis at Red Cross War Memorial Children’s Hospital in Cape Town documented almost 70 000 injured children, of whom 40% had sustained moderate or severe trauma.[5] Furthermore, many of those who survive are permanently disabled as a result of severe traumatic brain injury,[3,4] and in the public sector have little access to adequate rehabilitation facilities. The psychological, physical and economic burdens that are imposed on the individual, the family and society are incalculable. In 2004 the National Department of Transport released a report estimating the costs of road traffic casualties.[18] Based on the value of lost output or productivity, by making use of average life expectancy, employment rate and income of the population, the average unit human casualty cost was ZAR500 000 per fatality, ZAR200 000 per serious injury and ZAR114 000 per slight injury. Given the annual fatality rate of 14 000 and a conservative estimate of three serious injuries per fatality, the annual costs are exorbitant. In keeping with the United Nations concerns and the most recent South African National Road Agency report,[19] our results confirm that PMVCs dominate severe childhood injuries, being almost three times as common as severe injuries of paediatric passengers. Increasing urbanisation, coupled with a lack of road safety awareness, undoubtedly contributes to the incidence, especially when small children are accompanied only by their older siblings on the way to school, a not uncommon sight on our roads. Although less common than pedestrian collisions, childhood passengerrelated trauma was associated with a higher mortality rate. On impact, unrestrained children are propelled within or ejected from the vehicle, resulting in multiple body compartment injuries. A recent amendment to the National Transport Act enforceable in April 2015 stipulates that all infants under 3 years of age must be restrained in suitable car seats and all children must wear conventional seat belts. Unfortunately this does not apply to public transport, and until the law changes children in minibus taxis or buses remain at high risk for propulsion within, or ejection from, a vehicle. Of equal concern is the transportation of unrestrained passengers in the cargo area of light delivery vehicles. In a report by Howlett et al.,[20] one-third of these were children and virtually all were ejected upon impact. Injuries to the head, spine and extremities predominated, 21% of patients died and one in ten survivors was permanently disabled, a finding commensurate with our own data. Compared with previous publications in SA,[3,4] little has changed with respect to mechanism of injury and outcome; of pedestrians or passengers with severe traumatic brain injury, more than half die. Although motor vehicle-related paediatric trauma is quite correctly an international cause for concern, GSWs to children are equally if not more distressing, given that the majority of patients in our database were in the first 5 years of life. The youngest are injured while being carried by their mothers, typically when caught in crossfire. Tragically, similar findings have been reported from other SA studies over the

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past two decades.[10,11] In KZN, Mars and Hadley[10] reported the peak incidence of GSWs in children to occur in the first quintile of life, multisystem injuries were the commonest presentation, and of those who survived, one in ten was left severely disabled. Of major concern was their finding that 94 patients with GSWs were admitted to hospital, but three times as many died before admission and were taken straight to mortuaries, showing the heavy burden of gunshot injuries to children. In the Western Cape Province at Red Cross War Memorial Children’s Hospital, Campbell et al.[11] found the same incidence as Mars and Hadley but with a ten-fold increase in prehospital compared with in-hospital deaths. Although the Firearms Control Act of 2004 appeared to have an impact, the effect appears to be waning with a steady increase in incidence in the latter part of their study. Internationally, road traffic injuries are the leading cause of childhood death and disability, and significant increases are predicted over the next 15 years in low- and middle-income countries.[21] The continent of Africa especially faces major challenges.[4] In SA the Arrive Alive campaign has identified a number of factors contributing to the unacceptable incidence of motor vehicle-related injuries, among which are the public attitude towards road safety, lack of effective policing, poor driving skills and road conditions, and rapid urbanisation. Compounding these problems are the social conditions of many children, of whom only 30% live with both parents, a significant risk factor for childhood injury whether deliberate or accidental.[22] There is a drastic need for improved safety measures, road traffic education and stringent legislation. The single most important factor, however, is the political will to enforce such policies.[4] Few areas can be more relevant to the adage, ‘Prevention is better than cure’. References 1. Langerveld HR, van As AB. Paediatric trauma. CME 2013;31(1):5-7. http://www.cmej.org.za/index. php/cmej/article/view/2621/2681 (accessed 4 September 2015). 2. Mortality and Causes of Death in South Africa, 2013. Findings from Death Notification. Statistics South Africa. www.statssa.gov (accessed 4 June 2015). 3. Van As AB, Miller AJW. From the pursuit for excellence to the quest for significance: Promotion of a Childsafe South Africa. S Afr Med J 2012;102(6):427-428. 4. Ademuyiwa A, Usang UE, Oluwadiya KS, et al. Pediatric trauma in sub-Saharan Africa: Challenges in overcoming the scourge. J Emerg Trauma Shock 2015;5(1):55-61. [http://dx.doi.org/10.4103/0974-2700.93114] 5. Herbert HK, van As AB, Bachani AM, et al. Patterns of pediatric injury in South Africa: An analysis of hospital data between 1996-2007. J Trauma Acute Care Surg 2012;73(1):168-174. [http://dx.doi. org//10.1097/TA.0b013E31824d67c3] 6. Semple P, Bass D, Peter J. Severe head injury in children: A preventable but forgotten epidemic. S Afr J Med 1998;88(4):440-444. 7. Schrieff L, Thomas K, Dollman A, et al. Demographic profile of severe traumatic brain injury admissions to Red Cross War Memorial Childrens’ Hospital. S Afr J Med 2013;103(9):616-620. [http:// dx.doi.org/10.7196/SAMJ.7137] 8. Osifo D, Iribhogbe P, Ugiagbe E. Epidemiology and pattern of paediatric and adolescent trauma deaths in a level 1 trauma centre in Benin city, Nigeria. Injury 2012;43(11):1861-1864. [http://dx.doi. org/10.1016/j.injury.2011.07.016] 9. Ngambi T, Bongstein E. Epidemiology of paediatric trauma admission at Queen Elizabeth Central Hospital, Blantyre. Malawi Med Journal 2005;17(1):5-6. [http://dx.doi.org/10.4314/mmj.v17i1.10860] 10. Mars M, Hadley GP. Gunshot injuries in infants and children in KwaZulu-Natal: An emerging epidemic, S Afr Med J 1998;88(4):444-447. 11. Campbell NM, Colville JG, van der Heyde Y, et al. Firearm injuries to children in Cape Town, South Africa: Impact of the 2004 Firearms Control Act. S Afr J Surg 2013;51(3):92-96. [http://dx.doi.org/10.7196/SAJS.1220] 12. Hyder AA, Peden M, Krug E. Child health must include injury prevention. Lancet 2009;373(9658):102103 [http://dx.doi.org/10.1016/S0140-6736(08)61736-5] 13. Baker SP, O’Neill B, Haddon W, Long WB. The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14(3):187-196. 14. World Health Organization. Global Status on Road Safety 2013. Supporting a Decade of Action. Luxembourg: WHO, 2013. www.who.int/violence_injury_prevention/road_safety_status/2013/ report/en (accessed 27 March 2015). 15. Road Traffic Management Corporation. Road Traffic Report March 2011. Faerie Glen: Department of Traffic, Republic of South Africa. http://www.rtmc.co.za/index.php/reports/traffic-reports (accessed 10 April 2015). 16. Cheddie S, Muckart DJJ, Hardcastle TC, et al. Direct admission versus inter-hospital transfer to a level I trauma unit improves survival. S Afr Med J 2011;101(3):176-178. 17. Hardcastle TC, Finlayson M, van Heerden M et al. The prehospital burden of disease due to trauma in KwaZulu-Natal: The need for Afrocentric trauma systems. World J Surg 2013;37(3):1513-1525. [http:// dx.doi.org/10.1007/s00268-012-1852-1] 18. National Department of Transport. The Estimation of Unit Costs of Road Traffic Accidents in South Africa. CR-2004/6 March 2004. Pretoria: CSIR Transportek, 2004. 19. South African National Road Agency. 2014 www.nra.co.za/content/SANRAL_Annual_Report_2104_ PRESS_14_9_15.pdf (accessed 10 April 2015). 20. Howlett JB, Aldous C, Clarke DL. Injuries sustained by passengers travelling in the cargo area of light delivery vehicles. S Afr J Surg 2014;52(2):49-52 [http://dx.doi.org /10.7196/sajs.1963) 21. World Health Organization. World Report on Child Injury Prevention www.who.int/violence_injury_ prevention/child/injury/world_report/en/ (accessed 27 March 2015) 22. Seggie J. The ch in children stands for cherish. S Afr Med J 2015;105(3):160-161 [http://dx.doi. org/10.7196/SAMJ.9452]

Accepted 24 June 2015.

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Interpersonal violence as a major contributor towards the skewed burden of trauma in KwaZulu-Natal, South Africa C Lewis, MB ChB, Dip ROM RCSEd; D Wood, MB BCh, FCEM, MPhil, BPharm Department of Emergency Medicine, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa Corresponding author: C Lewis (drcarolynlewis@yahoo.com)

Background. Trauma is one of the foremost causes of death worldwide, but there is a paucity of data on demographics and injury patterns in developing countries. Objectives. To quantify and describe the major trauma burden at a regional hospital in KwaZulu-Natal (KZN), South Africa (SA), over a 5-year period. Methods. Ngwelezane Hospital is a large regional hospital in northern KZN. A database is maintained of all major trauma patients admitted to the Emergency Department (ED) resuscitation unit. Statistical analysis was performed to quantify the burden of trauma and analyse trends in these data. Results. Over a 5-year period, 3 735 major trauma patients were admitted to the ED resuscitation unit. Analysis showed a male predominance, with a mean patient age of 28.6 years. An average of 62 patients per month were admitted, the rate peaking over the holiday seasons. Trauma secondary to interpersonal violence (IPV) predominated. A disproportionately high level of pedestrian-motor vehicle collisions (PMVCs) in relation to total road traffic collisions was noted. Blunt force trauma secondary to motor vehicle collisions was the leading cause of death, while blunt force trauma secondary to PMVCs carried the highest mortality rate. Conclusion. This study highlights the high incidences of both IPV and PMVCs typical of trauma in an SA setting. The demographics and injury patterns noted may be used to drive public health interventions to address this burden of trauma. S Afr Med J 2015;105(10):827-830. DOI:10.7196/SAMJnew.8380

Trauma is a leading cause of death worldwide, with a higher incidence in low- and middle-income countries than in high-income countries.[1] There is a paucity of data on demographics and injury patterns in developing countries, and without such data public health interventions to address this burden cannot be accomplished.[2] Muckart[3] likened trauma in South Africa (SA) to a malignant epi demic almost 25 years ago. Little has changed since then, and SA has maintained its place as one of the ‘capitals’ of trauma in the world. What is of concern is the type of trauma being reported, i.e. the high incidences of interpersonal violence (IPV) and pedestrian-motor vehicle collisions (PMVCs). KwaZulu-Natal Province (KZN) is the most populous of SA’s nine provinces, with almost 11 million people.[4] Numerous studies have analysed various aspects of trauma in KZN. Hardcastle et al.[5] assessed the burden of trauma with regard to care provided in public hospitals over a 2-month period, and showed a high burden of trauma with a predominance of intentional trauma. Parkinson et al.[6] assessed the burden of trauma secondary to road traffic collisions (RTCs) in a regional trauma centre in KZN over a 10-week period, their data highlighting both a significant burden of trauma secondary to RTCs and a relatively high proportion of PMVCs. Laing et al.[7] assessed the burden of trauma in the Pietermaritzburg Metropolitan Trauma Service throughout 2013. These studies all demonstrated a high incidence of trauma and alluded to the skewed number of IPV cases with significant morbidity and mortality outcomes. We aimed to add to the reported data by quantifying the trauma burden at a large regional hospital in KZN over an extended period and sought to evaluate trends from the extracted data.

Objectives

To describe the incidence rate of major trauma at a regional hospital in KZN with a focus on the demographics of trauma patients,

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seasonal trends, mechanism of injury, length of stay, disposition and mortality.

Methods

We analysed data from Ngwelezane Hospital (NH), a 554-bed regional hospital in northeastern KZN, over the 5-year period from January 2009 - December 2013. All major trauma in the region is referred to NH through the hospital’s emergency department (ED). The resuscitation unit of the ED at NH is responsible for assessment and admission of all patients with major injuries. All patients are triaged on arrival. Major injuries are defined according to the South African Triage Scale (SATS) as red (physiologically unstable patients) or orange (serious cases with potentially unstable physiology or potentially life-threatening or limb-threatening pathology).[8] The ED maintains a Microsoft Office Access database (based on MS Excel 2007) of all patients admitted to its resuscitation unit. Data are collected prospectively on all patients admitted to the ED by the senior medical officer or specialist trainee on call during the 24-hour on-call period. The study population included all persons within the drainage area of NH. The sampling frame was all patients admitted to the resuscitation unit at NH from January 2009 to December 2013, inclusive. The study sample was the subset of these patients whose admissions were a result of major trauma. Patients with minor trauma who did not require admission to the resuscitation unit for stabilisation, and non-trauma-related admissions, were excluded from analysis. Data extracted included age, gender, injury type, month of admission, length of hospital stay, disposition and mortality. Statistical analysis was performed using Intercooled Stata version 13.

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Ethical considerations

Ethics approval was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE022/14).

1 800

Results

1 200

Patients, n

1 400 1 000 723

800

568

600 400

288

245

170

200 0

0 - 10

11 - 20

21 - 30

31 - 40

41 - 50

51 - 60

61 - 70

Over 71

Age groups (years)

Fig. 1. Breakdown of patients according to age group. 405

400

382 322

350 300 250

325

296

303

270

244

237

310

239

200

er No ve m be r De ce m be r

to b Oc

pt em

Au g

ly Ju

Ap r

ru Fe b

nu Ja

ar ch

150 100 50 0 y

Patients, n

450 400

Month

Fig. 2. Monthly admissions over a 5-year period. 1000

911

900 800 650

Patients, n

700

632

600

542

500 340

400

285

300

205

200

170

100

ss um aa tra

ra u

un tf or ce

yt Po l

au lt

s Bu

m aP M

ry ju

Cr us h

um aG tra g

ry ju ra tin Pe n

la te d

aM ra um

yt Po l

Iso

ra tin

tra

um as

Pe n

A total of 10 390 patients were seen as emergencies during the period January 2009 - December 2013. Of these 3 735 were classified as having sustained major trauma, and their demographics were as follows: 3 036 (81.3%) were male, 671 (18.1%) were female, and 28 had no gender documented. The mean age was 28.6 years (standard deviation 13.55). The majority of patients admitted were between 20 and 30 years of age (Fig. 1). An average of 62 patients a month were admitted, with the rate peaking over the months of January, April and May (Fig. 2). Breakdown of all cases of major trauma showed the following: IPV 2 594 patients (69.4%), with penetrating trauma secondary to stabbing in 911 (24.3%), isolated head injury in 632 (16.9%), penetrating trauma secondary to gunshot wounds (GSWs) in 542 (14.5%), crush injury secondary to community assault in 340 (9.1%), blunt force trauma secondary to assault in 170 (4.5%), blunt force trauma secondary to motor vehicle collisions (MVCs) in 650 (17.4%), blunt force trauma secondary to PMVCs in 285 (7.6%), and burns in 205 (5.4%). Our experience is that most isolated head injuries are caused by IPV. Fig. 3 summarises the mechanisms of injury. One hundred and sixty-eight patients died while admitted in the resuscitation unit of the ED, giving a mortality rate of 4.5% and a case fatality rate of 1.6/100 admissions. Analysis of the mechanism of injury resulting in death revealed that IPV predominated, with 92 deaths (54.7%). Of the patients who died, 39 (23.2%) sustained penetrating trauma secondary to GSWs, 36 (21.4%) an isolated head injury, 7 (4.1%) penetrating trauma secondary to stabbing, 7 (4.1%) blunt force trauma assault, and 3 (1.7%) crush injury secondary to community assault. Other causes of death were as follows: 42 patients (25.0%) sustained blunt force trauma secondary to an MVC, 25 (14.8%) blunt force trauma secondary to a PMVC, and 9 (5.3%) burns. Fig. 4 summarises mortality according to mechanism of injury. The single mechanism of injury respon sible for the highest overall mortality was blunt force trauma secondary to a PMVC (8.7%), followed by penetrating trauma secondary to a GSW (7.1%) and blunt force trauma secondary to an MVC (6.4%). These findings are summarised in Table 1.

1 625

1 600

Mechanism of injury

Fig. 3. Mechanisms of injury.

The majority of patients (n=2 717) admitted to the resuscitation unit were admitted for <12 hours (72.7%). Of those admitted, 1 942 patients (51.9%) were discharged from the resuscitation unit ward of the ED to a general ward, 715 (19.1%) went to theatre

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directly from the unit, 379 (10.1%) were discharged home once stabilised, 257 (6.8%) were discharged to a peripheral hospital, 248 (6.6%) were transferred to an intensive care unit, and 26 (0.6%) were transferred to a private hospital.

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42 39

Patients, n

35 30 25

25 20 15

7 3

5 0 Polytrauma Penetrating Isolated Polytrauma MVC trauma head injury PMVC GSW

Burns

Penetrating Blunt force trauma stab trauma assault

Crush injury

Mechanism of injury

Fig. 4. Mechanisms of injury causing death.

Table 1. Mechanism of injury v. mortality Mortality rate (%)

Case fatality rate/100 admissions

Mechanism of injury

Deaths

Polytrauma PMVC

285

8.7

0.2

Penetrating trauma GSW

542

7.1

0.3

Polytrauma MVC

650

6.4

0.4

Isolated head injury

632

5.6

0.3

Burns

205

4.3

0.08

Blunt force trauma assault

170

4.1

0.06

Crush injury

340

0.8

0.02

Penetrating trauma stab

911

0.8

0.06

Discussion

Hospitals in developing countries manage a large volume and range of major trauma. In contrast to the spectrum of trauma seen in a developed world, where blunt force trauma secondary to RTCs and self-inflicted injuries predominates,[1] a significant proportion of major trauma admissions to NH are the result of IPV. Hofman et al.[2] describe the mortality rate for injury secondary to intentional violence as ten times higher in low- and middle-income countries than in high-income countries. Similar patterns are observed for disability-adjusted life-years. This observation is borne out in our study. The demographic group most affected by trauma was males aged 20 - 30 years, in whom the majority of injuries are due to IPV. There was a peak in admission rates over the months of January, April and May. This peak distribution was consistent over the study period, but unexpectedly did not appear to be associated with all the holiday seasons throughout the year. There was a trauma caseload peak over the

Easter April/May season, but the Christmas and New Year holidays did not show a significant peak in trauma cases. While our results do not take specific days into account, our experience is that there are significant trauma peaks on holidays such as Christmas Day, the Day of Goodwill (Boxing Day) and New Year’s Day. Penetrating trauma secondary to stabs and GSWs were significant contributors to the trauma numbers in our study. The high proportion of crush injuries following assault is also striking. Crush syndrome following assault is a uniquely SA phenomenon[9] and is usually the result of community justice or ‘kangaroo courts’. These patients sustain rhabdomyolysis secondary to muscle trauma with the risk of acute kidney injury. Many of these patients also suffer defence injuries such as fractures of the forearm. The high rate of IPV also contributes to the number of isolated head injuries. The incidence rate for isolated severe head injuries in our study is 24/100 000 population

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in our district. International and currently available SA data assess all traumatic brain injuries (TBIs), mild, moderate and severe, of which mild TBIs constitute 75 - 95%. [10,11] Our findings reflect those of the World Health Organization (WHO), which demonstrated an increased incidence rate of all TBIs from 150 to 170/100 000 in Latin America and sub-Saharan Africa, respectively, in contrast to the global rate of 106/100 000.[12] Over two decades ago, Nell and Brown[13] documented an annual incidence rate of TBIs (mild, moderate and severe) of 316/100 000 in Johannesburg, SA. International data suggest that nearly 60% of all traumatic head injuries are a result of RTCs, 20 - 30% are due to falls, 10% are due to IPV, and another 10% are a result of a combination of workplace and sports-related injuries,[12] whereas the high SA incidence rates reflect the high levels of IPV typical of SA trauma.[13] Despite their different study population, Hardcastle et al.[5] also found a high incidence of IPV. Parkinson et al.[6] assessed the burden of victims of RTCs presenting to Edendale Hospital (one of the major trauma centres in Pietermaritzburg, the second-largest city in KZN). They demonstrated a high burden of trauma as a result of RTCs, with PMVCs accounting for 41%. Of 935 admissions secondary to RTCs in our study, 69.5% were due to MVCs and 30.5% to PMVCs. Based on estimated global road traffic fatalities, PMVCs account for 22% of all road traffic deaths worldwide.[14] The WHO notes a clear geographical distribution, with the proportion of pedestrians killed in relation to other road users highest in the African region (38%).[14] Both Parkinson et al.’s[6] and our study correlate with the findings of the WHO. IPV among young adult males is a major contributor to the trauma burden in our study. The WHO notes that countries around the world are at differing stages with regard to their capacity for data collection. Although mortality data are widely collected all over the world, data pertaining to nonfatal outcomes are not available in most countries of the world.[1] In comparison with WHO available data, the contribution of IPV to the total trauma burden is significantly higher than figures quoted in developed countries. [1] In our experience, alcohol intake and lack of employment opportunities in the region are factors contributing to the reported violence. Studies are needed to identify factors that either increase or decrease the risk for violence and further more identify which of these factors can be modified through intervention.

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In our experience, the low socioeconomic status of our patient population often results in lack of transport and therefore a high proportion of pedestrians. Studies are needed to identify factors that increase or decrease the risk of RTCs, particularly PMVCs, in order to successfully implement effective interventions and legislation.

Acknowledgements. The authors wish to acknowledge that the design and maintenance of the ED Microsoft Office Access database from which data were collated for this study is attributed to Dr Naas Postma, MB ChB, DipEC, MPhil, of the Department of Emergency Medicine, University of KwaZulu-Natal.

Study limitations

References

There are limitations to our study. Patients with major trauma were assessed according to the SATS (which is the standard triage of all emergency departments in SA) as red or orange, but no formal injury severity score or similar assessment was performed. Notably, a SATS score of red or orange does not necessarily correlate with injury severity; a physiologically unstable patient may rapidly become physiologically stable after treatment of their underlying condition (such as correction of hypovolaemic shock), which may account for many of the 10% of victims of major trauma in this study who were discharged directly home from the ED. While data were collected on all patients admitted to the ED prospectively, it is a limitation of our study that data may not have been accurately recorded on those holidays that anecdotally have peaks of trauma admissions, owing to the high workload and ensuing time constraints. This may result in the peak distribution of admission rates per month not reflecting all holiday seasons throughout the year.

Conclusions

Regional hospitals in developing countries attend to a large volume and wide variety of major trauma. Our study highlights a disproportionately high level of IPV with resultant morbidity and mortality when compared with developed countries. It further highlights the burden of PMVCs as a proportion of all RTCs. This high incidence of IPV and comparatively high incidence of PMVCs are areas that would benefit from further study, effective legislation and community intervention.

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1. Peden M, McGee K, Krug E. Injury – a Leading Cause of the Global Burden of Disease 2000. Geneva: World Health Organization, 2000. 2. Hofman K, Primack A, Keusch, G, et al. Addressing the growing burden of trauma and injury in low- and middle-income countries. Am J Public Health 2005;95(1):13-17. [http://dx.doi.org/10.2105/ AJPH.2004.039354] 3. Muckart. Trauma – the malignant epidemic. S Afr Med J 1991;79(2):93-95. 4. Statistics South Africa. Census 2011. www.statssa.gov.za/publications/p03014/p030142011.pdf (accessed 22 December 2014). 5. Hardcastle T, Samuels C, Muckart D. An assessment of the hospital disease burden and the facilities for the in-hospital care of trauma in KwaZulu-Natal, South Africa. World J Surg 2013;37(7):1550-1561. [http://dx.doi.org/10.1007/s00268-012-1889-1] 6. Parkinson F, Kent S, Aldous C, et al. Road traffic crashes in South Africa: The burden of injury to a regional trauma centre. S Afr Med J 2013;103(11):850-852. [http://dx.doi.org/10.7196/ samj.6914] 7. Laing G, Skinner D, Bruce J, et al. Understanding the burden and outcome of trauma care drives a new trauma systems model. World J Surg 2014;38(7):1699-1706 [http://dx.doi.org/10.1007/s00268014-2448-8] 8. Gottschalk SB, Wood D, de Vries S, et al. The Cape Triage Score: A new triage system South Africa. Proposal from the Cape Triage Group. Emerg Med J 2006;23(2):149-153. [http://dx.doi.org/10.1136/ emj.2005.028332] 9. Muckart D, Abdool-Carrim A. Pigment-induced nephropathy after sjambok injuries. S Afr J Surg 1991;29(1):21-24. 10. Get the stats on traumatic brain injuries in the United States. 2013. www.cdc.gov/traumaticbraininjury (accessed 27 December 2014). 11. Evans R. Concussion and mild traumatic brain injury. 2014 UpToDate. www.uptodate.com (accessed 27 December 2014). 12. Hyder A, Wunderlich C, Puvanachandra P, et al. The impact of traumatic brain injuries: A global perspective. Neurorehabilitation 2007;22(5):341-353. 13. Nell V, Brown D. Epidemiology of traumatic brain injury in Johannesburg – II. Morbidity, mortality and etiology. Soc Sci Med 1991;33(3):289-296. [http://dx.doi.org/10.1016/0277-9536(91)90363-H] 14. World Health Organization. Pedestrian Safety: A Road Safety Manual for Decision Makers and Practitioners. 2013. www.who.int/roadsafety/en/ (accessed 12 February 2015). 15. Garrib A, Herbst A, Hosegood V, et al. Injury mortality in rural South Africa 2000-2007: Rates and associated factors. Trop Med Int Health 2011;16(4):439-446. [http://dx.doi.org/10.1111/j.13653156.2011.02730.x]

Accepted 16 July 2015.

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RESEARCH

The epidemiology of major incidents in the Western Cape Province, South Africa D J van Hoving,1 MB ChB, Dip PEC (SA), MMed (EM), MScMedSci (ClinEpi); H J Lategan,2 BSc, MB BCh, MMed (EM), FCEM (SA); L A Wallis,1,2 MB ChB, MD, DIMCRCSEd, Dip Sport Med, FRCS (Ed) (A&E), FRCP (Ed), FRCEM, FCEM (SA), FEMSSA, FIFEM; W P Smith,2 MB ChB, EMDM, FCEM (SA) 1 2

ivision of Emergency Medicine, Stellenbosch University, Tygerberg, Cape Town, South Africa D Division of Emergency Medicine, University of Cape Town, South Africa

Corresponding author: D J van Hoving (nvhoving@sun.ac.za)

Background. Major incidents put pressure on any health system. There are currently no studies describing the epidemiology of major incidents in South Africa (SA). The lack of data makes planning for major incidents and exercising of major incident plans difficult. Objective. To describe the epidemiology of major incidents in the Western Cape Province, SA. Methods. A retrospective analysis of the Western Cape Major Incident database was conducted for the period 1 December 2008 - 30 June 2014. Variables collected related to patient demographics and incident details. Summary statistics were used to describe all variables. Results. Seven hundred and seventy-seven major incidents were reviewed (median n=11 per month). Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district had the highest incidence (11.97/10 000 population). Transport-related incidents occurred most frequently (94.0%, n=730). Minibus taxis were involved in 312 major incidents (40.2%). There was no significant difference between times of day when incidents occurred. A total of 8 732 patients were injured (median n=8 per incident); ten incidents involved 50 or more victims. Most patients were adults (80.0%, n=6 986) and male (51.0%, n=4 455). Of 8 440 patients, 630 (7.5%) were severely injured. More than half of the patients sustained minor injuries (54.6%, n=4 605). Conclusion. Major incidents occurred more often than would have been expected compared with other countries, with road traffic crashes the biggest contributor. A national database will provide a better perspective of the burden of major incidents. S Afr Med J 2015;105(10):831-834. DOI:10.7196/SAMJnew.7766

A major incident can be defined as ‘any incident where the location, number, severity or type of live casualties requires extraordinary resources’.[1] Major incidents can be further classified into: (i) natural or man-made; (ii) simple or compound (infrastructure is lost); and (iii) compensated or uncompensated (healthcare system unable to cope despite additional resources).[1] Major incidents happen more frequently than is generally recognised. Britain has 0 - 11 major incidents each year (average 3 - 4 per year), of which the majority (59.2%) involve public transportation.[2] In Pakistan, emergency medical services responded to 438 major incidents in only 6 months, the majority (48.6%) also related to road transportation.[3] The incidence in South Africa (SA) is unknown. Prevention of future incidents is vital but nearly impossible, as the related hazards will never be completely eliminated.[4] The focus should be on actions that can change both the nature of the hazard and the risk that a hazard will evolve into a major incident, with the aim of decreasing the risk of the incident (in terms of both frequency and magnitude).[4] Risk management attempts to modify the probability that an incident will occur.[4] Risk management strategies mainly apply to man-made incidents and may include appropriate education and training, developing and implementing codes of practice, and developing preventive services.[4] However, risk management is only possible if appropriate risk markers can be identified.[4] There are currently no studies describing the epidemiology of major incidents in SA. The lack of data makes planning for major incidents and exercising major incident plans difficult. Gaining an understanding of the ‘pathophysiology’ of major incidents should provide insight that could be applied to develop appropriate

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strategies for the prevention and modification of major incidents. The knowledge attained will also result in a better state of preparedness for major incidents.

Objective

To describe the epidemiology of major incidents in the Western Cape Province of SA.

Methods

Study design

A retrospective analysis of the Western Cape Major Incident database was conducted. The study was approved by the Health Research Ethics Committee of the University of Cape Town (ref. 441/2011).

Study setting

The Western Cape covers an area of 129 462 km² and is home to more than 5.8 million people.[5] The province is divided into six district municipalities, five rural districts (Cape Winelands, Central Karoo, Eden, Overberg, West Coast), and one metropolitan district (City of Cape Town).[6] The City of Cape Town has the highest population density (1 520.3/km2) and the Central Karoo the lowest (1.8/km2). The population densities for Eden, Overberg and West Coast are 24.6/km2, 22.6/km2 and 12.6/km2, respectively.[6] The Western Cape Major Incident database was started on 1 December 2008 by the Disaster Medicine and Special Events section of the divisions of emergency medicine at the University of Cape Town and Stellenbosch University and the Western Cape Government. It collects data on all major incidents in the Western Cape. SA standardised the Major Incident Medical Management and Support (MIMMS) principles in terms of major incident management as part

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entries (no patients injured n=32, incidents before 1 December 2008 n=3, double entry n=1). There was a median of 11 incidents per month (minimum n=0, maximum n=39) (Fig. 1). Most major incidents occurred in the City of Cape Town (57.8%, n=449), followed by the Cape Winelands (18.4%, n=143), Central Karoo (10.9%, n=85) and Overberg (4.8%, n=37). Only 30 incidents (3.9%) occurred in the West Coast region and 17 (2.2%) in the Eden district (location not specified n=16). The Central Karoo district had the most incidents per 10 000 population (Fig. 2). Transport-related incidents were the most frequent type of major incidents (Table 1). Road traffic crashes made up most of the transport-related incidents (99.2%, n=724), with the remainder divided between boats (n=3, 0.4%) and aircraft (n=3, 0.4%). Minibus taxis were involved in 312 major incidents (40.2%), heavy vehicles in 56 (7.2%) and buses in 46 (5.9%). The prevailing weather conditions at the time of the major incidents are presented in Table 2. There was no significant difference

Statistical analysis

Summary statistics were used to describe all variables. Ranges and percentages were used as indicators of spread and medians as the measure of central tendency. Distributions of variables are presented with frequency tables. The population totals according to the 2011 Census were used as the denominator to calculate the incidence per health district.[6]

Results

There were 813 major incidents entered into the database. Seven hundred and seventyseven major incidents were included for the 67 months under review after excluding 36

Incidents n (%)

Patients n (%)

Transport

730 (94.0)

7 910 (90.6)

Chemical

12 (1.5)

229 (2.6)

Fire

10 (1.3)

76 (0.9)

Interpersonal violence

6 (0.8)

47 (0.5)

Food poisoning

5 (0.6)

316 (3.6)

Structural collapse

2 (0.3)

18 (0.2)

Other

12 (1.5)

136 (1.6)

Total

777 (100.0)

8 732 (100.0)

30 25 20 15 10

Month

Fig. 1. Major incidents in the Western Cape for the period 1 December 2008 - 30 June 2014.

11.97

12 10 8 6 4 2 0

1.20

1.82

City of Cape Cape Town Winelands

1.43 Central Karoo

Overberg

0.77 West Coast

0.30 Eden

Western Cape health districts

Fig. 2. The incidence of major incidents in the Western Cape according to health districts.

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1.31 Overall

Jun 2014

Mar 2014

Dec 2013

Jun 2013

Sep 2013

Mar 2013

Dec 2012

Jun 2012

Sep 2012

Mar 2012

Dec 2011

Jun 2011

Sep 2011

Mar 2011

Dec 2010

Jun 2010

Sep 2010

Dec 2009

Mar 2010

Jun 2009

Sep 2009

5 Dec 2008

Variables collected related to patient demographics (age, gender, injury severity) and incident details (date, time, location, type and weather). Patients aged >12 years were classified as adults. Injury severity was assessed according to the MIMMS Triage Sieve tool, prioritising live patients as ‘priority 1’ (immediate priority), ‘priority 2’ (urgent priority), or ‘priority 3’ (delayed priority).[1] Data were stored on a passwordprotected work computer.

Major incidents, n

Data collection and management

Table 1. Types of major incidents in the Western Cape

Incidence of major incidents/10 000 population

All data in the Western Cape Major Incident database were analysed for the period 1 December 2008 - 30 June 2014. Incomplete data points were excluded from analysis.

between the times of the day when major incidents occurred (Fig. 3). A total of 8 732 patients were injured (median n=8 per incident); the maximum number of patients per incident (n=193) was associated with a food poisoning episode.

Study population

Mar 2009

of the FIFA 2010 Soccer World Cup legacy. Major incidents were accordingly defined as ‘any incident where the location, number, severity or type of live casualties requires extraordinary resources’. [1] Incidents were only entered onto the database after they had been declared a major incident by the emergency medical services (EMS) officer commanding the scene (medical scene commander). Standardised data collection sheets are completed by the EMS Central Control Centre, which receives the data from the scene commander by means of a two-way radio network with the forms completed as part of their day-to-day tasks. No personal or other identifying details (e.g. vehicle registration numbers) are collected. Completed forms are sent to the EMS Head Office, where the data are imported into an electronic spreadsheet (Microsoft Excel; Microsoft Corporation, USA). A single research assistant inserts the data. The database is stored on a passwordprotected work computer situated in the EMS Head Office, and access is limited to senior management personnel employed by the EMS.

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Punjab province, 73 major incidents occurred per month, while South Korea averaged 26.6 incidents per month;[3,7] 1.25 major incidents per month were registered during a 5-year study in southern Germany, and the city of Helsinki experienced less than one a month (59 incidents over a 6-year period).[8,9] The 11 incidents per month in the Western Cape are difficult to compare with international studies for two main reasons: firstly, a standard definition was not used in all studies, which may have resulted in over- or underestimation of the frequency of major incidents; and secondly, the Western Cape is only one of nine provinces in SA, whereas South Korea has 16 provinces, with an average number of incidents per province of about 1.7 per month.[7] The Pakistan experience is also unique in that the Punjab province is home to more than half the population and their prehospital system is

Ten incidents had ≥50 victims. The majority of patients were adults (80.0%, n=6 986) and male (51.0%, n=4 455). Only 7.5% of patients (n=630) were severely injured and subsequently triaged as priority 1, and 33.6% (n=2 832) were triaged as priority 2. More than half of the patients were triaged as priority 3 (54.6%, n=4 605), while 4.4% (n=373) died on the scene (Table 3). Two hundred and ninety-two patients were triaged into a triage category that is not part of the Triage Sieve tool, and were excluded from analysis pertaining to injury severity.

Discussion

This study set out to describe the epi demiology of major incidents in the Western Cape over a 67-month period. Major incidents happened more frequently than would have been expected compared with other countries. In contrast, in Pakistan’s

151

148

160 Major incidents, n

140 120 100

116

08h00 11h59

12h00 15h59

102

126

80 60 40 20 0

00h00 03h59

04h00 07h59

16h00 19h59

20h00 23h59

Time of day Fig. 3. Major incidents in the Western Cape according to time of day.

Table 2. Prevailing weather conditions associated with major incidents in the Western Cape* With rain, n

With snow, n

With mist, n

With wind, n

Light (n=397, 51.1%)

Dark (n=344, 44.3%)

Cloudy (n=34, 4.4%)

*Not indicated n=2.

Table 3. Patients involved in major incidents according to injury severity*, gender and age Adult Priority 1

Child

Male, n (%)

Female, n (%)

Male, n (%)

Female, n (%)

Total, n (%)

307 (3.6)

162 (1.9)

101 (1.2)

38 (0.5)

630† (7.5)

Priority 2

1 266 (15.0)

1278 (15.1)

155 (1.8)

133 (1.6)

2 832 (33.6)

Priority 3

1 728 (20.5)

1 649 (19.5)

471 (5.6)

757 (9.0)

4 605 (54.6)

Dead

209 (2.5)

101 (1.2)

39 (0.5)

24 (0.3)

373 (4.4)

Total

3 510 (41.6)

3 190 (37.8)

766 (9.1)

952 (11.3)

8 440 (100.0)

*Patients triaged into a category not part of the Triage Sieve were excluded (adult n=271, child n=21). † Triaged as priority 1 but gender missing (adult n=15, child n=7).

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so severely under-resourced that incidents involving three or more patients are classified as major (this is calculated from the number of patients per incident, which averaged <8[3] v. the Western Cape average of 11.2). The incidence of major incidents per 10 000 people in the Western Cape is higher than reflected in international studies. Although the denominators used in the calculations are admittedly arbitrary, they do provide an idea of the current situation. The overall figure for the Western Cape (1.31/10 000) is considerably higher than in more densely populated areas such as South Korea (0.67/10 000) and the Punjab province (0.06/10 000).[3,7,10] While the City of Cape Town had the most incidents (n=449), the sparsely populated Central Karoo district had the highest incidence of major incidents (11.97/10 000), reflecting the fact that it is transected by national roads infamous for their high traffic loads and road traffic crashes – notably, all major incidents in that district were related to road traffic crashes. Worldwide, transport-related incidents are the chief cause of major incidents, with the proportion in the Western Cape (94.0%) exceeding that in both South Korea (74.5%) and Spain (71.6%).[7,11] This wide discrepancy increases if only the road traffic crashes are taken into account (Western Cape 93.2% v. South Korea 78.6%,[7] Finland 62.7%,[9] and Pakistan 48.6%[3]). Road traffic injuries are currently the eighth leading cause of death in the world and are soon expected to be ranked even higher.[12] A number of key risk factors (speed, drink-driving, and failure to use motorcycle helmets, seat-belts and child restraints) need to be addressed with both legislation and law enforcement.[12] Minibus taxis are significant role players and were involved in 40.2% of all major incidents. The minibus taxi industry in SA is part of the public transport system, with 69% of households using taxis (90% minibus and 10% metered), 20.2% buses and 9.9% trains. [13,14] Although taxis are often perceived as unsafe, they are a preferred mode of transport, cutting down on travel time (and offering a door-to-door service with shorter waiting time compared with queuing at bus and train stations).[14] Driver attitude and vehicle roadworthiness of minibus taxis have long been flagged as the most important road safety aspects to address. With current strategies clearly falling short, as the fatal injury levels year-on-year remain largely unchanged,[14,15] it is time to shift the focus to ensure the ‘crashworthiness’ of vehicles, with legal requirements for seatbelts for all passengers, laminated windows and sideimpact protection beams.

RESEARCH

There were minimal differences between the times of day at which the incidents occurred. The suggestion of a bimodal distribution can be explained by the high portion of road traffic crashes that occurred during peak traffic periods (Fig. 3). Studies in Pakistan and Germany similarly indicated that time of day had no effect on the frequency of major incidents.[3,8] Twenty percent of victims of major incidents in the Western Cape were children, compared with 14.1% in Finland.[9] However, the proportions of children injured in major incidents can range between 10% and 100% per incident.[16] Although difficulties in managing children are encountered in all phases of any major incident, triage has always been a concern, as most are placed in a higher category (effectively, over-triaged) when adult physiologybased triage scores are used. This may even compromise the care of adults when less severely injured children are channelled to high-priority care areas.[16] It is recommended that the adult triage score be modified in preference to implementing paediatric-specific triage scores,[16] as most of the latter have poor sensitivity for major incidents and fail to identify patients with serious injury. The overtriage of children could even be beneficial, especially when only small numbers of children are affected.[17] The mortality rate in major incidents differs depending on the definition of a major incident used. This study defined major incidents as any significant incident that demanded extraordinary resources for live casualties and that overwhelmed the healthcare system.[1] The portion of patients who died was similar to international studies: 4.4% in the Western Cape compared with 10.4% in Pakistan, 6% in Korea and 3.8% in Finland.[3,7,9] In contrast, most patients (54.6%) sustained only minor injuries. Similar findings are reported in major incidents in Britain.[2]

Study limitations

There is no external method available to confirm that the scene commander appropriately declared a major incident or that data were recorded accurately at the time of the incident. All EMS personnel are trained according to the MIMMS principles that contain the definition of a major incident.[1] Personnel from the EMS control centre were also trained on the completion of the data collection sheets and to elicit the required data from the scene commanders. This should have ensured quality of the data, while minimising missing data points. The transcription process was done by a single research assistant but was not cross-checked; errors may therefore

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have occurred that could have influenced the results. Incomplete data forms with missing variables also limited the generalisability of the study results.

Conclusion

Major incidents occurred frequently in the Western Cape, and contingency plans should always be in place. Road traffic crashes were by far the biggest contributor, requiring both legislation and enforcement regarding road safety. A national database on major incidents will provide a better perspective of the burden of disease they create. References 1. Advanced Life Support Group. Major Incident Medical Management and Support. 3rd ed. Oxford: Wiley-Blackwell, 2011. 2. Carley S, Mackway-Jones K, Donnan S. Major incidents in Britain over the past 28 years: The case for the centralised reporting of major incidents. J Epidemiol Community Health 1998;52(6):392-398. [http://dx.doi.org/ 10.1136/jech.52.6.392] 3. Waseem H, Carenzo L, Razzak J, et al. Epidemiology of major incidents: An EMS study from Pakistan. Int J Emerg Med 2011;4(1):48. [http://dx.doi.org/ 10.1186/1865-1380-4-48] 4. World Association for Disaster and Emergency Medicine. Health disaster management: Guidelines for evaluation and research in the Utstein Style. Volume I. Conceptual framework of disasters. Prehosp Disaster Med 2003;17(Suppl 3):1-177. http://www.wadem.org/guidelines.html (accessed 7 September 2015). 5. Statistics South Africa. Census 2011 Statistical Release – P0301.4. Pretoria: SSA, 2012. http://www. statssa.gov.za/publications/P03014/P030142011.pdf (accessed 4 September 2014). 6. Statistics South Africa. Census 2011 Municipal Report – Western Cape. Pretoria: SSA, 2012. https:// www.statssa.gov.za/Census2011/Products/WC_Municipal_Report.pdf (accessed 4 September 2014). 7. Kim SJ, Kim CH, Shin SD, et al. Incidence and mortality rates of disasters and mass casualty incidents in Korea: A population-based cross-sectional study, 2000-2009. J Korean Med Sci 2013;28(5):658-666. [http://dx.doi.org/ 10.3346/jkms.2013.28.5.658] 8. Beck A, Bayeff-Filloff M, Bischoff M, et al. [Analysis of the incidence and causes of mass casualty events in a southern Germany medical rescue area]. Unfallchirurg 2002;105(11):968-973. [http://dx.doi.org/ 10.1007/s00113-002-0516-2] 9. Kuisma M, Hiltunen T, Määttä T, et al. Analysis of multiple casualty incidents – a prospective cohort study. Acta Anaesthesiol Scand 2005;49(10):1527-1533. [http://dx.doi.org/ 10.1111/j.13996576.2005.00761.x] 10. Government of Punjab, Pakistan. Quick Stats – Punjab Portal. Lahore, Punjab, 2014. http://www. punjab.gov.pk/punjab_quick_stats (accessed 22 August 2014). 11. Arcos González P, Pérez-Berrocal Alonso J, Castro Delgado R, et al. Trends in disasters in Spain and their impact on public health: 1950-2005. Public Health 2007;121(5):375-377. [http://dx.doi. org/10.1016/j.puhe.2006.11.014] 12. World Health Organization. Global Status Report on Road Safety 2013: Supporting a Decade of Action. Geneva: WHO, 2013. http://www.who.int/violence_injury_prevention/road_safety_status/2013/ report/en/ (accessed 4 September 2014). 13. Statistics South Africa. National Household Travel Survey 2013. Pretoria: SSA, 2014. http://beta2. statssa.gov.za/publications/P0320/P03202013.pdf (accessed 4 September 2014). 14. Arrive Alive South Africa. Minibus Taxis and Road Safety. http://www.arrivealive.co.za/MinibusTaxis-and-Road-Safety (accessed 4 September 2014). 15. Road Traffic Management Corporation. Annual Report 2011/2012. Faerie Glen: RTMC, 2013. http:// www.rtmc.co.za/images/docs/publication.pdf (accessed 4 September 2014). 16. Carley SD, Mackway-Jones K, Donnan S. Delphi study into planning for care of children in major incidents. Arch Dis Child 1999;80(5):406-409. [http://dx.doi.org/ 10.1136/adc.80.5.406] 17. Wallis LA, Carley S. Comparison of paediatric major incident primary triage tools. Emerg Med J 2006;23(6):475-478. [http://dx.doi.org/ 10.1136/emj.2005.032672]

Accepted 15 September 2014.

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Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury (GSH ASCI) Unit, Cape Town, South Africa, over the past 11 years J Sothmann, MB ChB; J Stander, MB ChB; N Kruger, BSc, MB ChB, FRCS (Ed), FCS Orth (SA); R Dunn, MB ChB, MMed (Orth), FCOrth (SA) Acute Spinal Injury Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: J Sothmann (pjsoth@yahoo.co.uk)

Background. Spinal cord injury (SCI) is devastating to both patient and society, with acute management and ongoing care being extremely expensive. Few epidemiological data are available on SCIs in South Africa (SA). Objectives. To identify the epidemiological profile of SCI patients at Groote Schuur Hospital (GSH), Cape Town, SA, and identify seasonal trends and peak periods. As the majority of the injuries are preventable, these data are important to develop prevention strategies. Methods. A retrospective review of prospectively collected data was conducted on all patients admitted to the Acute Spinal Cord Injury (ASCI) Unit at GSH from 1 April 2003 to 31 March 2014. All cases registered on a prospectively maintained database were included in the study. Results. The total number of patients admitted to the ASCI Unit was 2 042, with an average of 185 admissions per year. The male/female ratio was 5.25:1. The 21 - 30-year-old age category was the largest, comprising 33.5% of the patients. The most prevalent cause of injury was motor vehicle accidents (44.6%), followed by violence-related injuries (27.2%). Thirty-two point two percent of patients needed ventilatory support, and 91.5% of mechanically ventilated patients were successfully weaned. December was the busiest month in the unit. In patients in whom neurological deficit was incomplete, the average motor function improvement was 16.0%. Conclusions. Data capturing and analysis of SCIs should be encouraged in SA to guide management and prevention strategies, and to optimise outcomes. This study establishes the ASCI Unit at GSH to be one of the key role players in acute SCI management in SA. S Afr Med J 2015;105(10):835-839. DOI:10.7196/SAMJnew.8072

Spinal cord injury (SCI) is devastating to both the patient and society, with loss of productivity of this predominantly young and healthy age group and increased dependence on family and societal support. Acute management and ongoing care are extremely expensive.[1] Few epidemiological data are available on SCIs in South Africa (SA). Worldwide reviews[2-4] often include SA data based on studies done two decades ago.[5-7] Such data are important to develop preventive strategies, as many of these injuries are preventable.

Objectives

To identify the epidemiological profile of SCI patients at Groote Schuur Hospital (GSH), Cape Town, SA, identify seasonal trends and peak periods, and determine whether specific causes of injury are on the incline or decline.

Methods

The Acute Spinal Cord Injury (ASCI) Unit at GSH is a specialised unit for the management of patients from the Western Cape Province with acute traumatic spinal cord injuries. The unit has 21 beds, with 6 beds allocated to intensive care (4 ventilated and 2 non-ventilated). The mission of the unit is to manage the acute phase of the SCI, and its role is to stabilise patients from a mechanical and physiological point of view to optimise neurological outcome. The unit was established on 1 April 2003, and every admission since then has been documented on a prospective database. We conducted a retrospective study on all patients admitted to the ASCI Unit at GSH from 1 April 2003 to 31 March 2014. Data were extracted from a prospectively maintained database in the unit, into

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which patient information is entered on discharge. All cases that were registered on the database were included in the study. Information on age, gender, cause of injury, level of injury and referring hospitals was extracted from the database. Additional information that was extracted from the database was the proportion of patients who required surgery, whether ventilatory support was rendered, waiting periods for admission to the unit and duration of hospital stay. The waiting period before admission to the unit was calculated as the time between the date of the injury and the date of admission to the unit (expressed in weeks). The duration of stay in the unit was calculated as the time between the date of admission to the unit and the date of discharge (expressed in months). Patients’ neurological status was documented using the American Spinal Injury Association (ASIA) score. The total ASIA score (motor function plus sensation to soft touch plus sensation to pin prick) on admission was deducted from the total ASIA score on discharge from the unit, to determine the change in neurological status at the time of discharge. Of the patients with improvement in total ASIA scores, those with motor function improvement were identified (motor function score out of 100). The average improvement in motor function on discharge was determined separately for patients with incomplete and complete neurological deficit (some preservation of neurological function below the level of SCI and no function below the level of the injury, respectively, with the level defined as the last normal functioning level, e.g. in C6 motor complete injury, wrist dorsiflexion is normal and below this level there is no motor function except for a possible zone of partial preservation corresponding with spinal cord

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oedema. In C6 motor incomplete injury, wrist dorsiflexion is normal and below this level there is preservation of some motor function down to the sacral segments). Admission of patients to the unit was based on the ASCI Unit admission criteria and priority scale shown in Table 1.

Table 1. Acute spinal cord injury admissions to ASCI Unit, priority scale* P1

Incomplete acute SCI in need of urgent spinal cord decompression operation/procedure

Acute SCI with unstable cervical spine fracture in need of spinal fusion operation

Acute SCI with unstable thoracic/lumbar spine fracture in need of spinal fusion operation

Acute SCI with SCI-related complication e.g. spinal shock, respiratory failure

Acute SCI with unstable fracture of the spine for conservative management in traction

Acute SCI for removal of bullet

Acute SCI with stable fracture of the spine

Acute SCI, not fit for rehabilitation (e.g. infection or SCI-related complications)

Stable post-acute SCI fit for rehabilitation

Results

P10

Stable post-acute SCI with sacral, ischial or trochanteric pressure ulcer, otherwise fit for rehabilitation

Between 1 April 2003 and 31 March 2014, 2 042 patients were admitted to the ASCI Unit. This represents an average of 185 patients per year. Of the patients, 84.0% (n=1 715) were male and 16.0% (n=327) female. The male/female ratio was 5.25:1.

*Inclusion criteria: acute traumatic spinal cord injury; exclusion criteria: severe head injury, Glasgow Coma Score <13/15 or <9T/15, polytrauma.

60 - 70

50 - 60

165

40 - 50

339

30 - 40

514

20 - 30

684

10 - 20

237 0

100

200

300

Referring hospitals

The majority of the patients (45.3%, n=925) were referred directly from GSH, followed by 20.7% (n=422) referred from Tygerberg Hospital and 10.7% (n=218) from George Hospital. Most of the remaining referrals were from other hospitals in the Western Cape, with a small number of patients from other hospitals across SA. The top ten referring hospitals were GSH (45.3%), Tygerberg Hospital (20.7%),

500

600

700

800

Fig. 1. All patients by age group. 1 000 900 800 700 600 500 400 300 200 100 0

910

316

r he

Ru gb y

vin

As s

ot or cy cle

175

cy cle

294

Level of injury

Of 2 042 patients, 59.3% (n=1 210) had cervi cal, 27.2% (n=556) thoracic and 11.2% (n=228) lumbosacral injuries. For the remaining 2.3% (n=48), no data were available.

400

Patients, n

St a

The most prevalent cause of injury was motor vehicle accidents (MVAs), which accounted for 44.6% of all injuries (n=910). Falls accounted for 15.5% of all injuries (n=316) and gunshot wounds (GSWs) for 14.4% (n=294). Fig. 2 shows the causes of the injuries in descending order. MVAs were divided into three categories (Fig. 3). MVA passenger accounted for 56.0% of the total number of MVA injuries (n=510), MVA driver for 25.6% (n=233) and MVA pedestrian for 18.4% (n=167).

GS W

Causes of SCIs

>80 70 - 80

Fa ll

The mean age of the patients was 34 years. The largest age category was 21 - 30 years (33.5% (n=684) of the total number of patients), followed by the 31 - 40-year age category (25.2%, n=514) and the 41 - 50-year age category (16.6%, n=339). Fig. 1 shows the breakdown of all patients by age group.

Age

Other − no information

Total number of patients and gender

Age groups (years)

Ethics approval was obtained from the Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (HREC/REF: 405/2014).

Patients, n

Ethics approval

Cause

Fig. 2. All patients by cause.

George Hospital (10.7%), New Somerset Hospital (2.7%), G F Jooste Hospital (2.3%), Worcester Hospital (2.1%), Victoria Hospital (1.8%), Vredenburg Hospital (1.5%) and Paarl Hospital (1.1%). The hospital was unknown in 1.0% of cases.

Surgery and ventilation

Of the patients, 64.6% underwent spinal surgery, 23.4% required mechanical ventilation, and 8.8% required non-invasive ventilatory support (32.2% in total requiring ventilatory support).

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Of the mechanically ventilated patients, 91.5% were successfully weaned off venti lation, 0.9% remained ventilator dependent, and 7.6% died.

Mortality rate

The mortality rate of the ASCI Unit inpatients was 2.2%.

Waiting periods and hospital stay

Of the patients, 69.9% (n=1 427) were admitted within the first week of injury,

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Neurological status

On admission, 31.7% of patients had com plete and 68.3% incomplete spinal cord injuries. In 50.7% (n=1 035) there was an improvement in total ASIA score by the time of discharge from the unit, in 39.1% (n=798) the ASIA score remained the same, and in 10.2% (n=209) there was a deterioration in ASIA score by the time of discharge. Of the patients who experienced an improvement in total ASIA score, 85.4% (n=884) showed improvement in motor function. Motor function in patients with incomplete neurological deficit improved by an average of 16 (median improvement 10, interquartile range 5 - 22). Motor function in patients with complete neurological deficit improved by an average of 8 (median improvement 5, interquartile range 3 - 8).

Trend analysis

The total number of admissions was evaluated according to the month of admission in an effort to determine a monthly admission trend. Fig. 6 shows all patient admissions per month over 11 years. Analysis of causes of injury over the years revealed the trends shown in Fig. 7, a and b.

drivers, yet pedestrians accounted for 18.4% of the total number of MVAs (and 8.2% of patients in total), which is related to alcohol abuse and disregard for road safety. It is clear that there needs to be a focus in this area as an important component of MVA prevention campaigns. Since falls were a significantly large aetiological category of SCI (third after MVAs and violence), further investigation regarding the circumstances of falls is needed to determine where prevention should be aimed, e.g. at work safety regulations, falls in the elderly, etc. The 3.6% (n=74) of remaining injuries included a spectrum of causes such as train accidents, wrestling injuries, objects falling onto patients, aeroplane accidents, paragliding accidents, horse riding accidents, surfing and angle grinder accidents. Other

Percentage of patients admitted

510

500 400 300

233 200

167

100 0

MVA passenger

MVA driver

MVA pedestrian

Category

Fig. 3. MVA categories.

80 70 60 50 40 30 20 10 0

1 week

2 weeks

3 weeks

4 weeks

>4 weeks

No data

Time period: day of injury to day of admission to the ASCI unit

Fig. 4. Time period to admission after injury.

Other − wrong dates >3 months

154

2 - 3 months

124 448

1 - 2 months

Discussion

1 310

<1 month 0

200

600 800 Patients, n

400

1 000

1 200

1 400

Nov

Dec

Fig. 5. Length of stay.

180 Patients, n

Our patient profile mirrors international literature in terms of gender and age, with a male/female ratio of 5.25:1[3] and age distribution and mean age being similar to other studies, with the 21 - 30-year category the largest (33.5%).[3,5] Similarly, the causes of injuries in this study compare with the international literature, with MVAs and falls being the two largest cate gories.[2-4,8] Previous SA literature described violence as the number one cause of SCI.[5,7] This could be influenced by grouping causes. If we add our study results for violence-related causes (GSWs plus stabs plus blunt assault), violence accounts for 27.2% of injuries. Violence-related SCI therefore remains second to MVAs as a cause of SCI in the ASCI Unit. Prevention strategies are currently focused on

600

Patients, n

13.4% (n=274) within the second week, 5.5% (n=113) within the third week and 3.2% (n=66) within the fourth week. In 154 cases (7.5%) there was a delay of more than one month before admission (Fig. 4). Regarding length of stay in the unit, 64.2% (n=1 310) of the total number of patients stayed for <1 month, 21.9% (n=448) of patients for 1 - 2 months, 6.1% (n=124) for 2 - 3 months and 7.5% (n=154) for >3 months (Fig. 5). The average length of stay in the unit was 28 days.

140

100

Jan

Feb

March April

May

June Month

Fig. 6. All patient admissions per month (age >11 years).

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July

Aug

Sept

Oct

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a 120

Patients, n

100 80

MVA

Fall

GSW Stab

20 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11

Patients, n

b 16

Assault

Diving

12 10

Rugby Motorcycle

8 6

Bicycle

4 2 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11

Fig. 7. Yearly trends for causes: (a) MVAs, falls, GSWs and stab wounds; (b) assaults and diving, rugby, motorcycle and bicycle accidents.

causes for admission included readmissions for special investigations, and in some cases no specific information was available on the cause of injury. An additional 84 patients were managed in the unit but could not be included in the study owing to incomplete data capturing. Admissions are prioritised according to the severity of the SCI, the need for decompression/surgery and potential neuro logical outcome. Owing to our unit’s prioriti sation of admission of patients requiring supportive care, the profile may not fully represent the SCI profile. As more SCI patients are referred to the unit than can be accommodated, stable patients and those who are not in need of surgery are redirected to the local rehabilitation centre. This could account for the highest percentage of injuries being cervical SCIs (59.3%), as these injuries are associated with a higher incidence of complications than thoracic and lumbosacral injuries. This would also account for the high incidence of patients in need of ventilatory support, 32.2% in total (ventilated patients as well as non-invasive ventilator support). For 2.3% of the patients no specific data were available on the level of injury. Of the total number of ventilated patients, 0.9% were ventilator dependent at discharge and transferred to a rehabilitation facility on a mobile ventilator. Our study shows that the majority of patients (69.9%) were admitted to the unit within 1 week. The total proportion of patients admitted within 2 weeks was

83.3%. Admissions are prioritised according to previously mentioned criteria, which explains the longer waiting periods for uncomplicated or stable injuries. Length of patients’ stay in hospital affects the ability of the unit to admit new patients. The length of stay for 64.2% of patients was <1 month, and 7.5% stayed in hospital for >3 months. Patients requiring a prolonged stay (>3 months) mainly comprised those with complications such as pressure ulcers that limited their progression to rehabilitation (this is worthy of future research). SCI mortality rates differ between countries and regions, with available data suggesting that mortality, calculated as death in the first year after injury, ranges from 4.0% (North America) to 84.0% (West Africa).[9] The low mortality rate of 2.2% in the GSH ASCI Unit reflects the rate calculated at discharge from the post-acute ward. Neurological recovery after a traumatic SCI is influenced by the cause and severity of the injury.[10] The motor function ASIA score was extracted because it correlates with functionality. The motor function improvement data followed an abnormal distribution pattern, but it needs to be remembered that the reported improvement reflects only the acute phase, over an average admission period of 28 days (admission to discharge from post-acute ward), while neurological recovery can be expected for 5 years and longer after injury.[11,12] December is the busiest month of the year in the unit. Other peak periods (Fig. 6)

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coincided with school holidays – the Western Cape is a popular holiday destination during holiday seasons, with additional road traffic load. The ASCI Unit admission criteria and priority scale proved especially useful during these periods, when new referrals tend to exceed available resources. The top three causes of SCIs (MVAs, falls, GSWs) showed a slight incline per year, following the opening of our unit (Fig. 7a). That stab wounds showed a decline could be explained by the fact that the majority of patients with isolated SCI secondary to a stab wound tend to be fairly stable and are referred directly to a rehabilitation centre, bypassing the ASCI Unit. Fig. 7b shows that assaults remained stable, diving injuries showed a decline (possibly as result of active prevention strategies), rugby injuries showed a steady decline (reflecting good practices and prevention campaigns such as Boksmart by SA Rugby), motorcycle accidents decreased, and bicycle accidents stayed the same.

Conclusion

There are limited data available on the causes of SCIs in SA. The finding of MVAs as the top cause of SCIs seen in the ASCI Unit at GSH indicates the thrust of preven tion strategies. More emphasis should be on all road users, including pedestrians. Prevention campaigns directed at MVAs should be re-evaluated and learn from other campaigns, such as rugby and diving, which have resulted in a significant decline in the incidence of injury. Violence, identified as the second most prevalent cause of traumatic SCIs, calls for a focused, effective prevention campaign. The evidence that there are obvious peak periods of SCI, as identified over the past 11 years, suggests motivation for additional beds to be made available to the unit during these periods. These data create a platform for further studies that could be helpful in many aspects of preventing SCIs. This information could be used by the Western Cape Provincial Government to determine the incidence of SCI for the province and where prevention campaigns should be aimed, while emphasising the importance for adequate facilities for the disabled. One aspect that calls for further study is comparison of the cost of SCIs with the cost of prevention campaigns. Strategies should be implemented to encourage SCI, trauma and rehabilitation centres to create methods of data collection, as very few data are available regarding the causes of SCIs in other provinces of SA.

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Our experience of SCIs, showing a low mortality rate of 2.2%, a successful weaning rate of 91.5% and average motor function improvement in incomplete injuries of 16.0%, reveals the clear advantages of a dedicated spinal unit. References 1. Mahabaleshwarkar R, Khanna R. National hospitalization burden associated with spinal cord injuries in the United States. Spinal Cord 2014;52(2):139-144. [http://dx.doi.org/10.1038/sc.2013.144] 2. Cripps RA, Lee BB, Wing P, Weerts E, Mackay J, Brown D. A global map for traumatic spinal cord injury epidemiology: Towards a living data repository for injury prevention. Spinal Cord 2011;49(4):493-501. [http://dx.doi.org/10.1038/sc.2010.146] 3. Ackery A, Tator C, Krassioukov A. A global perspective on spinal cord injury epidemiology. J Neurotrauma 2004;21(10):1355-1370. [http://dx.doi.org/10.1089/neu.2004.21.1355] 4. Draulans N, Kiekens C, Roels E, Peers K. Etiology of spinal cord injuries in sub-Saharan Africa. Spinal Cord 2011;49(12):1148-1154. [http://dx.doi.org/10.1038/sc.2011.93] 5. Hart C, Williams E. Epidemiology of spinal cord injuries: A reflection of change in South African society. Paraplegia 1994;32(11):709-714. [http://dx.doi.org/10.1038/sc.1994.115]

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6. Odendaal T. Injuries of the cervical spinal cord. S Afr Med J 1991;80(2):75-79. 7. Velmahos GC, Degiannis E, Hart K, Souter I, Saadia R. Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries. J Trauma 1995;38(3):334-337. [http:// dx.doi.org/10.1097/00005373-199503000-0004] 8. International Spinal Cord Society. SCI global mapping. Archive global data TSCI. Supplementary Table 2 – 20/8/2010. Incidence and aetiology of traumatic SCI by region and author(s) of published data. http://iscos.org.uk/page.php?content=57 (accessed 2 February 2015). 9. International Spinal Cord Society. SCI global mapping. Archive Global data TSCI. Supplementary Table 3 - 20/8/2010. Survival of SCI (1-year and 10-year mortality) by region and author(s) of published data. http://iscos.org.uk/page.php?content=57 (accessed 2 February 2015). 10. Marino RJ, Ditunno JF Jr, Donovan WH, Maynard F Jr. Neurologic recovery after traumatic spinal cord injury: Data from the Model Spinal Cord Injury Systems. Arch Phys Med Rehabil 1999;80(11):13911396. [http://dx.doi.org/10.1016/S003-9993(99)90249-6] 11. Kirshblum S, Millis S, McKinley W, Tulsky D. Late neurologic recovery after traumatic spinal cord injury. Arch Phys Med Rehabil 2004;85(11):1811-1817. [http://dx.doi.org/10.1016/j.apmr.2004.03.015] 12. Choe AS, Belegu V, Yoshida S, et al. Extensive neurological recovery from a complete spinal cord injury: A case report and hypothesis on the role of cortical plasticity. Front Hum Neurosci 2013;7:290. [http://dx.doi.org/10.3389/fnhum.2013.00290]

Accepted 29 June 2015.

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Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa: More ambulances won’t help C Stein,1 PhD; L Wallis,2 MB ChB, FCEM, MD; O Adetunji,3 PhD epartment of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, South Africa D Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 Department of Industrial and Systems Engineering, Faculty of Engineering, Built Environment and Information Technology, University of Pretoria, South Africa

Corresponding author: C Stein (cstein@uj.ac.za)

Background. Response time is viewed as a key performance indicator in most emergency medical services (EMS) systems. Objective. To determine the effect of increased emergency vehicle numbers on response time performance for priority 1 incidents in an urban EMS system in Cape Town, South Africa, using discrete-event computer simulation. Method. A simulation model was created, based on input data from part of the EMS operations. Two different versions of the model were used, one with primary response vehicles and ambulances and one with only ambulances. In both cases the models were run in seven different scenarios. The first scenario used the actual number of emergency vehicles in the real system, and in each subsequent scenario vehicle numbers were increased by adding the baseline number to the cumulative total. Results. The model using only ambulances had shorter response times and a greater number of responses meeting national response time targets than models using primary response vehicles and ambulances. In both cases an improvement in response times and the number of responses meeting national response time targets was observed with the first incremental addition of vehicles. After this the improvements rapidly diminished and eventually became negligible with each successive increase in vehicle numbers. The national response time target for urban areas was never met, even with a seven-fold increase in vehicle numbers. Conclusion. The addition of emergency vehicles to an urban EMS system improves response times in priority 1 incidents, but alone is not capable of the magnitude of response time improvement needed to meet the national response time targets. S Afr Med J 2015;105(10):840-844. DOI:10.7196/SAMJnew.8087

Access to emergency care, including that delivered outside hospital, is guaranteed for all South Africans under section 27 of the Constitution.[1] A logical component of this notion of access to emergency care is that the care provided should be timely, as determined by the acuity of the patient’s condition.[2] Indeed, timeliness of care goes beyond access to healthcare; it has also been identified as an important dimension of healthcare quality.[3] Although questions remain about the impact of emergency medical services (EMS) response times on patient outcomes in a range of high-acuity conditions, response time is still viewed as a key performance indicator in most EMS systems,[4,5] expressed through response time targets. In South Africa (SA), national response time targets exist and are used as a standard against which to measure the performance of EMS provided by the provinces. In urban areas, 90% of high-acuity (priority 1, P1) incidents should be responded to within 15 minutes, and all other incidents should be responded to within 60 minutes.[6-8] In this context, ‘response time’ refers to the time interval between receipt of a call for emergency assistance at an emergency dispatch centre and arrival of the first EMS vehicle at the corresponding incident location. Annual reports published by provincial departments of health detail their compliance with the response time targets. Review of these annual reports for three provinces with the largest urban centres (Gauteng, Western Cape and KwaZulu-Natal) over the past 2 years shows that none of them have met the targets, although some have shown improvement.[6-8] Others have regressed in their ability

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to provide timely emergency care,[7] and the reason most often cited for this situation is the lack of operational vehicle numbers.[6-8] Many services supplement ambulances (which carry patients) with primary response vehicles (PRVs, which deliver providers to the patient) to help meet targets. There is a common perception in EMS that there is a more or less inverse linear relationship between vehicle numbers and response times, and that meeting the response time targets would be greatly aided by buying more vehicles. We undertook a study to determine the effect of increased numbers of ambulances and PRVs on response time performance in P1 incidents using a discrete-event simulation model of operations in a large urban SA EMS system.

Methods

The simulation model was based on input data from the modelled system’s operations and computer-aided dispatch system, and was validated against a set of response data from the same system. A number of different scenarios were then constructed with increasing ambulance and PRV numbers, using the validated simulation model and its outputs to determine the effect of increased vehicle numbers on response time performance.

The modelled EMS system: Cape Town

Cape Town’s EMS system, serving a population of approximately 3.74 million people,[9] is geographically divided into six sectors, each of which is associated with the drainage area of a provincial hospital. Public requests for medical emergency assistance are received at an

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emergency control centre where caller and incident details are recorded, the incident is prioritised and an appropriately staffed emergency vehicle from the sector in which the incident occurred is dispatched. Incidents are classified as P1 or priority 2 (P2), which are high and lower acuity, respectively. Emergency vehicles consist mainly of ambulances, which may be either advanced life support (ALS) or non-ALS (ALS means that the ambulance is staffed by at least one ALS paramedic). Non-transport PRVs staffed by an ALS paramedic or a doctor are also used, but there are few of these in the system and they are only dispatched to major incidents (a small subset of P1 incidents).

The emergency response interval

The total time interval required for servi cing an emergency incident is referred to as the emergency response interval,[10] which is in turn broken up into a number of other intervals, the first of which is the response interval. The response interval begins from the time when an incident is created at the emergency call centre following receipt of a call for emergency assistance and ends when the first emergency vehicle arrives at the location of the corresponding incident. The response interval is therefore made up of two parts, one devoted to call taking and dispatch activities in the emergency control centre and one to travel of an emergency vehicle from an originating point to the incident location.[10] The response interval is followed by the scene interval, transport interval and postincident interval. The term ‘response time’ typically refers to the elapsed time of the response interval as defined above, and forms the major focus of this study.[10]

The simulation model

Simulation modelling followed the Banks stepwise approach:[11] conceptual modelling, EMS system input data collection and modelling, model translation and verification, and validation. The conceptual model, a high-level software independent description of the system, was derived from observation of the real system and system documents, and information obtained from system experts. This was followed by extraction of computer-aided dispatch data spanning the period 1 January - 31 December 2012. Only data from four of the six sectors representing an urban environment were used, comprising 312 387 incidents. These four sectors corresponded with the drainage areas of Groote Schuur, GF Jooste, Tygerberg and Victoria hospitals.

Computer-aided dispatch data were used to establish statistical probability distri butions for incident occurrence rates, dispatching times and scene times for P1 and P2 incidents. Incident geographical co-ordinates were used, in conjunction with a Geographic Information System appli cation, to determine geospatial distribution of incidents in the four sectors. System documents and information from system experts were used to record the geographical locations of EMS bases and emergency vehicle holding points as well the numbers of ambulances and PRVs available under typical operating conditions. Vehicle dispatch policies and procedures comprised an important part of the conceptual model. Triage category (P1 or P2), type of vehicle (ambulance or PRV), type of ambulance (ALS or non-ALS) and distance from the incident to the closest available ambulance were all reflected in the dispatch logic of the conceptual model as they were implemented in the real system. Although only response times for P1 cases were included in this study, the conceptual model took into account incident occurrence rates, spatial distribution and dispatching of vehicles to P1 and P2 incidents. The conceptual model and EMS system input data were translated into a computer software representation using an objectorientated simulation software application (Simio Design Edition, version 6.97; Simio LLC, USA). Verification of the simulation model was conducted throughout the translation process by assessing data outputs of the model and by using model animation and debugging tools in order to ensure that emergency vehicle and other behaviour was in keeping with processes described in the conceptual model. Once completed, the model was validated by comparing its outputs during 15 replications of 7 days of simulated operations with a random sample of real system data. Comparative analysis of these data showed that, with regard to response, scene and transport intervals, percentage differences between model and real data ranged between 0.59% and 1.31%. These differences were considered to be small enough to be of no practical significance, so for the purpose of this study the model was considered a valid representation of the system.[12]

Addition of vehicles

The effect of adding vehicles to the simu lated system was assessed by creating seven different scenarios in two categories. The first category included both ambulances and PRVs, as in the real system. Scenario 1

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was configured with the baseline number of ambulances and PRVs existing in the validated model. Each subsequent scenario (2 - 7) involved adding the baseline number of vehicles to the cumulative number of vehicles each time. The second category was identical, except that it included only ambulances in the model. This was done in order to assess any difference between response time performance with ambulances and PRVs v. only ambulances, as the number of PRVs was small (at baseline, only one per sector). Process logic was incorporated into the model to automatically place the additional emergency vehicles with each scenario at EMS bases and holding points with the greatest demand so as to make the best use of these resources. Each scenario was run for 15 repetitions of the simulation equivalent of 7 days.

Data recording and analysis

Response time was measured in a way identical to that described for the response interval above. An important component of the response time, called the waiting time, was also recorded for each response. Waiting time was defined and measured as the time interval between an incident in the emergency control centre dispatch process being ready for allocation to a vehicle and the vehicle accepting the incident and beginning its response. Waiting time varies with vehicle availability – it may be short or non-existent under conditions of high vehicle availability, or moderate to long when vehicle availability is low. Data on emergency vehicle availability in the modelled system as a whole were also recorded. All data were written to and stored in a spreadsheet application with each replica tion of the simulation. Data analysis was Table 1. Vehicle numbers in simulation scenarios Model category Ambulances and PRVs Scenario 1

Ambulances

PRV

AMB

106

147

159

196

212

245

265

294

318

343

371

AMB = ambulance.

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Results

Scenarios and vehicle numbers

Vehicle numbers for the seven scenarios are shown in Table 1. PRV and ambulance numbers were increased sequentially by the baseline (scenario 1) number in each successive scenario. For the model with only ambulances, one ALS ambulance per sector was added to the baseline number in order to compensate for the removal of the same number of PRVs.

Mean response time, min

descriptive in nature, with all response times reported as the mean over 15 replications for each scenario and associated 95% confidence intervals (CIs). STATA (version 13.0, Stata Corporation, USA) was used for data analysis.

10 1

Fig. 2 shows the mean percentage of res ponses meeting the response time target in each scenario. The model with ambulances only had a better baseline performance against the target; a similar pattern was observed to Fig. 1, with an initial 14.2 - 17.0% increase in performance in scenario 2, followed by a progressive flattening out up to and including scenario 7. The target of 90% of responses within 15 minutes was not achieved despite a 150% increase in vehicles.

Waiting time and vehicle availability

The mean waiting time for each scenario was measured, along with mean vehicle availability, and is shown in Table 2 for each of the models. At baseline there was a longer mean waiting time with ambulances and PRVs; however, in both models there was a rapid decrease with the first incremental increase in vehicle numbers, followed by a series of smaller decreases with each successive addition of vehicles. Vehicle availability increased in a linear fashion and did not display the same pattern of change over the scenarios. This

Fig. 1. Mean response times for both models. (Error bars indicate 95% CIs.)

90 Responses meeting benchmark target, %

Percentage of responses meeting targets

Ambulances & PRVs Ambulances

Mean response times

Mean response times and 95% CIs for each scenario and both models are shown in Fig. 1. The simulation model with only ambu lances produced the better baseline response time performance (shorter mean response time in scenario 1). In both models, the first iteration of increased vehicle numbers (scenario 2) produced a 35.9 - 26.9% decrease in mean response time; this was followed by incrementally smaller decreases with an eventual plateauing.

4 Scenario

80 75

65 1

4 Scenario

Ambulances & PRVs Ambulances Fig. 2. Mean percentage of responses meeting the response benchmark target. (Error bars indicate 95% CIs.)

linear increase in vehicle availability across scenarios with a limited initial improvement in response time performance indicates a high degree of vehicle redundancy from scenario 1 to scenario 7.

Discussion

Providing timely access to EMS in SA remains elusive in both urban and rural environments. Research into the functioning of real EMS systems, particularly experi mental research focused on response times, is often not feasible for practical and ethical reasons. Consequently, most of what is known about the factors affecting response

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time performance in EMS systems has been obtained through simulation modelling.[13] Our simulation, based on part of a large urban SA EMS system, was designed to investigate the theory that response time performance in high-acuity incidents can be improved merely by increasing a single resource – emergency vehicles – while leaving the rest of the system in its original state. Our data suggest that increasing vehicle numbers in an urban EMS system does improve response time performance. How ever, two important facts emerge: firstly, this effect is not linearly related to the number

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Table 2. Mean waiting time and availability: PRVs and ambulances Ambulances and PRVs

Ambulances

Scenario

Waiting time (min) (95% CI)

Availability (%) (95% CI)

Waiting time (min) (95% CI)

Availability (%) (95% CI)

2.30 (2.06 - 2.54)

24.88 (24.52 - 25.23)

0.96 (0.79 - 1.13)

29.09 (28.76 - 29.41)

0.12 (0.09 - 0.16)

75.05 (74.74 - 75.36)

0.03 (0.01 - 0.06)

82.88 (82.54 - 83.21)

0.03 (0.01 - 0.05)

124.18 (123.88 - 124.47)

0.01 (0.00 - 0.01)

136.14 (135.92 - 136.37)

0.01 (–0.01 - 0.02)

173.20 (172.91 - 173.49)

0.01 (0.00 - 0.02)

189.15 (188.93 - 189.37)

0.01 (0.00 - 0.02)

222.19 (221.92 - 222.46)

0.00 -

242.07 (241.83 - 242.31)

0.01 (–0.01 - 0.02)

271.49 (271.16 - 271.81)

0.01 (–0.01 - 0.02)

295.15 (294.88 - 295.42)

0.01 (0.00 - 0.02)

320.28 (320.03 - 320.53)

0.00 -

348.21 (347.91 - 348.50)

of additional vehicles; and secondly, the number of vehicles required to bring about this transient improvement is unrealistically large. With the cost of an equipped ambulance (including staffing) estimated at ZAR3 670 998 (Dr Shaheem de Vries, vehicle cost estimates, personal correspondence 12 May 2015), the total cost of the initial 14% response time improvement in the ambulance-only model (Fig. 1) would be ZAR194 562 894 (ZAR13 897 349 per % improvement). The limited effectiveness of larger vehicle numbers can be explained by consideration of changeable and unchangeable determinants of response time performance. In our model, the addition of emergency vehicles was effective in minimising the waiting time and thus decreasing response times, which consist in part of the delay represented by waiting times. This effect is easy to understand – greater availability of vehicles means that delays in allocating a vehicle to a waiting incident will be minimised and the waiting time too will therefore be decreased. The initial changes shown between baseline (scenario 1) and scenario 2 illustrate this (Figs 1 and 2, Table 2). In relation to vehicle numbers, the waiting time can therefore be considered a changeable determinant of response time performance. Although there are a number of other determinants of response time performance, one of the most important is the proximity of an available vehicle to an incident at the time when it is deployed. Simulation research conducted since the late 1960s has made some advances in understanding ways of optimising emergency vehicle deployment and redeployment problems and, to some degree at least, in coupling EMS system demand patterns with available resources in order to minimise response time.[14-21] These studies, using a variety of approaches including mathematical modelling, use of geographic information systems, demand pattern analysis and dynamic allocation and reallocation of vehicles, have identified that the only way to significantly reduce response times is somehow to address the proximity problem. If this is not done, the addition of more vehicles to an EMS system can only have an impact on waiting time. Beyond this, the proximity of vehicles to incidents remains an unchangeable determinant of response times unless the way vehicles are deployed and redeployed is improved. Response time benchmark targets in SA are modest compared with those in parts of Europe and the USA, which range between 4 and 8 minutes for 90% of high-acuity cases.[22-24] The typical model of EMS

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vehicle location and allocation in SA may explain why these targets remain difficult to meet. In most of our EMS systems, vehicles are statically located at bases that are not strategically placed in terms of proximity to areas of demand, and certainly do not take into consideration changes in demand that occur over time. Under these conditions, the addition of vehicles to a system without any other changes will result in an initial response time improvement representing elimination of waiting times. This will only be possible through high availability and significant redundancy of vehicles, which can only be achieved at great cost. Many EMS systems also use the two-tiered PRV and ambulance model, which our data show to be inferior. The reason for this is again probably related to the proximity problem. In the modelled system, there were far fewer PRVs than ambulances (Table 1), which meant that each PRV needed to cover a larger distance in responding to the P1 incidents that it was dispatched to. In addition, longer responses were associated with decreased availability and increased waiting times. The addition of more PRVs with each successive scenario contributed to the improvement of response times in the two-tiered model relative to that of the single-tier model, mainly by decreasing waiting times and increasing availability (Fig. 1, Table 2). For decision-makers in SA EMS systems to improve response time performance in high-acuity cases, a different approach is required – not just more vehicles. This will require a fundamental realisation that the key to better response times is optimal vehicle utilisation and efficiency rather than numbers. The only way to address efficiency will be to rethink the old models of response system design (many of which have not changed in decades), and to develop a deep understanding of the dynamics of our urban EMS systems as a means to engage in a more scientific form of EMS system design and implementation.

Study limitations

The results produced by our simulation model are specific to the modelled EMS system and do not necessarily reflect the performance and operations of other EMS systems. In particular, EMS systems that are not currently as well resourced with vehicles as the modelled system may initially see more of an impact from additional vehicle numbers. However, we believe that a very similar response pattern will be seen in EMS systems with similar methods of emergency dispatch and vehicle deployment.

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Conclusion

This study showed that the addition of emergency vehicles to a busy urban EMS improves response times in high-acuity cases but alone is not capable of the magnitude of response time improvement needed to meet the national response time targets. Changes to the way emergency vehicles are deployed, and how proximity between available vehicles and high-acuity incidents is optimised, are required in order to bring about cost-effective and significant improvements in response time performance. Acknowledgements. The authors thank Simio LLC for a grant allowing the use of their software in this study. This study was supported in part by the National Research Foundation of South Africa (Unique Grant 86454). References 1. The Constitution of the Republic of South Africa. 1996. http://www.gov.za/documents/constitution/ chapter-2-bill-rights (accessed 5 May 2015). 2. Gulliford M, Figueroa-Munoz J, Morgan M, et al. What does ‘access to health care’ mean? J Health Serv Res Policy 2002;7(3):186-189. [http://dx.doi.org/10.1258/135581902760082517] 3. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. 4. Moore L. Performance measurement in EMS. In: Lerner E, Pirallo R, Swor R, White L, eds. Evaluating and Improving Quality in EMS. Dubuque, Iowa: Kendall Hunt Professional, 2009:80-98. 5. Dunford J, Domeier RM, Blackwell T, et al. Performance measurements in emergency medical services. Prehosp Emerg Care 2002;6(1):92-98. [http://dx.doi.org/10.1080/10903120290938896] 6. Western Cape Department of Health. Western Cape Department of Health Annual Report 2012-2013. pp. 100-109. 2013. http://www.westerncape.gov.za/dept/health/documents/annual_reports/2012 (accessed 5 May 2015). 7. Gauteng Department of Health and Social Development. Gauteng Department of Health and Social Development Annual Report 2012-2013. pp. 74-76. 2013. http://www.health.gpg.gov.za/Document/ Pages/AnnualReports.aspx (accessed 10 May 2015). 8. KwaZulu-Natal Department of Health. KwaZulu-Natal Department of Health Annual Report 20132014. Part B: Programme 3: Emergency Medical Services. pp. 121-131. 2014. http://www.kznhealth. gov.za/AnnualReport/2013_2014.pdf (accessed 10 May 2015).

9. Statistics South Africa. Census 2011. Pretoria: SSA, 2012. http://beta2.statssa.gov.za/publications/ P03014/P030142011.pdf (accessed 7 May 2015). 10. Spaite DW, Valenzuela TD, Meislin HW, Criss EA, Hinsberg P. Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med 1993;22(4):638-645. [http://dx.doi.org/10.1016/S01960644(05)81840-2] 11. Banks J, Carson JS, Nelson BND. Discrete-event System Simulation. Upper Saddle River, NJ: PrenticeHall, 2010:4-22. 12. Law A, Kelton DW. Building valid, credible, and appropriately detailed simulation models. In: Simulation Modeling and Analysis. 3rd ed. Singapore: McGraw-Hill, 2000:264-291. 13. Aboueljinane L, Sahin E, Jemai Z. A review on simulation models applied to emergency medical service operations. Computers & Industrial Engineering 2013;66(4):734-750. [http://dx.doi. org/10.1016/j.cie.2013.09.017] 14. Savas E. Simulation and cost-effectiveness analysis of New York’s emergency ambulance service. Manage Sci 1968;18(12):B608-B627. [http://dx.doi.org/10.1287/mnsc.15.12.B608] 15. Fitzsimmons JA. A methodology for emergency ambulance deployment. Management Science 1973;19(6):627-636. [http://dx.doi.org/10.1287/mnsc.19.6.627] 16. Berlin GN, Liebman JC. Mathematical analysis of emergency ambulance location. Socioecon Plann Scis 1974;8(6):323-328. [http://dx.doi.org/10.1016/0038-0121(74)90036-6] 17. Uyeno DH, Seeberg C. A practical methodology for ambulance location. Simulation 1984;43(2):79-87. [http://dx.doi.org/10.1177/003754978404300202] 18. Peleg K, Pliskin JS. A geographic information system simulation model of EMS: Reducing ambulance response time. Am J Emerg Med 2004;22(3):164-170. [http://dx.doi.org/10.1016/j.ajem.2004.02.003] 19. Ong ME, Ng FS, Overton J, et al. Geographic-time distribution of ambulance calls in Singapore: Utility of geographic information system in ambulance deployment (CARE 3). Ann Acad Med Singapore 2009;38(3):184-191. 20. Wu CH, Hwang KP. Using a discrete-event simulation to balance ambulance availability and demand in static deployment systems. Acad Emerg Med 2009;16(12):1359-1366. [http://dx.doi.org/10.1111/ j.1553-2712.2009.00583.x] 21. Lam SS, Zhang J, Zhang ZC, et al. Dynamic ambulance reallocation for the reduction of ambulance response times using system status management. Am J Emerg Med 2015;33(2):159-166. [http://dx.doi. org/10.1016/j.ajem.2014.10.044] 22. National Fire Protection Association. NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments. 2001 ed. National Fire Protection Association, 2001:1710-1719. 23. Morse A. Transforming NHS Ambulance Services. Norwich: HMSO, 2011. http://www.nao.org.uk/ report/transforming-nhs-ambulance-services/ (accessed 4 May 2015). 24. Overton J. Benchmarking EMS in Europe. 7th Congress of the European Resuscitation Council, 2004. http://www.eed-network.eu/assets/presentations/EED_Benchmarking.pdf (accessed 4 February 2014).

Accepted 26 August 2015.

The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa P R Newton,1 MTech (Emergency Medical Care); R Naidoo,1 MSc (Cardiology); P Brysiewicz,2 PhD (Health Science) Department of Emergency Medical Care and Rescue, Faculty of Health Sciences, Durban University of Technology, South Africa School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

1 2

Corresponding author: P R Newton (p.newton@brookes.ac.uk)

Introduction. Emergency medical services (EMS) are sometimes required to respond to cases that are later found not to be emergencies, resulting in high levels of inappropriate responses. This study evaluated the extent to which this occurs. Methods. All cases dispatched over 72 hours by the eThekwini EMS in Durban, South Africa, were prospectively enrolled in a quantitative descriptive study. Vehicle control forms containing dispatch data were matched and compared with patient report forms containing epidemiological and clinical data to describe the nature and extent of inappropriate responses based on patient need. Data were subjected to simple descriptive analysis, correlations and χ2 testing. Results. A total of 1 385 cases met the study inclusion criteria. Marked variations existed between dispatch and on-scene priority settings, most notably in the highest priority ‘red-code’ category, which constituted >56% of cases dispatched yet accounted for <2% at the scene (p<0.001). Conversely, >80% of ‘red-code’ dispatches required a lower priority response. When comparing resource allocation according to patient interventional needs, >58% of cases required either no intervention or transport only and almost 36% required basic life support intervention only (p<0.001). Moreover, <12% of advanced life support dispatches were for patients found to be ‘red code’ at the scene. Conclusion. There is a significant mismatch between the dispatch of EMS resources and actual patient need in the eThekwini district, with significantly high levels of inappropriate emergency responses. S Afr Med J 2015;105(10):844-847. DOI:10.7196/SAMJnew.8273

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Emergency medical services (EMS) attend cases involving patients who have been classified as having time-critical life-threatening illnesses or injuries. An EMS unit will typically respond to these cases on the basis of information provided by a caller to the EMS provider’s emergency medical communications centre (EMCC). Before the unit is dispatched, the caller, who may or may not be the patient, is routinely questioned by an emergency medical dispatcher, who ascertains the level of EMS response required based on the answers provided. When the responding EMS unit arrives at the scene, however, it is frequently found that many of these patients do not in fact represent an emergency; high levels of inappropriate EMS responses may therefore be occurring. Furthermore, many of the patients who are transported do not have a clearly defined need for EMS intervention,[1] yet there is an expectation that they must be taken to a medical facility. When these mismatches occur, the response may be deemed to be inappropriate. A response may be inappropriate in several ways,[2] i.e. when an EMS provider: • commits an underutilisation of resources for critical patients, resulting in an unmet need • commits an overutilisation of resources for persons with needs not ideally addressed by higher levels of EMS care • commits an overutilisation of resources for persons with needs not ideally addressed by EMS at all, and/or • commits resources to a response utilising ‘emergency response procedures’ to non-time-sensitive acute illness or injury. The reasons for inappropriate responses are not fully understood and are thought to be complex and varied. Reasons cited include public ignorance or misunderstanding relating to the use of EMS systems, poor or unavailable alternative public transport, inaccessible or distant primary healthcare facilities, deliberate misrepresentation or exaggeration of need, and malicious hoax calls.[3] Whether responses to calls are appropriate or inappropriate, the potential for vehicle or pedestrian collisions is often present. The unnecessary use of emergency driving procedures with lights and sirens may expose responding EMS crews and members of the public to an increased risk of serious injury or even death.[4] Moreover, once the responding unit arrives at the scene, the EMS crew is compelled to transport the patient to hospital, irrespective of his or her condition. This results in the unit being tied up in a system with already limited resources, frequently leaving no more units available to respond to further incoming calls. Studies conducted in developed countries suggest that widespread inappropriate use of EMS systems has been evident since the 1970s and that up to 52% of all requests for an EMS response are later found to be inappropriate.[5] Three studies have been undertaken in South Africa (SA). Frank and De Villiers[6] showed that up to 68% of the cases transported by the Caledon EMS in Overberg, Western Cape Province, were not emergencies and that the inappropriate use of EMS units resulted in unnecessary costs. McFarlane et al.[7] highlighted high levels of inappropriate use of EMS vehicles in the greater Johannesburg area, which overwhelmed a system that was already severely under-resourced, and Meents and Boyles[8] showed that 16.7% of all EMS requests in the Eastern Cape Province were never dispatched. In KwaZulu-Natal Province (KZN) there have been no studies relating to the possible inappropriate use of EMS resources, and there is a paucity of evidence relating to EMS in general. The studies mentioned in the preceding paragraph cannot be generalised to either KZN or the eThekwini district owing to differences

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in demographics, disease profiles, geography, and EMS operating systems and procedures.

Objective

To evaluate the appropriateness of EMS responses in the eThekwini district of KZN by asking whether the various levels of response assigned on dispatch adequately and routinely met the clinical needs of patients in terms of resource allocation.

Methods

Research setting and population

The study was conducted in the eThekwini health district of KZN, one of the province’s 11 health districts, encompassing the greater Durban area. The population of eThekwini was last recorded in the 2007 community census at almost 3.5 million people and the population density is estimated at 1 394 people per km2, with approximately 10% living in underdeveloped informal settlements. The study population comprised all EMS responses undertaken by the KZN Department of Health within the eThekwini health district, which according to unpublished statistical data averaged in excess of 400 daily.

Sample

Purposeful sampling comprised emergency calls to the eThekwini health district EMCC placed, logged and physically responded to over a busy 72-hour month-end period, 24 hours of which included a weekend peak period. By spreading the sampling over this period, the data collected gave a fair representation of the different categories of cases responded to and of the rates and frequencies of these responses. Data were collected over the period 24 - 26 November 2011, the first available period as described above immediately following ethical and organisational approval. Altogether 1 689 responses were recorded, of which 1 385 met the study inclusion criteria. A total of 304 records were excluded because data were incomplete or a dispatch did not actually occur (e.g. cancelled or duplicated cases).

Data collection and analysis

Computerised dispatch logs were accessed through the EMCC’s Zetron DCS-5020 digital console system, from which vehicle control forms were generated. Data extracted comprised the dispatch priority setting and the initial level of resource allocation. These were then matched and compared with the corresponding EMS unit patient report form, from which data relating to the on-scene priority setting and the required level of patient interventions were extracted. Dispatch and on-scene priority settings were categorised using a standardised triage scale, and the resource allocation and patient interventions were categorised against the capabilities of the responding emergency care providers as defined by the Health Professions Council of South Africa.[9] Data were then entered into IBM Statistics SPSS version 21 and, in consultation with a statistician, subjected to simple descriptive analysis, correlations and χ2 testing.

Ethical considerations

Ethical approval was granted by the Durban University of Technology’s Institutional Research Ethics Committee (ref. FHSEC 009/11) and the KZN Department of Health Research and Knowledge Management sub-component (ref. HRKM 159/11).

Results

There were more female than male patients (n=699 (50.5%) and n=645 (46.6%), respectively). The gender of the patient could not

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be established in 41 cases (2.9%). Patients ranged in age from newborn to 99 years old (mean 32.5 years for males and 33.1 years for females). Marked variations existed between dispatch and on-scene priority settings, which were most notable in the highestpriority, life-threatening ‘red-code’ category. This category constituted >56% of cases dispatched yet accounted for <2% at the scene (p<0.001). These figures represent an overtriage rate of >93% (Fig. 1). Similar albeit less notable results were seen in the yellow-code (urgent but non-life-threatening) category, with an over-triage rate of just over 13% and an under-triage rate of <2%. The green-code (non-urgent) category, however, showed a disturbing under-triage rate of >82%, with almost 1 in 10 patients being found to be red code by responding crews once at the scene (Table 1). When comparing resource allocation according to patient interventions, >58% of cases attended required no intervention or a means of transport only and <36% required basic life support (BLS) intervention (p<0.001). Patients requiring intermediate life support (ILS) and advanced life support (ALS) interventions comprised 4.0% and 1.4%, respectively. When BLS resources were dispatched, <2% of patients required intervention at a higher level. Conversely, when ALS resources were dispatched, almost 61% of patients required either no intervention or a means of transport only, with <15% actually requiring an ALS intervention (Table 2). Moreover, <12% of ALS dispatches were for patients found to be red code at the scene, with >80% of dispatches being for patients who were coded either yellow or green at the scene (Table 3). Patients were transported and delivered to a health institution in a total of 970 (70.0%) of the 1 385 cases in which EMS were dispatched. Patients who were not transported, irrespective of whether they received any intervention or not, totalled 415 (30.0%). This figure included 271 patients who were never located, leaving the total number of EMS patient contacts at 1 121.

Discussion

The disagreement rates demonstrated by the high levels of over-triage across the red- and yellow-code categories in this study compare unfavourably with modest rates as low as 26% reported else where.[10] Under-triage rates, particularly in the green-code category, also compared unfavourably with rates of between 4% and 7% reported elsewhere.[11]

Similar disagreements were evident when comparing the interventional requirements at the scene with the levels of dispatch. In the majority of cases in which ALS resources were dispatched, patients required no intervention or a means of transport only, leaving less than 2 in 10 patients actually requiring an ALS intervention. Although this mismatch has been evident in EMS systems elsewhere, such high levels of inappropriate ALS dispatch to lower-priority patients have not been seen. Surprisingly, >95% of patients required nothing more than a BLS-level intervention. It is clear from the results presented that appropriate allocation of resources aimed at meeting patient needs is not being achieved and that needs cannot be met effectively owing to the high levels of inconsistencies reported. Of particular concern is the high proportion of cases in which EMS resources are routinely dispatched to cases that either require no intervention or a means of transport only. Such cases represent almost 6 out of 10 dispatches by the eThekwini EMS. This figure is similar to that in one of the studies conducted in SA,[6] with international studies reporting rates of between 11% and 52%.[5] There is undoubtedly an urgent need for

the eThekwini EMS to review its existing strategies relating to decisions made on the allocation of resources based upon patient need. Adopting evidence-based alternatives to the traditional dispatch of emergency ambulances and the transportation of patients to primary admitting centres may be a way to achieve this.[12-14] Two important strategies that may be considered are computeraided dispatch, such as the Medical Priority Dispatch System (MDPS), and alternative routing of patients.

The Medical Priority Dispatch System

The MPDS is designed to accurately highlight and prioritise patients into order of clinical need, and involves protocols that assign different levels of response based on caller answers to a set of standardised questions. Additionally, pre-arrival or post-dispatch instructions can be offered to the caller if, for example, a lifesaving intervention is needed immediately. This is generally achieved through the use of complex algorithmic computer programs that utilise protocolbased, scripted interrogation processes. The MPDS has been developed through evidencebased research, and the literature shows that

Dispatch priority

Triage at the scene

20% Red code

40% Yellow code

60%

80%

Green code

100%

Blue code

Fig. 1. Comparison of dispatch priority v. triage code at the scene.

Table 1. Comparison of priority/triage allocations between dispatch and at the scene, n (%) Triage code at the scene Red code/ priority 1

Yellow code/ priority 2

Green code/ priority 3

Blue code/ priority 4

Total

Red code/ priority 1

14 (2.4)

469 (79.8)

68 (11.6)

37 (6.3)

588 (100.0)

Yellow code/ priority 2

7 (1.4)

407 (82.6)

75 (15.2)

4 (0.8)

493 (100.0)

Green code/ priority 3

3 (7.5)

30 (75)

7 (17.5)

0 (0.0)

40 (100.0)

24 (2.1)

906 (80.8)

150 (13.4)

41 (3.7)

1 121 (100.0)

Triage code on dispatch

Total

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Table 2. Qualification level of emergency care provider v. intervention at the scene, n (%) Nature of intervention None required

Transport only

BLS

ILS

ALS

Total

Emergency care provider qualification

Conclusions

BLS

178 (25.4)

216 (30.8)

294 (41.9)

9 (1.3)

4 (0.6)

701 (100.0)

ILS

164 (26.7)

213 (34.6)

193 (31.4)

39 (6.3)

6 (1.0)

615 (100.0)

ALS Total

39 (56.5)

3 (4.3)

9 (13.0)

8 (11.6)

10 (14.5)

69 (100.0)

381 (27.5)

432 (31.2)

496 (35.8)

56 (4.0)

20 (1.4)

1 385 (100.0)

Table 3. Qualification level of emergency care provider v. triage code at the scene, n (%) Triage code at the scene Red code/ priority 1

Yellow code/ priority 2

Green code/ priority 3

Blue code/ priority 4

Total

Emergency care provider qualification

The study findings clearly confirm that there is a significant mismatch between the dispatch of EMS resources and actual patient need in the eThekwini district of KZN, with significantly high levels of inappropriate emergency responses. This situation is likely to continue unless strategies designed to optimise the use of limited resources are employed. Further research and development in the areas of medical priority dispatch systems and alternative routing of patients in a wider SA context are needed and encouraged. References

BLS

9 (1.6)

480 (85.9)

61 (10.9)

9 (1.6)

559 (100.0)

ILS

10 (1.9)

396 (76.3)

84 (16.2)

29 (5.6)

519 (100.0)

ALS

5 (11.6)

30 (69.8)

5 (11.6)

3 (7.0)

43 (100.0)

24 (2.1)

906 (80.8)

150 (13.4)

41 (3.7)

1 121 (100.0)

Total

population was restricted to the urban and periurban districts of eThekwini. The results might have been slightly different had the study been conducted longitudinally, over an extended period of time, and within the greater SA geographical context.

where priority dispatch systems are used, and compliance and quality assurance controls are in place, the system is more effective at triaging calls correctly than an emergency medical dispatcher.[14] The eThekwini EMS currently does not make use of a recognised MPDS, and the system in use has few procedures in place to ensure the thorough and structured interro gation of callers. Additionally, only three levels of dispatch priorities are routinely allocated and callers are offered little in terms of pre-arrival instructions. It is important to note that this system is not limited to the eThekwini district but is in widespread use throughout KZN.

Alternative routing of patients

The need to match patient need to limited EMS resources more efficiently has driven many EMS systems to consider safe alternatives to traditional response methods. At the point of dispatch, these may include referral to non-emergency access numbers, such as the NHS 111 number in the UK, or alternative appropriate services or facili ties. [12] Additionally, if patients can be identified as suffering from minor illness or injury once an EMS unit reaches the scene, it may be possible to offer alternatives to emergency ambulance transportation. [13]

These alternatives, based on patient presen tation, may include a straightforward refusal to transport, treatment at the scene and/or referral to a further care facility by other transportation means, or on-scene treatment and discharge. However, caution should be advised, as few rigorous trials have been reported and the evidence of the safety and efficacy of alternative responses is conflicting and weak. At present, unless the patient specifically refuses to be transported, the eThekwini EMS transports all patients to hospital irrespective of their condition. Patients with relatively minor illness or injury are frequently transported over extended distances, often bypassing facilities that may be more appropriate. This is also common practice throughout KZN, and arguably wastes expensive and limited resources that could be utilised better elsewhere. Moreover, patients transported directly to hospital may overburden already under-resourced emergency departments.

Study limitations

There were three main limitations to the study: the cross-sectional design did not take into account seasonal changes in patient need; the sample size was relatively small considering the population; and the

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1. Gratton MC, Ellison SR, Hunt J, Ma OJ. Prospective determination of medical necessity for ambulance transport by paramedics. Prehosp Emerg Care 2003;7(4):466-469 [http:// dx.doi.org/10.1080/31270300220X] 2. Berry M, Blocker J, Bryant K, et al. A Strategic-based Emergency Medical Services Blueprint for Oklahoma City. Oklahoma City: City Council of the City of Oklahoma City, 2009. 3. Palazzo FF, Warner OJ, Harron M, Sadana A. Misuse of the London ambulance service: How much and why? Journal of Accident and Emergency Medicine 1998;15(6):368-370 [http://dx.doi.org/10.1136/ emj.15.6.368] 4. Anderson J. Lights, siren to become optional: Fire department rating its responses. Baltimore Sun, 1 July 2008. http:// articles.baltimoresun.com/2008-07-01/news/0806300239_1_ emergency-responders-lights-and-sirens-arundel-county (accessed 17 April 2013). 5. Snooks H, Wrigley H, George S, Thomas E, Smith H, Glasper A. Appropriateness of use of emergency ambulances. Journal of Accident and Emergency Medicine 1998;15(4):212-218. [http:// dx.doi.org/10.1136/emj.15.4.212] 6. Frank SA, de Villiers PJT. An analysis of the appropriate use of the Caledon amblance service in the Overberg: A short report. S Afr Med J 1995;85(11):1185-1186. 7. MacFarlane C, van Loggerenberg C, Kloeck W. International EMS systems in South Africa – past, present, and future. Resuscitation 2005;64(2):145-148. [http://dx.doi.org/10.1016/j. resuscitation.2004.11.003] 8. Meents E, Boyles T. Emergency medical services – poor response time in the rural Eastern Cape. S Afr Med J 2010;100(12):790. 9. Health Professions Council of South Africa. Capabilities of Emergency Care Providers. Pretoria: HPCSA, 2011. 10. Palumbo L, Kubincanek J, Emerman C, Jouriles N, Cydulka R, Shade B. Performance of a system to determine EMS dispatch priorities. Am J Emerg Med 1996;14(4):388-390. [http://dx.doi. org/10.1016/S0735-6757(96)90056-X] 11. Lammers RL, Roth BA, Utecht T. Comparison of ambulance dispatch protocols for nontraumatic abdominal pain. Ann Emerg Med 1995;26(5):579-589. [http://dx.doi.org/10.1016/ S0196-0644(95)70008-0] 12. Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: Alternatives for cases that are neither life threatening nor serious. BMJ 2002;325(7359):330-333. [http://dx.doi.org/10.1136/ bmj.325.7359.330] 13. Snooks HA, Dale J, Hartley-Sharpe C, Halter M. On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: A review of the literature. Emerg Med J 2004;21(2):212-215. [http://dx.doi.org/10.1136/ emj.2003.005199] 14. Clawson J, Olola CH, Heward A, Scott G, Patterson B. Accuracy of emergency medical dispatchers’ subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol’s recommended coding based on paramedic outcome data. Emerg Med J 2007;24(8):560563 [http://dx.doi.org/10.1136/emj.2007.047928]

Accepted 10 October 2015.

RESEARCH

A 10-year review of fatal community assault cases at a regional forensic pathology facility in Cape Town, South Africa C I Herbst, MB ChB, Dip For Med (SA) Path, FC For Path; MMed For Path; M Tiemensma, MB ChB, Dip For Med (SA) Path, FC For Path, MMed For Path; S A Wadee, BSc, MB ChB, MMed For Path, FC For Path Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa Corresponding author: C I Herbst (celesteherbst@hotmail.com)

Background. An increase in autopsied community assault (CA) fatalities was observed at the Tygerberg Forensic Pathology Services (FPS), Cape Town, South Africa (SA). There is a paucity of information on the incidence and prevalence of these cases in SA. Objectives. To determine the patterns and trends of injuries sustained in so-called CA fatalities. Methods. A retrospective and descriptive study was conducted. Fatal CA cases admitted to the Tygerberg FPS over the 10-year period 1 January 2003 - 31 December 2012 were reviewed. Data were collected from autopsy/postmortem reports, contemporaneous notes, attached hospital records, the South African Police Services (SAPS) 180 form (completed by the SAPS representative) and other FPS documentation. Results. A total of 424 cases of fatal CA were seen during the study period, with an annual increase between 2003 and 2007 and a second peak in 2012. The cause of death in most cases was multiple injuries (42.0%), with blunt-force trauma being the basis of most injuries sustained. The area with the greatest burden of injury was the township of Mfuleni (73 CA deaths per 100 000 population). There was a predominance of males, with only one female fatality recorded. Conclusion. Adequate policing in prevalent areas is essential to address unnecessary loss of life and the burden imposed by these cases on the criminal justice system and healthcare services. S Afr Med J 2015;105(10):848-852. DOI:10.7196/SAMJnew.8274

Violence remains the leading cause of death in South Africa (SA), accounting for more than onethird of all unnatural deaths.[1] Community assaults (CAs), also known as bundu or kangaroo courts, and sometimes mob killings or vigilante justice, have contributed to this high incidence of violence. Bundu or kangaroo courts are informal courts/hearings held in the townships by community members who are allegedly dissatisfied with the lack of adequate law enforcement and take the law into their own hands by punishing alleged criminals before they are arrested and tried. These unauthorised forms of ‘lawfulness’ originated in townships during the apartheid era and also have deep roots in customary urban traditions such as lekgotla, a form of restorative justice. Lekgotla were tribunals consisting of seniors in the neighbourhood who presided over disagreements and rendered a verdict. Punishment, if decided on, consisted of physical retribution, payment of penalties and rendering of ‘community service’. Lekgotla encouraged the re-establishment of accord and rehabilitation of wrongdoers back into society.[2] There has been much recent focus on CA cases in the SA media, with particular emphasis on the fact that these practices of community-instigated retribution are endemic to the country’s townships. Sometimes they are also referred to as people’s courts or community/vigilante justice, and are viewed as a variant of vigilantism – as seen in some other developing countries.[3] Newspaper reports emphasise the spontaneity of these mob killings. These so-called acts of vigilantism were a significant topic during the Khayelitsha Commission of Inquiry held in 2014.[4] An increase in the number of these CA cases has been noted at the Tygerberg Forensic Pathology Services (FPS), Western Cape Province.

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Most studies have focused on the clinical findings in CA cases. An investigation into these fatalities will provide invaluable information into the extent of the external and internal injuries sustained as well as the epidemiological burden and impact.

Methods

This retrospective descriptive study reviewed all CA cases seen at the Tygerberg FPS from 1 January 2003 to 31 December 2012. The Tygerberg FPS serves a population of approximately 1.3 million and admits cases reported to police stations in the following Western Cape metropolitan areas: Belhar, Bellville, Bellville South, Bishop Lavis, Bonteheuwel, Bothasig, Brackenfell, Delft, Durbanville, Elsies River, Goodwood, Harare, Khayelitsha, Kleinvlei, Kuilsriver, Kraaifontein, Lingelethu West, Mfuleni, Parow and Ravensmead. Owing to their large populations, the subsections Lingelethu West and Harare of Khayelitsha have their own police stations. Data were collected and entered by the principal investigator (CIH) using Microsoft Excel spreadsheets. The statistical analysis was performed by CIH in conjunction with a statistician from the Department of Statistics at Stellenbosch University. A summary of the statistics was achieved through constructing frequency tables for categorical variables, and calculating means and standard deviations for continuous data. Results were graphically depicted using histograms. Case files of all deaths from homicide over the study period were drawn by CIH. Data were gathered by reviewing the documents listed in Table 1. All cases referred to Tygerberg FPS for a medicolegal autopsy with a history of CA/bundu court/kangaroo court in the final autopsy/postmortem examination report and/or other attached

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contemporaneous notes were included. Cases in which no definite history of CA/ bundu court/kangaroo court was found after perusal of the final autopsy/postmortem examination reports, contemporaneous notes, collateral information from police and attached hospital records, e.g. cases of other traumatic deaths from gunshot wounds, assaults or multiple injuries, were excluded, as were cases in which the final autopsy/ postmortem examination report was not completed or was not available. All information was anonymised and treated confidentially. Ethics approval was obtained from the Health Research Ethics Committee (HREC) of the Medicine and Health Sciences Faculty, Stellenbosch University (ethics reference No. S13/09/162).

Table 1. Documents from which data were obtained Final autopsy/postmortem examination report SAPS 180 form completed by SAPS officials (police report that accompanies the body to the mortuary) TH13/FPS100 form (summary of clinical findings and medical/surgical treatment), when available and completed by the treating medical practitioner in cases where the deceased was hospitalised prior to death Copies of hospital records, if available and attached to the autopsy/postmortem examination report Interview questionnaires completed by the forensic pathology officers during an interview with relative(s) of the deceased, if available Any additional statements added to the autopsy report Copies of laboratory results, if available and attached to the autopsy report SAPS = South African Police Services.

Results

A total of 8 634 autopsy/postmortem examination reports of homicidal deaths were perused, and 424 fatal CA cases were identified during the study period (Fig. 1).

Age and gender

The age range of victims was 14 - 62 years (mean 27) (Fig. 3). Most victims were male, with only one female.

Observations, n

Most fatalities were reported in Khayelitsha (n=166) and Harare (subsection within Khayelitsha, n=84) (Fig. 2). The other areas where fatalities frequently occurred were Mfuleni (n=47), Delft (n=37), Kraaifontein (n=24) and Lingelethu West (another subsection within Khayelitsha, n=16). These are all socioeconomically deprived areas in the region. However, when considering the total population per area, the highest burden of injury is seen in Mfuleni (73 CA deaths per 100 000 population)[5] (Table 2). Fifteen CA fatalities included in the study fell outside the range of areas that present to the Tygerberg FPS, reflecting the fact that the assaults occurred in another suburb/ township and the victims were transferred to hospitals within the drainage areas of the facility for further treatment and subse quently died.

49/11.6%

50/11.8%

44/10.4%

39/9.2% 35/8.3%

34/8.0%

27/6.4% 23/5.4%

10 0

2003

2004 2005

2006 2007 2008

2009 2010

2011 2012

Year of death Fig. 1. Total number of cases of fatal CA over the study period.

166

Khayelitsha 84

Harare 47

Mfuleni 37

Delft 24

Kraaifontein 16

Lingelethu West

Injuries sustained

In 42.0% (178/424) of the fatal CA cases, the cause of death stated on the autopsy/ postmortem examination report was multi ple injuries, indicative of the extent and multiplicity of injuries sustained in the CA fatalities. This was followed by head injuries (22.9%, 97/424), blunt-force trauma (13.9% 59/424) and soft-tissue injuries (13.0%, 55/424) (Fig. 4).

61/14.4%

Area involved

Areas where assaults occurred

62/14.6%

Langa

Lwandle

Grabouw

Nyanga

Ravensmead

2 9

Other 0

100

Observations, n

Fig. 2. Areas where CAs occurred.

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120

140

160

180

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Table 2. Distribution of CA cases in the areas of highest prevalence, per 100 000 population Police station

Population

CA deaths, n

CA deaths/100 000 population

Khayelitsha (including Harare and Lingelethu West)

391 749

266

67.9

Mfuleni

64 269

73.1

Delft

152 030

24.3

Kraaifontein

62 933

38.1

140 121

120

114

Observations, n

100 84 80

40 25 20 10 0

Objects found at the scene of death

1 15

1 60

Age (years)

Fig. 3. Age distribution of victims of fatal CA.

Abrasions

317/74.8%

Lacerations

315/74.3% 244/57.6%

Skull fractures 184/43.4%

Contusions

131/30.9%

Closed brain injury

111/26.2%

Injuries

Tramline bruises Internal organ injury

83/19.6%

Skeletal fractures

83/19.6%

Rib fractures

In 10.1% of cases definite evidence of restraint was seen, in that the hands and/or feet and/or neck were bound. In a cluster of cases, two decedents were allegedly assaulted and died on the scene, and in another instance three decedents were assaulted at the same time and died simultaneously. This was usually because the decedents had allegedly committed crimes together and been caught in the act, or had been caught by community members when together.

78/18.4%

Incised wounds

59/13.9%

Fourth-degree burns

13/3.1%

First-degree burns

9/2.1%

Second- and third-degree burns

8/1.9%

Chop wounds

6/1.4%

Gunshot wounds

5/1.2%

Necklacing

4/0.9%

Genital

1/0.2% 0

100

In some cases, bloodied objects were found at the scene of death and listed on the SAPS 180 form attached to the autopsy/ postmortem examination report. These were assumed by SAPS officials to be the objects used during the assault. In 72.9% of cases no mention was made of any objects at the scene, but in 21.0% of cases these were blunt objects: stones (10.9%), wooden sticks (5.0%) and bricks (5.0%). A sjambok, which is a whip or rod-like object sometimes made from rubber or animal hide, was seen in 2.0% of cases.

Restraints/ligatures used

100/23.6%

Stab wounds

The subclassification of the individual injuries sustained for all cases was as follows: abrasions 74.8% (317/424), lacerations 74.3% (315/424), skull fractures 57.6% (244/424), contusions 43.4% (184/424), closed brain injury 30.9% (131/424), tramline bruises 26.2% (111/424) and stab wounds 19.6% (83/424). This indicates that most cases showed evidence of blunt-force trauma. A combination of blunt- and sharp-force trauma was seen in only 4.0% of cases. Fourth-degree burns were seen in only 3.1% of cases, and first- and second/thirddegree burns in only 4.0%. ‘Necklacing’ (the practice whereby victims are set alight by placing a motor vehicle tyre around their necks, dousing it with a flammable liquid, and then setting it alight) was seen in 0.9% of cases (4/424). Gunshot wounds accounted for 5/424 deaths. In 74.3% of cases, a true history of CA was available. Others were assumed to be CAs by the South African Police Services (SAPS) official involved with the case, based on the injuries sustained or hearsay history. These bodies were often found at the side of the road or in an open field, with no witnesses to the crime, and the deceased was frequently unidentified at time of autopsy.

150

200

250

300

350

Injuries, n

Hospitalised cases

Of the victims of CA, 8.5% were hospital ised. The main complications in hospital

Fig. 4. Injuries sustained by victims of fatal CA.

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Hospital complications

Pneumonia

3.3%

Rhabdomyolysis

2.6%

Renal failure

1.9%

0.9%

Hypovolaemic shock

0.5%

Sepsis 0

Patients, n

Fig. 5. Hospital complications experienced by victims of CA.

were pneumonia (3.3%), followed by rhabdo myolysis (2.6%) and renal failure (1.9%) (Fig. 5).

Blood alcohol concentration

Blood specimens for measurement of the blood alcohol concentration are taken in all cases in which postmortem examinations are performed after presumed natural or unnatural death of an adult, unless they were hospitalised for more than 24 hours prior to death. Fifty-eight percent of cases had a blood alcohol concentration of 0 - 0.05 g/100 mL, followed by 14.4% with a level of 0.10 0.15 g/100 mL, 7.1% with a level of 0.16 0.20 g/100 mL and 5.2% with a level of 0.21 - 0.25 g/100 mL. The last three levels correspond to being moderately to severely under the influence of alcohol, and confirm that alcohol is a risk factor in violent or homicidal deaths.[6]

Discussion

The results of this study reflect a steady increase in CA fatalities from 2004 to 2008, with a decrease thereafter and then a second peak from 2010 to 2012. No definite reason explains the dramatic peak in 2008. However, a study on homicidal deaths by Cocks and Saayman[7] listed a total of 67 cases of CA/mob justice fatalities between 2007 and 2008 at the Pretoria MedicoLegal Laboratory, with most of those cases (n=51) occurring in 2008. The authors proposed that this peak was due to the ‘xenophobic attacks’ that occurred at that

time. Review of the autopsy/postmortem examination reports and additional notes in our study showed no written record that any of these fatalities were related to xenophobia. The drop in CA fatalities noted in 2010 (Fig. 1) could be attributed to the strict policing enforced during the 2010 Soccer World Cup held across SA at that time. Information on what types of crimes precipitated these attacks was not available on the autopsy/postmortem examination report, so whether these were petty or more serious crimes was unknown. This conflicted with a study in Tanzania, where most alleged ‘mob justice’ killings were due to alleged theft.[8] The ages of the decedents were similar to those in a local study by Forgus et al.[3] in Khayelitsha, where CA cases seen at a hospital in Khayelitsha were 18 - 61 years of age. Rosedale and Wood[9] found the age range to be 14 - 53 years.[9] It should be noted that even teenagers are falling victim to this type of assault. Rosedale and Wood found that the CA victims who presented to hospital were ‘beaten with sticks, metal bars and sjamboks’ – all blunt objects. This corresponds with the evidence of blunt-force trauma to the body noted in most cases in our study. These objects were ordinary items that were incidentally found at the scene and easily accessible to the perpetrators of the presumably spontaneous assaults. Another important finding was that ‘necklacing’ fatalities accounted for only 0.9% of cases, suggesting that this practice,

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which started during the apartheid era, with the first necklace killing reported in Port Elizabeth in 1985,[10] is no longer as common as it was during the political unrest of the latter part of the apartheid era. The very low incidences of gunshot and ‘necklacing’ fatalities could also be due to the fact that tyres and firearms may not be readily available in the townships. The low percentage of cases that were hospitalised could be because very few victims of CA survived long enough to get to hospital, succumbing to the severe and extensive injuries sustained. In the studies by Proctor et al.[11] and Rosedale and Wood,[9] most victims of CA who presented to hospital developed acute kidney injury secondary to rhabdomyolysis. This is a known complication of which clinicians need to be aware in cases where extensive blunt-force injuries to soft tissue are sustained.[9,11] This adds to the load on the healthcare system in terms of requirement for dialysis and financial cost. This study has highlighted the public health burden relating to common assault in the communities described, with a view to providing insight into the injuries sustained and their complications to clinicians who treat these cases and to the public health authorities of the Western Cape Province of SA.

Study limitations

There are several limitations to our study. Cases could have been missed because no history of CA was known or specified on the SAPS 180 or TH13/FPS 100 forms. More detailed information, documented or verbal, from the SAPS official involved would have prevented some cases being excluded. Also, cases were drawn from only one major medicolegal facility in Cape Town. A duplication of this study using data from all medicolegal facilities in the Western Cape may show a more accurate representation of the incidence of these cases at a provincial level. Comparing the results of this study with others proved difficult because no formal or publicised medicolegal postmortem data relating to CA fatalities exist in SA.

Recommendations

Arising from our study, we offer the following recommendations: (i) these deaths should officially be termed ‘CA fatalities’, and the term ‘vigilante justice’ should not be used; (ii) CA fatalities should be subclassified as a form of violence and be reported as such by the SAPS and included in the national formal crime statistics; and (iii) monitoring the number of CA cases presenting to healthcare

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facilities – especially trauma units – will establish the burden placed on clinicians and healthcare facilities as a whole. All these will aid in enhancing stricter policing protocols by the SAPS in areas where this form of violence is prevalent, as well as in suggesting better strategies to combat the problem.

Conclusion

In this retrospective review of CA fatalities, it was found that the cause of death in most cases was multiple injuries due to blunt-force trauma. The area with the highest burden of injury was the township of Mfuleni. Males were almost exclusively assaulted, and the fatalities are increasing annually. They create an additional burden on the forensic pathologist/ forensic medical officer in terms of autopsy time, additional investigations, and completion of the autopsy/postmortem examination report. Adequate policing in prevalent areas is essential in order to address unnecessary loss of life and the additional burden imposed on the criminal justice system and healthcare services.

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References 1. Medical Research Council. A Profile of Fatal Injuries in South Africa 2008: Tenth Annual Report of the National Injury Mortality Surveillance System. Cape Town: Medical Research Council, 2008. http:// mrc.ac.za/crime/nimss.htm (accessed 23 July 2013). 2. Monaghan R. Community-based justice in Northern Ireland and South Africa. International Criminal Justice Review 2008;18(1):83-105. [http://dx.doi.org/10.1177/1057567708316639] 3. Forgus S, Delva W, Hauptfleisch C, Govender S, Blitz J. Community versus non-community assault among adults in Khayelitsha, Western Cape, South Africa: A case count and comparison of injury severity. S Afr Med J 2014;104(4):299-301. [http://dx.doi.org/10.7196/samj.7615] 4. Cronje J. Khayelitsha ‘still has some faith in police service’. Weekend Argus 22 February 2014. 5. Cape Town Statistics from Census 2011. www.capetown.gov.za/statistics (accessed 1 May 2015). 6. Ehmke U, du Toit-Prinsloo L, Saayman G. A retrospective analysis of alcohol in medico-legal autopsied deaths in Pretoria over a 1 year period. Forensic Sci Int 2014;245(12):7-11. [http://dx.doi.org/10.1016/j.forsciint.2014.09.009] 7. Cocks J, Saayman G. The incidence, pathology of trauma and victim profiles of homicidal deaths in Pretoria, South Africa (2007-2008). Med Sci Law 2013;53(2):61-66. [http://dx.doi.org/10.1258/msl.2012.012027] 8. Ng’walali, Kitinya JN. Mob justice in Tanzania: A medico-social problem. Afr Health Sci 2006;6(1):3638. [http://dz.doi.org/10.5555/afhs.2006.6.1.36] 9. Rosedale KJ, Wood D. Traumatic rhabdomyolysis (crush syndrome) in a rural setting. S Afr Med J 2012;102(1):37-39. 10. Lang IR. ‘Necklace murders’: A review of a series of cases examined in a Port Elizabeth Mortuary. Med Law 1994;13(5-6):501-509. 11. Proctor M, Carter N, Barker P. Community assault – the cost of rough justice. S Afr Med J 2009;99(3):160-161.

Accepted 25 August 2015.

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A review of primary and secondary burn services in the Western Cape, South Africa H Rode,1 FRCS, FCS (SA), MMed; A D Rogers,2 FC Plast Surg, MMed; A Numanoglu,1 FCS (SA); L Wallis,3,4 MD, FRCEM; R Allgaier,3 MAMS; L Laflamme,5 PhD; M Hasselberg,5 PhD; L Blom,5 MGH; R Duvenage,6 FCS (Surg) Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa 2 Ross Tilley Burn Centre, Division of Plastic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Canada 3 Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa 4 Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 5 Karolinska Institute, Department of Public Health Sciences, Global Health/IHCAR, Stockholm, Sweden 6 Department of Surgery, Worcester Regional Hospital, Western Cape, South Africa 1

Corresponding author: H Rode (heinz.rode@uct.ac.za)

Background. In 2011, the Department of Health of the Western Cape Province, South Africa, requested a review of current burn services in the province, with a view to formulating a more efficient and cost-effective service. This article considers the findings of the review and presents strategies to improve delivery of appropriate burn care at primary and secondary levels. Methods. Surveys were conducted at eight rural and urban hospitals, two outreach workshops on burn care, four regional hospitals and at least 60 clinics in Cape Town and in the Western Cape as far as Ladismith. A survey on community management of paediatric burns was also included in the study. Results. The incidence of burns was highest in the winter months, more than half of those affected were children, and the majority of burns were scalds from hot liquids. Most burn injuries managed at primary level were minor, with 75% of patients treated by nurse practitioners and discharged. The four regional secondary hospitals managed the majority of moderate to severe burns. There is room for improvement in terms of treatment facilities and consumables at all levels, regional hospitals being particularly restricted in terms of outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a burns unit when indicated. Conclusion. The community management of paediatric burns was satisfactory, although considerable delays in transfer and insufficient pain control hampered appropriate care. A great need for ongoing education at all levels was identified. Ten strategies are presented that could, if implemented, lead to tangible improvements in the management of burn patients at primary and secondary levels in the Western Cape. S Afr Med J 2015;105(10):853-857. DOI:10.7196/SAMJnew.8187

Burn care in South Africa (SA) has traditionally (and erroneously) been viewed as purely an emergency service rather than a complex multidisciplinary three-tiered service requiring appropriate expertise, including rehabilitation, at primary, secondary and tertiary levels. If one of these levels fails, undue strain is placed on the next level and the whole system disintegrates, resulting in increased patient morbidity and mortality. Those involved in strategic planning for provincial burn care need to realise that appropriate triage can only follow the establishment of a suitable infrastructure at each level. Burn care in SA is variable in terms of organisation, clinical management, mortality, facilities and staffing.[1-4] In 2011, the Western Cape Government Department of Health (WCG DoH) requested a review of current burn services in the province (Circular H73 of 2011, unpublished) with a view to formulating a more efficient and cost-effective service. This article reports the findings of an initiative to obtain information to guide this process. We present data on urban and rural burn care at primary and secondary levels and make recommendations for improving service delivery. Data collected included patient demographics, mechanism and severity of injuries sustained, level of care received, referral pathways or patterns, and aspects of service delivery at primary and secondary levels.

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Methods

Data were gathered from numerous sources and collected under the direction of the corresponding author (HR). All the surveys listed below were conducted by senior clinicians involved in burn care and/ or research. All resources are available on request from HR. 1. Minutes of the Reorganisation of Burn Services Western Cape Task Group meetings (2009). The task team was asked to rationalise burn services in the teaching group of hospitals in the Western Cape. 2. Review of Highly Specialised Services in the Public Hospital Sector, Directorate: Health Financing & Economics (June 2001). 3. Reorganisation of Burn Services Western Cape (2009) by HR. An extensive review with recommendations towards a seamless burn care strategy. 4. Report to the WCG DoH (November 2013). A study to assess the burden of 2 172 burn injuries from rural and urban areas presenting to public hospital emergency centres during the period June 2012 - May 2013. 5. Hallén H. The socio-demographic distribution of burn injuries of different severity levels in resource poor settings: A hospitalbased study in the Western Cape Province, South Africa. (Subset of a student project from the Karolinska Institute, Sweden, 2012.) 6. Surveys undertaken at four regional hospitals during 2012 - 2013. 7. Surveys from 13 hospitals and nine rural clinics at a burns management workshop held in Ladismith during 2012.

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Table 1. The proposed structure of burn services (2009) Facility

Day hospital clinics

Level 1: PHC + district hospitals, e.g. G F Jooste, Karl Bremer hospitals

Level 2: regional hospital, e.g. New Somerset, Victoria, George, Worcester hospitals

Level 3: provincial tertiary hospital, i.e. Tygerberg, Red Cross War Memorial, Groote Schuur hospitals

Service to be provided

Basic management of minor burns

Selected cases Complete service Referral protocols

Complete service Selected cases Referral protocols

Complete service Major and specific burns

Personnel required

Medical officers & nurse practitioners

Surgeons, medical officers, nurses Level 2 staff

Dedicated trained staff: plastic surgeon, paediatric surgeon

Resources required

Clinic facility with appropriate burn medication, dressings

Clinic facility with appropriate burn medication

Specific burn care facilities including theatre, ICU and diagnostic services

Links, supporting services/specialties on site

Referral and transport protocols

Referral and transport protocols Step-down facility

General or plastic surgeon, full or part time Step-down facility

Emergency rehabilitation services, team services with occupational therapy, physiotherapy, dieticians, social work Step-down facility

Description of casemix and referral proposed by level

Only minor burns for treatment, larger/special burns to be referred

Only minor burns

Minor and moderate burns

SABS admission criteria with modification

Teaching function

Basic burn care Possible EMSB course

Basic burn education to medical and supporting personnel, EMSB course

Pre- and postgraduate Special nurse training, EMSB course

8. Surveys from 11 rural clinics at a burns workshop held in Worcester during 2012. 9. Surveys from nine City of Cape Town clinics and 16 urban clinics and community health centres (CHCs) during 2012/13. 10. Information from the surgical data bank, Department of Surgery, Worcester Hospital, 2013. 11. Clinical guidelines for the management of burn wounds: WCG DoH Circular H73 of 2011. 12. Report on the evaluation of burn services in the Western Cape (2012) by HR.

Patients, n

PHC = primary healthcare; SABS = South African Burn Society; EMSB = Emergency Management of Severe Burns (Australian/New Zealand Burn Association; internationally registered acute burn course).

Ethical clearance

Fig. 1. Distribution of patients by participating hospital (N=2 172, June 2012 - May 2013).

Ethical clearance was obtained from the University of Cape Town (HREC Ref. 329/2015) and the WCG DoH.

Results

The 2009 Task Group reviewed the current status of burn care and formulated a broad-based organisational structure for a provincial burn care platform (Table 1). The report to the WCG DoH from Stellenbosch University and the Karolinska Institute study reflected the extent of the challenges facing burn care in the Western

600

Urban (n=1 329)

Rural (n=843)

500 400 300 200 100 0

Ceres

Hermanus Montagu Robertson Worcester Gugulethu Khayelitsha

Site B

Hospital

Cape (Fig. 1). The increase in the incidence of burn injury during the winter months among both children and adults is depicted in Fig. 2. Fifty-two percent of patients were children and 53% males. Comorbidities existed in 11%, hot liquids were responsible for 65% of injuries and fire for 12%, 42% of burns involved less than 20% total body surface area (TBSA), and 70% were partial-thickness burns. The emergency medical service transported only 20% of the patients. Seventy-four percent of patients

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were treated and discharged home, 7% were admitted to the facility, and 13% were transferred to another facility. Two-thirds of all patients presenting with injuries spent less than 5 hours at the facility. A mortality rate of 0.1% of all patients presenting with burn injuries was recorded. The Abbreviated Injury Scale was used to determine the severity of burns in this cohort of patients: 81.5% of patients had a score of 1, 16% a score of 2, 3% a score of 3, and 0.2% a score of ≥4.

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300

Patients, n

250 200 150

Urban

100

Rural Total

Au gu st Se pt em be r Oc to be r No ve m be r De ce m be r

Ju ly

Ju ne

ay M

il Ap r

ar ch

y ua r

y Ja

Fe br

nu ar

Month

Fig. 2. Distribution of patients by month (N=2 172, June 2012 - May 2013). 3 19

6 21

106

127

4 32 26 No v

4 13

2 11

2 14

Au g

110

2 34

6 18

160

4 23

Ap r

210

ar ch

Surgical admissions, n

260

ne Ju

Fe b

-40 Month Elective surgery or work-up

Non-trauma emergency

Trauma

Burns

Unexpected readmission

Fig. 3. Surgical admissions to Worcester Hospital, 2012.

The South African Burn Association’s cri teria for admission to a burns unit were only met in 7% of children under 1 year of age, in 4% of patients with deep burns, in 10% of patients with comorbidities and in 48% of patients with burns in special areas (face, hands and genitalia).[5] This information was essential to establish a baseline for evaluation of service delivery, as requested by the WCG DoH. The facilities for burn care at regional hospitals, namely Paarl, Worcester, New Somer set and George hospitals, were reviewed. All the qualified specialists employed had support from registrars and medical officers. The consultant surgical staff had had some formal, albeit limited, exposure to burn surgery during their surgical training. The surgical infrastructure was sufficient to manage most of the patients presenting to the facilities. Operating time was limited, however, and burn patients were often accommodated only during emergency operating time. The operating theatres were generally well equipped to perform all surgery within the scope of the secondary hospital (with some advanced equipment perhaps more in keep-

ing with a tertiary hospital setting), except for burn surgery. Basic surgical equipment at secondary level was old and often dysfunctional, and there was limited access to modern technology and burn wound dressings. None of these regional hospitals had a dedicated burns unit or beds, or any capacity to isolate burn patients; both adults and children were accommodated in surgical wards. The nursing staff in several settings (the wards, clinics and operating theatres) had varying experience in organising a major burn theatre case or motivating for and implementing specific wound care strategies for their patients. Fig. 3 depicts the burn workload of a typical regional hospital based on information drawn from the extensive surgical data bank for 2013 of the Department of Surgery, Worcester Hospital. This hospital managed most of the burns referred to it, because the receiving tertiary hospital for adult burns, Tygerberg Hospital (TBH), seldom had the capacity to accept referrals. Two of 30 patients meeting the criteria for referral were accepted by TBH in 2012. Referral to a higher level from the other three hospitals followed a similar pattern, with 7 of

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542 over 9 years (2003 - 2011) from George Hospital, 8 of 23 patients from New Somerset Hospital over 4 months in 2012, and 10 of 50 adults and 6 of 33 children from Paarl Hospital during 2012. The Western Cape Government ‘Clinical guidelines for the management of burn wounds’ (circular H73 of 2011, unpublished and available on request from the corresponding author) was available in these hospitals and the senior staff acknowledged its contribution to the care of burn patients. A major problem encountered was the shortage of intensive care unit (ICU) beds at secondary level. At the time of the survey, Worcester Hospital had only four surgical ICU beds to serve all surgical disciplines (for adults and children), George Hospital had six ICU beds for the entire hospital’s needs, whether surgical or medical, Paarl Hospital had eight potential high-care beds and only two ICU beds (one for a surgical patient), and New Somerset Hospital had three ICU beds, of which one was typically allocated to all of surgery. The results from workshops assessing burn care at rural sites yielded the following results. Burns were usually initially treated by nurse practitioners and only occasionally assessed and managed by medical practitioners (Table 2). Burns outside nurse practitioners’ scope of practice were referred to more advanced service sites. Basic topical therapies available to nurse practitioners included silver sulphadiazine, acraflavin and Jelonet. Only three of 87 nurse practitioners had any prior education in wound or burn care. The primary healthcare facilities visited yielded further important information relevant to the reorganisation programme. Some clinics saw as many as four burns a week, while others rarely managed burn injuries. The patients were assessed and treated by nurse practitioners with wound care consisting of cleansing, the application of cold compresses, analgesia, and referral to a higher level when deemed necessary. If the wounds were relatively small and non-compromising, patients were seen at the clinic on a daily basis for ongoing treatment until healed. A typical dressing room for such wound care was very basic and probably inappropriate for this function. Dressing rooms were small and overcrowded, with little privacy offered. These facilities were also simultaneously used for minor procedures such as abscess drainage, as well as for acute and chronic wound care. Provincial clinics and CHCs managed patients directly referred from nurses from feeder clinics. Burns were assessed by a medical practitioner who had the capacity to institute emergency care and then refer patients to level 2 or 3 centres. Alternatively, they could elect to manage the patient on an ambulatory basis

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Table 2. Survey during workshop in Ladismith (2012) with 12 participating hospitals Regional hospital

PHC

Table 3. Ten-point plan to improve burn services in the Western Cape

Oudtshoorn, Heidelberg, Knysna, Uniondale, Vredenburg, Riversdale, Robertson, Alan Blyth Hospital, Stellenbosch, Mossel Bay, Hopefield, Beaufort West

9 regional clinics between Stellenbosch and Ladismith

2. F acility upgrade at primary level

Information from

Doctor/nurses

Clinic staff

Admissions of burn patients, n

2 - 40/month

3 - 4/month

Gender

Males = females

b. S urgical equipment

Main causes of burns

Hot water, fire, chemicals, electricity

c. W ound care stations

Emergency care

H₂O, Burnshield

H₂O/nothing

e. R ehabilitation

Clinical management

Doctor/nurses (all)

Nurses (all)

Time from injury to treatment

Min. 2 days Often delayed

Often delayed

Topical therapy

Flamazine, Betadine, acriflavin, Burnshield, Jelonet

Jelonet, acriflavin

Pain control

Occasional

Initial management

Only major burns referred

Dealt with many of the small burns

Referral

No evidence that the provincial protocol was implemented on a general basis. Referral was more based on ad hoc decisions

Similar

No formal education in the principles and management of burn care among the majority of participants

No formal education in the principles of burn care

Region

Education

1. P revention a. W ound care stations b. R estructure c. N ew facilities 3. F acility upgrade at secondary level a. I CU beds

d. N ew facilities 4. R ational availability of consumables a. E SMB course b. W ound care c. T ertiary hospital rotation d. A ccessible resources and guidelines 6. E ducation of nursing staff a. E SMB course b. W ound care 7. I mprove resources and personnel of adult tertiary burn service, especially TBH 8. B urns registry a. L ines of communication upgrade b. K nowledge of resource utilisation 9. T elemedicine system 10. Burn disaster plan

PHC = primary healthcare.

themselves. Dressing facilities were similarly ill equipped to offer patients modern standards of wound care. These services seldom managed more than two to ten such patients per month, with some seasonal variation. Basic treatment available on a daily basis consisted of Burnshield (for use up to 24 hours after injury), silver sulphadiazine and Jelonet; more expensive options, including Aquacel, Inadine, Bactigras, Acticoat and Actisorb, were sometimes (and inconsistently) available, and the rationale for their use was not always clear to the staff. The Western Cape Government ‘Clinical guidelines for the management of burn wounds’ was not available at any of the sites visited, although the ‘Emergency medicine guidelines for the Western Cape’ (2013, unpublished and available on request from the corresponding author) was available at a few sites. Three hundred and fifty-three patient presen tations to Red Cross War Memorial Children’s Hospital, Cape Town, during 2012 were included to evaluate community treatment of paediatric burns. The following fac-

5. E ducation of medical staff

tors were assessed: demographics, emergency home management, wound cover, analgesia and transport to medical facilities. Patient ages ranged from 1 month to 14 years. The average TBSA was 15% (range 1 - 86%). Two hundred and nineteen patients initially presented to a CHC, with only 22 attending the hospital directly. The average time to present at the referring clinic was 4.56 hours (range 30 minutes - 24 hours). Emergency care consisted of the application of Burnshield as primary wound cover in all, and 295 children (83.6%) had received pain medication at clinic level.

Discussion

Total burn care, from prevention to rehab ilitation of the burn patient, is a long and difficult process, and burns frequently leave their victims scarred and disfigured. Every effort should therefore be made to maximise outcomes at each stage of management. Based on the findings of these various surveys, ten factors were identified that could, if implemented, lead to significant improvements

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EMSB = Emergency Management of Severe Burns (Australian/New Zealand Burn Association; internationally registered acute burn course).

in the management of burns at primary and secondary levels in the Western Cape (Table 3). Such improvements would require the WCG DoH to accept and implement the proposals within the context of other health service reforms and budgetary restraints. Many of the previously published docu ments included in this study corroborated the findings of the surveys. In keeping with population distributions, the vast majority of patients treated for burn injury during the study period resided in urban areas (including both formal and informal settlements) and were treated at primary and secondary levels. An unknown factor, however, was the individual outcome of these patients. Of concern was the finding that only a few of the patients who met the South African Burn Society’s criteria[5] for admission to a burns unit for treatment in terms of extent and severity of body surface area involved, were transferred to a higher

RESEARCH

level. This emphasises the need to ensure adequate facilities, at local level, to treat the great majority of burn injuries. This is a major consideration with a direct impact on the efficiency of healthcare delivery in general and burn care specifically. Although all secondary hospitals accepted responsibility for the majority of adult patients with burns and provided appropriate levels of care with few referrals, the shortage of high-care or ICU beds was one of the major reasons for referral to tertiary level being requested. Had ICU beds been available in the secondary hospitals, more patients could have been dealt with at that level without referral. Staff also rotated regularly, operating time was restricted, equipment was outdated, and there was limited access to modern dressings and technology. Referral of patients with major burns to the burns unit at TBH remained the greatest single problem in the system. While there are newly upgraded facilities at TBH, the extremely limited theatre time available remains the ‘Achilles heel’ of the service and prevents TBH from fulfilling its mandate as the Western Cape’s dedicated adult burns centre. Turnover needs to be increased threefold, thereby opening spaces for referrals. To reduce demands on the TBH service further, surgical facilities for minor to moderate-size burns will need to be developed at the new Khayelitsha and Mitchell’s Plain hospitals. Adult burn patients seldom presented at the City of Cape Town CHCs (meant only for children aged <13 years with burn injuries), and were infrequently seen at provincial sites. If they were seen at the latter, it was usually only for emergency management followed by appropriate referral to level 2 facilities. Children with burns were initially treated at the nearest CHC, where the facilities and nursing expertise were often suboptimal and frequently resulted in poor diagnoses and initial management. Unnecessary referrals to a tertiary centre were commonplace. The ‘Emergency medicine guidelines for the Western Cape’ were only available at the various provincial hospitals, rather than at both primary and secondary levels. In our opinion, these guidelines and the ‘Clinical guidelines for the management of burn wounds’ are too extensive and should be more goal-directed towards the level of care at which they are intended to be used. A review of guidelines for use at primary level for the management of minor burns, and the emergency initial care of major burns, should be undertaken. Clear guidelines also need to be established for the management of burn patients at secondary level. We suggest that four strategically placed CHCs be identified as primarily dedicated to burn care for children. Potential sites identified were the Delft, Elsie’s River, Khayelitsha and Mitchell’s Plain CHCs. These facilities would then act as referral sites to secondary level or as step-down facilities, where adequate burn treatment and possible rehabilitation could be delivered for minor to moderate-sized burns. There would be initial cost implications, but once the facilities were established, patients with burn wounds would benefit greatly. Regarding consumables and equipment, two aspects need to be highlighted. Basic consumables should include only a few topical antiseptics, Burnshield to cool the acute burn wound, elastic tubular mesh retention bandages and appropriate dose-related analgesia for both children and adults. Acquisition of such consumables and equipment should be streamlined. The second area requiring revision is the currently rudimentary wound dressing facilities at these various hospitals and clinics, which are small and congested with patients. The universal dressing rooms lacked basic equipment for proper wound care, had bath tubs instead of shower facilities, and lacked work surfaces for dressing changes. Dressing stations need to be upgraded with appropriate space and facilities for proper wound care, including a hand-held shower, a wash basin, a working surface, prepacked dressing packs and storage space. An additional reason to upgrade all of these facilities, especially the surgical facilities, is that the entire network would be filled to capacity in

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the event of a burn disaster. The surge capacity would be exceeded, with catastrophic consequences due not only to the shortage of beds, ICU facilities, nursing staff and medical personnel, but the lack of adequate resources to care for a single major burn over a long period of time.[6] Personnel interviewed at all levels expressed the need for ongoing education in wound care programmes, theatre education and basic skills development, so that healthcare workers could become familiar with the latest advances and trends in burn care research and practice.[7-9] They also suggested that educational programmes should preferably be in-house, take place during normal working hours, and not last more than 45 - 60 minutes. Such programmes should be very practical, discuss current concepts, and require no special leave or travel arrangements on the part of staff. Telemedicine or teleconferencing systems would facilitate effective burn care at appropriate levels, as burns are often either over- or under-triaged, with severe consequences for the patient. Initial on-site evaluation can be performed accurately via telemedicine, at low cost. Such a system would improve initial assessment, treatment, and decisions regarding need for transfer and resource utilisation, and would be especially valuable to outlying and smaller clinics.[10,11] Development of a burns registry to monitor the incidence and causes of burns, the nature of the injuries and geographical areas affected should be considered, to evaluate areas of weakness within the system.

Conclusion

Reorganisation of burn services is a worldwide phenomenon, despite varying circumstances and infrastructures, but ultimately all have the goal of improving care for the victims of circumstance. Reorganisation must be practical, attainable and affordable within the fiscal framework of, in this case, the Western Cape Provincial Administration. The suggested guidelines are not intended to be rigid or proscriptive, but to emphasise changes that would improve burn care. Ten crucial areas have been identified in which our proposals, if implemented, would ultimately prove cost-effective and substantially improve the standard of burn care. They are intended to guide practice and not to replace clinical judgement. The service envisaged must also be equitable and accessible, irrespective of location, directed principally towards acute care without neglecting the entire process of recovery and rehabilitation. An intensive range of preventive programmes should include the provision of safe energy, adequate housing and education, and emergency services would have to be developed to complete the comprehensive burns management programme. References 1. Albertyn R, Bickler S, Rode H. Paediatric burn injuries in sub-Saharan Africa: An overview. Burns 2006;32(5):605-612. [http://dx.doi.org/10.1016/j.burns.2005.12.004] 2. Rode H, Cox SG, Nomanuglo A, Berg AM. Burn care in South Africa: A micro cosmos of Africa. Pediatr Surg Int 2014;30(7):699-706. [http://dx.doi.org/10.1007/s00383-014-3519-5] 3. Van Niekerk A, Rode H, Laflamme L. Incidence and patterns of childhood burn injuries in the Western Cape, South Africa. Burns 2004;30(4):341-347. [http://dx.doi.org/10.1016/j.burns.2015.05.024] 4. Van Niekerk A, Laubscher R, Laflamme L. Demographic and circumstantial accounts of burn mortality in Cape Town, South Africa, 2001-2004: An observational register based study. BMC Public Health 2009;9:374. [http://dx.doi.org/10.1186/1471-2458-9-374] 5. Karpelowsky S, Wallis L, Madaree A, Rode H. South African Burn Society burn stabilisation protocol. S Afr Med J 2007;97(8):574-577. 6. Rogers AD, Price CE, Wallis LA, Rode H. Burn disasters – a plan for South Africa. S Afr Med J 2011;10(1):16-17. 7. Potokar T, Moghazy A, Peck M, Bendell R, Fanstone RA. Setting Standards for Burn Care Services in Low and Middle Income Countries. An Interburns Publication. September 2012. http://interburns. org/wp-content/uploads/2013/12/Interburns-Standards-Report-2013.pdf (accessed 15 January 2015). 8. International Best Practice – Effective skin and wound management of non-complex burns. Wounds International 2014. Expert Working Group 2014. http://www.woundsinternational.com/media/ issues/943/files/content_11308.pdf (accessed 15 January 2015). 9. Rogers AD. Comments regarding ‘The Inadequacy of wound management training for medical professionals.’ Wound Healing Southern Africa 2013;6(2):98. 10. Boissin C, Laflamme L, Wallis L, Fleming J, Hasselberg M. Photograph-based diagnosis of burns in patients with dark skin types: The importance of case and assessor characteristics. Burns 2015;41(6):11253-1260. [http://dx.doi.org/10.1016/j.burns.2014.12.014] 11. Saffle JR, Edelman L, Theurer L, Morris SE, Cochran A. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009;67(2):358-365. [http://dx.doi.org/10.1097/TA.0b013e3181ae9b02]

Accepted 7 July 2015.

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RESEARCH

Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective M Govender,1 FCS (SA); C Aldous,2 PhD; L Ferndale,1 MMedSci; S R Thomson, MD,3 FRCS; D L Clarke,1 PhD epartment of Surgery, Pietermaritzburg Metropolitan Complex and College of Health Sciences, Nelson R Mandela School of Medicine, D University of KwaZulu-Natal, Durban, South Africa 2 School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Gastrointestinal Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 1

Corresponding author: D L Clarke (damianclar@gmail.com)

Background. Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience. Patients and methods. All patients who had SEMS placement for oesophageal cancer at Grey’s Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007 - 2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications. Results. A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age >70 years n=95 patients, tumour >8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality. Conclusion. The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance. S Afr Med J 2015;105(10):858-861. DOI:10.7196/SAMJnew.8329

Although the 5-year survival rate for oesophageal cancer has improved from 5% to 19% over the past 4 decades, the prognosis remains poor.[1-3] This is especially so in rural South Africa (SA), where patients present with advanced disease and therapy is typically directed at alleviating dysphagia, overflow of saliva, pulmonary aspiration and tracheo-oesophageal fistula. Over the past decade self-expanding metal stents (SEMS) have replaced surgical bypass and rigid plastic stents as the gold standard for mechanical palliation of this disease. Studies have shown good relief of dysphagia with SEMS insertion, with minimal risk.[4,5] In SA and in other countries, SEMS insertion is currently usually performed under fluoroscopic guidance, which requires access to a fluoroscopic suite. At Grey’s Hospital in Pietermaritzburg, KwaZulu-Natal Province, SA, fluoroscopy is under great demand. We are also faced with a significant burden of inoperable oesophageal cancer. In response to this high demand for a limited resource, we developed an alternative direct-vision approach that does not require fluoroscopy. This technique, first described in the literature in 2001,[6] has been validated with several small studies in equally resource-constrained environments.[7-9] This study at Grey’s Hospital was undertaken to describe the technique of stent placement using endoscopy alone and to document our periprocedural experience over a 5-year period (2007 - 2011). We hope that this alternative direct-vision approach will gain

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acceptance in the SA context, leading to more centres providing the service and ultimately improving patient access.

Methods

This was a retrospective analysis of all patients stented for oesophageal cancer at Grey’s Hospital over the 5-year period 2007 - 2011. Data were analysed from completed gastrointestinal procedure reports and included patient demographics, tumour length, presence of a fistula, stent size used and immediate complications. Other variables included the indication for stenting, as well as the need and indication for repeat stenting during the study period.

Technique

All patients gave consent for the endoscopy, dilatation and stenting using a standard hospital consent form. Patients were counselled in the appropriate language before the procedure regarding the dietary modifications that the stent would mandate. All stenting was performed in the gastrointestinal unit, under sedation using midazolam and fentanyl. The stents used were nitinol partially covered ones with a proximal release mechanism (Ultraflex; Boston Scientific, USA). An initial gastroscopy was performed and the oesophageal tumour identified. If the endoscope could be passed beyond the tumour, proximal and distal measurements of the tumour were taken. If the scope could not initially traverse the

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Initial gastroscopy

Insertion of guidewire beyond tumour

Scope removed

Dilatation performed if required up to 12/14 mm

Patient rescoped Proximal and distal measurements obtained to select stent size Guidewire reinserted

lesion, a guidewire was passed and the lesion dilated using SavaryGilliard dilators up to 12 mm diameter. The scope was then reintroduced and tumour measurements obtained. These were then used to select the stent size. Optimal stent size is at least 4 cm longer than tumour length in order to achieve adequate proximal and distal coverage (of 2 cm on either side of the lesion). The guidewire was then inserted under vision beyond the tumour into the stomach, and the scope was removed. The stent delivery system, which has markings in centimetres, was then passed over the guidewire and positioned using the proximal tumour measurement as a guide. The scope was then reinserted alongside the stent delivery system and the SEMS carefully deployed under direct vision, allowing for adjustment of its position. Following the procedure, the patient recovered in the day ward unless a complication occurred. Once the patient was awake, advice regarding dietary modification was repeated. The patient was discharged with analgesia and a diet sheet back to his/her referral hospital or, in the case of inpatients, back to the ward. Fig. 1 is a photo montage of the technique of SEMS deployment.

Results

A total of 506 stents were placed in 453 patients between 2007 and 2011. Fig. 2 shows a breakdown of the numbers of procedures per year. There were 436 treatment-naive patients and 43 in whom a pre-existing SEMS had become obstructed and who required a salvage procedure. The mean age was 60 years, with the youngest patient being 38 and the oldest 101. There were 185 female patients (40.8%) and 268 male patients (59.2%). In terms of racial distribution (Fig. 3), black patients overwhelmingly predominated. The reasons for stenting were refusal of surgery (n=1), post-oesophagectomy leak (n=1), and inoperable cancer in the remainder. Six percent of patients presented with a tracheooesophageal fistula (TOF). Twenty-two percent of patients were older than 70 years, 32.7% had tumours that were >8 cm in length, and 39.4% (170/453) were deemed inoperable owing to comorbidities, locally advanced tumours and the presence of metastases. The reasons for irresectability are depicted in Fig. 4.

Repeat procedures

Stent delivery system passed Scope reinserted parallel to stent Positioned above proximal tumour

A total of 43 patients required a repeat procedure, 15 for stent migra tion, 26 for tumour overgrowth, 1 for a blocked stent and 1 for a stricture. Of the 436 new patients, 26 required restenting, giving a restent rate of 5.9%; an analysis of this subset is shown in Table 1. Restenting in all patients was uneventful. Six periprocedural complications (1.3%) occurred and included iatrogenic TOF (n=2), false tracts created through long tumour (n=3) and a single tumour perforation. All were successfully restented without the use of fluoroscopy, and there was no periprocedural mortality.

Discussion

Stent slowly deployed under direct vision Fig. 1. A photo montage of the technique of deployment.

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The burden of disease due to oesophageal cancer in SA is large. This 5-year study reveals a significant number of patients with advanced oesophageal cancer who required palliation. In keeping with available epidemiological data, there was a male predominance and older patients were in the majority, although 15.3% of the patients were <50 years of age. Oesophageal stent placement is usually performed under fluoroscopic guidance in most centres in SA. We set out to show that the purely endoscopic technique of SEMS placement is a safe and effective alternative in the palliation of malignant dysphagia. Oesophageal SEMS

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RESEARCH

160

1.3%

140

3.3%

Patients, n

120

Black

100 95.4%

White Indian

60 40 20 0

2007

2008

2009

2010

2011

Year Fig. 2. SEMS deployment per year at Grey’s Hospital.

45 40 Patients, n

35 30 25 20 15 10 5 0

TOF

Age >70 years

Lesion >8 cm

Unspecified

Reason for inoperability Fig. 4. Reasons for inoperability.

Table 1. Analysis of restenting Reason

Patients, n

Time from initial stent

Stent migration

21 days - 7 months (mean 2.1)

Proximal overgrowth

2 - 17 months (mean 7.3)

Distal overgrowth

2 - 9 months (mean 5.6)

Blocked stent

10 months

Stricture

2 months

Table 2. Comparison with other series using the direct-vison approach Our series

Perforation, %

Mortality, %

Migration, %

Restent, %

436

1.4*

2.5

5.9

Wilkes et al., 2007

3.1

8.9

Ben Soussan et al., 2005[13]

White and Mungatana, 2001[14]

2.8

4.2

[7]

*False tract and TOF included in our series.

insertion forms the core of palliation in patients in whom curative resection is not possible because they are too old or frail or because lesions are too advanced or

extensive. In our series, 21.9% of patients were >70 years old (a local cut-off for oesophagectomy), and the rest had locally advanced or metastatic disease or were

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Fig. 3. Racial distribution of patients requiring a SEMS for oeosphageal cancer.

generally in a poor cachetic condition. Delays in seeking medical attention, as well as the lack of awareness of oesophageal cancer in our communities, probably contribute significantly to the advanced stage of disease at presentation. This study suggests that an exclusively endoscopic technique is a safe and effective alternative to fluroscopically guided placement in a resource-limited setting. Accurate placement of stents was confirmed in 100% of our patients with endoscopic evaluation at the time of stent deployment. This was true for palliating dysphagia as well as for stenting over malignant TOF. Our recorded complication rates with respect to perforation, need for a salvage procedure due to stent migration and/or tumour overgrowth compare favourably with other published series utilising both the fluoroscopically guided and purely endoscopic technique.[7,10-14] Tables 2 and 3 compare our outcomes with those reported in the literature. Currently we reserve fluoroscopic place ment for a select group of patients. These include patients in whom complete luminal obstruction makes safe passage of either the endoscope or the guidewire impossible. Such patients comprise about 15 - 20% of cases at our institution. The direct-vision approach allows for the majority of patients to be stented at a regional level and selects out those for whom fluoroscopy would be necessary. Use of routine fluoroscopy for all patients therefore appears to be a waste of a valuable resource, as well as contributing to an unnecessary delay in patient management.

Conclusion

We have developed a safe technique to accurately deploy SEMS under direct vision, thus obviating the need for fluoroscopy. Our study shows that the periprocedural complication rate is low and reaffirms that the exclusively endoscopic technique of stent insertion is a safe and effective option,

RESEARCH

Table 3. Comparison with series using fluoroscopy N

Perforation, %

Mortality, %

Migration, %

Restent, %

Our series

436

1.4*

2.5

5.9

Dobrucali and Caglar, 2010[10]

4.0

Christie et al., 2001[11]

100

8.7

5.1

Cwiekiel et al., 1998[12]

100

3.0

7.5

*False tract and TOF included in our series.

especially in units with limited or no access to fluoroscopy. This technique is also applicable to patients with recurrent dysphagia (whether due to stent migration or tumour overgrowth) and to the management of malignant TOF. References 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62(1):10-29. [http://dx.doi.org/10.3322/caac.21149, http:// dx.doi.org/10.3322/caac.20138, http://dx.doi.org/10.3322/caac.21153] 2. Dubecz A, Gall I, Solymosi N, et al. Temporal trends in longterm survival and cure rates in esophageal cancer: A SEER database analysis. J Thorac Oncol 2012;7(2):443-447. [http:// dx.doi.org/10.1097/JTO.0b013e3182397751]

3. Berry MF. Esophageal cancer: Staging system and guidelines for staging and treatment. J Thorac Dis 2014;6(Suppl 3):S289-S297. 4. Knyrim K, Wagner HJ, Bethge N, Keymling M. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329(18):1302-1307. 5. Sarper A, Oz N, Cihangir C, Demircan A, Isin E. The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas. Eur J Cardiothorac Surg 2003;23(5):794798. [http://dx.doi.org/10.1016/S1010-7940(03)00091-5] 6. White RE, Mungatana C, Topazian M. Esophageal stent placement without fluoroscopy. GI Endoscopy 2001;53(3):348351. [http://dx.doi.org/10.1016/S0016-5107(01)70415-4, http:// dx.doi.org/10.1067/mge.2001.112844] 7. Wilkes EA, Jackson LM, Cole AT, Freeman JG, Goddard AF. Insertion of expandable metallic stents in esophageal cancer without fluoroscopy is safe and effective: A 5-year experience.

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GI Endoscopy 2007;65(6):923-929. [http://dx.doi.org/10.1016/j. gie.2006.11.007] 8. Rathore OI, Coss A, Patchett SE, Mulcahy HE. Directvision stenting: The way forward for malignant oesophageal obstruction Endoscopy 2006;38(4):382-384. [http://dx.doi. org/10.1055/s-2005-921040] 9. Lazaraki G, Katsinelos P, Nakos A, et al. Malignant esophageal dysphagia palliation using insertion of a covered Ultraflex stent without fluoroscopy: A prospective observational study. Surg Endosc 2011;25(2):628-635. [http://dx.doi.org/10.1007/s00464010-1236-2] 10. Dobrucali A, Caglar E. Palliation of malignant esophageal obstruction and fistulas with SEMS. World J Gastroenterol 2010;16(45):5739-5745. [http://dx.doi.org/10.3748/wjg.v16. i45.5739] 11. Christie NA, Buenaventura PO, Fernando HC, et al. Results of expandable metal stents for malignant esophageal obstruction in 100 patients: Short-term and long-term follow-up. Ann Thorac Surg 2001;71(6):1797-1801. [http://dx.doi.org/10.1016/S00034975(01)02619-4] 12. Cwikiel W, Tranberg KG, Cwikiel M, Lillo-Gil R. Malignant dysphagia: Palliation with oesophageal stents. Radiology 1998;207(2):513-518. [http://dx.doi.org/10.1148/radiology.207.2.9577503] 13. Ben Soussan E, Antonietti M, Lecleire S, et al. Palliative esophageal stent placement using endoscopic guidance without fluoroscopy. Gastroenterol Clin Biol 2005;29(8-9):785-788. [http://dx.doi. org/10.1016/S0399-8320(05)86348-1] 14. White RE, Mungatana C. Esophageal stent placement without fluoroscopy. Gastrointest Endosc 2001;53(3):348-351. [http:// dx.doi.org/10.1067/mge.2001.117153]

Accepted 13 July 2015.

RESEARCH

Pulmonary tuberculosis in a South African regional emergency centre: Can infection control be improved to lower the risk of nosocomial transmission? H Casey,1 MB ChB; A Smith,2 MB ChB, MMed (EM), FCEM (SA); L Parker,1 MB ChB, MRCP; M Dipper,1 BM; T Gould,3 MB BCh, FCP (SA), MMed HS Thames Valley and Wessex Leadership Academy, UK N Department of Emergency Medicine, George Hospital, Western Cape, South Africa 3 I nternal Medicine Unit, George Hospital, Western Cape, South Africa 1 2

Corresponding author: H Casey (helenrosecasey@gmail.com)

Background. George Regional Hospital (GRH) is a 272-bed regional referral hospital for the Eden and Central Karoo districts, Western Cape Province, South Africa. The perception among emergency centre (EC) staff is that a high burden of tuberculosis (TB) is being diagnosed and that infection control procedures are currently lacking, leading to a high risk of nosocomial transmission. Objectives. To establish the burden of pulmonary TB (PTB) presenting to GRH via the EC and audit current infection prevention and control practices, to quantify the risk of transmission of PTB in the EC and to establish whether infection control measures are inadequate. Methods. An audit of infection control based on the Centers for Disease Control audit tool for TB, analysis of results, and implementation of new infection control measures including a new standard operating procedure based on a set of triage criteria. Results. Implementation of new triage criteria and a standard operating procedure led to the longest length of stay of a patient with suspected TB in the EC being reduced by 40% (from 142 hours to 84 hours). The average time between seeing a doctor and leaving the EC for patients with suspected TB was reduced by 20% (from 20 hours 40 minutes to 16 hours 45 minutes). Conclusion. Simple measures implemented in the EC led to a significant reduction in the time patients with suspected or confirmed TB spent in the EC. This should lead to a reduced risk of nosocomial transmission of TB to both staff and patients. S Afr Med J 2015;105(10):862-865. DOI:10.7196/SAMJnew.8329

Tuberculosis (TB) is a major burden in South Africa (SA), and prevalence rates in the Western Cape Province are exceptionally high. In 2010, TB was the second leading cause of male deaths after interpersonal violence, with the burden of TB highest in the younger population, contributing to a large number of early deaths.[1] The most significant change in disease burden in recent years is the simultaneous increase in comorbid HIV infection and the rise of multidrug-resistant (MDR) TB. The challenge over the coming years will be to prevent hospitals from becoming sources of nosocomial infections for both healthcare workers and patients.[2] The Western Cape Government healthcare strategy up to 2030[2] states that ‘All acute admitting institutions must have appropriate infection control measures to the extent that they would be comfortable to retain a drug-resistant case for 24 to 72 hours …’. To be confident in managing acute presentations of pulmonary tuberculosis (PTB) at a facility level, the infection prevention and control (IPC) measures used in the hospital must be of a high standard. IPC measures for use in low-resource settings have been published by both the World Health Organization (WHO) and the US Centers for Disease Control (CDC).[3,4] Infection control is divided into three areas: administrative, environmental, and personal protective equipment. Studies looking at the implementation of infection control in SA at facilities ranging from primary healthcare facilities to specialist centres for MDR TB have found that practice between practitioners and facilities is highly variable.[5-7]

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Research carried out in low- and middle-income countries has shown that healthcare workers are at considerable risk of contracting TB in high-risk settings through nosocomial transmission.[8] Studies in SA have shown a high rate of TB among healthcare workers in settings ranging from primary healthcare facilities to tertiary teaching hospitals.[6,9] This includes a high rate of conversion to latent TB infection by medical students and practising healthcare workers.[10] In high-income settings the emergency centre (EC) has been shown to be a high-risk area owing to presentation of patients with undiagnosed TB, slow diagnosis of their TB, and failure to isolate them appropriately.[11,12] Efforts have been made to improve infection control procedures to try to reduce the risk of nosocomial spread of TB within the EC.[11,13] A search using Ovid Medline did not find any comparable work from SA.

Motivation

George Regional Hospital (GRH) is a 272-bed regional referral hospital for the Eden and Central Karoo districts of the Western Cape, covering a mixed urban and rural population of 500 000 people. The Western Cape is an area with a high prevalence of TB. The GRH EC is the only public healthcare facility in the George district that provides a 24-hour service, with approximately 3 200 attendances a month. The perception among EC staff is that a high burden of PTB is being diagnosed and infection control procedures are lacking, resulting in a high risk of nosocomial transmission. Our literature search found that while there has been research in SA looking at the risk of nosocomial transmission of TB, none has been carried out in the setting of the EC, identified internationally as a high-risk area.

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Objectives

To focus on establishing the burden of PTB presenting to GRH via the EC and then auditing current IPC practice regarding patients with PTB (using the CDC audit tool[3] as a guide). This would confirm whether the EC is a high-risk environment for the transmission of PTB, as demonstrated in high-income countries, and assess the adequacy of current IPC policy to prevent transmission. If this was found to be inadequate, simple IPC measures as outlined in the WHO policy could be implemented with a view to undertaking a re-audit to determine whether IPC had improved. Ethical approval was granted by the Stellenbosch University Health Research and Ethics Committee 2 on 3 December 2014 (protocol No. N14/10/153).

Methods and discussion Phase 1: Baseline assessment

National data from the National Health Laboratory Service[14] showing the number of patients diagnosed with TB on Xpert MTB/RIF were used to calculate the burden of PTB in the EC and relate this to the burden in the George and Eden districts. According to these data, 20% of PTB diagnosed in the George District is at GRH; this constitutes 7% of PTB diagnosed in the Eden District (Table 1). A cohort of patients was then created using the monthly facility alert organism report and International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) coding from the monthly GRH Outpatient Department Appointment Clinicom data spreadsheet. This included: (i) all patients with a positive Xpert MTB/ RIF assay test for Mycobacterium tuberculosis (MTB); (ii) all patients with a positive finding on direct sputum microscopy for acid-fast bacilli; and (iii) all patients with an ICD-10 code that correlates with a diagnosis of TB (A15-19), and excluded: (i) patients who on review of clinical records were not seen in the EC; and (ii) patients who were incorrectly coded and did not have PTB. A cohort of 102 patients was created using data from August and September 2014, of whom 81 had confirmed TB. Five of these patients had drug-resistant TB, and 40% had attended the hospital in the previous 6 months. Data on IPC in the EC were then collected for 1 week on the twice-daily ward rounds. For each patient with suspected or confirmed PTB, the IPC measures in place were assessed. It was found that there were 32 patient encounters in 1 week: 22% of patients were in an isolation room, 66%

Table 1. Positive Xpert MTB/RIF assay results as a proportion of all assays sent Results of Xpert MTB/RIF assays sent in a 4-month period Location

Total number sent

Positive results, n (%)

George Regional Hospital

477

102 (21.4)

George District

3 350

506 (15.1)

Eden District

9 288

1 371 (14.7)

Western Cape

73 575

11 319 (15.4)

Worcester

467

117 (25.1)

Paarl

359

104 (28.9)

Comparative hospitals

Assessment by doctor: Patient has suspected TB Does the patient meet any of these criteria? with help/stretcher 1. Triaged on arrival as mobilising 2. Chest drain required 3. Significant haemoptysis 4. Significant comorbidity, e.g. severe lung disease, electrolyte disturbance, hyperglycaemia 5. Compliance issues and won't be able to complete treatment in community, e.g. defaulted treatment, language issues, social barriers No Yes Patient needs admission Isolate patient in the EC Complete investigations and treatment Refer to internal medicine or family medicine as necessary for urgent admission Yes Reassess using criteria once results Patient to be admitted to available side-‐ back. Does the patient meet the room/isolation room on ward criteria? Send Xpert MTB/RIF marked as URGENT and call through to laboratory staff No Family medicine/internal medicine wards Isolation criteria: • Patients who need admission should be immediately isolated in a single room Patient can go home • If the patient is found to have rifampicin-‐sensitive Fill in TB discharge summary: MTB on Xpert MTB/RIF, they can then be moved 1. Copy for patient into a drug-‐sensitive TB bay 2. Email copy to clinic and HAST • All MDR/XDR TB should remain in single rooms 3. Copy for notes • Xpert MTB/RIF negative patients can be moved Patient to go outside and produce sputum out of isolation sample for Xpert MTB/RIF and direct Treat patient in ward Aim for discharge to Harry Comay (TB) Hospital or home microscopy On discharge, fill in TB discharge summary: Send Xpert MTB/RIF marked as ROUTINE 1. Copy for patient Patient can be discharged and followed up 2. Email copy to clinic/Harry Comay and HAST 3. Copy for notes

at clinic

Fig. 1. SOP for patients with PTB.

were in an open bay but wearing a surgical mask, and 12% had no IPC measures in place. Only the patients in the isolation room had any signage identifying them as requiring IPC measures. Of these patients, 35% were positive on Xpert MTB/RIF assay, confirming the suspicion that high numbers of patients with PTB are in the EC on a daily basis with no infection control measures in place.

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Based on the CDC infection control audit tool,[3] a full audit of administrative, environmental and personal protective measures in the EC was carried out. This included a review of all records of 102 adult patients with suspected TB in the EC to determine patient flow and reasons for delay. The key issues identified were: (i) poor flow to discharge through the EC, especially after initial review by a doctor (see Table 3);

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Table 2. Number of hours spent in the department by patients with suspected/ confirmed TB Length of stay (hours) 0-6

6 - 12

12 - 24

24 - 48

48 - 72

>72

>96

August/September, %

December/January, %

Table 3. Times spent in the EC, comparing pre- and post-phase 2 interventions August/September

December/January

Mean

1 h 3 min

59 min

Median

45 min

31 min

Range

0-5h

0-8h

Total

100 h 34 min

63 h 29 min

Mean

1 h 40 min

Median

1 h 30 min

1 h 10 min

Range

10 min - 8 h 50 min

0-7h

Total

197 h

122 h - 56 min

Mean

20 h 40 min

16 h 45 min

Range

1 h 50 min - 142 h 30 min

1 h 5 min - 83 h 51 min

Total

1 875 h

1 226 h

Arrival to triage

Triage to doctor

Doctor to leaving EC

(ii) delay in waiting for Xpert MTB/RIF assay results that meant patients were waiting longer in the department for a definite diagnosis; (iii) no knowledge of how the airflow systems in the EC worked or whether they worked correctly; and (iv) masks being worn incorrectly by staff of all grades.

Phase 2: Interventions

Improving patient flow The baseline data were reviewed to deter mine which patients stayed overnight in the EC, were admitted, or were discharged to an outpatient clinic. It was found that the standard SA triage scale[15] used in the EC was not a good predictor of admission in this group of patients. Although patients were triaged red, often with a high triage early warning score, owing to the chronic nature of their infection they were typically well compensated and not clinically acutely unwell. A set of criteria were designed that could be used by doctors when first seeing a patient to assess whether the patient needed referral or could be discharged (Fig. 1). Once these criteria were finalised, a new standard operating procedure (SOP) for

patients with suspected PTB in the EC was designed (Fig. 1). The aim was to provide criteria for patients needing admission and a protocol for their isolation and referral. If a patient did not need to be admitted, a separate protocol to facilitate a speedy discharge from the EC was drawn up. A shortage of isolation rooms in the hospital was identified, especially in the internal and family medicine wards. A system to allow cohort isolation of patients with TB was incorporated into the SOP to try to improve the flow of patients and avoid blockage of isolation rooms by long-staying patients with confirmed TB. The delay in sputum Xpert MTB/RIF assay results was also addressed. It was decided that if a patient clearly needed admission, whether he/she had confirmed PTB based on sputum Xpert MTB/RIF or not, referral should take place and the results of Xpert MTB/RIF were not needed to determine admission. It was agreed that sputum Xpert MTB/RIF assay tests for patients who were being admitted to the hospital (those in which the results would affect decisions on isolation) could be marked as ‘urgent’, and the laboratory staff could be requested by

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phone to run the test on the next batch as a priority. This pathway was agreed upon by consultant staff in internal, family and emergency medicine and then presented to the junior staff in all departments before implementation. The policy was approved by hospital management for use and uploaded to the Electronic Capture Medium (ECM) system. It was also made available as a physical copy in the EC for ease of reference, and in the intern handbook. Improving communication with primary care A need was identified by staff working in the EC, and also the staff working in the Harry Comay (TB) Hospital and clinics (which receive many of the discharged patients), to have a standard discharge summary for patients with TB that contained the key information required and was quick to fill in/read. It was also identified that there was no safety net for patients once discharged from the EC if they did not present to a clinic. In consultation with clinical staff in the hospital and colleagues at Harry Comay Hospital, a new discharge summary template was created. This could be filled in electronically or printed, and options were given for key information that could be deleted as appropriate to decrease the time needed to fill it in. It was revised according to feedback from all staff and then made available on the ECM computer system for use. To increase the ease of communication and provide a ‘safety net’, an email system was created. A generic email was made available through the Outlook Web App on all computers in the EC and in the family medicine and internal medicine wards. The email address book was populated with email addresses for each primary healthcare clinic, Harry Comay Hospital and the HAST (HIV, sexually transmitted infections, TB) co-ordinator. This email was then used to send discharge summaries in real time to the clinic where the patient was to be followed up, allowing the nursing staff to trace any patient who failed to arrive. Training was given to all staff in the EC and instructions were made available on the computers. Improving the use of N95 masks A teaching session was designed and delivered to the EC staff on correct use of N95 masks. A poster with key information on it was also designed and printed in the EC handbook and made available in the EC as a reminder.

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Updating infection control policy The infection control policy for TB at GRH was updated to reflect current knowledge and include the new protocols in the EC. This was approved by the quality assurance manager and accepted officially in the hospital.

Further improvements, e.g. creation of a sputum collection room and regular assessment of the ventilation system in the EC, would probably further decrease the infection risk in the EC and will be studied in the near future. References

Phase 3: Reassessment

Using the same method as outlined in the baseline assessment, the flow of patients through the EC was re-audited to determine whether there had been a change following implementation of the new policy. Patients seen in December 2014 and early January 2015 were selected using the same criteria as outlined in baseline assessment. The longest length of stay of a patient was reduced by 40% (from 142 to 84 hours), and the average time between seeing a doctor and leaving the EC was 20% shorter (Tables 2 and 3). On reassessment of patient records, it was clear that there had been a reduction in the time patients with PTB spent in the EC. There was a much higher awareness and understanding among staff of the risk of TB and the preventive measures to be taken, including swift identification on ward rounds of patients needing to be moved into isolation and those for whom early discharge was appropriate.

Conclusion

The implementation of simple measures in assessment and management of patients with suspected TB in the EC significantly reduced the length of patient stay. This potentially reduces the risk of transmission of TB to both staff and patients. The data collected in the reassessment phase included the festive period and yearly staff changeover, both extremely busy times of year in the EC. If reassessed again in a few months, the length of stay may decrease even further.

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1. Groenewald P, Berteler M, Bradshaw D, et al. Western Cape Mortality Profile 2010. Cape Town: South African Medical Research Council, 2013. 2. Western Cape Government Health. Healthcare 2030: The Road to Wellness. Cape Town: Western Cape Government Health, 2014:66-68. 3. Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. Atlanta, GA: MMWR, 2005:54(No. RR17), Appendix B. 4. Stop TB Department. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva: World Health Organization, 2009. 5. Farley J, Tudor C, Mphahlele M. A national infection control evaluation of drug-resistant tuberculosis hospitals in South Africa. International Journal Tuberculosis and Lung Disease 2012;16(1):1-16. [http://dx.doi.org/10.5588/ijtld.10.0791] 6. Claassens MM, van Schalkwyk C, du Toit E, et al. Tuberculosis in healthcare workers and infection control measures at primary healthcare facilities in South Africa. PLoS One 2013;8(10):1-8. [http:// dx.doi.org/10.1371/journal.pone.0076272] 7. Mphahlele MT, Tudor C, van der Walt M, Farley J. An infection control audit in 10 primary health-care facilities in the Western Cape Province of South Africa. Int J Infect Control 2012;8(3):8-12. [http:// dx.doi.org/10.3396/ijic.v8i3.10303] 8. Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in low- and middleincome countries : A systematic review. PLoS Med 2006;3(12):e494. [http://dx.doi.org/10.1371/ journal.pmed.0030494] 9. Sissolak D, Bamford CM, Mehtar S. The potential to transmit Mycobacterium tuberculosis at a South African tertiary teaching hospital. Int J Infect Dis 2010;14(5):e423–8. [http://dx.doi.org/10.1016/j. ijid.2009.06.030][PMID: 19889562] 10. Van Rie A, McCarthy K, Scott L. Prevalence, risk factors and risk perception of tuberculosis infection among medical students and healthcare workers in Johannesburg, South Africa. S Afr Med J 2013;103(11)853-857. [http://dx.doi.org/10.7196/samj.7092] 11. Behrman A, Shofer F. Tuberculosis exposure and control in an urban emergency department. Ann Emerg Med 1998;31(3):3-8. [http://dx.doi.org/10.1016/S0196-0644(98)70349-X] 12. Moran GJ, McCabe F, Morgan MT, Talan DA. Delayed recognition and infection control for tuberculosis patients in the emergency department. Ann Emerg Med 1995;26(9):290-295. [http:// dx.doi.org/10.1016/S0196-0644(95)70074-9] 13. Sokolove PE, Lee BS, Krawczyk JA, et al. Implementation of an emergency department triage procedure for the detection and isolation of patients with active pulmonary tuberculosis. Ann Emerg Med 2000;35(4):327-336. [http://dx.doi.org/10.1016/S0196-0644(00)70050-3] 14. National Health Laboratory Service. NPP GeneXpert Summary Report 01 March 2011 to 30 June 2014. Johannesburg: NHLS, 2014. 15. South African Triage Group. The South African Triage Scale (SATS). 2012. http://emssa.org.za/sats/ (accessed 5 January 2015).

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Prevalence of breast tuberculosis: Retrospective analysis of 65 patients attending a tertiary hospital in Durban, South Africa D P Ramaema,1 FCRad (Diag) SA; I Buccimazza,2 FCS (SA), FACS; R J Hift,3 MMed (Med), PhD, FCRP, FCP (SA) ivision of Radiation Medicine (Radiology), School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, D University of KwaZulu-Natal, Durban, South Africa 2 Division of General Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Division of Medicine, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZuluNatal, Durban, South Africa 1

Corresponding author: D P Ramaema (ramaema@ukzn.ac.za)

Background. Breast tuberculosis (BTB) is uncommon, but not rare. Knowledge of the ways in which it can present can prevent unnecessary invasive procedures and delay in diagnosis. Objectives. To describe the clinical and radiological findings in patients with BTB, including evaluation of current treatment methods. Methods. We retrospectively analysed 65 patients diagnosed with BTB at Addington and King Edward VIII hospitals, Durban, South Africa, between 2000 and 2013. Demographic, clinical and radiological findings and treatment outcomes were noted. Results. A total of 11 092 patients underwent breast investigations between 2009 and 2013, with a prevalence of BTB for the period of 0.3% (30 patients). Of the 65 patients diagnosed between 2000 and 2013, 64 were female (98.5%) and one was male (1.5%). The age range was 23 69 years (mean 38.5). The most common mammographic pattern was density (39.4%) and the least common a mass (6.1%). Isolated axillary lymphadenitis was found in 12.1%. Abscess was the commonest ultrasound pattern (39.0%). Of the 47 patients with a known history of pulmonary tuberculosis (TB), 68.1% (n=32) did not have radiological evidence of previous or concurrent pulmonary TB, nor was there evidence of TB elsewhere. Of 47 patients with known HIV status, 34 were HIV-positive. Fine-needle aspiration cytology had sensitivity of only 28% compared with 94% for histology. Of those treated, 72.7% obtained full resolution following 9 months of TB treatment; 25.0% did not complete treatment, and 2.3% (n=1) died while on treatment. Follow-up data on relapse rates after treatment completion and disease resolution are scanty. Conclusion. Understanding and being aware of the various presentations of BTB make it possible to treat most patients successfully. S Afr Med J 2015;105(10):866-869. DOI:10.7196/SAMJnew.7704

It is estimated that over 1 billion people worldwide have tuberculosis (TB).[1] However, breast tuber culosis (BTB) is a rare condition. The incidence has been reported as <0.1% of all surgical breast lesions seen in developed countries and 3 - 4.5% of breast lesions in countries where BTB is endemic,[2,3] although even in this setting, carcinoma is far more commonly encountered.[4] While BTB is considered a manifestation of extrapulmonary tuberculosis (EPTB), it represents only about 0.1% of the disease burden of EPTB. However, there has been a resurgence of EPTB as a result of HIV, with estimated incidences as high as 50% in countries where HIV infection is endemic.[5] The right and left breasts are equally affected by BTB, which may be bilateral in ~3% of cases.[6] Up to 70% of patients may have associated axillary lymphadenopathy, often with visible axillary swelling.[7] Constitutional symptoms are unusual in the absence of systemic and particularly pulmonary TB.[4] No clinical or radiological features are absolutely diagnostic of BTB. The diagnosis is usually readily confirmed by biopsy with histological examination or fine-needle aspiration and staining for acid-fast bacilli (AFB), mycobacterial culture or polymerase chain reaction (PCR) testing. While the main differential diagnosis is carcinoma, other considerations are idiopathic granulomatous mastitis and fungal infections. Most patients respond to standard antiTB therapy (ATT).[8] It has been suggested that patients in endemic

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areas who have a breast mass with granulomatous inflammation on histological examination should receive ATT, even if culture results are negative for TB.[9] There have been reports that sinuses, fistulas and deformities may occasionally require primary localised excision or simple mastectomy, but this is not standard care.[4]

Objectives

To identify the various radiological patterns of BTB, and to assess available treatment options and response to treatment.

Methods

We identified 64 patients with a histological or cytological confirmed diagnosis of BTB. One patient with discharging axillary nodes and breast oedema was included even though cytological findings were not confirmatory; 65 patients were therefore included in the data analysis. Patients were diagnosed between 2000 and 2013. Data were collected from Addington (n=60 patients) and King Edward VIII hospitals (n=5), Durban, South Africa. The study was approved by the Bioethics Research Committee at the University of KwaZuluNatal, Durban (Reference No. BF213/13). A retrospective chart and radiology review focused on demographic, clinical, mammographic and ultrasound patterns and diagnostic and treatment methods. Mammograms (mediolateral oblique (MLO) and craniocaudal views) were done using a standard Mecatronica analogue mammo graphic unit (± digital processing). Ultrasound images

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were obtained on the various standard units using a 7.5 - 12.5 MHz linear probe. Mammographic patterns were classified as follows: asymmetrical density, asymmetrical density with axillary nodes, inflammation with axillary nodes, mass, mass with axillary nodes, nodes only, and normal. Ultrasound patterns were classified as abscess, abscess with axillary nodes, mass, mass with axillary nodes, oedema, Table 1. Demographic and clinical features (N=65)

oedema with nodes, thickening, nodes only, and normal. Histological and microbiological diag nosis was done by obtaining core biopsy samples using a 14-gauge needle. Cytological diagnosis was done by FNA biopsy. Lesion localisation was either achieved by palpation or ultrasound guided. Descriptive statistics using proportions were used to analyse results.

Results

Range

23 - 69

Mean (SD)

38.5 (10.3)

Sixty-four records of patients with pathology-proven BTB and one with strong clinical but inconclusive cytological findings were identified during the period 2000 2013. Accurate clinic attendance records were available for the years 2009 - 2013, and during this 5-year period a total of 11 092 patients underwent breast investigations and 30 were diagnosed with BTB (prevalence for the period 0.3%). Demographics and

Left

30 (46.2)

Table 2. Associated clinical features

Right

33 (50.8)

Characteristics

Unknown

2 (3.1)

History of pulmonary TB (N=47)

Characteristics Gender, n (%) Female

64 (98.5)

Male

1 (1.5)

Age at presentation (years)

Side, n (%)

Axillary nodes, n (%) Yes

21 (33.9)

41 (66.1)

Clinical presentation, n (%)

n (%)

CXR normal

32 (49.2)

CXR abnormal

15 (23.1)

Pregnant/lactating assessed (N=65)

Abscess

2 (3.1)

Adenitis + oedema

16 (24.6)

64 (98.5)

Mass (nodular) form

17 (26.2)

Yes

1 (1.5)

Inflammatory mass (disseminated)

26 (40.0)

Occult mass

1 (1.5)

Unknown

3 (4.6)

SD = standard deviation.

HIV status (N=47) Negative

12 (18.5)

Positive

34 (52.3)

Refused testing

1 (1.5)

CXR = chest radiograph.

clinical presentation are described in Table 1. The age range was 23 - 69 years (mean 38.5 years). Of the 65 patients, 26 presented with an inflammatory mass or disseminated form of BTB. Other associated clinical features are set out in Table 2. Of the 65 patients, only one was lactating. HIV status was known in 47 patients, of whom 34 were HIV-positive. While 47 patients had a history of previous pulmonary TB, only 15 had radiological evidence of either previous or concurrent pulmonary TB. Radiological features on mammograms and ultrasound scans are summarised in Fig. 1 (a and b, respectively). Of the 33 patients who had mammograms, 16 demon strated ipsilateral or bilateral axillary lymphadenopathy. A density pattern was seen in 13 cases. Ultrasound scans were done in 41 patients. The commonest pattern was that of an abscess (16 cases, 39.0%). Sensitivity for fine-needle aspiration cytology (FNAC) was 28% as opposed to 94% for histology. AFB were seen in 10.3% of the FNAC specimens and 29.7% of the histology specimens. Of the 65 patients, 59 received medical treatment, 3 received surgical intervention, and 3 were lost to follow-up after diagnosis. Of those who were treated, 72.7% obtained full resolution, 25.0% did not complete treatment, and 2.3% died (n=1).

Discussion

Clinical and radiological findings

Inflammatory/disseminated This pattern was the most common clinical presentation of BTB. However, among patients who had mammograms, this pattern was seen in 21.2% (Fig. 2, a). The mammogram typically demonstrated nonspecific diffuse stromal thickening. We noted that all cases with an inflammatory/disseminated form also

8 6 4

Mammogram

Patients, n

Total 41

Ab sc es

Asym. Asym. Inflam. Mass Mass Normal Nodes density density with without with only without with nodes nodes nodes nodes nodes

Ultrasound

sw Ab itho ut sc e n M ss w ode as s w ith n s o ith ou des M t a Oe n de ss w ode s i m a w th n od Oe ith es de out m a w nod ith es no d Th ick es en in No de g so nl No y rm al

Total 33

16 14 12 10 8 6 4 2 0

Fig. 1. (a) Of 33 patients who had mammograms, 16 demonstrated ipsilateral or bilateral axillary lymphadenopathy. An asymmetrical density pattern was seen in 13 cases. (b) Ultrasound scans were performed in 41 patients. The commonest pattern was an abscess variety in (16 cases, 39%).

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had nodes. This supports the hypothesis that this form may be due to either reactive oedema or retrograde spread from the axillary lymph nodes.[10] To date, no study has specifically determined whether AFB are present in the oedematous or diffusely inflamed breast. Because of the appearances, it has been suggested that this in fact represents the clinical spectrum from inflammatory mass/disseminated to oedema. The major differential diagnosis of this form is inflammatory breast cancer. However, the combination of an inflammatory breast lesion and sinuses or fistulas favours BTB rather than cancer.[3] On the ultrasound scan, some disseminated forms appeared as diffuse trabecular thickening and oedema (Fig. 2, c), whereas others demonstrated a diffuse inflammatory mass. Oedema with adenitis The clinical presentation of oedema was noted in 24.6% of cases, and an ultrasound pattern of oedema was seen in 26.9% (n=11). In contrast to the disseminated/inflammatory form, where all had associated axillary lymph nodes, seven patients in this group (17.1%) did not have associated lymphadenopathy. This pattern can be found in other forms of mastitis. Abscess variety Even though clinical evaluation classified an abscess variety of BTB in only 3.1%, this was the most common pattern on ultrasound, seen in 39.0% (n=18), with or without adenitis. Ultrasound scans demonstrated complex solid-cystic heterogeneous hypoechoic masses and fluid collections. In our study, asymmetrical density was the commonest mammographic pattern (39.4%, n=13) associated with this classification. Three patients only had ultrasound diagnosis. The differential diagnosis was a pyogenic abscess, and some of our patients had in fact received treatment with antibiotics; it was only after lack of response to this that the diagnosis of tubercular abscess was considered. It is therefore important to obtain samples specifically for TB analysis in all cases of non-lactational breast abscess, even if there is no history of TB elsewhere. Nodular (focal mass) Clinically this form of BTB presented as a focal mass. On the mammograms the focal mass opacities had variable outlines, some having smooth margins while others were irregular. Some were a

Fig. 2. Inflammatory/disseminated BTB, images taken from various patients. (a) mammogram, MLO views. The right breast is enlarged. Diffuse stromal thickening and skin oedema is evident. (b) Photograph of the left breast, showing inflammation of the skin. (c) Ultrasound images showing diffuse trabecular thickening with oedema as hypoechoic bands in between hyperechoic fibrofatty tissue.

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single mass lesions, and others were multiple (Fig. 3). This was the third most common mammographic pattern, seen in 18.2% of patients. On ultrasound this form appeared as a hypoechoic solid or heterogeneous mass with a variable outline ranging from welldefined round to irregular. Lesion size based on ultrasound ranged from 0.9 cm to 6.1 cm. The differential diagnosis of this form can range from benign fibroadenoma to breast cancer, depending on the lesion character on imaging. We did not find microcalcification to be a feature in our study. Tuberculous lymphadenitis Although isolated lymphadenitis was not reported on clinical presentation, it was seen in 12.1% of mammograms (n=4) and 2.4% of ultrasound scans (n=1). Nodes were intramammary, axillary, or both. Clinically, large nodes can extend to the skin surface to form discharging sinuses (Fig. 4, a). The intramammary nodes appeared as well-defined round, dense masses on the mammogram. These can be confused with a breast mass when they are solitary. Radiological differentiation of tuberculous axillary nodes from metastatic nodes a

Fig. 3. Nodular form of BTB. Mammogram, MLO views. (a) At presen tation – multiple rounded mass opacities in the right breast, and enlarged dense right axillary nodes. (b) After 4 months of treatment with ATT, one small round mass opacity remains in the upper part. a

Fig. 4. Tuberculous lymphadenitis. (a) Left axilla, enlarged nodes discharging onto skin sinuses. (b) Ultrasound Doppler scan showing hilum vessel and thick cortex. (c) Ultrasound scan showing node with thick 7 mm cortex (callipers). (d) Breast MRI T1 post-contrast axial image. Right axillary lymph nodes have peripheral rim enhancement and central low signal (PRECLO).

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remains difficult. In our series, ultrasound scanning of axillary nodes demonstrated oval, hypoechoic solid masses with thick cortices and loss of normal fatty hilum (Fig. 4, b and c). This appearance cannot be differentiated from that of a malignant or metastatic lymph node. Post-contrast magnetic resonance imaging (MRI) showed peripheral enhancement with a central low signal (Fig. 4, d). Another author described nodes as having peripheral enhancement with central low attenuation (PRECLO) on positive emission tomography with fluorodeoxyglucose integrated with computed tomography (18F-FDG PET/CT).[11]

Pathological findings

We found FNAC to be only 28% sensitive, whereas the sensitivity of histopathology was 94%. Necrotising granulomatous inflammation was seen in histological specimens. In support of the literature, the yield of AFB in our study was low, being positive in 10.3% of cytology and 29.6% of histology specimens. In one case, AFB were detected histologically by PCR testing. Harris et al. [12] reported a 2% rate of positive Ziehl-Neelsen smears for AFB from tuberculous breast abscess fluid. Furthermore, an AFBpositive smear is not always adequate for a definitive diagnosis of Mycobacterium tuberculosis, as it should be differentiated from other Mycobacterium species.

Treatment

Of the 65 patients, 59 received medical treatment comprising 9 months of standard ATT, 3 received both medical and surgical intervention involving abscess drainage, and 3 were lost to followup and were never treated following diagnosis. Of those who were treated, 72.7% obtained full clinical resolution, 25.0% did not complete treatment, and one patient died. Response to treatment was assessed by clinical examination and repeated radiological investigations (ultrasound, mammography or both). Although there are no documented criteria for radiological response, drug resistance may be suspected when lesions fail to reduce in size or change their appearance on ultrasound or mammography. Ultrasound is especially useful in monitoring the abscess form of BTB, to detect residual fluid collections. In single studies, both MRI[13] and 18F-FDG PET/CT[11] have shown promise as tools for monitoring response.

Risk factors

Our data demonstrate the varied spectrum of BTB presentation, both clinical and radiological, as well as good outcome with medical treatment. Furthermore, the study illustrates some association of BTB with HIV. Although most patients with BTB are females, male patients are occasionally affected. Our study supports this, with only one of 65 patients (1.5%) being male. The mean age of the patients in our study was 38.5 years, with a range of 23 - 69 years, demonstrating that BTB is not limited to females of reproductive age, as has been reported in the literature.[14] Several risk factors for BTB have been described, including lactation, multiparity and HIV/ AIDS.[12] We found only one patient (1.5%) to be lactating. HIV status was known in 47 of our patients, of whom 72.3% (n=34) were HIV-positive. Although HIV infection has been associated with an increased incidence of EPTB, BTB still remains rare. BTB has been classified as primary or secondary. Whereas most studies report that the primary form of BTB is rare,[9] we found the opposite. A history of pulmonary TB was obtained from 47 patients, of whom 68.1% (n=32) had a normal chest radiograph and no evidence of pulmonary or

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concurrent TB or of TB elsewhere in the body. This finding suggests that half of our cohort had the primary form of BTB.

Study limitations

Limitations due to the retrospective nature of the study include incomplete data on follow-up after treatment completion, even though patients were scheduled for further visits.

Conclusions

Our findings demonstrate the varied clinical and radiological presentations of BTB. Early diagnosis can lead to full response following treatment with standard ATT, resulting in avoidance of more invasive surgical treatment which can potentially cause breast disfigurement. Clinicians need to be aware of these patterns and to have a high index of suspicion in order to prevent misdiagnosis and inappropriate management. Sources of support. The University of KwaZulu-Natal (UKZN)’s Medical Education Partnership Initiative (MEPI) Enhancing Training, Research and Education (ENTRÉE) programme (Grant No. 5R24TW008863) provided seed funding and support for the development of this study. MEPI is a National Institutes of Health/PEPFAR-funded grant awarded to UKZN in 2010 that aims to develop or expand and enhance models of medical education in sub-Saharan Africa. Acknowledgements. Part of the material from this article was presented at the European Congress of Radiology (ECR 2015) as the Electronic Poster Online Submission (EPOS).[15] The authors thank the staff at the breast units at Addington and King Edward VIII hospitals, who facilitated access to radiological and clinical information on study participants. Conflict of interest. Some of the material in this article was presented at ECR 2015 as the EPOS.[15] References 1. Gupta R, Singal RP, Gupta A, Singal S, Shahi SR, Singal R. Primary tubercular abscess of the breast – an unusual entity. J Med Life 2012;5(1):98-100. 2. Meerkotter D, Spiegel K, Page-Shipp LS. Imaging of tuberculosis of the breast: 21 cases and a review of the literature. J Med Imaging Radiat Oncol 2011;55(5):453-460. [http://dx.doi.org/10.1111/j.17549485.2011.02306.x] 3. Tewari M, Shukla SH. Breast tuberculosis: Diagnosis, clinical features and management. Indian J Med Res 2005;122(2):103-110. 4. Mehta G, Mittal A, Verma S. Breast tuberculosis – clinical spectrum and management. Indian J Surg 2010;72(6):433-437. [http://dx.doi.org/10.1007/s12262-010-0166-5] 5. Akbulut S, Sogutcu N, Yagmur Y. Coexistence of breast cancer and tuberculosis in axillary lymph nodes: A case report and literature review. Breast Cancer Res Treat 2011;130(3):1037-1042. [http:// dx.doi.org/10.1007/s10549-011-1634-8] 6. Baslaim MM, Al-Amoudi SA, Al-Ghamdi MA, Ashour AS, Al-Numani TS. Case report: Breast cancer associated with contralateral tuberculosis of axillary lymph nodes. World J Surg Oncol 2013;11:43. [http://dx.doi.org/10.1186/1477-7819-11-43] 7. Kumar M, Chand G, Nag VL, et al. Breast tuberculosis in immunocompetent patients at tertiary care center: A case series. J Res Med Sci 2012;17(2):199-202. 8. Tanrikulu AC, Abakay A, Abakay O, Kapan M. Breast tuberculosis in southeast Turkey: Report of 27 cases. Breast Care (Basel) 2010;5(3):154-157. [http://dx.doi.org/10.1159/000314267] 9. Shushtari MHS, Alavi SM, Talaeizadeh A. Breast tuberculosis: Report of nine cases of extra pulmonary tuberculosis with breast mass. Pak J Med Sci 2011;27(3):582-585. 10. Oh KK, Kim JH, Kook SH. Imaging of tuberculous disease involving breast. Eur Radiol 1998;8(8):14751480. [http://dx.doi.org/10.1007/s003300050578] 11. Sathekge M, Maes A, D’Asseler Y, Vorster M, Gongxeka H, van de Wiele C. Tuberculous lymphadenitis: FDG PET and CT findings in responsive and nonresponsive disease. Eur J Nucl Med Mol Imaging 2012;39(7):1184-1190.. [http://dx.doi.org/10.1007/s00259-012-2115-y] 12. Harris SH, Khan MA, Khan R, Haque F, Syed A, Ansari MM. Mammary tuberculosis: Analysis of thirty eight patients. ANZ J Surg 2006;76(4):234-237. [http://dx.doi.org/10.1111/j.1445-2197.2006.03692.x] 13. Fellah L, Leconte I, Weynand B, Donnez J, Berlière M. Breast tuberculosis imaging. Fertil Steril 2006;86(2):460-461. [http://dx.doi.org/10.1016/j.fertnstert.2006.03.020] 14. Afridi SP, Memon A, Rehman SU, Baig N. Spectrum of breast tuberculosis. J Coll Physicians Surg Pak 2009;19(3):158-161. [http://dx.doi.org/03.2009/jcpsp.158161] 15. Ramaema DP, Buccimazza I, Hift RJ. Breast tuberculosis: Radiology spectrum with clinical correlation – a retrospective analysis of 65 patients. ESR EPOSTM. [http://dx.doi.org/10.1594/ecr2015/C-1154]

Accepted 18 June 2015.

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RESEARCH

Prenatal BoBsTM in the cytogenetic analysis of products of spontaneous miscarriage S Mellali,1,5 PhD; K Haoud,1,2,3,4,5 PhD; L Gouas,2,3,4 PhD; M B Khaled,5 PhD; P Vago,2,3,4 MD, PhD; S Moulessehoul,1,5 PhD aboratoire de biotoxicologie, Department of Biology, Djillali Liabes University, Algeria L UFR médecine, cytologie, histologie, embryologie cytogénétique, université Clermont 1, Clermont-Ferrand, France 3 Service de cytogénétique médicale, CHU d’Estaing, Clermont-Ferrand, France 4 ERTICA EA4677, UFR médecine, université Clermont 1, Clermont-Ferrand, France 5 Faculty of Life and Natural Science, Department of Biology, Djillali Liabes University of Sidi Bel Abbès, Algeria 1 2

Corresponding author: S Mellali (sara.mellali@yahoo.fr)

Background. Fifty percent of spontaneous miscarriages (SMs) are attributed to chromosomal abnormalities. Cytogenetic analysis is an important tool for patient counselling and assessment of the risk of recurrence in future pregnancies. Conventional karyotyping has been the gold standard for chromosomal investigation of products of conception (POC), but it has limitations due to sample maceration, culture failure and maternal cell contamination. Molecular cytogenetic approaches have therefore been developed and found valuable in the cytogenetic investigation of these samples. The Prenatal BoBsTM and KaryoLite BoBsTM, based on the newly developed BACs-on-BeadsTM technology, have been described as reliable tests for rapid detection of aneuploidies in prenatal and POC samples, respectively. Objective. To describe our clinical experience of routine screening of POC samples with Prenatal BoBsTM, the test used by our laboratory in France. Methods. Seventeen samples collected at the University Hospital of Sidi Bel Abbès (Western Algeria) and a further 60 from the University Hospital of Clermont-Ferrand (France) were analysed (19 chorionic villi from products of curettage, 12 placentas, 9 amniotic cells and 37 biopsy specimens). All were screened for the frequent aneuploidies (chromosomes 13, 18, 21, X and Y) in addition to nine microdeletion/ microduplication syndrome regions by Prenatal BoBsTM. Standard karyotyping was performed on 51 samples, but failed in 38 cases. Results. Prenatal BoBsTM identified one trisomy 21 and one deletion of 17p13.3. Furthermore, it provided a conclusive result in cases of culture failure (n=38) and in samples with macerated tissue (n=19). The overall failure rate was 11.4%. Conclusions. Prenatal BoBsTM is a promising technology that represents a fast, sensitive and robust alternative to routine screening for chromosomal abnormality in products of SM. Furthermore, it overcomes the limitations of conventional karyotyping and current molecular cytogenetic techniques. S Afr Med J 2015;105(10):870-873. DOI:10.7196/SAMJnew.8121

Of all diagnosed pregnancies, 10 - 15% end in spontaneous mis carriage (SM).[1] Chromosomal abnormalities are the most common cause, more than 50% of aborted fetuses in the first trimester showing numerical abnormalities including trisomies, X monosomies and tripoidies. Aneuploidies become less prevalent as pregnancy progresses (30% in the second trimester), because most abnormal fetuses have miscarried earlier. A number of other factors (maternal factors, infections, etc.) may also play a role.[2,3] Cytogenetic analysis of fetal tissue after SM is recommended for prognostic and diagnostic purposes, and to give a better estimate of the risk of recurrence in future pregnancies. It enables detection of possible unbalanced segregation associated with advanced maternal age or the presence of balanced structural rearrangement.[3,4] Conventional karyotyping has been the gold standard for the cytogenetic analysis of products of SM. However, SM products in the first trimester are often collected at advanced stages of maceration as a result of tissue disintegration of the dead fetus in utero, which may cause significant DNA damage, or are haemorrhagic samples contaminated with maternal blood. Because karyotype analysis requires cell culture to obtain metaphase spreads, the poor quality of SM products often means that it is impossible to obtain a result because of culture failure, or that results are invalid due to maternal cell contamination (MCC). Some molecular cytogenetic approaches such as FISH (fluorescence in situ hybridisation), MLPA (multiplex ligation probe amplification) and QF-PCR (quantitative fluorescence-polymerase chain reaction) have been described as valuable in the cytogenetic analysis of SM

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products.[5-7] Performed within 24 - 48 hours, as opposed to weeks for karyotyping, these do not require cell culture, and DNA can be analysed directly after it is extracted. However, while it is possible to investigate several regions with FISH, the number of regions that can be explored with QF-PCR is limited, and MLPA requires the use of two commercial kits to invesigate subtelomere regions.[8] An additional approach is array-comparative genomic hybridisation (CGH), which has a better diagnostic yield than conventional karyotyping in the screening of products of conception (POC)[1] but with the disadvantage of high cost. A new rapid method for the detection of whole-chromosome aneuploidies, based on a BACs-On-BeadsTM technology (Perkin Elmer, Finland), has recently been introduced. Two assays are available, Prenatal BoBsTM for the detection of trisomy 13, 18, and 21 and the most frequent syndromes associated with microdeletions, and KaryoLite BoBsTM, which can detect aneuploidy in all chromosomes by quantifying the proximal and terminal regions of each chromosome arm. Prenatal BoBsTM has been shown to be a robust technology for the prenatal investigation of fetuses with or without abnormalities on ultrasound,[5,9] whereas KaryoLite BoBsTM has been found clinically useful for the investigation of SM products.[10] Since September 2012, Prenatal BoBsTM has been used for prenatal diagnosis in the routine clinical setting in the Medical Cytogenetic Service of the University Hospital of Clermont-Ferrand (France). We describe our clinical experience of the screening of SM products collected at the university hospitals of Clermont-Ferrand and Sidi Bel Abbès (Western Algeria) using Prenatal BoBsTM.

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RESEARCH

Patients and methods Biological samples and DNA extraction

Seventeen POC were collected after SMs in the maternity department of the Hassani Abdelkader University Hospital of Sidi Bel Abbès, and 60 additional samples were collected at the University Hospital of Clermont-Ferrand after medical abortion due to suspicion of a molar pregnancy (n=1), spontaneous abortion (n=8) or fetal death in utero (n=51). Samples included chorionic villi from products of curettage (n=19), placenta (n=12), amniotic cells (n=9) and biopsy specimens (n=37). Gestational ages ranged from 5 to 40 weeks (mean 21.5): 17 specimens were from the first trimester (5 - 12 weeks), 35 from the second trimester (13 - 24 weeks) and 25 from the third trimester (25 - 41 weeks). Women who had SMs were between 19 and 43 years of age (mean 30.3), 23.3% being of advanced maternal age (≥35). All women provided written consent. Placental chorionic villi from maternal decidua, blood clots and mucus were dissected under a dissecting microscope into fragments a few millimetres in size. DNA was obtained from chorionic villus cells, amniotic cells or fetal skin fibroblasts without cell culture using the QIAamp DNA Mini Kit (Qiagen, Germany).

Prenatal BoBs™ assay

All the samples collected were analysed using the Prenatal BoBsTM kit. Fig. 1 shows the main steps of the assay. Prenatal BoBsTM is a multiplex bead-based suspension array technology designed for gain-and-loss screening of chromosomes 13, 18, 21, X and Y and nine targeted microdeletion regions. It uses the LuminexTM xMAPTM technology (Luminex Corp., USA), a multiplexing tech nology utilising polystyrene beads approxi mately 5 μm in diameter that have been impregnated with a specific ratio of two different fluorescent dyes. Ten concentrations of both dyes were used, and a range of >100 different dye/bead combinations with distinct fluorescent signatures or spectral addresses that can be identified through excitation of the impregnated dyes when read by the LuminexTM analyser was created. In Prenatal BoBsTM, each bead was coupled with bacterial artificial chromosomes (BACs) derived from chromosome regions of interest. Using a flow cytometry approach, each bead was read by two separate lasers in a LuminexTM 100/200TM analyser equipped with xPONENT 3.1 software. The BoBsoftTM software generated a ‘Results tab’ with a numerical and graphical representation of the fluorescent probe ratio v. female and male references. A sample was defined as ‘normal disomic’ when the fluorescent ratio was ~1.0 for all loci analysed.

Genomic DNA DNA labelling Biotin-labelled DNA

Day 1

DNA purification Purified biotin-labelled DNA Hybridisation to BACs-on-BeadsTM

Overnight DNA hybridised to beads

Washing and reporter binding Day 2

Beads ready for analysis Measurement and analysis Results

Fig 1. Main steps of the Prenatal BoBsTM assay. Briefly, genomic DNA is labelled with biotin, purified and hybridised to BACs-on-BeadsTM probes. Then the reporter molecule (streptavidin-phycoerythrin) is bound to biotin-labelled DNA. Thereafter, fluorescent signals are measured with the LuminexTM 100/200 and data are analysed with BoBSoftTM software.

Table 1. Microdeletion syndromes with the chromosomal regions targeted by Prenatal BoBs™ Aneuploidies/microdeletion syndromes

Target chromosomal region

Number of probes

Wolf-Hirschhorn syndrome

4p16.3

Cri du chat syndrome

5p15.3-p15.2

Williams-Beuren syndrome

7q11.2

Langer-Giedon syndrome

8q23-q24

Prader Willi/Angelman syndrome

15q11-q12

Miller-Dieker syndrome

17p13.3

Smith-Magenis syndrome

17p11.2

Di George 1 syndrome

22q11.2

Di George 2 syndrome

10p14

Patau syndrome (trisomy 13)

13q13.3-q21.2

Edwards syndrome (trisomy 18)

18p11.32-q22.1

Down syndrome (trisomy 21)

21q22.11-q22.3

Aneuploidy of chromosome X

Xp22.31-q27.3

Aneuploidy of chromosome Y

Yp11.2-q11.23

Where deletions or duplications were present, probe ratios were outside the normal expected ratio range determined by the software for each sample. The contents of the Prenatal BoBsTM kit were sufficient for 96 reactions. This assay was used for the rapid detection of gains

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and losses of DNA in 75 regions, including aneuploidies of chromosomes 13, 18, 21, X and Y, as well as gains and losses in nine microdeletion syndrome regions that are often associated with genetic disorders. Eighty-three BAC probes were used in the Prenatal BoBsTM panel: five for each of chromosomes 13, 18, 21,

RESEARCH

X and Y, four to eight each for the nine well-defined target loci, and six autosomal controls, as shown in Table 1. Selection of the nine microdeletion syndrome regions was based on their association with chromosomal disorders with a relatively high prevalence, and syndromes in which the deletion was the major mechanism underlying the pathology. Deletions of these regions are generally not detectable or may be missed by conventional karyotyping. The syndromes have well-described phenotypes and known clinical significance.[11]

Results

We attempted analysis using Prenatal BoBsTM in 70 of the 77 samples collected. Of the remaining seven, six were empty gestational sacs, haemorrhagic samples with MCC or macerated samples with absence of chorionic villi; the last sample was excluded owing to a low DNA amount after DNA extraction (<5 ng/μL). Cytogenetic analysis using Prenatal BoBsTM gave a conclusive result for 62 of the 70 samples (88.6%). Failure to deliver a result in the remaining eight cases (11.4%) was due to poor DNA quality. Of the 62 samples, 60

were considered normal (96.8%) and two had abnormal results (3.2%) (Table 2): one trisomy 21 (intrauterine fetal death at 11 weeks’ gestation), and a deletion of 17p13.3 (Miller-Dieker syndrome, MDS) (Fig. 2). Standard karyotyping was not attempted in 26 samples, 19 of which were too macerated for cell culture. Karyotyping failed in 38 samples because of absence of cell proliferation and microbial contamination in the cell cultures. Thirteen samples had normal karyotypes. Trisomy 21 was detected in a female fetus who died in utero at 11 weeks’ gestation. At autopsy, the fetus was found to have a hygroma and generalised subcutaneous oedema. As the cell culture failed, we could not determine whether the trisomy was total or partial. The deletion of 17p13.3 (MDS) was identified in a female fetus who died in utero at 38 weeks’ gestation. MDS is characterised by a developmental defect of the brain (type 1 lissencephaly), which is caused by incomplete neuronal migration. This microdeletion syndrome is also characterised by distinctive facial features and other congenital malformations. Serum markers in the first and second trimester were normal and the second ultrasound scan revealed a single umbilical artery. At autopsy, the fetus was found to be hypotrophied and short in length (<25th percentile) and

Fig. 2. Prenatal BoBsTM profiles of case 1 (left) and 2 (right). Red spots show sample-to-female references ratios and blue spots sample-to-male references ratios. Arrows show the range of (A) normal ratios, and (B) abnormal ratios. C = female gonosome profile showing that the patient has the same number of copies of chromosome X as female references (red dots in the normal range) but more than male references (blue dots in amplification), and has the same number of copies of chromosome Y as female references (red dots in the normal range) and less than male references (blue dots in deletion). D = 21q22 amplification showing trisomy 21 profile. E = 17p13.3 deletion.

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RESEARCH

Conclusion

Table 2. Abnormal results of the Prenatal BoBs™ Cases

Maternal age (years)

Gestational age (weeks)

Type of sample/ fetal outcome

BoBs result

Karyotype result

Biopsy/IUFD

47,XX,+21

Failure

Placenta/IUFD

46,XX,del 17p13.3

46,XX

IUFD = intrauterine fetal death.

to have a decreased head circumference (<3rd percentile). However, there were no facial dysmorphic features or cardiac, pulmonary or renal abnormalities. Neuroanatomical examination did not show lissencephaly. FISH analysis showed that the LIS1 gene, monosomy of which is responsible for MDS, was not deleted. The deletion was characterised further by array genomic comparative hybridisation (4 × 180K, Agilent, USA), which showed a deletion of 2.3 Mb encompassing 40 genes. This deletion, which is not typical of the MDS, was probably responsible for the short stature of the fetus, but the fact that the single umbilical artery could have contributed to death could not be excluded.

Discussion

Prenatal BoBsTM is a recently developed molecular cytogenetic screening tool for the most common aneuploidies (chromosomes 13, 18, 21, X and Y) and the nine most frequent microdeletion syndromes found in POC, which are not detectable or may be missed by conventional karyotyping. This rapid targeted assay is dependent on DNA extraction and does not require live or intact cells, and represents an interesting alternative to conventional cytogenetics that require cell culture.[5,9,11,12] In our study, cell culture failure prevented standard karyotype analysis of 38 samples. However, Prenatal BoBsTM provided a conclusive result in all cases, making it a useful tool for the cytogenetic analysis of POCs, especially when culture fails. We analysed 70 DNA samples extracted from chorionic villi of products of SM, skin fibroblasts, amniotic cells and products of curretage. Eight cases were uninterpretable, giving a technical failure rate of 11.4%, which was higher than the rate of ~3% registered for prenatal screening using Prenatal BoBsTM[5,12] and also higher than the rate of ~ 2% reported for the screening of POCs using Karyolite BobsTM.[6,10] These results may be explained by the fact that we had numerous samples with poor DNA quality due to advanced maceration of fetal tissue. Among the remaining cases, Prenatal BoBsTM revealed the presence of two chromosomal abormalities: one case of trisomy 21 that could not be detected by karyotyping because of cell culture failure and was associated with advanced maternal age (42 years), a risk factor well known to

increase the risk of aneuploidies, mostly trisomies,[7] and one case of microdeletion of 17p13.3 (2.3 Mb) that could not be detected by karyotyping because of its low resolution, or by Karyolite BoBsTM because of limitations in the detection of structural rearrangements. These structural rearrangements account for ~6% of abnormalities found in POC.[6] MDS is a rare malformation syndrome manifested by type I lissencephaly and characteristic facial features and associated with a microdeletion of chromosome 17pl3.3, which can be detected by high-resolution cytogenetic techniques in ~50% of cases.[13] Cytogenetic investigation of 1 599 prenatal samples using Prenatal BoBsTM revealed 11 cases of microdeletions and microduplications (0.75%), among which deletion of 22q11.2 (Di George syndrome) was the most frequent abnormality detected.[5] Prenatal BoBsTM is a targeted assay, so the loci of the genome that may have clinical relevance in an unbalanced state and that are not targeted by the probe set will go undetected.[5,9,11] Better coverage throughout the genome would lead to the detection of additional clinically relevant imbalances, but would also identify gains or losses of unknown or unclear clinical significance.[11,14] Moreover, Prenatal BoBsTM has some limitations in the detection of polyploidies (triploidies and tetraploidies),[5,9] which account for nearly 16% of abnormalities found by conventional karyotyping of POC.[6] Another disadvantage of SM products is the high rate of MCC. Only a few studies have tested the ability of Prenatal BoBsTM to identify mosaicism and MCC. It has been shown that Prenatal BoBsTM can detect mosaicism in fetal tissue at a level of 20 40% abnormal cells or higher,[9,15] and that MCC in the fetal tissue becomes apparent at a level of 20 - 30% of normal female cells.[11] Prenatal BoBs has been described as more informative than rapid FISH and QF-PCR, which screen only frequent aneuploidies.[9] This technique also enabled us to provide rapid results with conclusive outcomes within 24 hours of receipt of the sample,[5,9,11,12] which is about half the time of fast FISH aneuploidy screening, because it is possible to interpret the profiles of several samples in few minutes.[5,9] Furthermore, it is cheaper than other technologies that are able to detect more alterations (array-CGH), being of the same order of cost as fast FISH.[9,12]

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On analysis of 77 samples of POC collected, we found the cause of fetal death in two cases using Prenatal BoBsTM technology. One of these fetuses had trisomy 21 and the other a 17p13.3 deletion, which were missed by karyotyping (owing to culture failure in one case and low resolution in the second). Prenatal BoBsTM appears to be fast, sensitive and a good alternative to other conventional technologies such as karyotyping in the routine screening of SM products, especially when tissue is damaged and macerated, preventing cell culture. In combination with other molecular approaches, use of Prenatal BoBsTM could improve detection of chromosomal abnormalities in POCs and prove helpful in parental counselling. Acknowledgments. We gratefully acknowledge Prof. Philippe Vago, Dr Laetitia Gouas and all the staff of the medical cytogenetic service, CHU d’Estaing, Clermont-Ferrand, for their technical experise and advice on Prenatal BoBs™. References 1. Robberecht C, Schuddinck V, Fryns JP, et al. Diagnosis of miscarriages by molecular karyotyping: Benefits and pitfalls. Genet Med 2009;11(9):646-654. [http://dx.doi.org/10.1097/ GIM.0b013e3181abc92a] 2. Doria S, Carvalho F, Ramalho C, et al. An efficient protocol for the detection of chromosomal abnormalities in spontaneous miscarriages or foetal deaths. Eur J Obstet Gynecol Reprod Biol 2009;147(2):144150. [http://dx.doi.org/10.1016/j.ejogrb.2009.07.023] 3. Solveig M, Pflueger V. The cytogenetics of spontaneous abortion. In: Gersen SI, Keagle MB, eds. The Principles of Clinical Cytogenetics. Totowa, NJ: Humana Press, 2005:323-345. [http:// dx.doi.org/10.1385/1-59259-833-1:323] 4. Azmanov DN, Milachich TV, Zaharieva BM, et al. Profile of chromosomal aberrations in different gestational age sponta neous abortions detected by comparative genomic hybridization. Eur J Obstet Gynecol Reprod Biol 2007;131(2):127-131. [http:// dx.doi.org/10.1016/j.ejogrb.2006.04.037] 5. Vialard F, Simoni G, Gomes DM, et al. Prenatal BACs-on-Beads™: The prospective experience of five prenatal diagnosis laboratories. Prenat Diagn 2012;32(4):329-335 [http://dx.doi.org/10.1002/pd.2934] 6. Paxton CN, Brothman AR, Geiersbach KB. Rapid aneusomy detection in products of conception using the KaryoLite™ BACs-on-Beads™ assay. Prenat Diagn 2013;33(1):25-31. [http://dx.doi.org/10.1002/pd.4003] 7. Carvalho B, Doria S, Ramalho C, et al. Aneuploidies detection in miscarriages and fetal deaths using multiplex ligation dependent probe amplification: An alternative for speeding up results? Eur J Obstet Gynecol Reprod Biol 2010;153(2):151-155. [http:// dx.doi.org/10.1016/j.ejogrb.2010.06.022] 8. Haoud K, Mellali S, Gouas L, Tchirkov A, Vago P, Molessehoul S. Prevalence of aneuploidies in products of spontaneous abortion: Interest of FISH and MLPA. Morphologie 2014;98(320):40-46. [http://dx.doi.org/10.1016/j.morpho.2014.02.001] 9. Vialard F, Simoni G, Aboura A, et al. Prenatal BACs-onBeads: A new technology for rapid detection of aneuploidies and microdeletions in prenatal diagnosis. Prenat Diagn 2011;31(5):500-508. [http://dx.doi.org/10.1002/pd.2727] 10. Grati FR, Gomes DM, Ganesamoorthy D, et al. Application of a new molecular technique for the genetic evaluation of products of conception. Prenat Diagn 2013;33(1):32-41. [http://dx.doi.org/10.1002/pd.4004] 11. Shaffer LG, Coppinger J, Morton SA. The development of a rapid assay for prenatal testing of common aneuploidies and microdeletion syndromes. Prenat Diagn 2011;31(8):778-787. [http://dx.doi.org/10.1002/pd.2766] 12. Gross SJ, Bajaj K, Garry D, et al. Rapid and novel prenatal molecular assay for detecting aneuploidies and microdeletion syndromes. Prenat Diagn 2011;31(3):295-266. [http://dx.doi.org/10.1002/pd.2674] 13. Dobyns WB, Curry CJR, Hoyme HE, Turlington L, Ledbetter DH. Clinical and molecular diagnosis of Miller-Dieker syndrome. Am J Hum Genet 1991;48(3):584-594. [http://dx.doi. org/0002-9297/91/4803-0018502.00] 14. Sharp AJ. Emerging themes and new challenges in defining the role of structural variation in human disease. Hum Mutat 2009;30(2):135-144. [http://dx.doi.org/10.1002/humu.20843] 15. Cheng YKY, Wong C, Wong HK. The detection of mosaicism by prenatal BoBs™. Prenat Diagn 2013;33(1):42-49. [http://dx.doi. org/10.1002/pd.4006]

Accepted 27 March 2015.

CME EDITORIAL

A variety of conditions This month’s CME is comprised of a series of case reports, covering a variety of conditions, including entities such as the little-known Kounis syndrome. The wonderful thing about case reports is that they can be about just about anything. While they are seldom peer reviewed and are certainly not regarded as research, they are very useful. Simple reporting is one of their functions – alerting clinicians to potential problems of well-known diseases that may not have surfaced in someone else’s experience. They can also be used to alert people to unexpected drug side-effects, such as ataxia in children taking efavirenz. There is even a Journal of Medical Case Reports, which I find fascinating reading. If you have a broad interest in all things medical, this is for you. Case reports should highlight clinical concerns, such as the importance of taking a good history, the pitfalls of assumptions, and descriptions of rare or even novel clinical entities. The current edition of CME brings you a case of bacillary angiomatosis in an HIV-positive man;[1] a case of paraplegia that was not what it seemed to be;[2] an unusual presentation of cryptococcal laryngitis;[3] a report of ataxia as a side-effect of efavirenz use in children;[4] the value of endobronchial ultrasound;[5] the problem with a false-negative polymerase chain reaction

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test for HIV;[6] a case of metatstatic hepatocellular carcinoma in a pregant woman;[7] and Kounis syndrome.[8] Bridget Farham Editor, CME ugqirha@iafrica.com 1. Madua MC. Bacillary angiomatosis: A rare finding in the setting of antiretroviral drugs. S Afr Med J 2015;105(10):874. [http://dx.doi.org/10.7196/SAMJnew.8766] 2. Smith L, Kemp T, van der Meyden CH, Schutte C-M. Basedow paraplegia: A possible misnomer. S Afr Med J 2015;105(10):875. [http://dx.doi.org/10.7196/SAMJnew.8768] 3. Atiya Y, Masege SD. Cryptococcal laryngitis: An ucommon presentation of a common pathogen. S Afr Med J 2015;105(10):875. [http://dx.doi.org/10.7196/SAMJnew.8779] 4. Hauptfleisch MPK, Moore DP, Rodda JL. Efavirenz as a cause of ataxia in children. S Afr Med J 2015;105(10):876. [http://dx.doi.org/10.7196/SAMJnew.8780] 5. Vorster MJ, Schubert PT, Koegelenberg CFN. The real value of endobronchial ultrasound. S Afr Med J 2015;105(10):876. [http://dx.doi.org/10.7196/SAMJnew.8788] 6. Oladokun R, Korsman S, Ndabambi N, et al. False-negative HIV-1 polymerase chain reaction in a 15-month-old boy with HIV-1 subtype C infection. S Afr Med J 2015;105(10):877. [http://dx.doi.org/10.7196/SAMJnew.8787] 7. Mnyani CN, Hull JC, Mbakaza MB, Krim AOA, Nicolaou E. Delayed presentation and diagnosis of metastatic hepatocellular carcinoma in pregnancy. S Afr Med J 2015;105(10):877. [http://dx.doi. org/10.7196/SAMJnew.8781] 8. Ntuli PM, Makambwa E. Kounis syndrome. S Afr Med J 2015;105(10):878. [http://dx.doi.org/10.7196/ SAMJnew.8767]

S Afr Med J 2015;105(10):874. DOI:10.7196/SAMJ.9979

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CASE REPORT

Bacillary angiomatosis: A rare finding in the setting of antiretroviral drugs M C Madua, MB ChB, FCP (SA) Rob Ferreira Hospital, Nelspruit, South Africa Corresponding author: M C Madua (chasneyza@yahoo.com)

An HIV-positive 39-year-old man presented with generalised nodular lesions. He was apyrexial and normotensive, with a normal respiratory rate. The rest of the examination was normal. He had been on antiretroviral therapy for >4 years; most importantly, he was on a secondline regimen (lopinavir/ritonavir (Aluvia) based). The appearance of the lesions, together with the history, led to the following possible diagnoses: bacillary angiomatosis, cutaneous cryptococcosis, nodular Kaposi sarcoma or cutaneous histoplasmosis. S Afr Med J 2015;105(10):874. DOI:10.7196/SAMJnew.8766

An HIV-positive 39-yearold man presented with generalised nodular lesions (Figs 1 - 4). He was apyrexial and normotensive, with a normal respiratory rate. The rest of the examination was normal. He had been on antiretroviral therapy for >4 years; most importantly, he was on a second-line regimen (lopinavir/ritonavir (Aluvia) based). The appearance of the lesions, along with the history, led to the following possible diagnoses: bacillary angiomatosis, cutaneous cryptococcosis, nodular Kaposi sarcoma or cutaneous histoplasmosis. Investigations revealed the following: • absolute CD4 count: 15 × 106/L (500 - 2 010) • HIV viral load: 1 764 copies/mL • blood cultures: aerobic and anaerobic – negative • full blood count: normocytic anaemia, with haemoglobin: 8 g/dL (14.3 - 18.3) • urea and electrolytes: normal • liver function test: normal • calcium, magnesium and phosphate: normal • urine microscopy culture and sensitivity: negative • sputum for GeneXpert for tuberculosis: negative • bone marrow trephine biopsy: multi factorial cause of anaemia, no obvious infiltrates • skin biopsy – vascular proliferative lesions in keeping with Bartonella, substantiated by a polymerase chain reaction (PCR) • tissue culture: no growth • chest radiography: normal. A diagnosis of bacillary angiomatosis is clinical and can be confirmed by serology, blood culture and histology.[1-3] It is difficult to culture Bartonella;[1,2] serology cannot

Fig. 3. Vascular lesions of bacillary angiomatosis on the right elbow.

Fig. 1. Bacillary angiomatosis lesions on the forehead.

Fig. 2. Bacillary angiomatosis lesions on the back.

differentiate between species.[1,2] WarthinStarry silver staining is the gold standard for diagnosis, revealing clusters of bacilli.[1,2] Vascular proliferative lesions are typical histological features.[1,2] In our case, however, Warthin-Starry silver staining did not reveal the bacilli; therefore, tissue was sent for PCR testing, which confirmed the diagnosis. Nested PCR yielded 19 positive results from 188 specimens from HIV-positive patients.[4] After being treated with erythromycin and rifampicin for 1 month, our patient’s lesions regressed.

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Fig. 4. Vascular lesions of bacillary angiomatosis on the right knee.

Discussion

There are >30 different species of Bartonella,[1,2] of which 13 have been isolated in humans.[1,2] Bartonella species are fastidious, facultative, intracellular, slowgrowing Gram-negative bacteria that cause a broad spectrum of dis eases in humans.[1] The two most commonly associated with HIV are B. quintana and B. henselae.[1,2,5] Transmission of Bartonella to humans occurs via a cat scratch that is contaminated with Bartonella-infected fleas.[1,2,5,6] The prevalence of Bartonella in HIV-positive persons is reported to be very

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low.[1,2,6] Various organs or systems may be involved in Bartonella infection, ranging from skin, subcutaneous tissue, bones, mucosa, central nervous system, lymph nodes, liver and spleen.[1,2,7-10] Unspecific manifestations, such as bacteraemia, endocarditis and unexplained fever, have also been reported.[1,2] References

1. Longo D, Fauci A, Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill, 2011. 2. Goldman L, Schafer AI. Goldman’s Cecil Medicine. 24th ed. New York: Saunders, 2012. 3. Koehler JE, Sanchez MA, Garrido CS, et al. Molecular epidemiology of Bartonella infections in patients with bacillary angiomatosis-peliosis. N Engl J Med 1997;337(26):1876-1883.

4. Frean J, Arndt S, Spencer D. High rate of Bartonella henselae infection in HIV-positive outpatients in Johannesburg, South Africa. Trans R Soc Trop Med Hyg 2002;96:549-550. 5. Tappero JW, Perkins BA, Wenger JD, et al. Cutaneous manifestations of opportunistic infections in patients infected with human immunodeficiency virus. Clin Microbiol Rev 1995;8(3):440-450. 6. Plettenberg A, Lorenzen T, Burtsche BT, et al. Bacillary angiomatosis in HIV-infected patients – an epidemiological and clinical study. Dermatology 2000;201:326-331. 7. Koehler JE, Quinn FD, Berger TG, et al. Isolation of Rochalimaea species from cutaneous and osseous lesions of bacillary angiomatosis. N Engl J Med 1992;327:1625-1631. 8. Perkocha LA, Geaghan SM, Yen TSB, et al. Clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection. N Engl J Med 1990;323:1586. 9. Spach DH, Panther LA, Thorning DR, et al. Intracerebral bacillary angiomatosis in a patient infected with human immunodefiency virus. Ann Intern Med 1992;116:740-742. 10. Mohle-Boetani JC, Koehler JE, Berger TG, et al. Bacillary angiomatosis and bacillary peliosis in patients infected with human immunodeficiency virus: Clinical characteristics in a case-control study. Clin Infect Dis 1996;22:794-800.

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CASE REPORT

Basedow paraplegia: A possible misnomer L Smith,1 MB ChB, DOH&M, MMed (Int Med), Cert Endo&Metab (SA) Phys; T Kemp,1 MB ChB, MMed (Int Med), Cert Endo&Metab (SA) Phys, MSc (Clin Epi); C H van der Meyden,2 MB BCh, FCP, MD; C-M Schutte,2 MB ChB, MMed (Neurol), MD 1 2

ivision of Endocrinology, Department of Internal Medicine, Faculty of Health Sciences, University of Pretoria, South Africa D Department of Neurology, Faculty of Health Sciences, University of Pretoria, South Africa

Corresponding author: L Smith (drlizlsmith@gmail.com)

Thyrotoxic myopathy frequently occurs in clinical practice; however, the association of hyperthyroidism with a flaccid, areflexic paraplegia, so-called Basedow paraplegia, appears to represent a controversial and doubtful entity. An 18-year-old female with undiagnosed and untreated Graves’ disease presented with acute onset of global weakness predominantly in the lower limbs, but also affecting the upper limbs. The weakness was accompanied by hypotonia and areflexia. Clinically, the patient had a goitre and signs of thyroid ocular disease. Laboratory testing confirmed the presence of hyperthyroidism, and thyroid-stimulating hormone receptor antibodies were positive. The cerebrospinal fluid protein level was raised. The electroneuronographic and needle examinations were compatible with a clear denervation process, such as acute motor axonal neuropathy, a variant of Guillain-Barré syndrome. Intravenous immunoglobulin therapy, carbimazole and propranolol were administered. The occurrence of hyperthyroidism with a flaccid, areflexic paraplegia appears to represent more of a fortuitous than a causative association. It is important to consider and treat other causes, such as acute idiopathic polyneuritis. S Afr Med J 2015;105(10):875. DOI:10.7196/SAMJnew.8768

Common neurological complications of untreated Graves’ disease include cognitive dysfunction, tremor, ophthalmopathy, myopathy and polyneuropathy. Myasthenia gravis and seizures are uncommon associations, while thyrotoxic periodic paralysis, stroke and chorea occur only rarely.[1] We present a patient with Graves’ disease and the acute motor axonal neuropathy (AMAN) variant of Guillain-Barré syndrome, which masqueraded as so-called Basedow paraplegia.[1-5] Had the diagnosis of Basedow paraplegia been adhered to, the patient would have been denied the opportunity of receiving gammaglobulin therapy.

Case report

An 18-year-old female was admitted in November 2014 with acute onset of severe global leg and arm weakness that had started 4 days before her admission. There was a background history (over the previous 11 months) of proptosis, dysp noea on exertion, palpitations, irritability and forgetfulness. General examination revealed tachycardia and a symmetrical diffusely enlarged goitre. Proptosis and lid lag were also present. Neurological examination revealed motor weakness, with her legs more affected than her arms. There was global hypotonia and deep tendon areflexia, with sparing of all

sensory modalities. Blood tests confirmed the clinical suspicion of hyperthyroidism. Serum potassium levels were repeatedly

normal (Table 1), urine porphobilinogen screening was negative and antiganglioside antibodies were absent.

Table 1. Laboratory results On admission TSH (mIU/L) (0.48 - 4.26)

1 week after admission

2 weeks after admission 27.5

0.08

Free thyroxine (pmol/L) (7.6 - 16.1)

30.4

Potassium (mmol/L) (3.5 - 5.1)

4.9

4.0

TSH receptor antibody (U/L) (<1.75)

36.26

Cerebrospinal fluid protein (g/L) (0.15 - 0.45)

0.86

TSH = thyroid-stimulating hormone.

Table 2. Electroneuronographic study, 11 November 2014 Motor nerve responses

Sensory nerve responses

Nerve

Muscle

CMAP amplitude

R median

APB

2.6 mV

>4.0 mV

Palmar

50.7 µV

>50 µV

R ulnar

ADM

530 µV

>6 mV

Palmar

34.5 µV

>15 µV

R peroneal

EDB

127 µV

>2 mV

R tibial

1.7 mV

>4 mV Point B

24.0 µV

>6 µV

R sural

Normal values

Peak latency

SNAP amplitude

Normal value

R = right; CMAP = compound muscle action potential; SNAP = sensory nerve action potential; APB = abductor pollicis brevis; ADM = abductor digiti minimi; EDB = extensor digitorum brevis; AH = abductor hallices. The R median, ulnar, peroneal and tibial nerve latencies were 2.8 ms, 2.4 ms, 3.0 ms and 3.5 ms, respectively (within normal limits), and their conduction velocities 54.4 m/s, 70.3 m/s, 43.4 m/s and 55.3 m/s, respectively, were also normal. The sensory peak latencies of the R median (palmar), R ulnar (palmar) and R sural (point B) nerves were 1.9 ms, 2.0 ms and 3.3 ms, respectively (within normal limits), and their conduction velocities 56.3 m/s, 51.3 m/s and 51.5 m/s, respectively (within normal limits).

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Table 3. Electroneuronographic study, 25 November 2014 Motor nerve responses

Sensory nerve responses

Nerve

Muscle

CMAP amplitude

Normal values

Peak latency

SNAP amplitude

Normal value

L median

APB

2.2 mV

>4.0 mV

Palmar

52.3 µV

>50 µV

L ulnar

ADM

339.0 µV

>6 mV

Palmar

17.9 µV

>15 µV

L peroneal

EDB

195.0 µV

>2 mV

R peroneal

EDB

92 µV

>2 mV

L tibial

No response

>4 mV

R tibial

853 µV

>4 mV Point B

14.1 µV

>6 µV

L sural

L = left; R = right; CMAP = compound muscle action potential; SNAP = sensory nerve action potential. The L median, L ulnar, L peroneal, R peroneal and R tibial nerve distal latencies were 2.6 ms, 2.6 ms, 4.4 ms, 4.9 ms and 3.8 ms, respectively (within normal limits), and their conduction velocities 46.8 m/s, 56.6 m/s, 43.2 m/s, 50.0 m/s and 52.2 m/s, respectively, were also ‘essentially’ normal. The sensory peak latencies of the R median (palmar), R ulnar (palmar) and R sural (point B) nerves were 2.0 ms, 2.2 ms and 3.8 ms, respectively (within normal limits), and their conduction velocities 54.6 m/s, 50.6 m/s and 46.1 m/s, respectively, were also ‘essentially’ normal.

The electroneuronographic studies of 11 and 25 November 2014 showed significantly decreased compound muscle action potential (CMAP) amplitudes and preserved sensory nerve action potential (SNAP) amplitudes, with normal distal latencies and conduction velocities, favouring a diagnosis of an AMAN variant of the Guillain-Barré syndrome (Tables 2 and 3). Needle examination of the tibialis anterior muscle on 25 November 2014 showed the presence of fibrillation potentials and clear neurogenic polyphasic motor units. A 5-day course of intravenous immuno globulins, 24 g/day, was admin istered. Carbimazole was prescribed at 20 mg 8-hourly, and on the development of a skin reaction the dose was decreased to 10 mg 8-hourly. Propranonol was administered at a dose of 20 mg 6-hourly. The thyrotoxicosis gradually improved, but the patient’s neurological condition had only marginally improved at the time of discharge.

Discussion

Joffroy coined the term Basedow paraplegia in 1894, after Charcot had referred to ‘paraplegia like weakness’ in severe hyper

thyroidism in 1889.[3] Joffroy went on to describe the concept as follows: ‘A flaccid paraplegia with absent reflexes, minimal or no sensory disturbance, and absent sphincter disturbances,’[3] which Pandit in 1998 commented ‘could very well fit the description of acute post infective polyneuritis’.[3] Feibel and Campa[2] used the term ‘thyrotoxic neuropathy (Basedow paraplegia)’ in 1976 and Pandit,[3] in 1998, published a report ‘Acute thyrotoxic neuropathy – Basedow’s paraplegia revisited,’ with the suggestion of an implicit causal relationship between the hyperthyroidism and the neuropathy. However, on closer scrutiny this association may well be fortuitous. Descriptions of Basedow paraplegia[1-5] appear to conform to the development of an ‘acute flaccid paraplegia with absent reflexes’ against the background of hyper thyroidism. It is, however, possible that this clinical presentation may reflect the occurrence of an acute idiopathic polyneuritis,[6] possibly associated with an underlying predisposition to autoimmune diseases.[1]

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The association between hyperthyroidism and acute flaccid areflexic neuropathy receives little credence in the following well-known clinical textbooks: Dyck and Thomas’ Peripheral Neuropathy[7] comments on its uncertain association and the difficulty to distinguish it from acute idiopathic polyneuritis; Bradley’s Neurology in Clinical Practice[8] refers to its association as fortuitous; and Williams’s Textbook of Endocrinology[9] and Harrison’s Internal Medicine[10] do not even mention the association.

Conclusion

It is important to consider the occurrence of other treatable causes of motor paralysis in patients with Graves’ disease, such as acute idiopathic polyneuritis presenting with a rapid onset of flaccid paralysis. The entity of Basedow paraplegia as a diagnosis, per se, was found to be misleading. Acknowledgements. We thank Mr Sagren Naidoo for his valuable assistance. References 1. Rubin DI, Aminoff MJ, Ross DS, Wilterdink JL. Neurologic manifestations of hyperthyroidism and Graves’ disease. In: Basow, ed. UpToDate. Waltham, MA: UpToDate, 2013. 2. Feibel JH, Campa JF. Thyrotoxic neuropathy (Basedow’s paraplegia). J Neurol Neurosurg Psychiatry 1976;39(5):491-497. 3. Pandit L, Shankar SK, Gayathri N, Pandit A. Acute thyrotoxic neuropathy –Basedow’s paraplegia revisited. J Neurol Sci 1998;155(2):211-214. [http://dx.doi.org/10.1016/S0022-510X(97)00313-4] 4. Sanghvi LM, Gupta KD, Bauerjee K, Bose K. Paraplegia, hypokalaemia and nephropathy, with muscle lesions of potassium deficiency, associated with thyrotoxicosis. Am J Med 1959;27:817-823. 5. Fridberg DL, Egart FM. [A case of Basedow’s paraplegia.] Probl Endokrinol (Mosk) 1970;16:38-40. 6. Bronsky D, Kaganiek GI, Waldstein SS. An association between the Guillain- Barré syndrome and hyperthyroidism. Am J Med Sci 1964;247(2):196-200. 7. Pollard JD. Neuropathy in diseases of the thyroid and pituitary glands. In: Dyck PJ, Thomas PK, eds. Peripheral Neuropathy. 4th ed. Philadelphia: Elsevier Saunders, 2012:2043-2044. 8. Aminoff MJ, Josephson SA. Neurological complications of systemic disease: Adults. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley’s Neurology in Clinical Practice. 6th ed. Philadelphia: Saunders Elsevier, 2012: 894-915. 9. Davies TF, Larsen PR. Thyrotoxicosis. In: Kronenberg HM, Melmed S, Polonsky KS, Larson PR, eds. William’s Textbook of Endocrinology. 11th ed. Philadelphia: Saunders Elsevier, 2008:333-375. 10. Amato AA, Brown RH. Muscular dystrophies and other muscle diseases. In: Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill, 2012:3487-3509.

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CASE REPORT

Cryptococcal laryngitis: An uncommon presentation of a common pathogen Y Atiya, MB BCh, MMed (ORL), FCORL (SA); S D Masege, MB ChB, FCORL (SA) Division of Otorhinolaryngology - Head Neck Surgery, Department of Neurosciences, Faculty of Health Sciences, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa Corresponding author: Y Atiya (yatiya@gmail.com)

Cryptococcus neoformans is a ubiquitous encapsulated yeast found worldwide, especially in areas with pigeons. The fungus thrives in pigeon droppings and is responsible for primary pulmonary infection, but may disseminate and cause infection of the central nervous system, skin and bone. Most cases are reported in immunocompromised hosts, most commonly those infected with HIV. However, infection has been reported in immunocompetent hosts. Primary infection of the larynx is uncommon, and to date only 12 cases have been reported. We present the first South African report of a young woman with HIV who presented with hoarseness of uncertain aetiology, which was later confirmed to be cryptococcal laryngitis. S Afr Med J 2015;105(10):875. DOI:10.7196/SAMJnew.8779

Cryptococcus neoformans is a ubiquitous encapsulated yeast found worldwide, especially in areas with pigeons. The fungus thrives in pigeon droppings and is responsible for primary pulmonary infection, but may disseminate and cause infection of the central nervous system, skin and bone.[1] Most cases are reported in immunocompromised hosts, most commonly those infected with HIV. However, infection has been reported in immunocompetent hosts.[1,2] Primary infection of the larynx is uncommon, and to date only 12 cases have been reported.[3] We present the first South African report of a young woman with HIV who presented with hoarseness of uncertain aetiology, which was later confirmed to be cryptococcal laryngitis.

A 38-year-old woman presented to the outpatient department complaining of

hoarseness of 7 months’ duration, which had progressively worsened. She had no difficulty breathing, had never smoked, and was unemployed. There was no history of intubation or a preceding upper-respiratory tract infection. She had been diagnosed with HIV infection some months before, with a CD4 count of 220 cells/µL, and was not on antiretroviral medication. She had never had tuberculosis and had previously been well. Examination revealed a relatively healthy woman with oral thrush and a rash of the lower extremities that was initially thought to be Kaposi sarcoma. She had no other stigmata of retroviral disease. Her otolaryngological examination was unremarkable, except that flexible nasopharyngoscopy revealed thickening of both true vocal folds, which was more pronounced on the right, with normal mobility of the folds. The lesions did not appear obviously malignant, and there was no associated cervical lymphadenopathy.

Workup included a chest radiograph, which was normal, and sputum for micros copy as well as examination for acid-fast bacilli (AFB). The microscopy was strongly positive for C. neoformans; no AFB were detected. An abdominal ultrasound was also normal. She was taken to theatre for a direct laryngoscopy and biopsy of the vocal fold lesions. The clinical findings were confirmed in theatre, and no further abnormalities were detected. Histological examination of the tissue biopsies showed multiple fungal spores, with thick capsules, in the submucosa (Figs 1 - 3). There was no evidence of granulomatous disease or malignancy. The epithelium was hypertrophied. The patient was treated with intravenous fluconazole for 14 days, then continued on oral doses for a further month, to be reviewed as an outpatient. On discharge, her voice had improved. Unfortunately, she was lost to follow-up.

Fig. 1. Low-power haematoxylin-eosin stain showing fungal spores in the submucosa. Note the squamous hyperplasia.

Fig. 2. High-power haematoxylin-eosin stain. The fungal spores are evident as numerous small red entities.

Fig. 3. Grocott stain. The fungus appears black, on a green background. In this case, it is obscured owing to the high load of organisms, and the entire slide appears black.

Case report

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Discussion

Before the AIDS era, cryptococcal infection was uncommon, and usually occurred in patients with other immunosuppressive conditions such as haematological malig nancy, longterm steroid use and diabetes.[3,4] Currently, it is one of the most common life-threatening infections in patients with AIDS.[2] The most common infection is pulmonary, which is usually self-limiting. Central nervous system involvement results in high morbidity and mortality; mortality rates of up to 30% have been reported.[2] Laryngeal involvement is extremely uncommon and has only been reported in 12 other patients.[3] Features of these cases are outlined in Table 1. Hypotheses to explain laryngeal involvement include haematogenous spread from a primary focus, such as the lung, or direct implantation by inhalation.[1] The most common complaint is hoarse ness, usually of several months’ duration. The appearance of the vocal folds varies, from erythematous, oedematous to leukoplakic and cystic. Direct laryngoscopy and biopsy are essential to exclude other more common causes of vocal fold abnormalities, including malignancy and respiratory papillomatosis.[3] Grossly, crypto coccal laryngitis has been reported to simulate laryngeal carcinoma.[1] Therefore, the suspicion of fungal infection should be communicated to the pathologist so that appropriate staining can be done, or the diagnosis could be missed, as has been reported in a case.[3] Other fungal infections may simulate carcinoma and even Kaposi sarcoma.[1] There are no evidence-based guidelines for the treatment of laryngeal cryptococcosis.[3] Advice from infectious disease specialists is therefore prudent. Assessment should include exclusion of HIV and other immunosuppressive conditions, and a search for disseminated disease. Treatment options include amphotericin B and fluconazole. The former is only available as an intravenous formulation and is nephro toxic. Fluconazole, however, has excellent oral

Table 1. Characteristics of previously reported patients with cryptococcal laryngitis Cases

Age at presentation (years)

Mean 58 (31 - 87)

Male:female

3:1

Duration of hoarseness (months)

Mean 4 (1 - 12)

Comorbidities/cofactors

Local exposure Inhaled steroids Tobacco smoking Chicken manure Tuberculosis Systemic factors Oral steroids Infection: HIV, hepatitis C Diabetes mellitus Previous cryptococcal pneumonia

Findings on direct laryngoscopy (patients, n)

Leukoplakia (4) Oedema (3) Vocal fold erythema (3) Vocal fold mass/irregularity (5)

Histopathology (patients, n)

Pseudo-epitheliomatous hyperplasia (5) Granulomatous inflammation (9) Squamous cell hyperplasia (1) Submucosal cyst (1)

Treatment (patients, n)

Antifungal therapy (10) Endoscopic polypectomy (2)

Duration of antifungal treatment (weeks)

Mean 13.5 (4 - 40)

Outcome (resolution:recurrence:unknown)

10:1:1

Modified from Gordon DH, et al.,[3] with permission.

absorption and was the most commonly used agent in previous cases.[3] The average duration of treatment was 13.5 (range 4 - 40) weeks.

Conclusion

Although uncommon, otolaryngologists should remain vigilant and consider the possibility of crytococcal infection of the larynx, particularly in immunocompromised hosts and patients presenting with unusual or protracted symptoms. Prompt consultation with an infectious disease specialist and treatment can prevent significant morbidity and/or mortality.

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Acknowledgements. We acknowledge the assistance of Dr Gillian Davies Anamourlis of the Department of Anatomical Pathology for her assistance in preparing the high-resolution microscope images. References

1. McGregor DK, Citron D, Shahab I. Cryptococcal infection of the larynx simulating laryngeal carcinoma. South Med J 2003;96(1):7477. [http://dx.doi.org/10.1097/01.SMJ.0000047976.06958.D6] 2. Chongkolwatana C, Suwanagool S, Chongvisal S. Primary cryptococcal infection of the larynx in a patient with AIDS: A case report. J Med Assoc Thai 1998;81(6):462-467. 3. Gordon DH, Stow NW, Yapa M, et al. Laryngeal cryptococcosis: Clinical presentation and treatment of a rare cause of hoarseness. Otolaryngol Head Neck Surg 2010;142(3 Suppl):S7-S9. [http:// dx.doi.org/10.1016/j.otohns.2009.08.030] 4. Nadrous HF, Lewis JE, Ryu JH, Sabri AN. Cryptococcal laryngitis: Case report and review of the literature. Ann Otol Rhinol Laryngol 2004;113(2):121-123. [http://dx.doi.org/10.11 77/000348940411300207]

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CASE REPORT

Efavirenz as a cause of ataxia in children M P K Hauptfleisch,1 MB BCh, MMed (Paed), FCPaed (SA), Cert Paed Neuro (SA); D P Moore,2 MB BCh, MMed (Paed), FCPaed (SA), Cert ID Paed (SA), MPhil (Paed ID); J L Rodda,1 MB BCh, FCPaed (SA) Paediatric Neurology, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa 2 Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa 1

Corresponding author: M P K Hauptfleisch (marc.hauptfleisch@wits.ac.za)

Acute ataxia in childhood is often caused by toxin ingestion. With the increasing number of paediatric patients on antiretroviral medication, we observe more side-effects of these drugs. Acute ataxia is defined as unsteadiness of walking or fine motor movement of <72 hours. The most common causes are postinfectious acute cerebellar ataxia, toxin ingestion and Guillain-Barré syndrome. However, the possibility of a mass lesion must always be excluded. Reported neurological abnormalities in HIV-positive children range from 10% to 68%. A South African study found the prevalence of neurological complications to be 59%, the most common of which were HIV encephalopathy and long-tract motor signs; however, no cases of cerebellar dysfunction were documented. Ataxia rarely ocurs in an HIV-positive person, the chronic sequelae being neurocognitive impairment and polyneuropathy. Ataxia in the setting of HIV is generally secondary to an infectious, vascular or neoplastic cerebellar lesion. However, most infections are opportunistic and unlikely to occur when CD4 levels are adequate. The vascular or mass lesions are readily excluded with neuro-imaging. We report two cases of efavirenz toxicity that caused ataxia. We treated two children who presented in a 1-month period, which highlighted an important differential to consider in HIV-positive paediatric patients presenting with ataxia. S Afr Med J 2015;105(10):876. DOI:10.7196/SAMJnew.8780

Background

A child presenting with ataxia may pose a diagnostic dilemma. After excluding the common causes, e.g. toxins, infection and tumours, one needs to consider, more carefully, a possible genetic cause, but with limited genetic testing facilities available in South Africa (SA) a definitive answer is not always found. It is estimated that there are 360 000 HIV-positive children <15 years of age in SA,[1] 44% of whom are on antiretroviral therapy (ART).[2] These patients often pose unique diagnostic challenges. We treated two children who presented in a 1-month period, which highlighted an important differential to consider in HIVpositive paediatric patients presenting with ataxia.

Case 1

A 6-year-old girl presented with acute onset of confusion, vomiting and difficulty walking. She was HIV-positive and had been on firstline ART (abacavir, lamivudine and efavirenz) for the past year. The antiretrovirals were dosed appropriately according to the child’s weight and the Southern African HIV Clinicians Society guidelines. Her viral load 1 month before admission was <100 RNA copies/mL and her CD4 count 250 cells/µL. There was no history of toxin ingestion. On examination she was markedly ataxic, unable to walk or sit unsupported, and was noted to have titubation, dysmetria and dys diadochokinesia. Investigations for a possible infectious cause were done. The lumbar puncture (LP) was normal and serology for Varicella was

negative; however, a CT scan of her brain was suggestive of possible cerebelitis. Although the cerebellar signs started acutely, they continued for >2 weeks. We therefore investigated further for possible inherited causes of progressive chronic ataxia. Our differential diagnosis included ataxia telangiectasia (no telangiectasia were present clinically and the immunoglobulin levels were normal), abetalipoproteinaemia, Friedreich’s ataxia and spinocerebellar ataxia, but genetic testing was negative. A magnetic resonance imaging (MRI) scan to better delineate the posterior fossa structures revealed a normal brain. We considered medication toxicity because of the vomiting and the persistent ataxia. Therefore, an efavirenz level was determined and found to be 69 100 ng/mL (target trough concentration: 1 000 ng/mL). On discontinuing the efavirenz the patient showed signs of clinical improvement, with resolution of the vomiting and ataxia. A protease inhibitor was not started as the elevated efavirenz levels were expected to act as the third antiretroviral agent. A repeat efavirenz level 7 days after discontinuing the drug showed persistently high levels (49 000 ng/mL), but the patient was able to walk unsupported and the dysmetria and dysdiadochokinesia had improved. We decided to administer lopinavir/ritonavir to the patient, and a month after discontinuing efavirenz she showed no residual cerebellar signs.

Case 2

A 13-year-old girl was referred to the paediatric neurology clinic with acute onset of an ataxic gait. She was diagnosed with HIV 3 years previously and staged as World Health Organization clinical stage IV, but because of social issues was only started on ART (abacavir, lamivudine and efavirenz) 18 months before her referral to the neurology department. The doses of antiretrovirals were all appropriate for her weight, according to the Southern African HIV Clinicians Society guidelines. When she

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presented with ataxia she was virally suppressed, with an HIV viral load of 28 RNA copies/mL and a CD4 count of 554 cells/µL. On examination, she had a broad-based gait. Other cerebellar signs included dysmetria, dysdiadochokinesia and mild staccato speech, but no nystagmus. Initial investigations were done to determine a possible infective cause. The LP was normal, and Varicella serology was negative. An MRI scan of her brain showed no intracranial lesions, structural changes or features of infection. Before investigating further and because of our experience in the first case, we considered possible efavirenz toxicity – the level was 16 274 ng/mL. Three weeks after discontinuing the drug, and relying on the elevated efavirenz levels to continue to act as the third antiretroviral agent, the efavirenz level had decreased to 1 002 ng/mL, with clinical improvement in her gait and resolution of her dysmetria. It was decided to opt for lopinavir/ritonavir as her third antiretroviral agent, and efavirenz was discontinued.

Efavirenz drug level methodology in both cases

Efavirenz is administered as a once-daily dose given at night to ameliorate its potential neurological side-effects. In both of the children reported here, drug levels were collected during the day, before 12h00. Blood samples were collected in a 5 mL heparinised BD Vacutainer vial (BD Plymouth, UK). Specimens were stored at 2 - 8˚C until analysed. Analysis was performed using liquid chromatographytandem mass spectrometry (LC-MS MS) at Ampath’s laboratory in Johannesburg. An LC-MS MS TQD (triple quad detector) instrument from Waters in electrospray positive ionisation mode was used, employing an external standard from ChromSystems (Multilevel Plasma Calibrator Set Anti-HIV Drugs) for quantitation. Efavirenz is identified according to the molecular mass of its parent ion 316, as well as one daughter ion of molecular mass 244, and retention time.

Discussion

Acute ataxia is defined as unsteadiness of walking or fine motor movement of <72 hours. The most common causes are postinfectious acute cerebellar ataxia, toxin ingestion and Guillain-Barré syndrome.[3] However, the possibility of a mass lesion must always be excluded. Reported neurological abnormalities in HIV-positive children range from 10% to 68%.[4] An SA study found the prevalence of neurological complications to be 59%, the most common of which were HIV encephalopathy and long-tract motor signs; however, no cases of cerebellar dysfunction were documented.[4] The occurrence of ataxia in an HIV-positive person is rare, the chronic sequelae being neurocognitive impairment and polyneuropathy.[5] Ataxia in the setting of HIV is generally secondary to an infectious, vascular or neoplastic cerebellar lesion. Most infections are opportunis tic and unlikely to occur when the CD4 count is adequate.[5] The vascular or mass lesions are readily excluded with neuro-imaging. Efavirenz is a non-nucleoside reverse transcriptase inhibitor that disrupts HIV replication by inhibiting the reverse transcriptase enzyme. Efavirenz is known to have good central nervous system (CNS) penetration[6] and because of its long half-life is administered as a once-daily dose. The drug forms part of the SA first-line ART regimen for children >3 years of age and >10 kg in weight.[7] CNS symptoms are the most frequently reported side-effects in HIV-positive patients on efavirenz, including dizziness, headache, confusion, stupor, impaired concentration, agitation, amnesia, depersonalisation, hallucinations, insomnia and abnormal dreams.[6,8-14]

The frequency of CNS side-effects is estimated at 20 - 40%.[10] The majority of patients develop CNS and psychiatric adverse effects in the first 6 weeks of treatment,[11] with most symptoms resolving 6 - 10 weeks after treatment initiation.[6] Hoffmann et al.[12] documented neurocerebellar side-effects in patients using efavirenz. These symptoms were based on patient selfreported dizziness, ataxia, insomnia, bad dreams and hallucinations – there was no objective assessment of the ataxia. The neurocerebellar symptoms were again reported to occur most frequently in the first month of initiating efavirenz and declined with time.[12] Many studies have examined the effect of efavirenz drug levels on the frequency of side-effects. Marzolini et al.[10] reported a 24% increase in CNS side-effects if the plasma level was >4 000 ng/mL; however, other research groups have found no correlation between adverse effects and plasma concentrations.[8,9,13] Gutierrez et al.[13] showed that CNS side-effects associated with long-term efavirenz administration were related to efavirenz plasma levels. Wide variations in the plasma levels of patients on the same weight-appropriate dose of efavirenz have been demonstrated. One of the causes attributed to this individual variation in efavirenz levels is polymorphism of the CYP2B6 metabolising enzyme of the cytochrome P450, as efavirenz is a substrate of this enzyme.[9] A study done in Botswana found that the prevalence of the slow metabolising genotype was 30%, and other studies have also shown a higher incidence of this genotype in African populations.[14] We conclude that the cause of ataxia in both our patients was attributable to the high plasma concentration of efavirenz. In both cases, the efavirenz level was at least 4 times greater than the toxic level (4 000 ng/mL) described by Marzolini et al.,[10] and the ataxia improved when the drug was discontinued. Polymorphism of the CYP2B6 enzyme is a possibility in our patients, and may explain the very high plasma levels. When presented with a child with acute progressive ataxia, who is known to be on efavirenz, and after excluding the common causes, one should check the efavirenz plasma levels and, if toxic, consider discontinuing the agent and substituting it with an alternative class of antiretroviral drug. References 1. United Nations Programme on HIV/AIDS (UNAIDS). HIV and AIDS estimates 2012. http://www. unaids.org/en/regionscountries/countries/southafrica/ (accessed 15 January 2015). 2. United Nations Programme on HIV/AIDS (UNAIDS). The GAP report 2014. http://www.unaids. org/sites/default/files/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_ Gap_report_en.pdf (15 January 2015). 3. Whelan HT, Verma S, Guo Y, et al. Evaluation of the child with acute ataxia: A systematic review. Pediatr Neurol 2013;49(1):15-24. [http://dx.doi.org/10.1016/j.pediatrneurol.2012.12.005] 4. Govender R, Eley B, Walker K, Petersen R, Wilmshurst JM. Neurologic and neurobehavioral sequelae in children with human immunodeficiency virus (HIV-1) infection. J Child Neurol 2011;26(11):13551364. [http://dx.doi.org/10.1177/0883073811405203] 5. Anand KS, Wadhwa A, Garg J. A case of cerebellar ataxia associated with HIV infection. J Int Assoc Provid AIDS Care 2014;13(5):409-410. [http://dx.doi.org/10.1177/2325957414531620] 6. Treisman GJ, Kaplin AI. Neurologic and psychiatric complications of antiretroviral agents. AIDS 2002;16(9):1201-1215. 7. Health Systems Trust. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults 2014. http://www.hst.org.za/publications/national-consolidated-guidelines-prevention-mother-childtransmission-hiv-pmtct-and-man (accessed 15 January 2015). 8. Van Luin M, Bannister WP, Mocroft A, et al. Absence of a relation between efavirenz plasma concentrations and toxicity-driven efavirenz discontinuations in the EuroSIDA study. Antivir Ther 2009;14(1):75-83. 9. Takahashi M, Ibe S, Kudaka Y, et al. No observable correlation between central nervous system side effects and EFV plasma concentrations in Japanese HIV type 1-infected patients treated with EFV containing HAART. AIDS Res Hum Retrovir 2007;23(8):983-987. 10. Marzolini C, Telenti A, Decosterd LA, Greub G, Biollaz J, Buclin T. Efavirenz plasma levels can predict treatment failure and central nervous system side effects in HIV-1-infected patients. AIDS 2001;15(1):71-75. 11. Kappelhoff BS, van Leth F, Robinson PA, et al. Are adverse events of nevirapine and efavirenz related to plasma concentrations? Antivir Ther 2005;10(4):489-498. 12. Hoffmann CJ, Fielding KL, Charalambous S, et al. Antiretroviral therapy using zidovudine, lamivudine, and efavirenz in South Africa: Tolerability and clinical events. AIDS 2008;22(1):67-74. 13. Gutierrez F, Navarro A, Padilla S, et al. Prediction of neuropsychiatric adverse events associated with long-term efavirenz therapy, using plasma drug level monitoring. Clin Infect Dis 2005;41(11):16481653. 14. Gross R, Aplenc R, Tenhave T, et al. Slow efavirenz metabolism genotype is common in Botswana. J Acquir Immune Defic Syndr 2008;49(3):336-337. [http://dx.doi.org/10.1097/QAI.0b013e31817c1ed0]

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CASE REPORT

The real value of endobronchial ultrasound M J Vorster,1 MB ChB, MRCP (UK), FCP (SA); P T Schubert,2 MB ChB, FCPath (Anat) (SA), MMed, MScMedSc, MPhil, MIAC; C F N Koegelenberg,1 MB ChB, FCP (SA), FRCP (UK), PhD Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa 2 Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa 1

Corresponding author: M J Vorster (mvorster@sun.ac.za)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure worldwide, used in conjunction with bronchoscopy to obtain biopsies for mediastinal disorders. A 67-year-old man with a 40 pack-year smoking history presented with a 2-year history of hoarseness and weight loss. He also had a history of asbestos exposure. On examination under anaesthesia a lesion of the right false vocal fold was found and histology showed a moderately differentiated infiltrating keratinising squamous carcinoma. The question posed was whether this mass could be ascribed to metastatic supraglottic carcinoma or if it was indeed a metachronous primary bronchus carcinoma, as the treatment of these two malignancies differs significantly. Traditional bronchoscopy with TBNA is the least invasive procedure to obtain a cytological diagnosis, but the proximity of the aorta and pulmonary arteries and the mass being 14 mm from the bronchus would have made sampling by means of this procedure near impossible. We used EBUS to localise the mass and noted the position of the major vessels on Doppler ultrasound. Real-time ultrasound guidance allowed us to bridge the tissue plane between the mass and bronchial lumen using the longer EBUS needle and to obtain a fine-needle aspirate of the mass, which proved to be a keratinising squamous carcinoma. We describe this case in which EBUS-TBNA was pivotal in reducing the number of invasive procedures in a patient with metastatic supraglottic carcinoma. S Afr Med J 2015;105(10):876. DOI:10.7196/SAMJnew.8788

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure worldwide, used in conjunction with bronchoscopy to obtain biopsies for mediastinal disorders. We describe a case where EBUS-TBNA was pivotal in reducing the number of invasive procedures in a patient with metastatic supraglottic carcinoma.

Case report

A 67-year-old man with a 40 pack-year smoking history presented with a 2-year history of hoarseness and weight loss. He also had a history of asbestos exposure. On examination under anaesthesia a lesion of the right false vocal fold was found and histology showed a moderately differentiated infiltrating keratinising squamous carci noma. A subsequent computed tomography (CT) scan provisionally staged his supraglottic carcinoma as T2N0M0 and he underwent radical treatment with external beam radiation therapy, to which he responded well. He had been attending our clinic regularly and remained well, but on a visit 4 years later possible recurrence was considered – with hilar lymphadenopathy noted on his chest radiograph. On the CT scan of his chest there was a heterogenously enhancing soft-tissue mass (42 mm × 30 mm) in the posterior segment of the left upper lobe, adjacent to the proximal descending thoracic aorta, with a tissue plane between the mass and mediastinal structures appreciated. The mass demonstrated encasement of the left main pulmonary artery (Fig. 1). There was also a left diaphragmatic calcified plaque. The question posed was whether this mass could be ascribed to metastatic supraglottic carcinoma or if it was indeed a metachronous primary bronchus carcinoma, as the treatment of these two malignancies differs significantly. Considering traditional bronchoscopy with TBNA as the least invasive procedure to obtain

Fig. 1. A CT scan showing a heterogeneously enhancing soft-tissue mass in the posterior segment of the left upper lobe, adjacent to the proximal descending thoracic aorta, with a tissue plane between the mass and mediastinal structures appreciated. The mass also demonstrated encasement of the main left pulmonary artery.

a cytological diagnosis, the proximity of the aorta and pulmonary arteries and the mass being 14 mm from the bronchus would have made sampling by means of this procedure near impossible. With the assistance of EBUS the mass was localised, despite it not abutting the bronchus, and the position of the major vessels duly noted on Doppler ultrasound. Under real-time ultrasound guidance (Fig. 2) the tissue plane between the mass and bronchial lumen could be

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Fig. 3. Keratinising squamous cell carcinoma, with hyperchromatic, irregular nuclei without nucleoli. The cytoplasm is scant to moderate with eosinophilic keratinisation (Papanicolaou stain, × 1 000).

Fig. 2. An endobronchial ultrasound image, showing a mass (M) with a needle (N) during fine-needle aspiration. The needle is bypassing the pulmonary artery (PA).

bridged by the longer EBUS needle to traverse safely between the major vessels, a window of <10 mm, and obtain a fine-needle aspirate of the mass. The result, which proved to be a keratinising squamous carcinoma (Fig. 3), was most likely of supraglottic origin. The patient was discharged the same day, with a follow-up appointment to see an oncologist.

Discussion

Conventional TBNA (cTBNA) has a history of >3 decades of use for mediastinal sampling in lung cancer, especially in more bulky disease. Traditionally, patients presenting with mediastinal lymphadeno pathy would undergo conventional bronchoscopy and TBNA done blindly, while reserving mediastinoscopy for cases where cTBNA failed to elucidate a final diagnosis. There is now increased use of EBUS-TBNA, whereby needle aspirations are no longer done blindly but under real-time ultrasound guidance. There are two types of EBUS probes: the radial probe EBUS (RP-EBUS) and convex probe EBUS (CP-EBUS). RP-EBUS provides 360° images of the airway wall and surrounding structures. The major advantage of RP-EBUS is its ability to visualise the layers of the airway wall in detail. CP-EBUS provides a view parallel to the shaft of the bronchoscope – the angle of view is 90° and the direction of view is 30° forward oblique. Colour flow and Doppler features permit identification of vascular, ductular, and cystic structures. The major advantage of CP-EBUS is its ability to guide real-time sampling. The dedicated 22-gauge needle has an echogenic dimpled tip to enhance visibility on ultrasound. The

maximum extruding stroke is 40 mm, with a safety mechanism that stops at 20 mm. The needle has an internal sheath, which prevents contamination of the sample by bronchial wall tissue. EBUS has now become an established practice in many centres as the first-line mediastinal investigation for the diagnosis and staging of lung cancer.[1] In combination with endoscopic ultrasound the major part of the mediastinum can be assessed; this approach has been shown to be as accurate as surgical staging.[1] This strategy is also cost-effective.[1] EBUS-TBNA has been demonstrated to be a safe[2] and valuable diagnostic tool in lung cancer,[3] sarcoidosis,[4] tuberculosis[5] and lymphoma.[6] In our patient, the value of EBUS was threefold: (i) the technique is minimally invasive and safe compared with a surgical procedure; (ii) it was used to localise the lesion not abutting the bronchial wall and the proximity of major vessels, precluding conventional bronchoscopy; and (iii) the longer EBUS needle was used owing to the depth of the lesion. References 1. Rintoul RC, Ahmed R, Dougherty B, Carroll NR. Linear endobronchial ultrasonography: A novelty turned necessity for mediastinal nodal assessment. Thorax 2015;70(2):175-180. [http://dx.doi. org/10.1136/thoraxjnl-2014-205635] 2. Agarwal R, Srinivasan A, Aggarwal AN, Gupta D. Efficacy and safety of convex probe EBUS-TBNA in sarcoidosis: A systematic review and meta-analysis. Respir Med 2012;106(6):883-892. [http://dx.doi. org/10.1016/j.rmed.2012.02.014] 3. Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest 2010;138:795-802. [http://dx.doi.org/10.1378/chest.09-2100] 4. Tremblay A, Stather DR, MacEachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest 2009;136:340-346. [http://dx.doi.org/10.1378/chest.08-2768] 5. Navani N, Molyneaux PL, Breen RA, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: A multicentre study. Thorax 2011;66(10):889-893. [http://dx.doi.org/10.1136/thoraxjnl-2011-200063] 6. Steinfort DP, Conron M, Tsui A, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the evaluation of suspected lymphoma. J Thorac Oncol 2010;5:804-809. [http://dx.doi. org/10.1097/JTO.0b013e3181d873be]

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CASE REPORT

False-negative HIV-1 polymerase chain reaction in a 15-month-old boy with HIV-1 subtype C infection R Oladokun,1 MB BS, FMCPaed, FWACP, Cert ID (SA) Paed; S Korsman,2,3 MB ChB, MMed (Virol), FCPath (SA) Viro; N Ndabambi,2 MSc; N Hsiao,2,3 MB BCh, FCPath (SA) Viro, MMed (Virol), MPH; L Hans,4 MB ChB, MMed (Virol), FCPath (SA) Viro; C Williamson,2,3 PhD; M-R Abrahams,2 PhD; B Eley1 MB ChB, FCP (SA) (Paeds), BSc (Hons) P aediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Department of Paediatrics and Child Health, University of Cape Town, South Africa 2 D ivision of Medical Virology, Faculty of Health Sciences, University of Cape Town, South Africa 3 N ational Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa 4 N ational Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa 1

Corresponding author: S Korsman (stephen.korsman@nhls.ac.za) Polymerase chain reaction (PCR) testing is the gold standard for determining the HIV status in children <18 months of age. However, when clinical manifestations are not consistent with laboratory results, additional investigation is required. We report a 15-month-old HIV-exposed boy referred to our hospital after he had been admitted several times for infectious diseases. A rapid antibody test on the child was positive, while routine diagnostic HIV PCRs using the Roche COBAS Ampliprep/COBAS TaqMan HIV Qual Test were negative at 6 weeks, 6 months, 7 months and 15 months. In addition, the same PCR test performed on the HIV-infected mother was also negative. Alternative PCR and viral load assays using different primer sets detected HIV RNA or proviral DNA in both child and mother. Gag sequences from the child and his mother classified both infections as HIV-1 subtype C, with very rare mutations that may have resulted in PCR assay primer/probe mismatch. Consequently, the child was commenced on antiretroviral therapy and made a remarkable recovery. These findings indicate that more reliable PCR assays capable of detecting a wide range of HIV subtypes are desirable to circumvent the clinical problems created by false-negative PCR results. S Afr Med J 2015;105(10):877. DOI:10.7196/SAMJnew.8787

Even at a very early stage in paediatric HIV infection, polymerase chain reaction (PCR) has been shown to be highly sensitive and specific.[1] However, when the clinical picture is inconsistent with laboratory results, additional investigation is warranted. Several published studies have reported concerns about the ability of PCR tests to detect all current subtypes as a result of HIV-1 genetic diversity.[2-6] These concerns include the COBAS AmpliPrep/COBAS Taqman (CAP/CTM) HIV-1 Qual Test (Roche Molecular Systems, Branchburg, NJ, USA) which, until recently, was widely used in South Africa (SA) and is reported to have 99.7% sensitivity and 100% specificity.[7] We describe a case of a false-negative HIV PCR using this assay to detect vertically transmitted HIV infection in an SA child. Failure to recognise HIV infection at an early stage severely compromised the health of this child. Gag-specific sequencing of the virus in both mother and child was carried out to explore the reason for lack of detection by the qualitative PCR assay.

Case description

In January 2014 a critically ill 15-month-old boy was transferred to Red Cross War Memorial Children’s Hospital, Cape Town, SA from a secondary hospital. He had acute gastroenteritis with hypovolaemic shock, a lower respiratory tract infection, septicaemia, pyogenic myositis of his left thigh, and subungual abscesses of both thumbs caused by methicillin-sensitive Staphylococcus aureus. He responded to cloxacillin, fluid and electrolyte replacement and nutritional rehabilitation. Of note in his background medical history was that his mother was diagnosed serologically with HIV infection 5 months into her pregnancy. Dual zidovudine and nevirapine prophylaxis was administered antenatally and during labour, and postnatally the child received 4 weeks of zidovudine prophylaxis. He was breastfed until 4 months of age. Between the ages of 6 and 9 months he was

hospitalised on three occasions for gastroenteritis and respiratory tract infection (two admissions) and tuberculosis (one admission). Table 1 shows the HIV-related test history of the child and his mother – alternative PCR assays were initiated at the time of the child’s correct diagnosis and performed retrospectively on previous archived samples. The earliest qualitative HIV PCR test using the routinely available method (COBAS AmpliPrep/COBAS Taqman (CAP/CTM) HIV-1 Qual Test version 1) at 6 weeks was negative. Repeat PCR tests during subsequent admissions were also negative. A rapid antibody test at 15 months during admission to our hospital was positive. Because of the clinical suspicion of HIV infection, an HIV viral load test (Abbott RealTime HIV-1, Abbott Molecular Inc., Des Plaines, IL, USA) was performed, which documented 1 562 169 HIV copies/mL (log10 6.19). Alternative PCR assays[8,9] using different primer sets also detected HIV proviral DNA. The child’s CD4 count was markedly reduced at 64 cells/µL (3.86%). He was commenced on abacavir, lamivudine, lopinavir/ritonavir and co-trimoxazole, made remarkable progress and was discharged after 14 days. HIV gag-specific PCR was performed for diagnostic purposes and to investigate viral genotypic characteristics, which could inform reasons for lack of detection by the CAP/CTM assay (methodology available on request). Samples taken from both mother and child around the time of diagnosis, as well as archived samples from the child taken at 6 and 7 months of age, were all gag PCR-positive (Table 1). Amplification of partial gag (160 base pairs)[8] confirmed the presence of HIV in the child. Sequence analyses of full-length gag[9] amplified from infant and maternal samples confirmed that both were infected with HIV-1 subtype C, the predominant subtype in SA, with no evidence of intersubtype recombination (Fig. 1A). We analysed the most conserved region of gag, the p24 capsid region, which is more likely to contain primer/probe target regions. The sequence of an HIV subtype C infectious molecular clone (IMC)

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Table 1. HIV-related test results Sample

Age

Test method

Result

6 weeks

CAP/CTM Qual PCR*

Negative

6 months

CAP/CTM Qual PCR*

Negative

[9]

Full-length gag PCR

Positive

CAP/CTM Qual PCR*

Negative

Full-length gag PCR

Positive

Child

7 months

[9]

15 months

Determine HIV-1/2 antibody†

Reactive

15 months

Enzygnost Anti-HIV 1/2 plus ELISA

Reactive

15 months

PanLeucogating CD4 count (Beckman Coulter)[10]

64 cells/μL (3.86%)

CAP/CTM Qual PCR*

Negative

Partial gag PCR

Positive

‡

[8]

15 months

Abbott RealTime HIV-1 viral load§

1 562 169 copies/mL (log10 6.19)

C8, C9, C10

15 months

CAP/CTM Qual PCR

Negative

C10

15 months

CAP/CTM Qual PCR version 2¶

Positive

Full-length gag PCR

Positive Reactive

[9]

Mother M1

19 years

Determine HIV-1/2 antibody†

19 years

ARCHITECT HIV Ag/Ab Combo ELISA||

Reactive

Enzygnost Anti-HIV 1/2 Plus ELISA

Reactive

CAP/CTM Qual PCR*

Negative

‡

Full-length gag PCR[9]

Positive

Abbott RealTime HIV-1 viral load

51 977 copies /mL (log10 4.72)

COBAS AmpliPrep/COBAS Taqman HIV-1 Qual Test (Roche Molecular Systems, Branchburg, NJ, USA). † Determine HIV-1/2 (Alere Medical, Chiba, Japan). ‡ Enzygnost Anti-HIV 1/2 Plus (Siemens, Marburg, Germany). § Abbott RealTime HIV-1 (Abbott Molecular Inc, Des Plaines, Ill., USA). ¶ COBAS Ampliprep/ COBAS Taqman HIV-1 Qualitative test, V2.0 (Roche Molecular Systems, Branchburg, NJ, USA). || ARCHITECT HIV Ag/Ab Combo (Abbott Laboratories, Wiesbaden, Germany). *

Fig. 1. Subtyping and identification of rare mutations in the mother and infant samples. (A) A neighbour-joining phylogenetic tree of global subtype reference and SA subtype C gag sequences (www.hiv.lanl.gov). Both the infant’s sample C6 (indicated by a closed circle) and the mother’s sample M2 (indicated by an open circle) cluster with subtype C sequences. Scale bar = 0.02. (B) Rare mutations and a rare pairing of mutations in gag p24 sequences from samples C6, M2 and the subtype C IMC plasmid pBR246-F10, when compared with a consensus subtype C sequence and database subtype C sequences from the CAPRISA 002 cohort (previously detected by the COBAS Amplicor 1.5/Taqman HIV-1 test),[11,12] are illustrated in a highlighter nucleotide mismatch plot (www.hiv.lanl.gov). Rare mutations shared by the infant and mother are indicated by clear grey bars and the rare mutation pair shared by the infant, mother and IMC are indicated by shaded grey bars. Nucleotide mismatches relative to the consensus are shown as coloured blocks. Nucleic acid numbering relative to consensus C gag p24 is indicated.

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(pBR246F-10, provided by B Hahn), previously identified in our lab as failing to amplify on the CAP/CTM assay, was included in the analysis. Three individual nucleotide mutations (A202C, G204T and C647T, shared by the infant and mother sequences) and one pair of mutations (G657A together with T672C/A, shared by the mother, infant and IMC sequences) were identified as rare, based on their frequency within 530 database SA subtype C sequences (www.hiv.lanl.gov) (present in <1% of subtype C sequences) (Fig. 1B). Because of the proprietary nature of the primers and probes of the Roche CAP/CTM HIV Qual assay, we were unable to obtain their sequences to compare with the primer/probe binding region sequences of the mother and infant viruses. However, Roche Diagnostics was able to confirm that the sequence of both the IMC and the mother/infant virus contained critical primer/probe mismatches that may prevent detection using the first version of the CAP/CTM HIV-1 Qual assay. They confirmed that the newer version of the CAP/CTM assay, released late in 2013, would detect the virus, which was confirmed by another laboratory evaluating the performance of version 2 of the assay.

logistic challenges in terms of cost and feasibility, negating their use in routine practice. In this case report, the false-negative CAP/CTM result could likely be explained by primer or probe mismatches. We identified three rare mutations and a rare pairing of mutations in both the mother and infant sequences, which could have accounted for lack of detection. However, this could not be confirmed in the absence of primer/ probe sequence information. Qualitative assays that are more reliable in detecting HIV would be the long-term solution to the problem of false-negative PCR tests.[2,3] Additional HIV diagnostic testing is required when there are doubts about the HIV status of a symptomatic exposed infant. Continued surveillance and reporting of cases of HIV non-detection are therefore necessary. Upgrading of the amplification tests for better detection of all HIV subtypes is also essential. The new version of the qualitative CAP/CTM assay (version 2), which targets both the gag and LTR regions of the virus, should have an improved sensitivity and inclusivity profile.

Discussion

Opportunities were missed for early diagnosis and treatment of HIV in this child. PCR assays that are more reliable in detecting a wide range of HIV subtypes and variants are desirable to prevent the problem of false-negative PCR tests. Clinicians should consider a negative PCR result to possibly be false in cases where the clinical picture does not match the laboratory report.

Bøgh et al.[2] reported that the Amplicor HIV-1 DNA PCR test (Roche Molecular Systems, Branchburg, NJ, USA) did not detect all subtypes with equivalent sensitivity and that 10% of the nonsubtype B samples tested negative. Kline et al.[3] reported a falsenegative Amplicor HIV-1 DNA PCR in an infant with subtype C HIV infection. Other studies have similarly shown that version 1.0 of the Roche COBAS Ampliprep/COBAS Taqman (CAP/CTM, Roche Molecular Systems, Branchburg, NJ, USA) HIV-1 viral load assay may rarely under-quantify or fail to detect non-B subtypes.[4-6] In a report[13] in which the majority of women were African and likely to have non-B subtypes of HIV-1, nearly a quarter of the 108 samples collected from pregnant women gave rise to false-negative results in the routine assay (Roche Amplicor version 1.0). In this setting, if additional tests had not been conducted, misdiagnosis in infants may have occurred. This report describes a case of a false-negative qualitative PCR in a young child and his mother, both of whom have HIV-1 subtype C infection, confirmed by positive antibody and alternative DNA and RNA PCR assays. It is not possible to determine the exact timing of the child’s infection; however, failure of the routine PCR to detect HIV despite repeated attempts represents a missed opportunity for early diagnosis and resulted in multiple admissions and severe illness, requiring intensive care. This emphasises the need for a high index of suspicion in an HIV-exposed infant with clinical evidence of recurrent infections and failure to thrive. To reduce the risk of false-negative PCR tests, some guidelines have suggested molecular testing of a maternal sample as part of routine paediatric diagnosis.[11] In cases where maternal HIV DNA cannot be detected on the routine assay, an alternative assay able to detect the maternal virus can be used to test the infant.[11] Testing samples with a qualitative PCR with a parallel quantitative assay has also been suggested.[11] However, in endemic settings with a high prevalence of HIV, implementation of these policies may pose

Conclusion

Acknowledgements. Roche Diagnostics International, Rotkreuz, Switzer land, for technical advice. References 1. Petru A, Dunphy MG, Azimi P, et al. Reliability of polymerase chain reaction in the detection of human immunodeficiency virus infection in children. Ped Infect Dis J 1992;11(1):30-33. 2. Bøgh M, Machuca R, Gerstoft J, et al. Subtype-specific problems with qualitative Amplicor HIV-1 DNA PCR test. J Clin Virol 2001;20:149-153. [http://dx.doi.org/10.1016/S1386-6532(00)00147-5] 3. Kline NE, Schwarzwald H, Kline MW. False negative DNA polymerase chain reaction in an infant with subtype C human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 2002; 21(9):885-886. 4. Sizmann D, Glaubitz J, Simon CO, et al. Improved HIV-1 RNA quantitation by COBAS AmpliPrep/ COBAS TaqMan HIV-1 Test, v2.0 using a novel dual-target approach. J Clin Virol 2010;49:41-46. [http://dx.doi.org/10.1016/j.jcv.2010.06.004] 5. Gueudin M, Plantier JC, Lemée V, et al. Evaluation of the Roche Cobas TaqMan and Abbott RealTime extraction-quantification systems for HIV-1 subtypes. J Acquir Immune Defic Syndr 2007;44:500-505. [http://dx.doi.org/10.1097/QAI.0b013e31803260df] 6. Damond F, Roquebert B, Bénard A, et al. Human immunodeficiency virus type 1 (HIV-1) plasma load discrepancies between the Roche COBAS AMPLICOR HIV-1 MONITOR Version 1.5 and the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 assays. J Clin Microbiol 2007;45:3436-3438. [http:// dx.doi.org/10.1128/JCM.00973-07] 7. Stevens W, Erasmus L, Moloi M, Taleng T, Sarang S. Performance of a novel human immunodeficiency virus (HIV) type 1 total nucleic acid-based real-time PCR assay using whole blood and dried blood spots for diagnosis of HIV in infants. J Clin Microbiol 2008;46:3941-3945. [http://dx.doi.org/10.1128/ JCM.00754-08] 8. Engelbrecht S, van Rensburg EJ. Detection of southern African human immunodeficiency virus type 1 subtypes by polymerase chain reaction: Evaluation of different primer pairs and conditions. J Virol Meth 1995;55(3):391-400. [http://dx.doi.org/10.1016/0166-0934(95)00088-7] 9. Chopera DR, Woodman Z, Mlisana K, et al. Transmission of HIV-1 CTL escape variants provides HLA-mismatched recipients with a survival advantage. PLoS Pathog 2008;4(3):e1000033. [http:// dx.doi.org/10.1371/journal.ppat.1000033] 10. Glencross D, Scott LE, Jani IV, Barnett D, Janossy G. CD45-assisted PanLeucogating for accurate, cost-effective dual-platform CD4+ T-cell enumeration. Cytometry 2002;50:69-77. [http://dx.doi. org/10.1002/cyto.10068] 11. Mlisana K, Werner L, Garrett N, et al. Rapid disease progression in HIV-1 subtype C-infected South African women. Clin Infect Dis 2014;59(9):1322-1331. [http://dx.doi.org/10.1093/cid/ciu573] 12. Tomita A, Garrett N, Werner L, et al. Health-related quality of life dynamics of HIV-positive South African women up to ART initiation: Evidence from the CAPRISA 002 acute infection cohort study. AIDS Behav 2014;18:1114-1123. [http://dx.doi.org/10.1007/s10461-013-0682-y] 13. O’Shea S, Mullen J, Tong CY. Pediatric diagnosis of human immunodeficiency virus type 1 infection: The problem of false negative DNA polymerase chain reaction results. Pediatr Infect Dis J 2003;22(5):476-477.

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CASE REPORT

Delayed presentation and diagnosis of metastatic hepatocellular carcinoma in pregnancy C N Mnyani,1 BA, MB ChB, FCOG (SA); J C Hull,1 MB BCh, MRCOG, FCOG (SA), DTM&H; M B Mbakaza,2 MB ChB, FC Rad Diag (SA); A O A Krim,2 MB ChB, FC Rad Diag (SA); E Nicolaou,1,3 MD, FCOG (SA), Dip Fet Med Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa 2 Department of Radiology, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa 3 Maternal Fetal Medicine Centre, Morningside MediClinic, Johannesburg, South Africa 1

Corresponding author: C N Mnyani (coceka.mnyani@wits.ac.za)

Hepatocellular carcinoma (HCC) is rare in women of reproductive age. If diagnosed, the underlying cirrhosis is associated with infertility in the majority of cases. There is limited literature on HCC in pregnancy, even more so for cases of metastatic disease. We present a case of delayed presentation and diagnosis of metastatic HCC in pregnancy. A 30-year-old pregnant woman presented at 23 weeks’ gestation and was diagnosed as HIV-infected, with anaemia. She was initiated on an efavirenz-based fixed-dose combination and oral haematinics. She subsequently presented at 32 weeks’ gestation with dyspnoea, and was diagnosed with pre-eclampsia. She was also found to have hepatosplenomegaly and ascites. She went into spontaneous preterm labour at 32 weeks and 4 days. A diagnosis of metastatic HCC was made postpartum, based on the radiological findings and biochemistry. We discuss the challenges of diagnosing metastatic HCC in pregnancy. S Afr Med J 2015;105(10):877. DOI:10.7196/SAMJnew.8781

Hepatocellular carcinoma (HCC) is rarely diagnosed in women of reproductive age. The major risk factors are hepatitis B and C infections, alcoholic liver disease, and non-alcoholic fatty liver disease associated with obesity and type 2 diabetes.[1] Most risk factors are associated with progression to cirrhosis, which is present in 80 - 90% of cases of HCC.[1] Cirrhosis is associated with infertility; hence, HCC is rarely diagnosed in pregnancy.[1] The literature suggests that pregnancy has an adverse effect on HCC, and that high levels of oestrogen associated with pregnancy may accelerate evolution.[2,3] Therefore, the discussions often focus around termination of pregnancy if the diagnosis is made during pregnancy.[2,3] The finding of a hepatic lesion in pregnancy is often incidental, and the diagnosis of early-stage HCC may be delayed as the symptoms are often nonspecific.[4] We report a case of delayed presentation and diagnosis of metastatic HCC in pregnancy.

She was again referred to the hospital for pre-eclampsia at 32 weeks’ gestation, with a blood pressure of 144/105 mmHg and 1+ proteinuria. There was also a history of shortness of breath. On clinical assessment, she was found to have pitting oedema extending to the level of the thighs bilaterally, and was noted to have ascites and an enlarged liver and spleen. A chest radiograph showed bilateral multiple nodules, and the patient was started on empiric tuberculosis treatment. She went into spontaneous preterm labour at 32 weeks and 4 days and delivered a live male baby, with a birth weight of 1 525 g. Postpartum the patient developed pyrexia of 38.8°C, a cough and right upper-quadrant pain. An abdominal ultrasound was done,

Case presentation

A 30-year-old primiparous patient, with an uneventful previous pregnancy delivered by caesarean section, presented for the first time for antenatal care at 23 weeks’ gestation at a primary healthcare facility. She was found to be anaemic, with a haemoglobin of 8.0 g/dL, and HIV-infected with a CD4 count of 183 cells/µL. She weighed 49.8 kg, with a body mass index of 22.2 kg/m2. No other abnormal clinical findings were recorded at the first antenatal visit. She was initiated on antiretroviral therapy with an efavirenz-based fixed-dose combination, and also started on oral haematinics. She was referred to the local hospital for assessment, as she had had a previous caesarean delivery. At the referral hospital, a full blood count was done to investigate the anaemia. The results were not checked until 9 weeks later, when she was found to have a thrombocytopenia of 86 × 109/L and a haemoglobin of 11.8 g/dL. In the interim, the patient had 3 follow-up visits at the local clinic and the referral hospital, and no abnormal clinical findings were detected.

Fig. 1. A CT scan of the chest (coronal view), showing bilateral cannon ball lesions (white lesions) in the lung fields (CT = computed tomography).

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which showed a large lobulated hepatic mass with central lakes and a whorled appearance. There was also evidence of splenomegaly and ascites. A subsequent contrast-enhanced computed tomography (CT) scan of the chest and abdomen showed multiple cannon ball lesions (Fig. 1) in both lungs and an elevated right hemidiaphragm. There was a vascular mass with central areas of breakdown in the right lobe of the liver, measuring 12.3 cm × 19.0 cm × 20.7 cm (Fig. 2), as well as features suggestive of spontaneous tumour rupture. Splenomegaly, with focal non-enhancing lesions, was also noted on the CT scan. Further blood tests were done and the most notable findings were as follows: alpha-fetoprotein 10 148 µg/L; beta-human chorionic gonadotrophin 236 IU/L; alkaline phosphatase 369 U/L; gamma-glutamyl transferase 514 U/L; and aspartate transaminase 283 U/L. Blood tests for malaria and hepatitis A, B and C were all negative. Because of the radiological findings and level of the alpha-fetoprotein the patient was diagnosed with metastatic HCC and assessed to be a candidate for sorafenib, based on the Barcelona Clinic Liver Cancer (BCLC) staging system. She unfortunately declined any further treatment and was lost to follow-up.

Discussion

The majority of hepatic lesions in pregnancy are benign and often have a good prognosis. However, they pose a diagnostic dilemma as contrast-enhanced imaging in pregnancy is usually avoided owing to concerns of adverse effects on the fetus. There are cases reported in the literature of good maternal and fetal outcomes with early-stage HCC diagnosed in pregnancy, with the mainstay of treatment being surgical resection.[4,5] Metastatic HCC, however, carries a poor prognosis, with an estimated 1-year survival of <10%.[1] In our case there was delayed presentation and diagnosis, and the patient declined any interventions. The case was also unusual as investigations for viral hepatitis, the most common risk factor for HCC, were negative. Furthermore, it has been recognised that there is an increased incidence of non-AIDS-defining malignancies, including liver malignancies, in HIV-infected persons, although these are often described in the older population.[6] Although anaemia is common in pregnancy and usually has a nutritional aetiology, and thrombocytopenia is not uncommon with advanced HIV disease, their occurrence in pregnancy warrant a full clinical examination and appropriate investigations.

Fig. 2. A CT scan of the abdomen (coronal view), showing a large mass in the right hepatic lobe and splenomegaly. The vascular mass occupies the whole of the right lobe, where dense and hypodense areas are seen within the liver. References 1. El-Serag HB. Hepatocellular carcinoma. N Engl J Med 2011;365(12):1118-1127. [http://dx.doi. org/10.1056/NEJMra1001683] 2. Giannitrapani L, Soresi M, La Spada E, Cervello M, D’Alessandro N, Montalto G. Sex hormones and risk of liver tumor. Ann N Y Acad Sci 2006;1089:228-236. [http://dx.doi.org/10.1196/ annals.1386.044] 3. Choi KK, Hong YJ, Choi SB, et al. Hepatocellular carcinoma during pregnancy: Is hepatocellular carcinoma more aggressive in pregnant patients? J Hepatobiliary Pancreat Sci 2011;18(3):422-431. [http://dx.doi.org/10.1007/s00534-010-0345-6] 4. Chen YY, Chen YR, Wu HK. Hepatocellular carcinoma in pregnancy. J Obstet Gynaecol 2013;33(1):8889. [http://dx.doi.org/10.3109/01443615.2012.721028] 5. Chen HW, Li JY, Huang PQ, Chen RF, Lai EC, Lau WY. Synchronous right hepatectomy and cesarean section in a pregnant lady with hepatocellular carcinoma. Int J Surg Case Rep 2013;4(1):112-114. [http://dx.doi.org/10.1016/j.ijscr.2012.10.014] 6. Wang CC, Silverberg MJ, Abrams DI. Non-AIDS-defining malignancies in the HIV-infected population. Curr Infect Dis Rep 2014;16:406. [http://dx.doi.org/10.1007/s11908-014-0406-0]

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CASE REPORT

Kounis syndrome P M Ntuli,1 MB ChB, FCP (SA), Cert Cardiology (SA); E Makambwa,2 MB ChB Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa 2 Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa 1

Corresponding author: P M Ntuli (ntulipm@yahoo.com)

Kounis syndrome is characterised by a group of symptoms that manifest as unstable vasospastic or non-vasospastic angina secondary to a hypersensitivity reaction. It was first described by Kounis and Zavras in 1991 as the concurrence of an allergic response with an anaphylactoid or anaphylactic reaction and coronary artery spasm or even myocardial infarction. Since then, this condition has evolved to include a number of mast cell activation disorders associated with acute coronary syndrome. There are many triggering factors, including reactions to multiple medications, exposure to radiological contrast media, poison ivy, bee stings, shellfish and coronary stents. In addition to coronary arterial involvement, Kounis syndrome comprises other arterial systems with similar physiologies, such as mesenteric and cerebral circulation resulting in ischaemia/infarction of the vital organs. The incidence of this condition is difficult to establish owing to the number of potential instigating factors and its relatively infrequent documentation in the literature. We report the case of an HIV-negative 39-year-old man with no coronary risk factors or family history of premature coronary artery disease, who developed Kounis syndrome after the administration of fluoroquinolone for dysuria. However, to the best of our knowledge, no data on the incidence and prevalence of Kounis syndrome in South Africa have ever been reported in the literature. The recent understanding of Kounis syndrome has led to the condition being classified into three syndrome variants. S Afr Med J 2015;105(10):878. DOI:10.7196/SAMJnew.8767

Kounis syndrome is charac terised by a group of symp toms that manifest as unsta ble vasospastic or non-vaso spastic angina secondary to a hypersensitivity reaction.[1] It was first described by Kounis and Zavras in 1991[2] as the concurrence of an allergic response with an anaphylactoid or anaphylactic reaction and coronary artery spasm or even myocardial infarction. Since then, this condition has evolved to include a number of mast cell activation disorders associated with acute coronary syndrome. There are many triggering factors, including reactions to multiple medications (non-steroidal anti-inflammatory drugs, antibiotics and anti neoplastic agents), exposure to radiological contrast media, poison ivy, bee stings, shellfish and coronary stents. In addition to coronary arterial involvement, Kounis syndrome com prises other arterial systems with similar physiologies, such as mesenteric and cerebral circulation resulting in ischaemia/infarction of the vital organs.[3,4] The incidence of Kounis syndrome is difficult to establish owing to the number of potential instigating factors and its relatively infrequent documentation in the literature. It remains unclear whether the reported lower rates of the condition are the direct result of underdiagnosis. We report the case of an HIV-negative 39-year-old man with no coronary risk factors or family history of premature coronary artery

disease, who developed Kounis syndrome after the administration of fluoroquinolone for dysuria. However, to the best of our knowledge, no data on the incidence and prevalence of Kounis syndrome in South Africa (SA) have ever been reported in the literature. The recent understanding of Kounis syndrome has led to the classification of this condition into three syndrome variants.[2]

Case report

Our patient was a 39-year-old man with excellent baseline health. His history is signi ficant because of exercise-induced asthma in childhood and an allergic reaction to cefixime

in 2008 that responded well to antistamine and corticosteroids. In 2009 he was administered ciprofloxacin, with no untoward reaction. He was well until February 2015, when he developed dysuria and was administered ciprofloxacin. The patient developed a red pruritic rash 15 minutes after ingestion of the drug, which was followed by swelling of his hands, feet and scrotum. Four hours later, he developed retrosternal chest pain, radiating to both shoulders, rated 8/10, which persisted for about 10 minutes, with diaphoresis and nausea. The following morning he presented at the emergency centre, and developed a second episode of typical chest pain. The ECG (Fig. 1) showed ST segment

Fig. 1. ECG demonstrating inferior and posterolateral ST elevation.

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elevation in the inferior leads, and a diagnosis of acute coronary syndrome with inferior, postero lateral myocardial infarction was made. He was thrombolysed with tenecteplase, with no resolution of ST segment elevation 1 hour post lysis. The patient was referred to our division for rescue percutaneous coronary intervention (PCI) after stat doses of aspirin, clopidogrel and atenolol. On arrival, on re-taking the history, allergic myocardial infarction was considered a likely diagnosis and blood was sent for determination of troponin, tryptase, and IgE (Table 1). The clinical examination was unremarkable: the patient was normotensive, with a blood pressure of 120/70 mmHg, tachycardia of 108 beats/ minute, and tachypnoea of 22 breaths/minute. Cardiovascular examination revealed a loud S1 and no murmurs. Prednisone 1 mg/kg/day, diphenhydramine 50 mg, ranitidine 150 mg and amlodipine 10 mg were administered orally, with resolution of pain and ECG changes. Administration of aspirin, clopidogrel and a beta-blocker was discontinued. Cardiac catheterisation and a coronary angiogram were performed within 24 hours and showed unobstructed coronary arteries (Figs 2 and 3). On receipt of the blood results, allergologists were consulted. The patient was discharged 3 days later with no resurgence of symptoms; also not at 3 months’ follow-up.

Table 1. Results of investigations Investigation

Result

Full blood count

Haemoglobin 13.3 g/dL; white cell count 8.34 × 109/L; platelet count 276 × 109/L; eosinophils 0.017 × 109/L (0.3%)

Urea and electrolytes

Na 143 mmol/L; K 4.6 mmol/L; urea 3.6 mmol/L; creatinine 77 µmol/L

Total IgE

43 kU/L

Thyroid-stimulating hormone

0.36 mIU/L

Antinuclear antibodies

0.1 ratio – negative

Mast cell tryptase

2.5 µg/L

HIV

Negative

Lipid profile

Total cholesterol 2.8 mmol/L; triglyceride 0.9 mmol/L; high-density lipoprotein 1 mmol/L; low-density lipoprotein 1.3 mmol/L

Troponin T

1 001 ng/L

Diverse cast ciprofloxacin

Positive

Discussion

Kounis syndrome was described in 1991 as the concurrence of acute coronary events with an allergic or a hypersensitivity response and an anaphylactic or anaphylactoid reaction.[2] Several possible causes of Kounis syndrome have been reported.[1,5,6] The condition has three variants,[1] i.e. type 1 – coronary spasm; type 2 – coronary thrombosis; and type 3 – drug-eluting stent thrombosis. It is important to distinguish the type, as it has management implications. The syndrome is caused by inflammatory mediators released mainly from activated mast cells and via bidirectional stimuli macrophages and T-lymphocytes.[1] As activated mast cells abound at the areas of plaque erosion or rupture in patients suffering from acute myocardial infarction, a common pathway between allergic and non-allergic coronary events seems to exist.[1,7] • Type 1 variant includes patients with normal coronary arteries without predisposing factors for coronary artery disease, in whom the acute release of inflammatory mediators can induce either coronary artery spasm without an increase in cardiac enzymes and troponins or coronary artery spasm progressing to acute myocardial infarction with raised cardiac enzymes and troponins.[1]

Fig. 3. Unobstructed left coronary artery. Fig. 2. Unobstructed right coronary artery.

• Type 2 variant includes patients with culprit, but quiescent, pre-existing athero matous lesions, in whom the acute release of inflammatory mediators can induce either coronary artery spasm with normal cardiac enzymes and troponins or plaque erosion or rupture manifesting as acute myocardial infarction.[1] • Type 3 variant includes patients with coronary thrombosis (including stent thrombosis), in whom aspirated thrombus specimens stained with haematoxylin-eosin and Giemsa demonstrate the presence of eosinophils and mast cells, respectively.[1] Histamine released by degranulation of mast cells can also be measured within 5 - 10 minutes, but remains elevated for only 30 - 60 minutes and therefore has very limited value. To date, serum tryptase has been identified as a reliable marker of an anaphylactic reaction. Review of the literature has suggested that serum tryptase

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may be considered as a new marker of the instability of atheromatous plaque with regard to the existence of mastocytes in heart tissue. Regardless of documented laboratory evidence of anaphylaxis, a diagnosis can still be made based on the clinical presentation and treatment carried out accordingly.[5] Treatment depends on the syndrome variant: • Type 1 variant: treatment of the allergic event alone may abolish type 1 variant. Administer corticosteroids, antihistamines, vaso dilators (e.g. nitrates), and calcium channel blockers.[3,8] • Type 2 variant: apply the acute coronary event protocol and administer cortico steroids, antihistamines, vasodilators (e.g. nitrates), and calcium channel blockers when appropriate. • Type 3 variant: the use of mast cell stabilisers in association with steroids and antihistamines is recommended. Harvesting of the intrastent thrombus together with histological examination of

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aspirated material and staining for eosinophils and mast cells should be undertaken. When allergic symptoms are present after stent implantation, desensitisation measures should be applied; if these fail, the stent should be extracted.

Conclusion

There is a paucity of data on the incidence and prevalence of Kounis syndrome in SA; nonetheless, it is important to be aware of the entity. There are no treatment guidelines for patients with this syndrome, and most of the treatment information has been gathered from individual case reports or case series. A diagnosis of Kounis syndrome should be considered in young, healthy patients with no atherosclerotic risk factors when they develop an acute coronary syndrome (especially inferior myocardial infarction) after administration of a potentially allergic agent. These patients need treatment with steroids, antihistamines, fluid resuscitation, possibly adrenaline, oxygen, and antithrombotic agents before transfer to

a cardiac catheterisation laboratory. An allergy work-up should include the assessment of allergies to food, insect bites and other environmental agents. Skin tests and food challenges may be useful in identifying the culprit agent. References 1. Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): A natural paradigm? Int J Cardiol 2006;110:7-14. 2. Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: The concept of allergic angina. Br J Clin Pract 1991;45:121-128. 3. Goto M, Matszaki AM, Fuchinoue A, et al. Chronic atherosclerotic mesenteric ischemia that started to develop symptoms just after anaphylaxis. Gastroenterology 2012;6:300-308. 4. González-de-Olano D, Alvarez-Twose I, Matito A, et al. Mast cell activation disorders presenting with cerebral vasospasm-related symptoms: A ‘Kounis-like’ syndrome? Int J Cardiol 2011;150:210-211. [http://dx.doi.org/10.1016/j.ijcard.2011.05.007] 5. Gangadharan V, Bhatheja S, Al Balbissi K. Kounis syndrome – an atopic monster for the heart. Cardiovasc Diagn Ther 2013;3(1):47-51. [http://dx.doi.org/10.3978/j.issn.22233652.2013.02.04] 6. Mytas DZ, Stougiannos PN, Zairis MN, et al. Acute anterior myocardial infarction after multiple bee stings. A case of Kounis syndrome. Int J Cardiol 2009;134:e129-e131. [http://dx.doi.org/10.1016/j. ijcard.2008.01.050] 7. Kovanen PT, Kaartinen M, Paavonen T. Infiltrates of activated mast cells at the site of coronary atheromatous erosion or rupture in myocardial infarction. Circulation 1995;92:1084-1088. 8. Sebaldt RJ, Sheller JR, Oates JA, et al. Inhibition of eicosanoid biosynthesis by glucocorticoid in humans. Proc Natl Acad Sci USA 1990;87:6974-6978.

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2016 & 2017 Postgraduate Programmes in

Applied Ethics

• Postgraduate Diploma in Applied Ethics (NQF 8), leading to • MPhil in Applied Ethics (Biomedical Ethics, Business Ethics or Environmental Ethics) These programmes, which are offered by the Philosophy Department and the Centre for Applied Ethics (CAE), aim to engage in the challenges of a developing nation by equipping professionals in the medical, business, government, NGO, environmental, development and educational sectors, with the knowledge and skills needed to address moral issues in their fields of expertise. Two one-year programmes are offered. The first is a Postgraduate Diploma (PGD) in Applied Ethics (offered in 2016), followed by an MPhil (Applied Ethics, with specialisations in Biomedical-, Business- or Environmental Ethics), (offered in 2017). The PGD normally grants access to the MPhil (Applied Ethics), but students with other suitable qualifications will also be considered for the MPhil (Applied Ethics), which will be offered in 2017. The MPhil (Applied Ethics) will be more extensively advertised during the course of 2016. Further information regarding these two programmes will also shortly be available on the Centre for Applied Ethics’ website: http://sun025.sun.ac.za/ portal/page/portal/Arts/Departments/philosophy/cae/programmes. Course content for the PGD in Applied Ethics: • Introduction to Philosophy and Critical Thinking Skills • Introduction to Ethics and Applied Ethics • Contemporary Trends in Moral Philosophy • The Methodology of Case Studies in Applied Ethics Structure: On-campus tuition (in English) for 2 two-week sessions combined with structured self-study. Requirements: Any Bachelor’s degree (or equivalent) Closing date for applications: 30 November 2015 Apply electronically at: www.sun.ac.za/pgstudies or for further information contact Ms J Engelbrecht, Department of Philosophy, University of Stellenbosch, Private Bag X1, Matieland 7602; tel 021 808 2418; fax 021 808 3556; e-mail: jengelb@sun.ac.za www.ayandambanga.co.za

CAREERS & CLASSIFIEDS

NATIONAL SCREENING SERVICE – BREASTCHECK IRELAND BreastCheck, Ireland’s national breast screening programme provides free mammograms to women aged 50-64. Women are screened at both static and mobile units across Ireland. In support of the expansion of BreastCheck to include women aged 65-69, BreastCheck is recruiting and invites applications for the following post:

n SENIOR RADIOGRAPHERS/MAMMOGRAPHERS (National Screening Service – BreastCheck)

REF: NRS02866

These posts are available on a full-time and part-time basis in Dublin, Cork and Galway however travel is required. BreastCheck radiographers are responsible for providing mammography to the highest standard of technical quality in a caring manner and in line with established guidelines and operating procedures. Access to transport is required as the post involves frequent travel. For a full job specification and application form visit: www.hse.ie/eng/staff/Jobs/Job_Search and enter NRS02866 in the ‘Job Reference’ box and click ‘Search Jobs’ at the end of the page. Eligibility criteria for the post is outlined on the job specification. If you experience any difficulty accessing the job specification or application form online, you may request them by Emailing: applyalliedhealth@hse.ie and enter ‘NRS02866 Senior Radiographer/Mammographer’ in the subject line of your Email. The National Screening Service encompasses BreastCheck and is part of the Health Service Executive (HSE). Remuneration is based on the Department of Health pay scale for Senior Radiographers. Closing date: Friday, 30th October 2015.

www.hse.ie/eng/jobs Easy Access • Public Confidence • Staff Pride

Screening for dementia in busy clinical practice? Use the The Cognitive Assessment Tool–Rapid Version (CAT-rapid). Available from the App Store @ R25 The YouTube link inside the app provides a clear demonstration of the CAT-rapid. Suitable for health providers including nurses and doctors. Established validity- see http://www.croiconference.org/sessions/comparison-5-brief-screeningtools-hand-usa-and-south-africa

SAMF

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The ESSENTIAL MEDICAL REFERENCE for every healthcare professional! The convenient pocket-sized design enables you to fit it comfortably into your hospital bag or coat pocket, so it can always be at hand for ready reference. South African Medicines Formulary (SAMF), produced by the Division of Clinical Pharmacology of the University of Cape Town, provides easy access to the latest, scientifically accurate information, including full drug profiles, clinical notes and special prescriber’s points. The thoroughly updated 11th edition of SAMF is your essential reference to the rational, cost-effective and safe use of medicines.

Please direct all order queries to: Diane Smith Tel: 012 481 2069 email: dianes@hmpg.co.za Tax invoice to be posted on dispatch of order.

CPD

OCTOBER 2015

The CPD programme for SAMJ is administered by Medical Practice Consulting. CPD questionnaires must be completed online at www.mpconsulting.co.za.

True (A) or false (B): SAMJ Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period 1. South Africa (SA) ranks among the top ten countries with the highest road traffic fatality rate per 100 000 of the population, and is the second highest in Africa. 2. The South African Law on Seatbelts in Regulation 213 of the National Road Traffic Act, in force since 30 April 2015, stipulates that the driver of a motor vehicle operated on a public road shall ensure that an infant travelling in such a motor vehicle is seated on an appropriate child restraint, provided that this provision shall not apply in a case of a minibus or bus operating for reward. Epidemiology of acute spinal cord injuries in the Groote Schuur Hospital Acute Spinal Cord Injury Unit over the past 11 years 3. The 31 - 50-year-old age category was the largest, with 33% of patients. 4. The most prevalent cause of injury was motor vehicle accidents (45%), followed by violence-related injuries (27%). The appropriateness of emergency medical services (EMS) responses in the eThekwini district of KwaZulu-Natal, SA 5. Present policy dictates that anyone summoning EMS must be transported to a medical facility. A review of primary and secondary burn services in the Western Cape, SA 6. Scalds from hot liquids remain the most frequent aetiology. 7. The majority of burn injuries are satisfactorily managed at primary level by nurse practitioners. Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective 8. Stent deployment, while palliating dysphagia, cannot be used to treat malignant tracheo-oesophageal fistula. Prevalence of breast tuberculosis: A retrospective analysis of 65 patients attending a tertiary hospital in Durban, KwaZulu-Natal 9. Patients usually have the typical constitutional symptoms. 10. Ultrasound showed abscess to be the most common pattern of disease, with or without adenitis.

CME Bacillary angiomatosis: A rare finding in the setting of antiretroviral drugs 11. Bartonella is easy to culture. Basedow paraplegia: A possible misnomer 12. Thyrotoxic periodic paralysis, stroke and chorea occur commonly with Graves’ disease. 13. Myasthenia gravis and seizures are uncommon associations of Graves’ disease. Cryptococcal laryngitis: An uncommon presentation of a common pathogen 14. Primary infection of the larynx is uncommon. Efavirenz as a cause of ataxia in children 15. Ataxia in the setting of HIV is generally secondary to an infectious, vascular or neoplastic cerebellar lesion. The real value of endobronchial ultrasound 16. Endobronchial ultrasound-guided transbronchial needle aspir ation (EBUS-TBNA) has become a standard procedure worldwide, used alone to obtain biopsies for mediastinal disorders. Delayed presentation and diagnosis of metastatic hepatocellular carcinoma in pregnancy 17. Cirrhosis of the liver is associated with infertility in women of childbearing age. 18. Pregnancy may accelerate evolution of hepatocellular carcinoma because of the high levels of oestrogen. Kounis syndrome 19. Kounis syndrome is characterised by a group of symptoms that manifest as unstable vasospastic or non-vasospastic angina secondary to a hypersensitivity reaction. 20. Triggering factors are myriad and include reactions to multiple medications (non-steroidal anti-inflammatory drugs, antibiotics, and antineoplastic agents), contrast exposure, poison ivy, bee stings and reaction to shellfish and coronary stents.

Readers please note: articles may appear in summary/abstract form in the print edition of the journal, with the full article available online via www.samj.org.za

A maximum of 3 CEUs will be awarded per correctly completed test.

INSTRUCTIONS 1. Read the journal. All the answers will be found there, in print or online. 2. Go to www.mpconsulting.co.za to answer the questions. Accreditation number: MDB015/167/02/2015

October 2015, Vol. 105, No. 10

CCRC CRITICAL CARE REFRESHER COURSE

PORT ELIZABETH 2015

CRITICAL CARE REFRESHER COURSE --------------20 - 22 November 2015 Boardwalk Hotel and Convention Centre Port Elizabeth www.ccrc2015.co.za

Whatever the reason, whatever the season

S4 AVAMYS Nasal Spray (Suspension). Reg. No.: 41/21.5.1/0968. Each 50 µl spray contains 27,5 µg of fluticasone furoate. Preservative: Benzalkonium chloride 0,015 % m/m. PHARMACOLOGICAL CLASSIFICATION: A.21.5.1 Corticosteroids and analogues. GlaxoSmithKline South Africa (Pty) Ltd, (Co. Reg. No.: 1948/030135/07), 39 Hawkins Avenue, Epping Industria 1, Cape Town, 7460. Tel: +27 11 745 6000. Fax +27 11 745 7000. Marketed by Aspen Pharmacare, Building 12, Healthcare Park, Woodlands Drive, Woodmead, 2191. All adverse events should be reported by calling the Aspen Medical Hotline number or directly to GlaxoSmithKline on +27 11 745 6000. For full prescribing information refer to the package insert approved by the medicines regulatory authority. A19340 05/15 ZAF/FF/0001/15a